1. 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

2. 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

3. 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

4. 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

5. 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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