NHS NOTTINGHAM NORTH AND EAST RISK ASSURANCE …€¦ · The Fig QIPP group reviews the QIPP...

RAG RATING KEY

Key Control Status Assurance Status Acton Plan Status

Effective Positive Complete

Developing Not Identified/Developing Ongoing - On Track

Not Effective Negative Ongoing - Slight Slippage - < 2 months

Ongoing - Significant Slippage > 2 months

NHS NOTTINGHAM NORTH AND EAST

RISK ASSURANCE FRAMEWORK March 2016

Impact Likelihood Score Jan-16 Mar-16 May-16 Jul-16 Sep-16 Dec-16 Feb-17

R01 Jonathan Bemrose, Finance and Information Group

The CCG is unable to deliver against plan due to continually increasing activity, unexpected costs and an inability to maintain QIPP savings.

5 4 20 20 20 20 20 8

R02 Jonathan Bemrose,

Finance and

Information Group

The fragility of the system impacts on the

capability of the CCG to deliver against its financial

duties. 5 3 15 15 15 15 15 6

R03 Sam Walters /

Sharon Pickett, Various

Demands impacting on short term performance

hinder the capability to support transformation and plans for the long term including new models of care. Due to competing demand and the complexity of the system, the CCG is unable to provide leadership in co-ordinating the delivery of

core standard and recovery actions across the local health economy.

5 4 20 20 20 20 20 8

R04 Nichola Bramhall,

Quality and Risk

Committee

The CCG is unable to provide confidence to its

local population that it is commissioning clinically

safe, high quality, compassionate services. Lack of adequate focus and challenge may lead to compromised quality, outcomes or inappropriate

prioritisation.

5 2 10 10 10 10 10 6

R05 Hazel Buchanan,

Clinical Cabinet and Service Imrovement

Group

Due to a lack of understanding and/or effort to

recognise the different population segments, the CCG is unable to plan effectively and reduce

health inequalities and/or demonstrate continuous improvements for the protected characteristics.

5 2 10 10 10 10 10 6

R06 Sam Walters,

Governing Body

There is a risk that pressures and fragility within

the system impact on the CCG's capability to deliver against targets. 5 4 20 20 20 20 20 8

R07 Chair, Primary Care

Commissioning Committee and Governing Body

Limited engagement between member practices

and with the CCG impacts on the capability to work together on delivery of transformational change, including gaining benefits through

commissioning, federation and to improve the quality of primary medical services.

4 3 12 12 12 12 12 6

R08 Sam Walters,

Governing Body

Leaders are not visible and are not able to focus

on the short and longer term priorities of the CCG, due to the resource and focus required as lead commissioner for NUH.

4 2 8 8 8 8 8 2

R09 Sam Walters, Governing Body

High turnover and lack of succession planning in the leadership team and the Governing Body impacts on the capability to evidence robust leadership. 4 2 8 8 8 8 8 2

RISK ASSURANCE FRAMEWORK - EXECUTIVE SUMMARY

Target Risk

Rating

Trend from

Previous

Report

Initial Risk RatingRisk ID

Lead and Committee Risk Narrative

Risk Rating Performance

Risk ID R01

Date Risk Established as Per New Framework 01/01/2016

Date Risk Last Updated 19/01/2016

Impact Likelihood Risk Score Impact Likelihood Residual Risk Score Trend

5 4 20 5 3 15

Gaps in Controls and Assurance

Description Status Date in place* Description Status Date in place Description Identified Action Deadline Owner Progress Status

Financial reporting - the Chief Finance Officer presents a financial

report to the Governing Body and financial information to the Clinical

Cabinet. Reports are tailored to reflect areas of influence.

Effective 01/01/2016 The financial report provides detail on performance against

duties.

Positive 01/01/2016 To consider in relation to any changes as per the planning

guidance. Allocations will now be provided every three years.

To continue to refine reporting in order to target

specific audiences.

01/06/2016 IL Finalising schemes on QIPP plan to cover required

savings. 01.07.16 A further exercise is being

carried out to identify QIPP schemes relative to

gap. Extraordinary GB held.

Finance and Information Group - the FIG is attended by Governing

Body (clinical and Lay representation) and senior executives. Full

financial and activity reports are presented. The Fig QIPP group

reviews the QIPP highlights in detail and a "deep dive" is carried out

within each meeting to discuss risks and alternatives.

Effective 01/01/2016 FIG minutes along with a verbal summary is provided to

the Governing Body.

Positive 01/01/2016 Cross CCG QIPP Group and 2016/17 QIPP Plan Ongoing with

First Draft of

Plan Due

IL Group has formed to discuss QIPP plan. As above.

Activity Reports - Comprehensive activity reports highlight key trends

and areas of risk.

Effective 01/01/2016 Activity reports are discussed in detail in the FIG and

presented in the Clinical Cabinet which allows for the

identification of any anomalies.

Positive 01/01/2016

Financial reports are produced and distributed to all CCG budget

holders on a monthly basis which relate to CCGs operating costs.

Effective 01/01/2016 Financial reports are signed by budget holders. Positive 01/01/2016

Practice based budgets are produced and included in a monthly GP

practice pack. The FIG review spend against budget and support the

prioritisation of practice visits for top overspending practices.

Effective 01/01/2016 Practice visits and discussions in the Clinical Cabinet have

indicated an understanding and recognition of spend

against budget.

Positive 01/01/2016

NHS England assurance process includes the financial position. Effective 01/01/2016 NHS England has carried out a "Deep Dive" on Nottingham

North and Nottingham East CCG. They have sent a letter

confirming their assurance.

Positive 01/01/2016

Annual reporting and annual accounts. Effective Internal and External Audit Positive 01/01/2016 To go out to procurement for external audit in 2016/17. This will

be against a standard service specification which is being written

by the Department of Health

Effective

Effective

Risk Description Strategic Objective

The CCG is unable to deliver against plan due to continually increasing activity, unexpected costs and an inability to maintain QIPP savings.The CCG has effective and appropriate financial

management including stretching itself financially, efficient

financial controls and processes and good governance.

Lead and Committee Responsible Current Risk Rating* Residual Risk Rating

Jonathan Bemrose, Finance and Information Group

Key Controls in Place Assurance on Effectiveness of Controls Action Plan to Mitigate Risk

The CCG has agreed detailed financial risk management

arrangements with other CCGs in the south of Nottinghamshire. The

risk pooling arrangements protects against unplanned variance in

commissioning spend associated with volume changes, as well as the

impact of small numbers of high cost patients. The risk management

arrangements also extend to the pooling of risk around continuing

care. The performance of the risk pool is reported to the FIG.

The CCG's risk management arrangements have been

examined and agreed by the FIG.

The CCG's accounts are subject to annual external audit by

KPMG and reported in the annual governance statement

and annual report.

The CCG's financial risk management arrangements have

been further developed with the finalisation of the PWC

supported risk pool to manage variance in commissioned

spend.

Positive

Risk ID R02

Date Risk Identified 01/01/2016


Impact Likelihood Current Risk Score Impact Likelihood Residual Risk Score Trend

5 3 15 5 2 10


Description Status Date in place Description Status Date in place Description Identified Action Deadline Owner Progress Status

Provider/Commissioner finance meetings - there has been an

agreement to review finances as a system.

Developing 01/01/2016 Governing Body reporting on delivery against financial will

provide an indication.

Developing 01/01/2016 Comprehensive reporting as asystem - supported through work

of Greater Nottingham Health and Care Partners.

To continue to develop relationships and processes

for managing finances as a system.

Ongoing (?) Jonathan Bemrose, Ian

Livsey

JB lead for GNHCP finance group. Group has

started to develop shared forecasts and business

planning tools. Draft STP has been completed.

The Greater Nottingham Health and Care Partners governance

structure includes a finance and performance workstream. This is

supporting the opportunity to work together as a system.

Developing 01/01/2016 This will come through the governance structures of the

Greater Nottingham partners.

Developing 01/01/2016 To produce strategic plans as per planning guidance final plans 11

April 2016, 1st

draft of STP 11

April 2016.

Final draft

June.

Rebecca Larder Working with mid-notts on first draft for

submission the 11 April. First draft submitted.

Steering Group has been formed. Next

submission June. Draft submission has been

made to NHS England. Comments will be

returned in July.

Collaborative agreements are in place to ensure partnership working

across Health and Social Care. These include regular meetings to

discuss joint commissioning agendas such as the Better Care Fund

(BCF) Working Group, the Health and Wellbeing Board Delivery Group

and participation in specific joint stakeholder events. The CCG has

significant representation in these meetings including the Chief

Finance Officer , Chief Officer and Chair.

Effective 01/01/2016 The CCG financial performance reporting. Effective 01/01/2016

Residual Risk RatingLead and Committee Responsible

Current Risk Rating

Action Plan to Mitigate Risk


The fragility of the system impacts on the capability of the CCG to deliver against its financial duties. The CCG has effective and appropriate financial

management including stretching itself financially, efficient

financial controls and processes and good governance.

Jonathan Bemrose, Finance and Information Group

Key Controls in Place Assurance on Effectiveness of Controls

Risk ID R03




5 4 20 4 3 12



CCG Committees will continue to monitor performance against short

term and CCG specific long term objectives. The Greater Nottingham

Partners governance structure and supporting infrastructure will

continue to progress the longer term, whilst working alongside CCG

staff on short term initiatives.

Effective 01/01/2016 Committee updates and Governing Body reporting will

provide assurance. The Greater Nottingham Health and

Care Partners governance structure and Board will provide

assurance on wider and longer term objectives.

Positive 01/01/2016 To produce operational plans as per the planning

guidance.

11/04/2016 Sharon Pickett First draft of operational plan has been completed

(with reviews with NHS England). Operational

plan complete.

Comprehensive performance reporting is presented to the Governing

Body with relevant action plans.

Effective 01/01/2016 Performance reporting is developed with changing

demands. Performance reporting demonstrates trends.

Positive 01/01/2016 To produce strategic plans as per the planning

guidance and as part of the footprint.

01/06/2016 Sam Walters Discussions being held on how to manage as a

footprint. Footprint steering group established.

Plan being developed as Nottinghamshire.

GNHCP plans developing and informing STP.

`

The Greater Nottingham Health and Care Partners has a supporting

infrastructure which allows the CCG to manage short term

performance.

Developing 01/01/2016 Transformation is able to progress without destabilising

CCG, including limiting resource constraints

Developing TBC - dependent

on new structure

New structure being implemented for the Greater Nottingham

Health and Social Care Partners. Need to then determine how to

align with CCG.

To include as part of a development session for the

Governing Body to ensure fully briefed. To include

presentation on the Vanguard to the Governing Body.

01/04/2016 Sam Walters Schedules for March

The CCG is part of a wider system and shared arrangements have

been tested and are working effectively across south

Nottinghamshire, providing checks and controls for short term

performance. This includes the System Resilience Group.

Effective 01/01/2016 Delivery against targets including outputs and decision

making from internal and external committees and groups.

Positive 01/01/2016

The System Resilience Group, System Resilience Implementation

Group and TAG meetings provide a comprehensive structure for

managing short term performance on urgent care.

Developing 01/01/2016 New EMAS protocols and operational plans have been

implemented.

Positive 01/04/2016


Capacity and demands impacting on short term performance hinder the capability to support transformation, the footprint and plans for the long term.The CCG has comprehensive and achievable plans as both a

CCG and as part of a wider system.

Lead and Committee Responsible Current Risk Rating Residual Risk Rating

Sharon Pickett/ Rebecca Larder - Various


Risk ID R04



Impact Likelihood Risk Score Impact Likelihood Risk Score Trend

5 2 10 4 2 8



Quality Report - a quality report is presented to the Governing Body

and discussed in detail in the QRC. This includes HCAI, serious

incidents, patient safety, safeguarding, transforming care, care

homes, continuing health care retrospective claims, quality visists,

patient experience, complaints, patient stories, primary care quality,

CQC inspections, quality monitoring and nursing and midwifery

council revalidation.

Effective 01/01/2016 Detail is discussed in the QRC and from this relevant items

are escalated to the Governing Body.

Positive 01/01/2016

Safeguarding Committees - the committee aims to ensure that

systems and process are in place to safeguard vulnerable adults and

children as a core component of the services provided and

commissioned by the following Nottinghamshire Clinical

Commissioning Groups (CCGs):

Effective Minutes and highlight reports are provided to the

Governing Body.

Positive

Quality and Risk Committee - through the committee details on all

providers are discussed and escalated where relevant to the

Governing Body. The Committee includes clinical, lay and executive

membership. The governance structure supporting the QRC includes

scrutiny panels and lay representation. Visists are made to the

providers.

Effective 01/01/2016 Minutes and summaries are provided to the Governing

Body.

Positive 01/01/2016

Quality Impact Assessments are completed for all changes and are

reviewed by the Director of Nursing and Quality. Any issues are

escalated to the QRC. QIAs support all members of staff to

understand and focus on elements related to quality.

Effective 01/01/2016 QIAs are reviewed by the Director of Nursing and are

escalated to the QRC.

Positive 01/01/2016

Equality Impact Assessments are done for all changes and initiatives

that directly impact on patients and public. The completion of the

EIAs supports the commisisoning of high quality compassionate

services.

Effective 01/01/2016 EIAs are reviewed by the E&D forum and are tested

through patient and public involvement.

Positive 01/01/2016

Clinical Cabinet - the Clinical Cabinet is attended by GPs from each of

the member practices as well as the secondary care consultant.

Through this committee members discuss what is clinically safe and

use this forum to highlight any concerns they may have with

providers.

Effective 01/01/2016 Clinical Cabinet minutes are reported to the Governing

Body

Positive 01/01/2016

Care Homes - the quality team work directly with the Local Authority

and visit care homes on a regular basis. Reporting on care homes is

provided to the Quality and Risk Committee and Governing Body.

Effective 01/01/2016 Detail is discussed in the QRC and from this relevant items

are escalated to the Governing Body.

Positive 01/01/2016

Medicines Optimisation - a Care Home Pharmacist focuses on

medication reviews and medicines management, including storing

medicines safely. The Pharmacist works closely with the Care Homes

team in order to discuss any areas of concern. A member of

thepharmacy team has a specific focus and responsibility for patient

safety and a south forum has been established to specifically discuss

issues in meds management.

Developing 01/01/2016 The pharmacists are supported by the Quality Team. Developing

Medicines Optimisation - Reviews and audits taking place with

additional focus on SIP feeds and medication prescribed for patients

with a learning disability

Developing 01/06/2016 The pharmacists are supported by the Quality Team and

Mental Health Liaison Nurse .

Developing

A primary care quality assurance framework is being developed to

incorporate a quality dashboard, risk matrix and escalation process.

Developing 01/04/2016 Homecare - monthly quality meetings with CCG/Citycare

established, audit tool drafted, Health and Social Home

Care programme board and operational groups established

to progress new contracts and establish joint quality and

contract monitoring arrangements.

Developing



The CCG is unable to provide confidence to its local population that it is commissioning clinically safe, high quality, compassionate services. Lack of adequate focus and challenge

may lead to compromised quality, outcomes or inappropriate prioritisation.

The CCG demonstrates that it is planning effectively

providing a basis for transforming services, improving

outcomes while ensuring that patients receive the high

quality, timely care that they have a right to expect today.


Nichola Bramhall, Quality and Risk Committee

Risk ID R05




5 2 10 4 2 8



Joint Strategic Needs Assessment (JSNA) - the JSNA is used as a

source of intelligence in understanding health inequalities. This is

applied to service specifications and patient and public involvement.

The CCG contributes directly to the writing of the JSNA.

Effective 01/01/2016 Chapters of the JSNA are approved by the Health and

Wellbeing Board. The JSNA is used by the Local Authority

and Public Health.

Positive 01/01/2016 Patient and public involvement - identifying segments

engaged with.

01/06/2016 Hazel Buchanan Recruiting for the position of Patient and Public

Engagment Manager. Position recruited to.

Establishing processes for involvement across

segments. Have identified learning disabilities

and men as areas to target due to CCG

population.

Equality Impact Assessments are done for all changes and initiatives

that directly impact on patients and public. The completion of the

EIAs ensures that different needs are considered in the design and

communication of service changes and any other CCG activities

directly impacting the local population.

Effective 01/01/2016 EIAs are discussed in the Equality Forum and escalated to

the Quality and Risk Committee as relevant. These would

in turn be brought to the attention of the Governing Body.

Positive 01/01/2016 All EIAs to be published on the web-site. Mapping data is to be provided by local super output

area and will cover health inequalities. This is being

produced by Public Health in liaison with the Health

and Wellbeing Board

22/03/2016

(workshop)

Hazel Buchanan Workshop in March being run by HWB. Action

plans developed. Discussions held in LA

Partnership.,

Lay member patient and public involvement will also hold

responsibility for championing e&d and reducing health inequalities.

Developing 01/02/2016 The Lay Member PPI sits on the Governing Body and

through responsibilities, facilitates inclusive leadership.

Developing 01/02/2016 This is developing as we have a new Lay Member for PPI starting

1 Feb 2016.

To publish EIAs and link directly to patient and public

involvement.

01/05/2016 Hazel Buchanan Working with service improvement team.

Establishing processes with recruitment of PPI

Manager. PPI Manager liaising with Service

Improvement.

The CCG is a member of the Community Safety Partnership which

provides detail on health inequalities. Through this the CCG sits on

the Hate Crime steering and implementation group.

Effective 01/01/2016 The community safety partnership reports to the Safer

Nottinghamshire Board.

Developing 01/01/2016 A means of reporting back to the Governing Body (and to other

south CCG GBs) in order to highlight areas discussed and agreed.

Operational and strategic plans to be produced for

2016/17. Strategic plan is to 20/21

01/06/2016 Sharon Pickett/Sam

Walters

Plans being developed with the support of

neighbouring CCGs. STP being developed with

mid-motts. External support has been procured

to develop plan for GNHCP and to support the

development of the STP.

Business cases and service specifications are completed for all

changes. These detail the needs of the population and reflect the

outcome of the EIAs.

Effective 01/05/2016 Business cases and service specifications are presented to

either the Service Improvement Group or the Clinical

Cabinet. These forums will ensure that health inequalities

have been taken into consideration.

Developing 01/01/2016


Due to a lack of understanding and/or effort to recognise the different population segments, the CCG is unable to plan effectively and reduce health inequalities and/or

demonstrate continuous improvements for the protected characteristics.






Sharon Pickett, Clinical Cabinet


Risk ID R06




5 4 20 4 4 16



Targets are included in the contracts with providers. Performance is

monitored by the Contract Executive Board and Quality Scrutiny

Group on a monthly basis along with all other performance measures.

The group agrees actions to resolve performance issues and ensures

that these are reflected in the contractual agreement between

provider and commissioner.

Effective 01/01/2016 The performance report indicates changes in performance

as impacted by discussions and action plans.

Positive 01/01/2016 Remedial Action Plans are being implemented. Ongoing Maxine Bunn Remedical Action Plans continue to be monitored

and penalties applied accordingly. Board to Board

meeting held with NUH.

The System Resilience Group and System Resilience Implementation

Groups manage pressures across the system. TAG meetings have

also been established to review processes and patients.

Effective 01/01/2016 NHS England and The TDA actively monitor performance

on key targets.

Positive 01/01/2016 2016/17 Operational Plans to be developed in line

with planning guidance.

Complete Sharon Pickett Operational Plan has been reviewed by NHS

England and relevant updates made. Operational

plan finalised.

Comprehensive performance reports are presented to the Governing

Body.

Effective 01/01/2016 The Governing Body review at every meeting. There is the

opportunity to develop the performance report.

Positive 01/01/2016 Right Care approach being implemented in the CCG

which will help to strengthen the CCG and mitigate

risk.

01/06/2016 Sharon Pickett Right Care Workshop in February. New

commissioning for value packs released and being

reviewed by CCG. Considering in relation to QIPP

plans.

The Greater Nottingham Health and Care Partners workstreams are

focusing on short term changes that will impact on the system,

alongside longer term changes.

Developing 01/01/2016 Workstream leads produce highlight reports which indicate

areas of progress. The workstream leads link in with the

CCG to ensure that projects are aligned.

Developing 01/01/2016 Plans to progress further. Right Care approach to be more fully

implemented.

Communications - the CCG carries out campaigns in order to change

the way the healthcare system is ued by patients. Campaigns focus

on urgent care, knowing local services, medical conditions, winter

pressures. Campaigns may be locally developed or part of a national

programme.

Effective 01/01/2016 Communications have demonstrated a change in patient

behaviour in relation to 111. The CCG works closeley with

NHS England in order to implement national campaigns at

a local level.

Positive 01/01/2016

Better Care Fund - the BCF provides an opportunity for joint health

and social care plans. Delivery against the BCF is monitored and

progress is reported back to the Health and Wellbeing Board. The

BCF supports collaborative working and change across the system.

Effective 01/01/2016 Progress is monitored and reported back to the CCG

through the performance report and also to the Health and

Wellbeing Board.

Positive 01/01/2016

EMAS protocols and operational plans have been implemented.

Harm reviews have been formalised and undertaken regularly.

Progress and improvements as a result will be included as

performance reporting.

Developing 01/03/2016 CQC Inspections on providers Positive EMAS 11/2015

Quality Scrutiny Panels - ED Pathway Quality Metrics established and

monitored quarterly through Quality Scrutiny Panel. Monitoring

recommendations from CCG/TDA visit (Feb 2016) . 2016/17 quality

schedules agreed with NUH to include regular harm review exception

reports for 12 hr breaches to be received by panel.

Developing 01/01/016-

01/13/2016



There is a risk that pressures and fragility within the system, ie ED, Cancer, EMAS, impact on the CCG's capability to deliver against targets.






Sam Walters, Governing Body

Risk ID R07




4 3 12 3 3 9



Primary Care Team - the primary care team work directly with

member practices and produce a weekly newsletter to provide

regular updates. The primary care team organise Practice Learning

Time events which cover both clinical and non-clinical topics.

Effective 01/01/2016 The work of the primary care team has demonstrated

improvements in engagement and supporting member

practices. The team directly support

Positive 01/01/2016 CCG to work with GP practices on federating/ Primary Care Home - this is a provider initiative and is

being supported by the CCG. An outcome will be

improved relationships between member practices.

NAPC

Deadlines

James Hopkinson/Sharon

Pickett

Regular meetings are being held. Leadership has

changed. Initiative being reviewed.

Clinical Cabinet - a GP representative from each of the practices is a

member of the Clinical Cabinet. The agendas of the Clinical Cabinet

support

Effective 01/01/2016 Clinical Cabinet attendance is good and discussions have

improved in relation to commissioning.

Positive 01/01/2016 The CCG have commissioned a GP to support

practices in identifying and working towards

federation.

Ongoing (now

linked to PCH).

Sharon Pickett The position has been recruited to and early

discussions have started with member practices.

Governing Body - There are 5 GP representatives on the Governing

Body which is further strengthened by the attendance at Locality

Meetings

Developing 01/09/2016 Governing Body attendance is good Developing 01/09/2016

Primary Care Commissioning Committee considers the outcomes

from the quality dashboard and is supported by a Primary Care

quality working group. Primary Care Commissioning Committee will

review all areas of performance.

Developing 01/01/2016 Performance and trends identified through the quality

dashboard. Reports from NHS England.

Positive 01/01/2016 GP recruitment to the Governing Body. 01/06/2016 Hazel Buchanan Interviews held, going to election. New GPs

recruited and attending first GB meeting in July.

NHS England Assurance Framework - the CCG completes a self-

certification on a quarterly basis on delegated responsibilities.

Developing 01/01/2016 NHS England review and feedback on the self-certification. Developing 01/01/2016 To tighten up internal processes for completion of the self-

certification.


Limited engagement between member practices and with the CCG impacts on the capability to work together on delivery of transformational change, including gaining benefits

through commissioning, federation and to improve the quality of primary medical services.To ensure effective and efficient management of delegated

functions and high quality primary care.


Chair, Primary Care Commissioning Committee and Governing Body


Risk ID R08




4 2 8 2 1 2



The exec team have a weekly meeting and review all priorties and

areas of pressure. Responsibilities are clearly defined between the

exec team.

Effective 01/01/2016 Progress of priorities by the CCG. Positive 01/01/2016 Responsibilities across CCGs have been revisited in

line with additional responsibility. This remains an

action to provide time for changes to settle in and a

review on the balance of capacity to be carried out.

Ongoing Sam Walters Chief Officers are taking forward new areas of

responsibility. The planning guidance and

footprint have impacted on how work together.

Thereis also the impact of SFHFT.

The Chair and Assistant Clinical Chair meet weekly at the CCG offices. Effective 01/01/2016 Knowledge and input of Chair and Assistant Clinical Chair

to CCG meetings.

Positive 01/01/2016 Board to boards and NNE Governing Body reporting to

be finalised.

01/04/2016 Hazel Buchanan Board to Board meeting with NUH held in April.

A bi-weekly Communications Cell is held with all staff to update on

initiatives.

Effective 01/01/2016 Staff survey will provide insight on visibility of the senior

leaders.

Positive 01/01/2016

Shared teams will continue to provide contracting support. Effective 01/01/2016 Reporting to the Governing Body Positive 01/01/2016 Governing Body role in relation to NUH responsibilities to be

formalised through Board to Board meetings.

The Chair and Chief Officer will continue to attend committees of the

Governing Body.

Effective 01/01/2016 The annual CCG survey will provide insight into the visibility

of senior leadership.

Positive 01/01/2016


Due to the resource and focus required as lead commissioner for NUH, leaders are not visible and are not able to focus on the short and longer term priorities of the CCG.

To ensure a well-led organisation including strong

leadership and good governance resulting in delivery of all

statutory functions and duties, partnership working and a

strong workforce.




Risk ID R09




4 2 8 4 1 4



The Governing Body structure includes an Assistant Clinical Chair

position which supports succession planning for the Chair. The CCG

organisational structure includes a Deputy Chief Officer. The overall

structure supports succession planning.

Effective 01/01/2016 Outputs from Governing Body meetings. Positive 01/01/2016 ? Review of the Governing Body structure to allow for

more direct exec input.

01/05/2016 Hazel Buchanan Tied into recruitment of new Chair. New COI

guidance indicates the need for a third lay

member.

Workforce reporting is carried out on a monthly basis and provides

information on turnover rates.

Effective 01/01/2016 Workforce performance against benchmarks. Developing 01/01/2016 Regular review of workforce data in exec meeting. To produce regular reporting for the exec team to

review (against benchmarks)

01/06/2016 Hazel Buchanan Have liaised with HR provider to amend reports.

First workforce report produced for the GB.

The leadership team and Governing Body are supported with group

and individual development sessions. Individuals have access to

coaching and part of this is to support succession planning.

Effective 01/01/2016 Outputs from Governing Body meetings. Self-Assessments

of Governing Body. (GB did peer review with Hardwick)

Positive 01/01/2016 There are going to be significant changes in Governing Body and

therefore need to consider when to do another self-assessment.

Governing Body recruitment. 01/05/2016 Hazel Buchanan Roles have been advertised. Interviews have

been carried out. Secondary Care Consultant

recruited. GPs recruited.

Development plans for the leadership team and the Governing Body Developing 01/01/2016 Confidence of the Governing Body. Exec team

performance.

Positive 01/01/2016 There have been new recruits to the GB and changes in

leadership which will impact on development plans. Governing

Body to challenge exec team.



Lack of succession planning in the leadership team and the Governing Body impacts on the capability to evidence robust leadership.

To ensure a well-led organisation including strong

leadership and good governance resulting in delivery of all

statutory functions and duties, partnership working and a

strong workforce.



Score: Rating:

1-2 Low

3-6 Low - Medium

7-10 Significant

11-15 Significant-High

16-25 High

NHS NOTTINGHAM NORTH AND EAST RISK ASSURANCE …€¦ · The Fig QIPP group reviews the QIPP...

Documents

Transcript of NHS NOTTINGHAM NORTH AND EAST RISK ASSURANCE …€¦ · The Fig QIPP group reviews the QIPP...