Trust Board Meeting: Wednesday 13 May 2015
TB2015.60
Title
Status
History
Board Certification of Organisational Capacity
For discussion
The Board certification of organisational capacity was provided to the
Foundation Trust Programme Board, at its meeting on 13 October
2014. It was also provided to the Trust Board at its seminar on 22
October 2014. The current version was reviewed and approved by the
Audit Committee on 27 April 2015.
Board Lead(s)
Key purpose
Eileen Walsh, Director of Assurance
Strategy Assurance Policy Performance
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Oxford University Hospitals TB2015.60
Executive Summary
1. This report provides the Trust Board with the opportunity to review the Board certification of organisational capacity and view the supporting evidence that was reviewed and reported to the Audit Committee on 27 April 2015.
2. In addition to the Board Governance Memorandum the Foundation Trust Programme
Board, at its meeting on 13 October 2014, discussed the additional Board certification as required.
3. The Board is to provide ‘board certification that the applicant has the organisational capacity to deliver the business plan and that plans are in place to ensure ongoing compliance with the conditions of the provider licence’.
4. A copy of the related certificate is provided at Appendix 1 and the certificate together with the supporting evidence is provided as Appendix 2.
Recommendations
5. The Trust Board is asked to:
•
Review and approve the certificate as presented for signature by the Chair of the
Trust on behalf of the Trust Board.
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Oxford University Hospitals TB2015.60
1. Purpose
1.1. This report provides the Trust Board with the opportunity to review the Board certification of organisational capacity and view the supporting evidence that was reviewed and reported to the Audit Committee on 27 April 2015.
2. Background
2.1. In addition to the Board Governance Memorandum the Foundation Trust Programme
Board, at its meeting on 13 October 2014, discussed the additional Board certification as required.
2.2. The Board is to provide ‘board certification that the applicant has the organisational capacity to deliver the business plan and that plans are in place to ensure ongoing compliance with the conditions of the provider licence’. A copy of the related statement is provided at Appendix 1 for information.
3. Review of Compliance
3.1. As part of the continued development of the Board Governance Memorandum, the
Assurance Team undertook a review of the statements in the self-assessment documentation. This review included assessment of the supporting evidence which underpinned the scores achieved in the self-assessment process, using Monitor’s scoring methodology.
3.2. The results of the review of the Board Governance Memorandum (BGM) were presented to the Trust Board in October 2014. The majority of the elements included in the certificate (Appendix 1) can be referenced to the assessment of the BGM.
3.3. The BGM review was extended to include all elements of the Board certificate using the Monitor ‘Guide for applicants’. The evidence to support the Board certificate has been summarised and included in Appendix 2 this was used to provide the Audit
Committee with the evidence base and assurance to support the certificate.
4. Recommendations
4.1. The Trust Board is asked to:
•
Review and approve the certificate as presented for signature by the Chair of the
Trust on behalf of the Trust Board.
Clare Winch
Deputy Director of Assurance
May 2015
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Oxford University Hospitals Appendix 1
Extract from Monitor Guide for Applicants October 2013
Appendix B12 Board statements
The board is required to confirm the following:
1. The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements.
2. The board is satisfied that processes and procedures are in place to ensure all health care professionals providing care on behalf of the trust have met the relevant registration and revalidation requirements.
3. Issues and concerns raised by external audit and external assessment groups (including reports for NHS Litigation Authority assessments) have been addressed and resolved.
Where any issues or concerns are outstanding, the board is confident that there are appropriate action plans in place to address the issues in a timely manner.
4. All recommendations to the board from the audit committee are implemented in a timely and robust manner and to the satisfaction of the body concerned.
5. The necessary planning, performance management and risk management processes are in place to deliver the integrated business plan, including but not restricted to: a) obtaining and disseminating accurate, comprehensive, timely and up-to-date information for board and committee decision-making; b) the timely and effective scrutiny and oversight by the board of the trust’s operations; c) effective financial decision making, management and control; and d) taking appropriate account of quality of care considerations.
6. An annual governance statement is in place, and the trust is compliant with the risk management and assurance framework requirements that support the statement pursuant to the most up-to-date guidance from HM Treasury (www.hm-treasury.gov.uk).
7. The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing access and outcomes metrics (after the application of thresholds) as set out in Appendix A of the Risk assessment framework ; and all known access and outcomes metrics going forwards
8. The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit.
9. The board has in place a register of interests, ensuring that there are no material conflicts of interest in the board of directors; that all board positions are filled, or plans are in place to ensure any board vacancies are filled.
10. The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.
11. The selection process and training programmes in place ensure that the non-executive directors have appropriate experience and skills.
12. The management team has the capability and experience necessary to deliver the integrated business plan.
13. The management structure in place is adequate to deliver the integrated business plan, including but not restricted to: e) effective board and committee structures;
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Oxford University Hospitals Appendix 1 f) clear responsibilities for the board, for committees to the board and for staff reporting to the board and those committees; and g) clear reporting lines and accountabilities throughout its organisation.
14. The board has considered all likely future risks to compliance with the NHS provider licence and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach of conditions occurring and the plans for mitigation of these risks to ensure continued compliance.
For an NHS trust engaging in a major joint venture, or Academic Health Science Centre
(AHSC), Monitor may ask the trust to provide evidence that the board is satisfied that the trust has fulfilled, or continues to fulfil, the criteria in Appendix E of the Risk assessment framework .
Signed for and on behalf of the board:
Title:
Date:
Trust:
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Oxford University Hospitals Appendix 1
Annex E, Risk Assessment Framework :
For NHS foundation trusts:
•
that are part of a major Joint Venture or Academic Health Science Centre (AHSC); or
•
whose boards are considering entering into either a major Joint Venture or an AHSC
The following statement should be made:
The board is satisfied it has or continues to:
1. ensure that the partnership will not inhibit the trust from remaining at all times compliant with the conditions of its licence;
2. have appropriate governance structures in place to maintain the decision making autonomy of the trust;
Risks and mitigating actions comprise:
The objectives of the Oxford AHSC, of which the OUH was a founding partner, are complimentary to those of the OUH.
Governance arrangements for the AHSC do not compromise those of OUH and indeed, it is expected that all/any major decisions required by the AHSC would be referred back to each of the four partners for the appropriate processes to be undertaken n/a the four partners are well established organisations
3. conduct an appropriate level of due diligence relating to the partners when required;
4. consider implications of the partnership on the trust’s financial risk rating having taken full account of any contingent liabilities arising and reasonable downside sensitivities;
5. consider implications of the partnership on the trust’s governance processes
The AHSC’s activities are not expected to impinge in any way on the financial risk rating for OUH. The AHSC does not add to the trust’s liabilities.
6. conduct appropriate inquiry about the nature of services provided by the partnership, especially clinical, research and education services, and consider reputational risk;
7. comply with any consultation requirements;
8. have in place the organisational and management capacity to deliver the benefits of the partnership;
See above – OUH’s Chief Executive OUH is on the Board of the AHSC – decisions that impact on the individual partners are referred back appropriately.
The application process for the establishment of the Oxford AHSC (which was successful in late 2013) outlined in detailed the plans that all four partners would be contributing to through the six themes and related activities.
The document was signed off by the individual partners and updates have been provided to the OUH Board and (as an example) to the
Joint Executive Group and Strategic
Partnership Board with the University of
Oxford (established through the Joint Working
Agreement in November 2011) n/a A number of stakeholder events were held as part of the application process to ensure the fullest engagement and commitment
The AHSC draws on the existing activities of the individual partners and coordinates activities across and between the partners for the benefit of individual members
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Oxford University Hospitals Appendix 1
The board is satisfied it has or continues to:
9. involve senior clinicians at appropriate levels in the decision-making process and receive assurance from them that there are no material concerns in relation to the partnership, including consideration of any re-configuration of clinical, research or education services;
10. address any relevant legal and regulatory issues (including any relevant to staff, intellectual property and compliance of the partners with their own regulatory and legal framework);
11. ensure appropriate commercial risks are reviewed;
Risks and mitigating actions comprise:
Senior clinicians are actively involved in the activities of the AHSC through its six themes.
OUH hosts the AHSC and hence all activities are governed through the governance structures and processes of the trust
12. maintain the register of interests and no residual material conflicts identified; and
13. engage the governors of the trust in the development of plans and give them an opportunity to express a view on these plans.
In addition, before entering into an accredited AHSC or other major Joint
Venture, boards of NHS foundation trusts are required to certify that they have:
14. received external advice from independent professional advisers with
15. taken into account the best practice advice in Risk Evaluation for
Investment Decisions by NHS
Foundation Trusts or comment by exception where this is not the case. appropriate experience and qualifications; and
If the AHSC becomes involved in commercial activity, the appropriate reviews/assessment of any risks would take place, drawing on the resources of the partners (e.g. the Joint
Research Officer, the Knowledge Transfer
Service at OBU, Isis Innovations etc).
In addition, one theme of the AHSC is particularly focused on developing collaborations with industry. n/a dealt with through the arrangements for individual partners
Governors of the trust will have full access to, for example, the Annual Report of the AHSC.
Reports on AHSC activities are included as part of the CEO’s report to public board meetings. It would be feasible and appropriate for a briefing on the AHSC and its activities to the Governors of OUH at a suitable point. n/a
OUH was a founding partner of the Oxford
AHSC and, working with the CEOs or equivalents of the University of Oxford, Oxford
Brookes University and Oxford Health NHS
FT, and led by the Regius Professor of
Medicine (also a NED of OUH).
The Board of OUH was kept informed on the process throughout.
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Oxford University Hospitals
Board Memorandum Supporting Summary
The Board is required to confirm the following:
Monitor Question
1. The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality
Commission’s registration requirements.
2. The board is satisfied that processes and procedures are in place to ensure all health care professionals providing care on behalf of the trust have met the relevant registration and revalidation requirements.
3. Issues and concerns raised by external audit and external assessment groups (including reports for NHS Litigation
Authority assessments) have been addressed and resolved.
Where any issues or concerns are outstanding, the board is confident that there are appropriate action plans in place to address the issues in a timely manner.
4. All recommendations to the board from the audit committee are implemented in a timely and robust manner and to the
Appendix 2
Supporting Evidence / summary commentary
The Trust is compliant with the registration requirements of the Care Quality
Commission. The Trust was inspected by the Care Quality Commission in
February 2014, and on a number of further occasions during the period until 12
March 2014. The Trust received an overall rating of ‘Good’ for the service provided. The Care Quality Commission identified a number of areas for improvement and issued five compliance actions. The Trust accepted these actions and developed an action plan in relation all actions raised within the reports. Updates on progress have been reported to the Quality Committee
( QC2014.44
: June 14, QC2014.55
: August 14, QC2014.97: December 14 and
QC2015.35: April 2015) and the Trust Board ( TC2014.75
: July 14, TB2014.97
:
July 14, TB2014.96
July 14, TB2014.116
Nov 14, TB2015.66
May 15).
The Trust has an electronic system to monitor the on-going compliance with the
CQC registration requirements; this is being update to reflect the changes in regulations with effect from 1 April 2015. A update was presented to the Trust
Management Executive in March 2015 ( TME2015.75
)
The Trust has a Professional Registration Procedure available to staff via the intranet.
The Trust Board is kept up to date on changes to the revalidation processes as required in March 2014 ( TB2014.4) it was updated on Nomination of RO and provided with Revalidation Progress Report (TB2014.30).
Updates in relation to recent changes to the revalidation of nurses and midwives have been provided to the Trust Management Executive in March 2015
(TME2015.86) and the Quality Committee in April 2015 ( QC2015.34)
Issues and concerns raised by external audit and external assessment groups are usually the subject of a separate action plan and this plan would be monitored by Audit Committee / Trust Management Executive / Trust Board as necessary. Summaries of issues or concerns that require follow-up by the Board would be included in the regular written report to the Board as mentioned in relation to point 4 below.
The Audit Committee provides a regular written report to the Board after each of its meetings, this report has a standard heading ‘Matters referred to the Trust
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Oxford University Hospitals
Monitor Question
Appendix 2 satisfaction of the body concerned.
Supporting Evidence / summary commentary
Board’ which is used to make recommendations to the Trust Board. All matters noted under this heading are included in the Trust Board Action Log, as required and implementation is monitored through consideration of the Action log at each
Trust Board meeting. Audit Committee reports ( TB2014.65
: May 14, TB2014.84
:
July 14, TB2014.137
Nov 14, TB2015.18
: January 15, TB2015.39
: March 15)
5. The necessary planning, performance management and risk management processes are in place to deliver the integrated business plan, including but not restricted to: a. obtaining and disseminating accurate, comprehensive, timely and up-to-date information for board and committee decision-making; b. the timely and effective scrutiny and oversight by the board of the trust’s operations; c. effective financial decision making, management and control; and d. taking appropriate account of quality of care considerations.
The Board considered this as part of the detailed evidence review of the Board
Governance Memorandum (BGAM), formally approved by the Trust Board in
October 2014 ( TBC2014.51
), the ‘Board Context’ section covered the Board committee structures and responsibilities.
In addition sections:
•
3.1 ‘Board performance and reporting’ self-assessed by the Trust Board as Amber/ Green covered reporting.
•
3.2 ‘Efficiency and productivity’ self-assessed by the Trust Board as
Green covered, risk, quality and financial decision making.
•
3.3 ‘Environment and strategic focus’ self-assessed as Amber/Green covered wider oversight of Trust operations.
•
3.4 ‘Quality of Board papers and timeliness of information’ self-assessed as Amber/Green covered committee reporting.
6. An annual governance statement is in place, and the trust is compliant with the risk management and assurance framework requirements that support the statement pursuant to the most up-to-date guidance from HM Treasury
( www.hm-treasury.gov.uk
).
The BGAM was subject to review by the Trust Internal Auditors, the Audit report formed part of the Board report.
Following feedback from Monitor proposals for the further review and development of financial planning (including capital planning), performance and transformation processes across the Trust were discussed at the Trust Board seminar in February 2015. These proposals were then presented to the Trust
Management Executive on 26 February 2015 ( TME2015.55
). It is proposed that further updates on processes are provided as they are developed.
The Annual Governance Statement for 2014/15 has been prepared in line with the latest guidance from HM Treasure. This guidance was provided to the Audit
Committee at its meeting in February 2015 ( AC2015.12
). The draft Annual
Governance Statement is presented to the Audit Committee for review in May
2015. ( AC2015.23
)
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Oxford University Hospitals
Monitor Question
Appendix 2
7. The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing access and outcomes metrics (after the application of thresholds) as set out in Appendix A of the Risk assessment framework ; and all known access and outcomes metrics going forwards
Supporting Evidence / summary commentary
A detailed paper outlining the progress in relation to the achievement of the access and outcomes metrics was presented to the Trust Management
Executive in March 2015 ( TME2015.82
). This set out the Trust’s historical position, current performance and forward plan for the next financial year. An update on the forward plan was presented to the Finance and Performance
Committee In April 2015 ( FPC2015.15
)
8. The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance
Toolkit.
9. The board has in place a register of interests, ensuring that there are no material conflicts of interest in the board of directors; that all board positions are filled, or plans are in place to ensure any board vacancies are filled.
10. The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.
11. The selection process and training programmes in place ensure that the non-executive directors have appropriate experience and skills.
12. The management team has the capability and experience necessary to deliver the integrated business plan.
The Trust has achieved an overall score of 91% ‘satisfactory’ as reported via the
Information Governance Toolkit website, this equates to a Level 2 performance rating.
The Board’s Register of Interests is updated throughout the year, and is formally received at the Trust Board meeting in May 2015 ( TB2015.69
). No conflicts of interest were identified in the review of the Register. The Trust is compliant with the Fit and Proper Persons requirements that were introduced in November
2014. All Board members have completed self-assessment declarations in relation to this requirement.
The Board considered this as part of the detailed evidence review of the Board
Governance Memorandum (BGAM), formally approved by the Trust Board in
October 2014 ( TBC2014.51
), specifically section 1.2 ‘Balance and calibre of
Board members’ covered this question. Self-assessed by the Trust Board as
Green. The BGAM was subject to review by the Trust Internal Auditors, the Audit report formed part of the Board report.
The Board considered this as part of the detailed evidence review of the BGAM, formally approved by the Trust Board in October 2014 ( TBC2014.51
), specifically section 2 ‘Board evaluation, development and learning’ covered this question. Section 2.1 ‘Effect Board level evaluation’ was self-assessed by the
Trust Board as Amber/Green and section 2.2 ‘Whole Board Development
Programme’ was self-assessed as Green. The BGAM was subject to review by the Trust Internal Auditors, the Audit report formed part of the Board report.
The Trust’s Integrated Business Plan and Annual Trust Business Plan have been considered in detail at the Foundation Trust Programme Board, the
Finance and Performance Committee (most recent papers FPC2015.18 & 19 ) and the Trust Board and are subject to formal review by Monitor and the TDA, following formal sign off by the Board.
As part of the process of drawing up the plans an assessment of management
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Oxford University Hospitals
Monitor Question
Appendix 2
Supporting Evidence / summary commentary capacity and experience is considered, and this is reflected within the Trust
Assurance Statements included in the TDA checklists supporting the plans.
The Board Governance Framework mentioned in other sections considered evidence in relation to Board level evaluation, development and training.
13. The management structure in place is adequate to deliver the integrated business plan, including but not restricted to: a. effective board and committee structures; b. clear responsibilities for the board, for committees to the board and for staff reporting to the board and those committees; and c. clear reporting lines and accountabilities throughout its organisation.
The Board considered this as part of the detailed evidence review of the BGAM, formally approved by the Trust Board in October 2014 (
Trust Board as Amber/ Green covered reporting. The BGAM was subject to review by the Trust Internal Auditors, the Audit report formed part of the Board report.
TBC2014.51
), specifically the ‘Board Context’ section covered the Board committee structures and responsibilities.
In addition section 3.1 ‘Board performance and reporting’ self-assessed by the
14. The board has considered all likely future risks to compliance with the NHS provider licence and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach of conditions occurring and the plans for mitigation of these risks to ensure continued compliance.
The Board considered this as part of the detailed evidence review of the Board
Governance Memorandum (BGAM), formally approved by the Trust Board in
October 2014 ( TBC2014.51
), specifically sections 3.2 ‘Efficiency and productivity’ self-assessed by the Trust Board as Green covered, risk, quality and financial decision making and 3.3 ‘Environment and strategic focus’ selfassessed as Amber/Green covered wider oversight of Trust operations including the BAF & CRR. The BGAM was subject to review by the Trust Internal Auditors, the Audit report formed part of the Board report.
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