GOVERNING BODY. Corporate Objective addressed by this paper (please select one or more with an X):

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1 Enclosure: H Agenda item: 12 GOVERNING BODY Title of paper: Governing Body Assurance Framework (GBAF) Report Date of meeting: September 2018 Presented by: Yvonne Leese Prepared by: Diane Goodenough Title: Director of Quality and Integrated Governance & contact: yvonne.leese@nhs.net Title: Patient Safety Manager & contact: d.goodenough@nhs.net Corporate Objective addressed by this paper (please select one or more with an X): sustainable, efficie reduce health inequalities with an additional focus on the urgent and emergency x care system improvement along the pathway. 2. To ensure the CCG s position recovers to meet its financial and governance duties and performance standards. x 3. To nurture and support primary care to be resilient and thrive. x 4. To strengthen productive relationships with partners and the public to work as a health and care system. x 5. To actively engage with our communities to improve their experience of healthcare. x 6. To play an active and influential role in shaping SE London and London wide commissioning. x Purpose of the report: NHS Greenwich Clinical Commissioning Group (CCG) has a Governing Body Assurance Framework (GBAF) that has been developed from the organisation s strategic objectives as identified by the Governing Body. The GBAF is the organisation s main process through which the Governing Body receives assurance on the management of high level risks to the achievement of the organisations strategic objectives. Issues arising: New Risks Closed Risks Reduced Risk Scores Increased Risk Scores None None None ID 293: Risk of the Continuing Healthcare (CHC) team not delivering its 1.34m QIPP target. This risk has been reassessed as red with a score of 16 due to the work on reducing backlog issues and strengthening the administrative processes in the CHC team.

2 Main risks There are six main risks to the CCG: ID Risk Description Changes since 284 There is a risk that Primary Care reducing GP workforce with an increasing population, will impact on service delivery and resilience over time. 281 The CCG's risk of not achieving the improvement trajectory for meeting the access to cancer treatment as measured by the constitutional standard for 62 days from urgent GP referral to treatment. 290 The CCG is at risk of fully delivering it core functions if acute contracts over perform in 2018/19. last assessment The CCG has a risk of not halving the numbers of patients waiting more than 52 weeks for treatment at March 2018 compared to numbers by March Risk of the Continuing Healthcare (CHC) team not delivering its 1.34m QIPP target. 282 There is a risk of failure to deliver the transformation work of the SEL Sustainability and Transformation Partnership (STP) by Our Healthier South East London [OHSEL] The process is supported by a formal risk management framework which considers the CCG s appetite for risk and roles and responsibilities for risk management within the organisation. 2

3 The criteria used to determine the level of impact and likelihood the risk will occur is shown in the following matrix, which demonstrates the range of scores available to be assigned against a risk: Severity/ Consequence RISK SCORE MATRIX Likelihood Rare Unlikely Possible Likely Almost certain 5 Catastrophic Major Moderate Minor Negligible Risk score Action Extreme risk Escalate to the Governing Body 8-12 High risk Escalate to the Greenwich Executive Group 4-6 Moderate risk Escalate to relevant Directorate Director 1-3 Low risk Manage within Directorate Teams The consequence and likelihood scores must be multiplied together to give an overall risk score. Summary of actions, if any, following this meeting: The current focus is on derisking the QIPP plan by: a) Fully assuring existing schemes at local and collaborative level. b) Developing new schemes through collaborative work programme with Bexley and Lewisham. c) Contract due diligence. The CCG has a QIPP of 14.3m in 2018/19 to achieve financial balance. The 14.3m has not been fully identified so there is a level of risk with delivering the target. Financial recovery remains the priority for the CCG, which is detailed in the Financial report. Previous committee involvement: Audit Committee: Date: 19 March 2018 for consideration and approval Governing Body: Date: 02 May 2018 for consideration and approval Greenwich Executive Group: Date: 20 June 2018 for consideration and approval Quality Committee: Date: 04 May 2018 for consideration and approval FPQ Committee: Date: 27 June 2018 for consideration and approval Recommendations to the Governing Body: The Governing Body is asked to: To scrutinise the risk register and consider if the controls are sufficient and appropriate to mitigate risks. (Please provide details below where Yes is indicated) 3

4 Impact on Governing Body Assurance Framework (x) Yes x No N/A Impact on Environment (x) Yes No N/A x Legal Implications (x) Yes x No N/A Resource and or financial implications (x) Yes x No N/A Equality impact assessment (x) Yes No N/A x Privacy impact assessment (x) Yes No N/A x Impact on current NHS Outcomes Framework areas (x) Yes x No N/A Patient and Public Involvement (x) Yes No N/A x Communications and Engagement (x) Yes No N/A x Impact on CCG Constitution (x) Yes No N/A x The report has identified: Impact on Governing Body Assurance Framework: The current GEG risk register outlines details of all identified organisational risks that may prevent the CCG from achieving its strategic objectives. Legal implications: All risks detailed on the risk register have legal implications attached to them as the CCG is required to meet statutory financial duties, Civil Contingencies Act duties and Section 11 duties. Resource and or financial implications: All risks detailed on the risk register have legal implications attached to them as the CCG is required to meet statutory financial duties, Civil Contingencies Act duties and Section 11 duties. Impact on current NHS Outcomes Framework areas: Risks in relation in relation to providers not delivering quality and safety standards to patients which could impact on the current NHS Outcomes Framework (specifically Outcome 5: treating and caring for people in a safe environment and protecting them from avoidable harm) linked to strategic objective 1. Attachments: (i) Governing Body Assurance Framework (GBAF) Report (ii) Appendix A: Governing Body Assurance Framework (GBAF) (iii) Appendix B: NHS Greenwich Clinical Commissioning Group Risk Register 4

5 GOVERNING BODY Governing Body Assurance Framework Report September Introduction NHS Greenwich Clinical Commissioning Group (CCG) has a Governing Body Assurance Framework (GBAF) that has been developed from the organisation s strategic objectives as identified by the Governing Body. The GBAF is the organisation s main process through which the Governing Body receives assurance on the management of high level risks (risks scored 12 and above) to the achievement of the organisations strategic objectives. This report provides the Governing Body with an overview of the totality of risks affecting the organisation s strategic objectives together with the action plans to address them. The detailed review and scrutiny of the GBAF ensures that appropriate controls and assurances are in place to manage the mitigations of these risks. Analysis identifies any objectives that are at greater risk and provides opportunities for remedial action which will increase the level of assurance. 2. NHS Greenwich CCG s Strategic Objectives 2018/19 sustainable, efficie inequalities with an additional focus on the urgent and emergency care system improvement along the pathway. 2. To ensure the CCG s position recovers to meet its financial and governance duties and performance standards. 3. To nurture and support primary care to be resilient and thrive. 4. To strengthen productive relationships with partners and the public to work as a health and care system. 5. To actively engage with our communities to improve their experience of healthcare. 6. To play an active and influential role in shaping SE London and London wide commissioning. Page 1 of 5

6 3. Activity since last report Table 1: Risk activity since the last report New Risks Closed Risks Reduced Risk Scores Increased Risk Scores None None None ID 293: Risk of the Continuing Healthcare (CHC) team not delivering its 1.34m QIPP target. This risk has been reassessed as red with a score of 16 due to the work on reducing backlog issues and strengthening the administrative processes in the CHC team. The full Governing Body Assurance Framework (GBAF) is detailed in Appendix A. 4. Main risks There are six main risks to the CCG: ID Risk Description Changes since last assessment 284 There is a risk that Primary Care reducing GP workforce with an increasing population, will impact on service delivery and resilience over time. 281 The CCG's risk of not achieving the improvement trajectory for meeting the access to cancer treatment as measured by the constitutional standard for 62 days from urgent GP referral to treatment. 290 The CCG is at risk of fully delivering it core functions if acute contracts over perform in 2018/ The CCG has a risk of not halving the numbers of patients waiting more than 52 weeks for treatment at March 2018 compared to numbers by March Risk of the Continuing Healthcare (CHC) team not delivering its 1.34m QIPP target. 282 There is a risk of failure to deliver the transformation work of the SEL Sustainability and Transformation Partnership (STP) by Our Healthier South East London [OHSEL] The CCG is working closely with Southwark s Integrated Contracts Delivery Team (ICDT) along with the North East London s Commissioning Support Unit (NEL CSU) to monitor its acute Page 2 of 5

7 providers to redesign patient pathways and improve quality and outcomes for patients. The CCG is also collaboratively working with all South East London (SEL) Clinical Commissioning Groups (CCGs) to strengthen monitoring processes of commissioned services to gain assurances on value for money, safety and clinical effectiveness in services received by the local population. The current focus is on derisking the QIPP plan by: a) Fully assuring existing schemes at local and collaborative level. b) Developing new schemes through collaborative work programme with Bexley and Lewisham. c) Contract due diligence. The CCG has a QIPP of 14.3m in 2017/18 to achieve financial balance. The 14.3m needs to be fully identified as there is a level of risk with delivering the target. The CCG s recovery plan recognises that it must deliver on the following 4 key areas to manage these risks: 1. Manage acute over-performance more effectively 2. Deliver QIPP programmes more consistently 3. Manage budgets more effectively not spending more money than we have 4. Build the capacity and capability to deliver this larger change programme Financial recovery remains the priority for the CCG, which is detailed in the Financial report. 5. Overview of the organisation s risk register monitoring process There are currently 14 risks on the GBAF. Table 2: Monitoring of identified risks: Objective Number of risks Monitoring 1 10 Quality Committee, FPQ Committee, GEG & Governing Body 2 2 FPQ Committee, GEG & Governing Body 3 1 FPQ Committee, GEG & Governing Body 4 N/A Monitored on the corporate Risk Register 5 N/A Quality Committee, GEG & Governing Body 6 1 FPQ Committee, GEG & Governing Body Total 14 The process is supported by a formal risk management framework which considers the CCG s appetite for risk and roles and responsibilities for risk management within the organisation. Page 3 of 5

8 The criteria used to determine the level of impact and likelihood the risk will occur is shown in the following matrix, which demonstrates the range of scores available to be assigned against a risk: Table 3: Risk Score Matrix RISK SCORE MATRIX Severity/ Consequence Likelihood Rare Unlikely Possible Likely Almost certain 5 Catastrophic Major Moderate Minor Negligible Risk score Action Extreme risk Escalate to the Governing Body 8-12 High risk Escalate to the Greenwich Executive Group 4-6 Moderate risk Escalate to relevant Directorate Director 1-3 Low risk Manage within Directorate Teams The consequence and likelihood scores must be multiplied together to give an overall risk score. Conclusion The GBAF has identified risks that may prevent the organisation from achieving its statutory duties e.g. the ability of the Governing Body to meet its statutory duties, particularly around managing breaching the 18 week RTT standard; breaching the 62 day referral to treatment cancer target and that acute contracts may over perform in 2018/19. Actions have been identified to mitigate these risks and the Governing Body will continue to monitor the progress on the action plans. Recommendations To scrutinise the risk register and consider if the controls are sufficient and appropriate to mitigate the risks. Page 4 of 5

9 Summary of all 14 Risks on the CCG s GBAF as at 02/08/18 ID Risk Description (Target) (Initial) Changes since last assessment 284 There is a risk that Primary Care reducing GP workforce with an increasing population, will impact on service delivery and resilience over time. 281 The CCG's risk of not achieving the improvement trajectory for meeting the access to cancer treatment as measured by the constitutional standard for 62 days from urgent GP referral to treatment. 290 The CCG is at risk of not fully delivering it core functions if acute contracts over perform in 2018/ The CCG is at risk of not halving the numbers of patients waiting more than 52 weeks for treatment at March 2018 compared to numbers by March Risk of the Continuing Healthcare (CHC) team not delivering its 1.34m QIPP target There is a risk of failure to deliver the transformation work of the SEL Sustainability and Transformation Partnership (STP) by Our Healthier South East London [OHSEL]. 280 The CCG's risk of not being able to maintain the patient tracking list (PTL) size at March 2018 levels. The PTL size is the total number of patients on the waiting list. The operating plan guidance for 2018/19 expects the Referral to Treatment (RTT) PTL at end of March 2019 should not be higher than the level at March The CCG fails to achieve its financial statutory duties in 2018/ Failure to deliver the 14.3m QIPP target for 2018/ There is a project delivery risk to the implementation of the frailty model ahead of winter 2018/ Non achievement of national 4 hour ED waiting time target could impact on patient care and clinical outcomes Vacancy for Designated Nurse for Looked After Children (LAC) post impact on care LAC children receive. 248 CCG is unable to meet the statutory requirements of the Deprivation of Liberty Safeguards (DoLS) 181 Appropriate systems and processes not in place to ensure monitoring of quality and safety of main commissioned services Page 5 of 5

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11 APPENDIX A: Governing Body Assurance Framework (GBAF) as at 02/08/18 ID Date Opened Risk Description Controls/Mitigation Gaps in controls/mitigation Assurance CCG's Objectives (Target) (Initial) Changes since last assessment Action Plan Director GP Lead Committee Responsible /09/2017 There is a risk that Primary Care reducing GP workforce with an increasing population, will impact on service delivery and resilience over time. Primary Care Risk Register. Bi-monthly reporting with updates to Primary Care Commissioning Committee (PCCC) and GP Forward View [GPVF] Board. Regular reporting on progress to SEL STP through Standard Assurance Process. Regular updates on progress to LMC. Successful bid for Pharmacists recruitment. Successful bid for GP recruitment. Applying GPFV resilience funding to target support to practice with biggest growth in list size. Inability to influnce primary care recruitment and retention. Financial and employment impact on practices to recruit more staff to address growing demand. Population growth through Greenwich regeneration programmes. Changing population profile to more mobile, younger population. Escalation of issues through the SEL Healthy London Partnerships (HLP) Assurance Return. Minutes of PCCC, GPVF Board and LMC Meetings. Monitoring list size and including reports in CCG Quality Report to ensure focus. Primary care team action plan to help improve patient registration process to ensure funding follows the patient. 3. To nurture and support primary care to be resilient and thrive Assurance Returns and feedback from HLP to SEL Primary Care Exec. Group supports local action planning to address issues that are escalated. August Update: Pharmacists recruitment in implementation stage by the Federation. The national GP recruitment scheme is expected to commence in September Shaw, Robert - Director of Commissioning Perera, Ranil - GP Clinical Commissioner /05/18 The CCG's risk of not achieving the improvement trajectory for meeting the access to cancer treatment as measured by the constitutional standard for 62 days from urgent GP referral to treatment. Trusts action plans to deliver their 62 day trajectory including a SEL Recovery plan focusing on shared pathway actions and performance. Monthly performance meeting with acute trusts - focus on internal trust performance and actions relation to them, covering areas not picked up by the 62 day leadership group. Fortnightly system leadership group - 62 day leadership meeting, focusing on shared pathway actions and performance. The Schared Care Cancer Delivery Team (SCCD) - the operational arm of the ACN to progress actopms on a day to day basis. Monthly ACN Steering Group. Monthly Members Board - a trust CEO. COO board which facilitates trust level escalation where plans are not progressed. Development of KPIs for all shared pathway commitments. Real time information. Trust level plans and SEL recovery plan with SMART actions and senior level action owners. Trust performance reports for performance meetings. Monthly performance against trajectory by Trust and CCG. Minutes of Performance Meetings. CCG Integrated Governance report papers. Trust performance report to 62 day leadership group showing progress updates for actions by Trust and Tumour Type. Minutes and Action Log from 62 day Leadership Meeting. Reports showing KPIs for -time to first outpatient (shared pathway commitment). Action Plans RAG ratings. Papers and minutes of the monthly Members Board The development of KPs for all shared pathwy commitments to allow near time monitoring of impact of actions to be in pace by end of Q2. This development is being led by the Operational arm of the ACN. Shaw, Robert - Director of Commissioning Wahba, Hany - GP Clinical Commissioner Page 1 of 6

12 APPENDIX A: Governing Body Assurance Framework (GBAF) as at 02/08/18 ID 290 Date Opened 29/03/17 Risk Description Controls/Mitigation Gaps in controls/mitigation Assurance CCG's Objectives (Target) The CCG is at risk of not fully delivering its core functions if acute contracts over perform in 2018/19. Contracts funded at outturn and specific growth levels for e.g. to sustain cancer and diagnostic activity and generic demographic growth editions. Detailed examination of activity level by point of delivery by NEL CSU and CCG MDT. CMBs. Regular update reports to the FPQ and Governing Body. Controls on prior approval and consultant to consultant referral require review. Variance analysis planned to actual by point of delivery by provider monthly analysis. Summary level to FPQ monthly. Monthly Operational Plan reporting to FRB. Notes and Action Trackers of CMBs. CSU and CCG MDT monthly meetings. Improved analysis of forward order book for Elective Care through referral management and referral data by source. Strengthening of integration of perfomance and finance reports to FPQ. (Initial) Changes since last assessment Action Plan Management of unplanned activity via QIPP schemes. Implementation of Planned Care Programme Board across Bexley, Greenwich and Lewisham with focus on high referring specialities, referral optimisation and increasing access to specialist opinion to reduce referral levels. Director GP Lead Shaw, Robert - Director of Commissioning Perera, Ranil - GP Clinical Commissioner Committee Responsible /06/18 The CCG has a risk of not halving the numbers of patients waiting more than 52 weeks for treatment at March 2018 compared to numbers by March GSTT and KCH both have agreed A specialty level plan and trajectory for trajectories to reduce the number key specialties with long waiters for KCH. of long waiters to zero over the course of the year. This is over and above the national requirement. LGT currently has not long waiting patients - the expectation is that this position will be maintainewd throughout 2018/29. Specialty level plan and trajectory for key specialties with long waiters for GSTT. Monthly performance meeting with acute trusts. Integrated Performance Reports to the Integrated Governance Committee. Contract Management Board (CMB) and Performance Meeting minutes and reports. CQRG minutes and reports. CSU service Auditors Reports (SARs). CG and CSU MDT A specialty level action plan has been provided by KCH by the end of Q1, which has senior level ownership. Currently working with the Trust to understand the intricacies of the plan to ensure progress can be tracked effectively. Shaw, Robert - Director of Commissioning Patel, Dr Nayan - GP Clinical Commissioner /05/18 Risk of the Continuing Healthcare (CHC) team not delivering its 1.34m QIPP target. CHC Improvement Programme and Action Plan. QIPP CHC milestones monitored monthly at QPDM with risks escalated to FRB. CHC monthly budget meetings. SEL CHC QIPP programme monitored by SEL QIPP oversight group. CHC has developed pricing structure to negotiate new packages of care in 2018/19. Risk of being unable to control costs and market resilience with current providers. Limited capacity to re-negotiate contracts from spot purchase to AQP providers. CHC information systems require development and strengthening. Monthly reports to QPDM. Monthly budget reports and minutes from CHC Governance Group meetings are also monitored for assurance at the Quality Committee. Minutes of FPQ and FRB meetings An end to end review of the systems and processes within the CHC budget is being undertaken to assess for further efficiencies to backup potential non-delivery of existing identified schemes. Action plan developed to deliver CHC System improvements for Invoice Management and monthly reconcilliation of the budget spend. Backlog of invoices and packages of care are being logged into CHC system. Quality Committee Leese, Yvonne - Director of Quality & Governance Nyame, Dr Sylvia - GP Page 2 of 6

13 APPENDIX A: Governing Body Assurance Framework (GBAF) as at 02/08/18 ID 282 Date Opened 24/05/18 Risk Description Controls/Mitigation Gaps in controls/mitigation Assurance CCG's Objectives (Target) There is a risk of failure to deliver the transformation work of the SEL Sustainability and Transformation Partnership (STP) by Our Healthier South East London [OHSEL]. The CCG's membership and participation in the following: SEL STP Steering Group; SEL STP Strategy Group and SEL STP work streams. CCG's Managing Director [MD] is Senior Responsible Officer (SRO) on Transforming Care Partnership (TCP). Reporting to the Governing Body (GB). Included into the CCG's workplan. STP work incorporated into the CCG's QIPP programme. Under developed systems and processes to update GB from various meetings. Financial gap yet to be closed. Regular reports to GB. CCG's membership and participation in various STP work streams. Weekly SEL Executive meetings with MD and Director of Finance. Shared Accountable Officer for the SEL Commissioning Alliance. 6. To play an active and influential role in shaping SE London and London wide commissioning. (Initial) Changes since last assessment Action Plan Quality surveilance monitoring of services being delivered. Development of Community Based Care (CBC) and Activity Based Care Programme Implementation of key workstreams. Director GP Lead Kennett-Brown, Neil - Managing Director Wright, Ellen - Chair Committee Responsible /05/18 The CCG's risk of not being able to maintain the patient tracking list (PTL) size at March 2018 levels. The PTL size is the total number of patients on the waiting list. The operating plan guidance for 2018/19 expects the Referral to Treatment (RTT) PTL at end of March 2019 should not be higher than the level at March GSTT, LGT and KCH all have agreed Recovery plans received from both KCH trajectories to deliver reduced PTL and LGT but further issues to be clarified. size (trust wide) by March 2019, which are reflected in start year contracts. Trusts have agreed trajectories to improve RTT performance levels of imcomplete, which is over and above the national requirment and should further the reduction of PTL size. Activity plan for GSTT for RTT delivery. Monthly performance meeting with acute trusts. Integrated Performance Reports to the Integrated Governance Committee. Contract Management Board (CMB) and Performance Meeting minutes and reports. CQRG minutes and reports. CSU service Auditors Reports (SARs). CCG and CSU MDTs. NHS England stocktakes A specialty level action plan to be provided by KCH and LGT, which has senior level ownership. Currently working with the Trusts to understand the intricacies of the plan to ensure progress can be tracked effectively. Shaw, Robert - Director of Commissioning Patel, Dr Nayan - GP Clinical Commissioner /03/18 The CCG fails to achieve its financial statutory duties in 2018/19. Monthly Financial Recovery Board (FRB) meetings. Monthly Finance, Performance & QIPP (FPQ) meetings. Contract Monitoring Board (CMB) meetings. Regular financial report to Governing Body. Regular assessment meetings with NHSE. Continuous review of the CCG's 2018/19 budget and expenditure. None. Weekly QIPP, Performance, Delivery and Monitoring (QPDM) meetings. Project Management Office (PMO) leading on QIPP delivery process. Monthly FPQ monitoring. Regular meetings with budget managers. Monthly Financial Recovery Board (FRB) meetings. Quarterly Audit Meetings. 2. To ensure the CCG's position recovers to meet its financial and governance duties and performance standards Joint working with other SEL CCGs to ensure achievement of SEL Control Total. Maloney, David - Chief Financial Officer Wright, Ellen - Chair Page 3 of 6

14 APPENDIX A: Governing Body Assurance Framework (GBAF) as at 02/08/18 ID 291 Date Opened 29/03/17 Risk Description Controls/Mitigation Gaps in controls/mitigation Assurance CCG's Objectives (Target) Failure to deliver the 14.3m QIPP target for 2018/19. Monthly reporting on progress to Organisation's ability and capacity to the Financial Recovery Board generalise large scale and focus projects. (FRB). Weekly QIPP, Performance, Delivery and Monitoring (QPDM) tracking of live schemes and development of new schemes. Robust assurance for all schemes within the QIPP programme. System tracking of delivery against all live schemes by project plan milestones. Continuous review of development opportunities in QIPP pipeline. Staffed Programme Management Office (PMO). CCG wide launch of PMO Operating Procedures. CEP process being implemented across SEL. Minutes and trackers of QPDM Group. Minutes/papers to FRB. Minutes/papers to FPQ. Minutes/papers to Governing Body. SOPs. 2. To ensure the CCG's position recovers to meet its financial duties and performance standards. (Initial) Changes since last assessment Action Plan Identify actions to be taken to reduce the risk of increased schemes and reduce the risk of non-delivery QIPP by the PMO. Horizon scanning of new QIPP opportunities. Current focus is on derisking the QIPP plan by: a) Fully assuring existing schemes at local and collaborative level. b) Developing new schemes through collaborative work programme with Bexley and Lewisham. c) Contract due diligence. Director GP Lead Shaw, Robert - Director of Commissioning Wright, Ellen - Chair Committee Responsible /11/17 There is a project delivery risk to the implementation of the frailty model ahead of winter 2018/19. Escalation plans. Arrangements in place to manage activity. Communication plans and ongoing escalation routes. Business continuity plans (DToC, UCC, ED flow). Weekly mobilisation meeting to review CAU activity and outcomes. Duncan House open to receive patients. Good Practice Visit to West London CCG to observe and embedded Frailty Model. Affordability of plan. Workforce - existing vacancies and staff needed to open the escalation capacity (both within acute and community). Failure of surge and proposed contingency measures to address pressures within the U&EC system/ Surge outside of the scope of the demand model - e.g. flu; impact of diverts to support local systems in heightened escalation Monthly reports to monitor breaches. Work with the SEL Surge Hub to ensure Surge and Escalation measures are fully agreed and underpinned by key partners e.g. LAS. Improved streaming and extended access to Ambulatory Care Pathways (ACP). Daily CAU activity reporting. Weekly Duncan House mobilisation meetings Stakeholders workshops for frontline staff across all frailty related services. Implementation of Task and Finish Groups for Discharge to Assess Remodelling. Shaw, Robert - Director of Commissioning Subbarayan, Krishna Page 4 of 6

15 APPENDIX A: Governing Body Assurance Framework (GBAF) as at 02/08/18 ID 279 Date Opened 18/05/17 Risk Description Controls/Mitigation Gaps in controls/mitigation Assurance CCG's Objectives (Target) Non achievement of national 4 hour ED waiting time target could impact on patient care and clinical outcomes. CCG attendance at ED Delivery Board meetings. Admission avoidance schemes supported by the CCG, Work to redesign patient pathways to improve patient flow and focus on improving the management of frailty patients. The ICDT leading work to redesign pathways to support patients avoided. Acute Frailty Unit Rapid Access Treatment (RAT) in place. UCC reconfiguration completed in October Discharge to Assess processes in place. Limited frailty/ambulatory care pathways in place. Current layout of the ED does not aid flow and limits available space for UCC patients. UCC & ED have different ways of recording breaches with different data. Requires agreement for standard methodology of data collection. LGT's estate plan to utilise available capital funding to improve capacity and flow. LGT's service transformation team working on improving patient flow. Performance scrutinized closely at the ED Delivery Board; LGT's CMBs and LGT's CQRGs. Ambulatory Emergency Care (AEC) opened in July This manages a range of conditions sent from GPs/ED/UCC and discharge on the same day. A&E Delivery board has appointed an independent Chair across the BGL system. PMO resourced to support key work streams with system SROs. Re-design of UCC Pathway for Mental Health. Telehealth Scheme for Care Homes launched in May (Initial) Changes since last assessment Action Plan LGT Emergency Pathway Improvement Plan. UCC Pathway re-design work undertaken for CAMHS work to improve patient flow. Frequent Attenders QIPP re-launched in July Care Homes medication review to reduce hospital admissions. Mapping work on Falls to be completed by end of August Director GP Lead Kennett-Brown, Neil - Managing Director Patel, Dr Nayan - GP Clinical Commissioner Committee Responsible /01/18 Vacancy for Designated Nurse for Looked After Children (LAC) post impact on care LAC children receive. Designated Nurse for Safeguarding Children is providing strategic and governance role within the CCG. Designated Nurse for Safeguarding Children provides information and support for service development. Designated Nurse for Safeguarding Children is working with the current part-time Designated Nurse for Looked After Children (LAC) to develop a service which reflects current national guidance and statutory regulation. Designated Nurse for Safeguarding Children does not have the expertise in LAC services and has competing workload priorities. Looked After Children (LAC) Doctor in post (part-time). LAC Nurse (part-time) in post. Designated Nurse for Safeguarding Children in post. Regular meetings with Designated professionals to review LAC CCG considering options to optimise recruitment. Leese, Yvonne - Director of Quality & Governance Salman, Dr Sabah - GP Joint Safeguarding Group Page 5 of 6

16 APPENDIX A: Governing Body Assurance Framework (GBAF) as at 02/08/18 ID 248 Date Opened 26/01/18 Risk Description Controls/Mitigation Gaps in controls/mitigation Assurance CCG's Objectives (Target) CCG is unable to meet the statutory requirements of the Deprivation of Liberty Safeguards (DoLS) Liaise with Continuing Health Care (CHC) team to scope approximate numbers where this ruling may apply. Legal support available on a case by case basis. Raised with National Safeguarding Steering Group/MCA & DoLS subgroup. None. CHC activity is controlled in-house and hence it is easier to seek assurance. It is likely that this ruling will apply to a small number of patients. Designated Nurse for Safeguarding Adults has met twice with the CHC team to scope this issue. Revised national CHC guidance has clarified that the CCG is responsible for making applications to the Court Protection (CoP) where they are the funding authority. (Initial) Changes since last assessment Action Plan CHC team have now scoped the number of patients that this is likely to apply to and have started discussions with RBG re:comissioning a service to complete the CoP applications. Director GP Lead Committee Responsible Joint Safeguarding Group Leese, Yvonne - Director of Quality & Governance Wahba, Hany - GP Clinical Commissioner /04/18 Appropriate systems and processes not in place to ensure monitoring of quality and safety of main commissioned services. Challenge and rigour of the quality monitoring systems in the: Quality Committee, CQRGs and CMB meetings. Receipt of Quality Reports at Quality Committee, GEG and Governing Body. Robust QIA & EIA process. Memorandum of Understanding with Public Health. Health & Wellbeing Board. Service contracts include quality and safety metrics. Quality Assurance Visits (QAVs). BRAVO system to share intelligence of quality and safety in contracts. Review of Impact Analysis via Quality Assurance Visits (QAVs) reporting back to the Quality Committee. Quality Surveillance Group NHSE. Contracts do not prioritise quality issues / Quality KPIs. Contracts review highlights lack of commissioning capacity. Limited capacity to monitor small contracts. Patient Alert Monitoring System (PAMS) and the Quality Alert Management System (QAMS) both appear under utilised across the health economy. Develop a consistent approach to KPIs that focus on outcome based care. Minutes and reports from Quality Committee. Quality Report to the Governing Body. Quality Issues Log. Monthly joint performance/quality/finance integrated report. Integrated Quality Dashboard. Escalation at CQRG to Contract Monitoring Board. Data from PAMS/QAMS used in reports to the Joint Safeguarding Group/Quality Committee. Annual Governance Statement and Report. Reports and minutes from the SI Review Panel. Quality Strategy. Evidence for CCG Statutory duties completed by July Development for a quality schedule / forward planner for each main contract. The CCG is considering mechanisms for monitoring of Primary Care contract. Leese, Yvonne - Director of Quality & Governance ddr Nayan Patel Quality Committee Page 6 of 6