Governance Manual supporting quality at the front line

Transcription

1 Governance Manual supporting quality at the front line Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and, as such, may not necessarily contain the latest updates and amendments. 1

2 Contents 1. INTRODUCTION GOVERNANCE AND THE PURPOSE OF THIS MANUAL RISK MANAGEMENT INCIDENTS GOVERNANCE COMMITTEES / GROUPS LOCAL GOVERNANCE STRUCTURE ASSURANCE ABOUT GOVERNANCE FROM EVIDENCE EFFECTIVE COMMITTEES GOVERNANCE MANUAL ADMINISTRATION / DOCUMENT CONTROL APPENDICES Appendix 1 Definitions Appendix 2 Arrangements for risk management and corporate governance V Appendix 3 Committee / Group Assurance, Escalation and Delegation Processes Appendix 4 Committee / Group Annual Evaluation Procedure (V4) Appendix 5 Committee / Group Administration Protocol (v9) Appendix 6 Report Cover Sheet (v7) Appendix 7 Template Meeting Record (Minute) Appendix 8 Template Meeting Outcome Summary Appendix 9 Template Action Plan Appendix 10 Template Meeting Agenda

3 1. INTRODUCTION GOVERNANCE AND THE PURPOSE OF THIS MANUAL What is Governance? The primary purpose of the NHS, and everyone working within it, is to provide a high quality service, free at the point of delivery to everyone who needs it. This common goal unites all those working in the NHS, from hospital doctors, to nurses, to GPs, to dentists, to allied health professionals, to clinical managers and non clinical staff. The Trust use the definition of quality set out by Lord Darzi in 2008 which stated that care provided by the NHS will be of a high quality if it is: Safe; Effective; With positive Patient Experience. Quality care is not achieved by focusing on one or two aspects of this definition; high quality care encompasses all three aspects with equal importance being placed on each. This is not an easy task; quality is a moving target. Continuous improvement in quality means that what is considered of an acceptable quality today may not be acceptable this time next year. Well publicised failures in quality are testament to the complexities associated with a service as large and multifaceted as the NHS working to ensure that all care, every day, for every person, is of a high quality. In order to improve the quality of care we provide, it is important for governance arrangements are in place to support the delivery. Governance is about how our Trust is managed and how decisions are made. In particular governance focuses on: Organisation how decisions are made by our Trust Board, its committees and the Governors Council; Management the roles and responsibilities established to manage our services and to help our Trust achieve its objectives; Policies providing our staff with guidelines to help them when making decisions while carrying out their roles Effective governance is fundamental to the success of the Trust. The autonomy that the Trust enjoys, its public service purpose and the fact that it is entrusted with public funds, demand that the Board of Directors, Governors Council and all employees operate according to the highest standards of governance. With good governance processes in place we can assure the public we serve that our Trust is operating efficiently and safely. At the same time, it helps us deliver our core vision for people in our communities to live happier, healthier and more hopeful lives and achieve our goals to: 1. Consistently deliver the highest quality of services we can. 2. Ensure we are using the full potential and talent of our staff, patients, carers and families. 3. Transform and improve our services. 3

4 Purpose of the Manual The manual aims to describe how governance works within the Trust and sets out details of the systems, processes and structures in place which support staff to deliver effective governance. The manual is a summary and does not detail every aspect of the governance framework, but will provide signposting to the suite of related Trust policies and procedures where the symbol on the left is used in the body of the manual. All policies are available on the Trust Website at This manual is not intended to be restrictive every member of staff within the Trust is encouraged to consider and expand on the basic principles to ensure governance at all levels is coherent and effective. The manual starts by describing governance and the benefits of effective governance and goes on to: Provide an overview of the key responsibilities of all staff members to highlight risks to quality and safety; Describe how risks, concerns and issues should be escalated once they are identified; and Clarify the roles of various committees and groups in identifying and mitigating risks to quality and safety. Assisting and enabling all employees to understand the pillar of good governance, described above, is essential in the provision of high quality care whilst meeting the challenges facing the Trust now, and in the future. A glossary of definitions has been provided at Appendix 1 to help clarify any terms which may be unclear. Benefits of effective governance Robust governance arrangements are essential in every NHS organisation. They ensure that service users and carers receive quality, safe services. They provides peace of mind to patients, clinicians, managers, governors and the Board that the organisation is running efficiently and effectively, and essential standards of quality and safety are being met. The benefits of effective governance can be summarised as: providing clear escalation routes for frontline staff to report risks and concerns, and therefore improve quality at the front line; providing clarity about what decisions have been made, by whom, when and why; and providing clarity about levels of authority to make decisions If all of these elements work as they should service users, carers and other family members will experience high quality, safe and effective care in a timely manner. 4

5 2 RISK MANAGEMENT Risk or issue? When considering risk management it is helpful to understand the difference between a risk and an issue. In basic terms: Risks MAY occur and you can put controls in place to stop it happening Issues HAVE occurred and can't be stopped so decisions must be made Individual responsibilities and reporting routes The organisation is fully signed up to the importance of effective risk management as a fundamental part of our governance framework and system of internal control. A detailed overview of risk management procedures is documented in the Risk Management Policy which covers initial identification, assessment and scoring of risks, assigning ownership, taking action to mitigate or anticipate them, and monitoring and reviewing progress. Responsibility for the identification, assessment of risks, issues or concerns rests with staff at all levels across the Trust, as well as at the various Committees and Groups. Steps that you can take to help the Trust manage risks are summarised below: Risk identification and assessment All personnel are encouraged to highlight concerns and issues with line managers through normal communication channels. This may result in the need to complete a formal risk assessment. A formal risk assessment will enable more detailed consideration of the following three elements which form the Risk Description : Risk Description Consideration should now be given to how likely the risk is to materialise. A scoring system is in place which combines the likelihood of a risk materialising with the potential impact it would cause. This results in a Risk Score. Risk Escalation The assessed risk score is used to determine the level at which the risk needs to be managed and monitored. Depending on the risk score and the options 5

6 available to minimise the risk, individual risks will be recorded on either a local or corporate risk register Where a risk score indicates the risk equals or exceeds local management threshold of 15 the risk will be escalated for inclusion on the corporate risk register. The following examples are provided to illustrate risk management and escalation: 1. Risk assessed, managed and resolved at local level A routine review of staff establishment and skill mix reveals a number of staff are approaching retirement age. The expected retirement of the staff members creates a risk service provision may be compromised due to insufficient staff with relevant skills available within the team. Assessment of the risk enables the identification of appropriate recruitment actions required to mitigate the risk (risk profile score below 15). Implementation of the actions, within an acceptable timescale, is within the authority of local management. Therefore the risk to service provision can be managed at a local level. 2. Risk escalated in order to seek urgent resolution: The condition of a Trust location has deteriorated and when coupled with the poor layout of the building creates a significant risk to patient, staff and visitor safety. Unless urgent action is taken injuries may be sustained and Care Quality Commission registration is likely to be compromised. The risk is assessed as significant (high risk profile score) and cannot be managed at a local level. Therefore, the risk is escalated urgently through the governance structure and entered on to the corporate risk register. Specific committee/group responsibilities regarding risk management Once a risk has been raised and reported, there are clearly defined routes and responsibilities to enable the risk to be mitigated on a timely basis. These routes are supported by a number of committees and groups within the governance structure: Initial responsibility for monitoring and managing risks that do not meet the criteria for escalation to the corporate risk register rests with individual service managers supported by local governance structures. In addition service managers are responsible for facilitating the provision of feedback to individuals identifying and assessing risks. 6

7 Care Group Leadership Teams / Clinical Governance Team are responsible for maintaining a systematic awareness of themes in order to eliminate, reduce and manage risks. This is achieved through effective use of divisional risk registers supported by accurate performance data. Review of divisional risk registers takes place at individual Care Group clinical governance group meetings with resulting issues escalated to the Trust Management Group or Clinical Governance Group as appropriate, based on the subject, for further consideration. The Clinical Governance Group acts as a focus for constructive challenge and improvement for all issues relating to the quality of clinical care offered by the Trust including consideration of clinical risk. The Trust Management Group (TMG) is responsible for obtaining assurance risk management arrangements, including the maintenance of risk registers, are effective and within Care Groups and support services. The TMG is also responsible for oversight of the mitigating actions, and will implement alternative actions if original steps have not successfully addressed the risk. The Audit Committee is responsible for maintaining oversight of the risk management process, and gaining assurance that these are being followed and remain robust and effective. The work of the Audit Committee therefore ensures local governance structures and TMG are held to account for their actions. The Board of Directors regularly consider strategic risks which could impact on the ability of the Trust to achieve its strategic objectives. These risks, controls and associated sources of assurance are recorded and monitored on the Board Assurance Framework. The Board of Directors also routinely review the Corporate Risk Register and monitor risks with a risk profile score of 15 and above. Risk Management Summary Step 1 You identify a risk Step 2 You assess and register the risk Option A - Risk profile score less than 15 Option B Risk profile score 15 or greater Step 3A Risk is monitored and managed at a local level supported through the local governance structure. Emerging themes are reported to the TMG through local governance structure Step 3B *Risk is escalated to the corporate risk register through the local governance structure to the TMG / Executive Management Group and Trust Board of Directors *All risks, irrespective of the grading, must be managed as far as reasonably practicable within the remit and resources available to the respective manager Step 4 Service managers facilitate the provision of feedback to You on the actions taken/planned in relation to the risk identified/assessed/recorded Step 5 Service managers, local governance structure and TMG are responsible for identifying and communicating emerging themes 7

8 2.1 INCIDENTS Individual responsibilities and reporting routes Incidents, complaints and all other forms of feedback are a valuable source of intelligence and, while every effort is made to prevent activity or actions which may result in complaints or adverse incidents, it is important to ensure that we respond to and learn from those that do occur to prevent the same things from happening in future. Incident reporting also enables risks to be identified, assessed and recorded. We also need to learn when things go well and when we get compliments from service users, carers and families. The Trust has policies in place which describe how action will be taken to report, investigate, analyse and importantly act upon all occurrences; see the Risk, Fire, Health, Safety and Security policy section of the Trust intranet. As with risk management, responsibility for the reporting of incidents rests with staff at all levels across the Trust. Escalation of concerns to the appropriate level is to be undertaken through local and corporate governance structures in accordance with Trust policy and procedures. Incident reporting and investigation We are all responsible for identifying incidents and making sure they are reported quickly. If you identify an incident you should report it as soon as possible (within 72 hours) by completing an electronic incident form available through the Trust intranet. The Trust has in place a tiered system for investigations appropriate to the severity of the incident. All incidents and events graded below 15, or otherwise not categorised as a Serious Incident Requiring Investigation (SIRI), will be investigated by the manager of the service area where the incident or event occurred (seeking advice or input from the Trust s specialist advisers as appropriate). Incidents or events graded 15 or above, or categorised as a SIRI, will be investigated in a robust manner, by a nominated investigation team, using the principles of root cause analysis. Following completion of an investigation into incidents, complaints, or claims, the findings will be considered and discussed with personnel to enable improvements to be implemented and lessons to be learned. In addition, service managers are responsible for monitoring actions taken and facilitating feedback to individuals reporting incidents or raising concerns. The role of Quality and Safety Managers within the Care Group structure includes specific responsibilities for the management of incidents and complaints and developing a learning culture. Developing and maintaining a learning culture will ensure we learn from our mistakes and engage in continuous improvement at the front line. 8

9 Specific committee responsibilities regarding incident management Once an incident has been reported, there are clearly defined routes and responsibilities to investigate the cause of the incident and identify immediate corrective actions to be taken. This also covers identification of cross-organisational themes (e.g. an increase in medication errors in both Children s and Mental Health care groups) and crossorganisational learning from incidents (e.g. Identification that an incident occurring in Specialist Services has a chance of occurring in the Community Health care group, allowing preventative measures to be taken in both care groups before another incident occurs). These responsibilities are supported by a number of committees within the governance structure: Care Group Leadership Teams / Clinical Governance Team are responsible for maintaining a systematic awareness of incidents, patient experience, risks, and associated themes in order to eliminate, reduce and manage risks and promote best practice. This is achieved through effective use of incident data and the results of investigation activity, patient experience information and divisional risk registers. Leadership teams will, as appropriate based on the subject, escalate issues to the Clinical Governance Group or Trust Management Group for further consideration. The Clinical Governance Group acts as a focus for constructive challenge and improvement for all issues relating to the quality of clinical care offered by the Trust. The Trust Management Group (TMG) is responsible for ensuring adequate controls and robust action plans are in place to investigate the cause of the incident and identify immediate corrective actions to be taken or mitigate associated risks in a timely manner. The TMG is also responsible for oversight of the mitigating actions, and will facilitate the implementation of alternative actions if original steps have not successfully addressed the issue. The Quality and Safety Committee is responsible for overseeing and scrutinising the effectiveness of the Clinical Governance Group. Where appropriate the Committee will escalate to the Board of Directors themes, trends, risks from incidents including Serious Untoward Incidents and the Trust s capacity to learn lessons. The Audit Committee is responsible for maintaining oversight of the risk management process, gaining assurance that this is being followed and remains robust and effective. The work of the Audit Committee therefore ensures the relevant elements of the local governance structure and Trust Management Group are held to account for their actions. The Board of Directors routinely review the Corporate Risk Register and incident performance data. 9

10 3 GOVERNANCE COMMITTEES / GROUPS In order to provide high quality services it is important that Cumbria Partnership NHS FT operates like a well-oiled machine. This allows the organisation to quickly and effectively respond to staff concerns, complaints from service users and carers, quality and safety related issues, regulatory requirements and many other factors that impact on our ability to deliver quality services. We have a Governance Committee structure which makes this happen (each Committee/Group is supported by approved Terms of Reference. Copies of Terms of Reference can be obtained through Committee/Group administrators or by contacting the Corporate Governance team). Board of Directors Executive Management Group Chair: Chief Executive Audit Committee Chair: Non-Executive Director Quality & Safety Committee Chair: Non-Executive Director Finance Investment & Performance Committee Chair: Non-Executive Director Strategy Planning Group Chair: Chief Executive Remuneration Committee Chair: Non-Executive Director OPERATIONAL ASSURANCE SEEKING ASSURANCE SEEKING ASSURANCE SEEKING OPERATIONAL ASSURANCE SEEKING Role summary: Role summary: Role summary: Role summary: Role summary: Role summary: Set the direction of travel for the Trust through making major operational and strategic decisions not reserved to the Board; To oversee the implementation of actions in relation to significant governance issues relating to clinical, operational and strategic areas. This To seek assurances as to the adequacy and effectiveness of internal control, corporate governance, and financial and non-financial reporting arrangements to support the delivery of safe and quality services for patients. This includes oversight of external and internal audit; and functions relating to the annual statutory accounts, standing orders, standing financial To promote and seek assurance on safe and effective clinical governance in the Trust. To ensure that the Trust is compliant with relevant national standards and statutory legislation. To promote continuous improvement in patient safety, clinical effectiveness and patient experience, including the wellbeing and safety of 10 To seek assurance and oversee the performance of the trust in terms of: finance investment performance against: 1) key goals as set out in the strategic and annual plan 2) other areas as deemed necessary by the committee Where performance is not Receive and interpret planning guidance to inform the development of the Trust s strategic plans; Provide guidance and receive information from clinical and nonclinical service areas to inform the strategic and annual planning processes; Monitor the development and Agrees remuneration & terms of service for Chief Executive and Exec Directors. Provides assurance that senior remuneration below Board is appropriate

11 ensures that the Trust operates safely, effectively and efficiently and in a patient focussed way; To co-ordinate a corporate response to significant clinical care group issues; To ensure the use of appropriate risk management controls in relation to strategic risks in accordance with the Trust s Risk Management Strategy. instructions and standards of business conduct. Identified risks will be considered and escalated to the Board of Directors as required. Trust employees. To ensure that the Trust s Quality Outcomes Framework is used effectively to improve patient safety, clinical effectiveness and patient experience. Identified risks will be considered and escalated to the Board of Directors as required. to the required standard the FIP committee will require and oversee effective remedial action Identified risks will be considered and escalated to the Board of Directors as required implementation of the Trust s Strategy Plan ensuring strategic fits with the vision, values and priorities; Provide assurance to the Board of Directors that the Trust s arrangement for planning is in accordance with its stated objectives and the requirements and standards determined by regulators. 11

12 3.1 LOCAL GOVERNANCE STRUCTURE The Board of Directors and Board level Sub-Committee governance structure is supported by the following Local Governance structure: Care Groups are specifically designed to simplify and specialise our operational leadership structure. Each care group will establish individual local clinical governance groups and further develop the clinical dashboard for each service. Local clinical governance groups will report to the overarching Clinical Governance Group and/or Trust Management Group in accordance with the associated Terms of Reference. 12

13 4 ASSURANCE ABOUT GOVERNANCE FROM EVIDENCE Key to effective governance is the need to seek and gain robust assurance about the standard of care being provided and the effectiveness of processes in place to check that out. This allows the organisation to identify which areas of the Trust may require additional support to address quality concerns and to continually improve. In addition, once actions have been taken to try and improve quality, assurance must be available to show whether these actions have been effective, or if additional steps might be required. To be considered robust, it is essential that assurance is gained through the assessment and consideration of supporting evidence. For data, information and other sources of intelligence to be considered as evidence it should be factual, reliable and be capable of withstanding relevant scrutiny; for example, which of the following gives you the most confidence? I think we have resolved this quality issue because my gut feeling tells me so. I think we have resolved this quality issue because we have had a 25% reduction in related serious incidents and specific related patient experience survey responses have improved. Qualitative and quantitative data The use of qualitative and quantitative data is important when providing assurance through evidence, through the use of performance reports, clinical audit findings, dashboards, scorecards and other reporting tools. Performance data and information used throughout the Trust is subject to data quality activity in accordance with the Trust Data Quality Policy (POL/002/064). Triangulation The value of assurance, based on robust evidence, can be further enhanced through triangulation. This involves collecting and evaluating evidence relating to a similar subject or activity from a number of different sources and considering them together rather than separately. Triangulation enhances staff and committee members ability to confirm the accuracy and completeness of what they are being told. The examples below demonstrate how triangulation can be used and illustrate its value: 13

14 Triangulation Use Visiting front line staff to determine whether data in performance reports is accurate and capturing all concerns Considering findings from internal quality and safety inspections alongside papers tabled at the committee to corroborate findings Reviewing qualitative information such as comments from patient feedback and staff surveys alongside data in performance reports Identifying potential risk areas through consideration of a range of different data simultaneously (e.g. HR data on staff turnover, financial data on spend/efficiency targets, quality indicators, etc) Triangulation Value There are detailed and credible assumptions underpinning action plans and actions are being delivered; Indicators or metrics of quality performance are valid; There is confidence in how Board/committee/group members work together and challenge the evidence; There is not a long-failed history of trying to sort out the issue or problem; The organisation has a track record of delivering something similar in the past; The issue can be resolved directly by the Board/committee/group; Independent advice has been sought from appropriately qualified people; The Board/committee/group has been free from bias and undue influence; and Peers would be likely to reach a similar judgment on the basis of the same information For example each of the following could indicate an emerging risk, but triangulating all of this information and looking at it as a big picture, would indicate a very significant risk which requires immediate corrective action Above average sickness rates, frequent use of bank and agency staff, regular occurrences of patient falls, staff supervision identifies difficulties in attending mandatory training sessions due to staffing levels, observations detailed within internal inspection/visit reports indicate concerns related to therapeutic support for patients. Individually these issues and observations have the potential to be managed in isolation and in isolation may not be considered significant or be communicated/considered at the right level. However, when considered collectively and particularly when compared with another location providing similar care the significance has the potential to be much greater and be required to be addressed in a more urgent, robust manner. 14

15 Actual Example: Data and information collected and reported in the Trust indicated an increase in the number and frequency of incidents of aggression in a specific service area. This prompted the completion of a clinical audit that focused on the effect and value of having an activity coordinator within the service. The results of the clinical audit and original incident data were used to support the need for change and were able to demonstrate effective change would lead to a reduction in incidents. As a result an activity coordinator was employed within the service and the expected reduction in incidents was realised. 5 EFFECTIVE COMMITTEES Once supporting evidence and information is available to enhance our understanding of the current position of the Trust, it is important that all Committees and groups operate effectively to interpret the information and agree robust actions to take going forwards. This section outlines key behaviours and requirements to ensure a committee or group runs smoothly whilst in session. Alongside the points below it is also important that in order to enable appropriate and effective administrative support to be given to committees / groups, members of each committee / group need to be aware of and act in accordance with the requirements and timescales detailed within the Committee/Group Administration Protocol detailed at Appendix 5. Effective Actions The following principles are set out to ensure committee and group meetings are effective and achieve desired outcomes: Meeting agendas prepared and distributed in accordance with the Committee / Group Administration Protocol are to be informed by referring to the relevant Terms of Reference, work plan and action log; Supporting reports and papers must be read prior to a meeting to gain an understanding of the subject and enable all committee members to contribute to discussions, which will focus on the relevant opportunities/issues presented and actions required; There should be a clear record maintained of the action requirements resulting from all discussions; Records of decisions of the committee or group should, as a minimum, clearly identify action requirements, expected outcomes, responsibility and timescale for action completion and when and where progress will be monitored; and 15

16 Where progress against previously agreed actions is monitored by the committee or group, closure of any action should only be considered where supporting evidence is available to demonstrate the action taken was sufficient to address the original issue, Effective Papers To enable a Board, Committee or Group to be effective it is necessary to provide relevant information in a format that enables readers to understand the subject and enable appropriate informed decisions to be made. Therefore, the following principles are set out to ensure papers are developed appropriately Is it clear why the paper is being presented to the committee/group? Is the paper structured according to the Report Requirements, as detailed in the associated committee/group work plan, so that the Committee/Group can decide whether these have been met? Does the paper recommend action/s and summarise the arguments for and against the recommendation/s? Does the paper include sufficient information for the committee or group to be able to make a decision without lengthy explanation at the meeting? Has the paper been edited to ensure that it is accurate, succinct and in as plain language as possible (including spelling out abbreviations when first used and avoiding jargon)? Has the paper been subject to peer review to pre-empt questions which may be raised by the committee, thereby helping the author to fully prepare for the committee? The principles set out above have been incorporated into a standard report/paper cover sheet template that is to be used by all committees and group meetings throughout the organisation. A copy of the template is available at Appendix 6. Effective Tools To promote consistency of approach within the governance framework the following tools have been developed and are available as appendices to this manual: Report/Paper cover sheet template The template requires authors to consider and provide fundamental summary information that is considered essential for readers to understand the subject, purpose of the report/paper and linkages to other internal and external objectives/requirements Minute template The template sets out the format for the production of meeting records Action Plan template The template sets out the minimum level of detail to be included within action plans for each committee/group 16

17 Assurance, Escalation and Delegation procedure Details arrangements for highlighting and escalating risks and issues identified during completion of committee or group activity Administration Protocol Details the administrative support to be provided to Board level sub-committees and groups Annual Evaluation procedure Details arrangements and action requirements to facilitate a robust review of committee or group activity to provide assurance Terms of Reference have been met and associated annual work plan outputs have been delivered The tools noted above are to be used by all committees and group meetings throughout the organisation. Copies of the documents are available within the Appendices at section 7. Specific Individual Responsibilities The Chair/Vice Chair is responsible for: Ensuring the agenda is followed and that all members of the committee or group have the opportunity to participate in discussions; to draw to the attention of the Board of Directors any issues that require disclosure to the full Board, or require Executive action; Driving pace and presuming papers are read in advance; Ensuring the so what or what if questions are asked and answered; Dealing with individual non-attendance at meetings; and Dealing with issues related to the receipt of late and/or poor quality papers Committee Chairs should use the best practice bullet points detailed above as a mini-checklist to assess each committee meeting. This will enable early detection of potentially ineffective committees, and allow additional support to be provided to ensure each committee is fulfilling its duty. On an annual basis a more detailed committee self-assessment must take place and involve all members of the committee. A template selfassessment questionnaire is incorporated within the Annual Evaluation Procedure at Appendix 4. The Management Lead is responsible for: Providing support to the Chair in the facilitation of meetings in accordance with the committee/group work plan; and Acting as the first point of contact for queries relating to meeting requirements and administration. 17

18 6 GOVERNANCE MANUAL ADMINISTRATION / DOCUMENT CONTROL DOCUMENT NUMBER Governance Manual Version 1.1 DATE RATIFIED 27 November 2014 DATE IMPLEMENTED 15 December 2014 NEXT REVIEW DATE December 2016 ACCOUNTABLE DIRECTOR POLICY AUTHOR Chief Executive Officer Company Secretary Version Date Lead Status/Changes V1.0 27/11/2014 Compliance Officer Approved Audit Committee V1.1 REVIEW 02/09/2015 Compliance Officer Review following change to the title of the Operational Management Group now Trust Management Group Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and, as such, may not necessarily contain the latest updates and amendments. 7 APPENDICES 1 Glossary of Definitions 2 Arrangements for risk management and corporate governance 3 Committee / Group Assurance, Escalation and Delegation Processes 4 Committee / Group Annual Evaluation Procedure 5 Committee / Group Administration Protocol 6 Template Report Cover Sheet 7 Template Meeting Record (Minute) 8 Template Meeting Outcome Summary 9 Template Action Plan 10 Template Meeting Agenda 18

19 Appendix 1 Definitions 2006 Act The National Health Service Act Assurance Assurance is a positive declaration intended to give confidence to the recipient. Robust assurance will be based on supporting evidence. Assurance Seeking (role) Board of Directors Care Group Chair Committee / Group Complaint Constitution Committees within the governance framework are required to seek assurance over a wide range of activities, to ensure the Trust is operating effectively and processes are resulting in positive outcomes (see also Assurance Seeking (role) below). Assurances received by the committee will be graded from Full Assurance to No Assurance depending on the level of confidence provided by the supporting evidence. See Committee / Group Assurance, Escalation and Delegation Processes detailed at Appendix 9 for detailed guidance on the various assurance levels and next steps once assurance levels have been determined. The role of an Assurance Seeking sub-committee is to receive and challenge assurances from committees and groups that have an Operational Performance Reporting role. Assurance seeking subcommittees will provide assurance and/or recommendations directly to the Board of Directors. The Board of Directors includes executive and non-executive directors and carries out a range of roles and responsibilities in accordance with the Trust Constitution. The way Trust services are structured. Centred on four key patient pathways or care areas: Mental Health Community Health Services Children and families; and Specialist Services Each Care Group will have a quality and support team who are there to support front line staff and the wider leadership team in the delivery of their quality objectives. The Chair is the individual appointed by the Governors Council to lead the Board of Directors and ensure it successfully discharges its overall responsibility for the Foundation Trust. The Chair also undertakes the role of Chair of the Governors Council. A group of people officially delegated to perform a function. Board level sub-committees Led by a Non-Executive Director Board level sub-groups Led by an Executive Director A complaint is an expression of dissatisfaction from anyone who has accessed services provided by the Trust or a third party which requires a response. The Constitution of the Foundation Trust. Describes the type of organisation, its primary purpose, governance arrangements and membership. A member of the Board of Directors. Director Governor An elected or appointed member of the Governors Council. Governors Council Governors Council of the Foundation Trust as constituted in accordance with the Trust s Constitution, which has the same meaning as the Council of Governors in the 2006 Act. Member Anyone who has signed up to become a member of the Foundation 19

20 Operational Performance Reporting (role) Risk Management Root Cause Analysis Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions Terms of Reference Trust, including staff and members of the public. The role of an Operational Performance Reporting subcommittee/group of the Board of Directors is to provide information and associated assurances to Assurance Seeking sub-committees of the Board of Directors. If appropriate, based on the level of assessed risk, a committee or group with an Operational Performance Reporting role may report directly to the Board of Directors. Identifying all risks which have the potential to adversely affect the quality of care and the safety of patients, staff and visitors; assessing and evaluating these risks at both Operational and Corporate levels; and taking positive action to eliminate or reduce them. To identify the basic or causal factors that underlie a variation in performance, including the occurrence or possible occurrence of a Significant Event, Complaint or Adverse Incident In conjunction with the Trust Constitution, this ensures the Trust operates within a statutory framework covering all aspects of financial management and control. This includes: responsibility for financial issues to be clearly established business rules for staff to follow clear arrangements for reservation and delegation of powers Terms of reference describe the purpose roles and structures of committees, groups and other formal forums. Terms of reference provide a written basis for making decisions and confirming a common understanding between members how they will make decisions and work together. 20

21 Appendix 2 Arrangements for risk management and corporate governance V7 Challenge / scrutiny Bold outline = assurance seeking role Process / outcome / assurance reporting Assurance reporting / decision seeking Non-bold outline = operational performance reporting role Escalation / performance reporting / decision-seeking Delegation / transfer Dotted outline = Independent challenge / scrutiny role Oversight Double line = strategic planning role Board of Directors Governors Council Strategy Planning Group (Exec Group) Executive Management Group Quality & Safety Committee (NED-led) Audit Committee (NED-led) Finance Investment & Performance Committee (NED- Led) Remuneration Committee (NED Committee) Trust Management Group (Exec led) Clinical Governance Group (Director led) Other Sub-Groups of Board Sub-Committees** Financial Improvement Group (Exec led) Board of Directors: Overall accountability Governors Council: Responsible for holding NEDs to account for the performance of the Board of Directors Audit Committee: Delegated responsibility for oversight of corporate governance, internal control, and strategic risk management Finance & Investment Committee: Delegated responsibility for oversight of financial & investment risk management Quality & Safety Group: Delegated responsibility for oversight of clinical governance and clinical risk management Remuneration Committee: Delegated responsibility for Board members remuneration & other designated financial approvals Strategy Planning Group: Provide assurance to the Board that planning arrangements are in accordance with objectives and meet compliance requirements Executive Management Group: Manage clinical and non-clinical services on behalf of Board, ensuring safe quality services for patients Trust Management Group: Delegated responsibility for development and implementation of risk management strategies and policies. Responsible for delivering & reporting upon operational performance Clinical Governance Group: dual role - clinical safety & risk management leadership function, outcome monitoring & assurance reporting **Further information in relation to Sub Groups of Board Sub-Committees and Executive/Operational Management Boards is available from the Corporate Governance Team Financial Improvement Group: The FIG is accountable for the development, monitoring and delivery of the Trust s programmes for cost improvement and performance related income such as CQUIN, PbR and Earn Back. 21

22 Appendix 3 Committee / Group Assurance, Escalation and Delegation Processes Communication Minutes of Board Committees/Groups shall be formally recorded as per the protocol for Administration of the Board Committees. Minutes of each Board Committee/Group will be available via the Trust s Intranet site. Board Committees/Groups will submit an annual report to the Board on how they each have met their agreed terms of reference and delivered against their agreed work plan throughout the year. Each committee should undertake an annual appraisal in advance of submitting the annual report in order to identify relevant issues. A corporate approach to the appraisal process will be developed. The Chair of each Board Committee/Group shall draw to the attention of the Board any issues that require disclosure to, or attention of, the full Board on an exception basis. Issues identified for escalation will be agreed by members of the respective Board Committee/Group and included within a Meeting Outcome Summary using the template at Appendix 14 of the Trust Governance Manual. Meeting Outcome Summaries that include clearly identified issues for escalation are to be forwarded to the Board for consideration at the next scheduled meeting immediately following the date of the Board Committee/Group. The Trust Chair is to agree whether the escalated issue should be discussed in the public or closed part of the Board meeting. If the Chair of the Committee/Group feels that the issue requires immediate action, this should be brought to the attention of the Trust Chair within 48 hours. The Board will provide feedback to the Board Committee/Group on all escalated issues to the next meeting or within the agreed timescale. Escalation The Chair of each Board Committee/Group has discretion to escalate any issue, irrespective of the agreed assurance level, at any time. The principles for escalation are outlined below:- No Assurance on any occasion, or Limited Assurance on three consecutive occasions; Automatic escalation to the Board. Board of Directors will receive a summary paper (Appendix 14) outlining the reasons for escalation and risks associated with current position. The paper will also indicate the decision or action required by the Board. Limited Assurance on one or two occasions; Board Committee/Group will consider whether to escalate, and if the decision is to escalate, notify Board of Directors of the reasons for escalation, risks with current position, and indicate the decision or action required by the Board Significant or Full Assurance; no routine notifications to the Board Delegation / Transfer The Chair or a nominated individual of each Board Committee/Group shall draw issues for transfer / delegation to the attention of the Chair of the identified Board Committee/Group to which they wish to delegate or transfer issues for further review and/or monitoring. The decision to transfer an issue will be recorded as an action on the action log of the transferring committee/group. 22

23 Minutes of each Board Committee/Group will reflect the decision to transfer / delegate. The receiving Board Committee/Group will decide how to address the issue, and resulting actions will be recorded on the action log of the receiving committee/group. An action must also be raised to ensure the Chair or a nominated individual of the receiving committee/group provides feedback to the transferring Committee/Group as to how they have dealt with the issue. Assurance Board Committees/Groups will work to the following general principles when seeking assurances for their delegated areas of accountability Full Assurance sound system of internal control designed to meet objectives and consistently applied to this area; evidence provided to demonstrate that systems and processes are being consistently applied and implemented across all relevant Trust services. This includes evidence to demonstrate that outcomes are consistently achieved across all relevant areas Significant Assurance Generally sound system of internal control designed to meet objectives and generally applied to this area; some weaknesses in design and/or inconsistent application of controls; evidence is available to demonstrate that systems and processes are generally being applied and implemented but not across all relevant Trust services. This includes evidence to demonstrate that outcomes are generally achieved but with inconsistencies in some areas Limited Assurance Weakness in design and/or inconsistent application of controls; some evidence is available that systems and processes are being applied but insufficient to demonstrate implementation widely across Trust services. This includes some evidence that outcomes are being achieved but this is inconsistent across areas and/or there are identified risks relating to current performance No Assurance Weakness in control and/or non-compliance with controls; little or no evidence is available that systems and processes are being applied or implemented within relevant Trust services. This includes little or no evidence that outcomes are being achieved, significant risks identified relating to current performance 23

24 Appendix 4 Committee / Group Annual Evaluation Procedure (V4) Scope The procedure sets out the responsibilities and actions to be completed to provide assurance to the Board of Directors that Board level sub-committees/groups operate as intended and provide effective support to the Board of Directors in accordance with associated Terms of Reference. This procedure applies to following committees/groups: Introduction Audit Committee Quality and Safety Committee Finance Investment and Performance Committee Remuneration Committee Executive Management Group Strategy Planning Group Board level sub-committee evaluation has been a major feature of good governance for a number of years and supports compliance with the principles of the UK Corporate Governance Code and Monitor s Code of Governance. Effective evaluation allows the Board of Directors and individual committees/groups to gain assurance through the assessment of progress against associated objectives and determine how well the committee/group functions as a unit to support the Board of Directors. Responsibilities: The Company Secretary, supported by the Corporate Governance Team, is responsible for the development and maintenance of this procedure and ensuring evaluation activity is completed as planned with appropriate supporting records retained. The company Secretary is also responsible for ensuring the results of evaluation activity are presented to the Board of Directors. Each member of a Board level sub-committee is responsible for engaging with and supporting annual evaluation activity. Details of the Procedure The Corporate Governance Team will: facilitate the annual evaluation of committee/group activity through the distribution of the questionnaire detailed at Appendix 1 to this procedure in accordance with the annual activity plan of each committee/group Provide support to individual committee/group members as required to assist the completion of the questionnaire analyse the responses given to the questions detailed on the questionnaire report the findings of the evaluation activity to the relevant committee/group and the Board of Directors retain records of evaluation activity for review and to inform associated periodic reporting requirements 24

25 APPENDIX 1 to Annual Evaluation Procedure Checklist 1 For Use Only By Audit Committee Ref Area / Question Yes No Comments/Action Composition, establishment and duties 1. Does the Committee have written terms of reference that adequately define the Committee s role in accordance with relevant guidance (for example from the Department of Health; NHS England; NHS Trust Development Authority or Monitor) 2. Have the terms of reference been adopted by the governing body (the Trust Board)? 3. Are the terms of reference reviewed annually to take into account governance developments and the remit of other Committees within the organisation? 4. Are committee members independent of the management team? 5. Are the outcomes of each meeting; the actions taken and the committee s view on the organisation s systems of internal control reported to the next governing body meeting? 6. Does the Committee prepare an annual report on its work and performance in the preceding year for consideration by the governing body (the Trust Board)? 7. Does the Committee assess its own effectiveness periodically? 8. Has the committee established a plan of matters to be dealt with across the year? 9. Are Committee papers distributed in sufficient time for members to give them due consideration? 10. Has the committee been quorate for each meeting this year? Compliance with the law and regulations governing the NHS 11. Does the committee review assurance and regulatory compliance reporting processes? 12. Does the Committee have a mechanism to keep it aware of topical, legal and regulatory issues? Internal control and risk management 13. Has the Committee formally considered how it integrates with other committees that are reviewing risk for example, risk management, quality and clinical governance committees? 14. Has the Committee reviewed the robustness and effectiveness of the content of the organisation s Assurance Framework? 15. Has the committee reviewed the robustness and content of the draft annual governance statement before it is presented to the governing body? 16. Is the committee s role in reviewing and recommending to the governing body the annual report and accounts clearly defined? 17. Does the committee consider the external auditor s report and those charged with governance including proposed adjustments to the accounts? Internal Audit 18. Is there a formal charter or terms of reference, defining internal audit s objectives, responsibilities and reporting lines? 19. Does the committee review and approve the internal audit plan at the beginning of the financial year? 20. Does the committee approve any material changes to the plan? 21. Is the committee confident that the audit plan is derived from a clear risk assessment process that links closely to the assurance framework? 22. Does the committee receive periodic progress reports from the Head of Internal Audit? 23. Does the committee effectively monitor the implementation of management actions arising from internal audit reports? 24. Does the Head of Internal Audit have a right of access to the committee and its Chair at any time? 25. Is the committee confident that internal audit is free of any scope restrictions and, if not, has it considered the impact of these on the annual Health of Internal Audit opinion? 25

26 Ref Area / Question Yes No Comments/Action 26. Is the committee confident that internal audit is free from any operational responsibilities or conflicts of interest that could impair its objectivity? 27. Does the committee hold periodic private discussions with the Head of Internal Audit? 28. Has the committee evaluated whether internal audit complies with the Public Sector Internal Audit Standards? 29. Has the committee agreed a range of internal audit performance measures to be reported on a routine basis? 30. Does the committee receive and review the Head of Internal Audit s annual opinion? External Audit 31. Do the external auditors present their audit plans and strategy to the committee for agreement and approval? 32. Does the committee receive and monitor actions taken relating to prior years reviews? 33. Does the committee review the external auditor s ISA 260 report (the report to those charged with governance)? 34. Does the committee review the external auditor s value for money conclusion? 35. Does the committee review the external auditor s opinion on the quality account when necessary? 36. Does the committee hold periodic private discussions with the external auditors? 37. Does the committee assess the performance of external audit? 38. Does the committee require assurance from external audit abut its policies for ensuring independence? 39. Has the committee approved a policy to govern the nature and value of nonaudit work carried out by the external auditors? 40. Does the committee receive information on all non-audit work undertaken by external audit? 41. Does the committee review the proportion of audit and non-audit work every time the external auditors change? Clinical Audit 42. Is the committee clear about where clinical audit assurances are received and monitored? 43. If the committee is NOT the main committee receiving direct feedback from clinical audit, does it receive a report from the relevant committee on the progress made by clinical audit during the year along with a clear view on the outcome of the annual work plan? 44. If the committee receives reports from clinical audit has it: Reviewed an annual plan which is clearly linked to clinical risks and clinical assurance needs? Received regular progress reports? Monitored the implementation of management actions resulting from clinical audit reviews? Received a report over the quality assurance processes covered by clinical audit activity? Counter (or anti-) fraud and security 45. Is the committee aware of NHS Protect requirements in relation to counter fraud and security activity? 46. Does the committee review the planned counter fraud and security work at the beginning of the financial year and in particular its scope and coverage? 47. Does the committee satisfy itself that the work plan is derived from clear processes based on risk assessments and that coverage is adequate? 48. Does the committee receive notification of any material changes to the plan? 49. Does the committee receive periodic reports about counter fraud and security activity? 50. Do those working on counter fraud and security activity have a right of direct access to the committee and its Chair? 51. Do those working on counter fraud and security activity have the necessary technical knowledge and experience to ensure that work is carried out as it should be? 52. Does the committee receive and review an annual report on counter fraud and 26

27 Ref Area / Question Yes No Comments/Action security activity? 53. Does the committee receive and discuss reports arising from inspections by NHS Protect in relation to quality of the counter fraud (and security) provision? Annual report and accounts and disclosure statements 54. Is the committee s role in the approval of the annual report and accounts clearly defined? 55. Is a committee meeting scheduled to discuss proposed adjustments to the accounts and issues arising from the audit? 56. Does the committee specifically review:- Changes in accounting policies? Changes in accounting practice due to changes in accounting standards? Changes in estimation techniques? Significant judgements made in preparing the accounts? Significant adjustments resulting from the audit? Explanations for any significant variances? 57. Does the committee ensure it receives explanations for any unadjusted errors in the accounts found by the external auditors? 58. Does the committee receive and review a draft of the organisation s annual governance statement? 59. Does the committee receive and review a draft of the organisation s annual report and accounts? 60. Does the committee receive and review the evidence required to demonstrate compliance with regulatory requirements (for example, ass et by the Care Quality Commission, Monitor and the NHS Trust Development Authority)? Other Issues 61. Does the committee provide a summary report of its meetings to the next available governing body meeting? 62. Has the committee reviewed its performance in the year for consistency with its:- Terms of reference? Programme for the year? Checklist 2 For Use By All Board Sub-Committees (Audit, Quality & Safety, Finance Investment & Performance, Remuneration) Statement Theme 1 Committee Focus The committee has set itself a series of objectives it wants to achieve this year. The committee has made a conscious decision about how it wants to operate in terms of the level of information it would like to receive for each of the items on its cycle of business. Committee members contribute regularly across the range of issues discussed. The committee is fully aware of the key sources of assurance and who provides them in support of the controls mitigating the key risks to the organisation. The committee clearly understands and receives assurances from third parties the organisation uses to manage / operate key functions for example, financial services operated by NHS Shared Business Services, other NHS bodies, commissioning Strongly agree Agree Disagree Strongly disagree Unable to answer Comments / action 27

28 Statement support units or private contractors. Equal prominence is given to both quality and financial assurance. Theme 2 committee team working All Committees except Audit Committee: The committee has the right balance of experience, knowledge and skills to fulfil its role Audit Committee only: The committee has the right balance of experience, knowledge and skills to fulfil its role described in the NHS Audit Committee Handbook. The committee has structured its agenda to cover quality, data quality, performance targets and financial control The committee ensures that the relevant executive director / manager attends meeting to enable it to secure the required level of understanding of the reports and information it receives (ie the right executive lead is there to discuss risk and internal matters in their area of responsibility rather than the committee having to rely on the CFO (or other manager) to act as conduit to the executive team) Management fully briefs the committee via the assurance framework in relation to the key risks and assurances received and any gaps in control / assurance in a timely fashion thereby eradicating the potential for surprises. Other committees provide timely and clear information in support of the committee thereby eradicating the potential for surprises. I feel sufficiently comfortable within the committee environment to be able to express my views, doubts and opinions. For Audit Committee only: I understand the messages being given by the organisation s assurance advisors (external audit / internal audit / counter fraud specialist / ) For All other Committees: I understand the messages being given by the organisation s assurance advisors (eg clinical audit, safety, information governance) For Audit Committee only: Internal audit contributes to the debate across the range of the agenda and not just on the papers they present Members hold their assurance providers to account for late or missing assurances. When a decision has been made or action agreed I feel confident that it will be implemented as agreed and in line with the timescale set down. Strongly agree Agree Disagree Strongly disagree Unable to answer Comments / action 28

29 Statement Theme 3 committee effectiveness The quality of committee papers received allows me to perform my role effectively. Members provide real and genuine challenge they do not just seek clarification and/or reassurance. Debate is allowed to flow and conclusions reached without being cut short or stifled due to time constraints etc. Each agenda item is closed off appropriately so that I am clear what the conclusion is; who is doing what, when and how etc and how it is being monitored. At the end of each meeting we discuss the outcomes and reflect back on decisions made and what worked well, not so well etc. The committee provides a written summary report of its meetings to the governing body. The governing body challenges and understands the reporting from this committee. There is a formal appraisal of the committee s effectiveness each year which is evidence based and takes into account my views and external views. Theme 4 committee engagement The committee actively challenges both management and other assurance providers during the year to gain a clear understanding of their findings The committee is clear about the complementary relationship it has with other governing body committees that play a role in relation to clinical governance, quality and risk management The committee receives clear and timely reports from other governing body committees which set out the assurance they have received and their impact (either positive or not) on the organisation s assurance framework. I can provide two examples of where we as a committee have focussed on improvements to the system of internal control as a result of assurance gaps identified. Theme 5 committee leadership The Committee Chair has a positive impact on the performance of the committee Committee meetings are chaired effectively and with clarity of purpose and outcome The committee Chair is visible within the organisation and is considered Strongly agree Agree Disagree Strongly disagree Unable to answer Comments / action 29

30 Statement approachable The Committee chair allows debate to flow freely and does not assert his/her own views too strongly. The Committee Chair provides clear and concise information to the governing body on the activities of the committee and the implications of all identified gaps in assurance / control. Strongly agree Agree Disagree Strongly disagree Unable to answer Comments / action 30

31 Appendix 5 Committee / Group Administration Protocol (v9) The Board of Directors and Board sub-committees will receive appropriate administrative support facilitated and provided by the Corporate Governance Team. In order to make the arrangements work as smoothly as possible it is important that members of committees are aware of and act in accordance with the approach detailed below: (i) Agenda The content of each agenda will initially be prepared by the Corporate Governance Team in liaison with the respective Executive Management Lead, prior to being considered by the Committee Chair. The initial draft agenda will be informed by the associated Committee activity schedule, previous meeting minutes and action plan. The agenda will use the standard agenda template contained within the Governance Manual; Subject to approval by the Committee Chair, an agreed initial draft agenda will be prepared a minimum of two (2) months in advance of the associated meeting. The initial draft agenda will then be distributed to Committee / Group members for information or comment/suggestions for amendment seeking comments by a specific date, in line with below; Committee members are required to return comments or suggestions for amendment to the initial draft agenda a minimum of three (3) weeks before the date of the meeting. All comments and suggestions for amendment will be considered by the respective Chair and Executive Management Lead and a final agenda will be agreed. Submission of comments or suggestions for amendment of an agenda received within three (3) weeks of the date of the meeting will only be considered/approved by the respective Chair in exceptional circumstances; Individuals identified as the lead for agenda items will be notified following the agreement of the final agenda. Through reference to the Committee activity schedule, previous meeting minutes and action plan the notification will include reference to the requirement for, and overarching content, of any associated reports and/or papers. Associated reports and/or papers must be prepared and submitted to the Corporate Governance team no later than seven (7) working days prior to the date of the meeting to enable final agenda distribution preparation 1. Any papers received outside of this period will only be considered for inclusion in exceptional circumstances and authors are responsible for seeking agreement for their inclusion in advance with respective Executive Management Lead and Chair; The agenda and associated papers will be issued at least five (5) working days prior to the date of the meeting by the Corporate Governance Team. This will be issued electronically via , First Class post for external addresses and using the Trust s internal mail system for Trust premises; and All Committee members (and those in attendance) will be expected to review the agenda and associated papers prior to each meeting. Papers presented at each meeting will be taken as read by the Chair 1 With specific reference to meetings of the Board of Directors, papers and reports (with the exception of routine Finance and Performance reports), are to be made available for Executive Team review prior to formal distribution with the Board meeting agenda 31

32 (ii) Minutes / Records of Decisions The Trust meeting record template will be used to develop meeting minutes or records of decisions; Draft minutes / records of decisions are to be produced as soon as practicable following each meeting and are to be subject to initial scrutiny by the respective Executive Management Lead to ensure they represent an accurate record of discussions. Formal consideration for approval by the Chair or a nominated individual 2 will then be sought; and Approved draft minutes / records of decisions and associated action plans are to be circulated to Committee members within seven (7) working days following each meeting. Committee members are required to return comments or suggestions for amendment for consideration by the Chair no later than seven (7) working days prior to the date of the next meeting. Members are encouraged to take this opportunity to highlight issues to reduce the time required to formally accept meeting records at the next meeting. (iii) Action Plan The Trust Action Plan template will be utilised for the development and maintenance of action plans for each Committee; Action plans will be updated and circulated to members of the respective Committee with the associated meeting record within seven (7) working days of the meeting. The plan will detail any actions agreed by the Committee, allocated lead responsibility together with appropriate timescales for completion; and Allocated leads for actions detailed within the plan will be responsible for the submission of progress updates for each action to the Corporate Governance team no later than seven (7) working days prior to the date of the next meeting to enable supporting documentation to be prepared for distribution with the meeting agenda. Where actions have not been achieved within agreed timescales, the allocated lead is responsible for communicating the reason and a proposal for a revised timescale within the associated progress update. (iv) Activity Schedules A record of issues and documents for discussion by the Committee will be maintained by way of a Committee activity schedule. This will be maintained through reference to associated action plans in order to enable identification of issues for recall; Any topics for discussion which have been escalated from other Committees / Groups should be clearly identified as such on the associated report / paper cover sheet. The content of the cover sheet will identify where the topic has been previously considered and the reasons for escalation; and A copy of the activity schedule will be included for information with the agreed agenda for each meeting. 2 Note: initial approval of draft meeting minutes by the Chair or nominated individual does not replace the need for accuracy of minutes to be formally confirmed at the next meeting of the Committee / Group 32

33 (v) Summary Records A one page (A4) summary of key areas of discussion undertaken by the Committee should be prepared and presented by the Chair of the Committee to the next meeting of the Board (or other relevant reporting committee) as documented in the Escalation Process detailed within the Governance Manual. (vi) Additional general administration undertaken by the Corporate Governance team Accurate records will be maintained of attendance, key discussion points, decisions taken, outcome and any actions agreed; Organising future meetings, notifying members accordingly; Filing and maintaining records of the work of the Committee via SharePoint Creating and maintaining records of meetings of the Board of Directors on the Trust Internet site (vii) Executive Team review of Board papers Each week the Executive team will discuss the status of papers associated with the Board or any committee taking placing within the following two (2) weeks. Agendas of the Executive team meeting will be constructed to reflect the following arrangements: Week 1 Draft agenda for the Board of Directors to be considered Quality & Safety Committee Executive Management lead will provide an update on key issues in advance of the Quality & Safety Committee meeting Week 2 Week 3 The Finance Information & Performance Executive Management lead will provide an update on key issues in advance of the FIP Committee. Review of papers due to be presented at the Board of Directors Audit Committee Executive Management lead will provide an update on key issues in advance of the Audit Committee (bi-monthly). 33

34 Appendix 6 Report Cover Sheet (v7) Report to: NAME OF MEETING/COMMITTEE Agenda reference: Title: Presented by: Prepared by: Date of meeting: Document date: Where else has this report been considered and when The purpose of this report is (indicate with X): For assurance For information For decision Supporting information 1. Purpose of the report Include: What question does this report seek to answer? Outcomes as a result of consideration of the report at other forums (as applicable) 2. Executive Summary - Include: Reference should be made to key issues, risks and benefits as applicable with confirmation of what is being undertaken to address/mitigate or deliver these. This should also confirm where details of this information can be found in the report) 3. Recommendations for action or details of actions being taken These should be details in SMART format i.e. Specific, Measurable, Attainable, Realistic and Timely) 34

35 4. Decisions required from this meeting (Cross reference Purpose of the report at 1 above) Alignment to Strategic Priorities (indicate with X): Consistently delivering the highest possible quality of service we can achieve Realising the full potential of everyone we work with and the talent of all our staff Transforming our services to improve them for the people we serve 35

36 Appendix 7 Template Meeting Record (Minute) Administration notes Not for inclusion on completed records: Font Arial size 11 is to be used for all text Guidance notes to aid record development are provided in italics and highlighted and should be deleted during record development UNCONFIRMED/CONFIRMED 3 MINUTES OF THE Insert title of the Committee/Group MEETING HELD ON Insert date of the meeting in the following format Day, Month, Year Insert location of the meeting Present: Detail the name and position/post title of each individual within a separate field E.g. Note: For meetings of Mr Daniel Scheffer the Board of Directors Associate Director of only voting members Corporate Governance should be listed as and Company present, other Secretary individuals should be detailed as attendees In Attendance: Detail the name and post title of each individual within a separate field Apologies: List the name and post title of each individual as applicable Actions Action references are to be recorded and be consistent with associated documentation as applicable Agenda item item and subsequent discussion/outcome are to be consistent with the associated agenda. Where applicable subsections of the agenda should be clearly segregated within this record Introduction and Administration 1. Apologies for Absence 2. Minutes of previous Meeting 3. Action log ANY OTHER BUSINESS Action by Detail lead individual DATE AND TIME OF THE NEXT MEETING Signed: Dated: Chair 3 Delete as applicable 36

37 Appendix 8 Template Meeting Outcome Summary MEETING OUTCOME SUMMARY Name of Committee/Group: Date of Meeting: Paper Prepared By: In case of query, please contact: Key topics and outcome(s) Any new key risks identified to be considered for BAF/Risk register? Any gaps in assurance identified that need addressing? Issues/concerns to be escalated to next level (this should include proposals on the next steps to address the issue) 37

38 Appendix 9 Template Action Plan X Committee Action Log ISSUE ACTION OUTCOME Action No Date of meeting Agenda Item Issue to be addressed Action Lead Timescale Update Report Action Complete (Yes/No) What is the desired outcome? Outcome evidence Outcome Achieved (Yes/Ref to additional action) Actions should be listed in sequential order State the date of the meeting Specify the agenda item reference from the meeting Set out why do we need this action Set out the actions needed in order to deal with the issue identified by the group Name of person responsible for completing the action State the expected date for completing the action This section enables the most up to date information to be provided to the group on the actions undertaken Yes/No confirmation if all actions have been completed Confirm what will be different as a result of completing the actions What evidence is available to show that the desired outcome has been achieved Yes/No confirmation if the outcome has been achieved. Additional actions must be listed where the outcome has not been achieved by the initial action 38

39 Appendix 10 Template Meeting Agenda Administration notes Not for inclusion on completed records: Font Arial size 14 is to be used for the title box Arial size 11 is to be used for all remaining text Guidance notes to aid record development are provided in italics and highlighted and should be deleted during record development MEETING OF Insert title of the Committee/Group TO BE HELD AT Insert time ON Insert Day, Date, Month, Year (M/T/W/T/F,dd,mm,yyyy) Insert location E.g - VOREDA, PENRITH, CA11 7BF No. Item Title of the item Sub-sections should be used to group associated items For example: 1. Welcome and Apologies Led by Post title Chair Outcome This field is to detail the expected outcome for the item. E.g. for action, for ratification etc To note apologies received AGENDA Reference This field is to identify/include associated information/papers/presentation method Time This field is to detail the time allocated to the item Verbal hrs Circulation information should identify individuals by name and position/post title and be segregated to identify members, attendees and others as appropriate. Distribution Members: In Attendance: For information: Page numbers should be included as applicable Ref: Reference to be inserted 39

40 40