CKWCB-13-20_Board_Assurance_Framework_January_2013

Page 1 of 53

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:

Terry Service

Discussion √

Information √

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:

N/A

Sub Group/Committee: Governance Committee

Recommendation (s):

That the board receives and notes the content of the report.

Page 2 of 53

1.0 Purpose of Report

1.1 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.

2.0 Background

2.1 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.

3.0 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.

4.0 Recommendations

4.1 Receive this report

3

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

Risk Owner 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)

Matt Walsh

Carol McKenna

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

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

Significant (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.

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

26th November

2012 Calderdale CCG Authorisation Moderation Final Report (25th

Oct 2012) confirmed Good governance arrangements in place.

Calderdale CCG rated green on all aspects of quality.

Wakefield CCG Authorisation Moderation Final Report (25th


Wakefield CCG rated green on all aspects of quality except two criteria regarding complaints and safeguarding

Greater Huddersfield CCG Moderation Report (3rd December 2012) confirmed

4

Chris Dowse

Jo Webster

through Transformation / QIPP governance

process

Participation in Board to Board reviews.

Good governance arrangements in place and rated green on all aspects of quality.

NKCCG Authorisation Panel date is on the 12th

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

Wakefield Safeguarding policy ratified by CCE.

Reasonable

Limited




Principal Risks







Corrective Action

Responsibility Target Date

1.2) Patients are Amb Triangulation of Quality Quality Significant (GIC) Risk summit held with

5

not receiving the expected standards of care through providers not adhering to the standards set by commissioners.

Risk Owner: Sue Cannon

Risk Manager (s)

Matt Walsh

Carol McKenna

Chris Dowse

Jo Webster

er

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

Dashboard report and exceptions to Quality Group and CCE’s

Board Quality reports

Governance Committee scrutiny

Internal audit review of governance arrangements

CQC Inspection reports

Safeguarding reports

CQC – Quarterly risk profiles

Calderdale CCG Moderation Report (25th

Oct 2012) confirmed Good governance arrangements in place and rated green on all aspects of quality.

Wakefield CCG Moderation Report (25th

except two criteria regarding complaints and safeguarding

Oct 2012) confirmed Good governance arrangements in place and rated green on all aspects of quality,

Greater Huddersfield CCG Moderation Report (3rd

December 2012) confirmed Good governance arrangements in place and rated green on all aspects of quality.

North Kirklees has its Site authorisation panel day on the 12th

of December 2012

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

Key controls are not fully embedded across all CCGs

One provider has had warning/compliance notices issues by the CQC.

(GIA)

Internal audit not yet undertaken.

the provider, SHA, CQC and commissioners.

Subsequent Quality Summit led by the CCG’s.

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

6

Reasonable

Limited




Principal Risks

Risk Owner

RAG Key Controls





Gaps in Assurance (GIA) Corrective Action

Responsibility

Target Date

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

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

Quality reports to CCE & CQBs on key performance indicators and escalation

Board Quality reports

Annual review and self-assessment of governance arrangements

Quarterly

Significant (GIC)

Key controls are not fully embedded across all CCGs

(GIA)

Adult safeguarding resource need to be increased.

Quality Handover Document will not complete until March 2013

Options appraisal underway to be considered by GHCCG, North Kirklees CCG and Calderdale CCG during December 2012

Quality handover Document continues to progress as per SHA timelines.

CQC Inspection reports

KSAB has held a challenge event with all providers including NHS Kirklees in September 2012.




7




Principal Risks

Risk Owner

RAG Key Controls






Responsibility

Target Date

Cannon

Risk Manager (

Matt Walsh

Carol McKenna

Chris Dowse

Jo Webster

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 representation on the PCT Close Down Steering Group

reporting to the SHA on safeguarding compliance activity.

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

8




Principal Risks

Risk Owner

RAG Key Controls






Corrective Action

Responsibility

Target Date

1.4) Clinical Commissioning Groups are not prepared and supported to take on their future roles with respect to quality


Risk Manager (s)

Matt Walsh

Carol McKenna

Chris Dowse

Jo Webster

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

Final recommendation from NHSCB on CCG authorisation

Significant (GIC)

None identified

(GIA)

Movement of staff as part of the matching and pooling processes may negatively affect the command and control of the quality

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

Internal audit plan includes Quality Plan


Oct 2012) confirmed Good arrangements in place and rated green on all aspects of quality




Greater Huddersfield CCG Moderation Report (3rd December 2012) confirmed Good governance arrangements in place and rated

9

NHSCB led authorisation process which will test preparedness in respect to quality

green on all aspects of quality.

NKCCG Authorisation Panel date is on the 12th

agenda

of December.

Reasonable

Limited

10




Principal Risks

Risk Owner

RAG Key Controls






Corrective Action

Responsibility

Target Date

1.5) During transition there is a deterioration in the patient experience of health services


Risk Manager (s)

Matt Walsh

Carol McKenna

Chris Dowse

Jo Webster

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, CCG Quality Groups established.

Scrutiny review through Clinical Quality Boards

Quality and Risk summits in place to monitor improvements at MYHT

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.

All providers submitted readiness declarations in terms of friends and family test.


Oct 2012) rated green on all aspects of quality.

Wakefield CCG Authorisation Moderation Final Report (25th


Wakefield CCG rated green on all aspects of quality except two criteria regarding complaints and

Greater Huddersfield CCG Moderation Report (3rd December 2012) confirmed Good governance arrangements in place

11

and rated green on all aspects of quality.

NKCCG Authorisation Panel date is on the 12th of December.

Reasonable

HSMR rates improving and performance at MYHT is improving

Limited


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

Risk Owner

RAG Key Controls






Responsibility

Target Date

2.1) Fail to Red Financial budgets, QIPP, Monthly Significant The Cluster Chief Executive and GIC

12

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

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


Wakefield CCG Moderation Report (25

Oct 2012) rated green on all aspects of financial controls

and performancemanagement

arrangements.

th

Oct 2012) rated green on all aspects of financial controls and

performancemanagement arrangements.

Greater Huddersfield CCG moderation report rated

greed on all aspects of financial controls and

performance management 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.

GIA

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

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.

Cluster DoF

End Q4 2012.13

Reasonable

Cluster Boards and CCG’s receive regular financial

reports on MYHT

Limited

13



Executive Director Lead; Ian Currell Executive Director of Finance and Efficiency - Update provided by Ian Currell on 03/12/2012

Principal Risks

Risk Owner

RAG Key Controls Assurances on Controls





Corrective Action

Responsibility

Target Date

2.2)Lack of effective systems in place to manage devolved budgets.


Risk Manager (s)

Matt Walsh

Carol McKenna

Chris Dowse

Jo Webster

Julie Lawreniuk

Amber

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

Monitoring of financial performance by CCG’s is 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.

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 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

Significant

Not fully implemented.

No chief finance officer for Wakefield

GIC

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.

Designate Chief Officers have been assigned to the CCGs. Designate Chief Finance Officers have been assigned, a shared post for

End July 12

Reasonable

Monthly CCE’s and Finance and

Performance groups

Limited

14

Steve Brennan

Jim Hayburn

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

Self-Assessment

Board to Boards

The annual internal audit plan will include the formal review of CCG financial management.

Calderdale and Greater Huddersfield and one person covering North Kirklees. This leaves a gap in Wakefield.



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

RAG

Key Controls Assurances on

Controls





Responsibility

Target Date

2.3)

QIPP challenge not met due to the lack of realistic QIPP plans from PCT /

Amber

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 (GIC)

(GIA)

Committee established to review effectiveness of primary care transformation scheme in Wakefield to

CFO’s

January 2013

Calderdale CCG Moderation Report (25th Oct 2012) confirmed Good strategic Plan and QIPP plans in place

15

CCGs and /or poor monitoring and delivery of the agreed plan.


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.

Under the new Governance arrangements QIPP proposals and performance against approved schemes are reviewed monthly by the relevant CCE Finance and Performance Group.

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

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 supported by CCG level detailed QIPP monitoring

Reasonable

Some shortfall in plans during 2012/13. In particular rise in NEL activity in Wakefield has caused concern.

reduce NEL activity.

Where there are shortfalls in QIPP schemes budget contingencies are available in 2012/13.

reported Monthly to and reviewed by the CCE’s and Finance and Performance

Groups

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

16


Provide Strong Health System Management

Executive Lead; Mike Potts Chief Executive Officer

Principal Risks

Risk Owner

Risk Status

RAG

Key Controls Assurances on Controls





Corrective Action Responsibili

ty Target Date

3.1) Major transformational programmes are not delivered across the commissioning economy.

Risk Owner:

Mike Potts

Risk Manager (s)

Carol McKenna

Matt Walsh

Jo Webster

Amber

Calderdale and Huddersfield

Programme Board established with membership from the 7 partners.

Steering group established

Well established PM methodology in place supported by PMO.

Programme in place setting out vision and objectives.

Programme Board reports through DCO to CCE

Regular updates to Cluster Board.

Minutes of Board meetings; minutes of steering group; outputs from whole systems events; developing business cases from care streams

Reports to Cluster Board and Exec team

MYHT

MY HEFT update reports to MY HEFT Board and Cluster Board, regularly. Updates to MYHT Board

Significant (GIA)

Reliance on National evidence.

Detail on major reconfiguration across the whole health economy still at early stages

SCAP and NCAT processes underway to quality assure the OBC at MYHT.

Scope for major reconfiguration may be limited

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.

Priorities agreed with Health and Well Being Boards x 3

High level risk

SCAP/NCAT quality assurance processes to be completed by February 2012. Jo Webster lead

Informal DH gateway review report (Oct 2012)

Evidence within CB moderation report for Calderdale (25th

Oct 2012)

Garland review of MYHT

Tri partite Formal Agreement MYHT

Reasonable

17

Chris Dowse

Clinical leadership at CCG fully committed

Programme Office in place with key performance indicator agreed and monitored for elements of the programme.

MYHT

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.

MY HEFT PMO survey of CCGs’ potential commissioning intentions

Review of MYHT CIPs by Ernst Young

Analysis of outputs from above

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.

(GIC)

(GIA)

MYHEFT high level risk register

No CHFT RR

register required for CHFT

Further investment and support from PMO in Wakefield

Limited

18

two activities by PMO

19




Principal Risks

Risk Owner

Risk Statu

s

RAG

Key Controls






Responsibility

Target Date

3.2) Safe and secure transfer of responsibilities from PCTs to new organisations does not occur

Risk Owner: Mike Potts

Risk Manager (s)

Gill Galdins

Amber

Governance Committee Terms of Reference revised September 2012 with specific remit for handover and closedown

Quality Legacy report submitted to SHA October 2012

Transition Steering Group meeting monthly with leads for all areas, reports to Governance Committee

Legal advice secured to support transition and ensure safe transfer.

Receiver Workshops being

Scrutiny & oversight by

Governance Committee

Audit Committee

Management oversight by executive team

Attend monthly North of England Governance Transition meeting

Performance management quarterly by North of England

Significant

(GIC)

Nationally a number of unallocated functions

(GIA)

Review of quality legacy report from SHA awaited

Advice still expected on some liability transfers r.eg. NHSLA

Reasonable

Monthly tracker assurance report completed for SHA with RAG rating of risks – mainly amber / green

Limited

20

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

21




Principal Risks







Responsibility

Target Date

3.3) Effective transition and delivery of Public Health functions to new commissioning landscapes may not be achieved

Risk Owner:

Gill Galdins

Risk Manager (s)

Andrew Furber

Amber

Transition plans for transfer of Public health functions to the Local Authority agreed by cluster board, local authorities and SHA.

Director of Corporate Development and Transition, & Directors of Public Health (3) attend PH transition groups with each Local Authority.

Shadow working arrangements with local authority in place, with Memorandum of Understanding on staffing in place

Board and Cluster Executive Team (CET) updates on progress with the development of the plans

Board report re implementation of plan

Significant

GIA

Some elements of national guidance still awaited.

Setting up a series of planning meetings to implement the transition

Plans to be updated on receipt of complete information.

DPHs

31st

October 2012

Letter from SHA agreeing each PCT’s individual plan

APL 12

Reasonable

Limited

22




Principal Risks







Responsibility

Target Date

Judith Hooper

Graham Wardman

23




Principal Risks

Risk Owner






Corrective Action

Responsibility

Target Date

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

Amber

Health Economy Risk Assessment Process annually

Programme of workforce assurance meetings in place with key Providers

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

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

Significant (GIC)

People transition policies adopted and process ongoing.

(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

24




Principal Risks

Risk Owner






Corrective Action

Responsibility

Target Date

Risk Manager (s)

Laura Smith

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.

mandatory training approved at Cluster Leadership Team (Aug 2011)

25




Principal Risks

Risk Owner

RAG Key Controls






Corrective Action


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)

Amber

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.

Monitor internal staff sickness levels and manage, in keeping with policy.

Business critical roles

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 individual SMTs as well as 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 2011

Agreed CKW People Transition Policy Jan 2012 Regional Social Partnership Forum

Reasonable

Limited

26




Principal Risks

Risk Owner

RAG Key Controls






Corrective Action


Laura Smith

Susan Moloney

identified.




Principal Risks

Risk Owner

RAG Key Controls






Responsibility

Target Date

3.6) Cluster Amb Revised governance arrangements NCB Significant GIC

27




Principal Risks

Risk Owner

RAG Key Controls






Responsibility

Target Date

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

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.

authorisation process reviewing CCG governance arrangements

Recommendations from NHSCB on CCG authorisation

SHA – CCG Risk Ratings

Internal Audit review of governance significant

assurance

CCGs currently populating structures for governance arrangements (in-house or via CSU SLAs)

Governance arrangements with West Yorkshire Local Area Team for NHS Commissioning Board to be developed once key staff in post.

GIA

Structures near to completion as at 20.12.12

Reasonable

Limited

28




Principal Risks

Risk Owner

RAG Key Controls






Responsibility

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




29

Principal Risks

Risk Owner

RAG Key Controls







3.7) Unauthorised access, loss or damage to data occurs due to inadequate information governance arrangements

Risk Owner:

Peter Flynn

Risk Managers:

Terry Service,

Amber

IG Toolkit submissions. Previously PCT based, Cluster based for 11/12

Local Audit and Governance groups have information governance in their Terms of Reference.

Port control and encryption implemented

Transition and close down board established.

Risk register updated on key risks

Risk register reviewed by key organisations

Inclusion if IG in CCG Authorisation process

Baseline and improvement plan considered by CET and by Governance Committee as reported February 2012

External:

Annual review by Internal Audit

Calderdale – Emergency Planning business continuity test included information governance

Cluster IG toolkit score

Significant

GIA

Corporate records audit underway for NHSK

Internal Audit report on Cluster 11/12 submission awaited.

GIC

Records management audit action plan across the cluster.

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:

Q3/4 12/13

Risk Owner:

Expected Q3 12/13

ABL appointed to support transition and closedown programme including records.

Reasonable

Review of corporate records completed for NHSWD and NHSC.

Limited

30




Principal Risks

Risk Owner

RAG Key Controls








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

RAG Key Controls






Responsibility

Target Date

4.1) Clinical Amb Each eCCG has PCT staff Board to Board Significant 2 practices currently not Support provided through

31




Principal Risks

Risk Owner

RAG Key Controls






Responsibility

Target Date

Commissioning Groups fail to achieve authorisation due to ineffective support from PCTs.

Risk Owner: Ann Ballarini

Risk Manager (s) Danny Alba

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.

Development and OD Plan in place

Reviews

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

CCG Authorisation process.

Confirmation that configuration of each CCG is appropriate by NHSCB.

Final Evidence report from NHSCB

allocated to an eCCG. Discussion on going to finalise arrangements With existing eCCG.

Delay in the alignment of staff to eCCGs

Potential weak areas in the assessment against the 6 areas for authorisation which may lead to conditions being attached to final authorisation

COO to reach a conclusion to this and offered from the Cluster leads. Issue resolved.

Development of a plan to address any conditions with authorisation is being agreed with each CCG within the

June 2012

Wave 1

Calderdale and Wakefield CCGs completed Nov 2012

Wave 2 Reasonable

32




Principal Risks

Risk Owner

RAG Key Controls






Responsibility

Target Date

Confirmation of which wave each CCG is going to put in an application

Compliance with the 6 domains required for authorisation

Submission of application for the appropriate wave deadline.

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..

appropriate timeframe G Huddersfield CCG to be completed by end December 2012

Wave 4

NKirklees by end January 2013

Limited


33



Principal Risks

Risk Owner

Risk Status

RAG


Controls





Corrective Action


4.2) New commissioning support offer does not deliver requirements of eCCGs


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 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.

Discussions progressing

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 WYCSU recruited MD August 2012

Feed back report for checkpoint 3

received from BDU October 2012

CSU structure agreed September 2012

Pooling and matching completed November

2012

SLA to be agreed with all 10 CCGs by end

November 2012

Feedback from BDU on checkpoints 1-3 received

and satisfactory

Reasonable

SHA monitoring

Limited

34




Principal Risks

Risk Owner

Risk Status

RAG


Controls





Corrective Action


with CCGs to agree SLAs by end of November 2012.

35




Principal Risks

Risk Owner

Risk Statu

s

RAG


Controls





Corrective Action

Responsibility

Target Date

4.3) Development of an ineffective model for direct commissioning function of NHS Commissioning Board


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

Monthly and quarterly returns

Clear reporting to the Cluster Board as a regular exception report.

Agenda of monthly DCD meeting with SHA

Significant

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

GIC

Director of Commissioning in WY LAT not yet recruited

National recruitment of Director

Cluster Director to oversee recruitment to structure until Director appointed.

Structures for the NHSCB Local Area Teams to be populated when published.

Pooling and matching to structure.

Gaps in structure to be

Published November 2012

Completed end November 2012

Reasonable

Limited

36




Principal Risks

Risk Owner

Risk Statu

s

RAG


Controls





Corrective Action

Responsibility

Target Date

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.

advertised and recruited to . December 2012.

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

RAG






Corrective Action

Responsibility

Target Date

5.1a) Reduced capacity in PCT emergency preparedness teams leads to lack of preparedness for emergencies.

Risk Owner:

Judith Hooper

5.1b) Reduced director-level capacity reduces ability of NHS to coordinate the healthcare response to an incident

Risk Owner:

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. 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)

Significant No current gaps in assurance.- risks on RR

All PCTs score 12

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 March 2012 return

Exercise Chadwixk

38




Principal Risks

Risk Owner

Risk Status

RAG






Corrective Action

Responsibility

Target Date

Judith Hooper

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)

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

Some expectation that capacity could reduce towards April 2013 due to issues dedailedunder 5.2 below.

39




Principal Risks

Risk Owner

Risk Statu

s

RAG


Controls





Responsibility

Target Date

5.2). Gaps in future delivery model for Emergency Planning and Resilience in the NHS within Calderdale, Kirklees and Wakefield District

Risk Owner:

Judith Hooper

(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

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

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

Insufficient capacity in place within NHS CB Area Teams.

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.

MOU required prior to April 2013

Judith Hooper

Ben Fryer

Jan 13

Reasonable

Limited

LHRP Established

40




Principal Risks

Risk Owner

Risk Statu

s

RAG


Controls





Responsibility

Target Date

West Yorkshire Health Protection memorandum of understanding

Authorities.

41


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

RAG






Corrective Action

Responsibility Target

Date

6.1) Local trusts fail to achieve foundation trust status due to lack of sufficient support from commissioners

RED Mid Yorkshire Hospitals NHS Trust (MYHTMYHEFT 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 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 Nov 11. Report on

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 in circulation

Transformation Board set up with Jo Webster as RO

HEFT/PMO Ongoing

October 2012

October 2012

Outline Business case and Full business case

Reasonable

Limited

42



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

RAG






Corrective Action

Responsibility Target

Date

Risk Owner:

Ann Ballarini

Risk Manager (s)Jo Webster

Chris Dowse

Danny Alba

to work through Clinical Service Strategy options.

priorities widely circulated for action

Board updates through PO papers

Programmes of work managed by a programme office set up.

Programme Director recruited

Julia Docherty

October 2012 OBC Jan 2013

OBC Jan 2013

43



Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts

Principal Risks

Risk Owner

Risk Status

RAG




Gaps in Control or Assurance

(GIA) or (GIC)

Corrective Action

Responsibility

Target Date

6.2) Fail to deliver effective implementation of Any Qualified Provider (AQP) as set out in the guidance on 19 July 2011.


Risk Manager (s) Rachel Carter and Danny Alba

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;

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

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

1. Commissioning Development Portfolio is coordinated by the NHSCKW Programme Management Office (PMO) with the DCD as senior responsible owner;

2. Regular report to Cluster Board and CCEs;

3. Heads of contracting from each PCT comprising the Cluster as designated leads.

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.

Patient choice of AQP for relevant services being implemented as at December 2012 (wheelchair services is the only AQP with agreed national delay).

Local eCCGs supported by NHSCKW heads of contracting.

Rachel Carter, Matt England & Martin Pursey

AQP contracts now let with implementation

of service delivery underway.

Reasonable

Limited

44




Principal Risks

Risk Owner

Risk Status

RAG





(GIA) or (GIC)

Corrective Action

Responsibility

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.

45




Principal Risks

Risk Owner

Risk Statu

s

RAG


Controls




(GIA) or (GIC) Corrective Action

Responsibility

Target Date

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

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.

Reports on12/13 Operating Framework KPIs with under-performance &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

GIA

Performance roles in CCGs are relatively junior.

Support through CSS

CCG Accountable

Reasonable

External monthly scrutiny by the North of England

SHA of high level performance measures in the CKW health economy

Limited

46




Principal Risks

Risk Owner

Risk Statu

s

RAG


Controls





Responsibility

Target Date

from CCGs

Part of OD Plan and CSS Development

Officers

By end of Q4 12/13


Deliver high quality Communications and Engagement


47

Principal Risks

Risk Owner

Risk Status

RAG







7.1) Staff are not fully engaged in the reforms in line with the NHS Constitution

Risk Owner:

Gill Galdins

Risk Manager (s)

Eleanor Nossiter

Amber

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.

Consistent weekly bulletin across Cluster.

Creation of Cluster Intranet

Comms team members sit as part of the public health transition groups.

Staff awards and ‘moving on’ celebrations arranged

Workforce report to Board

Significant

(GIA)

(GIC)

No staff forum arrangement in Wakefield

Will be covered by joint Cluster forum being established

Staff survey 2011- cluster response 74%.

Reasonable

Limited

48




Principal Risks

Risk Owner

Risk Status

RAG







across the Cluster.

Internal comms co-ordinated with ABL to ensure consistency of messages – in preparation for move to WY CSU.

49



Executive Lead; Mike Potts Chief Executive Officer – Updated by Eleanor Nossiter on 07/12/2012

Principal Risks

Risk Owner

Risk Statu

s

RAG


Controls





Responsibility

Target Date

7.2) Fail to ensure constituent PCTs continue to meet their statutory responsibilities for communication and engagement

Risk Owner: Gill Galdins

Risk Manager (s)

Amber

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 (GIA)

Capacity issues in comms and engagement – insufficient staffing resource to cover all requirements of CCGs, Cluster and two transformation programmes.

Lack of clarity regarding funding and hosting for comms and engagement support for transformation programmes post-April 13.

(GIC)

Escalated to SROs to progress discussions with CSU.

Seeking temporary external support to March 2013.

Eleanor Nossiter

Jan 2013

Pre-consultation communications and engagement plan for MY programme agreed with Joint OSC

Reasonable

Limited

50



Executive Lead; Mike Potts Chief Executive Officer – Updated by Eleanor Nossiter on 07/12/2012

Principal Risks

Risk Owner

Risk Statu

s

RAG


Controls





Responsibility

Target Date

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.

51

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.

52

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

53

**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

Documents

CKWCB-13-20_Board_Assurance_Framework_January_2013