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

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.