Board Assurance Framework Update Summary Report - November 2025
Meeting: Public Board Meeting
Date: 5 November 2025
Report Title: Board Assurance Framework (BAF) Update Summary Report
Agenda Item: PUB25/11/2.1
Author: Stanley Mukwenya, Deputy Director of Governance.
Lead Director: Hein Scheffer, Director of Strategy, Transformation and Governance
Purpose: Discussion / Review
Assurance: Reasonable
Link to CQC domain:
- Caring
- Responsive
- Effective
- Well-led
- Safe
Link to EEAST Strategic Mission:
- Patient Mission
- Partnership Mission
- People Mission
- Productivity Mission
Link to Strategic Risk:
- SR1 Demand and Capacity
- SR2 Quality Governance
- SR3 Infrastructure
- SR4 Finance and Resource
- SR5 Cyber Security
- SR6 System Partnership
- SR7 Workforce Sustainability
- SR8 Staff Retention
- SR9 Organisational Development
Equality Impact Assessment: No negative impact identified
Previously considered by: Executive Directors as part of monthly BAF reviews.
Purpose: The report seeks to provide the Board with an overview of changes to the strategic risks in the last quarter.
Recommendation:
- Review if controls and actions in place are adequate, with gaps identified.
- Check and challenge assurance sources provided if there are sufficient, duplicated or absent.
- Triangulate with other agenda items if they provide confidence on assurance, controls and actions
Executive Summary:
The Board Assurance Framework (BAF) identifies strategic risks ensuring systems and controls in place are adequate to mitigate any significant risk which may threaten the delivery of Trust strategic missions.
Whilst the Board of Directors delegates authority to its Board Assurance Committees to monitor assurance against its strategic risks, it is ultimately responsible for the oversight of the BAF and the committees are expected to escalate any significant assurance issues as they arise. There are currently ten strategic risks on the BAF, these are aligned to the Trust strategic missions
The Trust Board approved a new BAF format earlier this year which relies on the three lines of defence risk model demonstrating how the trust management and assurance functions operate and interact. The model shows the boundaries between different roles and responsibilities in the management and assurance of risks. This helps to avoid duplication and gaps in risk management, performance management, governance and control arrangements.
As a result, there has been significant improvement to the structure and presentation on controls, actions, sources of assurance on our BAF. However, refinement work remain ongoing ensuring sources of assurance/controls are supported by evidence and of high quality with no duplication in assurance and controls.
The format has clearly differentiated between controls and assurance and link between the gaps identified and the action plans as well as clarity on where the assurance is coming from.
Level 1 – Assurance obtained at departmental level Level 2 – Assurance obtained at organisational level i.e. supported by HR, Finance etc Level 3 – External assurance has been obtained through audit / inspection processes
Introduction / Background:
The Board Assurance Framework has been re-formatted taking into account recommendations from the internal auditors and looking at best practice in terms of format and content of a Board Assurance Framework. The Board agreed new missions 2025-26 and the BAF identifies and articulates the potential risks to delivery.
Our strategic risks are connected to our organisational vision and purpose, aligned with our four strategic missions and reinforced by our digital and estates strategic plans.
Description of text in image above:
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Top layer shows: Our vision and our purpose.
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Middle layer shows: People, Sustainability and Clinical Strategies,
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Bottom layer shows: Patient, People, Partnership, and Productivity Missions and Digital and Estates Strategic Plans
Changes to the BAF in the last Quarter and risks direction of travel Formerly Infrastructure strategic risk has been split into two stand alone risks re Estates (SR3) and Digital (SR10) There were no changes to the risk scorings in the last quarter. However, strengthening controls, actions and sources of assurance remain ongoing.
BOARD ASSURANCE FRAMEWORK DASHBOARD 2025/26
| BAF Risk | Committee | Exec Lead | 01/04/25 | Q1 | Q2 | Q3 | Q4 | Aspirational Target |
|---|---|---|---|---|---|---|---|---|
| SR1 Demand and Capacity | Performance Committee | COO | C4 x L4 16 (RED) | C3xL3 9 (AMBER) | C3xL3 9 (AMBER) | C3xL2 6 (GREEN) | ||
| SR2 Quality Governance | QGC | DoQ/MD | C4xL4 8 (RED) | C3xL3 6 (AMBER) | C3xL3 6 (AMBER) | C2xL2 4 (GREEN) | ||
| SR3 Estates | Finance and Sustainability | CFO | 01/10/25 C5xL4 (RED) | C4xL4 (RED) | C2xL2 4 (GREEN) | |||
| SR4 Finance and use of resource | Finance and Sustainability | CFO | C5xL5 20 (RED) | C4xL3 12 (AMBER) | C4xL3 12 (AMBER) | C4xL3 12 (AMBER) | ||
| SR5 Cyber security | Finance and Sustainability | DoDI | C5xL4 20 (RED) | C4xL3 12 (AMBER) | C4xL3 12 (AMBER) | C3xL3 6 (GREEN) | ||
| SR6 Partnership working | Performance Committee | DoST&G | C4xL4 16 (RED) | C3xL3 9 (AMBER) | C3xL3 9 (AMBER) | C2xL2 4 (GREEN) | ||
| SR7 Workforce sustainability | People Committee | CPO | C5xL4 20 (RED) | C3xL3 9 (AMBER) | C3xL3 9 (AMBER) | C2xL2 4 (GREEN) | ||
| SR8 Staff retention | People Committee | CPO | C4xL4 16 (RED) | C4xL3 12 (AMBER) | C4xL3 12 (AMBER) | C2xL2 4 (GREEN) | ||
| SR9 Organisational development | People Committee | CPO | C4xL4 16 (RED) | C4xL3 12 (AMBER) | C4xL3 12 (AMBER) | C3xL2 6 (GREEN) | ||
| SR10 Digital | Finance and Sustainability | DoDI | 01/10/25 C5xL4 (RED) | C4xL3 12 | C2xL2 4 (GREEN) |
**BOARD ASSURANCE FRAMEWORK Assurance Summary Map for October 2025 **
| Mission | Risk | Scores: Inherent | Scores: Current | Scores: Target | Operational oversight: Exec owner / control forum | Link to IPR: Input Metric | Link to IPR: Output Metric | Strategies / Long term plans | Committee oversight Committee / agenda item / level of assurance | Board oversight Agenda item |
|---|---|---|---|---|---|---|---|---|---|---|
| Patient Mission | SR1 Operational Effectiveness and demand and capacity | 16 (RED) | 12 (AMBER) | 6 (GREEN) | Transformation Programme Board Accountability reviews Performance Improvement delivery Group | OPIP measures | C1 response time C2 response time Hear and Treat rate On-scene time (non-conveyed) Patients seen per DSA Shift | |||
| SR2 Quality Governance | 16 (RED) | 9 (AMBER) | 4 (GREEN) | Risk and compliance Group Transformation Programme Board Accountability reviews Patient Safety and Experience Group Clinical Best Practice Group Medicines Management Group. Safeguarding Group. Infection Prevention and Control Group. Medical Devices Group. Regulated Provider Assurance Group. | Statutory Mandatory Training Regulatory improvements Clinical guidelines Clinical Innovations | Call Pickup Time ROSC - All ROSC - Utstein Survival to Discharge All – 30 Day Survival Survival to Discharge Utstein – 30 Day Survival ROSC Care Bundle Stemi Care Bundle Falls in Older People – Discharged At Scene Care Bundle | Clinical Strategy | Quality Governance Committee | IPR review Quality Governance Committee Annual Safeguard Report Infection Annual Report Regulatory Update Report Patient/Staff Story | |
| Productivity Mission | SR3 Estates | 20 (RED) | 16 (RED) | 4 (GREEN) | Capital Investment Group | 6-Facet Survey Estates QCIP Targets Disposal and acquisition of property | % change in Energy use compared to the same month in the previous year Asbestos Risk Compliance % | Sustainability Strategy Green Plan | Finance and Sustainability Committee | Infrastructure and Support Services Change Programme Board Green Plan Delivery |
| Productivity Mission | SR10 Digital | 20 (RED) | 12 (AMBER) | 4 (GREEN) | Digital Innovation Group Digital Quality and Safety Group Data Quality and Security Group | Operational KPIs monitoring TOM and value propositions Model System Data IT Score card Infrastructure review SASC collaboration Architecture model Asset Lifecycle process | Number of 999 CAD Patients Managed by Robotic Process Automation | Digital Strategy | Finance and Sustainability Committee | XXXX |
| Productivity Mission | SR4 Finance use of Resources | 25 (RED) | 12 (AMBER) | 12 (GREEN) | Capital Investment Group | QCIP | (Surplus)/Deficit Efficiency Savings | Annual Budget and Plan Year-end Forecast Finance Report and Cash Flow Forecast | Finance & Sustainability Committee | Finance and Sustainability Committee Capital development Financial statement and investment Finance report and cash flow forecast Corporate efficiency programme |
| Productivity Mission | SR5 Cyber security | 20 (RED) | 12 (AMBER) | 9 (AMBER) | Digital Innovation Group Digital Quality and Safety Group Data Quality and Security Group | Cyber penetration test and external audits. | Implementation of Cyber assurance framework | Digital Strategy | Finance and Sustainability Committee | DSPT outcome standards |
| Partnership mission | SR6 Partnership working | 16 (RED) | 9 (AMBER) | 4 (GREEN) | Monthly KPI Business Partnership meetings Regional UCCH standards group to be implemented | Reducing unnecessary Ambulance Dispatch | C3-C5 Dispatch (Attendance) Rate % (% of A7) (8am – 7pm) C3-C5 Conveyance Rate % (% of A7) (8am – 7pm) | Performance Committee | IPR | |
| People Mission | SR7 Workforce sustainability | 20 (RED) | 9 (AMBER) | 4 (GREEN) | Targeted plan for retention and Workforce Planning Group Staff Partnership Workforce Planning and Modelling Team development of protected characteristics | PSLT Metrics, ELT Inclusivity Plan Targeted plan for retention and development of protected characteristics | Staff Turnover Rate % | People Strategy Clinical Workforce & EOC Workforce Plans | People Committee | WRES, WDES & Gender Pay Gap national submissions |
| People Mission | SR8 Staff retention | 16 (RED) | 12 (AMBER) | 4 (GREEN) | Staff Health and Wellbeing Group Targeted plan for retention and Workforce Planning Group Staff Partnership | Staff Surveys | I would recommend my organisation as a place to work % Team Members often meet regularly to discuss the teams effectiveness. % | People Strategy People Strategy Year 3 Action Plan | People Committee | IPR Volunteer Assurance Report |
| People Mission | SR9 Culture and organisational development | 16 (RED) | 12 (AMBER) | 4 (GREEN) | OD Transformation Group Project Team Transformation Programme Group Change Programme Group Internal Recruitment Pathway Time to Lead Programme | Big Conversations Internal Recruitment Pathway | Declared Disability % BME Staff % LGB Staff % | Leadership Development Framework People Strategy | People Committee | Staff Survey Results and Action Plan Health & Safety Integrated Service Report |
