SELF-EVALUATION GUIDE for assessing governance in voluntary organisations who provide social care in Scotland

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1 SELF-EVALUATION GUIDE for assessing governance in voluntary organisations who provide social care in Scotland

2 SELF-EVALUATION GUIDE for assessing governance in voluntary organisations who provide social care in Scotland Social Work Inspection Agency, 2008

3 Crown copyright 2008 ISBN: Social Work Inspection Agency (SWIA) Ladywell House Ladywell Road Edinburgh EH12 7TB Produced for the Social Work Inspection Agency by RR Donnelley B /08 Published by the Social Work Inspection Agency, November 2008 Further copies are available from Social Work Inspection Agency Ladywell House Ladywell Road Edinburgh EH12 7TB Telephone: Fax: The text pages of this document are printed on recycled paper and are 100% recyclable

4 CONTENTS Page Foreword 01 What is governance? 02 Who is this guide for? 03 Why evaluate governance? 04 The self-evaluation process 06 Deciding what to evaluate 08 How to gather evidence 10 How to evaluate the evidence 11 Reporting the findings 13 Implementing action 14 Monitoring progress 15 Next steps 16 Appendix One: Areas for evaluation 18 Appendix Two: Sample self-evaluation report 28 Appendix Three: Sample improvement plan 40 Appendix Four: Gathering the views of service users, staff and stakeholders 42

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6 Foreword This guide aims to assist voluntary organisations delivering social care services to self assess and then plan to improve their governance arrangements where needed. It was developed following a review of governance we did with Turning Point Scotland, at their request. Self-evaluation models are being used more and more by different organisations to improve service performance and the quality of life for people who use services. It is entirely optional whether an organisation might use this guide. We have designed it so that it can be used in part, or as a whole, depending on the needs of the organisation. Some areas could be the subject of a review one year, and others in the next year. The guide can be used alongside other evaluation and improvement processes the organisation may already have in place. It suggests using a range of information an organisation may already have available to provide evidence of what is working well and what areas need to be improved. To be effective as a guide, it is important that the boards of organisations support the process and are willing to act on the conclusions the evaluation reaches. I hope that this guide will provide a welcome addition to the tools already available to support the voluntary social care sector in the process of continuous improvement. Alexis Jay Chief Social Work Inspector Social Work Inspection Agency 1

7 What is governance?... the systems and processes concerned with ensuring the overall direction, effectiveness, supervision and accountability of an organisation. 1 Governance of a voluntary and community organisation includes: Creating a clear, shared vision. Formulating plans and policies to bring about the organisation s objectives. Maintaining a sense of urgency about the vision. Recruiting and supervising the chief executive officer. Ensuring compliance with policy and the law. Keeping within budget. Governance is about the whole system that enables an organisation to make effective decisions. The board of directors (or trustees) has ultimate responsibility for these areas, to ensure the organisation delivers good outcomes for the people it has been set up to serve. The senior officers of the organisation are charged with carrying out the operations, measuring and demonstrating the impact of services and actively reporting this back to the board. 1 Good Governance: A Code for the Voluntary and Community Sector. The Governance Hub

8 Who is this guide for? This guide is for any voluntary organisation providing social care in Scotland that wants to critically self-evaluate its own arrangements for governance. It can be used by small as well as large organisations, in any way that suits the needs of that particular organisation. However, to do this an organisation needs a board and a staff group who are willing and committed to a process of continuous improvement to better serve those with whom they work. 3

9 Why evaluate governance? In the last thirty years good governance has become increasingly important for organisations to demonstrate in both the private and public sectors. This is in part so that external stakeholders can be confident that an organisation is accountable and acts in a transparent way for the benefit of those it serves. However, it also allows the organisation to know it is operating in the most effective way possible and making the best use of all its resources. There have been three key pieces of work over these years that have pointed to what boards of voluntary organisations must pay attention to. First, Lord Nolan, while chairing the Committee on Standards in Public Life in the 1990s set out what are now commonly referred to as the Nolan principles. These were originally designed for those working in the public or governmental sector, but they have since been widely adopted and have been seen to have relevance across the voluntary and charitable sector. The seven principles are: Selflessness Integrity Objectivity Accountability Openness Honesty Leadership. Secondly, the Governance Hub in 2005 published Good Governance: A code for the voluntary and community sector. Drawing on the Nolan principles, this code identified seven principles of governance in the voluntary and community sector: Board leadership The board in control High performance board Board review and renewal Board delegation Board and trustee integrity Board openness. 4

10 Thirdly, the Office of the Scottish Charity Regulator (OSCR) published in 2006 Guidance for Charity Trustees: Acting with due care and diligence. This guide was written to support trustees of charities to help them understand what was expected of them. It identified four core responsibilities of charity trustees; to act in the interest of the charity; to operate in a manner consistent with the charity s purpose; to act with due care and diligence; and to ensure the charity complies with the provisions of relevant legislation. This guide has been informed by these principles and from what SWIA learnt from reviewing the governance arrangements in Turning Point Scotland. 2 It also uses the experience SWIA has gained from doing performance inspections of local authority social work services across Scotland. 2 In 2007 SWIA was invited by Turning Point Scotland to undertake an independent review of its governance arrangements. This was published as a report in December 2007 and is available on the SWIA website. 5

11 The self-evaluation process Self-evaluation includes six distinct phases: 1. Deciding what to self-evaluate 2. Evidence gathering 3. Evaluating that evidence 4. Reporting the findings 5. Implementing action 6. Monitoring progress. However, the self-evaluation is not an end in itself and should be seen as part of a cyclical improvement process. Initial self-evaluation, identifying and prioritising areas for action and targeted improvement. Reviewing progress against action plan, and initiating new self-evaluation cycle. Finalise targeted improvement plan based on evidence provided by initial self-evaluation. There are different ways that the organisation could do this. Your organisation could decide to use your own staff and resources to co-ordinate and undertake the work. The advantages of this are that you can directly oversee the whole process and respond quickly to issues as they arise. You will be aware of the time commitments that are required and therefore alter, where necessary the resources committed. However, the challenge will be making sure that the evidence is rigorously scrutinised to ensure that it is as fairly evaluated as possible. It is inevitable that staff and board members will have their own views as to how an organisation is doing, however, this process is about making sure that this is confirmed by the evidence gathered. 6

12 Your organisation could decide to pay an external consultant to come and assist you in doing this work. The advantages with this approach would be that the consultant would provide an independent voice in looking at and understanding the evidence available. It would also mean that staff would not need to add this responsibility to their existing commitments. However, staff will still need to give time to providing and making sense of the evidence. The challenge with this approach is the additional explicit cost this adds to the organisation. The person is also unlikely to know the detail of your organisation and may therefore take more time to become familiar with it. Your organisation could decide to pair up with another voluntary organisation to consider a peer review exercise. This would mean identifying another organisation that would be prepared to work with you and provide an external verification of your governance processes. You may want to ask the other organisation to undertake the whole or part of this process for you. There are a number of key issues that you would need to consider in doing this: Are you of a similar size and purpose? What issues does this raise? How will you address these? Given possible conflicts of interest would it be better working with an organisation offering services in a completely different field? Are you offering to work together and evaluate each other? How will you manage issues of confidentiality? How will you manage financially sensitive information? For instance where you may be/have been in competition for funding? How will you recompense each other, if at all? What kind of agreement will you need to manage and guarantee the work? How will you address any problems that arise through the process? The advantages of this approach include being able to have an external evaluator consider the evidence, as outlined above. However, additional benefits would come from the experience of working with another voluntary organisation including shared learning and the fact that they would have a good understanding of the contextual issues that affect the voluntary sector. The challenge of this approach would be finding a way to deal with the questions raised above. Whichever way it is undertaken the process itself must be one that is fully led and supported by the board. The board must set the parameters of the evaluation (see next page), the timeframes and regularly review and monitor the process. Most importantly, the board must take ownership of the findings of the self-evaluation and commit to acting on them. 7

13 1. DECIDING WHAT TO EVALUATE This guide identifies five high level areas for evaluation: Openness Integrity Accountability Leadership Board in control. These five areas lead to five key questions the organisation needs to ask itself: How open is our board of directors and our organisation? Does our board of directors operate with integrity? How accountable is our board of directors? How good is our board leadership? Is our board of directors in control? This guide suggests key factors which are standards of good practice to look for when evaluating each area. There are also key questions for the organisation to ask itself which help identify the evidence needed and a list of possible sources of that evidence. These are all outlined in the table in appendix one. Evidence should be gathered against each area for evaluation and it is recommended that the organisation rates itself on each area using a given scale. There is likely to be overlap between these five areas for evaluation. Evidence to support a key factor in one area may also be used to support a key factor in another. Where this is the case, users of the framework should make it clear how one piece of evidence supports more than one evaluation area and/or key factor. In particular, the section on board in control is aimed at ensuring that the board is clear that it is ultimately responsible for the governance of its organisation. There is therefore significant overlap between this section and all the other areas of evaluation. It is important to state that it is up to the board how it wants to look at these five areas. The guide is designed to be used flexibly, and each of the five areas can be considered in their own right. In part this decision will inevitably be informed not only by what priorities the organisation identifies but also on the resources it has available to undertake this work. 8

14 As a first step the board needs to take an overview of these five areas and decide what it believes to be the most important areas to be addressed, based on high level information it has available. The information that might be considered would include: Annual reports Business plan Financial accounts Any future changes in board membership Any future changes in senior officers Any significant feedback from users of the service, partner organisations, including funders and/or staff Any significant changes in policy in the area in which the organisation operates. The board then needs to decide how it is going to approach the work. Questions to consider will include: Do we need to do all five areas at the same time? Can we prioritise? What should we prioritise? What resources do we have available? Do we need help to do this? Who would help us to do this? How will we support this work? What is the timeframe we want to work to? How will this work be reported to us? The board may find it beneficial to use project management skills to draw up and oversee the process. The board may also want to identify one of its members as a sponsor for the work. This will enable the work to be co-ordinated more easily, and if an external consultant or peer review process is used, offer a single point of contact. If the organisation decides to prioritise certain areas, it needs to develop a long term strategic approach to considering all the areas for evaluation over a three- to five-year timescale. This will ensure that a whole picture is developed of the strengths of the governance arrangements of the organisation. 9

15 2. HOW TO GATHER EVIDENCE In this section we suggest how your organisation could gather evidence to demonstrate performance in each of the five areas for evaluation. The organisation could choose to use some or all of these suggested sources of evidence depending on how the model is used. However, it is important to collect data from more than one source where possible. You will have more confidence in your assessment if findings from an initial source of evidence are backed up by another and corroborated by a third line of enquiry. This strengthens the findings of the analysis and evaluation. We talk more about this in the next section. Good assessments rely on both quantitative and qualitative evidence gathered in a variety of ways, for example: Surveys of staff, stakeholder, and service user questionnaires. 3 Review of organisational and board procedures and other evidence 4 to critically review content. Interviews with board members, key staff members and service users. Appendix one contains a list of sources of evidence that could be used to illustrate the key factors for the areas for evaluation. This is not intended to be exhaustive or prescriptive and not all organisations will have all of these. When asking questions of board members and staff, the questions should be focused on the areas for evaluation. Some stakeholders may be able to comment more on some areas than on others this should be taken into account when interviewing. For example, the board chair should be able to answer detailed questions about how the board functions, whereas from a staff member you may only be looking for what level of awareness they had of the board and its purposes. Appendix four provides some core advice about how you might undertake surveys or interviews with services users, staff and stakeholders to gain the information needed Appendix four provides some general guidance on gathering the views of staff, service users and stakeholders. 4 Other evidence could include board meeting minutes, subcommittee minutes, and recent evaluations of programmes or events with stakeholders (see appendix one for more examples).

16 3. HOW TO EVALUATE THE EVIDENCE All evidence should be scrutinised to test how well it supports the key factors. Where there is room for improvement, this should be noted. Where good practice is identified this should also be noted. As already stated evidence that is used in reaching any conclusions should come from at least two different sources, preferably three. For instance you may have a policy document that states that the board is going to ensure that service users have a say on how services are provided. Staff might also tell you of a number of meetings they have had with users to hear their views. A third source of evidence may be that service users themselves, in focus groups or interviews, may tell you that this has really changed and they can see how their ideas are taken seriously. From these three sources you could be certain that the policy you had agreed was being implemented and making a difference. You may feel that this might illustrate some good practice within your organisation, perhaps that other areas of the service might benefit or learn from. You may find that you do not have sufficient evidence to be able to draw any specific conclusions on a particular issue. This may be lead you to make a recommendation to ensure that evidence start to be regularly gathered in the future. Service user feedback is often a good example of this; staff may hear what users are telling them most working days, but it is perhaps not collated in a meaningful way for the organisation as a whole to use. Evidence may point you towards a clear gap in your governance arrangements. If this is the case then you will need to think about making a recommendation about how to address this. This is explored further in the next section. It is useful to grade your evaluation in order to help you and the readers of your report to understand what your overall impression of the evidence is. It will also help you to benchmark your organisation against other organisations. HMIE, SWIA and the Care Commission all use a six-point evaluation scale in their inspections. This grading scale is suitable for use in the context of this guide too, as it can help to develop a sense of improvement and progress when used over time. Users of this guide may wish to develop or adopt another scale, as required. LEVEL DEFINITION DESCRIPTION Level 6 Excellent Excellent or outstanding Level 5 Very good Major strengths Level 4 Good Important strengths with some areas for improvement Level 3 Adequate Strengths just outweigh weaknesses Level 2 Weak Important weaknesses Level 1 Unsatisfactory Major weaknesses 11

17 An evaluation of excellent will apply to governance arrangements that are a model of their type: Board performance will be of a very high quality. They will be of an outstanding standard which exemplifies the very best. This standard of practice will be worth disseminating across the sector. It will imply that this very high level of performance is sustainable and will be maintained. An evaluation of very good will apply when there are major strengths: There will be very few areas for improvement and any that do exist do not significantly diminish the strengths. Strength will completely outweigh weakness, but there will be clear areas where things can get better. It is a highly achievable standard that all should attain. Arrangements may continue as are. However, there should be an intention to improve further and aim for excellence. An evaluation of good will be characterised by important strengths which, taken together, clearly outweigh any areas for improvement: This represents a standard in which strengths have a significant, positive impact. Strengths will significantly outweigh weaknesses. An evaluation of good will apply to performance where significant improvement is possible and where there are important strengths to build on. An evaluation of adequate will be characterised by strengths which just outweigh weaknesses: Overall performance will be at a very basic level. Strengths will have a positive impact on outcomes and experience. Weaknesses are not important enough to have a substantially adverse impact, however they will constrain the overall quality of outcomes and experiences. The organisation will need to take action to address areas of weakness while building on its strengths. An evaluation of weak will apply where there are some strengths, but important weaknesses: While there may be some strengths, the important weaknesses, either individually or collectively, will be sufficient to diminish outcomes and experiences in substantial ways. It will indicate that there is a need for structured and planned action on the part of the organisation. 12

18 An evaluation of unsatisfactory will apply where there are major weaknesses in critical aspects: This will require the urgent investigation of the practices that have led to this performance and immediate remedial action particularly where there are clear risks to service users or the organisation as a whole. In almost all cases, aspects of governance evaluated as unsatisfactory will require support from the board and senior managers in planning and carrying out the necessary actions to effect improvement. This may involve working alongside other organisations. 4. REPORTING THE FINDINGS The organisation should produce a short report from the self or peer evaluation process, with each area for evaluation given a grading based on the six-point scale described above. The report should contain the following general information: An outline of why the organisation has chosen carry out this process. What the organisation hopes to achieve from the process. What areas have been selected to be evaluated and why these were chosen. An outline of how the evaluation has been done. For each area that has been evaluated the report should include: Some analysis of the findings of the evaluation. This will help readers to understand why any recommendations or areas for improvement have been identified. Areas where the organisation thinks it is demonstrating good or innovative practice. Areas the organisation thinks requires improvement. A grading for each area evaluated. Any recommendations coming from the areas that require improvement. A completed improvement plan (see appendix three). Appendix two contains an example of a format for reporting on your findings. The board should approve and review the report and make it available to staff and external stakeholders. To be most effective, the organisation should repeat the process on a regular basis. 13

19 5. IMPLEMENTING ACTION The evaluation of the evidence should lead to the identification of areas for improvement. The report might make distinct recommendations or have points in the text of the report that identify areas for improvement. Where recommendations are made, they should be kept to a minimum, focus on priority areas and be clear and measurable. The board, along with senior officers and other key staff, should consider the report and identify what areas will be worked on and how to prioritise these. An improvement plan should be produced in response to the report. This plan should include dates for review and completion and allocate staff and/or board members with responsibilities for specific tasks. Where possible and appropriate, board members and the organisation should engage stakeholders in this process. It is helpful to define actions in plans that are: S: Specific M: Measurable A: Achievable R: Realistic T: Timebound Appendix three provides a suggested framework for an improvement plan. It also includes an example of an action point that illustrates how the SMART principles can be put into practice. The board will need to prioritise these action points. The board may not be able to undertake all these at the same time, and the achievement of some areas may depend on the completion of other recommendations first. It is the role of the board to put these actions into a meaningful plan of activity. Each activity will also call on the resources of the organisation, be that through staff time, financial expenditure or use of skills and knowledge in the organisation. It is the board s responsibility to ensure that where activity is agreed, the resources are identified to make sure they can be achieved. 14

20 6. MONITORING PROGRESS The board needs to maintain an oversight of all action that has been identified. It needs to decide a means by which progress towards the action will be regularly and meaningfully reported. If the improvement plan is written clearly it will be easier for the board to monitor its progress. The implementation plan should outline who is responsible for each area of activity and for reporting on progress. The board will also need to make contingency plans for where some activity cannot be achieved or where other improvements may be necessary beforehand. This means that the monitoring progress has to be a proactive and a responsive process. 15

21 Next steps The board needs to determine what happens next. Key questions will be: If only one or two areas of evaluation have been considered at this stage, when will the other areas be evaluated? If all of the areas have been evaluated what will the timetable be for any re-evaluation process? What has been the learning from the process of evaluation? If this was done again, how would it be done differently? Is there any scope for sharing the learning from this with other voluntary organisations? We hope that by following this guide through its various stages, voluntary sector social care organisations will strengthen their approach to governance and set it firmly within their overall process of continuous improvement. 16

22 Appendices

23 18 Appendix one Areas for evaluation OPENNESS HOW OPEN IS OUR BOARD OF DIRECTORS AND OUR ORGANISATION? The board has clear and open decision-making processes. There are ways for the board to communicate both directly and indirectly with all stakeholders of the organisation. There are effective and regular means of consulting with stakeholders, including service users. The organisation publishes an annual report which reports on annual accounts, the activities of the board of directors and how the organisation is meeting its targets. Information about the board and the organisation is made easily accessible and is widely disseminated to stakeholders and the wider public.

24 KEY FACTORS KEY QUESTIONS TO ASK POSSIBLE SOURCES OF EVIDENCE Is it clear how and why the board reaches Interviews with senior staff There is effective communication between the board, senior officers and the staff of the organisation. The board has clear and open decision-making processes. The organisation knows who its stakeholders are. There is a communication strategy developed in consultation with stakeholders. There is effective and regular communication with stakeholders that informs planning. Policies and procedures are developed in consultation with relevant stakeholders. There is a clear system for complaints and there are regular reports to the board, any trends are made known to stakeholders. The organisation publishes annual reports and accounts. decisions? Are senior officers and staff clear about what the board decides needs to be done? How do we communicate this in the organisation? How do senior staff communicate to the board? Are the roles and relationships between board members and senior staff written down? How do we know who our stakeholders are? How do we consult with stakeholders and service users? What do we do with the results of these consultations? Focus groups with staff Interviews with board members Interviews/focus groups with stakeholders Survey of stakeholders Survey of staff Board meeting minutes Scheme of delegation Terms of reference for the board Senior officer job descriptions Role descriptions for board members Results/reports from consultation events List of the organisation s stakeholders Minutes of meetings with stakeholders and service users Annual report and accounts 19

25 20 INTEGRITY DOES OUR BOARD OF DIRECTORS OPERATE WITH INTEGRITY? The board and individual members act according to high ethical and professional standards. All board members have clear responsibilities and functions which are reviewed regularly. Responsibilities and expectations are made clear to all new board members. The performance of the board and individual members are reviewed regularly. There are clear policies which govern the activities of board members. The board ensures that the whole organisation operates within an equal opportunity policy. Integrity is reflected in the organisation s decision-making processes and also in the quality of its financial and performance reporting.

26 KEY FACTORS KEY QUESTIONS TO ASK POSSIBLE SOURCES OF EVIDENCE What financial regulations and procedures do we Board members do not financially benefit from their contribution to the organisation. There are clear and thorough recruitment procedures for board members. Co-opted board members are appointed on the basis of the skills and experience that they bring to the organisation. The Board takes collective responsibility for its decisions. Board members are clear about their individual roles and responsibilities. Board members receive all relevant documents when taking up their role and there is a planned induction. Board members set, review and uphold the vision, values and aims of the organisation. The board ensures that there is an equal opportunity policy in operation. Regular reviews take place with each board member, conducted by either the chair or vice chair of the board. The board regularly reviews its own effectiveness. There is a clear whistle-blowing policy for board members to report any concerns. There is a policy for how board members should declare particular interests. Board members are well prepared for meetings and other activities undertaken on behalf of the organisation. Board members are familiar with all relevant policies. Board constitution and memorandum and articles have in place for the payment of board members? Do board members know what to do if they have a conflict of interest in any of our activities? How do we recruit board members? How do we ensure that they are the right people, offering the right skills for us? How do we maximise the effectiveness of board members? How do we ensure that board members receive the right support in their role? What administrative support do we have in place for board members? Do board members think that they receive the information they need when they need it? How fit for purpose is our equal opportunity policy? How do we evaluate our effectiveness? How do we induct new board members? What is our charitable vision and how do we work to sustain it? Do board members know what to do if they are concerned about the activities of a colleague? Do we have a system for declaring outside interests, including membership of other organisations? Policies for harassment, whistle blowing, equal opportunity and diversity and bullying Recent board evaluations Induction pack for board members Recruitment procedures Minutes of board meetings Register of interests Interviews with board members 21

27 22 ACCOUNTABILITY HOW ACCOUNTABLE IS OUR BOARD OF DIRECTORS? The board and senior officers of the organisation take appropriate responsibility for; the financial wellbeing of the organisation; making and implementing decisions and actions; developing and implementing policy; and delivering outcomes for service users and other stakeholders. The board operates and models principles of regular monitoring. The board actively supports regular internal and external scrutiny of the organisation s activities through quality assurance, quality management and audit processes.

28 KEY FACTORS KEY QUESTIONS TO ASK POSSIBLE SOURCES OF EVIDENCE Do board members have the right skills and Interviews with senior managers and board The board ensures the organisation is solvent whilst upholding its charitable mission. All board members are clear about the organisation s purpose, vision and mission. The organisation complies with all relevant legislation and charitable obligations. The board has approved a scheme of delegation governing expenditure. The board ensures that the organisation complies with all its governing documents. Sub-committees of the board are fully accountable to the board of directors. The board ensures accountability to the public and stakeholders for the organisation s performance. There are rigorous procedures in place for the reporting, reviewing and management of both financial and other risks to the organisation. There are clear and rigorous procedures in place for the reporting, reviewing and management of performance. The organisation has a clear system for reporting on and monitoring projects or services that are operating at a financial deficit or are of poor quality. knowledge to understand and manage the finances of the organisation? What training and support do we make available? Do board members understand their responsibilities for the finances of the organisation? Do we have a clear purpose, vision and mission? How do we share that purpose, vision and mission within the organisation? How do we know what legislation and charitable obligations we are working to? How do we communicate this to the board and within the organisation? Do we have a scheme of delegation? Is everyone clear about their financial responsibilities? Are board members familiar with the governing documents of the organisation? How do we measure our performance? How do we report on our performance? What do we do when we are worried about the performance of one of our services? members Board constitution and memorandum and articles Annual reports and annual accounts Organisation s policies and procedures Board meeting minutes Communication strategy Terms of reference for the board and its committees Training policy for board members Scheme of delegation Observing board meetings and sub committee meetings Quality improvement assessments and/or plans Auditors reports 23

29 24 LEADERSHIP HOW GOOD IS OUR BOARD LEADERSHIP? The board leads the development and implementation of a strategic vision. This is linked with effective operational management. There is a programme of continuous improvement which ensures that the organisation delivers its current range of services to a consistently high standard. Board leadership also guides the organisation into the future by making effective strategic decisions. The board endorses operational decisions that ensures the sustainability of the organisation and the furthering of its charitable mission.

30 KEY FACTORS KEY QUESTIONS TO ASK POSSIBLE SOURCES OF EVIDENCE Are we clear about the vision, values and aims for Interviews with staff, senior managers and board Board members promote and uphold the vision, values and aims of the organisation. The board establishes the strategic direction and aims of the organisation in partnership with staff, users and stakeholders. The board provides strategic leadership to the organisation. The board ensures the delivery of the organisation s business plan. The board has in place succession planning for key roles in the organisation. The board undertakes regular audits of the skill and experience of its membership. Board members can evidence that senior officers are implementing the strategic direction There is a clear division of labour between the board of directors and staff of the organisations. The board avoids becoming involved in day to day operational decisions and matters. 5 the organisation? How are these promoted inside and outside the organisation? Do we have long term strategy? What was the board s role in developing this? Do we have a business plan? What was the board s role in developing this? What plans do we have for the succession of senior staff and board members? What skills and experience does our board have? How do we ensure that this meets our needs as an organisation? How do board members know that activity is happening in the organisation as they have directed? Do board members get involved in operational matters? If so, how is this managed to ensure an appropriate separation of roles? members Reports from stakeholder events Annual reports Key strategic documents Annual business plan Role descriptions for board members Minutes of board and sub committee meetings Communication documents (i.e. newsletters, s sent to staff, board members and other stakeholders) Training policy Survey of stakeholders Survey of staff 5 Some smaller organisations with few staff may require more involvement of board members in operational decisions. 25

31 26 BOARD IN CONTROL IS OUR BOARD OF DIRECTORS IN CONTROL? The board is collectively responsible and accountable for ensuring and monitoring the overall performance of the organisation. Board members are able to constructively challenge, question and contribute to the activities of the organisation through regular reporting at board meetings and other meetings as appropriate. The board takes decisions for the organisation based on clear evidence that action is required for the sustainability of the organisation and the upholding of the organisation s charitable mission.

32 KEY FACTORS KEY QUESTIONS TO ASK POSSIBLE SOURCES OF EVIDENCE The board: Has the ability, skill and authority to make informed decisions. Ensures these decisions are effectively actioned. Upholds the mission of the charity while managing its finances responsibly and prudently. Acts as guardian of the organisation s assets. Has comprehensive plans for how to optimise the organisation s reserves. Ensures the overall sustainability of the organisation. Makes proper arrangements for the appointment (and if necessary dismissal), supervision, appraisal and remuneration of the chief executive or equivalent. Ensures compliance with all statutory employment requirements. Ensures that the organisation is performing well. Regularly reviews the organisation s system of internal controls, performance reporting, policies and procedures. Ensures that staff, volunteers and agents have sufficient delegated authority to discharge their duties. Regularly monitors the use of all delegated authorities. Provides appropriate and robust challenge to senior management whilst working within a framework of corporate responsibility. Interviews with staff, senior managers and board What skills and experience do the members of the board have? Do these meet the needs of the organisation? What processes do we have in place to ensure good short and long term financial and asset management by the board? How do we know the board is effective in carrying out its responsibilities? What do we do if we think the board is not fully carrying out its responsibilities? How do we appoint, supervise and appraise our chief executive? How do we know how well our organisation is doing? What processes do we have in place to manage situations where we are not doing so well? How do we review and monitor our scheme of delegation? members Board meeting minutes Annual reports and annual accounts Terms of reference for the board and its committees Scheme of delegation Focus groups or interviews with stakeholders service users, purchasers, external auditors Strategic plans 27

33 Appendix two Sample self-evaluation report Self-evaluation framework for assessing governance in voluntary organisations who provide social care in Scotland. Self-Evaluation Report Format. INTRODUCTION This document is a self-evaluation report format that helps you to evaluate your own performance on the five areas for evaluation. These are: Openness Integrity Accountability Leadership Board in control. It asks you to summarise the evidence for the conclusions and grading you reach. For each of the five areas, consider the key factors given in the framework. The suggested format asks you to analyse your current performance based on these indicators of good governance, to summarise the evidence that exists to support this analysis, and set out what you are planning in that area for the future. The framework gives suggestions of what sources of evidence you might use. 28

34 THE EVALUATION SCALE FOR THE REPORT The questionnaire asks you to provide qualitative analysis of various aspects of your corporate governance. It is suggested that you use the following scale in arriving at your grading for each area. The guide explains the scale in more detail. Excellent Outstanding Very good Major strengths Good Important strengths with some areas for improvement Adequate Strengths just outweigh weaknesses Weak Important weaknesses Unsatisfactory Major weaknesses 29

35 Area for evaluation 1: Openness The board has clear and open decision-making processes. There are ways for the board to communicate both directly and indirectly with all stakeholders of the organisation. There are effective and regular means of consulting with stakeholders, including service users. The organisation publishes an annual report which reports on annual accounts, the activities of the board of directors and how the organisation is meeting its targets. Information about the board and the organisation is made easily accessible and is widely disseminated to stakeholders and the wider public. CURRENT PERFORMANCE Strengths (include how you evidence this performance) Areas to develop (include how you evidence this performance) CURRENT OR PLANNED INITIATIVES Are you taking any specific action to improve the openness within the board and organisation? (Include objectives and actual or anticipated start and completion dates) 30

36 GRADING 1. Unsatisfactory 2. Weak 3. Adequate 4. Good 5. Very good 6. Excellent GOOD PRACTICE EXAMPLES RECOMMENDATIONS 31

37 Area for evaluation 2: Integrity The board and individual members act according to high ethical and professional standards. All board members have clear responsibilities and functions which are reviewed regularly. Responsibilities and expectations are made clear to all new board members. The performance of the board and individual members are reviewed regularly. There are clear policies which govern the activities of board members. The board ensures that the whole organisation operates within an equal opportunity policy. Integrity is reflected in the organisation s decision-making processes and also in the quality of its financial and performance reporting. CURRENT PERFORMANCE Strengths (include how you evidence this performance) Areas to develop (include how you evidence this performance) CURRENT OR PLANNED INITIATIVES Are you taking any specific action to improve the openness within the board and organisation? (Include objectives and actual or anticipated start and completion dates) 32

38 GRADING 1. Unsatisfactory 2. Weak 3. Adequate 4. Good 5. Very good 6. Excellent GOOD PRACTICE EXAMPLES RECOMMENDATIONS 33

39 Area for evaluation 3: Accountability The board and senior officers of the organisation take appropriate responsibility for; the financial wellbeing of the organisation; making and implementing decisions and actions; developing and implementing policy; and delivering outcomes for service users and other stakeholders. The board operates and models principles of regular monitoring. The board actively supports regular internal and external scrutiny of the organisation s activities through quality assurance, quality management and audit. CURRENT PERFORMANCE Strengths (include how you evidence this performance) Areas to develop (include how you evidence this performance) CURRENT OR PLANNED INITIATIVES Are you taking any specific action to improve the openness within the board and organisation? (Include objectives and actual or anticipated start and completion dates) 34

40 GRADING 1. Unsatisfactory 2. Weak 3. Adequate 4. Good 5. Very good 6. Excellent GOOD PRACTICE EXAMPLES RECOMMENDATIONS 35

41 Area for evaluation 4: Leadership The board leads the development and implementation of a strategic vision. This is linked with effective operational management. There is a programme of continuous improvement which ensures that the organisation delivers its current range of services to a consistently high standard. Board leadership also guides the organisation into the future by making effective strategic decisions. The board endorses operational decisions that ensures the sustainability of the organisation and the furthering of its charitable mission. CURRENT PERFORMANCE Strengths (include how you evidence this performance) Areas to develop (include how you evidence this performance) CURRENT OR PLANNED INITIATIVES Are you taking any specific action to improve the openness within the board and organisation? (Include objectives and actual or anticipated start and completion dates) 36

42 GRADING 1. Unsatisfactory 2. Weak 3. Adequate 4. Good 5. Very good 6. Excellent GOOD PRACTICE EXAMPLES RECOMMENDATIONS 37

43 Area for evaluation 5: Board in control The board is collectively responsible and accountable for ensuring and monitoring the overall performance of the organisation. Board members are able to constructively challenge, question and contribute to the activities of the organisation through regular reporting at board meetings and other meetings as appropriate. The board takes decisions for the organisation based on clear evidence that action is required for the sustainability of the organisation and the upholding of the organisation s charitable mission. CURRENT PERFORMANCE Strengths (include how you evidence this performance) Areas to develop (include how you evidence this performance) CURRENT OR PLANNED INITIATIVES Are you taking any specific action to improve the openness within the board and organisation? (Include objectives and actual or anticipated start and completion dates) 38

44 GRADING 1. Unsatisfactory 2. Weak 3. Adequate 4. Good 5. Very good 6. Excellent GOOD PRACTICE EXAMPLES RECOMMENDATIONS 39

45 Appendix three Sample improvement plan With a sample recommendation and smart plan 40

46 IMPROVEMENT PLAN Recommendation Action Timescale Monitoring Arrangements Resources Required Target/Outcome Lead Officer For example: The organisation needs to develop a formal process for consulting with all service users about the quality of current services. a Collate all current processes in place for gathering service user s views. b Contact other organisations for examples of good practice. c Develop a guidance for our services to use, including a collation and reporting mechanism. d Develop an implementation plan for the guidance including training. March 2009 A small development group to be set up to meet regularly. March 2009 Regular reporting to development group. September 2009 December 2009 Approval of guidance by Board in September meeting. Approval of plan by board in December meeting. x x hours Policy officer x x hours Policy officer x x hours x for printing the guidance x x hours Training costs Guidance approved Policy officer Implementation plan approved Policy officer e Implement plan. January 2010 Development group. Policy officer f Review and evaluate progress. July 2010 Report presented to board in July Meeting. x x hours Evaluation report completed Policy officer 41

47 Appendix four Gathering the views of service users, staff and stakeholders INTRODUCTION It is important that you make surveys and feedback a day-to-day activity. Those whom you may want to survey include; people who use services and carers; parents, guardians, carers and families; employees from external partner agencies; senior managers; staff from across the organisation; trade unions and professional associations; and members of the public. The remainder of this appendix is the advice of a professional statistician about how best to organise and deliver surveys to a reliable standard. DOING SURVEYS GENERAL GUIDANCE Aim To provide numerical data on the experiences and perceptions of employees, service users, carers, or other stakeholders. Essentials You should issue enough questionnaires to support robust conclusions. The exact number of questionnaires that should be issued will depend on a number of factors including: the total number in the population of interest; the likely response rate to the questionnaire; the required level of precision required in the results; and whether or not you require to compare different types of respondent. As a rough guide, you should issue enough questionnaires to ensure at least 100 are returned. This will mean that the overall results are generally reliable to within +/-10%. You should randomly select people to get a questionnaire. In some cases, it may be possible to send a questionnaire to everyone in the population of interest. 42

48 OTHER POINTS TO CONSIDER If you guarantee respondents confidentiality, their responses are likely to be more honest and response rates are likely to be better. Surveys can be conducted by; Post using paper-based questionnaires; Telephone; Face-to-face interview; or Electronically, via or the Internet. Each method has advantages and disadvantages, in terms of cost and effect on response rates. Some may be better for some groups than others, e.g. younger people may be more likely to respond to an electronic survey than older people may. Some of the methods may exclude some groups, e.g. visually impaired people may not be able to complete a paper questionnaire. If you think different categories of respondents will have different views, you can select a minimum number of people in each category as part of building the sample. If you select different proportions in different categories, then you will need to apply overall weightings appropriately to obtain reliable overall results. The questions asked in a survey have an effect on the results and their interpretation. Points to consider include: Is the question clear and unambiguous? Do you need to define the terms you use in the question? Will different respondents interpret the question differently? Is the question unbiased or does it lead the respondent to give a specific response? A closed question may be appropriate to obtain specific information (e.g. have you attended a training course within the past year? ). A more subjective question may be appropriate to obtain qualitative information (e.g. Rate the usefulness of the training course you attended on a scale of 1 to 6 ). In some cases, a completely open question may be appropriate, although the results will be more difficult to quantify (e.g. Please suggest any improvements that could be made to the training course ). If time and resources allow, it is always beneficial to pilot a survey before running it. 43

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