ckwcb-12-60b_v23__cluster_baf_2

NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2011/12

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.

1

February 2012 (V23)

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 Risk Owner

Risk Status RAG

Key Controls Assurances on Controls Key Positive Assurance

(**External / Independent) Gaps in Control (GIC) and/or

Gaps in Assurance (GIA) Corrective Action

Responsibility Target Date

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) Julie Lawreniuk Carol McKenna Gill Galdins

Amber 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. Scrutiny and review through Clinical Quality / Contract Management Boards Scrutiny and review through Transformation / QIPP governance

Transition report to Board Quality reports to CCEs and Quality Boards Audit and Governance Group report through CCE Governance Committee oversight of quality reporting CCGs initial SHA rating Internal audit of governance arrangements CCG authorisation process Participation in Board to Board reviews.

Significant (GIC)

Key controls are not fully embedded across all CCGs

(GIA)

Reasonable

Limited



2




Risk Status RAG





1.2) Patients are not receiving the expected standards of care through providers not adhering to the standards set by commissioners. Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins

Amber

Triangulation of Quality information from a range of services such as

- Incidents - PALS - Complaints - CQC QRPs - Patient feedback - National / regional

reviews/ audit - CQUINS

Policies & procedures to support such as risk management, whistle-blowing and safeguarding Quality governance arrangements in place

- Board - Governance committee - CCEs/Quality Groups - Contract Quality Boards

Quality Dashboard report and exceptions to Quality Group and CCE’s Board Quality reports Governance Committee scrutiny Internal audit review of governance arrangements

Significant (GIC) Key controls are not fully embedded across all CCGs (GIA) Internal audit not yet undertaken.

CQC Safeguarding reports

CQC – Quarterly risk profiles

Reasonable

Limited



3




RRisk Status 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. Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins

Amber 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. Quality governance arrangements in place

- Board - Governance committee - CCEs/Quality Groups - Contract Quality Boards - LSCB & LSAB

CCG Leadership in place Annual work plan for key safety priorities

Quality reports to CCE & CQBs on key performance indicators and escalation Board Quality reports Annual review and self assessment of governance arrangements

Significant (GIC) Key controls are not fully embedded across all CCGs (GIA)

Reasonable

Internal audit and risk management report - Calderdale

Limited



4




Risk Status RAG





1.4) Clinical Commissioning Groups are not prepared and supported to take on their future roles with respect to quality Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins

Amber

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 GP leadership on Quality Boards

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

Significant (GIC) Quality Groups are not yet fully embedded in the governance structure (GIA) Internal audit not yet undertaken.

Internal audit plan includes Quality Plan

Reasonable

Limited



5




Risk Status RAG





1.5) During transition there is a deterioration in the patient experience of health services Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins

Amber

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, including the establishment of the Quality Group. Scrutiny review through Clinical Quality Boards

Quality reporting to CCEs including key performance indicators and escalation Board Quality report Internal audit review of governance arrangements Dr Foster reports

Significant (GIC) Key control are not yet fully embedded across CCGs (GIA) Internal audit best practice guidance is not yet fully implemented.

Reasonable

Limited

Internal audit report Calderdale & Kirklees



6


Sustain the Integrated Finance, Operations and Delivery System Executive Director Lead; Jonathan Molyneux Interim Executive Director of Finance and Efficiency


Risk Status RAG





2.1) Fail to maintain financial control and service performance with constituent PCTs. Risk Owner: Jonathan Molyneux Risk Manager (s) PCT COO’s Julie Lawreniuk Carol Mckenna Gill Galdins PCT Finance leads Julie Lawreniuk Steve Brennan Kay Hughes

Red

Financial budgets, QIPP, activity and other key targets agreed for each PCT by the Board for 2011/12. 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 has been agreed by the Audit Committee 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.

Monthly reporting on the financial position, including QIPP, by PCT. These reports are reported to and reviewed at 1 Finance and Performance Groups 2 CCE’s 3 Executive Team meetings 4 Public Board Meetings (Bi monthly) 5 SHA level on behalf of the DH Annual audit of accounts

Significant GIC MYHT is reporting a deficit after taking into account potential additional income from the PCT. There is currently a potential financial risk to the PCT for 2011/12. MYHT financial position may have a significant impact on the plans of both MYHT and the PCT for 2012/13. MYHT is not achieving a number of the key operational targets. Financial control not maintained at constituent PCT level GIA

The Chair, CE and Cluster Executive team are working with MYHT Board and Executive team as part of a formal process to ensure the Hospital Trust resolves its financial position and achieves its operational targets as part of the process of preparing to become a Foundation Trust. A number of external reviews have taken place during the last quarter of 2011 and as at 3 January the PCT is awaiting the formal outcome from these. It is anticipated that the issue of the financial position and additional income for MYHT for 2011/12 and the formal outcome of the reviews should be known by the end of February 2012.

Cluster DoF End February

2012

Reasonable

Limited



7




Risk Status RAG





2.2) Lack of effective systems in place to manage devolved budgets. Risk Owner: Jonathan Molyneux Risk Manager (s) Risk Owner: Jonathan Molyneux Risk Manager (s) PCT COO’s Julie Lawreniuk Carol McKenna Jo Webster PCT Finance leads Julie Lawreniuk Steve Brennan Kay Hughes

Amber

Scheme of delegation to CCG’s agreed at October and December 2011 Cluster Board meetings Budgets have been allocated to and reported on, at CCG level, in 2011/12 and specific budgets will allocated and formally agreed for 2012/13. Monitoring of financial performance by CCG’s will be part of the formal governance arrangements, including Finance and Performance groups and the CCE’s. The Cluster Director of Finance retains overall accountability for financial management during the transition period. 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. CCG OD plans include financial management and financial Governance

Finance report to the Board Performance against CCG budgets will be monitored by the Finance and Performance Groups on a monthly basis. The Cluster Director of Finance will ensure robust performance management processes are in place at CCG level and will retain an overview of performance across the cluster. Internal Audit reviews will be reported to the Audit Committee/s CCG authorisation process Self Assessment Board to Boards The annual internal audit plan will include the formal review of CCG financial management.

Significant Not fully implemented. GIC Structure not fully in place

Reasonable

Limited



8




Risk Status RAG





2.3 QIPP challenge not met due to the lack of realistic QIPP plans from PCT / CCGs and /or poor monitoring and delivery of the agreed plan. Risk Owner: Jonathan Molyneux Risk Manager (s) PCT COO’s Julie Lawreniuk Carol McKenna Gill Galdins

Amber

3 Year QIPP plan has been submitted to SHA. Annual Operating Plans for 2011/12 included the QIPP plans – these were reviewed and agreed by the PCT Boards QIPP plans relating to healthcare contracts are built into annual SLA’s. Under the new Governance arrangements QIPP proposals and performance against approved schemes are reviewed monthly by the relevant CCE Finance and Performance Group.

PCT QIPP Plans in place to 2014/15 Monthly finance reports detail main schemes and performance against these. Monthly SMT and Finance and Performance Group Monitoring of QIPP schemes. Quarterly DH/SHA monitoring. Board reporting CCE reporting

Significant (GIC) (GIA) Some shortfall in achievement of schemes during 2011/12. QIPP plans are being reviewed and developed for 2012/13 as part of the Business Planning process.

Performance has been reviewed Underachievement has been offset by allocation of contingency funding. Original plans for 2012/13 need to be refreshed in light of experience during 2011/12

Cluster DoF 20 April 2012 PCT COO’s 31 March 2012

Reasonable

Limited



9


Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer


Risk Status RAG

Key Controls Assurances on Controls

Key Positive Assurance

(**External / Independent)

Gaps in Control (GIC) and/or Gaps in Assurance (GIA)

Corrective Action Responsibility Target Date

3.1) Major transformational programmes are not delivered across the commissioning economy. Risk Owner: Sheila Dilks Risk Manager (s) Risk Owner: Chris Dowse Risk Manager(s): Martin Land Judith Salter

Amber

CHFT Calderdale and Huddersfield Whole system Transformation Board in place. Clinical leadership at CCG fully committed MYHT Programme Office in place with key performance indicator agreed and monitored for elements of the programme .

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 11/12 QIPP schemes. MY HEFT PMO survey of CCGs’ potential commissioning intentions Review of MYHT CIPs by Ernst Young Analysis of outputs from above two activities by PMO

Supported By National Team for LTCS under leadership of Sir John Oldham Reports to Cluster Board and Exec team MY HEFT update reports to MY HEFT Board and Cluster Board, regularly. Updates to MYHT Board 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. Report on CCGs’ commissioning intentions provided to MYHT and Cluster senior team. 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.

Significant (GIC) Stakeholder engagement. Lack of cluster agreement on the scale of transformation (GIA) reliance on National evidence. Detail on major reconfiguration across the whole health economy still at early stages . Scope for major reconfiguration may be limited (GIC) (GIA) My HEFT high level risk register

Transformation workshops across whole health economy to agree shared vision . Clinical commissioning Groups priorities aligned with whole health economy strategy . Priorities agree with Health and Well Being Board Risk register under construction

End January 2012 (CD)

Garland review of MYHT Tri partite Formal Agreement MYHT

Reasonable

Limited



10




Risk Status RAG





3.2) Safe and secure transfer of responsibilities from PCTs to new organisations does not occur Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins

Amber

Stock take conducted in July 2011 Legacy reports from constituent PCTs – submitted to SHA September 2011 Quality Group development meeting Legacy documents reviewed January 2012 and planned quarterly thereafter Standing agenda item on Board committees regarding items for inclusion in legacy documents.

Scrutiny & oversight by Governance Committee Audit Committee

Management oversight by executive team Performance management quarterly by North of Englnad SHA Audit Committee Scrutiny & oversight re close down of board committees.

Significant (GIC) (GIA) Quarterly quality reviews at an early stage (January 2012)

Reasonable

Internal review of legacy reports from SHA - satisfactory

Limited



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Risk Status RAG





3.3) Effective transition and delivery of Public Health functions to new commissioning landscapes may not be achieved Risk Owner: Ann Ballarini Risk Manager (s) Directors of Public Health AndrewFurber Judith Hooper Graham Wardman

Amber

Existing transition plans for the approach to the transfer of Public health functions to the Local Authority New planning round for 2012/13 focuses on having an integrated plan including public health transition by 16th March 2012 Directors of Public Health (3) joint transition groups with each Local Authority (Calderdale, Kirklees and Wakefield district) Transition plan in place, to be updated in the light of new national guidance with a new plan for 2012-2013 – February 2012-2013 Transition plans will be signed off with the respective Local Authority as part for the Operating Plan Submission for 2012/13

Board and Cluster Executive Team (CET) updates on progress with the development of the plans Board report re implementation of plan February 2012 Board development session on Public Health transition

Significant GIA Complete national guidance not yet available.

Setting up a series of planning meetings to structure the approach Plans to be updated on receipt of complete information.

DPHs March 2012 Louise Auger January 2012

Reasonable

Limited



12




Risk Status 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. Risk Owner: June Goodson-Moore Risk Manager (s) Laura Smith

Amber

Health Economy Risk Assessment Process annually Training Needs analysis undertaken. Turnover monitored in cluster via workforce scorecards. Business Continuity Plans in place to prioritise work Assignment to CCG and CSO roles (letter dated January 2012). Provision of career development and resilience support to staff. Shared working across Cluster within functions. PDR process and time management support. Escalate workforce planning issues with providers as appropriate.

LDA Schedule 3 documents. Workforce integration of Board performance reports bi-monthly. Board Performance reports includes Staff in Post against trajectory plus turnover plus sickness absence. National staff survey results and actions plans report to Board and CCE Training Plan including mandatory training approved at Cluster Leadership Team (Aug 2011)

Significant (GIC) People transition policies to be adopted. (GIA) Training plan to be approved

SHA reviews of Schedule 3 Implementation of OLM to ensure Cluster Mandatory Training take-up. CQC registration.

Reasonable

Limited



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Risk Status 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. Risk Owner: June Goodson-Moore Risk Manager (s) Laura Smith Susan Maloney

Amber

Sickness absence is monitored monthly in each PCT. Positive employee relations and staff partnerships arrangements in place. Staff health and resilience initiatives in place. Monitor internal staff sickness levels and manage, in keeping with policy. Actions from industrial action been implemented Business critical roles identified.

Cluster workforce scorecard reports. Board Performance Reports. Staff survey results and action plans to Board and CCE. Staff Forum in place – Calderdale. IIP Group, Kirklees. Employee relations and staff participation forums in place (Staff side meeting) Workforce reports to Board

Significant (GIC) Public health/CCG/CSO transition plans predicated on DH guidance (GIA)

Feedback timetable via Regional Social Partnership Forum

June Goodson-Moore

Staff Survey Agreed CKW People Transition Policy Jan 2012 Regional Social Partnership Forum

Reasonable

Limited



14




Risk Status RAG





3.6) Cluster Governance arrangements are not fully embedded therefore decisions may be made without due authority. Risk Owner: Sue Cannon Julie Lawreniuk Carol McKenna Gill Galdins

Amber Shared operating for CKW PCT Clusters model implemented (September 2011 Boards) SOS/SFIs reviewed and approved for the Cluster (November 2011Board) Scheme of Delegation approved (November 2011Board) Terms of Reference in place for Committees and Sub Groups. All CKW staff communications on SOS/SFIs CCG OD plan includes Governance External and internal Audit completed training on governance for CCGs.

Board to CCG Board CCG Authorisation process Internal Audit review of governance arrangements (February 2012) Governance report to Board Committee minutes to Board Policy on policies approved by Governance Committee (December 2011) Communication Plan fully implemented

Significant GIC Not all CCGs have fully implemented Governance arrangements GIA Internal Audit review of governance not yet completed

Work being done with South Elmsall and Rycroft and The Grande to agree appropriate governance arrangements.

Gill Galdins

SHA – CCG Risk Ratings

Reasonable

Limited



15




Risk Status RAG





3.7) Unauthorised access, loss or damage to data occurs due to inadequate information governance arrangements Risk Owner: Peter Flynn Risk Managers: Vicky Pickles, Terry Service, Michael Goodson

Amber

IG Toolkit submissions. Previously PCT based, Cluster based for 11/12 Governance Committee and local Audit and Governance groups. Local Audit & Governance groups have information governance in their Terms of Reference. Cluster IG team in place Port control and encryption implemented

Baseline and improvement plan considered by CET and to be on Governance agenda Governance Committee report February 2012 External: Annual review by Internal Audit Calderdale – Emergency Planning business continuity test included information governance Cluster IG toolkit score

Significant GIA Recommendations from Internal Audit regarding records management.

Implement records management audit action plan across the cluster.

Reasonable

Limited

Internal Audit Report re records management received December 2011



16


Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development


Risk Status RAG





4.1) Clinical Commissioning Groups fail to achieve authorisation die to ineffective support from PCTs. Risk Owner: Ann Ballarini Risk Manager (s) Danny Alba

Amber

Each eCCG has PCT staff 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. Development and OD Plan in place Compliance with the 6 domains required for authorisation

Board to Board Reviews

Delivery against the key milestones for eCCG authorisation is monitored through the Commissioning Development Assurance Framework with the SHA

CCG Authorisation process. Monthly and quarterly monitoring return to SHA Review of progress through the Programme Office and clear reporting to the Cluster Board as a regular exception report. Collation of evidence demonstrating compliance with 6 domains

Significant 2 practices currently not allocated to an eCCG and aspire to become a eCCG in their own right but have not yet set up a Board Delay in the alignment of staff to eCCGs Potential weak areas in the assessment against the 6 areas for authorisation

Support provided through COO to reach a conclusion to this and offered from the Cluster leads Staff alignment at top level to be completed in January 2012 Delivery of a plan to address areas of underachievement will be developed when the national assessment criteria is issued.

CLT January 2012 eCCGs when appropriate

Reasonable

Limited



17




Risk Status RAG





4.2) New commissioning support offer does not deliver requirements of eCCGs Risk Owner: Ann Ballarini Risk Manager (s) Rachel Spilsbury

Amber

Delivery against the key milestones of the Commissioning Development Assurance Framework for SHA which covers requirements of delivering the West Yorkshire CSO Support through National and Regional team, membership of Regional DCD group and input to national workshops WY Footprint Project Group in place CCG partnership in developing offer Recruitment of a shadow ‘Managing Director’ for the West Yorkshire CSO in early January 2012. The job description for the post is currently being developed

Monthly CSO Programme Board meetings with supporting task and finish groups

Business Plan Prospectus

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

Significant Programme Board

April 2013

Reasonable

SHA monitoring

Limited



18




Risk Status RAG





4.3) Development of an ineffective model for direct commissioning function of NHS Commissioning Board Risk Owner: Ann Ballarini Risk Manager (s) Louise Auger and Danny Alba

Amber 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. Clear leads for areas of work identified across the Cluster contributing to the 6 portfolios. Sharing of information and intelligence across the Programme Office . 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.

Monthly and quarterly returns Clear reporting to the Cluster Board as a regular exception report. Agenda of monthly DCD meeting with SHA

Significant GIC Lack of national guidance on how NCB functions will be discharged.

Reasonable

Limited



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5. Strategic Objective Board Reports

Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Sue Cannon Executive Director for Quality and Governance


Risk Status RAG





5.1a) Reduced capacity in PCT emergency preparedness teams leads to lack of preparedness for emergencies. Risk owner: Sue Cannon (Ben Fryer) 5.1b) Reduced director-level capacity reduces ability of NHS to coordinate the healthcare response to an incident Risk owner: Sue Cannon 5.1c) Reducing public health capacity reduces on call cover and ability to activate Scientific and Technical Advice Cell. Risk Owner: Judith Hooper (Ben Fryer)

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. The director on call rotas have been merged across the cluster. The fully staffed rota 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 The cluster has a fully staffed Public Health on call rota. All rota members have received training in activating the STAC. The HPA operates a 2nd on call rota

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)

Significant No current gaps in assurance. N/A N/A

Reasonable

Successful coordination of planning for and response to industrial action in November 2011

Limited

Exercise Vespa Exercise Agora

SHA assurance December 2011 return



20


Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Sue Cannon Executive Director for Quality and Governance


Risk Status RAG





5.2). Lack of clarity regarding future delivery model for Emergency Planning and Resilience in the NHS within Calderdale, Kirklees and Wakefield District Risk Owner: Sue Cannon (Ben Fryer)

Amber 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 Active engagement with discussions on future health protection arrangements across the region Development of Commissioning Support Unit specification for Emergency Preparedness Series of workshops on Health protection and Emergency Planning West Yorkshire Health Protection memorandum of understanding West Yorkshire Emergency Preparedness CSO specification

Bimonthly West Yorkshire Resilience Forum Health Subgroup meetings Continued regular attendance at all meetings PCT emergency preparedness committees Updates provided for NHS partners at LRF meetings

Significant GIA - Lack of clarity on roles and responsibilities from DH

Awaiting guidance from DH

Reasonable

Limited



21


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


Risk Status RAG

Key Controls Assurances on

Controls Key Positive Assurance




6.1) Local trusts fail to achieve foundation trust status due to lack of sufficient support from commissioners Risk Owner: Chris Dowse Risk Manager (s) Rachel Carter

Amber 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 meetings between CCG GPs and MYHT clinicians to work through Clinical Service Strategy options. Ambulance Service Reports to Board. YAS Integrated Business Plan to support milestones for YAS FT application process Monitor assessment process

commences: July 2012

Minutes of meetings 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. Report on CCGs’ commissioning intentions provided to MYHT and Cluster senior team. Whole System Transformation event held *** Report on priorities widely circulated for action Board updates through PO papers

Significant Financial balance MYHT HEFT high level risk register

System wide review to create opportunities to improve financial resilience Regular updates on financial plans on aspirant FT Risk register under construction

HEFT/PMO Ongoing

End January 2012 Chris Dowse

Reasonable

Limited



22




Risk Status RAG


(**External / Independent) Gaps in Control or Assurance

(GIA) or (GIC) Corrective Action


6.2) Fail to deliver effective implementation of Any Qualified Provider (AQP) as set out in the guidance on 19 July 2011. Risk Owner: Ann Ballarini Risk Manager (s) Rachel Carter and Danny Alba

Amber

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; 3. Stakeholder (includes key providers) engagement and consultation process and activities;

4. DH guidance / directive on a future selection of services suitable for AQP, 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;

1. Commissioning Development Portfolio is coordinated by the NHSCKW Programme Management Office (PMO) with the DCD as senior responsible owner; Regular report to Cluster Board and CCEs

Significant 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.

Local eCCGs supported by NHSCKW heads of contracting.

Reasonable

Limited



23




Risk Status 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): Louise Auger

Amber

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.

Monthly Performance Report containing 11/12 Operating Framework KPIs with underperformance exception reporting for Provider and PCT Catchment presented to F and P Committees and CCEs Cluster Board report (Bimonthly) Report with recovery plans for underperformance to CCGs and through CCE DH/SHA monitoring of data and feedback to Cluster on areas of under performance Performance report to Cluster Board and CCEs

Significant GIC Level of knowledge of eCCGs during transition as future leads for this area

Development of dialogue at CCE level Support through CSO Part of OD Plan and CSO Development

Peter Flynn March 2012 When launched

Reasonable

Limited



24


Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer


Risk Status RAG





7.1) Staff are not fully engaged in the reforms in line with the NHS Constitution Risk Owner: June Goodson-Moore Risk Manager (s) Eleanor Nossiter

Amber

Comms and engagement strategy and action group. Regular monthly internal staff briefing. Consistent weekly bulletin across Cluster. Staff survey uptake and action plans. Communication and engagement staff in place in all PCTs. Creation of Cluster Intranet Communication and engagement plan 2011-2012 in place Staff forum in place – Calderdale IIP Group - Kirklees

Workforce report to Board Staff survey results report to Board

Significant (GIA) (GIC) No staff forum arrangement in Wakefield

Staff survey response to date at 75%.

Reasonable

Limited



25


Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer


Risk Status RAG





7.2) Fail to ensure constituent PCTs continue to meet their statutory responsibilities for communication and engagement Risk Owner: June Goodson-Moore Risk Manager (s) Eleanor Nossiter

Amber

MY Comms and engagement strategy and action group. Regular engagement with local MPs Fortnightly meetings. Daily monitoring of media coverage. Communication and Engagement Strategy Work Plan Governance Committee Terms of Reference PPI Engagement annual reports sign off by Board and CCE.

SHA monitoring conference calls; weekly

on Mid Yorkshire

Significant (GIA) Potential capacity issues in comms and engagement staffing the system (GIC)

Ongoing discussions and resilience assessment across CKW cluster, Mid Yorkshire and CHFT

Eleanor Rossiter March 2012

PPI and engagement reports to SHA

Reasonable

Limited



26

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, and seeks 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.

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.



27

Assurance

Examples of what constitutes differing levels of assurance:

Key Positive assurance (** External/Independent) EXAMPLES OF TYPES OF ASSURANCE

**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)

Key Positive assurance EXAMPLE OF LAYOUT 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

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

ckwcb-12-60b_v23__cluster_baf_2

Documents

risk management

quality of services

board quality reports

insufficient assurance

quality impact

board assurance framework

significant gic key

significant gaps