board assurance framework 2019 - 2020

Board Assurance Framework 2019 - 2020

Strategic Objective:2018-19 01 - Improving Quaility And SafetyEnabling Strategy:Quality Strategy

Monitoring Group:Quality Governance Group

Lead Director:Joanne Baxter

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Gaps in Controls Mitigation for Gaps in Controls(Actions)

Assurances

Internal External

Gaps in Assurances Mitigation for Gaps in Assurances (Actions)

Existing Controls Identified by theCommittee

1.1 The final year of the 3

year Quality Strategy willbe delivered 17-20delivering keytrajectories againstimprovements for allquality and safetymetrics.

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Key Control 01 Quality dashboard is reported to theboard and Quality Committee at eachmeeting - showing key progress onQuality Metrics / Trajectories.

Quality dashboard needs furtherrefinement to include all items and bealigned to CQC KLOE.

Performance on IPC audits,incident reporting, levels ofharm, serious incidents, duty ofcandour, complaints,safeguarding.

IPC Annual Report.

Monitored at QualityGovernance Group (QGG).

01 Full review andrebuild of QualityDashboard required

30/09/2019 01 Register to bedeveloped andongoing monitoringimproved

31/07/2019Quality Review Group,CQC andNHSI QRM also review QualityDashboard Metrics.

CQC Good rating.

Internal audit report providingsignificant assurance on riskmanagement, SI, IncidentManagement Processes andPatient Safety Alerts.

Triangulation with staffing andperformance needs developed.

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Key Control 02 Quality impact assessment process inplace and reported to QC throughQGG - monitors delivery of CIP,service change and serviceimprovement against key qualitymetrics..

Register of all trust QIA's no yet inplace.

No adverse patient safetyeffects reported from CIP orservice change.

Monitored at QualityGovernance Group (QGG).

02 Register to bedeveloped.

31/07/2019Monitored by Clinical.

Quality Review Group and CQCEngagement meeting.

None Identified

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Key Control 03 Serious Incident report and Incidentlevels of harm report, by service andlocation is received by QualityCommittee.

None Identified Themes and Trends relating totype, location, level of harmtracked and reported in SIreport.

No current themes identified.

Annual Learning Report -Incients, SI's & Complaints.

Serious Incident Reportincluding minutes from SeriousIncident Review Group (SIRG)

Monitored by Clinical.


Internal audit report on seriousincident providing significantassurance.

None Identified

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Key Control 04 Clinical Audit Dashboard reported toQuality and Committee and board atevery meeting showing delivery ofClinical Outcomes.

Full clinical audit dashboardhighlighting all outcomes from clinicalaudit to provide a fuller picture onquality of care delivered against KPI's.

Performance against NationalAQI's and care bundles areabove national average and onincreasing trajectory.

Clinical Audit Plan Deliveryprogress including OutcomeFindings.

Interim review of QualityStrategy & Quality Reportprogess delivery 19/20.

Clinical Advisory Group -Minutes including Assurancesand Risks.

04 Work underway tointegrate qualitydashboard andclinical auditdashboard andensure outcomesfrom all audit activityis reported

30/09/2019 04 Clinical Auditdashboard indevelopment

30/09/2019Benchmarked nationally withother ambulance trusts.

On National ambulancescorecard.


Quality Review Group and CQCEngagement meeting, NHSIand QRM.

Not all clinical activity currentlyreported to committee.

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Key Control 05 Strategic Safeguarding Groupestablished and assurances and risksare reported to the Quality Committeedirectly.

None Identified Minutes, assurances and risksand reported directly to QualityCommittee.

Safeguarding Annual Report.



Strategic Safeguarding Groupmembership includes regionaldesignated nurses.

None Identified

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Failure to deliver ourAmbulance KPI's inrelation to ourperformance trajectoryagreed by our leadCommissioners.Response times forcategory 2 and long waitsfor category 3 and 4.

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OR

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System change. TheNHS and social careeconomy in the NorthEast is undertakingSustainability andTransformation Planning,alongside thedevelopment of IntegratedCare Partnerships and anIntegrated Care System.The risk is of thesechanges affectingresponse performanceand the clinical safety ofpatients affected, orpotentially affected bythese changes

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OR

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The inability to develop,spread and embed arobust QualityImprovement culturewithin NEAS in order todrive continuousimprovement andinnovation in patientsafety, effectiveness andexperience

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OR

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Inability to recruit in linewith the workforce plan forthe trust for ScheduledCare, Unscheduled Care,Operations Centre andCorporate Services.

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Risk and Regulatory Services - BAF Version 5 Page: 1 of 21Date Printed: 21/06/2019





Key Control 06 Safe staffing report is provided to thequality committee each meetinghighlight clinical vacancies againstestablishment alongside fill rates.

None Identified Staff are deployed effectivelyagainst plan and risks to patientsafety through gaps inestablishment are visible andmitigation to reduce the risk inplace.

ORH report identifies staffingrequirements.

Patient Experience AnnualReport.

Health & Safety Annual Report.

Learning for Deaths Report(previous 6 month review).

Safe Staffing Report includingclinical vacancies againstestablishment.

Safe staffing report to the boardon a monthly basis and QRG.

Reported to CQC at relationshipmeetings.

None Identified

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Key Control 07 Performance Report Performance report requires review to

align to CQC KLOEPerformance report includingdelays reported to Clinical

07 Review ofperformance reportusing SPC underway

30/09/2019 07 PerformanceImprovement Plan tobe in place.

31/07/2019Report presented toContractural Group

Performance Improvement Planunderway




Monitoring Group:Quality Committee


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Assurances

Internal External



1.2 Plans will be developed

to ensure our journey toOutstanding is realised.

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Key Control 01 Recent Well Lead inspection outcomerating Good.

Actions from inspection required Monitored through BoardReports.

01 Action plan to bedeveloped.

31/07/2019 01 Plan monitored bySMT / ET

31/07/2019Current Good Rating in placeand Monitored by CQRG andCQC Engagement Meeting.

Actions incomplete.

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Key Control 02 Ongoing compliance with the CQCFundamental Standards is clearlymapped to existing governanceframework Committee reportingrequirements for each appropriateKLOE is clear.

Ongoing business as usual againstthe KLOE's is not currently in place onquality dashboard or IQPR.

CQC compliance is Monitoredby separate reports to Boardlevel committees.

02 Improvementrequired to mapdelivery of businessas usual quality andperformancereporting to the CQCKLOE

30/09/2019Monitored by Clinical.

Quality Review Group and CQCEngagement meeting, NHSIand QRM.

None Identified

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Key Control 03 CQC action plan responding to recentinspection is monitored monthly.

None Identified Staff are deployed effectivelyagainst plan and risks to patientsafety through gaps inestablishment are visible andmitigation to reduce the risk inplace.

ORH report identifies staffingrequirements.

Safe staffing report to the boardon a monthly basis and QRG.

Reported to CQC at relationshipmeetings.

None Identified

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Ability to achieveadequate NHSImprovement compliancein challenging times inaccordance with therequirements of theSingle OversightFramework (quality,performance, finance,well-led and strategicprogress).

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Assurances

Internal External



1.3 Improving The Safety

Culture.

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Key Control 01 Staff survey results. None Identified Monitored through Board

Reports.Current Good rating in placeand monitored by CQRG andCQC Engagement meeting.

None Identified

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Key Control 02 SI reports & Quality Dashboard,showing open reporting.

None Identified Monitored through PatientSafety Group and QualityCommittee and Serious IncidentReview Group.

Internal audit report on seriousincident providing significantassurance.

None Identified

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Key Control 03 Excellence Reports reported to QCthrough QGG

None Identifed Reports monitored via PatientSafety Group and QualityCommittee.

CQC Engagemement meetings. None Identified

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The inability to develop,spread and embed arobust QualityImprovement culturewithin NEAS in order todrive continuousimprovement andinnovation in patientsafety, effectiveness andexperience

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0 Implementation of 'JustCulture' principles withinthe organisation in orderto support improvementsin patient safety and staffhealth and wellbeing maynot be realised unlessembraced and supportedfrom board to front line

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Assurances

Internal External



1.4 Improve Clinical

Outcomes.

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Key Control 01 Scope of project developed and inplace. Community Services andRotational Working project boardestablished.

Management structure is yet to bedeveloped.

Reported in to DeliveringConstantly Group on a monthlybasis.

01 Clinical ServicesManager currentlyworking with projectmanager.

31/07/2019Recent Good grading from CQCWell Lead Inspection.

None Identified

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Key Control 02 National Ambulance Clinical Qualityindicators.

Acute trusts are not inputting MIMAPData on a monthly basis whichimpacts on the AQI informationrelating to Myocardial Infarction.

Clinical AQI's are reviewed andmonitored at Clinical ExcellenceGroup, Quality GovernanceGroup and Quality Committee.

02 Issue raised withQuality ReviewGroup and Nationallywithin the AmbulanceSector.

31/07/2019Reports shared withCommissioners via QualityReview Group. Reports areshared and benchmarkednationally.

Quality Report producedannually and submitted to NHSImprovement.

Reports are completed retrospectively- data is 3 months behind.

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Key Control 03 Clinical audit annual plan whichincludes clinical audits linked to knownPatient Safety risks.

Number of audits undertaken isdependant on the current resourceswithin clinical audit.

Monitored via the ClinicalExcellence Group, QualityGovernance Group, QualityCommittee, Audit Committee.

03 Business case beingdeveloped toincrease ClinicalAudit capacity

31/07/2019 03 Internal processthrough audit and careplatform can feedbackareas of improvementin realtime via CARE.

31/07/2019Monitored by Commissionersvia Quality Review Group.


None Identified

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Key Control 04 Learning from Deaths Policyimplemented.

Reports monitored via QualityGovernance Group, QualityCommittee and the Board.

04 Business case beingdeveloped toincrease clinical auditcapacity.

31/07/2019 04 Business case beingdeveloped to increaseclinical audit capacity.

31/07/2019Monitored via Commissionersthrough Quality Review Group.


Lack of resources within the clinicalaudit team causes delays in reportproduction.

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Key Control 05 Patient Safety Incidents reported andinvestigated

Timeliness of Investigations. Monitored via Patient SafetyGroup, Quality GovernanceGroup, Quality Committee.

Quality Dashboard.

Annual Learning Report.

05 Incident Reportingand InvestigationProject underway.

30/09/2019Monitored via Commissionersat Quality Review Group.


Monitored via CQC RelationshipMeeting.

None Identified

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Key Control 06 Large portfolio of research studies toimprove clinical outcomes.

None Identified. Monitored via ClinicalExcellence Group, QualityGovernance Group, QualityCommittee.

Monitored by Local ClinicalResearch Network.

None Identified.

ME

D0

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The potential loss ofclinical skill availabilitydue to requirementshighlighted in the NHSplan regarding theemployment ofParamedics into Primarycare Networks

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Strategic Objective:2018-19 02 - NHS 111 And Clnical Assessment ServiceEnabling Strategy:Clinical Strategy

Monitoring Group:Finance Committee

Lead Director:Mathew Beattie

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Assurances

Internal External



2.1 Develop and Implement

IUC operational model.






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Internal External



2.2 Development of the

North East ProviderAlliance.






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Internal External



2.3 Development of Clinical

Modelling.



Strategic Objective:2018-19 03 - Clinical Care And TransportEnabling Strategy:Performance Management


Lead Director:Victoria Court

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Assurances

Internal External



3.1 Unscheduled Care

Service Transformation.

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Key Control 01 Project board reporting and riskmanagement, escalation toTransformation Board with riskhighlighted. Monthly reporting to theFinance Committee.

None Identified Monthly project board meetingsare discussing this with a highpriority. Meetings are takingplace between NEAS andNEASUS to identify mitigationsin order to manage vehicle flowfor both new and existingvehicles.

Finance Committee over view

01 New role in NEAS toact as bridge betweenorganisations

31/10/2019Commissioners receive monthlyprogress reports with any keyareas of concern highlighted

Contracting meetings

Improved flow of information betweenNEAS and NEASUS

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None Identified A service reconfiguration grouphas been formed to meetregularly to discuss known andpotential servicereconfigurations. This will lookat impacts holistically acrossNEAS to better understand andmodel any required changes.

NEAS is also represented atICS and ICP level forawareness of all potentialchanges.

02 Feedback on changeswill be channelledthrough the SMT andET.

31/03/2020Regular meetings withcommissioners on progress willenable assurances orescalations to be progressedvia this route.ICS and ICP representation willprovide regular communicationroutes for any changes to bediscussed.

Reconfiguration group is newly set upand its effectiveness will need to bemonitored.

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None Identified A project plan is in place to workon reducing conveyance whichcovers front line and EOCactivities. There are clearactivities for the clinical hub anddispatch as well as trainingopportunities. This will bereported on monthly along withprogress against targetedlevels.

03 Discussions withCommissionersscheduled.

31/07/2019Commissioners receive monthlyprogress reports with any keyareas of concern highlighted.

External Influences.

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3 There is a risk to thesuccessfulimplementation of theORH recommendationsas a result of potentialreconfigurations within theNHS across the NorthEast. These are changesoutside of NEAS directcontrol as they arechanges to acuteprovision but thereseveral that couldprogress which mayrequire changes in NEASprovision in some areasto meet demand.

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9 If NEAS do not meetperformance targets setfor increasing Hear andTreat & See and Treatand a reduction of overallconveyance by DCAvehicles then the fundingapproved for EOC staffingmodel will be revoked orfinacial penalties applied.

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OR

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That some, or all of thethirteen DCAs due fordelivery by the end ofMarch 2019 to increasethe fleet size will not beavailable because ofdelivery delays.

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Strategic Objective:2018-19 03 - Clinical Care And TransportEnabling Strategy:Performance Management


Lead Director:Victoria Court

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Assurances

Internal External



3.2 Scheduled Care Review

Implementation.

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Key Control 01 Business case created and submittedwhich proposes the solution to thisrisk. If agreed, the outcome of thebusiness case will have a hugepositive impact upon this risk andallow for successful projectimplementation.

Potential for business case not beingapproved.

Monthly programme boardmeetings are discussing thisrisk and potential ways toovercome this for the project. Abusiness case has also beensubmitted to the Trust and iscurrently being assessed.

01 Create business caseclearly outlining thegap in capacity, theneed for such a roleand potential costsand risks associatedwith proposal. Alsoreview alternativeoptions if notapproved.

01/05/2019Discussed potential timescalesfor elements of the workstreams that are jointly ownedby NEAS and Commissioners,and NECS are assessingwhether they can free up somecapacity in their BusinessAnalyst department to supportproject.

None Identified

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Key Control 02 Programme Board reporting and riskmanagement, escalation toTransformation Board with riskhighlighted.

None Identified Monthly programme boardmeetings are discussing thisrisk and potential ways toovercome this for the project. Abusiness case has also beensubmitted to the Trust and iscurrently being assessed.

Discussed potential timescalesfor elements of the workstreams that are jointly ownedby NEAS and Commissioners,and NECS are assessingwhether they can free up somecapacity in their BusinessAnalyst department to supportproject.

None Identified

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Key Control 03 Fortnightly PTS Sub Group meetingsarranged and ongoing, which consistof key NEAS colleagues and leadCommissioners for scheduled care.

None Identified Monthly programme boardmeetings to discuss outcomesof discussions withCommissioners, and reviewoverall project plan.

Fortnightly PTS Sub Groupmeetings with LeadCommissioners to develop theService Development andImprovement Plan forscheduled care.

None Identifed

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8 Limited capacity in theforecasting and modellingrole within scheduled caremeans creating anevidence base for eachrecommendation is atrisk.

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9 Some scheduled carereview recommendationsare dependent ondecisions madeexternally, mainly withCommissioners to allowfor efficiencies.

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Strategic Objective:2018-19 04 - Developing A Sustainable WorkforceEnabling Strategy:Performance Management

Monitoring Group:Workforce Committee

Lead Director:Jason Emerson

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Internal External



4.1 Develop and deliver the

workforce plan.

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Key Control 01 The Workforce Metrics report ispresented to the WorkforceCommittee at each meeting showingkey demonstration progress on keymetrics.

WFC metrics report needs furtherrefinement to include directoratetrajectories.

WFC metrics report to be producedon a monthly basis.

Internal audit report providedsignificant assurance in relationto DBS May 2018.

Annual HCPC Referrals Update.

Annual DBS Assurance Report.

Volunteer Assurance Update.

Third Party ProviderAssurances Update.

Fit and Proper Persons AnnualReport.

01 Content of the WFCmetrics report to bereviewed.

31/07/2019Monitored by the Clinical QualityReview Group.

None Identified

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Key Control 02 Workforce Plan, Recruitment Plan andTraining Plan are presented to theWorkforce Committee on a bi-annualbasis and are reviewed by therelevant sub-groups at each meeting.

Unknown Unknown The Trust is registered is asponsoring organisation fornon-EU nationals.

None Identified

No

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Key Control 03 Workforce Strategy Group andWorkforce Operations Groupestablished and reported to theWorkforce Committee at eachmeeting.

Unknown Unknown Unknown Unknown

No

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Key Control 04 Workforce Safeguards Action Plan -reported to the Workforce Committeebi-annually.

Newly developed and actions andtimescales to be further refined.

Unknown Unknown Unknown

OR

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Inability to recruit in linewith the workforce plan forthe trust for ScheduledCare, Unscheduled Care,Operations Centre andCorporate Services.

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WD

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Risk of not being able torecruit Paramedics toalign with the outcomes ofthe ORH report and thecontractual agreementwith commissioners for2018/19, 2019/20,2020/2021 and 2021/2022(Risk originally opening in2017/18 - wording updateto reflect current position).

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Internal External



4.2 Develop and deliver

Leadership andprogressionopportunities.

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Key Control 01 Employee Stories presented to theWorkforce Committee on a bi-annualbasis.

None Identified Unknown01 24 month review of IIPprogress including staffsurvey to beundertaken

31/08/2019Unknown Unknown

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Key Control 02 Summary of Assurance and Minutesof the Organisational DevelopmentGroup presented to each WorkforceCommittee.

Unknown Unknown Investors in People (IIP)Developed standards awardedto the Trust in July 2017.

The Trust is seeking to reach IIP"High Performing" standard by 2021

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Key Control 03 NHS Staff Survey Results and ActionPlans presented to the WorkforceCommittee on an annual basis andmonitored by the OrganisationalDevelopment Group.

None Identified Unknown Annual NHS Staff Survey Unknown

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Key Control 04 Annual Review of Education &Training presented to the WorkforceCommittee.

Unknown Unknown Audits undertaken byaccreditation agencies

Unknown

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4 There is no dedicatedleadership for theSpecialist Skills Teamcurrently. Due to capacityconstraints, there isminimal attention beingpaid to this team.

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Internal External



4.3 Strengthen

Organisational Healthand Wellbeing.

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Key Control 01 Health and Wellbeing Strategy andAction Plan presented to theWorkforce Committee.

Mental Health and Wellbeing Lead. Board Champion - JohnMarshall.

MIND Blue Light Champions.

01 Business Case hasbeen developed forthe role

30/09/2019

01 2019/20 plan is indevelopment. FluPlanning Groupestablished.

30/06/2019

01 Content of the IQPRcurrently underreview

30/04/2019

CQOSH.

Investors in People (IIP)Developed standards awardedto the Trust in July 2017.

Annual NHS Staff SurveyResults.

Unknown

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Key Control 02 Annual Flu Campaign Updatespresented to the WorkforceCommittee bi-annually.

2019/20 plan needs to be developed. Weekly monitoring during theFlu Campaign period.

Unknown Unknown

No

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Key Control 03 Health and Wellbeing Groupestablished. Summary of assuranceand minutes to be presented to eachWorkforce Committee.

Unknown Unknown Unknown Unknown

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Key Control 04 Integrated Quality & PerformanceReport (IQPR) is reported to theBoard at each meeting.

Integrated Quality & PerformanceReport (IQPR) is reported to theBoard at each meeting.

Unknown NHSI and NHSE benchmarkingwith other ambulance trusts.

Unknown

OR

R-3

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High levels of sicknessabsence is adverselyimpacting on theworkforce and theorganisations ability todeliver quality care andrequired performancestandards

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Lead Director:Caroline Thurlbeck

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Internal External



4.4

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Key Control 01 Equality & Diversity Groupestablished. Summary of assurancesand minutes presented to theWorkforce Committee at eachmeeting.

Unknown Workforce Race EqualityWorkforce Standards Report(WRES).

Workforce DES.

Pride@NEAS.

Enable@NEAS.

Together@NEAS.

Equality & Diversity AnnualReport.

Board Champion - CarolynPeacock.

Hate Crime Champions.

01 Action plan has beendeveloped.

31/03/2020 01 The Trust has electedto move fromStonewall to theEmployers Network forEquality & Inclusion(ENEI).

31/03/2020Equality & Diversity AnnualReport.

Stonewall Workforce EqualityIndex (WEI) Report.

Equality Delivery System 2.

Gender Pay Audit.

Disability Confidence Scheme.

No comprehensive equality index inplace.

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Key Control 02 Freedom to Speak Up (FtSU) updatespresented to the WorkforceCommittee bi-annually.

Further action required to fully embedFtSU.

FtSU Champions

Board Champion

Unknown Unknown

OR

R-1

5

Inappropriate behavioursunderpin a culture thatimpacts negatively on theTrust's ability to deliverhigh quality safehealthcare

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Strategic Objective:2018-19 05 - Communication And EngagementEnabling Strategy:Communications Strategy

Monitoring Group:Executive Team

Lead Director:Paul Liversidge

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Internal External



5.1 Driving improvement of

internalcommunications.

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Key Control 01 Communications and EngagementStrategy in place. Media management

There needs to be greater assurancewithin the operations directorate thatkey messages are being received onthe frontline.

Strong staff survey results in2018 with an action plan inplace to ensure that NEAScontinue to listen and respondto staff feedback.

Workplan in place containing 17actions relating to internalcommunications which ismonitored on a quarterly basisat ET.

Quarterley report to ETregarding media coverage.

01 Review thecommunicationsmechanisms and testknowledge of keyissues throughdiscussions with frontline staff.

30/09/2019Independant external evaluationof media coverage highlightspositive coverage and complieswith the Francis Reportrecommendations fromMid-Staffs.

None Identified

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Key Control 02 Regular meetings held with TradeUnions.

None Identified. Staff Engagement &Communications quarterlyreport presented to ET.

Staff FFT results show highnumber of employees wouldrecommend NEAS as a place towork.

Executive Walkarounds andvisability.

Joint Consultation Committee

Full time Union Officialsengaging with Executive Team

02 Annual staff surveycomplied by externalagency.

31/03/2020Annual Staff Survey Septemberthrough December.

Staff FFT scores have a low samplesize and can dispropriantly reflectmore positive results

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Key Control 03 Corporate chanels in place andworking - Summary, Board Brief,Pulse and Staff App.

Systems and processes need to bereviewed to ensure two-waycommunications.

EDS2 grading exercisedemonstrates improvementsmade.

03 Project started withoperations, PMO andOD group support,including team briefreview.

30/09/2019Benchmark of NHS staff surveyresults and national peer groupsurveys high scores for NEAS.

None Identified

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Key Control 04 Board and senior leader visibilitythroughout Quality Walkrounds,station visits and observations.

Systems and processes need to bereviewed to ensure two-waycommunications.

Visibility tracker is in place forBoard members.

04 Project started withoperations PMO andOD group support,including team briefreview.

30/09/2019Benchmark of NHS staff surveyresults and national peer groupsurveys shows high scores forNEAS

None Identifed

OR

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Internal External



5.2 Introduce new intranet

on SharePoint to createa collaborative digitalenvironment thatsupports agile working.

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Key Control 01 Project to replace intranet withSharePoint platform to allow agateway to all other NEAS systems.

Office 365 roll-out is delaying theproject.

Lack of engagement from certainareas of the Trust to not provide NewIntranet Authors.

Project is being managedthrough project group withoversight from SMT and ET.

Business case approved andfunding available to procure thesystem and resources to build.

01 Launch of intranetpostponed untilSeptember

30/09/2019

01 Senior Digital andInternal CommsOfficer who willidentify and addresslack of engagementas part of role.

01/09/2019

01 Business caseunderway to sourcefunding for apermanent resource.

01/12/2019Third Party Provider supportoffered by AMT Evolve.

Senior Digital & Internal CommsOfficer funded on a fixed termtemporary contract until December2019.

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3 Delay in Office 365implementation

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5.3 Develop and support

NEAS presence onSocial Media.

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Key Control 01 Social Media policy and guidance iswidely used and reviewed.

Lack of a social media enterpriseplatform to govern and audit futuregrowth.

On-call communication is inplace to horizon scan potentialcriticisms, advise SMT onrepution and respond whenneeded.

01 Business case iswritten and awaitingconsideration onceprioritised fordecision making.

30/09/2019 01 Training programmecurrently beingdeveloped

30/09/2019NACOM guidance approved byAACE to support enahncedsocial media use.

Weakness exists in training staff andoverall awareness of social mediapitfalls.

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Key Control 02 Funding via Global Digial Exempler fora 12 month period is now available.

None Identified. Communications &Engagement workplan contains3 actions.

Social Media utilisation focusgroups, where feedback willinform training and guidance.

National AmbulanceCommunications Group.

None Identified.

28

4 Social Media platformBusiness Case has beenand still waits approval.

33 9



Strategic Objective:2018-19 06 - Organisational SustainabilityEnabling Strategy:


Lead Director:Kevin Scolley

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6.1 Achieving the Financial

Plan.

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Key Control 01 Monthly Financial Performance reportand dashboard presented to theFinance Committee and Trust Board.

Report details:

* Key variance from Plan* Remedial actions being undertaken* Key risks against Plan delivery* Contracting issues including deliveryagainst conveyance rate trajectory* CIP progress* Capital Programme position* Cash Flow position* NEASUS SOCI position plus Groupposition reported* Corporate Priorities update reportpresented monthly.

None Identified. Delivering Consistently -monthly financial position andkey issues reported by serviceline.

Transformation Board - monthlydetailed analysis of schemedelivery and forecast outturnreview; Future CIP planningreport presented from Q1 withiterative review in-year forfuture schemes.

SMT Update - Presentation ofmonthly financial performanceto group.

Workforce Committee andWorkforce Planning &Development Group - Monthlyupdate of WF Plan andRecruitment Plan delivery.

Quality Committee - CQUINperformance update (quarterly)identifying areas of concern.

IQPR - Finance Metric reporting

Business Cases - Prioritisationprocess, FM team support formanagers, Training formanagers

Losses and Special Paymentsupdates to Audit Committee

NEASUS - 6-monthly contractreview presented to FinanceCommittee includingperformance against KPIs.

NEASUS - Monthly reportdetailing SOCI, Cash Flow,SOFP and loan positionpresented to NEASUS Boardmeeting.

NEASUS Contract meetingmonthly.

NEASUS - Quarterly financialperformance update presentedto Investment Committee.

Quarterly Specialist Skillbusiness unit report presentedto FC, supported by AnnualOutturn report and futureplanning reports.

The Committee also receivesQuarterly Procurement updatereports.

01 Vehicles/ Eqpt. - Toreport into DeliveringConsistently andNEASUS ContractingGroup.

31/07/2019

01 All estates schemes'capital progress to bereported to ECSG.

30/09/2019

01 Additional reporting toDC, NEASUSContracting Group andECSG.

30/09/2019Internal Audit reports on systemand process control adequacy.

Local Counter Fraud requestsand investigations.

External audit reporting onNEAS and NEASUS position.

NHSI Monthly Monitoringreporting on financial, CIP andworkforce plan delivery.

NHSI QRM financial overviewslides.

Contract Review Meetings -identify potential issues thatmay have financialconsequences to be managed.

None Identified

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3 Failure to deliver ouragreed NHSI ControlTotal, CIP, Workforce andCapital Plan for 2019/20

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Key Control 02 Finance Committee also receivesQuarterly update reports on ourCapital Programme

Whilst IT scheme progress is reportedand monitored at internal group, thereis no similar reporting and monitoringof Estate and Vehicle/ Eqpt schemes.

IM&T Strategy - Capital planprogress and future planning.

Estate 'Invest-to-Save' schemeupdates presented toEnvironmental Compliance andSustainability Group.

Quarterly review of Capital Planundertaken through in-yearreviews of progress with capitalscheme managers.

NHSI Monthly Monitoringreporting on capital planprogress and forecast outturn.

NHSI QRM financial overviewslides.

Communication of issues withscheme delivery is not fully visible.






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6.2 supporting development

of Integrated CareSystem and associatedIntegrated CarePartnerships.

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Key Control 01 Contracting Update reported monthlyto Finance Committee - identifyingany known or potential reconfiguration/ system changes having a likelyfinancial consequence.

Annual Review of contracts register toFC in Q1 each financial year.

Proposals for contract negotiations forthe following year presentedSeptember and final proposedcontract agreement positionpresented for approval by FC in Q4.

None Identified. Per Corporate Objective updateto FC, progress againstsub-objectives is monitoredthrough RAG rating reporting.

Service Reconfiguration Groupmeets monthly to reviewposition and is providing widerinternal engagement andassurance on changes acrossthe region. Areas of concern areflagged at this Group andactions allocated to identifiedsystem change owners withinthe Group.

Joint NEAS/Commissioner postappointed (Senior ProgrammeLead for UEC) adding additionalparticipation and influence atsystem transformational events/groups.

SRG members have beenallocated areas of coverage andare required to attend externalreconfiguration meetings andfeedback.

Executive Team membersattend System TransformationBoards, LADB, NE UECNmeetings, etc.

Monthly Contract Review Groupmeetings with NECS as well ascontract management meetingsin respect of non-core contracts(such as S Tyne OOH/HomeVisiting).

QRG meeting attended byClinical and Medical Directorateleads.

None Identified.

OR

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Strategic Objective:2018-19 06 - Organisational SustainabilityEnabling Strategy:Information Governance


Lead Director:Caroline Thurlbeck

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6.3 Delivering digital

enablers.

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Key Control 01 Quarterly report produced for theFinance Committee on IM&T relatedprogress, escalation of risks andissues.

All IM&T projects monitored andprioritised in the bi monthly IM&TStrategy Group. Risks and issues arealso reviewed.

All GDE projects reported intobi-monthly programme group whichhas external (NHSD/E) representationfor oversight. Risks and issues arealso reviewed.

External Independent NetworkPenetration Testing undertakenannually.

DSPT (former IG toolkit) AnnualWorkplan requirements.

Monthly budget meetings for generaland GDE related spend.

Regular dialog and meetings withCommunications team.

DSPT Annual Workplan did not resultin a score over 95%

All new IM&T related projects tobe evaluated against the newbusiness case prioritisation bythe SMT and subsequentlyagreed with ET.

IM&T / GDE spend reported upto Finance Committee.

Communications plans, andengagement events being heldwith staff and communicationsteam.

Regular GDE / IT updates inPulse, Intranet and summary.

Information Security Workinggroup meets monthly to reviewsecurity issues and related newrequests.

Audit reports for remedial actionoverseen through AuditCommittee.

DSPT Annual Workplandeveloped and monitoredthrough the IGWG

Top 3 IG/IT related issuesoverseen and monitored by theFinance Committee.

DSPT Annual recovery actionplan monitored monthly byAssistant Director of IM&T

01 DSPT recoveryaction plan devisedand agreed withNHSE

31/12/2019Annual plan of IM&T relatedaudits produced by AuditOne incollaboration with the AuditCommittee and AssistantDirector of IM&T

DSPT Annual submissionaudited by AuditOne andremedial actions reported.

Annual Network penetrationtesting and remedial actionsreported.

High severity security issuesreported to NHSE and or ICO

DSPT Annual recovery actionplan monitored by NHSE.

None Identified

26

6 The Data Protection andSecurity Toolkit has astatus of ''Standards NOTmet'' as the Toolkitsubmission fell short of 19mandatory evidenceitems.

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board assurance framework 2019 - 2020

Documents