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

4. Our Governance
Royal Devon and Exeter NHS Foundation Trust
Annual Report and Accounts 2012/13
93
Risk management is included in
the Trust’s mandatory training
programme and follow up
refresher training. The Trust’s
risk management policies and
procedures are available on the
Trust’s intranet, IaN.
3.6 In June 2011, the Trust
implemented Datix web, an
electronic Governance System,
which has the ability to record
and monitor incidents, complaints
and risks. Since its implementation
the reporting and management
of incidents has improved. The
complaints and risk register
module were implemented in
December 2011 and January 2012,
and the legal claims module was
implemented in October 2012.
3.7 Senior clinical staff and
Governance Co-ordinators
are trained to conduct Serious
Incidents Requiring Investigation
(SIRI). The Risk Management Team
co-ordinates SIRIs and adverse
incidents which are reported and
managed through the Incident
Review Group (a sub group of the
Safety and Risk Committee) and
learning points are made available
to all relevant staff. All SIRIs and
action plans are shared with the
Trust’s lead commissioner, NHS
Devon.
4. The risk and
control framework
4.1 The Board of Directors is
responsible for the strategic
direction of the Trust. The Board
of Directors has reviewed and
approved a revised Risk Strategy
and updated, amended and
approved the Board Assurance
Framework accordingly. The Board
Assurance Framework identifies
the key risks and mitigations
related to the Trust's strategic
objectives and key priorities. The
Board Assurance Framework
is reviewed by the Board of
Directors on a quarterly basis.
The Corporate Risk Register is
reviewed by the Governance
Committee each time it meets. The
Governance Committee reports to
the Board of Directors quarterly.
The Audit Committee considers
the Assurance Framework when
setting Internal Audit’s annual
work plan.
4.2 Any material gaps in controls of
assurance are highlighted and
reported to the Board of Directors.
When identified, risks to the Trust’s
strategic objectives that cannot be
immediately eliminated are placed
on the corporate register and
action plans put in place to address
any gaps. The Board of Director’s
risk and control framework is
supported by the Audit Committee
and Governance Committee which
provide assurance to the Board
of Directors on risk and control
management issues.
4.3 The Audit Committee is a
Non-Executive Committee of the
Board of Directors and reviews the
establishment and maintenance of
an effective system of integrated
governance across the whole of
the Trust’s activities that supports
the achievement of the Trust’s
objectives. The Committee
provides assurance to the Board
of Directors that the governance
system is functioning in accordance
with the framework agreed by the
Board.
Specifically, the committee reviews
the adequacy of:
• All risk and control-related
disclosure statements together
with the Head of Internal Audit
Opinion and external audit
opinion (ISA 260 report) prior to
endorsement by the Board
• The annual audit plans (and
approves these)
• The data assurance process
underpinning the Trust’s Quality
Report
• The underlying assurance processes
that indicate management of
risks that may impact the degree
to which achievement of the
corporate objectives is secured,
together with the effectiveness
of the management of principal
risks and the appropriateness of
disclosure statements
• The policies and procedures
for all work related to fraud
and corruption as required by
the counter fraud and security
management service