Date of meeting / March 16 / Confirm part one or two / Part One /
Title of paper / Annual Compliance Update
Responsible director / Head of Workforce and Governance
Author / Governance Manager
Action required / Approval / / Decision / ☐ / Discussion / ☐ / Information / /
Purpose of the report: / Annual compliance update.
Executive summary (maximum 500 word limit) / The CCG allocates resource to ensure key compliance areas are monitored and policy and procedure are implemented to mitigate risk and ensure activities are delivered within statutory and best practice guidelines. This report includes
- Chief Executive Officers Annual Fire Statement (see Appendix 1) – for assurance
- Fire Health and Safety Compliance Summary (see Appendix 2) – for assurance
- Equality and Diversity (see Appendix 3) – for assurance and approval
The recommendation is to: / 1.Review the accompanying appendices that form the annual compliance update for Governing Body assurance in respect of the following regulated aspects governing corporate compliance:
- Chief Executive Officers Annual Fire Statement (see Appendix 1)
- Fire Health and Safety Compliance Summary (see Appendix 2)
- Equality and Diversity (see Appendix 3)
Related to the CCG strategic objectives: / Effectiveness / /
Quality / ☐ /
Improved experience / ☐ /
Make a difference for local people / ☐ /
Reduce inequalities and delivery / ☐ /
Sustainable financing / ☐ /
Links to the CCG strategic risk register: / Compliance Risk Part 1 Integrated Risk Register
Risk scoring and description:
Consequence
(impact) / Rare / Unlikely / Possible / Likely / Almost
Certain
1 / 2 / 3 / 4 / 5
1 Negligible / 1 / 2 / 3 / 4 / 5
2 Minor / 2 / 4 / 6 / 8 / 10
3 Moderate / 3 / 6x / 9 / 12 / 15
4 Major / 4 / 8 / 12 / 16 / 20
5 Catastrophic / 5 / 10 / 15 / 20 / 25
/ Compliance risk requires the CCG ensure it puts in place relevant activities in line with statutory and regulatory requirements. Controls are in place to mitigate risk to staff, resource, finance and commissioning reputation.
Primary care conflict of interest / Conflict of interest exists (Y/N) / No /
Potential conflict of interest exists (Y/N) / No /
Impact
Quality and safety / Positive / / Negative / ☐ / Neutral / ☐ /Corporate Health and Safety
Patient experience / Positive / / Negative / ☐ / Neutral / ☐ /
Equality and Diversity Objectives
Clinical/operational effectiveness / Yes – includes third party competent health and safety advisor assurance statement
Financial/performance (see business case template attached where applicable) / n/a
QIPP/better care fund / n/a
Statute/compliance/
governance issues / This report provides assurance on key corporate governance requirements in respect of Fire, Health and Safety and Equality and Diversity.
NHS Constitution / The CCG must maintain compliance to deliver the requirements of the NHS Constitution in its delegated authorities.
Equality impact / Positive / / Negative / ☐ / Neutral / ☐ /
The Equality and Delivery Scheme in Appendix 3 lists the performance against the deliverables in 2015/16 and objectives to be approved for 2016/17.
Human resources / Currently work relating to compliance is borne by services with minimal corporate resource to manage, monitor and administer for assurance purposes. This enables the focus to be on the resourcing of controls development within services where the risk is likely to occur.
Patient engagement / The Equality and Delivery Scheme (EDS) includes new objectives for 2016/17 that are taken from the national EDS2 scheme. Patient engagement is sought during significant pathway redesign and formal consultation processes.
System incl. primary care,NHS providers, local authority, voluntary sector etc. / This report refers to corporate compliance requirements in respect of Fire and Health and Safety Compliance. The Equality and Delivery Scheme lists the objectives that are delivered across the range of work programmes with NHS providers, local authority and voluntary sector where relevant.
Supporting documents (List all appendices or further attachments) / See three appendices.
Communications Strategy
(How this initiative will
be disseminated) / This report will remain in Governing Body papers on the website. The Equality and Diversity Scheme will be noted on the website and a link provided to this appendix within this report on the website.
Acronyms used in the report
(List alphabetically and list in full within the report) / EDS – Equality Delivery Scheme
Directorate involvement and sign off prior to submission to committee / board. Please state role titles or state n/a if appropriate
FinanceCommissioning
QIPP and Delivery
Information
Contracting
Engagement
Governance / Head of Workforce and Governance/Accountable Officer
Quality and Safety
Annual Compliance Update
- Background / History
The CCG maintains a compliance infrastructure to ensure that key statutory obligations and compliance best practice activities are implemented ongoing. Included in this report are the following:
- Chief Executive Officers Annual Fire Statement (see Appendix 1) – for assurance
- Fire, Health and Safety Compliance Summary (see Appendix 2) – for assurance
- Equality and Diversity (see Appendix 3) – for assurance and approval
Other areas of corporate compliance including Information Governance, Freedom of Information and Subject Access Requests are monitored by the Audit Committee and Information Governance Executive Assurance Group.
- Proposal
The compliance assurance reports are set out to provide the context and a position statement for the year in respect of Fire, Health and Safety and Equality and Diversity.
- Progress / Barriers to Progress / Key Risks
Implementation of the Fire Policy is monitored by the Audit Committee. The HealthEast Executive Team monitor the following:
-Health and Safety Action Plan
-Progress against the desktop assessment grid
-Fire and Health and Safety Assessment action plans to progress the implementation of recommendations generated from the formal assessments carried out by the landlord to safeguard tenant risks in respect of Fire and Health and Safety.
- Options for consideration
The Equality Delivery Scheme includes the national Equality and Delivery Scheme 2 objectives which the CCG has agreed to adopt in full. The Governing Body are recommended to continue to adopt the objectives that make up this significant document seen as best practice for NHS organisations in delivering its Equality and Diversity duties.
- Conclusion
The documents included in the appendices following are intended to provide assurance and by reporting them together as part of an Annual Compliance update it is envisaged the strategic assurance and any subsequent feedback will be consistent across compliance agendas.
- Recommendation
The Governing Body area asked to review the report appendices as follows:
- Review the accompanying appendices that form the annual compliance update for Governing Body assurance in respect of the following regulated aspects governing corporate compliance:
- Chief Executive Officers Annual Fire Statement (see Appendix 1)
- Fire, Health and Safety Compliance Summary (see Appendix 2)
- Equality and Diversity (see Appendix 3)
2. Approve the objectives set out in the Equality and Diversity Objectives and Outcomes Grid in section 3.2 to Appendix 3.
- Appendices
Appendix 1 Chief Executive Officers Annual Fire Statement
Appendix 2 Fire, Health and Safety Compliance Summary
Appendix 3 Equality and Diversity
Appendix 1Chief Executive Officer’s Annual Statement of Fire Safety
- Assurance Required
This assurance report is presented by the Chief Executive Officer as the role with overall responsibility for Fire Safety for the CCG, as required by the NHSGYW CCG Fire Policy (section 7.) The section notes:
The Chief Executive is required to provide evidence annually of compliance with the Regulatory Reform (Fire Safety) Order 2005 this will be done via an Annual Statement of Fire Safety prepared by the Nominated Director for reporting to the Governing Body on behalf of the Chief Executive. This will be reported on to the area responsible for Estates Monitoring via NHS Property Services.
- Fire Risk
There remains an ongoing fire risk at Beccles House. The risk is assessed as low in relation to the activities on site being office and administration in nature. Whilst the risk is low, the CCG considers the requirements to mitigate this risk as high priority to secure the Health and Safety of staff and site resources of the CCG and NHS Property Services. To that end the CCG ensures the following activities are maintained to mitigate the risk:
- Liaison with landlord in respect of the mix of responsibilities between tenant, joint occupying entities and landlord via contribution to Beccles House User Group and Annual Fire Risk Assessment;
- Work with ECCH Health and Safety Officer to ensure full list of Fire Marshals and procedure and Fire Emergency Plan are maintained and equipment for example high visibility jackets and fire equipment is maintained and tested (including regular fire alarm testing);
- Annual compliance in respect of annual fire drill, fire marshal training, mandatory employee fire training and annual compliance update to the Chief Executive for the purposes of this Fire Safety Statement. Implementation of relevant actions to meet the recommendations following the Fire Risk Assessment
- Annual Fire Risk Assessment and Audit Committee Review
A noted above a key part the CCG assurance process in respect of Fire Safety is the review of compliance with the Fire Officer recommendations made following theirdetailed Annual Fire Risk Assessment in 2015. This assessment includes building Fire Safety, operational practice in respect of staff and resources, drills, incidents and false alarm management and the policy and procedure infrastructure in place at the CCG. As part of the ongoing work programme the detailed requirements of these recommendations are considered and any required actions implemented as part of the Beccles House Joint User Group and liaison with landlord and facilities coordinator, NHS Property Services to ensure the building remains compliant. The 2015 assessmentrecommendations were added to the action plan reference in Appendix 2.
The following were reviewed as part of the annual Audit Committee Review into Fire Safety in January 2015:
- The detailed controls and position in respect of the full scope of fire safety work
- Implementation of the policy
The Audit Committee are to receive an update of the progress in implementing the recommendations following the 2015 assessment in March 16.
This Audit Committee review forms part of its role in providing assurance that the CCG controls and practices in this respect are compliant and follow best practice.
- CCG Fire Policy and Procedure and Beccles House Emergency Fire Plan
This is the second and ongoing annual reporting commitmentrequired as part of the assurance processes underpinning the implementation of the Fire Policy and Procedures for the CCG. The CCG along with other occupying entities of Beccles House, contributed to the setting of the Fire Emergency Plan, led by the ECCH Health and Safety Officer. TheFire Policy and Procedure was approved by the Audit Committee at itsJanuary 2014 meeting and the revised document sent out to all staff. It is next due for review January 2017 subject to any change in legal requirements that would necessitate an earlier review of the policy.
- Health and Safety Action Planning and Third Party Assurance
The CCGprocures consultancy advice from a Health and Safety specialist advisor who provides an update on Health and Safety compliance at the year end. The CCG has in place a general Health and Safety Policy and Health and Safety WorkAction Plan. In addition a staff presentation on the Risk Assessment process was carried out in year. These assurance mechanisms are referenced in Appendix 1 to this compliance report.
- Current Resourcing and Training
The Director of Partnership and Delivery monitors Fire Safety on behalf of the Chief Executive Officer and the Nominated Officer and provides steer for the Governance Manager in the operational delivery of Fire Safety requirements. Various staff contribute to the Beccles House User Group Meetings and work with the lead fire marshal and the ECCH Health and Safety Manager in respect of compliance requirements highlighted above. Several fire marshals are in place and these roles receive specific fire marshal training with the wider staff group receiving mandatory training in respect of Fire Safety.
Signed:
Chief Executive Officer NHSGYW CCG
Date:
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Appendix 2 Fire, Health and Safety Compliance Summary
Title / Approvals/Refresh etc… / Current ProgressHealth and Safety Compliance
Health and Safety Policy (approval to include staff consultation process) / Refreshed every 3 years or when significant business change requires earlier review
Approval required by Governing Body due to significant legal risk to Accountable Officer role re corporate manslaughter / Governance Manager updated policy for approval (presenting to staff involvement group initially for staff consultation.)
Quality Support resourceprovided support re Health and Safety Audit Tool, grid presented at Audit Committee.
Policy includes Health and Safety Audit Tool / To be completed for first time in 15/16 – suggest refresh in line with policy noted above / See comments above re H&S Policy
Health and Safety Induction leaflet / Head of Workforce and Governance / In place
Competent H&S Advisor Resource in place to provide support / Best practice guidance advises a ‘competent’ role be in place to support operational activities / Serco role in place – contract to continue into 16/17
Met in Jan 16 discussed support required re Serco Competent Advisor Update to Governing Body that is included as appendix in Annual Compliance Update
Risk assessment training scoped out and took place Feb 16 at all staff briefing
Annual Compliance Statement (includes H&S/Fire/E&D etc…) / Annually to Governing body / To be reported to March 16 Governing Body.
Health and Safety Training
Mandatory training
Adhoc sessions with competent Health and Safety Advisor / See Mandatory Training Log for those who have attended these sessions through the year ongoing
Health and Safety Lead (currently Governance Manager RB) attending sessions with the competent advisor
Other examples – Display Screen Assessor Training / No further training identified at this time (Head of Workforce and Governance and Governance Manager to consider further potential training topics with Serco competent H&S advisor.)
Health and Safety Annual Assessment carried out by NHS Prop co. / Carried out every 3 years
To be reviewed along with Fire Assessment by Audit Committee / Completed Nov 15 next due 18
To be taken to Audit Committee re their role in reviewing implementation of policy. Delivery and Partnership/Ops Directorate monitoring implementation of recommendations. Some remain o/s for NHS Prop Co in relation to landlord and facilities management actions.
Fire Compliance
Fire Safety Policy Management Procedure / Approved every 3 years by Audit Committee or when significant business change requires earlier review
Evidence on implementing policy to be taken to Audit Committee / Fire Policy in date last approved Jan 14. Next review due Jan 17.
Implementation evidence reviewed by Audit Committee ongoing. In 15/16 policy updated for appendix relating to need for PEEP – Personal Emergency Evacuation Plans (plan template established via Delivery and Partnership/Ops Directorate)
Beccles House Emergency Plan / Updated by Fire Health and Safety Officer (ECCH) on behalf of all Beccles House Occupying Entities
Taken to Audit Committee as part of policy compliance / Last updated July 2013
Due to pending change in occupants, a new owner of this document will need to be identified
Fire Training
All staff receive mandatory training
Marshalls receive specific training / Lead Beccles House Fire Marshal currently Fire Health and Safety Officer (ECCH WS)
Lead CCG Fire Officer (JWB) holds training log
Marshalls training arranged regularly to include new marshal and refresher training
See Mandatory Training Log for those who have attended these sessions through the year ongoing / Last Marshals training took place in year - 15/16. Local CCG lead fire marshal in place to ensure group maintain awareness of need for regular training and cover arrangements.
Due to pending change in occupants, a new Lead Fire Marshal of this document will need to be identified.
Fire Annual Assessment carried out by NHS Prop co. / Carried out every 3 years
To be reviewed along with Health and Safety Assessment by Audit Committee / Completed Nov 15 next due 18
To be taken to Audit Committee re their role in reviewing implementation of policy. Delivery and Partnership/Ops Directorate monitoring implementation of recommendations. Some remain o/s for NHS Prop Co in relation to landlord and facilities management actions.
Fire Induction leaflet / Head of Workforce and Governance / In place
Security Standards
NHS Protect Security Standards 15/16
Detailed Standards due to change in 16/16 / Assurance Security Statement report to Audit Committee for 2016/17 following publication of 1617 standards:
Expected to be more summary form focusing for CCGs on monitoring of security standards within provider environ.
Expect alert in spring regarding these new standards
Local Adoption and Actions to Implement required to be reported to Audit Committee around start of new financial year / No work required 15/16 re 15/16 standards
New 16/17 standards awaiting publication following which review of local requirements to be made and resource to be put in place to deliver. Audit Committee to receive assurance update.
Continue to monitor NHS Protect guidance on whether CCGs are to resource specific Local Security Management Specialist (LSMS) Role (Pooling funds to resource role across x5 CCGs to be considered or call off contract)
Log agenda item on this with Audit Committee around start of new financial year
Operational Management (H&S and Fire)
Desktop Workplace Risk Assessments / Refresh annually (or more often where need arises)
Review by HEX
Update on progress summarised in Compliance Year End Statement to Governing Body / HEX update planned for 16/17
Health and Safety Work Action Plan / HEX update planned for 16/17
Staff Involvement Group review of key HR and other policies impacting on staff / Meet regularly to provide consultation forum for HR and other policies impacting on staff - staff from across CCG are members of this group / Ongoing reviews in place Meetings ongoing.
15/16 Health and Safety Policy refresh taken to this group for consultation purposes
Health and Wellbeing Group / Meets regularly and produces guidance leaflets and signposts to useful resources for staff – staff from across CCG are members of this group / Meetings ongoing
Joint Users Working Arrangements via Beccles House User Group (BHUG) / ECCH resource chairing. / Next meeting date established and action plan re implementation of Fire and H&S Assessments to be brought to the meeting for NHS Prop Co to comment regarding progress against outstanding actions.
Landlord Responsibilities and Regular Assessment and Facilities Management Support
Responsibilities document in lieu of contract with NHS Prop co / This document requires regular review by CCG management and should be used to support deliberations at regular meetings with NHS Prop Co / Document reviewed at BHUG Group. Dir of Ops to confirm progress on developing local lease agreement for Beccles House
This document should be used as a check in respect of due diligence action planning regarding pending occupancy change.
Lease Agreement / Dir of Delivery and Partnership managing landlord tenant dialogue / Need update on progress
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