governance manual - cumbria partnership nhs foundation ... · with good governance processes in...

1 20150902 – Governance Manual V1.1

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.


Contents

1. INTRODUCTION – GOVERNANCE AND THE PURPOSE OF THIS MANUAL ............... 3

2 RISK MANAGEMENT.................................................................................................................. 5

2.1 INCIDENTS ............................................................................................................................... 8

3 GOVERNANCE COMMITTEES / GROUPS .......................................................................... 10

3.1 LOCAL GOVERNANCE STRUCTURE .............................................................................. 12

4 ASSURANCE ABOUT GOVERNANCE FROM EVIDENCE ............................................... 13

5 EFFECTIVE COMMITTEES ..................................................................................................... 15

6 GOVERNANCE MANUAL ADMINISTRATION / DOCUMENT CONTROL ...................... 18

7 APPENDICES ............................................................................................................................. 18

Appendix 1 – Definitions ................................................................................................................... 19

Appendix 2 – Arrangements for risk management and corporate governance – V7 ............... 21

Appendix 3 – Committee / Group Assurance, Escalation and Delegation Processes ............ 22

Appendix 4 – Committee / Group Annual Evaluation Procedure (V4) ....................................... 24

Appendix 5 – Committee / Group Administration Protocol (v9) .................................................. 31

Appendix 6 – Report Cover Sheet (v7) ........................................................................................... 34

Appendix 7 – Template – Meeting Record (Minute) ..................................................................... 36

Appendix 8 – Template – Meeting Outcome Summary ............................................................... 37

Appendix 9 – Template – Action Plan ............................................................................................. 38

Appendix 10 – Template – Meeting Agenda .................................................................................. 39


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.


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 www.cumbriapartnership.nhs.uk.

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.

http://www.cumbriapartnership.nhs.uk/


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’:

◦ 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

Risk

Description


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

2. Risk escalated in order to seek urgent resolution:

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.

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.

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.


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

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

Option B – Risk profile score 15 or

greater

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


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.


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 cross-

organisational 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.


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).

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

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 non-clinical 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

Board of Directors

Executive Management Group

Chair: Chief Executive

Audit Committee

Chair: Non-Executive Director

Quality & Safety Committee


Finance Investment & Performance Committee


Strategy Planning Group

Chair: Chief Executive

Remuneration Committee



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.


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.


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?

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:

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.


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.


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

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.


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


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 self-

assessment 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.


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 Chief Executive Officer

POLICY AUTHOR 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


Appendix 1 – Definitions

2006 Act The National Health Service Act 2006.

Assurance Assurance is a positive declaration intended to give confidence to the recipient. Robust assurance will be based on supporting evidence.

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.

Assurance Seeking (role)

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 sub-committees will provide assurance and/or recommendations directly to the Board of Directors.

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.

Care Group 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.

Chair 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.

Committee / Group 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

Complaint 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.

Constitution The Constitution of the Foundation Trust. Describes the type of organisation, its primary purpose, governance arrangements and membership.

Director A member of the Board of Directors.

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


Trust, including staff and members of the public.

Operational Performance Reporting (role)

The role of an Operational Performance Reporting sub-committee/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.

Risk Management 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.

Root Cause Analysis

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

Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions

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

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.


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

Audit Committee

(NED-led)

Finance Investment

& Performance

Committee (NED-

Led)

Remuneration

Committee (NED

Committee)

Governors Council

Executive

Management

Group

Quality & Safety

Committee (NED-led)

Trust

Management

Group (Exec led)

Strategy

Planning Group

(Exec Group)

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.

Other Sub-Groups of Board Sub-Committees**

Clinical

Governance

Group (Director

led)

Financial

Improvement

Group (Exec led)


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.


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


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:

Audit Committee

Quality and Safety Committee

Finance Investment and Performance Committee

Remuneration Committee

Executive Management Group

Strategy Planning Group

Introduction

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


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?



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 non-audit 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



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 Strongly agree

Agree Disagree Strongly disagree

Unable to answer

Comments / action

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




Unable to answer

Comments / action

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.




Unable to answer

Comments / action

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




Unable to answer

Comments / action

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.


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 preparation1. 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 e-mail, 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


(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 individual2 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


(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 The Finance Information & Performance Executive Management lead will

provide an update on key issues in advance of the FIP Committee.

Week 3 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).


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)


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


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/CONFIRMED3 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. Mr Daniel Scheffer Associate Director of Corporate Governance and Company Secretary

Note: For meetings of the Board of Directors – only voting members should be listed as ‘present’, other 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 sub-sections of the agenda should be clearly segregated within this

record

Action by – Detail lead individual

Introduction and Administration

1. Apologies for Absence

2. Minutes of previous Meeting

3. Action log

ANY OTHER BUSINESS

DATE AND TIME OF THE NEXT MEETING

Signed: Chair

Dated:

3 Delete as applicable


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)


Appendix 9 – Template – Action Plan

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

Outcome Achieved

(Yes/Ref to additional

action)

X Committee Action Log

ISSUE ACTION OUTCOME

Action NoDate of

meeting

Agenda

ItemIssue to be addressed

Action

Lead Timescale Update Report

Action

Complete

(Yes/No)

What is the desired

outcome?Outcome evidence


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

AGENDA

No. Item Title of the item – Sub-sections should be used to group associated items

Led by Post title

Outcome This field is to detail the expected outcome for the item. E.g. for action, for ratification etc

Reference This field is to identify/include associated information/papers/presentation method

Time This field is to detail the time allocated to the item

For example:

1. Welcome and Apologies

Chair To note apologies received

Verbal 13.30 – 13.35 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

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

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