Annual governance statement

Scope of responsibility

As an 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 2023 and up to the date of approval of the annual report and accounts.

Capacity to handle risk

LCHS has a comprehensive approach to risk management, accountability, ownership and responsibility of risks and issues. The risk management process is owned by Trust Board with Executive Directors and Deputy Directors being directly accountable for each risk and issue and for the appropriate and effective mitigating actions, in line with the Code of Governance, the NHS Provider Licence and the Orange Book, principles and concepts of risk management. The trust Risk Management Strategy outlines the responsibilities of the Trust Board, Executive Directors, Deputy Directors, the Deputy Director of Corporate Governance, senior leaders, and employees in accordance with roles, and the process of a monthly review of all Trust risks and the escalation process.

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. Monthly assurance meetings discuss and review risks and issues, mitigations in place and learning from the management of these, which is shared through leaders across the trust, the trust leadership team and extended leadership team discussions and in Trust Board Committees. The Deputy Directors, Divisional Leads, Heads of Service, Specialist Advisors and Quality Performance and Improvement Leads play a key role, individually and collaboratively, in effecting consistency in the assessment of risks and issues, the escalation and improvement of risks and issues and their subsequent movement onto and between LCHS corporate risk registers.

LCHS actively collaborates with partners across the Lincolnshire system to review and manage risks and issues proactively, collaboratively and collectively. Examples of effective collaboration of risk management to prevent patient harm are the supportive approach to Spalding Surgery patients during 2022-23 and the joint provision of covid vaccinations through two large vaccination sites.

On an annual basis, the Trust Board reviews the Trust Risk Appetite Statement along with examples of how this has been utilised in practice throughout the financial year to support decision-making. The 2022-23 Trust Risk Appetite Statement was aligned to the Trust’s strategic aims to enable strategic decision-making in light of the Trust’s appetite and capacity for risk for each of the strategic aims.

The risk and control framework

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

The Trust Risk Management Strategy has been reviewed by key stakeholders and risk champions within LCHS and proposed revisions have been discussed in assurance groups and Trust Committees prior to ratification by the Trust Board in March 2022 in preparation for the 2022-23 financial year. This included a full review and realignment of the Trust’s Risk Appetite Statement following board development sessions in-year and testing the 2022-23 risk appetite alignment to strategic objectives through Board decision discussions during the year.

The strategy is available to the public and employees on the Trust website. The purpose of the strategy is to ensure that risks and issues 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 identification, management, ownership, review of risks and issues along with risk criteria, control and gaining assurance of risk or issue and the methods in which risks and issues are considered, assessed, and mitigated.

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 Operational Risk Register for risks holding an overall score of 4 to 11, monitored through the Trust Leadership Team monthly and informed by local risk registers held by divisions with support from Quality Performance and Improvement Leads and/ or risk owners for corporate functions. Local Risk Registers for risks that have an overall score of 1 to 3 are owned by the risk lead and managed through local assurance groups. Robust mechanisms are in place to ensure risks are managed effectively, moved between registers appropriately and 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 can identify, assess, and develop mitigating action plans to reduce and manage each risk or issue effectively.

The organisation’s Risk Appetite Statement is published on the website and reviewed periodically through strategic decision making application and 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:

• Corporate Risk Registers
• 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 in best practice and is regularly reviewed and assessed through internal processes. While the Strategy was collaboratively rewritten and published in March 2022, in preparation for the 2022/23 financial year, regular reports at every meeting of the Trust Board reflect developments, movements and mitigations of risks, issues 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. Regular Deputy Director huddles, risk and control management forming a key part of these discussions, have supported the development of the risk culture, and promoted collective as well as individual responsibility at the highest level and consistency in assessment.

A significant development over the last two years has been the process to embed how the trust approaches potential fraud risk within the overarching risk and issues management processes. A key aspect of this has been for all Deputy Directors to meet regularly with the Fraud Specialist to discuss the current risks relating to potential fraud, monitoring processes in place and any incidents or occurrences. A key part of these reviews also seeks to support learning and improvement to reduce the risk of fraudulent activity.

The key high-scoring risks on the Corporate Risk Register during 2022/23 included the following:

1. Risk that Trust services are disrupted due to the NHS or the trust being targeted in a cyber-attack which could result in significant disruption to clinical and corporate services if systems fail
2. Risk that staffing levels are not sufficient to meet demand in urgent care, community hospitals and community nursing services due to an increase in demand for services, increased interventions, and activity to reduce waiting lists, staff sickness and vacancies that could result in a negative patient experience and potential for patient harm as well as loss of staff morale and possible closure of departments
3. Risk to delivery of efficiency requirement and due to non-delivery of planned schemes, delays, or inability to implement efficiency savings of increased complexity due to system implications and potential reputational negative impact and ability to meet financial duties
4. Risk to water supply to patients, staff, and visitors due to third-party routine maintenance of the estate by the landlord being ineffective which could result in patient, staff, or visitor harm
5. Risk of inadequate ventilation in buildings due to dysfunctional plant systems and maintenance by third-party landlords resulting in potential disruption of services, adherence to infection prevention and patient safety
6. Risk that patients treated within LCHS services could deteriorate due to delays while awaiting ambulance transfer, resulting in patient harm.

Of the high-scoring risks from 2022-23 detailed above, mitigating actions for each risk continue to be implemented, such as the recruitment of additional staff in community hospitals, nursing, and urgent care teams to support increased service demands. The remaining risks continue to be managed and reviewed regularly.

Additional high-rating risks during 2022-23 that were closed or mitigated to the extent of movement to corporate operational or local risk registers were:

1. Risk to Spalding GP Surgery patients receiving safe and effective care due to vacancy gaps and recruitment challenges as a result of the contract coming to an end for provision of LCHS services at the practice and delays in notes summarisation and addition to clinical systems which could result in patients being unable to access timely care, continuity of care provision and access to timely long-term conditions support and potential to impact on patient safety. Risk closed
2. Risk that the trust fails to deliver all aspects of its financial plan due to service pressures, the level of demand being experienced and unforeseen events which could result in reputational damage, reduction in SOF rating and potential lack of sustainability. Risk closed
3. Risk that the adult community therapy service does not have the capacity to meet the current demand for the service due to a significant increase in demand and referrals received outweighing service capacity and the increased complexity of referrals received following the pandemic. This could result in increased waiting list delays, impact on patient care and deterioration of patient conditions. Risk closed
4. Risk that the trust will fail to meet the speech and language needs of the adult population of Lincolnshire due to demand exceeding commissioned capacity which could result in failure to provide timely specialist interventions and treatment, the potential for deterioration of patients waiting and potential harm. Risk mitigated, reduced, and moved to the operational risk register
5. Risk of key financial information and data being lost due to a change in the ledger provider, which could result in loss of data and infrastructure, an inability to make or receive payments, an impact on the reputation of the trust and failure of the trust to meet financial requirements. Risk mitigated, reduced, and moved to the operational risk register.

LCHS is passionate about learning from risk management and during the 2022/23 year the deputy director of corporate governance has been working with teams and leaders across the organisation to provide advice about risk management, develop an understanding of definitions of risks and issues, the differences between controls for risk and actions to mitigate and supporting through coaching methodology. The governance structure and Matters Reserved for the Board and Scheme of Delegation set out the route, responsibilities, and accountabilities of Trust Board, Committees and Specialist Groups for risk management and the escalation and improvement of risks and issues. Ensuring corporate, operational, and local risk registers and the trust Board Assurance Framework shape each agenda has helped to embed the risk management culture of the Trust. Additional support to staff at all levels has been provided throughout the year to support identification, ownership of risk and appropriate escalation of risks and issues. It is planned that this will continue throughout 2023/24 as the trust moves to the management of risks through the Datix system supported by training to 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 aims and objectives. The Board Assurance Framework is aligned with 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 – the Quality and Risk Committee (QRC) and the Finance, Performance, People, and Innovation Committee (FPPIC) – assess every business item against the Board Assurance Framework and the Trust’s noted appetite for risk for each strategic aim. This enables direct assessment against compliance on all fronts, including the Care Quality Commission (CQC) requirements. The committees review the corporate risk register monthly, with an overall score of 12 or above, in addition to risks on the operational risk register, with an overall score 4-11, where the trust risk appetite is noted as ‘cautious’. The trust has a cautious risk appetite for risks and issues relating to patient safety or harm, staff safety and wellbeing, cyber security, health and safety and recruitment compliance. Board members agreed when reviewing and setting the 2022-23 risk appetite that upward reporting from committees to Board will identify such risks that require Board’s attention on the operational risk register.

The Risk Management Strategy and the Trust Governance Manual (Standing Orders, Standing Financial Instructions and the Matters Reserved to the Board and Scheme of Delegation) stipulate the accountability for risk management and approval of changes to the Corporate Risk Register lies with the Trust Board. Operational management and oversight for the Operational Risk Register (ORR) reside with TLT.

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 and People Plan progress reports, assurance reports and update risk and work plans to FPPIC. All policies approved by this forum can be escalated to Board for endorsement and/or challenge. Quality and Equality Impact Assessments are completed to assess substantive changes to the workforce or services and are reviewed and approved through the Quality and Equality Impact Assessments Panel, which reports to QRC. As a pilot Equality Delivery System 3 site the Trust has championed initial assessments for each of the three domains for patients, our people, and our leadership, along with the development of action plans for services identified and for the Trust Board and senior leaders for Trust leadership outlined in domain 3.

The Digital Executive Group (DEG) was also established in 2022-23 with delegated responsibly and oversight for digital, cyber and information governance and data privacy, significantly developing and strengthening the trust position to respond to the increasing cyber and digital threats and opportunities for developing patient care provision in the home.

Sharing the learning gained through risks and issues, incidents, complaints and claims management processes is an essential component of maintaining the risk management culture within the trust. Learning is shared through divisional and corporate structures and trust-wide governance committees and groups as outlined in the trust organisational structure. Assurance and learning conversations take place in local assurance groups, such as the Quality Assurance Groups that support each clinical division, and report to specialist groups like the Stakeholder, Engagement and Involvement Learning from Deaths, Drugs and Therapeutics Group and the Health and Safety Committee.

Learning is acquired from a variety of sources that include:

• analysis of incidents, complaints, claims and acting on the findings of investigations
• quality impact assessments
• equality impact assessments
• equality delivery system
• freedom to speak up
• non-executive champions
• external Inspections
• internal and external audit reports
• clinical audits
• outcome of investigations and inspections relating to other organisations

Our Freedom to Speak Up Guardian (FTSUG) is well embedded into the trust and 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 (NGO) and the outcomes include:

• A culture of speaking up is 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
• 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 on matters and issues that are raised by people who are speaking up
• Safety and quality are assured.

12 principles for responding to speaking up have been introduced and utilised by the FTSUG.

1. NGO principles for responding to speaking up
2. There will be clear and accessible information on how to speak up.
3. Speaking up processes will be designed so that all workers can speak up easily.
4. Everyone who speaks up will be thanked.
5. Where appropriate, workers will be encouraged and supported to speak up locally.
6. If another organisation (e.g., another national body) better addresses a matter, workers will be supported to speak up to that organisation.
7. Workers will be offered information on other sources of advice and support.
8. Workers speaking up will be provided with a response in a timeframe that is made clear to them.
9. Responses to speaking up will include details setting out how the information provided was used for learning and improvement.
10. The confidentiality of those who speak up will be respected, subject to the need to ensure safeguarding requirements are met.
11. Where matters are raised anonymously, they will be responded to in accordance with these principles to the extent possible.
12. Workers will be given the opportunity to feedback on their experience of speaking up.

The speaking up arrangements’ effectiveness will be monitored, and opportunities to improve taken.

Results of the 2022 NHS Staff Survey – Speak up questions

There was a small amount of change in the responses of staff to the “speak up questions” contained in the NHS Staff Survey 2022.

• Q19a – would feel secure raising concerns about unsafe clinical practice. 2021- 83%. 2022 - 81% (national average 81%)
• Q23e – would feel safe to speak up about anything that concerns me in this organisation. 2021 - 74%. 2022 - 75% (national average 72%)
• Q23f – if I spoke up about something that concerned me, I am confident my organisation would address my concern. 2021 – 63.2%. 2022 – 63.9% (national average 61%).

Annual contact numbers

The Guardian had 95 contacts in 2022/23 (comparable to 94 contacts in 2021/22). This has shown a steadying off in the rate of contacts from previous years. This could signal a benchmark figure of how the role is now embedded in LCHS and should enable a greater ability to detect changes in culture in either direction.

As with previous years, the greatest number of contacts were pertaining to staff experience. Patient safety or quality issues were 14% and related to staffing levels, which were rapidly escalated.

• 8 of the contacts were from exit questionnaires
• 3 contacts were anonymous
• 20 contacts have left the organisation the majority pertaining to the issue that led to the speak up contact.
• 22 contacts were identified as having protected characteristics.

Note: Staff experience includes behaviours, bullying, relationships and working conditions. Worker safety includes health and safety at work and emotional wellbeing issues.

Note: some staff were both nurses and managers

Three contacts have advised that they have felt disadvantaged by speaking up. This has been addressed and the FTSUG has followed the Midlands Guardians Guidance in this aspect and escalated with the CEO and non-executive director for oversight.

As the Chief Executive, I am accountable to the Trust Board and NHS England to deliver the wider objectives of the trust. Effective and integrated partnership working is fundamental to this, in addition to the internal governance and control framework. In July 2022, new primary legislation was passed by the Department of Health and Social Care that created a duty for NHS providers to collaborate. This new legislation created integrated care systems (ICS), with the aim of bringing providers closer together to improve patient care and outcomes. We also heard that our regulators were planning to assess us on how well we work with and through the Lincolnshire system to tackle challenges as regulators including the Care Quality Commission (CQC) and NHS England place a greater emphasis on system performance and quality of care outcomes. As such, myself and the Board are responsible for ensuring that the trust works effectively in partnership across the wider health community in Lincolnshire.

After being established in ‘shadow’ form in 1 April 2021, the Lincolnshire system formally established the ‘Better Lives Lincolnshire’ ICS in July 2022. This new partnership brought together organisations across health and care in the county to collectively improve services and the health and wellbeing of the people of Lincolnshire, including:

• Three NHS trusts provide community, acute and mental health services across Lincolnshire (Lincolnshire Community Health Services NHS Trust; United Lincolnshire Hospitals NHS Trust; and Lincolnshire Partnership Foundation NHS Trust)
• East Midlands Ambulance Service NHS Trust
• Lincolnshire County Council (and seven District Councils which work with the County Council)
• NHS Lincolnshire Integrated Care Board (coterminous with County Council) which replaced Lincolnshire Clinical Commissioning Group in July 2022
• Lincolnshire’s GP practices are grouped into 14 Primary Care Networks
• Lincolnshire Care Homes Association (the membership organisation for around 300 care homes in the county)
• Lincolnshire Voluntary Engagement Team (LVET, a collective of voluntary, community and social enterprise organisations with a focus on developing and delivering health, care, and wellbeing services in Lincolnshire)
• Other key partners for example, Lincolnshire Police, housing services, education, the independent sector, and groups that represent the community and public including Healthwatch.

In line with national aims of ICSs, the Better Lives Lincolnshire aims to:

1. Improve outcomes in population health and healthcare
2. Tackle inequalities in outcomes, experience, and access
3. Enhance productivity and value for money
4. Help the NHS support broader social and economic development.

The formation marked the transition from NHS Lincolnshire’s Clinical Commissioning Group to the new NHS Lincolnshire Integrated Care Board (ICB) for the county, as part of statutory changes which have been introduced across the NHS in England. The Board of NHS Lincolnshire’s ICB was established to improve health and care for local people across the county, held its first meeting in public on 1 July 2022. The ICB features representatives from local NHS trusts, primary care, local authorities, voluntary organisations, and community providers. It is ultimately responsible for planning and coordinating services on behalf of local people, as well as working with partners and the public to develop plans for meeting the health needs of its population, managing the local NHS budget, and arranging for the provision of local health services.

The Lincolnshire Integrated Care Partnership (ICP) helps to meet the needs of the population including more joined-up, preventative, and person-centred care. The ICP brings together leaders from the NHS and local authorities along with representatives from the voluntary and community enterprise sector, private providers, criminal justice agencies, and community representatives such as Healthwatch and residents. During 2022, the partnership produced an interim Integrated Care Strategy to improve health and care outcomes and experiences for the people of Lincolnshire, for which they are all accountable. The ICP will continue to engage with the population throughout 2023. This will have a great impact on the Lincolnshire population, as well as our Trust, and will support our own strategy development over the coming years.

During this year, the Lincolnshire Provider Collaborative – Lincolnshire Health and Care Collaborative (LHCC) was established to drive the provision of high quality, cost-effective integrated health, and care services through greater collaboration across all providers. In August, the Provider Collaborative undertook a ‘stocktake’ to ensure it is focusing on the right priorities and that providers are working effectively together. In January 2023, following the recommendations, Elaine Baylis – chair of United Lincolnshire NHS Hospitals Trust and then chair of LCHS, was appointed as the Non-Executive Director to chair the LHCC Delivery Board.

Examples of what we have delivered through our great partnerships in Lincolnshire can be exemplified by the work of driving personalised care for Lincolnshire. This care means that people have choice and control over the way their care is planned and delivered. It is based on ‘what matters’ to them and their individual strengths and needs. This year, partners from across health, social care and the voluntary sector came together to support the wider Lincolnshire Personalisation Programme. Some of the work that went on during 2022, consisted of looking at how colleagues from the NHS, the voluntary sector, and people with long COVID worked together to co-produce the Lincolnshire Post COVID Service.

In addition to the above, through partnership, LCHS has led and contributed to the delivery of:

• Complex neurology, cardiology, respiratory and frailty virtual wards with a palliative and end-of-life virtual planned for implementation
• ‘Winter’ initiatives which helped to create additional bed capacity
• discharge initiatives that supported more timely discharge from hospital.

To further meet the workforce challenges, we experience across the system, as well as the wider NHS, LCHS worked with our partners in the Lincolnshire People Board to develop solutions for a more sustainable workforce pipeline. LCHS already invests in apprenticeships and upskilling our existing workforce, however, these are often long-term developments and recent service expansion provides a more immediate challenge. During this year we developed an innovative partnership with Humber and North Yorkshire ICB, the Department of Health and Social Care (DHSC) and NHSE to develop an international recruitment (IR) framework that will enable us to work directly with the Kerala State Government in India to recruit directly into our system.

Kerala has one of the highest standards of health and care in India. It intentionally trains a surplus of health and care professionals including doctors, nurses, and other health care professionals, recognising that a significant number leave to work overseas. Developing the IR framework in partnership with another system, and with support from DHSC and NHSE, enables LCHS to gain experience and expertise in international recruitment at lower risk to us. On November 4 of our leaders travelled to India to interview prospective employees for both registered nurse and allied health professional (AHP) roles with the aim of appointing up to 40 staff to posts in LCHS services in 2023.

These examples show that greater integration delivered through effective partnership working will continue to allow us to achieve more financially sustainable services and provide better care coordination through improvements in experience, access, and outcomes for our communities, whilst also enhancing the overall welfare of our local communities through a place-based approach to out-of-hospital care.

Care Closer to Home celebrates its first year

Launched just over 12 months ago, the Care Closer to Home programme has been providing coordinated care for patients in their homes or in the local community. Care Closer to Home enables those with complex care needs, or who have multiple medical conditions or are frail, to live healthy and independent lives at home or in a place they call home and out of the hospital wherever possible. Its principles are:

joined-up services, where everyone who is caring for patients understands their medical history and the health and care services, they use

access to a wide range of professionals and diagnosis facilities in the community, so patients can get access to the professionals and the services they need in a single appointment

different ways of getting advice and treatment including digital, telephone-based, and face-to-face services, matched to the patient’s individual needs

shorter waiting times, with appointments at a time that works around patient’s life

greater involvement of patients (when they want it) in decisions about their care

an increased focus on preventing ill health and enabling people to take greater control of their own health.

Some of the highlights of the last 12 months have included supporting the national 100-day discharge challenge to improve patient discharge from hospital, developing the Discharge to Assess service, launching the Urgent Community Response service, and the palliative single point of access receiving its 1000th call.

Integrated Community Nursing

The delivery of the Integrated Care programme will be in phases and the priority is Integrated Community Nursing. Pilot sites in Boston, South Lincoln, and First Coastal Primary Care Network (PCN) are exploring new templates for working for improve joined up care in the community between Lincolnshire Community Health Services (LCHS) community nursing team and PCNs. The learning and evaluation of the pilot sites will be used to inform future models of working across the county.

New app to help people WaitLess for urgent and emergency care services in Lincolnshire

The Lincolnshire system has introduced a smartphone app, which is designed to help people choose the least pressured urgent and emergency care services and to understand waiting times better.

The WaitLess app combines current waiting time, queue numbers and travel time at urgent care facilities in the county. This displayed information helps people make an informed decision about where to seek the fastest treatment for minor illnesses and

injuries. Along with this, the app displays all available pharmacies in the area as an alternative treatment options. The times shown on the app combine travel, waiting and treatment time, to give patients the most accurate picture of how long they may spend at each location, allowing them to decide on the most appropriate setting to attend. The app also displays a full list of services available at each site, as well as parking and opening-time information. The app supports patients to access the care they need at the best place for their needs and supports reducing pressure on urgent care services.

Organisation’s statutory obligations

The Trust is fully compliant with the registration requirements of the Care Quality Commission and the NHS trust Provider Licence conditions of G6 and FT4(8), against which LCHS is fully compliant as noted within this report.

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 and all Board members are required to annually declare whether they meet the fit and proper persons test, which all Board members completed in April 2022 and upon appointment in-year.

As an employer with staff entitled to membership in 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 plans in place which take account of the ‘Delivering a Net Zero Health Service’ report under the Greener NHS programme. The trust ensures that its obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.

Information governance

There were no Data Breach Incidents relating to information governance reported to the Information Commissioner’s Office.

The Digital Executive Group (DEG) oversees all Information Governance and Data Protection issues and reports to the Finance, Performance, People, and Innovation Committee whilst also providing assurance to the Trust Board to ensure that legal, statutory, and regulatory requirements are met. The DEG is chaired by the Senior Information Risk Owner, who is the Director of People and Innovation.

Staff are encouraged to report Data Breach Incidents and seek further advice and guidance regarding any additional actions that may need to be taken and implemented.

Mandatory information governance (IG) training follows the Core Skills Training Framework and is an annual requirement for all staff. Induction training for new starters is delivered through the accredited e-learning ‘Data Security Awareness Training’ which requires a minimum of 80% pass mark.

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.

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

The submission for the Data Security and Protection Toolkit (DSPT) was published on 13 June 2022 with all standards met and achieved ‘Significant Assurance with some improvement required’ from the auditors.

This level of assurance has been achieved for three consecutive years.

Data quality and governance

The Portfolio Managers within the Finance and Business Intelligence Directorate conduct regular data quality checks on datasets and reports. The team connects with the 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. The team also provide key data that informs Performance Management Reviews, which are conducted with each division and corporate area to assess performance against agreed key performance indicators and metrics to drive measurement, review, and improvement.

Performance data and reporting is a key component of FPPIC and Quality and Risk Committee (QRC) assurance, highlighting areas where key performance indicators and metrics are being achieved and can be celebrated, or enable committees to focus attention to inconsistent performance or where indicators are not being achieved and to prompt appropriate action to be taken.

Key FPPIC performance indicators relate to our people, recruitment, health and safety, digital programmes, access and tackling digital inequalities, strategic planning, partnership working and feedback from commercial stakeholders and financial planning.

The Quality and Risk Committee considers a wealth of performance information from complaints, incidents, safeguarding contacts and referrals, compliments, claims received, national Quality Board data, patient friends and family test percentage responses through to collating lessons learned following feedback and demonstrating the impact of acting on feedback and learning in service developments.

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 (until August 2022)
• Sam Wilde, Director of Finance and Business Intelligence
• Ceri Lennon, Director of People, and Innovation
• Dr Yvonne Owen, Medical Director (until 31 July 2022)
• Dr Anne-Louise Schokker, Medical Director (from 18 July 2022)
• Reva Stewart, Chief Operating Officer (from 22 August 2022, non-voting board member)
• Dr Karen Dunderdale, Director of Nursing, Quality and AHPs (from 17 October 2022)

Non-Executive Directors (NED)

• Alan Kent, Audit Committee Chair (until 31 October 2023)
• Gail Shadlock, Doctors Disciplinary and Wellbeing Guardian Champion
• Ian Orrell, Audit Committee Chair (from 1 January 2023)
• Jim Connolly, Quality and Risk Committee Chair and Freedom to Speak Up NED Champion
• Malcolm Burch, Security Management Champion
• Murray Macdonald, Finance, Performance, People, and Innovation Committee Chair

Also, in attendance:

• Deputy Director of Corporate Governance
• Corporate Administration Manager and Personal Assistant.

The board met monthly throughout 2022-23 alternating between formal public and private meetings one month and board strategy, development, and training sessions the next. The Board’s main committees – the Quality and Risk Committee and the Finance, Performance, People, and Innovation Committee – met monthly. The Remuneration Committee met 4 times during the year. The Board of Trustees for Charitable Funds met three times during the year.

During 2022/23 the Board engaged with Deloitte’s to work with the Trust and system partners to review its effectiveness in line with the Well-Led framework, Care Quality Commission’s revised strategy and national developments. Deloitte worked with the Board members, the Executive and Deputy Director teams Senior Leaders within the trust and system partners comprising the local authority, fellow NHS provider trusts and the Integrated Care Board. The review celebrated strengths the trust embodied, such as system partners noting the skills, experience and reputation of Board members, which are highly regarded both within the Trust and by partners across the broader health and care system. In particular, Board Members were seen to uphold the values of the Trust, viewed as leading by example in their style and behaviours and highlighted LCHS as a proactive and active partner who can be relied upon both to step in to support system working and to provide leadership where needed. The review also recognised the need for the trust to rationalise and refocus participation in system activities and identified areas for development to improve assurance conversations, such as simplified reporting into Trust Board Committees and upward reporting into Board, review of succession planning opportunities and develop a robust plan for 2023-24 onwards, in additional to the equality delivery system 3 pilot site board action areas to be implemented in 2023-24.

Changes to the Board membership in-year were:

• Tracy Pilcher, Director of Nursing, Operations and Allied Health Professionals and Deputy Chief Executive, left the trust on 31 August 2022
• Dr Yvonne Owen, Medical Director, retired on 31 July 2022
• Dr Anne-Louise Schokker, Medical Director commenced with LCHS on 18 July 2022
• Reva Stewart, Chief Operating Officer started in post on 22 August 2022, as a non-voting board member
• Dr Karen Dunderdale commenced a joint Director of Nursing position with United Lincolnshire Hospitals Trust on 17 October
• 2022
• Alan Kent, Chair of the Audit Committee, stepped down as a Non-Executive Director on 31 January 2023.
• Ian Orrell commenced in the post as Audit Committee Chair and Non-Executive Director in a joint position with Lincolnshire Partnership NHS Foundation Trust on 1 February 2023.

Register of directors’ interests

Review of effectiveness

As the Accountable Officer, I have the 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 improvement required, the second highest rating an organisation can receive.

During the year the trust has made real and sustainable improvements to its control and governance arrangements. It has embedded further structure and guidance in relation to the understanding and management of risk and clinical audit and further improvements to re-align and enhance its governance arrangements relating to population health management, health inequalities and digital inequalities.

Audit Committee

The Audit Committee meets quarterly 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.

During the year the Committee Chair transitioned from Mr Kent to Mr Orrell. To ensure effective consistency of assurance and oversight of controls transitional handover days and meetings took place during January 2023 prior to Mr Orrell officially commencing in post. The Committee during the year gave particular consideration to the developmental areas highlighted to trust through internal audits completed during the year with relevant leads in the trust providing follow-up assurance of completion of actions and improvement realised, such as the significant positive reduction of overdue Datix incidents, overdue the National Institute for Health and Care Excellence (NICE) guidance updates and e-rostering improvements implemented in-year. LCHS continued to undertake the role of lead provider and the Trust’s CQC registration for the provision of COVID vaccinations through the Lincolnshire vaccination centres, in collaboration with system partners, in addition to undertaking the role of the lead employer on 1 October 2022 to support proactive population health improvement and outreach to marginalised groups through a variety of outreach models.

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 2022/23. It approves a programme of work by internal audit (Grant Thornton LLP), external audit (Mazars LLP) and counter fraud (Counter Fraud Plus Collaborative), based on risk analysis and clinical assurance mechanisms, 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 (until 31 January 2023)
• Ian Orrell – Chair (from 01 February 2023– present)
• Gail Shadlock – Non-Executive Director
• Malcolm Burch – Non-Executive Director
• Sam Wilde – Executive Director of Finance and Business Intelligence

Also, in attendance:

• Deputy Director of Finance, Performance, and Information
• Deputy Director of Corporate Governance
• Medical Director/ Deputy Medical Director
• Client manager (internal audit)
• Director (external audit)
• Local Counter Fraud Specialist.
• Quality and Risk Committee (QRC)

The Quality and Risk Committee met each month by virtual means, inclusive of a development session in December 2022. The Committee provides assurance to the Trust Board that appropriate and effective clinical and quality governance mechanisms are in place for all aspects of quality and risk including safety of clinical services, management of risk, understanding and acting on patient feedback, clinical effectiveness including health outcomes, learning from incidents and complaints, clinical audits, NICE guidance and review, medications management and medical devices, delivery of the Clinical Strategy, equality, diversity, inclusion and health inequalities (access to services, impact of change on patients and the public), population health management, verbal updates, as necessary, from Non-Executive Director Champions (Freedom to Speak Up and Doctor’s Disciplinary), compliance with national, regional and local regulatory requirements.

During the year the quality team underwent a restructure which enabled a revised support structure for quality and clinical governance to be recruited and the development of roles to incorporate an increased focus on quality improvement and performance support to clinical teams and divisions. Revised reporting through the clinical safety and effectiveness group (CSEG) and into the Committee has ensured increased focus on exception reporting and celebrated significant developments in the reduction of overdue incident reporting, improvement in supervision and developments in quality data dashboards and performance information to effectively and positively shape patient safety conversations and decision-making. Substantial development of triangulation across complaints, incidents, claims and patient advice and liaison contacts received through revised reporting mechanisms and development of Datix, and business intelligence data has also commenced supporting improved reporting, assurance discussions and decisions. Weekly complaints, incidents and claims executive review meetings have driven improved responses to patients, increased accountability and further data and themed triangulation.

Finance, Performance, People and Innovation Committee (FPPIC)

The committee provides assurance to the Trust Board that appropriate and effective governance mechanisms are in place for all aspects of financial and operational strategy, policy, management and reporting, people and innovation, health and safety, performance management and reporting, procurement strategy and investment policy, integrated business planning, associated strategies, digital health and cyber security, security management, information governance, equality, diversity, inclusion and health inequalities, population health management (performance, finance, data and staff aspects), verbal updates, as necessary, from Non-Executive Director Champions and compliance with national, regional and local regulatory requirements.

The committee has provided effective challenge and assurance in oversight for strategic aims 3, 4 and 5, particularly relating to vacancy and recruitment developments, inclusive of international recruitment, financial accountability, planning, delivery and performance, such as the change of ledger provider and support infrastructure; development of business intelligence in addition to estates, innovation and digital developments, for instance, the trust-wide rollout of digital innovations and move to the SharePoint system, security upgrades to all hardware and cyber protections and measures introduced.

Trust Leadership Team

The Trust Leadership Team (TLT) continued to meet throughout the year. TLT comprises of Maz Fosh (Chief Executive and Chair), all Executive Directors (Sam Wilde, Ceri Lennon, Tracy Pilcher (until 31 August 2022), Yvonne Owen (until 31 July 2022), Dr Anne-Louise Schokker (from 18 July 2022), Reva Stewart (from 22 August 2022) and Dr Karen Dunderdale (from 17 October 2022), all deputy directors and for extended meetings divisional leads and heads of service joined meetings. TLT oversee the running of Trust business and connect into committees and the Trust Board as required. The team also hold responsibility for the corporate operational risk register.

In conclusion, I am assured that no significant control issues existed within the Lincolnshire Community Health Services NHS Trust during the 2022/23 year.

Maz Fosh, Chief Executive

Lincolnshire Community Health Services NHS Trust