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Our Vision – to Improve the Health & Wellbeing of our Communities

Item Number: 10.2

GOVERNING BODY MEETING Meeting Date: 26 November 2014 Report’s Sponsoring Governing Body Member: Philip Hewitson, Lay Member and Chair of Audit and Governance Committee

Report Author: Sally Brown, Associate Director of Corporate Affairs

1. Title of Paper: Integrated Governance Framework 2. Strategic Objectives supported by this paper: (check those which apply) ☒ To create a viable & sustainable organisation, whilst facilitating the development of a different, more innovative culture ☒ To commission high quality services which will improve the health & wellbeing of the people in Scarborough & Ryedale ☒ To build strong effective relationships with all stakeholders and deliver through effectively engaging with our partners ☐ To support people within the local community by enabling a system of choice & integrated care ☒ To deliver against all national & local priorities incl QIPP and work within our financial resources 3. Executive Summary: Good governance is a means of securing the delivery of the organisation’s aims and objectives in the most appropriate way. NHS SRCCG has set out the organisations objectives in their Strategic Plan which describes the strategic aims for the next 5 years. This document outlines NHS SRCCG approach to integrated governance in order to deliver the plan. Integrated Governance includes:

Corporate governance Clinical governance Risk management Financial governance Research governance Information governance Staff governance Governance between organisations

This framework describes how NHS SRCCG the systems and processes which reflect best practise and how they have been adopted and how they are monitored. 4. Risks relating to proposals in this paper: No risks identified .This paper describes how the organisation manages the different systems in an integrated way and provides assurance to the Governing Body 5. Summary of any finance / resource implications:

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Our Vision – to Improve the Health & Wellbeing of our Communities

For further information please contact: Name: Sally Brown Title: Associate Director of Corporate

Affairs ☎:01723 343671

None identified. 6. Any statutory / regulatory / legal / NHS Constitution implications: 7. Equality Impact Assessment: Each policy and plan has an equality impact assessment. 8. Any related work with stakeholders or communications plan: The NHS SRCCG Integrated Governance Framework should underpin governance arrangements with partnership organisations. 9. Recommendations / Action Required The Governing Body is asked to:

- Approve the Integrated Governance Framework - Note the committee responsibilities. - Note the report on progress towards compliance with best practise.

10. Assurance The Audit and Governance Committee will review the effectiveness of the committee and the Framework. Internal Audit work plans include audit of systems and processes

Integrated Governance Framework

July 2014 Authorship: Sally Brown, Associate Director of Corporate Affairs

Dawn Taylor, Corporate Service manager, CSU

Committee Approved: Audit and Governance Committee

Approved date: 26 November 2014

Review Date: 26 November 2016

Target Audience: SRCCG employees and Governing Body

Policy Reference No: SRCCG S 702

Version Number: 1.0

The on-line version 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.

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POLICY AMENDMENTS

Amendments to the Policy will be issued from time to time. A new amendment history will be issued with each change.

New Version Number

Issued by Nature of Amendment

Approved by & Date

Date on Intranet

1 S. Brown Draft 2 S. Brown Responsibilities agreed

at Audit and Governance Committee,15 October 2014

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CONTENTS

Page 1 Introduction

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2 Engagement

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3 Scope

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4 Purpose and Aims

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5 Definitions

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6 Roles / Responsibilities / Duties

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7 Implementation

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8 Training and Awareness

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9 Monitoring and Audit

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10 Review

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Appendices Appendix 1- Committee Responsibilities.

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1 INTRODUCTION

1.1. Good governance within an organisation is not an end in itself, but a means of securing the delivery of the organisation’s aims and objectives in the most appropriate way. For NHS Scarborough and Ryedale Clinical Commissioning Group, these are set out in Strategic Plan which describes our strategic aims for the next five years and sets out the evidence on which they are based. It builds on the plan we developed in 2012/13 with a clearer focus on community and mental health services. Our long term intention is to fundamentally change the way health and social care services are delivered for the population of Scarborough and Ryedale by:

• Developing integrated services around a community hub model of care to enable patients to be cared for as close to home as possible;

• Using innovative solutions to link primary, secondary and community services to encourage patient centred services;

• Developing integrated urgent and emergency care services to ensure patients access the right treatment at the right time;

• Ensuring mental health provision is increased to provide early support and diagnosis for adults and children

• Reducing the need for patients to attend and/or be admitted to secondary care by providing suitable alternative services in primary or community settings

• Our ambition and vision and that of our partners are simple. We want the best for local people:

1.2. This document outlines NHS Scarborough and Ryedale Clinical

Commissioning Group’s approach to integrated governance in order to deliver the CCG’s Strategic Plan through:

commissioning and providing safe, effective, reliable and high quality

services and patient care;

improving the health of the people of Scarborough and Ryedale;

providing public assurance on the quality and value for money of these

services

ensuring accountability for sound financial management and internal

control

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1.3. The Health and Social Care Act of 2012 that introduced Clinical Commissioning Groups has at its heart a desire to increase the involvement of both clinicians and the public in the design of the healthcare system. This intention is strengthened in the planning guidance issued by the Department of Health for 2014-19. NHS Scarborough and Ryedale have been keen, from the outset, to engage in a meaningful way with the public and patients. Our Patient Representative Group is up and running and patients are beginning the journey of true involvement and consultation such as with the ‘Chronic Obstructive Pulmonary Disease (COPD) and Me’ booklet consultation and the urgent and emergency care re-design engagement.

1.4. The need for Integrated Governance is set out in the Department of Health’s Integrated Governance Handbook (2006) and the Care Quality Commission’s Annual Health Check places the onus firmly on NHS boards to assure themselves of compliance and continuous improvement.

1.5. Integrated Governance can be defined as “the development of appropriate

systems and processes by which Trusts lead, direct and control their functions in order to achieve organisational objectives, safety and quality of services, where they relate to the wider community and partner organisations” (Deighan and Moore, 2004). It moves governance out of silos towards a more holistic approach.

1.6. Integrated Governance includes:-

Corporate governance

Clinical governance

Risk management

Financial governance

Research governance

Information governance

Staff governance

Governance between organisations

1.7 The Integrated Governance Handbook (2006) describes 8 elements which

constitute the high level governance framework:-

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Resources – be financially sustainable (probity, regularity, balance at year end), sufficient human resources, estate fit for purpose, appropriate information technology

Efficiency and Economy, Effectiveness and Efficacy (4Es) – the

organisation can be run effectively, efficiently, economically and challenged – why are we doing this activity, could someone else do it and do it better?

Compliance with authorisations – will be compliant at all times with

its authorisation to operate (NHS England, Health & Safety, Drug and Research management)

Compliance with national and local targets – meet and exceed

performance targets and local indicators. The Governing Body will ensure decision making is supported by intelligent information, characterised by sound analysis of reliable data.

The duty of quality as reflected in clinical governance – continue to

improve services for patients and be governed in accordance with current best practice

The duty of partnership – cooperate with local healthcare economies

The duty of patient and public involvement (Section 18 of the NHS

Act) – have a growing and representative membership to which it is responsible and accountable, in particular in the planning of services

The ongoing development of the Governing Body

1.8 Every CCG must have a constitution which sets out various matters

including:

• The arrangements it has made to discharge its functions and those of its governing body.

• Its key processes for decision-making, including arrangements for securing transparency in the decision-making of the CCG and its governing body;

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• The arrangements for discharging its duties with regard to registers of interest and managing conflicts of interest.

1.9 The CCG’s approach to governance is also underpinned by the requirement for all holders of public office to follow the principles established by the Nolan Committee in 1995 for standards in public life:

Selflessness

Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends.

Integrity

Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties.

Objectivity

In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for awards or benefits, holders of public office should make choices on merit.

Accountability

Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

Openness

Holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

Honesty

Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

Leadership Holders of public office should promote and support these principles by leadership and example.

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The Governing Body has agreed its own etiquette reflecting these principles.

1.10 Measures of success

This strategy sets out the objectives for governance in the CCG, in support of the delivery of the overall aims outlined in the Strategic Plan. NHS Scarborough and Ryedale Clinical Commissioning Group will consider these strategic objectives for governance to have been successfully delivered if its systems and audit processes demonstrate that:

• NHS Scarborough and Ryedale Clinical Commissioning Group has a

sound system of internal control.

• Clear lines of reporting and accountability are established and regularly reviewed.

• Governing Body-approved Scheme of Delegation, Standing Financial Instructions and Standing Orders are regularly reviewed and updated, with any breaches reported.

• The Governing Body Assurance Framework is owned and maintained by SMT, is scrutinised by the Audit and Governance Committee on a rolling programme and is reviewed by the Governing Body (ongoing).

• Key Performance Indicators are identified for both the commissioning organisation and for all providers. Performance monitoring reports are regularly presented to the Governing Body.

• NHS Scarborough and Ryedale Clinical Commissioning Group continues to improve compliance against the components of the Audit Commission’s Use of Resources process, NHSLA and other national standards and to ensure that its commissioned services comply with these standards.

• Commissioning leads ensure effective, clear and transparent commissioning and procurement processes and effective risk management are in place.

• It develops and maintains a register of partnerships and is clear on the relationships involved, together with regular updates on the anticipated outcomes and associated risks involved in each case.

• In addition to measures addressing specific objectives, there are other measures underpinning all of the above, and also framing the CCG’s forward actions to assure the comprehensive delivery of the strategy. These were identified as part of the review process undertaken as a

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precursor to the development of this strategy. They also identify key areas for development:

• The Audit and Governance Committee has an annual programme of

review, and reports to the Governing Body on implementation of its advice and recommendations

• Training on all aspects of governance is provided to staff e.g. risk management, counter fraud, information governance etc.

Detailed action plans to support delivery will be identified by Senior Management Team, at which time key leads will be agreed. Six monthly assurance reports will be made to the Audit and Governance Committee.

2 ENGAGEMENT

The Audit and Governance Committee, Governing Body and its committees were involved in the consultation of the framework.

3 SCOPE

This policy applies to all employees of the CCG in all locations including temporary employees, locums and contracted staff.

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4 PURPOSE & AIMS 4.1. The Strategic aims of NHS Scarborough and Ryedale Clinical Commissioning

Group have been set out in section 1 above, and underpin the approach to governance. Good governance offers a means of protecting the public, patients and staff, and the objectives below outline the robust framework for integrated governance provided by NHS Scarborough and Ryedale Clinical Commissioning Group.

4.2. The specific objectives to fulfil this aim are to ensure:

4.2.1. Clear, robust systems of accountability and assurance for all aspects of integrated governance, closely linking with performance management

4.2.2. Robust systems to ensure sound financial management, effective use

of resources and value for money

4.2.3. Sound systems of internal control, supported by the Governing Body Assurance Framework and underlying processes of risk management

4.2.4. Processes to ensure NHS Scarborough and Ryedale Clinical

Commissioning Group complies with all national standards, regulations and legislative requirements

4.2.5. Strong governance of the commissioning framework

4.2.6. Systems and processes for holding providers to account for the quality

of their services and commissioning for patient safety

4.2.7. Clear systems and processes for partnership working, emphasising the purposes, aims and objectives shared by parties, and clarifying / risk sharing arrangements and monitoring.

5 DEFINITIONS 5.1 Corporate Governance

Corporate governance refers to the system by which organisations are directed and controlled. The governance structure specifies the distribution of rights and responsibilities among different participants in NHS Scarborough and Ryedale Clinical Commissioning Group (CCG) (such as the Governing Body, managers, Council of Clinical Representatives, creditors, auditors, regulators, and other stakeholders) and specifies the rules and procedures for making

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decisions in corporate affairs. Governance provides the structure through which the CCG sets and pursue its objectives, while reflecting the context of the social, regulatory and market environment. Governance is a mechanism for monitoring the actions, policies and decisions of the CCG. Governance involves the alignment of interests among its stakeholders.

5.2 Quality and Clinical Governance

Clinical Governance is the overarching framework for continuously improving the quality and outcomes of the services the CCG commissions. Safeguarding high standards of care will be paramount. Effective clinical governance means creating an environment in which excellence in clinical care and care quality will flourish. The CCG has a statutory duty to secure these continuous improvements. Through the work of the Quality and Performance Committee, the CCG will determine and monitor the overall strategy in partnership with CCG members, other healthcare professionals, patients, carers and the public.

5.3 Financial Governance

Financial governance is achieved through day to day financial controls and the effective stewardship of public funds which allows the CCG to commission high quality services. This is a shared responsibility to allow the CCG to achieve the outcomes we wish to achieve with, and on behalf of, the patients and public we serve. Robust procedures for financial risk management, budgetary control and effective financial information will ensure this. Guidance can be found in the following documents: CCG’s Constitution, Standing Orders, Standing Financial Instructions, Scheme of Delegation and Terms of Reference for the Governing Body and its committees. The Finance and Contracting Committee has a role in ensuring financial governance within the CCG. There are also effective internal and external audit arrangements, under continual professional review and evaluation by the Chief Finance Officer.

5.4 Information Governance

Information Governance is the way by which the NHS handles all organisational information - in particular the personal and sensitive information of patients and employees. It allows organisations and individuals to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care. It provides a framework to bringing together the requirements,

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standards and best practice that apply to the handling of information. It has four fundamental aims: • To support the provision of high quality care by promoting the

effective and appropriate use of information. • To encourage responsible staff to work closely together, preventing

duplication of effort and enabling more efficient use of resources. • To develop support arrangements and provide staff with appropriate

tools and support to enable them to discharge their responsibilities to consistently high standards.

• To enable organisations to understand their own performance and manage improvement in a systematic and effective way.

The Department of Health produces and regularly updates a performance tool ‘the Information Governance Toolkit’ which draws together legal rules and central guidance from sources such as The Data Protection Act 1998 and The Freedom of Information Act 2000.

It presents them in one place as a set of information governance requirements. Organisations are required to carry out self-assessments of their compliance against the IG requirements. The Information Governance Steering Group and the Senior Management Team has a role in ensuring information governance within the CCG.

5.5 Research Governance

Research Governance can be defined as the broad range of regulations, principles and standards of good practice that exist to achieve, and continuously improve, research quality across all aspects of healthcare in the UK and worldwide. By healthcare research it is taken to mean any health-related research which involves humans, their tissue and/or data.

The CCG has a statutory duty to promote research on matters relevant to the health service and using evidence obtained from it. This means understanding, supporting and promoting Research and Development both internally and from commissioned services.

The CCG has a formal responsibility for Research Governance relating to member practices. The North Yorkshire and Humber Commissioning Support Unit (CSU) has been tasked with undertaking this responsibility on behalf of the CCG. This responsibility includes

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promoting and using research in the planning, commissioning and delivery of patient care and public health interventions. Specifically:

• ensuring research management and governance processes are

adhered to • providing advice and support on undertaking research, for example

distinguishing what is research, service evaluation and audit • ensuring the correct research processes and regulations are adhered

to, for example ethics application processes • providing strategic advice and direction for research and development. • providing advice on policy issues and management of research finance • facilitating and identifying support with funding bids and research

grants • providing education, training and support on research and development

issues, including support and advice on research development and methodology.

The CSU Research and Development Team also work in partnership with other research stakeholders to promote and enhance research delivery. The Northern and Yorkshire Primary Care Research Network (PCRN) is hosted by North Yorkshire and Humber Commissioning Support Unit and offers equal access to National Institute for Health Research (NIHR) portfolio research studies for primary care patients and clinicians.

The PCRN offers the following: · funding to train and support clinicians in research delivery · funding for activities involved in patient recruitment · support and advice at any point of the study life cycle · governance, advice and signposting for NHS permissions and

assurance to minimise delays with approvals. · identification and engagement of clinicians in primary care using

local knowledge · access to research accredited and experienced sites

The Research and Development Team will report to the CCG’s Senior Management Team.

6 ROLES / RESPONSIBILITIES / DUTIES

6.1 NHS Scarborough and Ryedale Clinical Commissioning Group will ensure

accountability at all levels for governance and the systems that support it:

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Governing Body level; Directorate level and individual level. The Governing Body ensures that accountability is clarified for each Director, and will set out a schedule of accountable officers, which will be reviewed on a regular basis by the Chief Officer.

6.2 The Governing Body

The Governing Body has collective responsibility for:-

Providing leadership to the organisation within a framework of prudent

and effective controls.

Setting strategic direction, ensuring management capacity and

capability and monitoring and managing performance.

Safeguarding values and ensuring the organisation’s obligations to its

key stakeholders are met.

Adding value to and promoting the success of the organisation.

Agreeing the threshold for ‘acceptable risk’.

6.3 The Chair

The NHS Commissioning Board Authority’s document entitled Clinical commissioning group governing body members: Role outlines, attributes and skills sets out the key responsibilities of the Chair as follows:

a) leading the governing body, ensuring it remains continuously able to

discharge its duties and responsibilities as set out in this constitution;

b) building and developing the group’s governing body and its individual members;

c) ensuring that the group has proper constitutional and governance

arrangements in place;

d) ensuring that, through the appropriate support, information and evidence, the governing body is able to discharge its duties;

e) supporting the accountable officer in discharging the responsibilities of

the organisation;

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f) contributing to building a shared vision of the aims, values and culture of

the organisation;

g) leading and influencing to achieve clinical and organisational change to enable the group to deliver its commissioning responsibilities;

h) overseeing governance and particularly ensuring that the governing

body and the wider group behaves with the utmost transparency and responsiveness at all times;

i) ensuring that public and patients’ views are heard and their expectations

understood and, where appropriate as far as possible, met;

j) ensuring that the organisation is able to account to its local patients, stakeholders and the NHS Commissioning Board;

k) ensuring that the group builds and maintains effective relationships,

particularly with the individuals involved in overview and scrutiny from the relevant local authority(ies).

6.4 Governing Body Lay Members

The National Health Service (Clinical Commissioning Groups) Regulations 2012 require each governing body to have two lay members who meet the requirements of the regulations. One lay person must have qualifications, expertise or experience such as to enable the person to express informed views about financial management. The second must be a person who has knowledge about public and patient engagement such as to enable the person to express informed views about the discharge of the CCG’s functions. Schedule 4 sets out those who are disqualified from being lay members of a governing body. A clinical commissioning group may choose to have more than two lay members on the governing body, provided they are not disqualified from this role by Schedule 4. If a group chooses to add more lay members as additional members to its governing body, then the group must specify this in the group’s constitution in accordance with section 14L(4)(c) of the 2006 Act, as inserted by section 25 of the 2012 Act (i.e. describe the role rather than name the individual person). Arrangements for appointing additional lay members to the group’s governing body should be set out in the group’s standing orders.

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6.5 Chief Officer

6.5.1 The Chief Officer is the Accountable Officer of the CCG, responsible

for Stewardship of Resources, including:

Statutory Accounts

Effective Management Systems

Regularity & Propriety of Spending

Advice to the CCG Governing Body

6.5.2 The Chief Officer has the overall accountability and responsibility for the operation of the organisation; for ensuring that high quality patient services are commissioned by NHS Scarborough and Ryedale Clinical Commissioning Group; for ensuring that an effective risk management system is in place and for meeting all statutory and regulatory requirements in respect of governance.

6.5.3 The Chief Officer is responsible for ensuring a sound system of internal control within NHS Scarborough and Ryedale Clinical Commissioning Group.

6.6 Associate Director Of Corporate Affairs

6.7 The Associate Director of Corporate Affairs is the person with overall responsibility for managing the strategic development and implementation of integrated governance. The Associate Director of Corporate Affairs is directly accountable to the Chief Finance Officer, and takes the lead on corporate governance, acting as principal advisor to the Board on governance-related issues. The Associate Director of Corporate Affairs also undertakes the role of Senior Information Risk Owner (SIRO).

6.8 Executive Nurse

6.8.1 The Executive Nurse is responsible for ensuring robust systems for risk

management and clinical governance are in place, as a means of capturing and monitoring both internal clinical governance and risk management issues and the quality of service provision.

6.8.2 The Executive Nurse is the Caldicott Guardian.

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6.8.3 The Executive Nurse is responsible for Service Development, Quality and Performance. The Executive Nurse attends the Quality and Performance Committee and is invited to attend meetings of the Audit and Governance Committee.

6.9 Chief Finance Officer

6.9.1 The Chief Finance Officer is the Governing Body member responsible

for financial governance for the CCG. The Chief Finance Officer attends the Finance and Contracting Committee, and is invited to attend meetings of the Audit and Governance Committee.

6.9.2 The Chief Finance Officer is responsible for:

Ensuring the accounts of the CCG are prepared under principles

and in a format directed by the Secretary of State for Health.

Signing the accounts on behalf of the Governing Body.

Operational responsibility for effective and sound financial management and information.

With the Chief Officer, ensuring appropriate advice is given to the Board and Clinical Executive on all matters of probity, regularity, prudent and economical administration, efficiency and effectiveness.

6.9.3 The Chief Finance Officer is also responsible for ensuring that robust information governance systems and processes are in place. The Chief Finance Officer is a member of the Information Governance Steering Group.

6.10 Senior Management Team

The Senior Management Team (SMT) has operational and management responsibility for governance, ensuring delivery of safe and effective services. It supports the Chief Officer in promoting good governance throughout NHS Scarborough and Ryedale Clinical Commissioning Group, in both its commissioned and provided services.

6.11 Directors and Senior Managers

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6.11.1 The Directors are responsible for ensuring the risks in their directorates and their programme boards are mitigated to an acceptable level and that any that require additional resources beyond their span of control are brought to the attention of SMT and the Governing Body.

6.11.2 Senior Managers are responsible to their Director for managing the

risks of their teams/services.

6.12 Strategic Plan Leads

6.12.1 Each Executive Lead identified in the Governing Body Assurance Framework is responsible for integrated governance of the strategic objective for which he / she leads.

6.12.2 Risk management is integral to the lead role. Project Leads will

maintain governance in line with the requirements of this strategy, and maintain a live risk register. They will flag high level risks (as agreed by the Executive Lead) to SMT and the Governing Body.

6.13 Governing Body Sub Committees

Audit and Governance Committee

6.13.1 The Audit and Governance Committee provides the governing body with an independent and objective view of the group’s financial systems, financial information and compliance with laws, regulations and directions governing the group in so far as they relate to finance. The governing body has approved and keeps under review the terms of reference for the audit committee, which includes information on the membership of the audit committee.

6.13.2 In addition the Governing Body has conferred or delegated the following functions, connected with the governing body’s main function, to its Audit and Governance Committee:

i) The Committee shall review the establishment and maintenance of an effective system of integrated governance, internal control and risk across the whole of the Clinical Commissioning Group’s activities that supports the achievement of its objectives.

6.14 Remuneration Committee

The Remuneration Committee makes recommendations to the Governing Body on determinations about the remuneration, fees and

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other allowances for employees and for people who provide services to the group and on determinations about allowances under any pension scheme that the group may establish as an alternative to the NHS pension scheme. The Governing Body has approved and keeps under review the terms of reference for the committee, which includes information on the membership of the Remuneration Committee.

6.15 Other Governing Body Sub Committees

Please see appendix 1 which provides details on the responsibilities for each Governing Body sub committee

7 IMPLEMENTATION

The Governing Body and Audit and Governance Committee will approve the Integrated Governance Framework for NHS Scarborough and Ryedale Clinical Commissioning Group and all employees and the Governing body will have access to the document via the intranet. It will form part of the induction for new employees and be included in team briefings. The Associate Director for Corporate |Affairs is responsible for making sure all employees are aware of the Integrated Governance Framework. NHS Scarborough and Ryedale Clinical Commissioning Group will ensure the following are in place:-

- An up to date version of the Integrated Framework is available on the intranet.

- New staff receive awareness training through induction. - The framework is reviewed regularly.

7.1 Accountability and Assurance

7.1.1 Clear systems of accountability; with assurance provided by the Audit and Governance Committee overseeing governance performance.

7.1.1 Governing Body-approved Scheme of Delegation, Standing Financial Instructions and Standing Orders and are widely communicated via intranet, newsletters, staff leaflet, induction etc.

7.1.2 Regular assurance to the Governing Body via minutes from assurance/sub committees, performance indicators and regular performance and governance reports.

7.1.3 The Governing Body holds meetings in public to provide external scrutiny of its systems and processes.

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7.1.4 NHS Scarborough and Ryedale Clinical Commissioning Group promotes managerial and clinical leadership and accountability at all levels through processes such as appraisal, personal development plans, management training and organisational development; ensuring all CCG staff are competent, knowledgeable and skilled.

7.2 NHS England Authorisation process 7.2.1 NHS England has a responsibility to assure that CCGs are capable

commissioning organisations and to support them to develop and improve. The purpose of the assurance framework is to enable NHS England, through area teams, to meet the statutory responsibility to make an assurance assessment. One of the outcomes of the assurance conversations will be a joint understanding of the development needs of the CCG and how NHS England can support them to meet these needs.

7.2.1 The CCG assurance process has been designed to provide confidence to internal and external stakeholders and the wider public that CCGs are operating effectively to commission safe, high quality and sustainable services within their resources. The assurance framework sets out six broad assurance domains under which this assessment will be made – allowing for a tailored conversation to take place locally which results in an assessment which meets statutory requirements but also contributes to on-going ambitions for CCG development

7.2.2 The six assurance domains reflect the key elements of an effective clinical commissioner which were integral to CCG authorisation and are shared with the direct commissioning assurance framework. These are listed below:

• Domain 1: Are patients receiving clinically commissioned, high quality services?

• Domain 2: Are patients and the public actively engaged and involved?

• Domain 3: Are CCG plans delivering better outcomes for patients?

• Domain 4: Does the CCG have robust governance arrangements?

• Domain 5: Are CCGs working in partnership with others?

• Domain 6: Does the CCG have strong and robust leadership?

7.3 Financial management

7.3.1 The Audit and Governance Committee monitors financial governance arrangements, following the Audit Commission Handbook.

7.3.2 Governing Body-approved Standing Financial Instructions and Standing Orders are in place and widely communicated (see above).

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7.3.3 The Finance and Contracting Committee and Quality and Performance Committee monitor the CCG’s performance in terms of quality and financial outcomes particularly against strategic targets and benchmark values.

7.3.4 Counter Fraud policies and systems are in place and communicated

widely to staff, supported by training. The Audit and Governance committee monitors the effectiveness of the counter fraud system.

7.4 Internal Control

7.4.1 Good governance means making sure an effective risk management system is in operation. NHS Scarborough and Ryedale Clinical Commissioning Group has robust Risk Management Policies in place, monitored by the Audit and Governance Committee.

7.4.2 All staff are trained in effective risk management as part of mandatory training and corporate induction.

7.4.3 The Governing Body is collectively accountable for managing risk and maintaining a sound system of internal control. It puts in place arrangements for gaining assurance about the effectiveness of this overall system of control and annual declaration made – the Annual Governance Statement.

7.4.4 The Governing Body Assurance Framework brings together all of the evidence required to support the Annual Governance Statement. It clearly identifies the risks of failing to meet the corporate objectives, the controls in place to mitigate those risks, the assurances on these controls, and action plans to meet any identified gaps. NHS Scarborough and Ryedale Clinical Commissioning Group has a “live” Governing Body Assurance Framework in place (with supporting risk registers), clearly identifying the risks of failing to meet the corporate objectives, the controls in place to mitigate those risks, the assurances on these controls and action plans to meet any identified gaps, which will drive the Governing Body agenda. The Governing Body will consider the Governing Body Assurance Framework on a regular basis.

7.4.5 All risks are closely monitored to ensure they are mitigated within the stated timetable to the agreed mitigated risk rating. Monitoring is undertaken by the Audit and Governance Committee, chaired by a Lay Member. The meeting ensures robust action plans are put in place for management of the CCG major risk profile.

7.4.6 There is a risk policy in place which clearly identifies the level of “risk appetite” (the amount of risk that the organisation is prepared to accept, tolerate or be exposed to at any point in time) which Directors and

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Strategy Leads manage and provides clear guidance on escalating risks to directorate, programme and corporate risk registers.

7.5 National Standards

7.5.1 NHS Scarborough and Ryedale Clinical Commissioning Group ensures that both commissioned and provided services meet standards set by the Care Quality Commission, Monitor (for Foundation Trusts), NHS Litigation Authority (NHSLA)/Clinical Negligence Scheme for Trusts (CNST) standards and other regulatory bodies.

7.5.2 All such healthcare standards and performance targets are reflected in the organisational objectives and strategic plan.

7.5.3 NHS Scarborough and Ryedale Clinical Commissioning Group minimises health & safety and environmental risks to staff and visitors in accordance with key legislation e.g. the Health & Safety at Work Act 1974, Management of Health & Safety at work Regulations 1999, Disability Discrimination Act 1995.

7.5.4 NHS Scarborough and Ryedale Clinical Commissioning Group ensures research governance is applied to all research & development activities within provided and commissioned services (refer to Research Governance processes).

7.5.5 NHS Scarborough and Ryedale Clinical Commissioning Group applies information governance standards and legislation as described in the Information Governance toolkit and by the Information Commissioner; ensuring confidentiality, integrity, security and accuracy of personal and business sensitive information and compliance with legislative requirements e.g. Freedom of Information Act, Data Protection Act etc. Progress with the toolkit is monitored by the Senior Management Team. NHS Scarborough and Ryedale Clinical Commissioning Group supports independent contractors to comply with their IG toolkit and information governance requirements.

7.6 Commissioning Governance

NHS Scarborough and Ryedale Clinical Commissioning Group employs robust governance and assurance systems for all its commissioning activities, including :

Governance of project programme boards

Using model contracts with quality indicators

Having clear criteria for procurement and contract management

Transparency between providing and commissioning services

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Ensuring clear governance of partnership arrangements with a range of partner organisations, whether covered by contracts or other forms of partnership agreement.

7.7 Governance between Organisations

Partnerships can take several forms, including those with a formal contract/Service Level Agreement (SLA) as their basis, and those without a formal contract, but with an agreed framework for joint delivery of common goals. Partnerships with no formal contractual arrangements

7.7.1 NHS Scarborough and Ryedale Clinical Commissioning Group recognises the need to work with multiple partners across the range of strategic aims and objectives. A partnership can be defined as having:

· An agreed framework for jointly delivering common goals; with · Shared risk and resources; which provide · Identified added value and measurable impact; based on · Shared accountability for outcomes, which cannot be obtained

in other ways It is important that, as in all other areas of the CCG’s activity, performance in partnership working is subject to appropriate governance arrangements.

7.7.2 The CCG endorses the principles set out in the Audit Commission’s

‘Governing Partnerships’ report, and will ensure that all partnership arrangements with statutory, independent and third sector organisations have clear, proportionate and jointly agreed governance arrangements in place.

7.7.3 In particular, NHS Scarborough and Ryedale Clinical Commissioning

Group will ensure that:

• There are clear roles and responsibilities for all the partners, and an agreed set of aims and objectives for the partnership;

• There are clear arrangements to govern decision making processes and delegated powers, including lines of accountability;

• Processes for the management of risks are agreed, and are consistent with partners’ corporate governance arrangements;

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• The matters set out in Appendix C are incorporated as appropriate in the Partnership Governing Document;

• Effective communication with the public is managed by the partnership to ensure consistency of message and development of local understanding of the nature and purpose of partnership, particularly where service delivery is the key objective;

Partnerships governed by contracts

7.7.4 NHS Scarborough and Ryedale Clinical Commissioning Group uses quality frameworks based on the requirements of the NHS clinical governance framework and standards contained within national quality frameworks (e.g. the Quality Outcomes Framework (QOF)) to monitor the performance of all provider services.

7.7.5 NHS Scarborough and Ryedale Clinical Commissioning Group sets clear performance and governance indicators/metrics with all their providers which are included in their contracts, with ‘trigger points’ for action where appropriate. Performance against these contracts is regularly monitored according to quality/performance schedules through contract meetings, Clinical Quality Review meetings etc. NHS Scarborough and Ryedale Clinical Commissioning Group provides feedback to providers and is clear as to penalties for breach of contract through poor performance.

7.7.6 NHS Scarborough and Ryedale Clinical Commissioning Group has agreements in place to delegate management of contracts for some services to a “lead commissioner”, which will usually be a CCG acting on behalf of several other CCGs. These arrangements include the expectation that communication with the service provider(s) will be primarily through the lead commissioner. However, NHS Scarborough and Ryedale Clinical Commissioning Group reserves the right to engage directly with service providers under these contractual arrangements in urgent or necessary circumstances.

7.7.7 NHS Scarborough and Ryedale Clinical Commissioning Group monitors and performance manages providers’ Serious Incidents (SIs) through the contracting process.

7.7.8 NHS Scarborough and Ryedale Clinical Commissioning Group uses both local and national intelligence available about its providers and takes into account findings from national reports and inquiries. The emerging information is escalated through the organisation as appropriate, through existing internal contractual reporting arrangements or, in the event of a significant risk issue being identified, via the internal risk management reporting systems.

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7.8 Implementation of the Integrated Governance Framework

Implementation of this framework requires a range of supporting policies and strategies and documents, including:

Scheme of delegation, Standing Financial Instructions, Standing Orders

Risk Management Strategy

Clinical Governance policies

Serious Incident Policy

Information Governance Strategy and supporting policies

Counter Fraud Policy

Research Governance policies

Health & Safety Policies

Corporate Complaints, Claims and Incidents policies (adverse events)

Business integrity and other corporate governance policies.

Reviews of these strategies and policies are routinely undertaken and assurance provided to the Governing Body.

8 TRAINING & AWARENESS

Staff will be made aware of this framework and associated policies through induction and the staff manual.

9 MONITORING & AUDIT

The CCG monitors and reviews its performance and the continuing suitability and effectiveness of the systems and processes it has in place to manage integrated governance through a programme of internal and external audit work, and through the oversight of the CCG Governing Body and Officer and senior managers.

10 REVIEW

This framework will be reviewed in 12 months. Earlier review may be required in response to exceptional circumstances, organisational change or relevant

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changes in legislation/guidance, as instructed by the senior manager responsible for this framework.

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Appendix 1

Governing Body Sub- Committee Roles & Responsibilities

Audit and Governance Committee

Remuneration Committee

• Financial reporting and internal control principles • Audit reports and recommendations. • Establishment and maintenance of an effective

system of integrated governance, risk management and internal control.

• Assurance Framework • Internal Audit work plan and performance • External Audit work plan and performance. • Counter fraud.

• Pay and remuneration of employees and Governing Body

• Annual salary awards • Allowances under pension schemes. • Severance payments of employees and

contractors • Policies and instructions relating to remuneration

Business Committee

• Delivery of Service Delivery project, operational plans and QIPP plans. • Service redesign and project delivery (CCG objectives and priorities) • Winter planning • National Strategy Implementation (e.g. autism, dementia) • NHS 111 • Medicines Management • Emergency Planning • Risk Management • Choice Agenda • End of Life • Better Care Fund delivery

Quality & Performance Committee

Finance & Contracting Committee

Communication & Engagement Committee

• Safeguarding • Infection Control • NICE guidance • Serious Incident Reviews • Quality & Patient Safety-

provider reports • Quality of 1⁰ care (support to

NHS CB) • Quality of specialist

commissioning • NHS Outcomes Framework

and delivery against domains • Continuing Health Care • Complaints (providers)

• Monitoring delivery of financial plan (commissioning and management budgets)

• Monitoring delivery of QIPP initiatives

• Continuing Care Funding • IFR process • AQP • Authorise direct payments to

patients • Power to generate income • Data Quality • Partnership Contracting • Medicines Management

(financial)

• Communications & Engagement

• Patient Experience • Media Management • Patient and Public Consultation • Equality & Diversity • Stakeholder Satisfaction

surveys • Complaints (commissioning)

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Senior Management Team The Senior Managers (Chair, Chief Officer, Chief finance Officer, Executive Nurse) have individual roles and responsibilities and meet regularly to review delivery and of the following areas:

Senior Management Team

• Business continuity • Policy management • Information governance • Freedom of Information • Corporate records keeping • Access to Health Records • Human Resources including staff satisfaction surveys • Employment rights • Organisation Development • Equality & Human Rights • Whistle blowing • Information Management and Technology • Sustainability • Research Governance • Health & Safety • Security • Vehicles for Disabled (section 5) • Co-operation with Prison Service • Crime & Disorder Act • Liaison with Deanery & WFP • Compliance with Children’s Acts • Compliance with Mental Health Act

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Corporate Governance Roles assigned to SMT/Officers: Assurance Update to Audit and Governance Committee September 2014

Author: Sally Brown Associate Director of Corporate Affairs. Purpose of Report: To provide assurance that there are policies and standards in place which set out the standards expected to achieve compliance with corporate business processes and that systems and processes in place to monitor and review compliance and progress against improvement plans.

Area Responsible Person

Accountable Person

Status Actions Progress 1 September 2014

Business Continuity Sally Brown Simon Cox • Draft policy circulated to SMT during May 2014

• Governing Body approved plan on 28 May 2014 pending completion of information on CSU Business Continuity Plan.

• Awaiting review dates of CSU Business Continuity Plan from JS.

• Information on CCG staff of band 7 and below to populated.

• Correct omission of PCM from Governing Body members/contacts

• SMT to agree location of Business Continuity Plan for ease of access but to maintain restricted access to staff personal details.

• Business continuity Plan approved by Governing Body and A&G committee.

• Available on intranet and in hard copy.

Action • To check need for PCU

Business continuity plan

Policy Management Sally Brown Simon Cox • Schedule of SRCCG policies maintained by Programme Coordinator with status and review dates.

• CSU support for most policy formation with regular meetings between Ass Director of Corp. Affairs and CSU service leads to monitor progress.

• Provide SMT with quarterly report on policies approved, being revised and those where review date has lapsed.

• Schedule of Policies, including status and review dates in place.

• Policies adopted by SRCCG and PCU.

• Progress with review of HR policies making very good progress and ahead of all other CCGs.

• Implementation plan of key HR policies now in place with training sessions arranged.

• SMT supportive of mandatory attendance by line managers

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• Policies available on intranet to all employees.

Information Governance

Carrie Wollerton-Caldecott Guardian Sally Brown- SIRO

Simon Cox • IG Toolkit submission at level 2 completed for 2013-14.

• Internal audit provide significant assurance status on evidence submitted

• All IG policies available on SRCCG Intranet

• Monthly IG mandatory training reports received and monitored by Ass.Director of Corp Affairs

• Regular meetings in place with CSU service lead and Ass.Director of Corp Affairs

• To map 2014-15 IG plan for submission in March 2015.

• Information Governance is highlighted in the SRCCG Induction Manual

• PCU IG toolkit established as standalone submission under SRCCG ICO registration.

• Quarterly Information Governance Steering Group established to follow SMT meetings from July

• Promote stat and mandatory training requirements through appraisal process.

• Data flow mapping exercise to validate by IG Manager (CSU) and SRCCG staff following review across of NY&H CCG returns.

• Confirm dates on SMT meetings for follow on IG steering Group meetings where IG Managers (CSU) will attend.

• IG steering group established with TOR reporting to A&G Committee

• IG steering group meeting quarterly

• Data flow mapping exercise being updated

• IG toolkit action plan in place for 214-15 submission and on target.

• Lessons learnt from incidents in PCU documented following investigations.

• Promote IG training before 31 December 2014

• PCU have separate IG toolkit 2014-15 and progress being made towards achieving standards.

Freedom of Information

Sally Brown Simon Cox • Policy adopted by Governing Body [date]

• Updated policy advised by CSU in January 2014

• Elements of scheme of publication now regularly

• Review Jan 2014 policy amendments and approve minor changes through SMT

• Assess compliance with policy and processes and document corrective actions to take to

• Governance arrangements for management of FOI by PCU on behalf of SRCCG agreed.

• Quarterly Reports reviewed by SMT including compliance

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updated on SRCCG website • Freedom of Information is

referred to in the SRCCG Induction Manual

• Quarterly FOI reports and compliance with Act reported with SMT receiving reports.

• SRCCG internal process supports timelines for responses by FOI team

• FOI team present at SRCCG HQ at least 2 days/month for advice.

• Training to admin staff on recording of minutes provided during March 2013

staff meeting. • Review scheme of publication

and identify gaps with action plan to address gaps

with Freedom of Information Act.

• Update reported to Audit and Governance Committee.

Corporate Records Keeping

Sally Brown Richard Mellor • Establish list of all corporate records through data flow mapping

• Detail responsibility for management of specific groups of records

• HR record management established with access limited to Exec Assistant, Line managers, AO and Associate Director of Corporate Affairs.

• Audit of completeness of HR files due November 2014.

• Information Asset Owners identified and data mapping flows to be completed by 30 November 2014.

Access to Health Records

Carrie Wollerton

Simon Cox • Ensure policy in place • Caldecott Guardian

responsible for this •

• Policy in place • To review implementation of

policy • Caldecott Guardian for PCU

confirmed Human resources Sally Brown Simon Cox • Twice monthly meetings

between S.Brown and Workforce team continue wit agreed actions and monitoring

• Staff survey ready for launch June 2014

• Assess report from review of recruitment process for new

• Twice monthly meetings for CSU workforce team service review continue with notes taken and circulated.

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of delivery • Monthly Workforce reports

reviewed by SMT which now contain appropriate information and trends.

• A separate report for PCU is provided to SRCCG and PCU

• Appraisal training, documentation and process to support performance related pay for 2014-15 in place.

• Schedule of HR Policies maintained with process for staff consultation (via intranet) prior to SMT review and approval by JTUPE policy committee.

• Review of recruitment process • Standards for HR file content

with retention and destruction guidelines in place

starters • Develop detailed succession

plan • Complete HR file review to

establish standard file content and compliance with standards

• Review of HR policies should all be completed by Feb 201

• Standards for recording keeping for HR files established and being audited.

• Stat and Mandatory training reports and work force reports reviewed by SMT and A& Committee.

• Staff survey results reviewed and shared at team meeting with action plan in place.

• Appraisal implementation completed and further training planned Q4.

• Primary care work force planning and survey being rolled out.

Organisation Development

Sally Brown Simon Cox • Learning and development Policy being processed which will support OD plan.

• OD plan being refreshed • Succession plan being

established.

• OD plan refresh planned for July to assess stakeholder survey, staff survey, individual learning plans from appraisal process, with recommended 2 year OD plan to be presented to Business Committee/Gove Body in August /September

• Learning and Development Panel established and first meeting took place.

• OD plan refreshed and Governing Body development plan in place.

• Succession plan to be agreed by 31 March 2015

Employment Rights Sally Brown Simon Cox • CSU Workforce team support SRCCG to ensure compliance.

• Policies in place • E&D data for staff updated • E&D for Governing Body

collected and published on website

• Review E&D data of Governing Body

• Present annual workforce report to Governing Body

• E&D data for Gov. Body now surveyed and included in in Annual Report.

• E&D data available on website • 2013-14 Annual Report

available. • Quarterly Workforce reports

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• E&D data included in Annual report

• Monthly workforce report from CSU and reviewed by SMT

for CCG and PCU reviewed by SMT

Whistle Blowing Sally Brown Simon Cox • Policy adopted in [ date] and to be reviewed in [date]

• Policy available on the SRCCG intranet

• Staff induction book refers to policies.

• No reports received.

Information Management and Technology

Sally Brown Richard Mellor • IM&T draft strategy to be reviewed by Data and IM&T Group by 31 January 2015 and to be brought to Governing Body in March 2015.

• Monthly service review meetings with CSU and service improvement plans in place.

• Monthly performance reports reviewed by SMT

Sustainability Sally Brown/Richard Mellor

Simon Cox • Sustainability assessment included in all policies and project documents.

• Training in use of sustainability assessments arranged for 10, 19 June 2014.

• Annual Report reference referred to level of work to date.

• Good corporate citizen standards inappropriate to CCG size and location.

• Arrange meeting with CSU lead to develop annual improvement plan in readiness for March 2015 submission.

• Sustainability to be included in SRCCG Induction Manual

• Meet with SBC to attain carbon foot print information for SRCCG HQ

• Identify how carbon foot print data can be obtained for Sovereign House NHS Property Services)

• Raised at SMT and agreed to accept risk associated with delay in progressing action plan to demonstrate compliance.

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Research and Development Governance

• Initial meeting held with network GP local clinical representative

• To establish annual plan and policies etc. to support and promote research in SRCCG

• R&D report received by A&G Committee Oct 2014.

• CSU nominated lead providing support through quality team

Health & Safety Sally Brown Simon Cox • H&S and responsibilities of employees are referenced in the SRCCG Induction Manual

• All staff completed Stat and mandatory training through CBLS.

• H&S Poster is displayed in the office

• First aid box available. • Fire safety Policy approved by

SRCCG which reflects Scarborough Borough Council policy

• S.Cox, K.Maud and S.Tilston trained as fire officers by SBC

• Monthly reports on stat and Mandatory training reviewed by SMT quarterly.

• Meeting with SBC to explore access to H&S support for SRCCG HQ and Sovereign House.

• Confirm management arrangements of H&S at Sovereign House.

• Complete H&S Policy • Complete risk assessments for

SRCCG offices. • Confirm reporting mechanism

for reporting of incidents the Ulysees or as an alternative introduce interim solution of accident book.

• S.Brown to complete IOSH training

• SRCCG staff to be trained as First Aiders.

• Document specification of H&S support required from SBC to SRCCG +/- Sovereign House.

• Provision of H&S training and advice sourced in partnership with PCU through SALUS at cost of circa £5K.( not through SBC)

• Training for ST,SB,SM completed 23 Sep 2014

• SALUS file and policies will be made available

• Work environment risk assessments required to be completed

• Incident reporting tool available on intranet from Oct 2014 via CSU- called Safeguard which will allow all incidents to be logged and tracked.

• Public Liability Insurance certificate displayed on office wall, H&S poster in place

• PAT testing of new equipment required by SBC

• Lone worker policy in draft format for consultation with PCU

• First aid training providers being sourced with 3 people to attend

• Process for auditing compliance with H&S Act established and will be reported to SMT and A&G

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Committee.

Security Sally Brown Simon Cox • National Standards for CCG security support and reporting not yet released.

• Agenda item on Audit and Governance Committee retained to record current status

• Risks associated with H&S identified and risk assessments being carried out, in particular lone worker policy.

• Security to data and information covered through IG policies.

NHS Outcomes Framework and delivery against domains

Carrie Wollerton

Simon Cox Monitored through Q&P committee and assessed through NHS England Checkpoint/Assurance quarterly meetings.

Compliance with Children’s Acts

Carrie Wollerton

Simon Cox Monitored through Q&P committee and assessed through NHS England Checkpoint/Assurance quarterly meetings.

Compliance with Mental Health Act

Carrie Wollerton

Simon Cox Monitored through Q&P committee and assessed through NHS England Checkpoint/Assurance quarterly meetings.

Co-operation with Prison Service

Simon Cox Details of responsibility yet to be established from national guidance

Vehicles for Disabled (section 5)

Simon Cox Details of responsibility yet to be established from national guidance

Crime & Disorder Act - work with Police on Strategy for drugs & alcohol

Simon Cox Details of responsibility yet to be established from national guidance