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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 MAY 2012 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 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

Risk Status RAG Amber

Key Controls 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

Assurances on Controls

Key Positive Assurance (**External / Independent)

Transition report to Board

Significant

Quality reports to CCEs and Quality Boards Audit and Governance Group report through CCE Governance Committee oversight of quality reporting

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

Corrective Action

Responsibility Target Date

(GIC)

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

Reasonable

CCGs initial SHA rating Internal audit of governance arrangements

Limited

CCG authorisation process Participation in Board to Board reviews.

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13

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 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

Risk Status RAG Amber

Key Controls 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

Assurances on Controls

Key Positive Assurance (**External / Independent)

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

Significant

CQC Inspection reports Safeguarding reports CQC – Quarterly risk profiles

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

Corrective Action

Responsibility Target Date

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

Reasonable

Quality governance arrangements in place Board Governance committee CCEs/Quality Groups Contract Quality Boards

Limited

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13

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 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

RRisk Status RAG Amber

Key Controls

Assurances on Controls

Incident management system in place.

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

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

Board Quality reports Annual review and self assessment of governance arrangements

Key Positive Assurance (**External / Independent) Significant

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

Corrective Action

Responsibility Target Date

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

CQC Inspection reports (GIA)

Reasonable

Internal audit and risk management report - Calderdale

CCG Leadership in place

Limited

Annual work plan for key safety priorities

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 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 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

Risk Status RAG Amber

Key Controls Quality CCG leadership identified

Assurances on Controls

Key Positive Assurance (**External / Independent)

Regular reports to CCE on implementation of OD plan including Quality developments

Significant

Delegation for responsibility for Quality CCG (PCT) via CCE Terms of Reference

CCG Self assessment completed and participation in Board to Board reviews

Internal audit plan includes Quality Plan

Quality Group established for each CCG

Transition report to Board

OD plan in place for each CCG ; which incorporates three domains of Quality

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

Corrective Action

Responsibility Target Date

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

Reasonable

GP leadership on Quality Boards

Limited

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 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 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

Risk Status RAG Amber

Key Controls 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.

Assurances on Controls

Key Positive Assurance (**External / Independent) Significant

Quality reporting to CCEs including key performance indicators and escalation

Corrective Action

Responsibility Target Date

(GIC) Key control are not yet fully embedded across CCGs

Board Quality report Internal audit review of governance arrangements

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

(GIA) Internal audit best practice guidance is not yet fully implemented. Reasonable

Dr Foster reports

Scrutiny review through Clinical Quality Boards

Limited Internal audit report Calderdale & Kirklees

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 2 Strategic Objective

Board Reports

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

Risk Status RAG Red

Key Controls

Assurances on Controls

Financial budgets, QIPP, activity and other key targets agreed for each PCT by the Board for 2012/13.

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

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.

Key Positive Assurance (**External / Independent) Significant

Gaps in Control (GIC) and/or Gaps in Assurance (GIA) GIC MYHT is reporting a deficit after taking into account Cluster support of £10M for 2012.13 including their internal savings programme of £24M of which only 60% identified to date (April 12).

Reasonable

Cluster Boards and CCG’s receive regular financial reports on MYHT

Annual audit of accounts

The financial results for the year are subject to review and by the External Auditors who report back to the Audit Committee.

Limited

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

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.

Corrective Action The Cluster Chief Executive and 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

Responsibility Target Date

Cluster DoF End Q1 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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 2 Strategic Objective

Board Reports

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

Risk Status RAG Amber

Key Controls 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

Assurances on Controls

Key Positive Assurance (**External / Independent)

Finance report to the Board

Significant

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.

Gaps in Control (GIC) and/or Gaps in Assurance (GIA) Not fully implemented. GIC No chief finance officer for Wakefield

Reasonable

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

Corrective Action 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’s and Finance and Performance groups where performance detailed reports are reviewed, under performance

Responsibility Target Date

End July 12

identified and then followed up. Monthly CCE’s and Finance and Performance groups

Internal Audit reviews will be reported to the Audit Committee/s CCG authorisation process Self Assessment Board to Boards

Limited

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

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.

Accountable Officers have been assigned in three of the four proposed CCGs Calderdale, Greater Huddersfield and Wakefield, the gap being in North Kirklees which is being addressed. Finance leads have been assigned, one person covering both Calderdale and Greater Huddersfield and one person covering North Kirklees. This leaves a gap in Wakefield.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 2 Strategic Objective

Board Reports

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

Risk Status RAG Amber

Key Controls

Assurances on Controls

Key Positive Assurance (**External / Independent)

3 Year QIPP plan has been submitted to SHA.

PCT QIPP Plans in place to 2014/15

Significant

Annual Operating Plans for 2012/13 included the QIPP plans – these were reviewed and agreed by the PCT Boards

Monthly finance reports detail main schemes and performance against these.

QIPP plans relating to healthcare contracts are built into annual SLA’s.

Monthly SMT and Finance and Performance Group Monitoring of QIPP schemes.

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

Quarterly DH/SHA monitoring. Board reporting CCE reporting

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

Corrective Action Performance has been reviewed Underachievement has been offset by allocation of contingency funding.

Responsibility Target Date CFO’s End of May 12

Original plans for 2012/13 need to be refreshed in light of experience during 2011/12

Reasonable 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

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 3 Strategic Objective

Board Reports

Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 3.1) Major transformational programmes are not delivered across the commissioning economy.

Risk Status RAG Amber

Key Controls CHFT Programme Office being established with key performance indicator agreed and monitored for elements of the programme for Calderdale and Huddersfield Whole system Transformation Board.

Assurances on Controls

CHFT Supported By National Team for LTCS

Risk Manager (s) Carol McKenna Matt Walsh Risk Owner: Mike Potts Risk Manager(s): Jo Webster

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

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

Mid Yorks HEFT Programme set up overseen by Programme Management Office, lead by Programme Director

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.

MY HEFT PMO review of relevant 12/13 QIPP schemes.

Report on CCGs’ commissioning intentions provided to MYHT and Cluster senior team.

MY HEFT PMO survey of CCGs’ potential commissioning intentions

Whole System Transformation event and report on priorities widely circulated for action

Review of MYHT CIPs by Ernst Young

Regular meetings between CCG GPs and MYHT clinicians to work through Clinical Service Strategy options.

Analysis of outputs from above two activities by PMO

Significant

Garland review of MYHT

Clinical leadership at CCG fully committed Risk Owner: Mike Potts

Key Positive Assurance (**External / Independent)

Tri partite Formal Agreement MYHT

Reasonable

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

Responsibility Target Date

Ongoing Transformation workshops across whole health economy to agree shared vision. Ongoing Clinical commissioning Groups priorities aligned with whole health economy strategy. Priorities agreed with Health and Well Being Boards x 3

End of July 12

High level risk register required for CHFT

Limited (GIC) (GIA) MYHEFT high level risk register No CHFT RR

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.

Corrective Action

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 3 Strategic Objective

Board Reports

Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 3.2) Safe and secure transfer of responsibilities from PCTs to new organisations does not occur

Risk Status RAG Amber

Key Controls 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

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

Standing agenda item on Board committees regarding items for inclusion in legacy documents.

Assurances on Controls

Key Positive Assurance (**External / Independent) Significant

Scrutiny & oversight by Governance Committee Audit Committee

Audit Committee Scrutiny & oversight re close down of board committees.

Corrective Action

Responsibility Target Date

(GIC) (GIA) Quarterly quality reviews at an early stage

Management oversight by executive team Performance management quarterly by North of Englnad SHA

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

Reasonable

Internal review of legacy reports from SHA - satisfactory

Limited

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 3 Strategic Objective

Board Reports

Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 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

Risk Status RAG Amber

Key Controls

Assurances on Controls

Existing transition plans for the approach to the transfer of Public health functions to the Local Authority Have been agreed with cluster board and local authorities and submitted to the SHA and agreed.

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

Directors of Public Health (3) joint transition groups with each Local Authority (Calderdale, Kirklees and Wakefield district) continue to oversee the transition.

Key Positive Assurance (**External / Independent)

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

Corrective Action

Responsibility Target Date

Significant GIA Letter from SHA agreeing each PCT’s individual plan APL 12

Some elements of national guidance still awaited.

Board report re implementation of plan

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

DPHs 31st October 2012

Reasonable

Shadow working arrangements in local authority by no later than 31st October 2012.

Limited

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 3 Strategic Objective

Board Reports

Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 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

Risk Status RAG Amber

Key Controls

Assurances on Controls

Health Economy Risk Assessment Process annually

LDA Schedule 3 documents.

Programme of workforce assurance meetings in place with key Providers

Workforce integration of Board performance reports bi-monthly.

Training Needs analysis undertaken. 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.

Board Performance reports includes Staff in Post against trajectory plus turnover plus sickness absence.

Key Positive Assurance (**External / Independent) Significant

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

Corrective Action

Responsibility Target Date

(GIC)

SHA reviews of Schedule 3

People transition policies to be adopted.

Implementation of OLM to ensure Cluster Mandatory Training take-up.

(GIA) Training plan to be approved

CQC registration.

Reasonable

National staff survey results and actions plans report to Board and CCE Training Plan including mandatory training approved at Cluster Leadership Team (Aug 2011)

Limited

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 3 Strategic Objective

Board Reports

Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 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 Status RAG Amber

Key Controls 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 Transition Sub Group across CKW and ABL as sub group of existing partnership arrangements

Risk Owner: June Goodson-Moore

Staff health and resilience initiatives in place.

Risk Manager (s) Laura Smith Susan Maloney

Monitor internal staff sickness levels and manage, in keeping with policy. Actions from industrial action been implemented Business critical roles identified.

Assurances on Controls

Key Positive Assurance (**External / Independent)

Cluster workforce scorecard reports. Board Performance Reports. Staff survey results and action plans to Board and CCE. Staff Forum in place – Calderdale.

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

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

Corrective Action

Responsibility Target Date

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

Feedback timetable via Regional Social Partnership Forum

June GoodsonMoore

Reasonable

IIP Group, Kirklees. Employee relations and staff participation forums in place (Staff side meeting)

Limited

Workforce reports to individual SMTs as well as to Board

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 3 Strategic Objective

Board Reports

Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 3.6) Cluster Governance arrangements are not fully embedded therefore decisions may be made without due authority.

Risk Owner: Sue Cannon

Risk Status RAG Amber

Key Controls Shared operating for CKW PCT Clusters model implemented (September 2011 Boards) SOS/SFIs reviewed and approved for the Cluster (March 2012 Board)

Key Positive Assurance (**External / Independent)

Board to CCG Board

Significant

CCG Authorisation process

Scheme of Delegation approved (November 2011Board)

Internal Audit review of governance arrangements (February 2012)

Terms of Reference in place for Committees and Sub Groups.

Governance report to Board

All CKW staff communications on SOS/SFIs

Committee minutes to Board

CCG OD plan includes Governance

Policy on policies approved by Governance Committee (December 2011)

External and internal Audit completed training on governance for CCGs. Julie Lawreniuk Carol McKenna Gill Galdins

Assurances on Controls

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

Corrective Action

Responsibility Target Date

GIC Not all CCGs have fully implemented Governance arrangements

SHA – CCG Risk Ratings Internal Audit review of governance significant assurance

GIA

Reasonable

Limited

Communication Plan fully implemented

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 3 Strategic Objective

Board Reports

Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 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

Risk Status RAG Amber

Key Controls 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

Assurances on Controls

Key Positive Assurance (**External / Independent)

Baseline and improvement plan considered by CET and to be on Governance agenda

Significant

Corrective Action

Responsibility Target Date

GIA Recommendations from Internal Audit regarding records management. Expected by end of Q1 12/13

Governance Committee report February 2012 External: Annual review by Internal Audit

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

Implement records management audit action plan across the cluster.

Risk Owner: Q2 12/13

Share Risk Manager with ABL and/or acquire additional capacity via THIS contract

Risk Owner: Q1 12/13

GIC Reasonable

Imminent departure of 2 Risk Managers

Calderdale – Emergency Planning business continuity test included information governance Cluster IG toolkit score

Limited Internal Audit Report re records management received December 2011

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 4 Strategic Objective

Board Reports

Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Principal Risks Risk Owner 4.1) Clinical Commissioning Groups fail to achieve authorisation due to ineffective support from PCTs.

Risk Owner: Ann Ballarini Risk Manager (s) Danny Alba

Risk Status RAG Amber

Key Controls 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

Assurances on Controls

Key Positive Assurance (**External / Independent)

Board to Board Reviews

Significant

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

Gaps in Control (GIC) and/or Gaps in Assurance (GIA) 2 practices currently not allocated to an eCCG. Discussion ongoing to finalise arrangements With existing eCCG.

Corrective Action

Responsibility Target Date

Support provided through COO to reach a conclusion to this and offered from the Cluster leads

Delay in the alignment of staff to eCCGs

Reasonable Potential weak areas in the assessment against the 6 areas for authorisation

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.

Delivery of a plan to address areas of underachievement will be developed when the national assessment criteria is issued.

eCCGs when appropriate

Limited

Collation of evidence demonstrating compliance with 6 domains

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 4 Strategic Objective

Board Reports

Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Principal Risks Risk Owner 4.2) New commissioning support offer does not deliver requirements of eCCGs

Risk Owner: Ann Ballarini Risk Manager (s) Rachel Spilsbury

Risk Status RAG Amber

Key Controls 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. Monthly CSO Programme Board meetings with supporting task and finish groups Business Plan submitted and discussed with SHA

Assurances on Controls

Key Positive Assurance (**External / Independent) Significant

Monthly and quarterly reports to SHA Board reports on progress and providing assurances against the key milestones for the development of the Prospectus, business plan and service level agreements

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

Corrective Action

Responsibility Target Date Programme Board April 2013

Reasonable

SHA monitoring

Limited

Consultation underway on high level structure for CSS

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 4 Strategic Objective

Board Reports

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

Risk Status RAG Amber

Key Controls 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.

Assurances on Controls

Key Positive Assurance (**External / Independent)

Monthly and quarterly returns

Significant

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

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

Corrective Action

Responsibility Target Date

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

Agenda of monthly DCD meeting with SHA Reasonable

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.

Limited

Gateway for documents relating to this area provided by the SHA so that all relevant transition communications go directly to the DCD.

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 5. Strategic Objective

Board Reports

Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Judith Hooper Executive Director of Public Health Kirklees Principal Risks Risk Owner 5.1a) Reduced capacity in PCT emergency preparedness teams leads to lack of preparedness for emergencies. Risk Owner: Judith Hooper 5.1b) Reduced directorlevel capacity reduces ability of NHS to coordinate the healthcare response to an incident Risk Owner: 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)

Risk Status RAG Amber

Key Controls

Assurances on Controls

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.

Plans, Rotas and training records are maintained for all relevant systems.

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

Key Positive Assurance (**External / Independent) Significant

Gaps in Control (GIC) and/or Gaps in Assurance (GIA) No current gaps in assurance.- risks on RR Wakefield score 12 Kirklees and Calderdale score 6

Corrective Action N/A

Responsibility Target Date N/A

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)

Reasonable

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

Limited

Exercise Vespa Exercise Agora SHA assurance December 2011 return

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 5. Strategic Objective

Board Reports

Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Judith Hooper Executive Director of Public Health Kirklees Principal Risks Risk Owner 5.2). Lack of clarity regarding future delivery model for Emergency Planning and Resilience in the NHS within Calderdale, Kirklees and Wakefield District Risk Owner: Judith Hooper (Ben Fryer)

Risk Status RAG Amber

Key Controls 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

Assurances on Controls

Key Positive Assurance (**External / Independent)

Bimonthly West Yorkshire Resilience Forum Health Subgroup meetings

Significant

Continued regular attendance at all meetings PCT emergency preparedness committees

Gaps in Control (GIC) and/or Gaps in Assurance (GIA) GIA - Lack of clarity on roles and responsibilities from DH .- risks on RR Wakefield score 12 Kirklees and Calderdale score 6

Corrective Action

Responsibility Target Date

Awaiting guidance from DH

Reasonable

Updates provided for NHS partners at LRF meetings

Series of workshops on Health protection and Emergency Planning

Limited

West Yorkshire Health Protection memorandum of understanding West Yorkshire Emergency Preparedness CSO specification

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 6. Strategic Objective

Board Reports

Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts Principal Risks Risk Owner 6.1) Local trusts fail to achieve foundation trust status due to lack of sufficient support from commissioners

Risk Owner: Ann Ballarini

Risk Manager (s) Rachel Carter Chris Dowse

Risk Status RAG RED

Key Controls Mid Yorkshire Hospitals NHS Trust (MYHT) MYHEFT programme set up with a plan and 4 key work streams. Structures are in place to support the transactional aspects of the FT application process. Governance is provided through the MYHEFT Board which meets every two months and the smaller executive group which meets every fortnight, led by a Programme Director. Regular high level meetings between MYHT, CKW Cluster and SHA to agree financial recovery plan. Regular meetings between CCG GPs and MYHT clinicians 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

Assurances on Controls

Key Positive Assurance (**External / Independent)

Minutes of meetings

Significant

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

Board papers QIPP outcome report sent to HEFT Executive group, Cluster CE, Cluster DoF, Wakefield District and Kirklees COOs, MYHT DoF and Dir Strategy Dec 2011 for action.

Corrective Action System wide review to create opportunities to improve financial resilience

Responsibility Target Date HEFT/PMO Ongoing

Regular updates on financial plans on aspirant FT MYHT HEFT high level risk register Reasonable

Report on CCGs’ commissioning intentions provided to MYHT and Cluster senior team.

Risk register in circulation Continued discussion between MYHT, CKW cluster and SHA

Limited

Whole System Transformation event held Nov 11. Report on priorities widely circulated for action Board updates through PO papers

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 6. Strategic Objective

Board Reports

Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts Principal Risks Risk Owner 6.2) Fail to deliver effective implementation of Any Qualified Provider (AQP) as set out in the guidance on 19 July 2011.

Risk Status RAG Amber

Key Controls

Assurances on Controls

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;

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

Risk Owner: Ann Ballarini

2. Project delivery trajectories for Phase 1 AQP implementation and Phase 2 AQP implementation;

Risk Manager (s) Rachel Carter and Danny Alba

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

Regular report to Cluster Board and CCEs

Key Positive Assurance (**External / Independent) Significant

Gaps in Control or Assurance (GIA) or (GIC) GIA) None identified (GIC) DH policy changes / directives that may influence phase 2 list of services suitable for AQP procurement not yet available.

Reasonable

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;

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.

Responsibility Target Date Local eCCGs supported by NHSCKW heads of contracting.

Limited

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.

Corrective Action

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 6. Strategic Objective

Board Reports

Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts Principal Risks Risk Owner 6.3) Insufficient oversight of the ‘NHS organisation failure regime’ within the cluster geographical area of responsibility.

Risk Owner: Peter Flynn Risk Manager (s): Louise Auger

Risk Status RAG Amber

Key Controls 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.

Assurances on Controls 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

Key Positive Assurance (**External / Independent) Significant

Gaps in Control or Assurance (GIA) or (GIC) GIC Level of knowledge of eCCGs during transition as future leads for this area

Reasonable

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

Corrective Action

Responsibility Target Date

Development of dialogue at CCE level

Risk Owner: Q1 2012/13

CCG level reporting to CCEs and to Cluster Board

CCG Accountable Officers

Support through CSS

When launched

Part of OD Plan and CSS Development

Limited

Performance reporting to Cluster Board at Cluster level and from CCEs Key Staff assigned to senior CCG roles

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 7. Strategic Objective

Board Reports

Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 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

Risk Status RAG Amber

Key Controls

Assurances on Controls

Comms and engagement strategy and action group.

Workforce report to Board

Monthly internal staff briefing. Consistent weekly bulletin across Cluster.

Staff survey results report to Board

Key Positive Assurance (**External / Independent) Significant

Corrective Action

Responsibility Target Date

(GIA) (GIC)

Staff survey - cluster response 74%.

Staff survey uptake and action plans. Communication and engagement staff in place in all PCTs.

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

No staff forum arrangement in Wakefield

Will be covered by joint Cluster forum being established

Reasonable

Creation of Cluster Intranet Communication and engagement plan 2011-2012 in place Cluster forum being established, which will incorporate Calderdale staff forum and Kirklees IIP Group.

Limited

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 Board Reports

7. Strategic Objective Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer Principal Risks Risk Owner 7.2) Fail to ensure constituent PCTs continue to meet their statutory responsibilities for communication and engagement

Risk Status RAG Amber

Key Controls 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

Assurances on Controls

Key Positive Assurance (**External / Independent)

Weekly monitoring conference calls with Mid Yorkshire & SHA Communications and Engagement is standing item on agenda of the two transformation boards

Significant

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

Responsibility Target Date

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

PPI and engagement reports to SHA

Corrective Action

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

Eleanor Nossiter July 2012

(GIC)

Reasonable

Communications and Engagement development sessions for CCGs Risk Owner: June Goodson-Moore Risk Manager (s) Eleanor Nossiter

Work Plan Governance Committee Terms of Reference

Limited

PPI Engagement annual reports sign off by Board and CCE.

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 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.

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.

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NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13 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

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.

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