sources of assurance for the committee · execellence award panel redundancies report to the...

Audit Quality Improvement & Safety Remuneration Estates Strategic Change Board Charitable Funnds

Quality Performance Risk Finance Estates Workforce Strategy Estates & Infrastructure

1. Suppporting Strategies: 1. Bi-monthly Quality Report 1. Risk Management policy 1. Bi-monthly finance report1. Strategic Estates Development

discussions and decisions.1. Workforce Strategy 1. Integrated Business Plan 2016/21 1. Estates strategy

- Quality strategy 2. Bi-monthly perfomance report. 2. Systems of internal control.

2. Bi-annual update on

implementing actions relating to

Lord Cater report on productivity

2. Bi-monthly Quality Report2. Bi-annual review of delivering the

Business plan 2. IM & T Strategy

- People Participation Strategy3. Bi-monthly risk report to the

Board.

3. Annual Report on claims and

litigation 3. Bi-annual workforce review

3. Periodic review and refresh of the Trust's

business plan.3. Business Continuity Plan

2. Bi-monthly Quality Report4. Annual Report on claims and

litigation 4. Annual Budget sign-off 4. Guardian of Safe Working Hours report 4. Sign-off of annual plans.

3. Patient Stories/Experience

Reports

5. Mandatory training compliance

data

5. Cost Improvement planning and

sign-off5. Diversity & Inclusion Annual Report

4. Guardian of Safe Working Hours

report

6. Annual review of modern slavery

statement.

5. Annual Winter Planning

Assurance 8 Annual Staff Survey Results

6. Bi-annual update on

Whistleblowing and Freedom of

Information Requests

9. Mandatory training compliance data

7. Diversity & Inclusion Annual

Report 10. Mandatory training compliance data

8. Business Continuity Plan11. Staff Stories/Experience Reports

9. Emergency Preparedness,

Resilience and Response (EPRR)

10. Major Incident Plan

11. Annual Report on claims and

litigation

12. Medical Revalidation Annual

Report


data

Trustwide

Clinical Operational Boards

Sub Committees of the Board

Chaired by Non-Executive Directors

BOARD

Key

Iss

uues

&

Esc

alat

ion

Sources of Assurance for the Committee

Policies & Procedures

Back to the Floors

Well Led improvement programme including bi-annual review and self-assessment.

Head of Internal Audit Opinion

Children & Young People

Luton Children & Adults

Ambulatory Care

Annual external audit report

Annual Board effectiveness review.

Annual Board member appraisals and 360

Evidence of Board members' training and

Head of Internal Audit Opinion

Bi-annual Stakeholder management update

STP Reports and updates

Audit Committee

Sources of Assurance for

Benchmarking data against peer organisations.

Independent assurance received through

external regulators e.g. NHS Protect Review

Head of Internal Audit Opinion.

NHS Improvement and other independent

regulatory approval and guidance.

Quarterly Internal Audit Progress

Report .

Quarterly Internal Audit Follow-up report.

External Audit annual report

Policies and Procedures

Key Issues from other Board sub committees.

Annual internal audit plan.

Quarterly Local Counter Fraud Services Update.

Annual review of all risks.

Direct link between Chair of the Audit Committee and

internal and external auditors.

Non-executive only membership.

Quarterly review of Waivers and Special

Payments.

Annual external audit plan.

Bi-anual update on clinical audit and other clinical governance issues overseen by QISCOM.

Annual signing of accounts.

Standing Financial Instructions, Standing

Orders.

Annual non-executives only meeting with internal and

external auditors.

Annual effectiveness review.

Service/Division

Locality

Team

Bi-Monthly Integrated Governance Reporting

Clinical Operational Boards

Sources of Assurance for the Bi-annual patient experience

thematic update including incidents, complaints &

claims Bi-annual update on implementation of

Clinical Audit actions.

Bi-monthly review of divisional risks scoring 12 and above

Annual winter preparedness update

Annual thematic analysis of divisional risks scoring 9 and

above

Learning from improvement, service redesign and transformation work.

Safeguarding Children & Adults

Bi-annual update on implementation of

Service level staff stories (Three

Per

form

ance

Fin

ance

Wor

kfor

ce

Qua

lity

Seri

ous

Inci

dent

s

- Senior management meetings

- Clinical governance meetings - Locality level learning events

- Team meetings

- Handover meetings

Inte

grat

ed r

epor

ting

to th

e C

linic

al O

pera

tion

al B

oard

sho

uld

refl

ect t

he d

iscu

ssio

ns ta

king

pla

ce a

t eve

ry le

vel o

f eac

h se

rvic

e, w

ith e

ach

leve

l fee

ding

into

the

next

. No

new

info

rmat

ion

shou

ld b

e re

port

ed a

t Clin

ical

Ope

rati

onal

Boa

rd th

at h

as n

ot b

een

cove

red

at o

pera

tion

al le

vel.

Ris

k

Update on planning and implementation of Cost

Improvement Plans

Annual update and learning on Information Governance.

Quality Impact Assessments

Annual committee effectiveness review.

Quality Risk Medicines Management Learning from Death Infection Prevention & Control Information Governance Safeguarding Children & Adults Serious Incidents including NPSAPatient Experience including

complaints & claims

Emergency Planning &

PreparednessClinical Audit / NICE

Clinical & Professional Committee All Sub Groups Medicines Safety & Governance Learning from Death Group Infection Prevention & Control IG Steering Group Safeguarding Children & Adults Resilience & On Call

1. Quality Strategy and annual

operational plan

1. Bi-annual review of quality risks

at QISCOM

1. Medicines policies and

procedures including Patient Group

Directions (PGDs).

1. Learning from death discussions

at Board and committee level.

1. Infection Prevention & Control

Policy 1. Information Governance Toolkit

1. Bi-annual update to QISCOM

including Safeguarding Children &

Adults Annual Report

1. Review by Intenal Audit 1. Review by Intenal Audit

1. Annual clinical audit plan

reviewed and approved by

QISCOM.

2. Bi-annual review of

implementation of the quality

strategy reported to QISCOM

2. Risk management policy

2. Evidence of engagement with the

National Medication Safety

Network

2. Learning from Death policy.2. Bi-annual update to QISCOM

including annual report.

2. Evidence of reporting to the

regulators any relevant serious

incidents

2. Participation in Local

Safeguarding Boards and other

multiagency work.

2. Evidence of reporting to the

regulators any relevant serious

incidents

2. Investigating and responding to

complaints.

2. Bi-annual report on clinical audit

activity across all services,

implementation of the clinical audit

plan and NICE guidance to

QISCOM.

3. Independent assurance received

through external regulators e.g CQC

or NHS Improvement.

3. Evidence of investigations and

reports of medical error incidents.

3. Engagement with other relevant

processes for investigating deaths

that fall outside the scope of the

Trust's learning from death policy.

3. Discussions at Health & Safety

Committee

3. Bi-annual Information

Governance update to QISCOM

3. Patients & service user group

discussions about safeguarding and

community inclusion.

3. Evidence of compliance with

Duty of Candour.

3. Review of clinical audit function

by Intenal Auditors.

4. Evidence dissemination of

medication safety communications

4. Coroners' reports, Serious case

reviews and other relevant external

reviews of deaths.

4. IG Mandatory training

compliance data

4. Trust Safeguarding Children

Training and Competences Matrix

for staff

4. People participation strategy

5. Medicines related risk recording,

reporting and updating.5. Bi-annual report to QISCOM.

5. Independent reviews by external

regulators.

5. Diversity and Inclusion annual

report

6. Conflict of interests and

gifts/hospitality records

6. Clinical Systems Team monthly

overview report of all patient deaths

notified to the Trust.

1. Handover meetings1. Senior Management Meeting

minutes and papers.

1. Frameworks for non-medical

prescribing

1. Evidence of implementation of

learnin from deaths.


data.

1. Contribution and attendance at

Local Safeguarding Audlts Board

Peer review


complaints.

1. Benchmarking of clinical audit

outcomes across different localities.

2. Senior Management Meetings 2. Learning from Deaths Dashboard

2. Annual conferences and other

forums for staff to learn from

safeguarding incidents.

2. Evidence of sharing of learning

across different localities and

services.

3. Annual Conferences 3. Joint working with L&D

4. Safeguarding data

1. Accurate reporting of locality

performance data

1. Minutes and papers from team

Meetings

1. Local Medicines Management

Standard Operating Procedure

1. Screening tool to review of

monthly report provided by clinical

systems team to assess if any deaths

should be investigated.

1. IPAC Audits1. Evidence of investigation of IG

incidents and sharing of learning.1. safeguarding supervision 1. "You said, we did"

1. Developing local clinical audit

plans and ensuring these are fed into

the Trustwide planning process for

approval by QISCOM.

2. Quality Early warbibg Trigger

Tool (QWETT)

2. Datix records of incidents and

near misses involving medicines.

2. Evidence of reporting to

informatics team where a patient's

data is not held on clinical systems

to ensure all deaths are included in

Trust records.

2. Mandatory safeguarding training

relevant to each role.


complaints.

2. Evidence of implementation of

recommendations and actions from

clinical audits.

3. Records of names, signatures and

initials of all healthcare staff,

including prescribers, who complete

documentation relating to

medicines.

3. Root cause analysis reports.3. Safeguarding and community

inclusion report.

3. Evidence of patient engagement

including outreach to 'hard to reach'

groups

3. Evidence of sharing of learning

across different localities and

services.

4. Records of risk assessments

conducted in relation to medicines.

4. Learning events from

safeguarding referrals and coroner

inquests.

5. Safeguarding policies and

procedures.

1. Accurate recording of

performance data

1. Identifying and recording of risks

on datix.

1. Incidents and near misses

reported using Datix.Participation in IPAC audits. 1. Datix reports of IG incidents 1. Job description & specification.

1. Individual reporting incidents and

recording them on datix

1. Participation in local clinical

audits.

2. Ongoing monitoring and updating

of risks owned by the individual.

2. Mandatory and essential training

compliance.

2. Safeguarding alerts made by

individual staff members.

3. Mandatory and essential

training compliance.

Quality Improvement and Safety Committee

Service Level

Sub Groups

Service/Locality Level

Individual

Trustwide

Key

Iss

uues

&

Esc

alat

ion

Sources of Assurance for the Committee

Policies & Procedures Evidence of training and CPD including mandatory training compliance, revalidation and professional

accredidation Personnel files

Quality Account

Shine a Light

Back to the Floor

Research

Annual staff survey CCS Quality Way including quality

way reviews

Human Factors Clinical Audit Friends & Family Test

External agency reports and registration

Whistleblowing

Self-assessments

Medical revalidation

Trust Leadership Values

Datix

Internal Audit Reviews

Job description and specification

Weekly governance log circulated to Wider Executive

CQC and other independent regulatory inspections

Cycle of Business

Remuneration Committee



Agenda for Change National Terms and Conditions

Annual Performance Review of each

Director.

External agency reports

National guaidance on senior managers' pay including

agenda for change and VSM


Directors' job descriptions and specifications



Clinical Execellence Award Panel

Redundancies report to the

Remuneration

Annual confirmation of Fit & Proper

Persons Test completion for all Board members

National guidance on Guidance on senior appointments.

Other relevant external research and reports.

Board skills and capability matrix.

Application for approval for NHS trusts of new or uplifted

salaries/remuneration at or above the Prime Ministers' Salary.

National guidance on off-payroll engagements.

Chair of Remuneration

Committee approves all redundancies before they are

actioned.

Directors' succession planning

Charitable Funds Committee



Independent assurance received through the Charity Commission.

External agency reports and guidance




Annual overview and fund analysis report on charitable

funds held by Cambridgeshire & Peterborough Foundation Trust on behalf of the Trust.

Quarterly Dreamdrops reports to the Charitable Funds Committee

External Audit annual report

Annual Investment Policy Review

Director of Finance & Resources is a member of the Charitable Funds Joint Management Panel for funds held by

Cambridgeshire & Peterborough Foundation Trust on behalf of the Trust.

Dreamdrops fundraising committee reports and proposals.

Strategic Change Board

Trustwide

Service Level

Chaired by the Service Directors


Outcomes from patient/staff consultations.

Project initiation documents

External reports and guidance.

Quality Impact Assessments

Internal and external benchmarking information.

Policies and Procedures Internal audit reviews.

Business Development and Transitions Programme.

iCaSH Programme. Norfolk Children &

Young People Programme.

Luton Adults Programme.

Luton Children's Programme. Cambridgeshire

Children & Young People Programme.

Horizon Scanning.

'At Home First' Programme.

Improving Organisational

Capability Programme.

Musculoskeletal Programme.

Post implementation reviews and benefits realisation reports.

Executive Programme

Board

Children & Young People Programme

Board

Luton Children & Adults

Programme Board

Ambulatory Care

Programme Board

Post implementation

Operational Delivery of Facilities Management - Hard FM

Health & Safety Infection Prevention & Control Sustainability

Estates Committee

Sub Groups

Key

Iss

uues

&

Esc

alat

ion

Sources of Assurance for the

Policies & Procedures

Evidence of training and CPD including mandatory training compliance, revalidation and professional

accredidation

Estates Strategy

Review and approval of annual

Bi-Annual Update on implementation of Estates

Strategy External agency reports and

registration

Bi-Annual Update on implementation of

Sustainability Strategy

Nov - Water Dec -

Electricity & CIBSE

"M"

Jan - Fire &

Asbestos

Feb - Water

Mar - Electricity & CIBSE

"M"

Apr - Fire &

Asbestos May - Water

Jun - Electricity & CIBSE

"M"

Jul - Fire &

Asbestos

Aug - Water

Sep - Electricity & CIBSE

"M"

Oct - Fire &

Asbestos

Nov - O/A - Electricity, CIBSE

"M", Fire, Asbestos, Water

Feb - O/A - Electricity, CIBSE


May - O/A - Electricity, CIBSE


Aug - O/A - Electricity, CIBSE


Mon

thly

Est

ates

U

pdat

e to

Exe

cuti

ve

Mee

ting

Annual Report on lessons learnt from capital projects and how these have

been built into programme management.

Review and approval of annual

Quarterly report on progress against capital

Bi-annual update on on annual fire report actions.

Quarterly updatet on on Estate Management

Services.

Quarterly review of estates risks.

Annual Review of Sub-group Risk Registers.

Annual statement on NHS Security Management

responsibility.

Annual fire declaration.

sources of assurance for the committee · execellence award panel redundancies report to the...

Documents