No Response Published
Link to recommendation 1
Recommendation · source text
Review the Audit Committee Terms of Reference against WG issued model Terms of Reference, other Health Board’s Audit Committee Terms of Reference and the NHS Wales Audit Committee Handbook for any further detail necessary to incorporate and to ensure there are no gaps
No Response Published
Link to recommendation 2
Recommendation · source text
Compile an annual Audit Committee Work Plan based on the enhanced Audit Committee Terms of Reference
No Response Published
Link to recommendation 3
Recommendation · source text
Healthcare Inspectorate Wales (HIW) and other regulatory body requirements to be explicitly included within Audit Committee’s Terms of Reference and annual Work Plan
No Response Published
Link to recommendation 4
Recommendation · source text
To ensure that all Board level Committees Terms of Reference are reviewed and presented to the Board annually for approval, rather than through Audit Committee
No Response Published
Link to recommendation 5
Recommendation · source text
Consider removing the requirement for a third Officer Member on Audit Committee i.e. the Deputy Chief Executive/Executive Director of Nursing and Midwifery, or identifying them in those ‘invited to attend’ within the Terms of Reference
Addressed to: BCUHB
No Response Published
Link to recommendation 6
Recommendation · source text
Consider removing the specific right of attendance to Audit Committee meetings for the Chair of BCUHB, in light of conflicting guidance within the NHS Wales Audit Committee Handbook
No Response Published
Link to recommendation 7
Recommendation · source text
Consider increasing Audit Committee meetings to a bi-monthly frequency to align with the Board’s cycle of business and to avoid any gaps in assurance
No Response Published
Link to recommendation 8
Recommendation · source text
Review the Quality, Safety and Experience Committee Terms of Reference against WG issued model Terms of Reference, other Health Board’s Quality and Safety Committee Terms of Reference and the NHS Wales Quality and Safety Committee Handbook for any further detail necessary to incorporate and to ensure there are no gaps (the review will need to take account of assurances required in respect of the new Duties of Quality and Candour)
No Response Published
Link to recommendation 9
Recommendation · source text
Compile an annual Quality, Safety and Experience Committee Work Plan based on the enhanced Quality, Safety and Experience Committee Terms of Reference
Addressed to: BCUHB
No Response Published
Link to recommendation 10
Recommendation · source text
In light of any current risks or concerns with health and safety issues across BCUHB, determine whether scrutiny of health and safety can be properly undertaken through a Committee with an already significant quality and safety agenda, and if it is considered that this would make the remit of the Quality, Safety and Experience Committee un-manageable, consider the establishment of a separate Health & Safety Committee for BCUHB
No Response Published
Link to recommendation 11
Recommendation · source text
Should a separate Health and Safety Committee be established, to consider placing emergency preparedness within this Committee’s remit given its natural alignment with health and safety
No Response Published
Link to recommendation 12
Recommendation · source text
Consider rationalising the number of Executive Directors in the formal membership of the Quality, Safety and Experience Committee, and identifying them instead for those ‘invited to attend’ within the Terms of Reference, taking into account the matters under consideration at each meeting
No Response Published
Link to recommendation 13
Recommendation · source text
Consider removing the two delegated powers, paragraphs 3.2.6 ‘To determine any new awards in respect of Primary Care contracts.’ and 3.4.2 ‘….to consider and determine any proposals from the Primary Care Panel (via the Executive Team) in relation to whether the Health Board should take on responsibility for certain GP Practices.’, and reserve these to the Board
No Response Published
Link to recommendation 14
Recommendation · source text
Remove paragraph 3.6 in the Terms of Reference ‘Approval on the Board’s behalf of business cases up to £1,000,000.’
No Response Published
Link to recommendation 15
Recommendation · source text
Review the Performance, Finance and Information Governance Committee’s Terms of Reference against other Health Board’s Committees with a similar remit for any further detail necessary to incorporate and to ensure there are no gaps
No Response Published
Link to recommendation 16
Recommendation · source text
Compile an annual Performance, Finance and Information Governance Committee Work Plan based on the enhanced Performance, Finance and Information Governance Committee Terms of Reference
No Response Published
Link to recommendation 17
Recommendation · source text
Consider rationalising the number of Executive Directors in the formal membership of the Performance, Finance and Information Governance Committee, and identifying them instead to those ‘invited to attend’ within the Terms of Reference, taking into account the matters under consideration at each meeting
No Response Published
Link to recommendation 18
Recommendation · source text
Review the Partnerships, People and Population Health Terms of Reference against other Health Board’s Committees with a similar remit for any further detail necessary to incorporate and to ensure there are no gaps
No Response Published
Link to recommendation 19
Recommendation · source text
Compile an annual Partnerships, People and Population Health Committee Work Plan based on the enhanced Partnerships, People and Population Health Committee Terms of Reference
No Response Published
Link to recommendation 20
Recommendation · source text
Consider delegating approval of appointments made by the Advisory Appointments Committee from the Board to the Partnerships, People and Population Health Committee
No Response Published
Link to recommendation 21
Recommendation · source text
Consider rationalising the number of Executive Directors in the formal membership of the Partnerships, People and Population Health Committee, and identifying them instead to those ‘invited to attend’ within the Terms of Reference, taking into account the matters under consideration at each meeting
No Response Published
Link to recommendation 22
Recommendation · source text
Review the Mental Health Compliance and Capacity Committee Terms of Reference against the Terms of Reference of other Health Boards that cover the Mental Health Act requirements for any further detail necessary to incorporate and to ensure there are no gaps
No Response Published
Link to recommendation 23
Recommendation · source text
Compile an annual Mental Health Compliance and Capacity Committee Work Plan based on the enhanced Mental Health Compliance and Capacity Committee Terms of Reference
No Response Published
Link to recommendation 24
Recommendation · source text
Consideration to be given to including the term ‘Act’ in the title of the Mental Health and Compliance Committee, and elsewhere within the Terms of Reference, where relevant
No Response Published
Link to recommendation 25
Recommendation · source text
Remove paragraph 3.2.13 Approve the appointment of Associate Hospital Managers from the Mental Health Capacity and Compliance Committee’s Terms of Reference if this is not a role for the Committee
No Response Published
Link to recommendation 26
Recommendation · source text
Consider rationalising the membership of the Mental Health and Capacity Compliance Committee to ensure the most appropriate representation required, identifying any not considered to be core officer members for those ‘invited to attend’, taking into account the matters under consideration at each meeting
No Response Published
Link to recommendation 27
Recommendation · source text
Include the Hospital Manager’s Power of Discharge Group as a formal Sub-Committee of the Mental Health and Capacity Compliance Committee to allow freer discussion on more sensitive areas away from the public domain
No Response Published
Link to recommendation 28
Recommendation · source text
Amend ‘Depravation of Liberty reports’ to ‘Deprivation of Liberty reports’
No Response Published
Link to recommendation 29
Recommendation · source text
Amend this sentence to read … ‘concerning mental health compliance and capacity matters.’
No Response Published
Link to recommendation 30
Recommendation · source text
Consider removing the Committee’s two delegated powers to ‘consider reports where exclusion in respect of Upholding Professional Standards in Wales (UPSW) has lasted more than 6 months’; and to ‘consider reports on the progress of performers list regulatory cases’, and attribute these to the (In Committee) Board.
Addressed to: BCUHB
No Response Published
Link to recommendation 31
Recommendation · source text
In light of the above, remove reference to UPSW as a delegated matter to the Remuneration and Terms of Service Committee in BCUHB’s Scheme of Reservation and Delegation of Power
No Response Published
Link to recommendation 32
Recommendation · source text
Consider removing the Committee’s delegated powers to consider reports on the position in regard to whistleblowing; and Speaking Out Safely, and attribute these to a more appropriate Committee
No Response Published
Link to recommendation 33
Recommendation · source text
Amend paragraph 3.2 to reflect WG issued model Remuneration and Terms of Service Committee Terms of Reference i.e. approve, on behalf of the Board, the remuneration and terms of service for the Chief Executive, Executive Directors and other senior staff within the framework set by Welsh Government
No Response Published
Link to recommendation 34
Recommendation · source text
Remove paragraph 4.3 ‘Approval of interim appointments at Band 9 or above where the proposed pay point exceeds 20% of the top of the established banding.’
Addressed to: BCUHB
No Response Published
Link to recommendation 35
Recommendation · source text
Reference to the ‘Approval of acting up salaries for interim Executive Directors to be retained by Remuneration and Terms of Service Committee’ will also need to be removed from BCUHB’s Scheme of Reservation and Delegation of Powers (under 10f - Personnel and Pay)
No Response Published
Link to recommendation 36
Recommendation · source text
Review the Remuneration and Terms of Service Committee’s Terms of Reference against other Health Board’s Committees with a similar remit for any further detail necessary to incorporate and to ensure there are no gaps
No Response Published
Link to recommendation 37
Recommendation · source text
Compile an annual Remuneration and Terms of Service Committee Work Plan based on the enhanced Remuneration and Terms of Service Committee Terms of Reference
No Response Published
Link to recommendation 38
Recommendation · source text
Consider reducing the Officer membership to two, dependent on whether removal of the delegated powers in respect of UPSW and performers list regulatory cases from the Committee’s Terms of Reference is agreed
No Response Published
Link to recommendation 39
Recommendation · source text
Remove reference to ‘Assembly’ in the term Welsh Assembly Government in the first bullet point of paragraph 2.1
No Response Published
Link to recommendation 40
Recommendation · source text
Remove reference to the NHS Wales Quality and Safety Committee Handbook in the third bullet point of paragraph 9.1
No Response Published
Link to recommendation 41
Recommendation · source text
Consider reducing the frequency for ‘receiving reports for ratification from the Executive Director of Finance, and to make and enact investment decisions taken’ to twice a year, in line with other Health Boards Charitable Funds Committees
No Response Published
Link to recommendation 42
Recommendation · source text
Consideration to be given to removing the requirement for Independent Members to hold the majority of votes at a meeting if it is not a necessary requirement
No Response Published
Link to recommendation 43
Recommendation · source text
Remove the term ‘approve’ from paragraph 3.1.6 to read ‘Receive and scrutinise the Charity’s Annual Report and Accounts on behalf of the Board’
No Response Published
Link to recommendation 44
Recommendation · source text
Replace reference to the Charities Act 1993 and 2006 with the ‘Charities Act 2011’
No Response Published
Link to recommendation 45
Recommendation · source text
Replace reference to the Charity Commissioner with the ‘Charity Commission’
No Response Published
Link to recommendation 46
Recommendation · source text
Re-word paragraph 4.1.3 along the lines of ‘… banking arrangements for charitable funds should be kept entirely distinct from BCUHB’s NHS funds’
No Response Published
Link to recommendation 47
Recommendation · source text
Re-word paragraph 4.1.4 along the lines of ‘Ensure that arrangements are in place to maintain current account balances at minimum operational levels consistent with meeting expenditure obligations, the balance of funds being invested in interest bearing deposit accounts’
No Response Published
Link to recommendation 48
Recommendation · source text
Remove reference to the NHS Wales Quality and Safety Committee Handbook
No Response Published
Link to recommendation 49
Recommendation · source text
Review the Charitable Funds Committee’s Terms of Reference against other Health Board’s Committees with a similar remit for any further detail necessary to incorporate and to ensure there are no gaps
No Response Published
Link to recommendation 50
Recommendation · source text
Compile an annual Charitable Funds Committee Work Plan based on the enhanced Charitable Funds Committee Terms of Reference
No Response Published
Link to recommendation 51
Recommendation · source text
Version control should be explicit in each Committees’ Terms of Reference on either the front or last page and in the footer to ensure latest version
No Response Published
Link to recommendation 52
Recommendation · source text
Consider inclusion of a structural diagram in each Committees Terms of Reference to aid understanding of the hierarchical flow of information and assurance
No Response Published
Link to recommendation 53
Recommendation · source text
Ensure the Executive Delivery Groups, Executive Management Groups and Tactical Delivery Groups that support each Committee are clearly identified within their Terms of Reference and structural diagram, and ensure timing of their meetings coincide with an appropriate flow of assurance to their nominated Committee
No Response Published
Link to recommendation 54
Recommendation · source text
Include the authority to hold private (In Committee) meetings in the Committees Terms of Reference
Addressed to: BCUHB
No Response Published
Link to recommendation 55
Recommendation · source text
Consider increasing the number of Independent Members on each Committee, once BCUHB’s Independent Member cohort is up to full complement
No Response Published
Link to recommendation 56
Recommendation · source text
Re-consideration to be given to the Chair of the Board attending all Board level Committees to maintain their independence
No Response Published
Link to recommendation 57
Recommendation · source text
Re-consideration also to be given to the Audit Chair attending all Board level Committees to maintain their independence
Addressed to: The Board Secretary
No Response Published
Link to recommendation 58
Recommendation · source text
The Board Secretary to consider attending all Board level Committees for any governance advice and support that may be required, and to maintain oversight of the governance of the Board and the Committee arrangements, enabling a strategic view of corporate governance to be held
No Response Published
Link to recommendation 59
Recommendation · source text
The routine attendance of Trade Union partners at Board level Committees could be reviewed for appropriateness, although this may not be necessary if all Committee meetings are to be live-streamed going forward
No Response Published
Link to recommendation 60
Recommendation · source text
Consider increasing the quoracy of Independent Members and include a third or a half of the Officer membership in quoracy requirements
No Response Published
Link to recommendation 61
Recommendation · source text
Consider removing the time limit on Independent Members serving on Board Committees if it is not necessary
No Response Published
Link to recommendation 62
Recommendation · source text
Consider generalising the delegated power to assure the Board that there is compliance with the Equalities Act 2010, the Public Sector Equality Duty and the Socio-Economic Duty
No Response Published
Link to recommendation 63
Recommendation · source text
Consider removing those standard delegated powers from Committee Terms of Reference which are not relevant, and where these are relevant, ensure they feature on the Committees annual Work Plans
No Response Published
Link to recommendation 64
Recommendation · source text
Review the Committee Terms of Reference to attribute the terms ‘Health Board’s’ and ‘Boards’ more appropriately
No Response Published
Link to recommendation 65
Recommendation · source text
Remove reference to the Annual Quality Statement and the Annual Governance Statement and replace with the accountability report in paragraph 3.2.1 of the Audit Committee Terms of Reference and paragraph 3.2.8 of the Quality, Safety and Experience Terms of Reference
No Response Published
Link to recommendation 66
Recommendation · source text
Consider truncating the statement ‘The requirement for the conduct of business as set out in the Standing Orders are equally applicable to the Committee except in the following areas – Quorum’ to read ‘The requirement for the conduct of business as set out in the Standing Orders are equally applicable to the Committee.’
No Response Published
Link to recommendation 67
Recommendation · source text
Review the Local Partnership Forum’s Terms of Reference to ensure their compliance against WG issued model Terms of Reference for Advisory Groups and to ensure their continued authority to meet
No Response Published
Link to recommendation 68
Recommendation · source text
Review the Stakeholder Reference Group’s Terms of Reference to ensure their compliance against WG issued model Terms of Reference for Advisory Groups and to ensure their continued authority to meet.
No Response Published
Link to recommendation 69
Recommendation · source text
Review the Healthcare Professionals Forum’s Terms of Reference to ensure their compliance against WG issued model Terms of Reference for Advisory Groups and to ensure their continued authority to meet.
No Response Published
Link to recommendation 70
Recommendation · source text
Items requiring approval and/or decision should be identified within Board and Committee Work Plans and care should be taken to align these items with Board and Committee meeting timescales to ensure only minimal use is made of Chair’s Action
No Response Published
Link to recommendation 71
Recommendation · source text
Consideration to be given to the CEO providing a briefing to the Audit Committee on a regular basis on the progress made with Special Measures
No Response Published
Link to recommendation 72
Recommendation · source text
Consider convening inaugural ‘business’ meetings for the Partnerships, People and Population Health Committee, the Mental Health and Capacity Compliance Committee, and the Charitable Funds Committee, to aid their reinstatement and ensure appropriate governance is in place
No Response Published
Link to recommendation 73
Recommendation · source text
Issue, with immediate effect, the Corporate Calendar up until March 2024 and ensure each subsequent annual version is prepared 6 months in advance
No Response Published
Link to recommendation 74
Recommendation · source text
A conversation to be held with the Executive lead for Welsh Language in regard to the extent of Welsh translation required according to BCUHB’s Welsh Language Standards, and compared to the rest of Wales
Addressed to: Executive Team
No Response Published
Link to recommendation 75
Recommendation · source text
Provide any Board and Committee agenda setting notes that are captured to Executive Team to ensure that reports to be produced are fully understood and meet the expectations required
No Response Published
Link to recommendation 76
Recommendation · source text
Develop and implement a comprehensive Standard Operating Procedure for the Management of Board and Committees
Addressed to: BCUHB
No Response Published
Link to recommendation 77
Recommendation · source text
Consider the introduction of a Standard Operating Procedure for Governance Arrangements at BCUHB to set out the standards of what is expected from those charged with governance, and those who are required to comply
No Response Published
Link to recommendation 78
Recommendation · source text
To re-introduce the discipline of Corporate Distribution Lists that are centrally updated and that all can have a confidence in
Addressed to: Office of Board Secretary
No Response Published
Link to recommendation 79
Recommendation · source text
A definitive list of Special Advisors to be shared across the Office of Board Secretary with the information that they receive to be limited to the purposes of their appointment
Addressed to: BCUHB
No Response Published
Link to recommendation 80
Recommendation · source text
To review the decision to extend the requirement to complete a declaration of interest to all staff within BCUHB in light of best practice elsewhere
No Response Published
Link to recommendation 81
Recommendation · source text
Review the management of WHCs and Ministerial Directions to ensure these are tracked through Committees in terms of the compliance achieved against each for onward assurance to the Board
No Response Published
Link to recommendation 82
Recommendation · source text
Consider moving reference to the BCU information e-mail address ’bcu.info@wales.nhs.uk’ further down the current webpage to reduce the number of inappropriate enquiries received through this route.
Addressed to: BCUHB
No Response Published
Link to recommendation 83
Recommendation · source text
In addition, to consider transferring the management of the BCU information in-box to either the BCUHB Communications Team, or the Information Governance Team given its links with FoI requests.
Addressed to: BCUHB
No Response Published
Link to recommendation 84
Recommendation · source text
Consider transferring out from the Office of Board Secretary to a more appropriate department, the functions of the Honours nominations/co-ordination/research to BCUHB’s Communications Team, and the operational co-ordination of international health partnerships/ International Health Group secretariat and chairing, to the Partnerships Directorate
No Response Published
Link to recommendation 85
Recommendation · source text
To consider reversing the current process in place for the management of the Common Seal in order that checks to ensure that all required documentation is appropriate to be undertaken prior to any register preparation, signature sourcing and sealing applied
Addressed to: BCUHB
No Response Published
Link to recommendation 86
Recommendation · source text
Review the financial limits for spend on external consultancy within BCUHB’s Scheme of Financial Delegation to ensure it mirrors other Health Boards and complies with any limit set out in Standing Financial Instructions
No Response Published
Link to recommendation 87
Recommendation · source text
Careful consideration to be given to the responsibilities and accountabilities within the vacant Deputy Board Secretary role,
No Response Published
Link to recommendation 88
Recommendation · source text
To review Job Descriptions, particularly where standard versions are in place, to ensure these are matched to defined roles
Addressed to: Office of the Board Secretary
No Response Published
Link to recommendation 89
Recommendation · source text
To programme in a piece of work to address the culture of the Office of the Board Secretary, to address any current/previous tensions, and to build the team going forward
Addressed to: Office of the Board Secretary
No Response Published
Link to recommendation 90
Recommendation · source text
To consider referring appropriate members of the Office of the Board Secretary to staff wellbeing/occupational health, or to support staff to self-refer to these services
No Response Published
Link to recommendation 91
Recommendation · source text
To offer minute-taking training to those members of the team who may need to undertake this function going forward
No Response Published
Link to recommendation 92
Recommendation · source text
To craft a Board paper – ‘Achieving Good Governance/Re-setting of Governance’ (the ‘Betsi Way’) in time for the September 2023 Board meeting to include: o revised Terms of Reference for all Committees and Workplans o an annual Schedule of Meetings (Corporate Calendar) up until March 2024 o reviewed Standing Orders, Standing Financial Instructions, Scheme of Delegation o a proposed structure for the Office of the Board Secretary
Addressed to: The Board Secretary
No Response Published
Link to recommendation 93
Recommendation · source text
To establish 7 or 8 key/fundamental objectives for the Board Secretary focused on governance which will need to align with their 90 Day Special Measures Outcomes/Deliverables i.e. o Refresh Committee Terms of Reference o Embed Special Measures into all Committees o Complete recruitment into Independent Member roles (temporary) o Implement phase 1 induction for all Board members o Develop Phase 1 Board Development Programme o Establish Board Committees o Complete Committee Induction o Development of Committee Work Plans Once the more governance related objectives have been addressed, focus can move to the remaining 90 Day Special Measures Deliverables i.e. o Commence review and revision of risk appetite and approach o Commence plan for the recruitment of a permanent Board Secretary o Including progressing the recruitment of the permanent Chief Executive o Develop and commence implementation of an assurance approach for the Special Measures response including the implementation of an organisational Maturity Matrix
No Response Published
Link to recommendation 94
Recommendation · source text
Review the Policy for the Management of Health Board Wide Policies, Procedures and other Written Control Documents with a view to getting this approved as soon as possible
No Response Published
Link to recommendation 95
Recommendation · source text
Review the policy management arrangements, establishing/re-establishing a structure underneath the management of policies (rather than a role) particularly in terms of the review of clinical policies, workforce policies, etc, with only ‘corporate’ policies requiring approval through Board level Committees (ideally Sub-Committees)
No Response Published
Link to recommendation 96
Recommendation · source text
Consider moving approval levels to an appendix within the Policy for the Management of Health Board Wide Policies, Procedures and other Written Control Documents to enable the policy to be updated more easily should approval levels need to change
No Response Published
Link to recommendation 97
Recommendation · source text
Prioritise work on the audit tracker to ensure it is maintained and captures the organisation’s compliance against the full range of external regulatory requirements to provide an appropriate level of assurance to Audit Committee on the progress of recommendations in accordance with agreed timescales
Addressed to: Communications Team
No Response Published
Link to recommendation 98
Recommendation · source text
Consider a review of the resource in place (2 x Band 7, 1 x Band 4) within the Communications Team to deal with MSs and MPs emails/correspondence i.e. 25 letters a week
No Response Published
Link to recommendation 99
Recommendation · source text
Determine where the substantive Covid-19 support for the Public Inquiry will fit within the organisation and whether this will be within the Office of the Board Secretary going forward
No Response Published
Link to recommendation 100
Recommendation · source text
To consider proposals for what should or could be included within the role of the Board Secretary
No Response Published
Link to recommendation 101
Recommendation · source text
To ensure the organisation’s compliance with model Standing Orders in respect of, for example, Chair’s Action, Common Seal, etc through the introduction of prescribed processes and procedures
No Response Published
Link to recommendation 102
Recommendation · source text
To ensure Executive Directors and Independent Members who necessarily need to comply with professional requirements in order to occupy their office have this explicitly documented within their Declarations of Interests
No Response Published
Link to recommendation 103
Recommendation · source text
To review the wider Board member complement to ensure compliance with The Local Health Boards (Constitution, Membership and Procedures (Wales) Regulations 2009
No Response Published
Link to recommendation 104
Recommendation · source text
To facilitate a conversation with the CEO regarding expectancies around Executive Directors and holding them to account for their role within governance