Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital

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4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13 91 Compliance with the NHS Foundation Trust Code of Governance The Code of Governance published in September 2006 (last updated 1st April 2010) contains recommended best practice to be followed by FTs in areas of corporate governance. The Code contains main and supporting principles, which are subject to ‘comply’ or ‘explain’ reporting procedures. Any provisions with which the Trust does not comply must be disclosed in the Annual Report. In last year’s Annual Report, the following provisions were reported under the ‘explain’ category: E.2.2 Definition of senior management – which states that “the Remuneration Committee should have delegated responsibility for setting remuneration for all Executive Directors, including pension rights and any compensation payments. The committee should also recommend and monitor the level and structure of remuneration for senior management. The definition of ‘senior management’ should be determined by the Board but should normally include the first layer of management below Board level.” It was reported to the Board in April 2013 that the Trust had maintained compliance with all the provisions of the Code for the current year. As explained in the section on Executive Director remuneration (see page 80) the EDRC, confirmed by the Board, have extended the definition of senior management to include the tier of management below Executive Directors and that the terms and conditions for this category of Very Senior Managers be taken out of AfC and be considered by the Executive Director Remuneration Committee. Therefore, the Board has declared that it is fully compliant with all the provisions set out in the Code of Governance. The Trust’s explanation for noncompliance with this provision was that the Board has defined ‘senior management’ to be limited to Board Members only. All other staff were covered by the Agenda for Change scheme of nationally agreed terms and conditions.
92 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13 Annual Governance Statement 1. Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust’s policies, aims and objectives, whilst 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 NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. 2. 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 the Royal Devon & Exeter NHS Foundation 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 the Royal Devon & Exeter NHS Foundation Trust for the year ended 31 March 2013 and up to the date of approval of the Annual Report and Accounts. 3. Capacity to handle risk 3.1 During 2010/11 the Board of Directors commissioned a review of the Trust’s governance framework and agreed a development plan which resulted in a revised governance architecture with effect from October 2011. An interim review undertaken by Internal Audit in July 2012 reported “the governance structure has been strengthened greatly”. A full review is currently underway and is due to be reported in April 2013. 3.2 The Audit Committee monitors and oversees both internal control issues and the process for risk management. Audit Southwest (internal audit) and PWC (external auditors) attend all Audit Committee meetings. The Audit Committee reviews all reports of the Internal and External Auditors and reports regularly to the Board. 3.3 Risk issues are reported through the Governance Committee via the Safety and Risk Committee and the Trust’s management structure. Management and ownership of risk is delegated to the appropriate level from Director through to local management through the divisional management teams. All Directorates have Governance Groups which meet regularly. There are established Governance Co-ordinator posts to support the Directorates in implementing robust risk and governance processes. Directorate Governance Groups report and escalate concerns to the five Governance sub-committees. Strategic risks are managed via the Board-owned Board Assurance Framework. This document lists all risks that could prevent the Trust from achieving its strategic objectives. 3.4 The Board has appointed a Senior Independent Director to be available to Governors and Members if they have concerns, which contact through the normal channels of Chairman, Chief Executive or Director of Finance has failed to resolve, or for which such contact is inappropriate. In addition the Trust has a Whistleblowing Policy to protect staff who raise issues of concern. 3.5 All staff joining the Trust are required to attend Corporate Induction, which covers key elements of risk management. This is further enhanced at departmental induction. Training courses are run on a regular basis and provide staff with the skills needed to undertake risk management duties. Staff are trained and equipped to manage risk in a way appropriate to their authority and duties.
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1. ACCOUNTING POLICIES (CONTINUED)
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