Corporate governance report

This section of the annual report will cover:

• Annual governance statement
• Freedom to speak up
• System working and partnerships
• Review of economy, efficiency and effectiveness of the use of resources
• Board and Trust Leadership

Directors’ report - Composition of the Board of Directors

Chair:

Elaine Baylis QPM

Chief Executive

Marie (Maz) Fosh

Executive Directors

Tracy Pilcher, Director of Nursing, Operations and Allied Health Professionals and Deputy Chief Executive

Ceri Lennon, Director of People and Innovation

Sam Wilde, Director of Finance and Business Intelligence:

Dr Yvonne Owen, Medical Director

Non-Executive Directors

Alan Kent

Liz Libiszewski

Kevin Lockyer

Gail Shadlock

Vacancy (not filled due to COVID)

Also in attendance:

Deputy Director of Corporate Governance

Corporate Administration Manager and Personal Assistant

During 2020-21, from May 2020, the Trust Board met six times in public via livestream as the Board was unable to meet in person due to the national pandemic. Six extraordinary Trust Board sessions took place on alternate months, also by electronic means, to enable the Trust to review and approve key actions taken as part of the Lincolnshire and Trust response to Covid-19.

The Trust Board consists of a chair, four non-executive directors (excluding the chair) and five voting executive directors (including the chief executive). The Deputy Director of Corporate Governance is also in attendance.

Annual governance statement

Scope of Responsibility

As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Trust’s policies, aims and objectives, while safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the organisation is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Trust Accountable Officer Memorandum.

The purpose of the system of internal control

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Lincolnshire Community Health Services NHS Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

The system of internal control has been in place in Lincolnshire Community Health Services NHS Trust for the year ended 31 March 2021 and up to the date of approval of the annual report and accounts.

Capacity to handle risk

The Trust has a Risk Management Strategy which is approved by the Trust Board. 

The Trust Risk Management Strategy was fully reviewed and rewritten following key learning and changes implemented as a result of the collaborative response to covid-19 and approved in March 2021. This included a full review and realignment of the Trust’s Risk Appetite Statement.

The strategy is available to the public and employees on the Trust website.  The purpose of the strategy is to ensure that risks to the quality and delivery of patient services and care are managed, to protect the services, reputation and finances of the Trust, to create a culture where staff acknowledge risk as the responsibility of everyone and to ensure that the Trust meets its statutory obligations. The strategy defines the structures for the recognition, management, ownership, review of risks and risk criteria, control and gaining assurance of risk and the methods in which risk issues are considered and assessed.

The risk management process is owned by Trust Board with Executive Directors and Deputy Directors being directly accountable for each risk and appropriate and effective mitigating actions, in line with the Corporate Governance Code and the Orange Book, principles and concepts of risk management. All risks with an overall score of 12 or above are noted on the Trust Corporate Risk Register are reviewed at least monthly by Deputy Directors in collaboration with Executives.  Feeding into this is the Corporate Services Operational Risk Register for risks holding an overall score above 4 and below 12, monitored through the Trust Leadership Team on a monthly basis and informed by local risk registers managed by Quality Assurance Managers.  Robust mechanisms are in place to ensure risks are managed effectively, moved between registers appropriately and to ensure sufficient time is allocated by each responsible committee or group for their consideration, review and management.

Through the risk identification process staff at all levels are able to identify, assess and develop mitigating action plans to reduce and manage each risk effectively. The Risk Management Strategy provides the overarching framework and guidance to enable this along with training and support provided by the Corporate Governance and Quality Teams. The Quality Assurance Managers play a key role, individually and collaboratively, in effecting consistency in the assessment of risks.  Collectively, the Quality Assurance Managers and Corporate Governance team work to extend this consistency from the operational risk register into the Corporate Risk Register.

The risk and control framework

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives.  The organisation’s Risk Appetite Statement is published on the website and reviewed periodically while the various risk registers are considered in its context.

The Trust Board is responsible for the management of key risks. The key areas of those risks are managed through:

• Covid-19 Risk Register
• Corporate Risk Register
• Large Vaccination Centre Risk Register
• Board Assurance Framework
• Financial risk management
• Compliance with targets
• Single Oversight Framework
• Operational Delivery Plan
• Performance management reporting.

The Trust’s approach to corporate governance is rooted within best practice and is regularly reviewed and assessed through internal processes.  While the Strategy was collaboratively rewritten and published in March 2021 regular reports at every meeting of the Trust Board reflect developments, movement and mitigations of covid and business as usual risks and improvements to control arrangements. The Corporate Risk Register is reviewed and approved by the Trust Board as part of this process and in each public board meeting.  A significant development during 2020-21 has been the oversight and management of risks being delegated to Deputy Directors, with accountability remaining with Executive Directors. Weekly deputy huddles, risk and control management forming a key part of these discussions, have supported the evolution and development of the risk culture.  This harmonisation process not only promotes collective as well as individual responsibility at the highest level but also promotes consistency in assessment.

Among the key high-scoring risks on the Corporate Risk Register during 2020-21 were:

1. Risks relating to the Trust and system response to Covid-19, such as the provision of personal protective equipment, the restoration of services and the Trust’s lead provider role for the two Lincolnshire large vaccination centres based in Boston and Lincoln.

2. Risk to service sustainability and deliverability due to future changes to commissioning, with the potential to result in reduction in income or opportunity to invest, affecting financial viability of the Trust and its services.

3. Risk that the inadequate maintenance of the NHS Property Services-owned estate could result in a loss of service and/or damage to persons.

4. Risk that urgent and emergency care services across Lincolnshire could become overwhelmed due to periods of high activity, resulting in patient safety issues.

5. Risk that patients treated within LCHS services could deteriorate due to delays while awaiting ambulance transfer, resulting in patient harm.

6. Risk that the UK left the EU with either ‘no deal’ or a deal and the possible impact upon LCHS activity, with potential to result in significant disruption to services, supply, business delay and logistics. This was revised post securing an exit agreement.

Another ongoing high-profile risk is the pursuit by the HMRC of a historic claim in relation to the employment status of GPs providing out of hours services.  This potentially adversely impacted on service delivery, as well as the financial and reputational standing of the Trust.  A hearing that was due to take place in January 2020 but was placed on hold during the pandemic. The legal proceedings are now paused, as a stay of proceedings, until the judgement is given in a similar case in England.  

To enable LCHS to respond effectively to the national emergency a separate risk register was developed from 1 April 2020. This addition supported the Trust to respond to Covid-19 risks at the pace in which they arose. By 8 April an interim process was established in line with the organisation’s Risk Management Process with the amendment of risks being managed through the Bronze, Silver and Gold Command response model.

The Covid-19 risk registers were in operation in addition to the Trust Corporate Risk Register and the Corporate Services Operational Risk Register (CSORR). Business as usual processes for managing risk and escalation has been maintained throughout the Covid-19 response period. Risk reporting processes were amended and actioned as follows:

• Covid-19 Risk Register: 
  • Weekly reporting of movement to the Trust Leadership Team
  • Monthly reporting to the Quality and Risk Committee
  • Monthly reporting to Board.
• Covid-19 Quality and Clinical Advisory Cell Operational Risk Register (CQCACORR)
  • Weekly reporting to the Trust Leadership Team.
• Trust Corporate Risk Register:
  •  Weekly reporting to the Trust Leadership Team (19 May onwards)
  • Monthly reporting to the Quality and Risk Committee
  • Monthly reporting to Board.
•  Corporate Services Operational Risk Register (CSORR)
  • Monthly to the Trust Leadership Team
• Large vaccination centre risk register
  • Monthly to the Quality and Risk Committee (from February 2021)

Both Covid-19 risk registers were closed on 14 July 2020 with the approval of Trust Board and in response to the significantly reduced Covid-19 related activity and risks at this time. Open risks were transferred to the Trust Corporate Risk Register and the CSORR for ongoing review, mitigation and management through business as usual processes.

Significant learning and coaching in relation to risk management has been realised during Covid-19 and key to the functioning of the ICC. Covid-19 risk management and the coaching provided identified gaps in knowledge across the Trust that have been continually mitigated as the response and year has progressed. Additional support to staff at all levels has been provided throughout 2020-21 to support identification, ownership of risk and appropriate escalation of risks and issues. It is planned that this will continue throughout 2021-22 as a further risk management training programme is piloted develop knowledge, competence and ownership of the risk process and increase the quality and responsiveness to risk reporting and mitigation activities.

There is a robust Board Assurance Framework in place which sets out the key controls and assurances on controls to safeguard against the key risks to the achievement of the strategic objectives. The Board Assurance Framework is aligned to the organisation’s Operational Plan and is reviewed at every meeting of Trust Board and its assurance committees.  In addition, there are formal risk management procedures in place with effective review and management procedures which incorporate both a controls assurance and a risk assessment.

The committees of the Trust Board – Quality and Risk Committee and Finance, Performance and Investment Committee – assess each and every business item against the Board Assurance Framework.  This enables direct assessment against compliance on all fronts, including CQC requirements.  The committees also review the corporate risk register monthly, immediately following their monthly review by Deputy Directors and prior to the committees’ findings/recommendations progressing to Trust Board. 

Separately, the People Executive Group (PEG), chaired by the Executive Director of People, has delegated responsibility for ensuring the Trust has developed and managed the short, medium and long-term workforce strategies and staffing systems to comply with the ‘Developing Workforce Safeguards’ recommendations.  In addition, PEG has provided People Strategy progress reports, assurance reports and updates risks and work-plans to FPIC. All policies approved by this forum are able to be escalated to Board for endorsement and/or challenge. Quality and Equality Impact Assessments are completed to assess substantive changes to workforce.

Sharing the learning through risk related issues, incidents, complaints and claims is an essential component to maintaining the risk management culture within the trust. Learning is shared through service line structures and trust-wide governance committees and groups as outlined in the Trust organisational structure such as the Quality and Risk Committee, Stakeholder, Engagement and Involvement Group, Infection Prevention and Control Group, Emergency Planning Group, Information Governance Management Assurance Group, Clinical Safety and Effectiveness Group, Safeguarding Group, Mortality Review Panel and the Health and Safety Committee.

Learning is acquired from a variety of sources which include:

• analysis of incidents, complaints, claims and acting on the findings of investigations
• quality impact assessments
• equality impact assessments
• external Inspections
• internal and external audit reports
• clinical audits
• outcome of investigations and inspections relating to other organisations.

Freedom to speak up

• Our Freedom to Speak Up Guardian (FTSUG) plays a lead role in engagement and interaction with our staff.
• This role supports the organisation in complying with the outcomes set up by the National Guardian Office and the outcomes include:
• A culture of speaking up being instilled throughout the organisation;
• Speaking up processes are effective and continuously improved;
• All staff have the capability to speak up effectively and managers have the capability to support those who are speaking up; and
• All staff are supported appropriately when they speak up or support other people who are speaking up;
• The Board is fully sighted on, and engaged in, all Freedom to Speak Up matters and issues that are raised by people who are speaking up; and
• Safety and quality are assured.

In October 2020 the National Guardian Office (NGO) published their index of the Guardians. This uses the national staff survey to benchmark the ‘speak up’ culture across the NHS and seeks to ensure that a culture of speaking up, listening and openness is the way our business is conducted on a day to day basis.

Lincolnshire Community Health Services has scored 85.5% in this index, an increase on last year’s score 83.6%. This places LCHS high on the national list, with the highest scoring Trust scoring 86.6%. The national average is 79.2% and the highest performing Trust was 87.6%.

The Trust has reviewed how the highest rated Trusts deliver this work and this learning is being embedded in LCHS, as follows: 

• The visibility of our leaders and executive team is seen as a priority;
• Back to floor visits from senior leaders and executives are increasing;
• An ethos of compassionate leadership is embedded;
• Staff have the opportunity for informal discussions with leaders;
• We have a robust induction programme which includes meeting an executive and hearing messages from the speak up guardian and staff side team; and
• We have an active staff side

During the pandemic technology was used to ensure that staff continued to have good access to support, and to ensure the guardian and other leaders were visible.

The National Guardians Office produced two e-learning modules Speak Up and Listen. These are now promoted across LCHS and are available to staff via the intranet.

In 2020-21 there was a total of 60 concerns raised with the Freedom to Speak Up Guardian compared to 29 for 2019-20, an increase of 206%.

The quarterly breakdown of concerns and movement across the year is shown here:

Themes of concerns raised 

The main reason for staff contacting the Guardian is from staff seeking an independent view of a situation they find themselves in. Often the support relates to helping them make decisions on next steps and actions on how to resolve a concern themselves. Staff experience in Figure 6 includes behaviours, bullying, relationships and working conditions/hours.

Note: Staff Experience includes behaviours, bullying, relationships and working conditions/hours.

Response and engagement from leaders and executives

The FTSUG is continuing to work with leaders at all levels to support investigations and address any concerns. Meetings with the Chair, Chief Executive, Executive Directors and Non-Executive Directors have taken place at regular intervals throughout 2020-21.    

Speak up Champions

There are currently 5 champions in areas that have acknowledged lower levels of speaking out for fear of detriment.  These being from the “Lived Experience” staff networks (2), preceptorship, apprenticeship & medics.  All have undergone the NGO’s training package and act to promote the speak up culture, identify any potential cases and signpost and be a supporter & listener to contacts.  They do not have any access to the records kept by the FTSUG.

Proactive Role of the FTSUG

In line with the guidance from the National Guardian the role of the FTSUG is designed to have a more proactive role with the focus on early support and intervention to prevent escalation of issues and the ensuing negativity this can bring.  This has been a working practice of the guardian within LCHS and many cases have only required pre-emptive minor actions and positive outcomes have been achieved.

Leadership support for Freedom to Speak Up Guardians

The strong commitment for the role and the support of the LCHS leaders is unchanged, in fact due attention to the response times required during the Covid 19 pandemic has expediated many cases to satisfactory conclusions. The FTSUG meets with all personnel and has solid links to staff side and safeguarding. The work of the FTSUG is also supported at Board level with a non-executive director giving regular oversight.

Annual Summary of Contacts

This year has seen the highest number of FTSUG contacts to the LCHS Speak up Guardian and this mirrors the national position from all guardians’ information collated nationally up to Q3.

Year                  Contacts

2017/18              6

2018/19              26

2019/20              29

2020/21              60

The NGO reported a national increase in the 2019/2020 period as 32% - data for 20/21 not yet available.

The following charts highlight the distribution of contacts by service and staff type. The ratios are as expected and there are no unexpected changes to highlight.

The main reason for staff contacting the Guardian is to seek an independent view of a situation they find themselves in. Often the support relates to helping them make decisions on next steps and actions to resolve a concern themselves.

System working and partnership

Fulfilling the wider objectives of the Trust requires effective partnership working in addition to the internal governance and control framework.  As the Chief Executive, I am accountable to the Trust Board, the Chair and NHS Improvement. I am also accountable, along with the Trust Board, to the Secretary of State via NHS Improvement.

I ensure that the Trust works effectively in partnership across the wider health community in Lincolnshire.  Key partnerships include:

• NHS Lincolnshire Clinical Commissioning Group and adjoining counties
• Health commissioners
• Health Scrutiny Committee
• Joint Staff Consultation and Negotiation Committee
• Lincolnshire County Council
• Lincolnshire Healthwatch
• NHS England and NHS Improvement (NHSEI)
• NHS Providers
• Sustainability and Transformation Partnership (STP) System Executive Team (SET)
• STP Executive group
• Executive STP groups (including Finance Bridge Group)
• System Winter Team
• Groups to monitor impact and preparedness for Brexit.

The Trust is fully compliant with the registration requirements of the Care Quality Commission.

Lincolnshire Community Health Services NHS Trust has taken all precautions, actions and Trust-wide reviews to comply with the NHS Provider licence and confirms compliance with conditions G6 (2), G6(3) and current and future compliance with FT4(8).

The trust has published on its website an up-to-date register of interests, including gifts and hospitality, for decision-making staff (as defined by the Trust with reference to the guidance) within the past twelve months, as required by the ‘Managing Conflicts of Interest in the NHS’ guidance.

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.

The Trust has undertaken risk assessments and has a sustainable development management plan in place which takes account of UK Climate Projections 2018 (UKCP18). The Trust ensures that its obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.

Review of economy, efficiency and effectiveness of the use of resources

Information Governance

There were no Serious Incidents Requiring Investigation (SIRI) relating to Information Governance reported to the Information Commissioner’s Office (ICO) during 2020-21.

The Information Governance Management Assurance Group (IGMAG) oversees all Information Governance (IG) and Data Protection (DP) issues and reports to the Finance, Performance and Investment Committee (FPIC) whilst also providing assurance to the Trust Board to ensure that statutory and regulatory requirements are met. 

The IGMAG is chaired by the Senior Information Risk Owner (SIRO), who is the Director of People and Innovation and whom is responsible for overseeing the development and implementation of the Trust’s Information Risk Management Strategy.

Staff are encouraged to report Information Governance incidents and seek further advice and guidance regarding any additional actions that may need to be taken and implemented.

IG training follows the Core Skills Training Framework (CSTF) and is an annual mandatory requirement for all staff, new starters, including temporary and bank.  Staff are governed by a code of confidentiality for any data they have access to which is strictly access controlled to authorised users through National Policy and Role Based Access Control (RBAC).

Each IT system; whether corporate or clinical, has a designated Information Asset Owner (IAO) with defined responsibilities, including risk management responsibility for identifying IG risks. These are supported by Information Asset Administrators (IAA) who provide support at a local level.

The submission for the Data Security and Protection Toolkit (DSPT) was published 1st May 2020 with all standards met and gained ‘Significant Assurance’ from the Auditors.

The Trust is fully compliant with the National Data Opt-Out which is a service that allows patients to opt out of their confidential information being used for research and planning.

Date quality and governance

The Performance and Information team conduct regular data quality checks on datasets and reports. They are also involved with national NHS Benchmarking work which enables the Trust to benchmark its own data with that of other Trusts to enable comparators and scope for improvement. The team works closely with the Digital Health team to enable front-end changes to correlate into meaningful data and analysis.

A Data Quality Group provides the Trust with assurance that the Trust’s data and information, provided both internally and externally, is being carefully monitored and that improvements are being identified and implemented where necessary. It also enables the Trust to demonstrate its commitment to encouraging a culture of continuous improvement and accountability. The Finance, Performance and Investment Committee has oversight for the Data Quality Group and receives a report from them every 6-8 weeks on data quality assurance.

The report then goes to the Trust Leadership Team and Trust Board meetings.

The Quality and Risk Committee considers a wealth of other relevant information through the year including quarterly updates on safeguarding, Quality Impact Assessment post implementation reviews, Lessons Learned reports and National Quality Board data.

Quality and Risk Committee includes attendance of Quality Assurance Managers and a culture of health two-way challenge ensures the validity of data and the scrutiny of reporting.  Internal Audit undertook a review of the Quality Account during the year and provided some recommendations, all of which were enacted and reported to the Quality and Risk Committee and monitored by the Audit Committee.

Board and Trust Leadership

The Trust Board at the close of the 2020-21 year comprised the Chair (Elaine Baylis QPM), four Non-Executive Directors (Alan Kent, Liz Libiszewski, Kevin Lockyer and Gail Shadlock), the Chief Executive (Maz Fosh) and four Executive Directors (Ceri Lennon, Tracy Pilcher, Yvonne Owen, Sam Wilde). As a result of difficulty recruiting during COVID the Trust maintained one Non-Executive Director vacancy. There were no in-year changes to the Trust Board membership.

The Trust needed to be able to release as much capacity as possible to support the Trust and system response to the Covid-19 emergency whilst retaining an appropriate level of control.  NHS England and Improvement published guidance on 28 March 2020 regarding reducing burden and releasing capacity. To support the reduced agenda and governance structure LCHS’ Trust Board received the following written updates:

• Covid-19 Response including a Chief Executive’s Overview Summary detailing any key decisions taken for retrospective approval. 
• Quality and Risk Covid-19 Report
• Finance, Performance and Investment Covid-19 Report
• Covid-19 Risk Register and the Trust Corporate Risk Register

The NHS England and NHS Improvement guidance stated that quality committees should continue, however, other committees should be streamlined and meetings suspended until later in the year.  Quality and Risk Committee continued to meet, however, both Finance, Performance and Investment Committee and Audit committee were suspended for the wave 1 Covid-19 response period, until 31st July 2020. 

Quality and Risk Committee (Q&RC)

Q&RC continued to meet (virtually) on a monthly basis.  All meetings aimed to be concise and last no longer than 60 minutes.  A streamlined agenda was delivered with the majority of content captured through the overarching report from the Director of Nursing, AHP’s and Operations covering the following 5 items

1. Safeguarding;
2. Patient Safety (including Serious Incidents and Risk);
3. Infection Prevention and Control;
4. Mortality;
5. Covid-19 response, and
6. Mass Vaccination Service Report to LCHS (from January 2021 as Lead Provider and under LCHS CQC registration).

Finance, Performance and Investment Committee (FPIC)

The committee was suspended until the 31st July 2020.  During this time the following items only from the FPIC forward planner were reported directly to Board through either verbal updates or as elements within the Finance, Performance and Investment Covid-19 written report:

1. Health & Safety Updates – Verbal updates provided, predominantly focused on Covid-19 related health & safety issues
2. Finance Report – A monthly written Finance report was maintained, although the scope was reduced to only include an analysis of Income and Expenditure and Cash-flow performance versus a Trust level forecast.  In addition, the first Finance report also incorporated an update on contracting arrangements during the Covid-19 emergency for information.
3. Integrated Performance Report – The Board continued to receive a reduced version of the Integrated Performance Report. This contained the scorecard and a short narrative on key adverse variances that were unanticipated. Performance Management Review (PMR) meetings were also stood down for this period. The Trust will fully restore its performance reporting process through the first six months of 2021/22.

Trust Leadership Team

The Trust Leadership Team continued to meet weekly on a socially distanced/virtual basis. The meeting was extended to include all Head of Service colleagues to ensure leaders were supportive to coordination and response efforts.

Duration of Emergency Arrangements

The emergency governance arrangements were in place from March 2020, with retrospective Board approval on 14 April 2020 and remained in place until 31st July 2020, in line with national guidance. Movement into phase 3, Recovery, in August 2020 meant Audit and FPIC committees met during August to review and provide position reports to 8 September Board in preparation for re-commencing meetings in September 2020. Through the remainder of 2020-21 Committees continued to meet to ensure that services continued to be supported. The Remuneration and Terms of Service Committee met as required.

Trust Board members, deputy directors and heads of service all reviewed and rated how LCHS stands in relation to CQC Well-Led criteria between June and September of 2020, through Board development sessions and deputies and heads of service sessions. The review and internal assessment outcomes revealed strong internal risk, control and assessment processes in place as well as effective leadership and communication mechanisms. Areas for development related to engaging patients, the public and community members in organisational business. New practice implemented as a result of the review included increased engagement activity throughout the Trust’s continued response to covid-19 along with developments to the patients friends and family questions, this service being rolled out through text messaging and the process to recruit a volunteering services manager. Work has also taken place to enhance and capture patient experience and sharing through the existing Patient Story initiative at Board meetings along with Staff Stories and consideration of Board’s dual role of having oversight and providing stewardship.

Audit Committee

The Audit Committee meets quarterly, although this was stepped down through wave 1 of the pandemic and has a key role in providing assurance to the Trust Board on the control mechanisms that are in place across the Trust. The Audit Committee reviews the adequacy of all risk and control related disclosure statements together with any accompanying head of internal audit statement prior to endorsement by the Trust Board.  The committee receives regular update reports from, among others, the Director of Finance and Business Intelligence, the Deputy Director of Corporate Governance and both internal and external audit.

In addition to a number of issues being reviewed on a continuous basis the Audit Committee gave further consideration during 2020-21 to risk management.  This involved maturing the risk, controls and governance arrangements in the Trust and system for covid-19 response and restoration. Support provided by LCHS to the system to develop and roll out two large mass vaccination centres, the Trust taking responsibility of the Lead Provider and CQC registration status for the two sites. A significant piece of work has been the development of the previous Trust Risk Appetite Statement, alignment of this to the Board Assurance Framework and strategic aims and objectives.

The committee continues to develop and enhance mechanisms to gain assurance on all areas that come within its terms of reference, which were also reviewed and amended during 2020-21. It approves a programme of work by internal audit (Grant Thornton LLP), external audit (KPMG LLP) and counter fraud (PWC to 31/08/20, Counter Fraud Plus Collaborative from 01/09/20), based on a risk analysis with a number of new and more in-depth clinical assurance mechanisms being introduced, to allow it to provide the necessary assurance to the Trust Board on an on-going basis.

Names of directors forming an audit committee

Alan Kent – chair

Kevin Lockyer – non-executive director

Gail Shadlock – non-executive director

Sam Wilde – director of finance and business intelligence

Also in attendance:

• Deputy Director of Finance and Business Intelligence
• Deputy Director of Corporate Governance
• Client manager (internal audit);
• Director (external audit);
• Senior manager (counter fraud)

Review of effectiveness

As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the NHS Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the information provided in this annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee and the Quality and Risk Committee, as well as sub committees and others within the group structure, and a plan to address weaknesses and ensure continuous improvement of the system is in place.

My review is informed in a number of ways. The Head of Internal Audit provides me with an opinion on the overall arrangements for gaining assurance through the Board Assurance Framework and on the controls reviewed as part of the internal audit work. Executive managers within the organisation who have responsibility for the development and maintenance of the system of internal control provide me with assurance. The Board Assurance Framework itself provides me with evidence of the effectiveness of controls that manage risks to the organisation.

My review was also informed by: 

• delivery of audit plans by external and internal auditors
• unconditional registration with the Care Quality Commission

The Head of Internal Audit is required to provide an annual opinion on the systems and processes of internal control employed in the Trust. The Head of Internal Audit Opinion provided a rating of “significant assurance with some improvement required”.

During the year the Trust has made real and sustainable improvements to its governance arrangements.  It has embedded further structure and guidance in relation to the management of risk and clinical audit. Following on from wider structural changes, further improvements to re-align and enhance its governance arrangements were undertaken. Following wave 1 of the Covid-19 response the Trust revised its organisational governance structure to ensure that infection prevention and control, safeguarding and quality impact assessment panel groups report directly into the Quality and Risk Committee. In additional Equality, Diversity and Inclusion group and the Information Governance Management Assurance Group were realigned to report into FPIC.

In conclusion, I am assured that no significant control issues existed within Lincolnshire Community Health Services NHS Trust during the 2020-21 year.

Maz Fosh, Chief Executive

Lincolnshire Community Health Services NHS Trust

Signature: 

Date: 8th June 2021