Leeds Community Healthcare NHS Trust
Board Assurance Framework October 2014
ID
What is the risk?
(Risk Description)
Lead Director
Level of Risk (consequence x How are we managing the risk? (Key
likelihood)
Controls)
Evidence that it is working (Assurance on
Controls)
CLINICAL RISK REVIEWED BY
QUALITY COMMITTEE
4x2 = 8
5x1 = 5
Impact: Harm to
patients; reputational
damage; regulatory
penalty
Angie Clegg
5x2 = 10
Risk: Poor
Implementation of
safeguarding
procedures leads to
harm /poor care of
vulnerable adults
5x3 = 15
358 (a)
4x2 = 8
4x4 = 16
Initial
Current Target
Principal objective 1: To provide high quality, safe services, continually improving the patient experience and measuring our success in outcomes.
Angie Clegg
205
Risk: Ineffective
1. Quality Committee
Reported to Board:
systems and processes
2. Trust Board
1.Integrated Performance Report
for assessing the
3. Quality Challenge
2.Serious Incident report
quality of service
4.Incident & Serious Incident
Reported elsewhere:
delivery and
Management Processes
Quality Committee:
compliance with
5. Dealing with complaints, concerns and 1.Regulatory compliance report
regulatory standards
compliments process
2.Serious Incident report
Impact: Poor patient
6. Clinical guidelines and policies
3. Directors and Non Exec Visits
outcomes; low patient
4. Quality Element of IPR
satisfaction;
5. External reviews reported to QC for
reputational damage;
monitoring
penalties from
Other positive assurances:
regulators
1. CQC inspection of South Leeds Independence
CLINICAL RISK Centre, November 2013
REVIEWED BY
2. Internal Audit reports on Serious Incidents,
QUALITY COMMITTEE
Complaints process and risk management
1.Safeguarding policies and procedures
2.Service standards
3.Director service visits
4.Statutory and mandatory training
5. Employment and Professional
Registration checks
6. Safeguarding Supervision, appraisals
and performance management
7. Internal audits
8. Escalation process complete and rolled
out
9. Policy and procedure for safeguarding
has been cascaded through teams and
published
10. Safeguarding action plan complete
Appendix 1
How often & when is the
next report due?
- Monthly
- Bi-monthly
Evidence that it is not
working (Gaps in
Controls or Negative
Assurances received)
Action to address the gaps in control and
gaps in assurance
1. No early warning
Indicators around quality
metrics identified and
embedded in services.
1. Peer review programme for Quality
Challenge to be introduced (30.09.14)
2. Early Warning Indicators to be developed
for Inpatients (30.09.14)
3. Opportunities for external quality
assessments to be considered
4. Quality metrics identified through service
review process, to inform development of
early warning indicators
5. Learning from CQC Inspections paper to
QC
6. Development of service specific outcome
indicators
7. Learning from desk top review
1. Safeguarding adults
training below target
2. Supervision rates
below target
3. Safeguarding serious
incident investigation
findings (CICU)
1. Plans to increase adult safeguarding
training compliance to 98% by December
2014)
2. Work underway to clarify definition and
reporting of "supervision" by December
2014)
3. Learning from incidents shared
4. Awareness raising for safeguarding
process increased
5. Refresh of Adult Safeguarding Group
membership
- Monthly
- Monthly
- Monthly
- Monthly
- Monthly
Reported to Board:
1. LSAB minutes
2. LSAB annual reports
3. Chief Executive's Report
4. Integrated Performance Report
- Bi-monthly
- Annually
- Monthly
- Monthly
Reported elsewhere:
Quality Committee:
1.Safeguarding Committee Minutes
2. Safeguarding Annual Report
3. Adult Safeguarding Report
4. HSEG minutes
- Quarterly
- Annually
- Bi-monthly
- Bi-monthly
1
Leeds Community Healthcare NHS Trust
Board Assurance Framework October 2014
Lead Director
658
Risk Poor
Implementation of
safeguarding
procedures leads to
harm /poor care of
children
Angie Clegg
Level of Risk (consequence x How are we managing the risk? (Key
likelihood)
Controls)
Impact: Damage to
patients; reputational
damage; regulatory
penalty
5x3 = 15
Initial
Current
CLINICAL RISK REVIEWED BY QUALITY
COMMITTEE
CLINICAL RISK REVIEWED BY
QUALITY COMMITTEE
4x1 = 4
Impact: Reputational
damage; low patient
satisfaction; loss of
business; FT
authorisation delayed
4x2 = 8
Angie Clegg
Risk: Failure to
implement and embed
lessons learned from
internal and external
recommendations
(Francis, CQC,
Winterbourne etc.)
4x3 = 12
590
Evidence that it is working (Assurance on
Controls)
How often & when is the
next report due?
1.Safeguarding policies and procedures
2.Service standards
3.Director service visits
4.Statutory and mandatory training
5. Qualifications check
6.Attendance at case conferences
7. Safeguarding Supervision, appraisals
and performance management
8. Internal audits
9. Escalation process complete and rolled
out
10. Procedure for safeguarding has been
cascaded through teams
11. Performance Management of
clinicians
12. Section 11 Audit
Reported to Board:
1. LSCB minutes
2. LSCB annual reports
3. Chief Executive's Report
4. Integrated Performance Report
- Monthly
- Annual
- Monthly
- Monthly
1. Quality Action Plan includes national
recommendations
2. Monthly Performance Panels
3. Policy for implementing National
Guidance
4. Policy for External agency Visits,
Inspections and accreditation
5. NICE guidance policy
6. CQC Working Group review of lessons
from previous inspections to inform
action plan
7. Quality Challenge launched June 2014
8. Quality Account
Reported to Board:
1. Integrated Performance Report
2. Quality Governance Framework reports
Evidence that it is not
working (Gaps in
Controls or Negative
Assurances received)
Action to address the gaps in control and
gaps in assurance
1. Incidents of noncompliance with
policy/Cause for concern
cases
2. Independent review of
practice
3. Supervision Training
1. RCPCH visit June 2-14 action plan
2. Report from external review
3. Plans to increased children safeguarding
training compliance
1. Staff & Patient Friends
& Family Test paper
results
2. Complaints/concerns
3. Comment from TDA
regarding MRSA root
cause analysis report
1.Paper to SMT outlining recommendations
around Inspection Project July 2014 with
implementation on-going to September
2014
2. Service Level assessments against the
Quality Challenge to be reported (30.09.14)
3. Provide organisational response to duty
of candour requirements
Target
5x1
What is the risk?
(Risk Description)
5x2 = 10
ID
Appendix 1
Reported elsewhere:
Quality Committee:
1.Safeguarding Committee Minutes
2. Safeguarding Annual Report
3. Report from Professional Bodies & External
Bodies
4. Section
11 Audit results
5. LSCB
assurance processes - audit
Reported elsewhere:
Quality Committee:
1. Quality Governance Framework reports
2. QGAF progress
3. Quality Account milestones report
4. NICE Compliance report through Clinical
Effectiveness Committee to QC
5. Clinical Effectiveness minutes
- Monthly
- As required
- As required
- Monthly
- 6 Monthly
- 6 Monthly
- Bi-monthly
Other positive assurances:
1. CQC inspection report relating to South Leeds
Independence Centre, Dec 2013
2. Regulatory/CCG events
2
Leeds Community Healthcare NHS Trust
Board Assurance Framework October 2014
ID
What is the risk?
(Risk Description)
Lead Director
Level of Risk (consequence x How are we managing the risk? (Key
likelihood)
Controls)
Evidence that it is working (Assurance on
Controls)
Appendix 1
How often & when is the
next report due?
Evidence that it is not
working (Gaps in
Controls or Negative
Assurances received)
Action to address the gaps in control and
gaps in assurance
1.Stakeholder
engagement and
relationship management
plan to be developed
2. Rules of engagement
not defined at service
level
3. Stakeholder activity
not tracked and reported
to Board
1.Stakeholder engagement and relationship
management plan and tracking system to be
developed Nov 14
2. Map of service / commissioner meetings
to be developed Nov 14
3.Stakeholder 360 survey to be undertaken
of the Board and appropriate action plan to
be developed Nov 14
4.Develop rules of engagement, roles and
responsibilities Nov 14
1. Need to clarify
objectives for individuals
involved in partnership
working
2. S75 for Leeds
Community Equipment
Service to be finalised.
3. Lack of soft
intelligence indicating
further work to do.
1. Role of Discharge Facilitators to be
embedded (ongoing)
2. Clarity of objectives for individuals
involved in partnership working (31.05.14)
3. Reporting of gaps / difficulties through
Datix (ongoing)
4. Clear response to any issues / difficulties
as they arise (ongoing)
5. S75 for Leeds Community Equipment
Service (30.06.14)
1. PPI to be built into
service change and
project implementation
2. Members to be
involved in strategy
development and
planning
3. Clear approach to
assessing the
effectiveness of
engagement
4. Need to ensure every
service has an
involvement plan
1. Service change involvement process to be
reviewed and revised as appropriate
2. Stakeholder engagement and relationship
management plan to be developed Nov 14
3. Develop measure to evaluate
effectiveness of all involvement activity and
incorporate into performance report Nov 14
4. Peer reviewed involvement plans agreed
for all services Dec 14
5. All services to be achieve silver
involvement standard by March 2015
Initial
Current Target
Principal objective 2: To work in partnership with service users, communities and stakeholders to deliver service solutions, particularly around integrated care and care closer to home principles.
Risk: Public and
patients are not
effectively engaged in
Trust decisions
Impact: Decisions are
challenged and/or not
delivered; service
change not delivered
making the Trust
unsustainable
4x1 = 4
4x1 = 4
Emma Fraser
1.Membership of Transformation Board
2.Chair and Chief Executive meetings with
CCG Chairs and Chief Officers
3.Contract management meetings
4. Leadership Executive
5. Service Level relationships
6. Medical Senate
7. Stakeholder Engagement Strategy
Reported to Board:
- Chief Executive's Report
- Service Issues and Developments report
1. Regular meetings with Adult Social Care
2. Transformation Board
3. Children's Trust Board
4. Strategic and Operational Urgent Care
Boards
5. Better Lives Through Integration Board
6. Range of operational meetings to
address specific services
Reported to Board:
1. Chief Executive's Report
2. Service Issues and Developments report
3. Children's Trust Board minutes
1. Stakeholder Engagement Strategy
2. Membership Strategy
3. Membership Engagement Plan and
programme of activity
Reported to Board:
1. Integrated Performance Report
2. FT Update
3x1 = 3
361
4x3 = 12
Impact: Duplication or
gaps in service
delivery; poor patient
outcomes; low patient
satisfaction
4x2 = 8
Risk: Inability to
Sam Prince
provide integrated care
for patients due to
poor partnership
arrangements
3x2 = 6
211
4x3 = 12
Impact: Loss of
business; reduction in
service and quality;
strategic plan not
delivered; reputational
damage
4x2 = 8
Risk: Relationship with Emma Fraser
stakeholders including
commissioners not well
managed
3x3 = 9
209
Reported elsewhere:
GP Engagement Plan to Business Committee
Monthly
Bi-monthly
25th June 2014
Other positive assurances:
- Stakeholder interviews conducted as part of
Board Governance Assurance Framework
assessment in July 2012
- Monthly
- Bi-monthly
- Bi-monthly
Monthly
Monthly
Principal objective 3: To engage and empower our workforce, ensuring we recruit, retain and develop the best staff.
3
Leeds Community Healthcare NHS Trust
Board Assurance Framework October 2014
Lead Director
360
Risk: Lack of internal
capacity to secure
quality and drive
transformational
change
Sue Ellis
Level of Risk (consequence x How are we managing the risk? (Key
likelihood)
Controls)
Initial
Sue Ellis
How often & when is the
next report due?
1.Staffside relationship via JNCF and
regular TU informal meetings
2.Monitoring metrics of turnover,
sickness and appraisal rates
3.Service review process being rolled out.
Transformation lead Executive Director of
Operations and additional HR & PMO
capacity embedded staff side support
4.Signiifncnat staff engagement as part of
service review methodology and
improvement ideas to be incorporated
5. Organisational Development Strategy
approved and Implementation plan to be
by the Board
Reported to Board:
1. Integrated Performance Report
2. Programme Management Board report
3. Chief Executive's Report
- Monthly
- Monthly
- Monthly
1.OD Strategy and implementation plan
2.Staff engagement plan as part of
Stakeholder plans
3.Staff appraisal process- improve uptake
and quality review
4.Community talk
5.Team brief
6.Listening events
7.Staffside relationship via JNCF and
regular informal meetings
8. Staff survey action plan generated after
Board and staff side workshop and
reviewed by SMT
9.Staff Friends and Family test includes
additional questions 10 Staff side
representatives embed in PMO
Reported to Board:
1. Integrated Performance Report
2. Chief Executive's Report
3. OD Strategy
Reported elsewhere:
Business Committee:
1. Integrated Performance Report
2. Programme Management Board report
- Monthly,
- Monthly,
Evidence that it is not
working (Gaps in
Controls or Negative
Assurances received)
Action to address the gaps in control and
gaps in assurance
1.Sickness absence rates
remain about 0.5%above
target
2. OD Strategy
implementation will
support leadership
capacity building with 6
months lead in
3. Appraisal completion
rates now nearer target
1. Sickness absence training and support for
line managers sustained through health and
wellbeing team (ongoing)
2. Focus on improvement of appraisal
completion rates to achieve target (ongoing)
1. Appraisal rates now
achieved over 90%
August 14 but revised to
100%target
2. Low response rate to
2013 national staff
survey and staff Friends
and Family test
3. Overall staff
engagement measure in
staff survey has gone
down and below average
for community trust
1.Introduction of staff questions under
Friends and Family test Q1report in IPR
September 2014)
2. Implementation of staff survey action plan
and OD Implementation plan Board in
October 2014
1. Staff capacity to meet
demand
2. Organisational
Development Strategy
and implementation plan
from October 14
3. Lack of business
intelligence/analyst
capacity to develop
coherent reporting on
Workforce Planning
4. Loss of
talent/organisational
knowledge
1. Safer staffing plans to create revised
establishment and regular reporting process
to the Board established from June 14
2. OD Strategy approved and
implementation plan to be approved
October
3. Analyst capacity being shared via PMO
where possible
Other positive assurances:
1. Improvement foundation report.
Recommendations re service improvement
- Monthly
- Monthly
- Bi - Annually, 10.09.14
Reported elsewhere:
1. Staff Survey Action Plan to SMT
1. OD Strategy section with focus on
Reported to Board:
Workforce planning
1. Integrated Performance Report
2. Proactive vacancy review process
2. Programme Management Board report
3. Longer notice periods introduced for
3. Organisational Development Strategy
some staff on certain bands in areas of
Impact: Service
higher turnover/hard to recruit
transformation and
4. Advertisements kept running and have
CIPs not delivered
agreed to recruit over establishment in
qualified nursing if candidates are present
5. Service review process includes
workforce analysis in baseline at start of
processes
6. Workforce Plan relating to the Trust's
annual and 5 year Business Plans
7. Recruitment difficulties reported to
SMT 8. Strategic approach to recruitment
developing across the Trust and Leeds as
a system
Principal objective 4: To become a viable and sustainable organisation with the ability
to invest in the community and with a relentless focus on value for money.
4x2 = 8
Sue Ellis
4x3 = 12
Risk: Risk to service
sustainability due to
ineffective workforce
planning.
4x3 = 12
223
3x4 = 12
Impact: Failure to
achieve strategic
objectives; low staff
morale
Evidence that it is working (Assurance on
Controls)
Target
3x2 = 6
Risk: Lack of staff
involvement and
engagement in the
organisation
3x4 = 12
218
4x4 = 16
Impact: Low staff
morale, reduction in
quality
Current
4x2 = 8
What is the risk?
(Risk Description)
4x3 = 12
ID
Appendix 1
- Monthly
- Monthly
- Annually
4
Leeds Community Healthcare NHS Trust
Board Assurance Framework October 2014
ID
What is the risk?
(Risk Description)
Lead Director
234
Risk: Loss of business Cherrine
or decommissioning of Hawkins
services
Level of Risk (consequence x How are we managing the risk? (Key
likelihood)
Controls)
Initial
Current
4x1 = 4
4x1 = 4
4x3 = 12
4x4 = 16
Impact: Trust becomes
unviable and
unsustainable
5x1 = 5
Risk: Failure to achieve Emma Fraser
Foundation Trust
status
5x2 = 10
516
4x4 = 16
FINANCIAL CONTROL
RISK - REVIEWED BY
BUSINESS COMMITTEE
4x4 = 16
Risk: National
Cherrine
efficiency
Hawkins
requirements cannot
be delivered
recurrently
Impact: Trust becomes
unviable and
unsustainable
5x3 = 15
312
Evidence that it is working (Assurance on
Controls)
How often & when is the
next report due?
1. Service Development Plan
2. Business Planning
3. PPI Strategy
4. Understanding requirements of GPs
5. Membership engagement
6. Engagement with commissioners in
leading whole system solutions
7. Contract Management Board or similar
formal arrangements with non CCG
commissioners
8. External Communications Strategy
delivered in Year 1
9. Regular and routine scrutiny of tender
portals being undertaken by the Head of
Business Development
10. Alignment of services with GP
practices and schools
Reported to Board:
- Business & Commercial Developments update
- Service Issues & Developments report
- Monthly
- Bi-monthly
Reported elsewhere:
Business Committee:
- Business & Commercial Developments report
- Monthly
1. Programme Management Office
reports monthly, including detailed
financial reporting and exception reports.
2. Management Board (chaired by Chief
Executive) meets monthly to receive
above reports.
3. Additional resources identified to
support efficiency delivery in the future.
4. Realignment of Executive Director
portfolios to strengthen implementation
5. PMB has approved the Service Review
methodology. (31.03.14)
6. Board approval of investment of £1m
as part of budget setting (28. March)
Reported to Board:
1. Integrated Performance Report
2. Programme Management Board report
- Monthly
- Monthly
1.CFT programme work plan reported to
SMT
2. Influencing through Aspirant
Community Foundation Trust Network
3. Robust Integrated Business Plan
4. Quality Governance Action Plan
5. Approach for CQC Inspection agreed by
SMT
Reported to Board:
1. CFT updates
Evidence that it is not
working (Gaps in
Controls or Negative
Assurances received)
Action to address the gaps in control and
gaps in assurance
1. Implement the
stakeholder engagement
plan including developing
an account manager role
1. Formal Stakeholder engagement strategy
and implementation plan to be developed
(End of September 2014)
2. Capture internal and external intelligence
to redesign and target the LCH service offer
to opportunities in the market (30.09.14)
3. Evidencing of outcomes and impact LCH
has on the system (30.09.14)
4. Development of a consortia bid with
partners in an attempt to maintain current
Contraceptive & Sexual Health Service.
1.Shortfall on 2013/14
efficiencies included in
annual financial plan for
2014/15
2. Formal sign off of
2014/15 efficiency plans
taken place
3. Forecast shortfall in
CIP delivery for 14/15
1. Business Committee and Board to approve
two year plans, including implementation
plans.
2. Programme Management Board (PMB) to
develop clear plans for each CIP scheme
(including each service review), and an
implementation plan for each scheme that
provides assurance to Business Committee
and Board that recurrent delivery, in time, is
probable.
3. Detailed SMT CIP review 30.09.14
4. TDA deep dive scheduled for early
October.
1. Actions to deliver
reduction in Quality
Governance Framework
score outstanding
2. TDA rating of 2
(emerging concern)
1. Robust monitoring of Quality Governance
Action Plan by Quality Committee (ongoing
2014)
Target
Impact: Trust becomes
unviable and
unsustainable
FINANCIAL CONTROL
RISK - REVIEWED BY
BUSINESS COMMITTEE
Appendix 1
Reported elsewhere:
Business Committee:
1. Integrated Performance Report
2. Programme Management Board report
Reported elsewhere:
1. Quality Committee:
2. Quality Governance Action Plan
Other positive assurances:
1. External assessments e.g. Historical Due
Diligence, BGAF
- Monthly
- Monthly
- Bi-monthly
- Bi-monthly
- July 2014
5
Leeds Community Healthcare NHS Trust
Board Assurance Framework October 2014
Lead Director
227
Risk: Income and
Cherrine
expenditure levels are Hawkins
not managed to
achieve target surplus
recurrently.
Level of Risk (consequence x How are we managing the risk? (Key
likelihood)
Controls)
Initial
FINANCIAL CONTROL
RISK - REVIEWED BY
BUSINESS COMMITTEE
FINANCIAL CONTROL
RISK - REVIEWED BY
BUSINESS COMMITTEE
Risk: Trust does not
meet its statutory and
regulatory duties: (a)
failure to report position
to the TDA (b) failure to
meet the requirements of
the Civil Contingency and
Climate Change Act
Impact: Reputational
damage, regulatory
sanctions
Bryan Machin
1.Monthly TDA monitoring report
2. Major Incident Plan
5x1 = 5
199
- Monthly
Reported elsewhere:
1. Business Committee:
2. Integrated Performance Report
- Monthly
Evidence that it is not
working (Gaps in
Controls or Negative
Assurances received)
Action to address the gaps in control and
gaps in assurance
1. Forecast overspending 1. Increased focus on accountability for over
on pay
and underspends in 2014/15. Will be clear in
budget framework for 2014/15 (01.04.14).
Monthly monitoring will be strengthened
and clearly defined through the revised
performance framework. (30 Sept 2014)
2. SMT escalation of hot spots (pay post Q1
detailed review of agency position)
3. Additional support to budget holders with
training packages and refreshed user friendly
finance manual to be developed and
delivered through 2014/15; this will clarify
responsibilities and strengthen links
between budget holders and the Financial
Management team.
4. Recurrent surplus heavily dependent upon
recurrent CIP delivery (see actions for risk
312).
None Identified
1. This risk focussed on achievement of inyear minimum CSRR. Other risks focussed
on recurrent surplus delivery. The 2013/14
CSRR has been achieved. The financial plan
for 2014/15 demonstrates delivery of the
required CSRR. This is dependent upon the
delivery of the in year cost savings. As the
recurrent savings are timed for the second
half of the year the Trust must make non
recurrent savings during Q1 and Q2 to
maintain the CSRR in the early part of the
year.
N/A
1. Business Committee to approve KPIs for
2014/15 ensuring that all TDA Accountability
metrics are included (24.09.14)
2. Sustainability Strategy and reporting
requirements to be defined by Business
Committee Oct 2014
- Monthly
- Monthly
4x1= 4
4x4 = 16
Impact: Target CSRR
not achieved, Trust is
penalised, Trust
becomes unviable
Reported to Board:
1. Integrated Performance Report
1. Financial Management Framework
Reported to Board:
2.Standing Financial Instructions
1. Integrated Performance Report
3.Cash flow monitoring
4. Updated Treasury Management Policy
agreed
Reported elsewhere:
Business Committee:
2. Integrated Performance Report
4x1 = 4
Cherrine
Hawkins
5x1 = 5
Risk: Finances not
managed to achieve
minimum acceptable
Continuity of Services
Risk Rating (CSRR)
5x4 = 20
591
How often & when is the
next report due?
Target
1. Financial Management Framework
2. Budgetary delegation
3. Budget reporting
4. Contingency reserve
4x4 = 16
Impact: Trust is
penalised, CSRR
worsens
Current
Evidence that it is working (Assurance on
Controls)
4x1 = 4
What is the risk?
(Risk Description)
4x4 = 16
ID
Appendix 1
Reported to Board:
1. Integrated Performance Report
2. TDA monitor report
Reported elsewhere:
1. Annual Report - Audit Committee
- Monthly
- Monthly
Other positive assurances:
1. Monthly TDA assurance meeting
6
Leeds Community Healthcare NHS Trust
Board Assurance Framework October 2014
New
Number
Risk: High levels of
Sue Ellis
sickness absence
impacts on quality of
care and staff morale
and is a net cost to the
organisation.
Risk: Failure to deliver Paul Morrin
the full benefits and
potential of the Adult
Health & Social Care
Integrated Programme
Impact: Efficiencies not
delivered, full benefits
of Programme not
realised, loss of
stakeholders
confidence
Evidence that it is not
working (Gaps in
Controls or Negative
Assurances received)
Action to address the gaps in control and
gaps in assurance
1.Chair and Chief Executive meetings with
CCG Chairs and Chief Officers
2.Membership of Transformation Board
3. System leaders meeting
4. Membership of Aspirant Community
Foundation Trust Network and influencing
5.Integration programme
6. Robust IBP
7. Provider to provider relationships
Reported to Board:
Chief Executive's Report
Service Issues and Developments
Monthly
Bi-monthly
Reported elsewhere:
Business Committee:
Integration Programme
1. TDA feedback on the
IBP awaited
2. A level of concern from
stakeholders over the
trust becoming a FT
Monthly
1. TDA Feedback due on IBP to Board in
October 2014
2. Focus on strengthening the strategy, USP
and benefits of the trust
3. Strengthen partnership working with LTHT
and primary care
`
Reported to Board
Monthly
1. Sickness absence
target not yet achieved
1. Differentiated trajectories continue to be
monitored and appropriate interventions to
assist those areas of greatest need. Training
for managers continues to be delivered and
a post-training questionnaire is sent to all
delegates to gain assurance that managers
are putting their knowledge from the course
into practice.
The Health, Work and Wellbeing Steering
group has been re-formed and has identified
key areas to improve the health and wellbeing of staff. (Ongoing monitoring)
Feedback from partners
Following agreement that a Business
Committee working party be established to
review and reconsider overall vision and
direction of travel and how to support the
integrated and health and social care
provider agenda and our ambition of being a
Foundation Trust organisation
Target
5x1 = 5
Current
How often & when is the
next report due?
1. Integrated Performance Report
4x4 = 16
224
1. Board discussion
2. SMT discussion
3. Business Committee
4. Programme team discussion
5. Partner engagement strategy
6. Communication strategy
4x3 = 12
Impact: Trust becomes
unviable.
5x3 = 15
Initial
Evidence that it is working (Assurance on
Controls)
4x3 = 12
Risk: Commissioners
Emma Fraser
decide that the
community trust model
is no longer supported.
4x2 = 8
592
Level of Risk (consequence x How are we managing the risk? (Key
likelihood)
Controls)
5x2 = 10
Lead Director
4x4 = 16
What is the risk?
(Risk Description)
4x3 = 12
ID
Appendix 1
1. Presentation to Business Committee - revised Reporting arrangements
work plan
currently under review
7