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Voluntary Action ScotlandGovernance Health Check Self-Assessment

Section A: Culture Mapping: Facilitated Exercise

Complete this culture mapping group exercise as the board or leadership steering group as either an integrated or partnership TSI. The purpose is to explore existing elements of the culture that are strong and healthy and elements you agree could be changed.

First insert an existing organisational / partnership vision statement. Don’t overthink this and keep it simple.

  1. Governance Cultural Refinement Improvement Plan

Existing state of play / Cultural Areas to refine and improve upon
Symbols: visual symbols, branding, sentimental imagery / Symbols: visual symbols, branding, affectionate / off-putting imagery
Power structures: hierarchical, democratic / organisational chart / Power structures: hierarchical, democratic / organisational chart
Organisational structures: formal and informal (or unspoken) structures / Organisational structures: formal and informal (or unspoken) structures
Control systems: cultural approaches and trusts arrangements for financial, risk, HR at all levels / Control systems: cultural approaches and trusts arrangements for financial, risk, HR at all levels
Rituals and routines: of meetings, of culture, of interactions / Rituals and routines: of meetings, of culture, of interactions
Stories and myths: external and internal perceptions, heritage of the culture, historic relationships / Stories and myths: external and internal perceptions, heritage of the culture, historic relationships

Section B Governance Processes AND Systems Self-Assessment

Criteria 1: Leadership Roles, Responsibility and Delegated Authorities

The board of trustees has defined roles and responsibilities and each member understands that it is jointly and severally liable for the actions and decisions that the board makes. The role of the CEO is also defined with clearly delegated authorities and autonomy appropriate to a CEO role.

Approaches to understanding Roles and Responsibilities and Delegated Authority / Deployment / Met / Partially Met / Not Met / Assessment of how well criteria is deployed using Section A. / Scoring after section A exercise
(1- low to 10 high)
EFQM CRITERIA: Excellent organisations have leaders who shape the future and make it happen, acting as role models for its values and ethics and inspiring trust at all times. They are flexible, enabling the organisation to anticipate and react in a timely manner /
  • 1a. Leaders develop the mission, vison, values and ethics and act as role models.
  • 1c. Leaders engage with external stakeholders.
  • 1e. Leaders ensure that the organisation is flexible and manages change effectively
/ met /
  • Board holds regular strategic review sessions to assess current vision/mission/strategy
  • Board and CEO in constant contact with stakeholders in public, third and private sector
  • ACVO has been able to be agile to demands of stakeholders, funders and sector to date
/ 4
Clear roles and delegated responsibilities: Is the role of your board clearly defined? /
  • Written role descriptions
  • Induction pack
  • Scheme of delegation between board and CEO
/ met /
  • In directors handbook
  • Induction pack needs updating
  • Scheme of delegation in place
/ 4
Trustee induction process: familiarisation with the organisation /
  • Clear induction process, pre-meetings with Chair/CEO before attending board meetings
  • Induction to staffing structure and roles within the organisation
  • Induction and awareness of the 5 TSI Common Outcomes (and/or the new SQUIG Outcomes Framework)
  • Induction to VAS and its role, specific VAS subcommittees: SQIG and Saltire
/ Partially met /
  • Pre meetings ok
  • Induction could improve
  • No induction on SQUIG or VAS specifically
/ 3
Trustees working to the same charitable and business aims: Are the board members aware of the mission, vision and values of the organisation? /
  • Governing document
  • Vision and mission statement
  • Organisational values
  • An agreed TSI mission statement and set of values?
/ met /
  • M&A’s in place
  • All others in business plan
/ 5
Personal liability: Do board members understand their legal responsibilities in relation to their role? /
  • Declaration explaining that all trustees are jointly and severally personally liable for the actions of the board and may be taken to court by a claimant
  • Duties in charity and company and trust law detailed in role descriptions (as per the above) and as referred to in the governing document
/ met /
  • Not in place
  • Duties in M&A’s and in induction pack
/ 5
Making an impact: Are the board members aware of the organisation’s operating environment and the top-line impact data they need to know /
  • Awareness of local need through research benchmarked against national research
  • Awareness of relevant Scottish Government legislation and policies: Community Empowerment Act, Public Sector Reform
  • Operational dashboards and intelligence reviewed at board meetings: (this could top-line information on number of people supported compared to previous years, not just information from Milo)
/ Partially met /
  • ACVO capacity to do this limited - rely on others for national comparisons
  • Legislative awareness good
  • Operational spreadsheets on risk/ finance/performance all at board meetings
Milo reports are operational not for board. / 4
Customer focus:Is the board clear about who the beneficiaries and stakeholders are and the contracts they are funded to deliver? /
  • Records of service users
  • Register of Members
  • Funders contracts
  • Statutory / public sector contracts / MOUs
  • Governing document
/ met /
  • Service users not listed for board –operational/confidentia
  • Members list
  • Funders, income list
  • MOU’s contracts file
  • M&A’s
/ 5
Buildings and assets:If you have premises and other assets, are they used and maintained effectively? /
  • Maintenance log
  • Fire safety procedures
  • Security procedures
  • Planning for renewal
  • Monitoring usage eg schedule of income analysis
  • Asset register
  • Insurance
  • Leases
  • Tenancy agreements
  • Franchise contracts
/ met / VSA undertake main facilities asset management. ACVO links on H/S aspects / 5
Constitutional membership involvement: Have you got a written up to date list of the voting members of your organisation? Are you clear on the differences between beneficiaries and members – are they? /
  • Register of members (as per your constitution and separate form beneficiaries and stakeholders)
  • Evidence of consultation with the membership so they are aware of their voting rights as per your constitution
  • Evidence of encouraging members to join your board
  • Evidence that your board reflects the diversity of your membership
/ met /
  • Current list of members updated monthly
  • No issues on clarity between beneficiaries and members
  • Annual correspondence prior to AGM
  • Board recruitment process/ adverts
  • Board covers:care/ equalities, housing, community centres, sport, arts, welfare more diversity could occur
/ 5
Governing document:Have you reviewed your governing document in the last three years? /
  • Has the governing document been reviewed and have amendments been necessary for trustee terms of office and so on?
/ Not met /
  • Not reviewed in last three years
/ 2
Registration, submissions and notifiable events with regulators:Have you checked your charity registration status with OSCR? /
  • Registrations and returns to OSCR, Companies house and other regulators such as the Care Inspectorate (if applicable).
  • OSCR want to support organisations facing difficulties and build an accurate picture of the sector. Have you contacted them about ‘notable events’ – e.g. significant reductions in income
/ met /
  • All submissions on time
  • No notable events to contact on
  • OSCR in regular contact as TSI support others.
/ 5
Persons of significant control –Companies House registration /
  • Companies House require registration of people with significant control- an example is a company were individuals have more than 20% of the shares or more than 20% of voting rights. Guidance here
/ met /
  • PSC registration in place as nil return as no shares and 1/1 voting.
/ 5
Organisational public benefit:If charitable, does your organisation fulfil the public benefit requirement? /
  • Are the aims of the organisation clearly defined as having public rather than private benefit
  • Are the aims of the charity the same as listed on the OSCR website?
  • Are the operations / powers sill consistent with the governing document (e.g. trustee terms of office)
/ met /
  • Public benefit well defined
  • Yes
  • To be reviewed
/ 5

Criteria 2 deleted as it is for partnership tsi’s

Criteria 3: People Working Well

The CEO and board are working well as individuals and as a team; this is reflected through a well-functioning staff and volunteer team within the organisation who are lead through example

People Working well / Deployment / Met / Partially Met / Not Met / From Section A
Testing it’s effectively deployed in culture and practice: evidence / Scoring after section A exercise
(1- low to 5 high)
EFQM Criteria: Excellent Organisations achieve and sustain outstanding results that meet or exceed the needs and expectations of their people. /
  • 7a. Perception Results – obtained from a number of sources, including surveys, focus groups, interviews and structured appraisals. These perceptions should give a clear understanding of the effectiveness the deployment of outcomes, policies and processes
  • 7b. Performance Indicators. The internal measures used in the organisation to monitor, understand, predict and improve the performance of the organisations people strategy and supporting policies and processes.
/ met /
  • Regular surveys of sector, feedback from individual clients and unsolicited testimonials
  • Range of performance indicators in place, targets, financial, etc.
/ 5
Effective board meetings: Are your board meetings and sub-committee meetings effective? /
  • Appropriate agenda
  • Quorums met
  • Minutes including records of decisions made
  • Regular reports and other info
  • Held regularly
  • Regular full attendance
/ met / All in place / 5
Skills and knowledge: Have you got adequate skills, or reasonable access to skills, and experience on your board? /
  • Skills audit
  • Training eg child protection, recruitment, governance
  • Evidence of advice obtained
/ Partially met /
  • Skills audit
  • Training to be identified
  • Advice e,g Brodies on dilapidations, Empire on HR
/ 4
Board development. Has your board received appropriate information and guidance in relation to governance? /
  • Induction pack/ materials
  • Governance training /events /
  • seminars/conferences
  • Regular policy updates
Mentoring / Partially et /
  • Induction palck
  • Training to be updated
  • VAS events
  • Policy updates to be given aCVO link
/ 4
Board recruitment: Does the board work to attract new members in accordance with its governing document? /
  • Rotation of board
  • Terms of office
  • Board members replaced when term of office expires
  • Process for admitting new members
  • Identify skills gaps
  • Advertising skills gaps
  • Recruitment policy
  • Board induction
/ Partially met /
  • Working in line with M&As
  • Skills gaps identified and posts advertised accordingly
/ 4
Board conflicts: Does the board have a policy to deal with internal conflicts within the board? /
  • Code of conduct
  • Clear role boundaries
  • Governing document
  • Whistleblowing policy
  • Legislation
  • Conflicts of information
  • Conflicts of interest
/ Partialy met /
  • Code of conduct in induction pack
  • Clarity between operational and strategic
  • ACVO whistleblowing policy
  • Conflicts not asked about at each meeting?
/ 4
Bribery policy - for gifts and hospitality /
  • Does the board have an anti-bribery policy for accepting gifts and hospitality?
/ met /
  • CEO undertook anti bribery training
  • No specific policy for board, use of common sense.
/ 4
Board performance: Does the board review its own performance on an annual basis? /
  • Board members survey
  • Board appraisal
  • Review days or sessions
  • Governance health check
/ met /
  • This governance health check
  • No other external review
/ 5
Staff engagement and understanding of organisational direction /
  • Staff engagement surveys – satisfaction, understanding and engagement to charitable aims and direction
  • EFQM Leadership and people criteria
/ met /
  • Annual appraisal includes satisfaction issues and understanding of aims as does job descriptions and team meetings
  • EFQM central to work
/ 5

Principle 4: Strategy

The organisation has a clear purpose and has a strategy to achieve organisational aims which are measurable

An effective board will provide good governance and leadership by ensuring delivery of organisational purpose. The board has ultimate responsibility for directing the activity of the organisation and delivering its stated purposes.

Strategy / Deployment / Met / Partially Met / Not Met / From Section A
Testing it’s effectively deployed in culture and practice: evidence / Scoring after section A exercise
(1- low to 5 high)
EFQM CRITERIA: Excellent organisations implement their mission and vision by developing a stakeholder focussed strategy. Policies plans, objectives and processes are developed and deployed to deliver the strategy. /
  • 2a. Strategy is based on an understanding the needs and expectations of the external environment,
  • 2b Strategy is based on understanding internal performance and capabilities
  • 2c. EFQM CRITERIA: Strategy and supporting policies are developed, reviewed and updated
  • 2d. Strategy and supporting policies are communicated, implemented and monitored.
/ met /
  • Updated at regular strategic review sessions
  • Resources and capabilities are of key consideration
  • Finance, HR, H/S policies all regularly reviewed and externally supported
  • All documentation on main communal drive and discussed at team meetings if changes arise.
/ 5
Actives are aligned to the objects of the charity: Are the activities of the organisation in line with the objects/purposes laid out in your governing document (e.g. constitution/articles/deed)? /
  • Up to date governing document
  • Review services offered
  • Needs assessment
  • Satisfaction surveys
  • Public benefit statement
/ Partially met /
  • M&A’s to be reviewed
  • Services reviewed regularly
  • Needs assessment done prior to funding applications
  • Regular satisfaction surveys
  • No public benefit statement
/ 4
Organisational strategy:Does the organisation have a written plan for what it wants to achieve including strategies for sustainability? /
  • Strategic Plan
  • Operational plan
  • Fundraising strategy
  • Diversified income streams
  • Impact statement
  • Do you have a person on your board that is capable of directing a strategy?
/ met /
  • Annually reviewed business plan
  • Operational plans for all funders
  • No fundraising
  • Varied income streams reviewed regularly
  • Several board capable of directing a strategy
/ 4
Organisational operational plan:Does the organisation have an annual work plan? /
  • Operational plan
  • Work plans
  • Service level agreements
/ met /
  • Several organisational workplans
  • SLA’s with ACC
/ 5
Operational data and dashboards:Have you gotthe procedures in place to help the board regularly monitor progress and evaluate the effectiveness of the organisation’s work? /
  • Operational plans
  • Action plans
  • Staff and/or volunteer reports
  • Reports to funders
  • On-going monitoring and review and evaluations
/ met /
  • Performance monitoring data
  • Staff reports and CEO reports
  • Funders reports
  • Financial monitoring, risk monitoring
/ 5
Responding to national and local public policy /
  • Community Empowerment Act, Community Justice Act and Public Service reform etc.
  • Community Planning, Health and Care partnerships and strategies
/ met /
  • Working on CEA actions in CPP , set up community justice forum
  • Funded staff on H&SC integration to support localities and gather views of sector.
/ 5

Criteria 5: Appropriate Control to Achieve Results

The board exercises appropriate control and has clear and transparent systems to ensure a safe operating environments, good finances and legal compliance

Exercising appropriate control to achieve and maintain results / Deployment / Met / Partially Met / Not Met / From Section A
Testing it’s effectively deployed in culture and practice: evidence / Scoring after section A exercise
(1- low to 5 high)
EFQM Criteria: Business Results - Excellent organisations achieve and sustain outstanding results that meet or exceed the needs and expectations of the organisation. /
  • 9a Business Outcomes – financial and non-financial business outcomes which demonstrate success of the organisations deployment of their strategy. The set of measures and relevant targets as defined and agreed with business stakeholders.
  • 9b. Business Performance Indicators – Key financial and non-financial business indicators that are used to measure the organisations operational performance.
/ met /
  • Monthly management accounts, CEO report bi monthly, monthly performance KPI reports
These cover outcomes and targets depending what is asked for by funders. / 5
Legal compliance:Do you adhere to the legal and compliance obligations of the organisation? /
  • Letters of offer
  • Insurance
  • Contracts of Employment
  • Leasing agreements(due diligence on photocopier contracts etc.)
  • Equal opportunities policy
  • Child protection and Adults at Risk policies
  • PVG checks where required
  • Charity law administration and reporting requirements
  • Company law administration and reporting requirements (notifiable occurrences to OSCR)
  • Data Protection 2018 changes
/ met /
  • Staff offer letters in place using HR advisor template
  • Fully insured to requirement of all funders
  • Contracts updated 2016
  • Leases under review annually
  • EOP in place
  • Not working directly with these groups
  • PVG for some staff
  • Adhering to charity reporting schedule
  • Adhering to OSCR reporting
  • Aware of GDPR and awaiting full guidelines
/ 5
Health and safety management: Do you ensure compliance with health and safety legislation and fulfil your duty of care obligation to employees, volunteers, service users and the general public? /
  • Health and Safety Policy and notices
  • Fire and Health and Safety Risk assessments
  • Fire alarms, extinguishers,
  • Accident book
  • Insurance policies
  • First Aid
  • Policies and procedures in line with legislation and good practice
/ met /
  • All in place
  • Work with VSA
  • Accident book in place
  • Insurance up to date
  • First aid trained
  • Folllowing external adviser on policy
/ 5
Financial systems:Have you got appropriate financial systems in place? /
  • Budget
  • Cash book,
  • Ledger
  • Cheque Journal
  • Cash flow forecast
  • Management accounts
  • Approved written financial procedures
  • Cash handling
  • Required cheque signatories
  • Bank reconciliations
  • Financial procedures policy
  • Using accrual accounting if over £250,000 pa
  • Board training on charity accounting (understanding of deferring income etc.)
/ met /
  • Annual budget produced and approved by board
  • Use SAGE for accounting
  • Produce monthly mgt accounts
  • Board approved financial procedures
  • Cash handling policy
  • 2 signatories required
  • Use accrual accounting
  • Board not trained in charity accounting
/ 5
Independent examination of accounts.Are your annual accounts externally examined by an independent person? /
  • Full audit (mandatory for organisations over £500,000)
  • Independent examination
  • Discussion on whether to be audited periodically for trustee comfort (if under threshold).
/ met /
  • Full annual audit
/ 5
Common understanding of financial position. Is the financial reporting to the board clear, transparent, readily understood by all board members at each meeting? /
  • Agenda of meetings
  • Treasurer input
  • Management accounts
  • Income and Expenditure sheet
  • Adequate guidance/mentoring
/ met /
  • Finance themed meetings
  • Treasurer and CEO input
  • Management accounts
  • Explanations and assumptions
/ 5
Risk management: Does the board consider and manage risks (uncertainties, threats), both short-term and long-term, in all aspects of the organisation’s work? /
  • Risk policy
  • Risk assessments carried out
  • Risk register in place Consideration of:
•Governance risks
•Operational risks
•Financial risks
•External risks
•Compliance risks
•Reputational risks
  • Training
  • Minutes of meetings
/ met /
  • Risk register in place and reviewed at bi monthly boards
  • All in place
/ 5
Authority, accountability and delegation:Does the board set out and communicate the functions of sub-committees, officers, staff and anyone performing duties on its behalf? /
  • Organisation chart
  • Terms of reference
  • Role descriptions
  • Job descriptions
  • Minutes
  • Policies and reporting processes
  • Induction
  • Governance manual
/ met /
  • Organisation chart in place
  • TOR for sub group and Short term groups
  • All others in place
/ 5
Sub-committee authority and delegation:Does the board regularly monitor and review the effectiveness of sub-committees? /
  • Minutes of meetings and sub-committee meetings
  • Reports
  • Evidence of decisions taken in line within agreed parameters
  • Terms of reference
/ met /
  • Only audit or short term groups and not acting without board knowledge
/ 5
Human Resource Management:Do you meet the legal requirements in relation to the recruitment and management of staff? /
  • Up to date staff contracts
  • Clear roles
  • Job descriptions and accountability
  • Regular supervision of all staff including most senior staff member
  • Training and development
  • Appropriate HR policies including
bullying and harassment / met /
  • Contracts 2016
  • Clarity of roles in workplans
  • Job descriptions
  • Supervision and appraisal
  • T/D regular update and appraisal
  • HR supported by Empire
/ 5
Human Resource Management:Have you got appropriate staff management systems in place? /
  • Leave entitlements
  • Disclosure / CRB checks
  • Recruitment and selection training
  • Pension provision
/ met /
  • Holiday sheets inplace
  • No disclosure
  • Recruitment process in place
  • Pension in place
/ 5
Volunteers and employment law legislation: Does the board have clear procedures/guidelines to distinguish between staff and volunteer responsibility? /
  • HR policies
  • Volunteer policies
  • Organisation charts
  • Role descriptions
  • Job descriptions
/ met /
  • Clarity in volunteer and staff roles
  • Volunteer policy clear
  • No job descriptions as they are volunteers!
/ 5
Volunteer Management: Have you got appropriate systems in place for recruitment and management of volunteers? /
  • Volunteer policy
  • Induction
  • Role descriptions
  • Agreements
  • Volunteer expenses policy
  • Training
  • Support and supervision
  • Volunteer ‘problem solving’ policy (so alternative to grievance policy used in employment law)
/ met /
  • Clarity in role of volunteers, induction, role description, expenses, training on systems, supervision by specific person
  • No policy - volunteer
/ 5

Criteria 6: Integrity and Openness