TRUST BOARD 26 MAY 2011 ANNUAL REVIEW OF BOARD COMMITTEES 2010/2011

Transcription

1 TRUST BOARD 26 MAY 2011 ANNUAL REVIEW OF BOARD COMMITTEES 2010/2011 D Summary The annual reviews of the Board s sub committees took place during April and May The Trust s standard terms of reference for committees require an annual reflection of activity undertaken and consideration of focus of attention for the next year. The annual review format has remained consistent and provides a view on the adequacy of the terms of reference, highlights key successes and achievements over the reporting period, and considers future plans and priorities of the sub committees. A summary of the reviews is provided a list of proposed changes to the terms of reference. Recommendation(s) The Board is recommended to: Receive and approve the report from the annual review of Board sub committees. Agree the revised terms of reference for the Strategic Programme Board and Finance and Investment. Note that formal proposals from the corporate governance review will be presented to the Trust Board in June. Implications for consideration Strategic implications Main Strategic Goal (description in full) Financial (funding discussed and confirmed as available Finance Department) Consultation Effective governance will be essential for the Board to stay in control of an agenda reflecting a fast changing environment Operate as a high performing organisation No direct budgetary implications arising from the paper Discussions at, and outside of, the sub committees have contributed to the reviews

2 Risk (risk reference from the trust risk register if applicable) CQC Registration Applicable Regulated Activity(s) Ensuring governance arrangements are fit for purpose as a Foundation Trust and there is a level of embeddedness All regulated activities Applicable Registration Outcome(s) Applicable Business Unit(s) Applicable Registered Location(s) (if a particular care setting please specify) Author Murray Eden, Assistant Trust Secretary All outcomes All business units All locations Presented by Frank Lusk, Director of Corporate Affairs/ Trust Secretary *Disclaimer: This report is submitted to the Trust Board for amendment or approval as appropriate. It should not be regarded or published as Trust Policy until it is formally agreed at the Board meeting, which the press and public are entitled to attend. *delete this paragraph for non-trust Board papers Page 2 of 16

3 TRUST BOARD 26 MAY 2011 ANNUAL REVIEW OF BOARD COMMITTEES 2010/11 Introduction/Background 1. The Board s sub committees undertake an annual review of their governance arrangements. Reviews are reported during April and May by way of preparation for the annual review to the Trust Board in May each year. The annual reviews have now taken place. 2. The key focus of the reviews was to look back at the scope of agenda items over the past year, check that the terms of reference were sufficiently and that was appropriate, consider key achievements/successes, and identify priorities for the forthcoming year. 3. A Health Informatics Service survey tool was used to collect date for the reviews of the Performance and Assurance Executive, Strategic Programme Board and Audit. Aim 4. To present the annual review of the work of the Board s sub committees over the last financial year. Recommendations 5. The Board is recommended to: Discussion Receive and approve the report from the annual review of Board sub committees. Agree the revised terms of reference for Strategic Programme Board and Finance and Investment. Note that formal proposals from the corporate governance review will be presented to the Trust Board in June. 6. Annex A provides a summary of the reviews for; Performance and Assurance Executive Strategic Programme Board Page 3 of 16

4 Remuneration Finance and Investment Audit Communities Rights and Inclusion 7. The revised proposed terms of reference for SPB and FIC are at Annex B. There are no proposed changes to the PAE, Remuneration, Audit and CRIC terms of reference. 8. Feedback on governance during Historic Due Diligence reviews, the Monitor review phase, and recent Strategic Health Authority Board to Board has given assurance that our governance arrangements are fit for purpose. The structure is a good platform upon which the changes can evolve. It is now opportune to consider the formulation of future corporate governance arrangements in light of the transfer of community services and the ambition to be a wellbeing Trust. The new organisation s governance arrangements must be fit for purpose in that it must; Conclusion meet all the requirements of Monitor, meet all the requirements of the Care Quality Commission, ensure the Board is focused on strategic issues and risks and assured of both organisational performance and governance, effectively monitor the delivery of CIPs in terms of both service quality and financial targets, ensure that decisions are made at the lowest feasible level equivalent to accountability, and are timely, and simplify corporate governance for line of reporting to Board. Initial discussions have been held, and will be further discussed at the Board Development session in May. 8. The Board s sub committees have effectively their delegated and responsibilities. The work undertaken during the year has moved forward the Board s agenda significantly across a wide range of activity. 9. Whilst the governance arrangements have been shown through external scrutiny to be, the governance review now underway gives the opportunity to strengthen the arrangements further. Annexes: A. Summary of outputs from annual reviews B. Proposed Terms of Reference change (SBP and FIC) Page 4 of 16

5 PAE = Performance and Assurance Executive SPB = Strategic Programme Board Rem Comm = Remuneration FIC = Finance and Investment Audit Comm = Audit CRIC = Communities Rights and Inclusion Summary of outputs from annual reviews Annex A PAE Yes review of agenda items, cross referenced to the terms of reference, demonstrated that there was broad coverage of the. This is supported by the result of the PAE evaluation survey One request from the evaluation survey was for improved clarification of the role of quality reviews of CIPs and business planning proposals. No changes are recommended. The now includes a senior allied health professional, Jane Parr, Speech and Language Therapist. Attendance of the group has generally been of their The Chairs of the Senior Clinical Group and Senior Operational Group report on any priorities or concerns to each PAE meeting. Improved interface between FIC & PAE for timing of reviews Reviewing & supporting progress on Health for All Report Action Plan lead on challenging and moving forward approach to improving the staff experience, and staff survey outcomes Monitoring progress on the LD The Annual Workplan continues to evolve to reflect the need for assurances from the reporting sub-groups, keeping a control on risk, and the ongoing development of interfaces FIC and Audit Developing the IQPR (and then locking-down) to ensure overview and quality of information has improved assurance level Taking the lead on quality debate eg quality strategy, quality accounts, Monitor s Quality Governance Framework etc Ensuring a vibrant Board Assurance Framework, and comprehensive 5

6 SPB Yes a review of agenda items, cross referenced to the terms of reference, demonstrated Please see key priorities and focus for next year, 2011/ Amend monthly to at least quarterly remove ref to World Class The includes excellent senior clinical representation. External partner is of their N/A Health Homes project to a successful conclusion by the end of December 2010 Deep dives on areas of specific concern in the performance report eg HoNOS target Development of the Integrated Quality and Performance Report. Excellent senior clinical & Exec team representation has been seen SPB has more of its objectives than in. The Annual Workplan continues to evolve to lead and reflect ongoing organisation and effective corporate risk register. Improving assurance to Trust Board on quality impact of CIPs Focus on key action plans/ programmes of high risk to the Trust are scrutinised regularly for assurance Developing further the alignment of work FIC and Audit committee Improved arrangements for preparation time for authors of presentations and papers. Moving to quarterly meetings will be of 6

7 that there was broad coverage of the. This is supported by the results of the SPB evaluation survey. Commissioning 11.6 Amend Our NHS Our programme to local and regional QIPP programmes. dependent upon the relevance of the agenda but the positive Leicester City Council rate has been encouraging. of their 09/10. All strategies other than Board owned or Finance/ Investments are seen at SPB for review and ratification. Keeps Vision alive and aligned to developments Now established itself as the prime forum for strategic developments, and review of high level programmes development, whilst covering the scope of the s. assistance in this regard. More strategic focus and reduced receiving of operational reports. Post TCS a refocus upon new priorities and opportunities arising from the transfer and integration of Community Provider Arm services. Being more proactive in calling for papers, and initiating reviews. Improved alignment of the work of SPB to other governance committees Improved 7

8 of their communications generally to the wider organisation Improving clarification of next steps arising from strategic discussions Rem Comm Yes No - key changes were made at the last review. Yes. However, the terms of reference state at 2.2; the committee shall not include the Chairman of the Trust Board. Therefore, until a substantive Chairman is appointed, from 1 April 2011 the Acting N/A N/A Benchmarking & review of Exec & NED remuneration. Prepare and agree proposals for an Exec performance and remuneration framework. See future plans 8

9 FIC Yes Add para Review the development and delivery of the Cost Chairman should not continue be a member. of their Yes Yes Robust review of LTFM and Financial Strategy, and financial downside planning Review Exec Directors contractual terms and revised contracts of employment to align FT requirements. Prepare and agree Rem Comm terms of reference as an FT. In the FIC Outline Annual Work plan for 2011/12 Ensure delivery of the comprehensive savings programme in a 9

10 Improvement Programme, in conjunction the Performance and Assurance Executive to ensure financial deliverability, and that clinical safety is not compromised Add 13.2 The shall agree an annual work programme for approval at the start of each financial year. Plus other various minor changes. of their at regular intervals to support Board s understanding and provide assurance on assumptions used in the model. Strengthened financial reporting, in particular on capital (creditors, debtors and cash) which is now embedded in routine reporting; and on financial risk reporting Focus on headcount monitoring in line annual plan Stronger focus on Cost improvement Programme monitoring, and the link between Quality and clinically safe manner Ensure strong financial assurance processes are in place and management of financial risk in new integrated organisation Development of a new LTFM and updated financial strategy for the integrated organisation, for reactivation of FT application in 2011/12 Greater focus on proactive capital management Proactive management of capital 10

11 Audit Yes Decision taken, after risk Very of their N/A Finance assurance between FIC and PAE Regular quarterly review of capital programme, linked to development of the Strategic outline case Greater insight and challenge to the Quality assurance programme and realisation of asset sales to facilitate delivery of 2012 vision for Inpatient centres of excellence Development of SLR and improved costing in preparation for PBR in line PID approved in 2010/11, leading to greater devolution of budgetary control. Development of Investment Strategy to support the Treasury Management Policy. Gaining enhanced 11

12 analysis of timings and workplan impact, to revert the frequency of meetings back to 6 meetings a year. Executive team representation has continued to augment the regular by MD of Finance, Director of Corporate Affairs, and Director of Quality, Performance and Planning. of their scope and quality of work of other senior governance committees, particularly clinical. Robust reviews for assurances on a number of issues eg financial waivers process, external consultancy costs, and PAYE issues. Improving understanding of topics of importance such as the EMIAS hosting and consortium arrangements. Sustained reduction in outstanding issues from Internal Audit reports, ensuring reporting back on and clinical audit, focus on patient care and experience, will become more significant in the work of corporate governance and hence attention for the audit committee. assurances that the corporate governance is appropriately particular focus on the assurance to the Board of the selfcertifications Seeking assurances that approved policies and systems are being used consistently in the expanded Wellbeing Trust through appropriate reviews Develop strengthened links to PAE for assurances around the corporate risks 12

13 of their planned work essentially completed in the annual reporting cycle, and pursuing robustly the assurances for improvements arising from Limited Assurance reports. and Quality Risk Profile assessment by the Care Quality Commission. Seeking improved assurance of robust clinical governance, clinical audit and its links to treatment of risks and taking forward lessons learned in reviews. Commissioning appropriate training for committee members and wider committee attendees/ support staff around the Monitor 13

14 of their assurances in the Compliance Framework and Audit Code, and our risk management approach. CRIC No gaps have been identified Recommendation for new members to join the committee. Attendance has markedly improved from the previous year but needs to improve for HR and Adult business unit The subgroups have been reviewed resulting in the Patient and Public Involvement Steering Group being suspended pending review. CRIC has overseen the development of the Trust s social enterprise support resulting in four active social enterprise programmes CRIC is overseeing 3 new programmes; mienterprise, The Focus Project, Whittick Community Café Project Approved the social enterprise Following the integration of community services into LPT from April this year CRIC is taking on representati ves of the two new Business Units for City and County. Over the Contribution to the strategic review of the Trust, in particular how communities, rights and inclusion will be embedded as core values and principles. Continuing to oversee the development of the social enterprise strategy and in particular support for new and emerging enterprises that fit 14

15 of their strategy Overseen the development of the LLR Integrated Equality and Human Rights Service Overseen the development of the enhanced patient experience programme next three months CRIC will be participating in the review of strategy and plans for the Trust and will need to revisit the work plan in accordance this. the Trust s strategic objectives. Continuing to oversee the development of the patient experience programme and the roll out across Business Units. Ensuring the Trust Board is able to fulfill its respect to equality and human rights and in particular leadership of the integrated equality and human rights service as it moves towards being commissioned by GP Consortia. Continuing to improve at meetings including 15

16 of their closer monitoring and reporting of to lead Directors. Improving CRIC identification, assessment and monitoring of risk across its core. 16