Governing Body Meeting in Public · 2016. 12. 13. · Date of Meeting: 21st July 2016 Governing...

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Agenda Item No: Item 6

Date of Meeting: 21st July 2016

Governing Body Meeting in Public

Paper Title: Governance Report

Decision Discussion Information Follow up from last meeting

Report author: Sarah Feal, Company Secretary

Report signed off by: Alan Pond, Chief Finance Officer

Purpose of the paper: To seek the approval of the Governing Body to a number of

matters, as required by the CCG’s Constitution, that have been agreed at Governing Body Workshops since the Governing Body Meeting in Public on 31st March 2016, including: Matters approved that require reporting to the Governing

Body Meeting in Public for ratification. To provide the Governing Body in Public with a summary of key corporate governance activities.

Conflicts of Interest involved:

There are none identified.

Recommendations to the Governing Body:

The Governing Body is asked to: note and ratify the decisions made at the Governing

Body Workshops; note the report from the Governance and Audit

Committee; note the Strategic Risk Register and Risk Controls

Assurance Dashboard;

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Governance Report 1.0 Introduction This paper provides information on corporate governance activities being undertaken by the Clinical Commissioning Group (CCG). 2.0 Terms / Acronyms Used in the Report CCG Clinical Commissioning Group

NHS National Health Service 3.0 CCG Governing Body Workshops Summarised below are key discussions and actions agreed from the Governing Body Workshops that have taken place since the Governing Body Meeting in Public on 31st March 2016:

3.1 Governing Body Workshop 14th April 2016: Approved recommendations made to them by Hertfordshire Medicines Management

Committee on NICE Technology Appraisals. The details of this are in the Prescribing Report.

Approved the Integrated Care Programme Board Delivery Plan for 2016-17. Approved the Primary Care Strategy. 3.2 Governing Body Workshop 28th April 2016: This meeting was deferred until 12th May 2016. 3.3 Governing Body Workshop 12th May 2016: Approved the Consolidated Funding Framework for 2016-17. Agreed to support the priorities set out in the Health and Wellbeing Strategy. Agreed the recommendations for Winter Resilience Schemes. Approved the Quality Premium. Agreed to revise the Hertfordshire Equipment Service offer and committed to the

associated funding requirement for 2016-17. 3.4 Governing Body Workshop 9th June 2016: Approved Locality allocations for 2016-17. Endorsed the priority ranking of the Estates and Technology Fund bids. 3.5 Governing Body Workshop 7th July 2016: Approved recommendations made to them by Hertfordshire Medicines Management

Committee on NICE Technology Appraisals. The details of this are in the Prescribing Report.

Agreed the principles of the System Resilience Group Winter Resilience Schemes.

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4.0 Governance and Audit Committee Meeting The Minutes of the Governance and Audit Committee meeting of 16th March 2016, as approved at the 18th May 2016 meeting are being submitted to this meeting, as required by the Committee’s Terms of Reference. Items of business considered by the Committee at its May meeting included a review of the following: Review of the draft Annual Report and Accounts 2015-16 including the Annual

Governance Statement. Review of the draft Report to the Audit Committee to those charged with governance

from External Audit. Review of the Annual Report from Internal Audit.

The Governing Body is asked to note the report from the Governance and Audit Committee. 5.0 Risk Profile Report 5.1 Strategic Risk Register (SRR) and Risk Controls Assurance Dashboard (RCAD) The SRR (Appendix A) and the RCAD (Appendix B-Red risks only) were reviewed by the Executive Team on 12th July 2016 and subsequently by the Governance and Audit Committee at its meeting on 20th July 2016. The SRR is a summary of key risks the organisation faces in delivering its objectives and is refreshed regularly to reflect changing circumstances. The RCAD enables the CCG to have an understanding of its risk profile and the controls used to mitigate those risks. 5.2 New Strategic Risk: It was proposed at the Executive Team meeting on 12th July 2016 that Strategic Risk 3 will be closed and replaced by one relating to the Sustainability and Transformation Plan (STP). Strategic Risk 3 remains on the SRR until the new risk has been developed.

5.3 Risks, Controls and Assurance Dashboard (RCAD) The RCAD enables the CCG to have an understanding of its risk profile and the effectiveness of controls to mitigate the risks. There are currently 33‡ risks on the RCAD, of which 32 risks have been assigned to the following categories. (‡ Risk 5.7, Pandemic Flu risk is currently unassigned a score as the scoring of this risk is currently being reviewed by the Executive Team).

Red Amber Yellow Green

3 17 5 7

5.4 Update: Four new risks have been added and eleven risks were closed. There are currently 3 red risks scoring 16+ (ID 1.52, 5.5, 5.8) on the RCAD and Risk 5.7, which is currently unscored, is also included. The Governing Body is asked to note the SRR and RCAD.

6A Appendix A Strategic Risk Register 2016_17.xlsx

PROGRESS KEY:

Appendix A

2016/17 Strategic Risk Register – June/July 2016

Q4

14/15

Q1

15/16

Q2

15/16

Q4

15/16

4x3=12

Ref 1.10 - Score 12 (4/3)

Ref 1.24 - Score 4 (2/2)

Ref 1.26 - Score 9(3/3)

Ref 1.32 - Score 12 (4/3)

Ref 1.33 - Score 12 (4/3)

Ref 1.34 - Score 12 (3/4)

Ref 1.46 - Score 9 (3/3)

Ref 1.50 - Score 12 (4/3)

Ref 1.51 - Score 9 (3/3)

Ref 1.52 - Score 16 (4/4)

Ref 1.54 - Score 12 (4/3)

Ref 1.55 Score 9 (3/3)

Ref 1.57 Score 12 (4/3)

Ref 2.2 - Score 4 (2/2)

Ref 3.11 - Score 4 (2/2)

Ref 4.1 - Score 9 (3/3)

Ref 4.21 - Score 12 (4/3)

Ref 5.2 - Score 12 (3/4)

Ref 5.3 - Score 15 (5/3)

Ref 5.4 - Score 15 (5/3)

Ref 5.5 - Score 20 (5/4)

Ref 5.6 - Score 2 (2/1)

Ref 5.7 - Score 20 (5/4)

Ref 5.9 - Score 12 (3/4)

Ref 5.10 - Score 12 (3/4)

Ref 5.12 - Score 15 (5/3)

Ref 5.13 - Score 12 (4/3)

Risk rating reduced from last report

Risk rating remains the same as last reported

Risk rating increased from last report

Date Target Risk

Rating

Progress Update

Strategic Risk 1:

Failure of the CCG to ensure delivery of safe, high quality and effective services from appropriately commissioned providers

Lead Director – Sheilagh Reavey – Director of Nursing and Quality

04/7/2016

CQC action plan in place

and being monitored for

all providers. Regular

quality assurance visits of

ED in place. All ENH

requirements reflected in

PAH quality schedule. All

posts recruited to.

16/02/2016 -

- Remedial action plan in

place for ENHT regarding

stroke performance and

ED.

- Remedial action

plan(RAP) and CPN

issued to PAH for stroke

and ED

- CPN issued to HCT

regarding diabetes

- Follow-up IPC visits

carried out.

- Mock CQC inspection at

PAH completed.

- Performance notices

issued to PAH by

WECCG.

A) Tripartite meeting of

ENHCCG, Herts Valleys &

West Essex quality team

B) Monitoring of HCT diabetes

service

C) Support to ENHT from

specialist staff

D) Recruitment of safeguarding

staff

E) HF confirmed CPN already

in place so added to progress

update.

F) Quality assurance visits to

Mount Vernon

Ongoing

Ongoing

Ongoing

3x3 = 9A) Levers for ENHCCG in

relation to associate contracts

regarding quality

4x4 = 16 4x3 =

12

4x3 =

12

Linked with: Inherent

Risk Rating

Key Controls Current Risk

Rating:

Q1 16/17

Actions requiredDate

Opened

Nov-13 4x3=124x3 =

12

1) Robust programme of quality monitoring and

assurance visits together resulting actions.

2) Actions from Quarterly Quality Committee

3) Actions from Quality review meetings with

providers

4) Programme to monitor CQUINs, and requirements

of quality and information schedules in contracts.

5) Actions from patient network quality meeting

- PPG involvement in quality monitoring

- Use of patient stories

6) Annual visits Programme of Section 11 visits to

providers.

7) Provider CQC action plans

8) Dedicated CCG ICP resource

9) Memorandum of Understanding with HVCCG for

safeguarding adults service

10)Health needs assessment and profile for Looked

After Children developed

11) Implemented the LAC model.

12) Mortality data framework agreed

13) Ongoing monitoring of staffing returns

14) Actions from Palliative and respiratory care

review with EN Herts agreed

15) Ward level indicators analysed (safer staffing

information and safety metrics from all providers

monthly now in place)

16) Action plan from diabetes contract review

meeting

1) & 2),13)14) Reports to quality committee

2) Service specific deep dives which utilise specialist

support for deep dives.

3) & 13) Review meetings with providers

2) Quarterly Governance and Audit Committee deep

dive

• Internal audit recommendations implemented:

- Risk management (green)

- Performance (amber/green)

2) Quarterly quality reports to Governance and Audit

10) 11) Externally commissioned report on LAC

5) Patient network quality meeting

6) CQC/Ofsted visit for safeguarding

7) CQC inspection outcomes of providers.

8) HCAI Network meeting

12) Mortality meetings now held with ENHT

1) 2) 3) Area Team Check Point Reviews and Quality

Surveillance Group

1) 2) 3) Bi- monthly Quality and performance reports

to Governing Body.

Whole risk) Provider cost improvement programmes

are signed off by the CCG

16) Diabetes contract review meeting in place

Assurance Gaps in Controls/Assurances Previous Risk Ratings:

SO1 - To commission safe and appropriate

health care services

RCAD Risks:

Page 1 of 7


Q4

14/15

Q1

15/16

Q2

15/16

Q4

15/16

RCAD Risks:

Ref 1.22 - Score 12 (3/4)

Ref 1.32 - Score 12 (4/3)

Ref 1.51 - Score 9 (3/3)

Ref 3.2 - Score 4 (2/2)

Ref 3.11 - Score 4 (2/2)

Target Risk

Rating

Progress Update

01July2016

Actions completed

- Primary Care Strategy

finalised and signed-off

- Consolidated Funding

Framework (CFF)

developed to integrate

with Locality

Commissioning

Framework:

- Signed-off CFF by

Governing Body

- Implementation of CFF

23/10/2015 -

Member practices

consulted on the Primary

Care Strategy. Each

Director has been

assigned a locality.

Draft Locality Plans are

being discussed in

localities.

Task and Finish Group

agreed for developing

Commissioning

Framework

DateInherent

Risk Rating

Key Controls Assurance Gaps in Controls/Assurances Current Risk

Rating:

Q1 16/17

Actions requiredDate

Opened

Nov-13 1) Actions from Monthly locality commissioning board

meeting for each locality

Monthly locality meeting

2) Regular monitoring of the commissioning

framework for practices to incentivise engagement in

place

2a) Governing Body approved strategic plan that

incorporates future financial outlook

3) Significant clinical involvement in Programme

Management via OPD/localities

4) Established locality structure with additional senior

management resources including finance and

information input - locality meetings allow the

opportunity for feedback to the localities on the

outcome of the Commissioning Intentions process

and the formulation of contracts for 2015/16

5)Clear Exec lead for strategic plan, with Programme

Management Office and Exec Team meetings

6) Regular reviews of all incentive payments

7) Ensure active member engagement on the design

of the commissioning framework

8) Commissioning intentions meetings held with all

localities and locality patient groups

9) Quarterly Reporting regarding the monitoring of

the commissioning framework (task and finish group)

10) Council of Members meeting involved in planning

11)Commissioning Framework 2016/17 agreed

12) Commissioning framework for 2017/18 to be

agreed Oct 2016

Whole risk) Internal audit on locality Governance

(+ve)

Whole risk) Regular updates provided to NHSE,

including the Joint Co-Commissioning Committee

and Health and Well Being Board, Scrutiny

Committee

1) Locality information pack produced monthly

provides oversight of activity and performance

- Monthly financial balance checks as part of

Commissioning Framework

2a)GB GPs and clinical leads are fully engaged

2a) Governing body meetings to discuss Locality

commissioning plans.

3) On-going engagement with practices regarding

implementation of Primary Care Strategy including

the CFF.

5) Positive assurance from Area Team on the CCG 5-

year strategic plan which has been developed in

partnership with localities

6) & 7),8) 9)Regular check and challenge review of

strategy and framework by GB

7) Member practices inform plans via the Locality

Groups

11) & 12) Production of commissioning intention

A) Development of locality

commissioning plans

3 x 3=93x3 = 9

Linked with:

Strategic Risk 2:

Failure to establish an adequate and appropriate commissioning plan that is informed by member practices

Lead Director - Harper Brown, Director of Commissioning

Previous Risk Ratings:

SO2 - To commission effective services that

enhance the well-being of our residents within

the available resources

SO3 - To engender a culture of engagement in

the decision making processes amongst

partners and stakeholders to ensure ownership

of service priorities

3x3 = 9 3x3 = 9 3x1 = 330 sep-16A) Detailed localised plans3x4 = 12 3 x 3=9

Page 2 of 7


Q4

14/15

Q1

15/16

Q2

15/16

Q4

15/16

Ref 3.2 - Score 4 (2/2)

Ref 5.6 - Score 2 (2/1)


Risk Rating

Key Controls Assurance Gaps in Controls/Assurances Current Risk

Rating:

Q1 16/17

Actions required

Executive team on

12/7/16 marked this risk

for closure , to be

replaced with a new risk

on STP.

01-Jul-2016

ENHCCG been actively

engaging with the West

Essex Configuration work

(KPMG). Significant

engagement with partners

has delivered the draft

STP on time, which

included clinical summit,

system leaders meetings

and partnership working

across the STP

organisations. Health and

Wellbeing strategy was

launched on 24/6/16.

1) Operation strategy outlines the two year

commissioning strategy

2) Patient representative sits on the Governing Board

3) The CCG supports sufficient capacity to enable a

wide range of staff) to develop external stakeholder

relationships

4) Attendance at strategic programmes which

includes the facilitation of meetings

5) Engagement with Local Authority and Health

Scrutiny which includes participation with council

education programmes and direct engagement with

the local community

6) The Governance arrangements in relation to the

Better Care Fund have been agreed

7) Annual General Meetings for key partners

8) Governing Body builds on engagement with GPs

through the provision of clearer objectives for the

locality groups

9) Through the community wellbeing team at HCC

we jointly commission the voluntary sector. ENHCCG

have a seat on a number of performance and

planning groups which have been established a

forum for patient representatives, service groups,

councils and CCGs to meet and discuss service

issues for service users and carers.

10) ENHCCG are active participants in wider system

forums (e.g. Health and wellbeing conference, carers

action day, accept invitations to Vol sector AGM,

Herts Forward etc.)

11) 360 degree stakeholder survey results (+ve)

12) Scrutiny Committee attendance and engagement

Date Target Risk

Rating

Progress Update

31-Mar-16 1) Strategy reviewed by NHSE

2) Active participation of patients reps at Governing

body

3) 4) 5) 7) 12) Staff work plans(+ve)

6) Better Care fund reports to Governing Body and

Health and Wellbeing board (+ve)

6) Better Care funds are submitted to NHSE (+ve)

8) Locality meeting notes(+ve)

• NHSE Area Team checkpoint reviews

• Joint communications strategy agreed with key

partners to ensure cooperation and delivery (e.g.

changes to stroke pathways at PAH)

• Service and procurement redesign with amended

spec (e.g. neurology work)

9) Oversight provided by reports sent from these

groups to the JCPB (+ve)

11) No actions to be implemented from the 360

degree stakeholder survey

12) Scrutiny Committee attendance and engagement

- positive contribution

• Representation and focus on services delivered by

HCC and ENHCCG

• Membership in stakeholder engagement groups

• Engagement with PPG's.

3x1=33x2 = 6

Strategic Risk 3:

Inability to achieve engagement/buy-in from our external stakeholders to ensure appropriate collaboration in developing plans that manage, meet and maintain their expectations.

Lead Director - Beverley Flowers, Accountable Officer

3x2 = 6 3x2 = 6SO3 - To engender a culture of engagement in

the decision making processes amongst

partners and stakeholders to ensure ownership

of service priorities

3x1 = 33x1=3


3x3 = 9

Date

Opened

Nov-13

RCAD Risks:

Page 3 of 7


Q4

14/15

Q1

15/16

Q2

15/16

Q4

15/16




RCAD Risks:

Ref 1.6 - Score 9 (3/3)

Ref 1.10 - Score 12 (4/3)

Ref 1.22 - Score 12 (3/4)

Ref 1.32 - Score 12 (4/3)

Ref 1.33 - Score 12 (4/3)

Ref 1.34 - Score 12 (3/4)

Ref 1.51 - Score 9 (3/3)

Ref 1.53 - Score 6 (3/2)

Ref 1.57 Score 12 (4/3)

Ref 3.4 - Score 12 (4/3)

Ref 3.11 - Score 4 (2/2)

Ref 4.1 - Score 9 (3/3)

Ref 5.9 - Score 12 (3/4)

Ref 5.10 - Score 12 (3/4)

Date Target Risk

Rating

Progress Update

7/7/2016

CCG Transformation

Reserve (£8m) has been

frozen by NHSE so cannot

be utilised. This reduces

the CCG's ability to drive

transformational change.

1) Regular finance reports to Executive Team,

Governance and Audit, Governing Body and NHS

England

2) Detailed Financial Policies

3)Budgetary framework in place which is rated as

adequate by internal audit

4) Agreed budget for 2015/16 which included new

investment funding, contingency reserves and funds

for transformation

5) Efficiency savings are low (in comparison to other

CCG’s) with plans in place to ensure delivery

6) Approved Scheme of Delegation which details

responsibilities of budget holders

7) Financial processes in place to easily identify

overspends

8) Early Warning Signals, forecasts for early year

9) Contract monitoring and validation processes

10) Trends in activity monitored and contracts set out

responsibility levels within overall financial plan

11) Enforcing contract terms, including sanctions

12) Monthly review of expenditure and forecasts - to

review whether any action is necessary

• Implementation of all internal audit

recommendations.

• Regular reports to Governing Body

• Regular audit coverage by internal and external

audit

• Regular report on Finance Risks to Governance

and Audit Committee

• Internal Audit report on Budgetary Control (+ve)

• NHS England review of financial management

(+ve)

A) Improve reporting for non-

PbR reporting

B) To improve integrated care

across providers

C) To create more aligned

incentives across providers D)

Improve understanding of

cause and effect, prioritising

initiatives with greater and

quicker return on investmen

4x4 = 16

Linked with:

Strategic Risk 4:

Failure of the CCG to manage the financial budget and meet its financial target

Lead Director – Alan Pond – Chief Finance Officer

31-Dec-16 3x1 = 3A) Non-PbR reporting

B) Provision of real-time data

and reporting to the CCG

C) Lack of aligned incentives

between Community Providers

and Acute Providers

Current Risk

Rating:

Q1 16/17

Actions required

3x3 = 9 3x3 = 93x3 = 9 3x1=3

Previous Risk Ratings:Gaps in Controls/AssurancesInherent

Risk Rating

Date

Opened

Nov-13 3x4=12

Key Controls Assurance

Page 4 of 7


Q4

14/15

Q1

15/16

Q2

15/16

Q4

15/16

Ref 1.22 - Score 12 (3/4)

Ref 1.24 - Score 4 (2/2)

Ref 1.26 - Score 9(3/3)

Ref 1.32 - Score 12 (4/3)

Ref 1.46 - Score 9 (3/3)

Ref 1.50 - Score 12 (4/3)

Ref 1.53 - Score 6 (3/2)

Ref 1.54 - Score 12 (4/3)

Ref 2.6 - Score 9 (3/3)

Ref 2.8 - Score 4 (2/2)

Ref 3.4 - Score 12 (4/3)

Ref 4.11 - Score 4 (4/1)

Ref 4.15 - Score 12 (4/3)

Ref 4.16 - Score 12 (4/3)

Ref 5.2 - Score 12 (3/4)

Ref 5.12 - Score 15 (5/3)

Ref 5.3 - Score 15 (5/3)

Ref 5.4 - Score 15 (5/3)

Ref 5.6 - Score 2 (2/1)

Ref 4.21 - Score 12 (4/3)

Ref 5.13 - Score 12 (4/3)

Gaps in Controls/Assurances

1/7/2016

Operational plan for 16/17

has more focus on

priorities. PMO Team

have undertaken Prince II

training.

Governing Body

development training in

May 16

17/02/16

- Operational plan to include

more refined list of priorities to

focus improvement activities.

- Training organised on Project

management skills for new

project managers in CCG.

- Stock-take to be reported to

the Board every 6 months.

- Clinical job descriptions

drafted for GP Leads to outline

responsibilities clearly for the

specific areas - to ensure

professional clinical input.

- AD Development programme

took place on 16/17 September

2015.

- Agreement to push for MH

leads for each locality.

- OPD effectiveness being

reviewed regularly.

3x3 = 9 3x3=93x3 = 9

Actions required Date Target Risk

Rating

Progress Update

2x4 = 8 3x3 = 9


Risk Rating

Key Controls Assurance

Strategic Risk 5:

Failure to implement key work streams to ensure delivery of the CCG’s strategic plan

Lead Director – Beverley Flowers, Accountable Officer

A) Talent mapping and

succession plan

B) No dedicated OD lead

Ongoing

Current Risk

Rating:

Q1 16/17

3x3=9


3x1 = 31) Established Programme management with

documented systems and processes

2) Objective setting for all staff including Governing

Body members

3) Executive receive regular update on workforce

performance indicators

4) Agreed programme of mandatory training and

monitoring of compliance

5) Board development programme

6) New Clinical Development Group meetings(?):

- clinical forum/meeting with main provider to test

clinical aspects of quality and delivery

7) Monthly Organisational Performance Delivery days

to:

- progress actions and processes for escalation to

the Governing Body,

- identify areas of poor performance,

- highlight schemes to Governing Body for pilots and

funding.

8) AD Development Programme

9) Engagement of the GP Governing body with

senior clinical colleagues in HPFT (bi-monthly)

1) 7) Governing Body decision making informed by

receive regular reports on the safety and

effectiveness of services. Reports also received from

OPD around potential new services. (pilots etc.)

Programme office with processes and reporting

templates available. Prince II training (+ve)

1) Systems Resilience Group, delivery across a

number of areas - reporting and scrutiny

2) Appraisals(+ve)

2) CCG directly responsible for undertaking

contracting, information, performance and human

resources management

2) Staff leadership development programmes

underway e.g. Mary Seacole leadership programme

3) Governing Body receive reports on the effective

services we commission. Strategy and actions

reported through health and well being board (+ve)

4) HR records (+ve) and uptake reported to

Governing board (+ve)

5) Program with recent away day (May 16)

6) Clinical Development sessions?

6) Regular Board to Board with main providers (to

ensure work streams are progressing)

• Ensure that clinical sub-groups (MH leads and LTC)

engage with localities in consultation with service

changes

8) AD Development Plan (+ve) and joint AD/Exec

meeting (+ve)

6), 9) Governing body meet with senior clinical

colleagues in HPFT

1) Talent mapping and

succession planning to be

developed

Date

Opened

Nov-13SO1 - To commission safe and appropriate





SO4 - To build an organisation with the

capacity and capability to deliver agreed

service priorities

RCAD Risks:

Page 5 of 7


Q4

14/15

Q1

15/16

Q2

15/16

Q4

15/16

SO1 - To commission safe and appropriate





Ref 5.4 - Score 15 (5/3)

Ref 4.21 - Score 12 (4/3)

4x4=16 4x4=16 Development and agreement of

system wide STP setting out do

nothing scenario and the

solutions to achieve financial

balance

30-Sep-16 3x3 = 9 7/07/16

- Initial STP submitted to

NHSE. This sets out do

nothing gap iof £480m

and does not demonstrate

system financial balance

by 2020/21.

RCAD Risks:

Assurance Gaps in Controls/Assurances

Lead Director – Alan Pond – Chief Finance Officer

15/09/2015 4x4 = 16 1) Oversight of operational delivery and quality of

services by CCG directorate teams provides an early

warning of any deterioration in performance or quality

or of proposed changes in service provision that

could lead to deterioration.

2) Formal meetings with Trust, NHS TDA, NHS

England and CCG ensures CCG Chief Executive

and CFO are party to formal discussions with ENHT

and able to ensure a balanced and risk assessed

approach is taken.

3) National requirement for System Sustainability and

Transformation Plans (STP) to demonstrate financial

balance by 2020/21 forces organisation to work

together for the wider system (and patient) benefit.

• Reporting of performance and quality metrics by

Trust.

A) There is no agreed solution

to the increasing deficit being

run by ENHT and the other

acute trusts within the system.

Part of the problem is the

inceasing demand for staffing

arising from safer staffing

guidance against a backdrop of

reduced supply leading to

premium costs being paid for

staff.

N/A N/A 4x4 =

16

Target Risk

Rating

Progress UpdateLinked with: Inherent

Risk Rating

Key Controls Current Risk

Rating:

Q1 16/17

Actions required DateDate

Opened


Strategic Risk 6:

Financial Sustainability of Providers in the Health Economy - Department of Health's departmental expenditure limit could be breached unless acute trust deficits (nationally and locally) are reduced. Deficit reduction might be attempted by driving down costs and

staffing, which could impact on performance and/or the quality of services; or by increasing national prices and/or topslicing CCG funds, leading to cost pressures for CCGs nationally and ENHCCG too. In response ENHCCG would have to restrict investment and/or

reduce services to achieve its financial plan.

Page 6 of 7


Q4

14/15

Q1

15/16

Q2

15/16

Q4

15/16

Ref 1.46 - Score 9 (3/3)

Ref 4.15 - Score 12 (4/3)

Actions required Date Target Risk

Rating

Progress Update

4x4=16 A) Strategic transformation

plans (STP)

B) Executive structure being

reviewed

• Support Workforce

partnership group (WPEG)

initiatives locally

• Work with district councils to

encourage increased level of

key worker housing

• Encourage providers to

consider innovative recruitment

campaigns

• Secure workforce support for

CCG

A) 30/6/16

B)

•) 31/12/16

3x3 = 9 4/7/16

Gap C is outside the

direct ENHCCG.


RCAD Risks:

15/09/2015 1) Bi-monthly workforce partnership meetings which

monitor progress of the work streams.

Work streams in place for :

- trainees

- recruits

- our staff

- New ways of working

2) Integrated care board established to support joint

working with providers and a number of joint services

have been established.

3) Primary care network established.

4) Clinical lead for primary care workforce and

education appointed to lead on GP workforce issues

and the development of clinical fellows.

5) Practice nurse tutors appointed to support

practice nurse workforce issues and develop

placement, for students and rotations across

providers.

6) GP locality leads appointed to support education

and retention activities in localities.

7) Requirement for providers to report workforce

vacancies, attrition and sickness levels.

8) Main providers report establishment by ward and

team.

9) Chief Executive workforce partnership meetings.

10) Agency cap in place.

11) Hertfordshire workforce group.

12) Practice nurse mentors being trained

13) GP fellowship scheme being recruited

Whole risk) Workforce issues to Governing body

through IPQR

1) Workforce supply analysis carried out

1) 3) Workforce reports to OPD

7) Workforce data supplied by all organisations

Primary care elements) Primary care workforce

proposal supported by Governing Body

A) Levers for ENHCCG in

relation to HEE and

commissioned services.

B) Lack of capacity for work

force issues

C) ENHCCG does no direct

influence over workforce

provision.

N/A N/A N/A 4 x 4 =

16

Current Risk

Rating:

Q1 16/17

Linked with: Date

Opened

Inherent

Risk Rating

Key Controls Assurance Gaps in Controls/Assurances

Lead Director – Sheilagh Reavey – Director of Nursing and Quality

Strategic Risk 7:

As a result of a shortage of appropriately skilled staff there is a risk that the CCG will not be able to effectively commission new services or provide existing services which could result in diminished services and poor outcomes for patients and

failure to deliver core services.

Page 7 of 7

2016-07-12 Risk Controls Assurance Dashboard v7.0 FINAL.xlsx

PROGRESS KEY:

Appendix B

2016/17 Risks Controls and Assurance Dashboard – (June/July 2016)

RCAD

Ref.Risk

Responsible Manager -

Area of Responsibility

Accountable

Director

Link to SR

and SODate Opened

Inherent Risk

Profile I/LControl Assurance in place

Gaps in Controls and

Assurances

Current Risk

ProfileAction Plans

Action Owner

and Timescale

Target Risk

Profile I/L

Risk profile

Acceptable?Progress Update

1.52 The Pathology Partnership (TPP):

Risk of patient treatment being

compromised due to delayed or

missing microbiology results

being received by requesting

chain.

(1) Delays in microbiology results

to primary care

(2) Delays in microbiology results

to ENHT due to IT failures

between TPP Beaker system and

ENHT CliniSys system

Holly Fairhurst

- Provider

Performance

Harper Brown SR1

SO1

14/07/2015 4/4 1. Microbiology Action Plan in place with key issues identified

relating to primary care issue.

2. Clinical Forum with agreed GP leads meeting between

ENHCCG,ENHT and TPP every 6 weeks.

3. Contract meeting led by C&PCCG monthly

1. Regular review of

action plan

2. Regular primary care

input to provide GP

perspective. This is both

through the clinical forum

and through the GP

hotline function.

On-going analysis of TPP

related hotline enquiries

within the CCG Quality

Team.

Appropriate escalation

from Clinical Forum

meeting to NHS England

and CQC (via QSG)

3. Regular ENHCCG

representation at monthly

contract meeting

(Contract Manager)

A. Whilst there are on-

going discussion

regarding IT solutions

relating to ENHT and TPP

issue, no immediate fix

has been identified.

Additionally the IT

systems are owned by a

number of providers.

B. For primary care issue,

PHE microbiology

recovery plan on ENH

Pathology service

monitored 6 weekly.

N/A N/A 3/4 4/4 4/4 A. External review requested, due to

begin mid July

A/B. 6 weekly clinical forum to

monitor agreed actions

B. Alternative providers being

scoped by CCG for GP direct

access contract.

A) S Reavey

11July2016

A/B

)28July2016

B)?

Sept 2016

3/2 Yes 22/6/16

Risk remains 4/4 .

21.4.16 Clinical forum held and

concerns raised by ENHT regarding

IT failures.

Discussions held with LMC. Verbal

escalation to NHSE and CQC

27.4.16 Formal escalation to NHSE

and CQC during QSG meeting

29.4.16 Specification for external

review written

Data relating to ENHT microbiology

results issues sourced from Trust.

3.5.16 TPP response to ENHT

issues received by CCG, confirming

IT issues does not affect GP

requested tests being sent to GPs

5.5 -

NHSPS

2

Planning and pre-testing of

generator at Charter House

Failure of generator resulting in

loss of all ICT services currently

provisioned out of Charter House

data centre

Technical Services

- Keith Fairbrother

Phil Turnock SR1

SO3

01/05/2015 5x3 = 15 1) Data centre services have UPS protection which will provide

circa. 30 minutes protection

2) 24x7 support with Dart for the UPS. Additionally, a schedule

of maintenance is in place

1) & 2) Interim activity with

load testing with DART

has been planned to carry

out a full load test across

Charter House (+ve)

A) Generator untested

B) Questions relating to

fuelling and ongoing

maintenance including

safety

5x3 = 15 5 x 4 =20 A) Work with NHSPS to deliver tests

of Generator

B) NHSPS has a contract for

maintenance ?

A) Keith

Fairbrother

B) NHSPS ?

4x1 = 4 29/6/16

Generator testing has still not taken

place and given the lessons from the

recent at Waverley road power

outage this risk has raised in

severity. NHS Property Services

(NHSPS) have scheduled test for

Saturday in August

01/10 Awaiting information from

NHSPS

7/2 - Pending information from

NHSPS, Interim activity with load

testing with DART has been planned

to carry out a full load test across

Charter House.

5.7 If the CCG is not sufficiently

prepared for Pandemic Flu there

is a risk that if pandemic flu

occurs delivery of essential

services could be compromised

resulting in poor outcomes for

patients.

Relevant Information: Based on

our understanding of previous

pandemics, a pandemic is likely

to occur in one or more waves,

possibly weeks or months apart.

Each wave may last between 12-

15 weeks. Up to half the

population could be affected. All

ages may be affected, but until

the virus emerges we cannot

know which groups will be most

at risk.

Sharn Elton Sharn Elton SR1 16/03/2016 5/4 1) Major Incident Plan in place for CCG.

2) Incident Coordination Centre (ICC) Action Plan for CCG.

3) Business Continuity Plan

- Business Impact Assessments (BIA)

4) Regular exercises and training for staff

5) Hertfordshire pandemic plan

6) NHS England Midlands and East Pandemic Influenza

Concept of operations (Draft)

7) Communication with patients via services such as 111 and

routing of patients to appropriate medical treatment. Medical

advice provided nationally to 111 and other communication

hubs by NHS England/DoH

8) Public Health notifications via NHS England. Other Global

Pandemic Flu Surveillance systems such as those provided by

WHO may provide early alert of Pandemic Flu.

9) If vaccine available, vaccinate key personnel (vaccine may

not be available or only available in limited quantities early on in

the pandemic)

1) to 4) CCG EPPR self

assessment, assurance

with full compliance rating

by NHS England

1) to 4) Emergency

planning and business

continuity advisors (Oskan

Edwardson & Ian

Croscan) provide subject

matter expert advice.

5) Assurance on

Hertfordshire plan signed

off by LHRP March 2016

6) Regional EPRR lead

attends LHRP

7) Business Continuity

arrangements written into

111 contract (same is true

of all providers)

In the event of a pandemic

controls 7) 8) and 9) are

largely outside the control

or influence of the CCG.

However local resilience

of communication hubs

such as 111 require

business continuity plans

for these services.7)

A) Scientific Summary of

Pandemic Influenza and

its mitigation by DoH

(2011) suggests that

issues relating to staff

absenteeism related to

willingness to work are

very likely. In a severe

pandemic only a minority

of staff may be willing to

work.

B) Alignment BIA across

CCG to support BCP

N/A N/A N/A 5/4 5/4 ? A) Scope the impact of developing

agile working for frontline e.g.

laptops, VPN access from home

and conference call

capability/information sharing

software and infrastructure. This

would also support the development

of our business continuity resilience

e.g. severe weather, fuel disruption,

loss of building etc. Review the need

for access to PPE for patient facing

staff.

B) Need to align BIA across CCG to

support BCP

A) Richard

Steadman

B) Richard

Steadman

Jul2016

5/3 Executive team want a further

discussion about the risk scoring

for this risk. So it is temporarily

unshaded.

New Risk agreed by Executive

Team on 11/05/2016.

04/07/2016.

Actions are ongoing as risk was only

recently added to RCAD.

Risk rating reduced from last report

Risk rating remains the same as last

reported

Risk rating increased from last report

Previous Risk Rating:

Q4 14/15 I Q1 15/16 I Q2 15/16 Q4 15/16

1 of 2

2016-07-12 Risk Controls Assurance Dashboard v7.0 FINAL.xlsx

RCAD

Ref.Risk

Responsible Manager -

Area of Responsibility

Accountable

Director

Link to SR

and SODate Opened

Inherent Risk

Profile I/LControl Assurance in place

Gaps in Controls and

Assurances

Current Risk

ProfileAction Plans

Action Owner

and Timescale

Target Risk

Profile I/L

Risk profile

Acceptable?Progress Update

Previous Risk Rating:

Q4 14/15 I Q1 15/16 I Q2 15/16 Q4 15/16

5.8 There is a national shortage of

beds for Children and Young

People who need an admission

for a mental health crisis. This is

commissioned by NHS England

Specialised Commissioning but

has a knock on impact on local

areas as children wait longer than

is idea for a bed and then are

often placed outside

Hertfordshire, meaning that it is

difficult for families to maintain

contact.

Simon Pattison Sheilagh

Reavey

24/05/2016 4/4 1) C-CATT team in place to quickly assess and support CYP in

crisis

2) Regular meetings between NHS England Specialised

Commissioners and local CAMHS commissioners to monitor

placements

3) New Care and Treatment Review process being

implemented

Monitored through HPFT

QRM.

1) Shortage of beds

nationally

2) NHs England make

decisions on placements

so we cannot influence

this

NEW NEW NEW 4/4 4/4 1) Audit of cases accessing CAMHS

crisis services at Lister

2) Negotiations with NHS England to

take back management of inpatient

beds

3) Provider discussions between

HPFT and ENHT to improve

communication and case

management between the two

providers.

1) Sarvjeet

Dosanjh June

2016

2) Simon

Pattison - tbc

dependent on

NHS England

3) Simon

Pattison

Ongoing

3/3 30/6/2016

Risk was added to register in May.

HPFT have expressed interest in

taking over the management of tier 4

beds from NHSE with decision

expected in July

2 of 2

RISK SCORING MATRIX

Strategic Objectives:

SO1: To commission safe and appropriate healthcare services.

SO2: To commission effective services that enhances the well-

being of our residents within the available resources.

SO3: To engender a culture of engagement in the decision making

processes amongst partners and stakeholders to ensure

ownership of service priorities.

SO4: To build an organisation with the capacity and capability to

deliver agreed service priorities.

Strategic Risks:

SR1: Failure of the CCG to ensure delivery of safe, high quality and effectives services from appropriately commissioned providers.

SR2: Failure to establish an adequate and appropriate commissioning plan that is informed by member practices.

SR3: Inability to achieve engagement/buy-in from our external stakeholders to ensure appropriate collaboration in developing plans that manage,

meet and maintain their expectations.

SR4: Failure of the CCG to manage the financial budget and meet its financial target.

SR5: Failure to implement key work streams to ensure delivery of the CCG’s strategic plan.

SR6: Financial Sustainability of Providers in the Health Economy - Depatment of Health's departmental expenditure limit could be breached

unless acute trust deficits (nationally and locally) are reduced. Deficit reduction might be attempted by driving down costs and staffing, which

could impact on performance and/or the quality of services; or by increasing national prices and/or topclicing CCG funds, leading to cost

pressures for CCGs nationally and ENHCCG too. In response ENHCCG would have to restrict investment and/or reduce services to achieve its

financial plan.

Appendix C - Guidance

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