Board Assurance Framework 2019 - 2020 Strategic Objective:2018-19 01 - Improving Quaility And Safety Enabling Strategy:Quality Strategy Monitoring Group:Quality Governance Group Lead Director:Joanne Baxter Reference Sub Objective Description Risk Reg Ref What may prevent the Objective being met? (Linked Risk) Severity Likelihood Total Score Current Level of Risk Assurance Adeguacy Gaps in Controls Mitigation for Gaps in Controls (Actions) Assurances Internal External Gaps in Assurances Mitigation for Gaps in Assurances (Actions) Existing Controls Identified by the Committee 1.1 The final year of the 3 year Quality Strategy will be delivered 17-20 delivering key trajectories against improvements for all quality and safety metrics. Partially Assured Key Control 01 Quality dashboard is reported to the board and Quality Committee at each meeting - showing key progress on Quality Metrics / Trajectories. Quality dashboard needs further refinement to include all items and be aligned to CQC KLOE. Performance on IPC audits, incident reporting, levels of harm, serious incidents, duty of candour, complaints, safeguarding. IPC Annual Report. Monitored at Quality Governance Group (QGG). 01 Full review and rebuild of Quality Dashboard required 30/09/2019 01 Register to be developed and ongoing monitoring improved 31/07/2019 Quality Review Group,CQC and NHSI QRM also review Quality Dashboard Metrics. CQC Good rating. Internal audit report providing significant assurance on risk management, SI, Incident Management Processes and Patient Safety Alerts. Triangulation with staffing and performance needs developed. Fully Assured Key Control 02 Quality impact assessment process in place and reported to QC through QGG - monitors delivery of CIP, service change and service improvement against key quality metrics.. Register of all trust QIA's no yet in place. No adverse patient safety effects reported from CIP or service change. Monitored at Quality Governance Group (QGG). 02 Register to be developed. 31/07/2019 Monitored by Clinical. Quality Review Group and CQC Engagement meeting. None Identified Fully Assured Key Control 03 Serious Incident report and Incident levels of harm report, by service and location is received by Quality Committee. None Identified Themes and Trends relating to type, location, level of harm tracked and reported in SI report. No current themes identified. Annual Learning Report - Incients, SI's & Complaints. Serious Incident Report including minutes from Serious Incident Review Group (SIRG) Monitored by Clinical. Quality Review Group and CQC Engagement meeting. Internal audit report on serious incident providing significant assurance. None Identified Partially Assured Key Control 04 Clinical Audit Dashboard reported to Quality and Committee and board at every meeting showing delivery of Clinical Outcomes. Full clinical audit dashboard highlighting all outcomes from clinical audit to provide a fuller picture on quality of care delivered against KPI's. Performance against National AQI's and care bundles are above national average and on increasing trajectory. Clinical Audit Plan Delivery progress including Outcome Findings. Interim review of Quality Strategy & Quality Report progess delivery 19/20. Clinical Advisory Group - Minutes including Assurances and Risks. 04 Work underway to integrate quality dashboard and clinical audit dashboard and ensure outcomes from all audit activity is reported 30/09/2019 04 Clinical Audit dashboard in development 30/09/2019 Benchmarked nationally with other ambulance trusts. On National ambulance scorecard. Monitored by Clinical. Quality Review Group and CQC Engagement meeting, NHSI and QRM. Not all clinical activity currently reported to committee. Partially Assured Key Control 05 Strategic Safeguarding Group established and assurances and risks are reported to the Quality Committee directly. None Identified Minutes, assurances and risks and reported directly to Quality Committee. Safeguarding Annual Report. Monitored by Clinical. Quality Review Group and CQC Engagement meeting. Strategic Safeguarding Group membership includes regional designated nurses. None Identified ORR-41 Failure to deliver our Ambulance KPI's in relation to our performance trajectory agreed by our lead Commissioners. Response times for category 2 and long waits for category 3 and 4. 4 5 20 ORR-45 System change. The NHS and social care economy in the North East is undertaking Sustainability and Transformation Planning, alongside the development of Integrated Care Partnerships and an Integrated Care System. The risk is of these changes affecting response performance and the clinical safety of patients affected, or potentially affected by these changes 4 4 16 ORR-55 The inability to develop, spread and embed a robust Quality Improvement culture within NEAS in order to drive continuous improvement and innovation in patient safety, effectiveness and experience 4 4 ORR-57 Inability to recruit in line with the workforce plan for the trust for Scheduled Care, Unscheduled Care, Operations Centre and Corporate Services. 4 4 Risk and Regulatory Services - BAF Version 5 Page: 1 of 21 Date Printed: 21/06/2019
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Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 01 - Improving Quaility And SafetyEnabling Strategy:Quality Strategy
Monitoring Group:Quality Governance Group
Lead Director:Joanne Baxter
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
1.1 The final year of the 3
year Quality Strategy willbe delivered 17-20delivering keytrajectories againstimprovements for allquality and safetymetrics.
Pa
rtially
As
su
red
Key Control 01 Quality dashboard is reported to theboard and Quality Committee at eachmeeting - showing key progress onQuality Metrics / Trajectories.
Quality dashboard needs furtherrefinement to include all items and bealigned to CQC KLOE.
Triangulation with staffing andperformance needs developed.
Fu
lly A
ss
ure
d
Key Control 02 Quality impact assessment process inplace and reported to QC throughQGG - monitors delivery of CIP,service change and serviceimprovement against key qualitymetrics..
Register of all trust QIA's no yet inplace.
No adverse patient safetyeffects reported from CIP orservice change.
Monitored at QualityGovernance Group (QGG).
02 Register to bedeveloped.
31/07/2019Monitored by Clinical.
Quality Review Group and CQCEngagement meeting.
None Identified
Fu
lly A
ss
ure
d
Key Control 03 Serious Incident report and Incidentlevels of harm report, by service andlocation is received by QualityCommittee.
None Identified Themes and Trends relating totype, location, level of harmtracked and reported in SIreport.
Quality Review Group and CQCEngagement meeting, NHSIand QRM.
Not all clinical activity currentlyreported to committee.
Pa
rtially
As
su
red
Key Control 05 Strategic Safeguarding Groupestablished and assurances and risksare reported to the Quality Committeedirectly.
None Identified Minutes, assurances and risksand reported directly to QualityCommittee.
Safeguarding Annual Report.
Monitored by Clinical.
Quality Review Group and CQCEngagement meeting.
Strategic Safeguarding Groupmembership includes regionaldesignated nurses.
None Identified
OR
R-4
1
Failure to deliver ourAmbulance KPI's inrelation to ourperformance trajectoryagreed by our leadCommissioners.Response times forcategory 2 and long waitsfor category 3 and 4.
45 20
OR
R-4
5
System change. TheNHS and social careeconomy in the NorthEast is undertakingSustainability andTransformation Planning,alongside thedevelopment of IntegratedCare Partnerships and anIntegrated Care System.The risk is of thesechanges affectingresponse performanceand the clinical safety ofpatients affected, orpotentially affected bythese changes
44 16
OR
R-5
5
The inability to develop,spread and embed arobust QualityImprovement culturewithin NEAS in order todrive continuousimprovement andinnovation in patientsafety, effectiveness andexperience
44
OR
R-5
7
Inability to recruit in linewith the workforce plan forthe trust for ScheduledCare, Unscheduled Care,Operations Centre andCorporate Services.
44
Risk and Regulatory Services - BAF Version 5 Page: 1 of 21Date Printed: 21/06/2019
Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 01 - Improving Quaility And SafetyEnabling Strategy:Quality Strategy
Monitoring Group:Quality Governance Group
Lead Director:Joanne Baxter
Key Control 06 Safe staffing report is provided to thequality committee each meetinghighlight clinical vacancies againstestablishment alongside fill rates.
None Identified Staff are deployed effectivelyagainst plan and risks to patientsafety through gaps inestablishment are visible andmitigation to reduce the risk inplace.
ORH report identifies staffingrequirements.
Patient Experience AnnualReport.
Health & Safety Annual Report.
Learning for Deaths Report(previous 6 month review).
Safe staffing report to the boardon a monthly basis and QRG.
Reported to CQC at relationshipmeetings.
None Identified
Fu
lly A
ss
ure
d
Key Control 07 Performance Report Performance report requires review to
align to CQC KLOEPerformance report includingdelays reported to Clinical
07 Review ofperformance reportusing SPC underway
30/09/2019 07 PerformanceImprovement Plan tobe in place.
31/07/2019Report presented toContractural Group
Performance Improvement Planunderway
Risk and Regulatory Services - BAF Version 5 Page: 2 of 21Date Printed: 21/06/2019
Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 01 - Improving Quaility And SafetyEnabling Strategy:Quality Strategy
Monitoring Group:Quality Committee
Lead Director:Joanne Baxter
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
1.2 Plans will be developed
to ensure our journey toOutstanding is realised.
Pa
rtially
As
su
red
Key Control 01 Recent Well Lead inspection outcomerating Good.
Actions from inspection required Monitored through BoardReports.
01 Action plan to bedeveloped.
31/07/2019 01 Plan monitored bySMT / ET
31/07/2019Current Good Rating in placeand Monitored by CQRG andCQC Engagement Meeting.
Actions incomplete.
Fu
lly A
ss
ure
d
Key Control 02 Ongoing compliance with the CQCFundamental Standards is clearlymapped to existing governanceframework Committee reportingrequirements for each appropriateKLOE is clear.
Ongoing business as usual againstthe KLOE's is not currently in place onquality dashboard or IQPR.
CQC compliance is Monitoredby separate reports to Boardlevel committees.
02 Improvementrequired to mapdelivery of businessas usual quality andperformancereporting to the CQCKLOE
30/09/2019Monitored by Clinical.
Quality Review Group and CQCEngagement meeting, NHSIand QRM.
None Identified
Fu
lly A
ss
ure
d
Key Control 03 CQC action plan responding to recentinspection is monitored monthly.
None Identified Staff are deployed effectivelyagainst plan and risks to patientsafety through gaps inestablishment are visible andmitigation to reduce the risk inplace.
ORH report identifies staffingrequirements.
Safe staffing report to the boardon a monthly basis and QRG.
Reported to CQC at relationshipmeetings.
None Identified
CE
11
Ability to achieveadequate NHSImprovement compliancein challenging times inaccordance with therequirements of theSingle OversightFramework (quality,performance, finance,well-led and strategicprogress).
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Risk and Regulatory Services - BAF Version 5 Page: 3 of 21Date Printed: 21/06/2019
Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 01 - Improving Quaility And SafetyEnabling Strategy:Quality Strategy
Monitoring Group:Quality Committee
Lead Director:Joanne Baxter
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
1.3 Improving The Safety
Culture.
Fu
lly A
ss
ure
d
Key Control 01 Staff survey results. None Identified Monitored through Board
Reports.Current Good rating in placeand monitored by CQRG andCQC Engagement meeting.
None Identified
Fu
lly A
ss
ure
d
Key Control 02 SI reports & Quality Dashboard,showing open reporting.
None Identified Monitored through PatientSafety Group and QualityCommittee and Serious IncidentReview Group.
Internal audit report on seriousincident providing significantassurance.
None Identified
Fu
lly A
ss
ure
d
Key Control 03 Excellence Reports reported to QCthrough QGG
None Identifed Reports monitored via PatientSafety Group and QualityCommittee.
CQC Engagemement meetings. None Identified
OR
R-5
5
The inability to develop,spread and embed arobust QualityImprovement culturewithin NEAS in order todrive continuousimprovement andinnovation in patientsafety, effectiveness andexperience
44 16
28
0 Implementation of 'JustCulture' principles withinthe organisation in orderto support improvementsin patient safety and staffhealth and wellbeing maynot be realised unlessembraced and supportedfrom board to front line
44
Risk and Regulatory Services - BAF Version 5 Page: 4 of 21Date Printed: 21/06/2019
Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 01 - Improving Quaility And SafetyEnabling Strategy:Quality Strategy
Monitoring Group:Quality Committee
Lead Director:Joanne Baxter
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
1.4 Improve Clinical
Outcomes.
Fu
lly A
ss
ure
d
Key Control 01 Scope of project developed and inplace. Community Services andRotational Working project boardestablished.
Management structure is yet to bedeveloped.
Reported in to DeliveringConstantly Group on a monthlybasis.
01 Clinical ServicesManager currentlyworking with projectmanager.
31/07/2019Recent Good grading from CQCWell Lead Inspection.
None Identified
Pa
rtially
As
su
red
Key Control 02 National Ambulance Clinical Qualityindicators.
Acute trusts are not inputting MIMAPData on a monthly basis whichimpacts on the AQI informationrelating to Myocardial Infarction.
Clinical AQI's are reviewed andmonitored at Clinical ExcellenceGroup, Quality GovernanceGroup and Quality Committee.
02 Issue raised withQuality ReviewGroup and Nationallywithin the AmbulanceSector.
31/07/2019Reports shared withCommissioners via QualityReview Group. Reports areshared and benchmarkednationally.
Quality Report producedannually and submitted to NHSImprovement.
Reports are completed retrospectively- data is 3 months behind.
Fu
lly A
ss
ure
d
Key Control 03 Clinical audit annual plan whichincludes clinical audits linked to knownPatient Safety risks.
Number of audits undertaken isdependant on the current resourceswithin clinical audit.
Monitored via the ClinicalExcellence Group, QualityGovernance Group, QualityCommittee, Audit Committee.
03 Business case beingdeveloped toincrease ClinicalAudit capacity
31/07/2019 03 Internal processthrough audit and careplatform can feedbackareas of improvementin realtime via CARE.
31/07/2019Monitored by Commissionersvia Quality Review Group.
Quality Report producedannually and submitted to NHSImprovement.
None Identified
Pa
rtially
As
su
red
Key Control 04 Learning from Deaths Policyimplemented.
Reports monitored via QualityGovernance Group, QualityCommittee and the Board.
04 Business case beingdeveloped toincrease clinical auditcapacity.
31/07/2019 04 Business case beingdeveloped to increaseclinical audit capacity.
31/07/2019Monitored via Commissionersthrough Quality Review Group.
Quality Report producedannually and submitted to NHSImprovement.
Lack of resources within the clinicalaudit team causes delays in reportproduction.
Fu
lly A
ss
ure
d
Key Control 05 Patient Safety Incidents reported andinvestigated
Timeliness of Investigations. Monitored via Patient SafetyGroup, Quality GovernanceGroup, Quality Committee.
30/09/2019Monitored via Commissionersat Quality Review Group.
Quality Report producedannually and submitted to NHSImprovement.
Monitored via CQC RelationshipMeeting.
None Identified
Fu
lly A
ss
ure
d
Key Control 06 Large portfolio of research studies toimprove clinical outcomes.
None Identified. Monitored via ClinicalExcellence Group, QualityGovernance Group, QualityCommittee.
Monitored by Local ClinicalResearch Network.
None Identified.
ME
D0
5
The potential loss ofclinical skill availabilitydue to requirementshighlighted in the NHSplan regarding theemployment ofParamedics into Primarycare Networks
44 16
Risk and Regulatory Services - BAF Version 5 Page: 5 of 21Date Printed: 21/06/2019
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
2.3 Development of Clinical
Modelling.
Risk and Regulatory Services - BAF Version 5 Page: 8 of 21Date Printed: 21/06/2019
Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 03 - Clinical Care And TransportEnabling Strategy:Performance Management
Monitoring Group:Quality Committee
Lead Director:Victoria Court
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
3.1 Unscheduled Care
Service Transformation.
Pa
rtially
As
su
red
Key Control 01 Project board reporting and riskmanagement, escalation toTransformation Board with riskhighlighted. Monthly reporting to theFinance Committee.
None Identified Monthly project board meetingsare discussing this with a highpriority. Meetings are takingplace between NEAS andNEASUS to identify mitigationsin order to manage vehicle flowfor both new and existingvehicles.
Finance Committee over view
01 New role in NEAS toact as bridge betweenorganisations
31/10/2019Commissioners receive monthlyprogress reports with any keyareas of concern highlighted
Contracting meetings
Improved flow of information betweenNEAS and NEASUS
Pa
rtially
As
su
red
Key Control 02 Project board reporting and riskmanagement, escalation toTransformation Board with riskhighlighted. Monthly reporting to theFinance Committee.
None Identified A service reconfiguration grouphas been formed to meetregularly to discuss known andpotential servicereconfigurations. This will lookat impacts holistically acrossNEAS to better understand andmodel any required changes.
NEAS is also represented atICS and ICP level forawareness of all potentialchanges.
02 Feedback on changeswill be channelledthrough the SMT andET.
31/03/2020Regular meetings withcommissioners on progress willenable assurances orescalations to be progressedvia this route.ICS and ICP representation willprovide regular communicationroutes for any changes to bediscussed.
Reconfiguration group is newly set upand its effectiveness will need to bemonitored.
Pa
rtially
As
su
red
Key Control 03 Project board reporting and riskmanagement, escalation toTransformation Board with riskhighlighted. Monthly reporting to theFinance Committee.
None Identified A project plan is in place to workon reducing conveyance whichcovers front line and EOCactivities. There are clearactivities for the clinical hub anddispatch as well as trainingopportunities. This will bereported on monthly along withprogress against targetedlevels.
03 Discussions withCommissionersscheduled.
31/07/2019Commissioners receive monthlyprogress reports with any keyareas of concern highlighted.
External Influences.
22
3 There is a risk to thesuccessfulimplementation of theORH recommendationsas a result of potentialreconfigurations within theNHS across the NorthEast. These are changesoutside of NEAS directcontrol as they arechanges to acuteprovision but thereseveral that couldprogress which mayrequire changes in NEASprovision in some areasto meet demand.
44 16
24
9 If NEAS do not meetperformance targets setfor increasing Hear andTreat & See and Treatand a reduction of overallconveyance by DCAvehicles then the fundingapproved for EOC staffingmodel will be revoked orfinacial penalties applied.
44
OR
H1
5
That some, or all of thethirteen DCAs due fordelivery by the end ofMarch 2019 to increasethe fleet size will not beavailable because ofdelivery delays.
53 15
Risk and Regulatory Services - BAF Version 5 Page: 9 of 21Date Printed: 21/06/2019
Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 03 - Clinical Care And TransportEnabling Strategy:Performance Management
Monitoring Group:Quality Committee
Lead Director:Victoria Court
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
3.2 Scheduled Care Review
Implementation.
Fu
lly A
ss
ure
d
Key Control 01 Business case created and submittedwhich proposes the solution to thisrisk. If agreed, the outcome of thebusiness case will have a hugepositive impact upon this risk andallow for successful projectimplementation.
Potential for business case not beingapproved.
Monthly programme boardmeetings are discussing thisrisk and potential ways toovercome this for the project. Abusiness case has also beensubmitted to the Trust and iscurrently being assessed.
01 Create business caseclearly outlining thegap in capacity, theneed for such a roleand potential costsand risks associatedwith proposal. Alsoreview alternativeoptions if notapproved.
01/05/2019Discussed potential timescalesfor elements of the workstreams that are jointly ownedby NEAS and Commissioners,and NECS are assessingwhether they can free up somecapacity in their BusinessAnalyst department to supportproject.
None Identified
Fu
lly A
ss
ure
d
Key Control 02 Programme Board reporting and riskmanagement, escalation toTransformation Board with riskhighlighted.
None Identified Monthly programme boardmeetings are discussing thisrisk and potential ways toovercome this for the project. Abusiness case has also beensubmitted to the Trust and iscurrently being assessed.
Discussed potential timescalesfor elements of the workstreams that are jointly ownedby NEAS and Commissioners,and NECS are assessingwhether they can free up somecapacity in their BusinessAnalyst department to supportproject.
None Identified
Fu
lly A
ss
ure
d
Key Control 03 Fortnightly PTS Sub Group meetingsarranged and ongoing, which consistof key NEAS colleagues and leadCommissioners for scheduled care.
None Identified Monthly programme boardmeetings to discuss outcomesof discussions withCommissioners, and reviewoverall project plan.
Fortnightly PTS Sub Groupmeetings with LeadCommissioners to develop theService Development andImprovement Plan forscheduled care.
None Identifed
26
8 Limited capacity in theforecasting and modellingrole within scheduled caremeans creating anevidence base for eachrecommendation is atrisk.
34 12
26
9 Some scheduled carereview recommendationsare dependent ondecisions madeexternally, mainly withCommissioners to allowfor efficiencies.
23 6
Risk and Regulatory Services - BAF Version 5 Page: 10 of 21Date Printed: 21/06/2019
Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 04 - Developing A Sustainable WorkforceEnabling Strategy:Performance Management
Monitoring Group:Workforce Committee
Lead Director:Jason Emerson
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
4.1 Develop and deliver the
workforce plan.
Fu
lly A
ss
ure
d
Key Control 01 The Workforce Metrics report ispresented to the WorkforceCommittee at each meeting showingkey demonstration progress on keymetrics.
WFC metrics report needs furtherrefinement to include directoratetrajectories.
WFC metrics report to be producedon a monthly basis.
Internal audit report providedsignificant assurance in relationto DBS May 2018.
Annual HCPC Referrals Update.
Annual DBS Assurance Report.
Volunteer Assurance Update.
Third Party ProviderAssurances Update.
Fit and Proper Persons AnnualReport.
01 Content of the WFCmetrics report to bereviewed.
31/07/2019Monitored by the Clinical QualityReview Group.
None Identified
Fu
lly A
ss
ure
d
Key Control 02 Workforce Plan, Recruitment Plan andTraining Plan are presented to theWorkforce Committee on a bi-annualbasis and are reviewed by therelevant sub-groups at each meeting.
Unknown Unknown The Trust is registered is asponsoring organisation fornon-EU nationals.
None Identified
No
t As
su
red
Key Control 03 Workforce Strategy Group andWorkforce Operations Groupestablished and reported to theWorkforce Committee at eachmeeting.
Unknown Unknown Unknown Unknown
No
t As
su
red
Key Control 04 Workforce Safeguards Action Plan -reported to the Workforce Committeebi-annually.
Newly developed and actions andtimescales to be further refined.
Unknown Unknown Unknown
OR
R-5
7
Inability to recruit in linewith the workforce plan forthe trust for ScheduledCare, Unscheduled Care,Operations Centre andCorporate Services.
44 16
WD
14
Risk of not being able torecruit Paramedics toalign with the outcomes ofthe ORH report and thecontractual agreementwith commissioners for2018/19, 2019/20,2020/2021 and 2021/2022(Risk originally opening in2017/18 - wording updateto reflect current position).
54 20
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Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 04 - Developing A Sustainable WorkforceEnabling Strategy:Performance Management
Monitoring Group:Workforce Committee
Lead Director:Jason Emerson
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
4.2 Develop and deliver
Leadership andprogressionopportunities.
No
t As
su
red
Key Control 01 Employee Stories presented to theWorkforce Committee on a bi-annualbasis.
None Identified Unknown01 24 month review of IIPprogress including staffsurvey to beundertaken
31/08/2019Unknown Unknown
Pa
rtially
As
su
red
Key Control 02 Summary of Assurance and Minutesof the Organisational DevelopmentGroup presented to each WorkforceCommittee.
Unknown Unknown Investors in People (IIP)Developed standards awardedto the Trust in July 2017.
The Trust is seeking to reach IIP"High Performing" standard by 2021
Pa
rtially
As
su
red
Key Control 03 NHS Staff Survey Results and ActionPlans presented to the WorkforceCommittee on an annual basis andmonitored by the OrganisationalDevelopment Group.
4 There is no dedicatedleadership for theSpecialist Skills Teamcurrently. Due to capacityconstraints, there isminimal attention beingpaid to this team.
43 12
Risk and Regulatory Services - BAF Version 5 Page: 12 of 21Date Printed: 21/06/2019
Board Assurance Framework 2019 - 2020
Strategic Objective:2018-19 04 - Developing A Sustainable WorkforceEnabling Strategy:Performance Management
Monitoring Group:Quality Committee
Lead Director:Jason Emerson
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
4.3 Strengthen
Organisational Healthand Wellbeing.
Pa
rtially
As
su
red
Key Control 01 Health and Wellbeing Strategy andAction Plan presented to theWorkforce Committee.
Mental Health and Wellbeing Lead. Board Champion - JohnMarshall.
MIND Blue Light Champions.
01 Business Case hasbeen developed forthe role
30/09/2019
01 2019/20 plan is indevelopment. FluPlanning Groupestablished.
30/06/2019
01 Content of the IQPRcurrently underreview
30/04/2019
CQOSH.
Investors in People (IIP)Developed standards awardedto the Trust in July 2017.
Annual NHS Staff SurveyResults.
Unknown
Pa
rtially
As
su
red
Key Control 02 Annual Flu Campaign Updatespresented to the WorkforceCommittee bi-annually.
2019/20 plan needs to be developed. Weekly monitoring during theFlu Campaign period.
Unknown Unknown
No
t As
su
red
Key Control 03 Health and Wellbeing Groupestablished. Summary of assuranceand minutes to be presented to eachWorkforce Committee.
Unknown Unknown Unknown Unknown
Pa
rtially
As
su
red
Key Control 04 Integrated Quality & PerformanceReport (IQPR) is reported to theBoard at each meeting.
Integrated Quality & PerformanceReport (IQPR) is reported to theBoard at each meeting.
Unknown NHSI and NHSE benchmarkingwith other ambulance trusts.
Unknown
OR
R-3
5
High levels of sicknessabsence is adverselyimpacting on theworkforce and theorganisations ability todeliver quality care andrequired performancestandards
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Strategic Objective:2018-19 04 - Developing A Sustainable WorkforceEnabling Strategy:Performance Management
Monitoring Group:Workforce Committee
Lead Director:Caroline Thurlbeck
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
4.4
Pa
rtially
As
su
red
Key Control 01 Equality & Diversity Groupestablished. Summary of assurancesand minutes presented to theWorkforce Committee at eachmeeting.
31/03/2020 01 The Trust has electedto move fromStonewall to theEmployers Network forEquality & Inclusion(ENEI).
31/03/2020Equality & Diversity AnnualReport.
Stonewall Workforce EqualityIndex (WEI) Report.
Equality Delivery System 2.
Gender Pay Audit.
Disability Confidence Scheme.
No comprehensive equality index inplace.
Pa
rtially
As
su
red
Key Control 02 Freedom to Speak Up (FtSU) updatespresented to the WorkforceCommittee bi-annually.
Further action required to fully embedFtSU.
FtSU Champions
Board Champion
Unknown Unknown
OR
R-1
5
Inappropriate behavioursunderpin a culture thatimpacts negatively on theTrust's ability to deliverhigh quality safehealthcare
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Strategic Objective:2018-19 05 - Communication And EngagementEnabling Strategy:Communications Strategy
Monitoring Group:Executive Team
Lead Director:Paul Liversidge
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
5.1 Driving improvement of
internalcommunications.
Fu
lly A
ss
ure
d
Key Control 01 Communications and EngagementStrategy in place. Media management
There needs to be greater assurancewithin the operations directorate thatkey messages are being received onthe frontline.
Strong staff survey results in2018 with an action plan inplace to ensure that NEAScontinue to listen and respondto staff feedback.
Workplan in place containing 17actions relating to internalcommunications which ismonitored on a quarterly basisat ET.
Quarterley report to ETregarding media coverage.
01 Review thecommunicationsmechanisms and testknowledge of keyissues throughdiscussions with frontline staff.
30/09/2019Independant external evaluationof media coverage highlightspositive coverage and complieswith the Francis Reportrecommendations fromMid-Staffs.
None Identified
Pa
rtially
As
su
red
Key Control 02 Regular meetings held with TradeUnions.
None Identified. Staff Engagement &Communications quarterlyreport presented to ET.
Staff FFT results show highnumber of employees wouldrecommend NEAS as a place towork.
Executive Walkarounds andvisability.
Joint Consultation Committee
Full time Union Officialsengaging with Executive Team
03 Project started withoperations, PMO andOD group support,including team briefreview.
30/09/2019Benchmark of NHS staff surveyresults and national peer groupsurveys high scores for NEAS.
None Identified
Fu
lly A
ss
ure
d
Key Control 04 Board and senior leader visibilitythroughout Quality Walkrounds,station visits and observations.
Systems and processes need to bereviewed to ensure two-waycommunications.
Visibility tracker is in place forBoard members.
04 Project started withoperations PMO andOD group support,including team briefreview.
30/09/2019Benchmark of NHS staff surveyresults and national peer groupsurveys shows high scores forNEAS
None Identifed
OR
R-4
5
System change. TheNHS and social careeconomy in the NorthEast is undertakingSustainability andTransformation Planning,alongside thedevelopment of IntegratedCare Partnerships and anIntegrated Care System.The risk is of thesechanges affectingresponse performanceand the clinical safety ofpatients affected, orpotentially affected bythese changes
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Strategic Objective:2018-19 05 - Communication And EngagementEnabling Strategy:Communications Strategy
Monitoring Group:Quality Governance Group
Lead Director:Paul Liversidge
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
5.2 Introduce new intranet
on SharePoint to createa collaborative digitalenvironment thatsupports agile working.
Pa
rtially
As
su
red
Key Control 01 Project to replace intranet withSharePoint platform to allow agateway to all other NEAS systems.
Office 365 roll-out is delaying theproject.
Lack of engagement from certainareas of the Trust to not provide NewIntranet Authors.
Project is being managedthrough project group withoversight from SMT and ET.
Business case approved andfunding available to procure thesystem and resources to build.
01 Launch of intranetpostponed untilSeptember
30/09/2019
01 Senior Digital andInternal CommsOfficer who willidentify and addresslack of engagementas part of role.
01/09/2019
01 Business caseunderway to sourcefunding for apermanent resource.
01/12/2019Third Party Provider supportoffered by AMT Evolve.
Senior Digital & Internal CommsOfficer funded on a fixed termtemporary contract until December2019.
18
3 Delay in Office 365implementation
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Strategic Objective:2018-19 05 - Communication And EngagementEnabling Strategy:Communications Strategy
Monitoring Group:Quality Governance Group
Lead Director:Paul Liversidge
Re
fere
nce
Sub ObjectiveDescription
Ris
k R
eg
Re
f
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
5.3 Develop and support
NEAS presence onSocial Media.
Pa
rtially
As
su
red
Key Control 01 Social Media policy and guidance iswidely used and reviewed.
Lack of a social media enterpriseplatform to govern and audit futuregrowth.
On-call communication is inplace to horizon scan potentialcriticisms, advise SMT onrepution and respond whenneeded.
01 Business case iswritten and awaitingconsideration onceprioritised fordecision making.
30/09/2019 01 Training programmecurrently beingdeveloped
30/09/2019NACOM guidance approved byAACE to support enahncedsocial media use.
Weakness exists in training staff andoverall awareness of social mediapitfalls.
Fu
lly A
ss
ure
d
Key Control 02 Funding via Global Digial Exempler fora 12 month period is now available.
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
6.1 Achieving the Financial
Plan.
Fu
lly A
ss
ure
d
Key Control 01 Monthly Financial Performance reportand dashboard presented to theFinance Committee and Trust Board.
Report details:
* Key variance from Plan* Remedial actions being undertaken* Key risks against Plan delivery* Contracting issues including deliveryagainst conveyance rate trajectory* CIP progress* Capital Programme position* Cash Flow position* NEASUS SOCI position plus Groupposition reported* Corporate Priorities update reportpresented monthly.
None Identified. Delivering Consistently -monthly financial position andkey issues reported by serviceline.
Transformation Board - monthlydetailed analysis of schemedelivery and forecast outturnreview; Future CIP planningreport presented from Q1 withiterative review in-year forfuture schemes.
What may prevent theObjective being met?(Linked Risk) S
eve
rity
Lik
elih
oo
d
To
tal
Sco
re
Current Level of Risk A
ssu
ran
ce
Ad
eg
ua
cy
Gaps in Controls Mitigation for Gaps in Controls(Actions)
Assurances
Internal External
Gaps in Assurances Mitigation for Gaps in Assurances (Actions)
Existing Controls Identified by theCommittee
6.2 supporting development
of Integrated CareSystem and associatedIntegrated CarePartnerships.
Fu
lly A
ss
ure
d
Key Control 01 Contracting Update reported monthlyto Finance Committee - identifyingany known or potential reconfiguration/ system changes having a likelyfinancial consequence.
Annual Review of contracts register toFC in Q1 each financial year.
Proposals for contract negotiations forthe following year presentedSeptember and final proposedcontract agreement positionpresented for approval by FC in Q4.
None Identified. Per Corporate Objective updateto FC, progress againstsub-objectives is monitoredthrough RAG rating reporting.
Service Reconfiguration Groupmeets monthly to reviewposition and is providing widerinternal engagement andassurance on changes acrossthe region. Areas of concern areflagged at this Group andactions allocated to identifiedsystem change owners withinthe Group.
Joint NEAS/Commissioner postappointed (Senior ProgrammeLead for UEC) adding additionalparticipation and influence atsystem transformational events/groups.
SRG members have beenallocated areas of coverage andare required to attend externalreconfiguration meetings andfeedback.
Executive Team membersattend System TransformationBoards, LADB, NE UECNmeetings, etc.
Monthly Contract Review Groupmeetings with NECS as well ascontract management meetingsin respect of non-core contracts(such as S Tyne OOH/HomeVisiting).
QRG meeting attended byClinical and Medical Directorateleads.
None Identified.
OR
R-4
5
System change. TheNHS and social careeconomy in the NorthEast is undertakingSustainability andTransformation Planning,alongside thedevelopment of IntegratedCare Partnerships and anIntegrated Care System.The risk is of thesechanges affectingresponse performanceand the clinical safety ofpatients affected, orpotentially affected bythese changes
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