Premises Assurance Model Governance SAQ G1- With regard to ensuring the Estates and Facilities governance framework has clear responsibilities and that quality, performance and risks are understood and managed 08/02/17 Programme Bit about us to set the context Bit about PAM and how it works WSFT experience Resources

Guidance Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: and CQC Guidance for providers on meeting the regulations 17(1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. 17(2)(a) assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services); 17(2)(b) assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity; NHS Constitution and Handbook to the NHS Constitution NHS England Five Year Forward View Quality Governance in the NHS National Quality Board A guide for provider boards Monitor Code of Governance for Foundation Trusts NHS TDA Delivering High Quality Care NHS Good Corporate Citizen Monitor: Risk Assessment Framework for NHS Foundation Trusts HSE five steps to risk assessment - INDG163 (rev 3) 06/11 Monitor: Developing strategy What every trust board member should know Programme Bit about us to set the context Bit about PAM and how it works WSFT experience Resources

SAQ Evidence 1) There is an effective governance framework to support the delivery of the Estates and Facilities strategy and good quality services Estate strategy Governance structure Governance assurance framework Work plans 2) Staff are clear about their roles and understand what they are accountable for Job descriptions Organisational structure Objectives Training records 3) Working arrangements with partners and third party providers are effectively managed? Responsibilities and communication defined in contracts Contract monitoring and performance Risk register 4) The governance framework and management systems are regularly reviewed and improved DGSG terms of reference DGSG minutes PAM assessment/action plan Audit Programme Bit about us to set the context Bit about PAM and how it works WSFT experience Resources

SAQ Evidence 5) There is a holistic understanding of performance, which integrates the views of people with safety, quality, activity and financial information DGSG (agenda, notes) Escalation routes SFI 6) There are comprehensive assurance system and service performance measures, which are reported and monitored, and action taken to improve performance Internal audit programme/reports Statutory audits/reports PAM assessment SFI compliance 7) There are effective arrangements in place to ensure that the information used to monitor, report (including regional and national data collections) and manage quality and performance is accurate, valid, reliable, timely and relevant (including PFI and non PFI costs) DGSG ERIC, FOI, complaints, incidents, risk, workforce performance, PLACE Local and DGSG discussion with finance manger/HR manager Review of ERIC definitions Analysis and assessment of efficiency and productivity dashboard Programme Bit about us to set the context Bit about PAM and how it works WSFT experience Resources

SAQ Evidence 8) There is a systematic programme of internal audit, which is used to monitor quality and systems to identify where action should be taken Internal audit programme/reports Deep dive presentation to audit committee DGSG Peer review ISO accreditation 9) There are robust arrangements for identifying, recording and managing risks, issues and mitigating actions Risk register corporate and directorate Risk assessment training Board approved risk management policy 10) There is alignment between the recorded risks and what people say is ‘on their worry list’ Escalation routes Walk rounds Back to the floor Freedom to speak up Open door approach 11) Costed action plan Programme Bit about us to set the context Bit about PAM and how it works WSFT experience Resources

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