Item 8 - Sheffield Health and Social Care

13.0 Annual Governance Statement13.1 Scope of ResponsibilityAs Accounting Officer, I have responsibility formaintaining a sound system of internal control thatsupports the achievement of the NHS FoundationTrust’s policies, aims and objectives, whilstsafeguarding the public funds and departmentalassets for which I am personally responsible, inaccordance with the responsibilities assigned tome. I am also responsible for ensuring that theNHS Foundation Trust is administered prudentlyand economically and that resources are appliedefficiently and effectively. I also acknowledge myresponsibilities as set out in the NHS FoundationTrust Accounting Officer Memorandum.Sheffield Health and Social Care NHS FoundationTrust forms part of the Sheffield social andhealthcare communities. As the AccountingOfficer I work closely with NHS Sheffield, who isthe main commissioner of the Trust’s services. Weare also accountable to Sheffield City Council forthe social care it provides through the Section 75Agreement which is monitored on a monthly basisby the Joint Performance Group, and quarterly viaa Partnership Board. Part of the agreement includesan accountability framework. We also have aNon-Executive Director on our Board of Directorswho is an elected member of the Council. Positiverelationships with NHS North of England, (formedin October 2011 from three Strategic HealthAuthorities – Yorkshire and the Humber, NorthEast and North West), have been maintained.Art therapy atMoncrieffe RoadOT exercise session at theLongley Centre13.2 The Purpose of the Systemof Internal ControlThe system of internal control is designed to managerisk to a reasonable level, rather than to eliminate allrisk of failure to achieve policies, aims and objectives;it can therefore only provide reasonable and notabsolute assurance of effectiveness. The system ofinternal control is based on an on-going processdesigned to identify and prioritise the risks to theachievement of the policies, aims and objectives ofSheffield Health and Social Care NHS FoundationTrust, to evaluate the likelihood of those risks beingrealised and the impact should they be realised,and to manage them efficiently, effectively andeconomically. The system of internal control hasbeen in place in Sheffield Health and Social CareNHS Foundation Trust for the year ended 31 March2013 and up to the date of approval of the AnnualReport and Accounts.13.3 Capacity to Handle Risk13.3.1 Risk Management leadership and StructureCorporate leadership, support and advice for handlingrisk is provided through the Integrated GovernanceTeam (including risk management and clinicalgovernance functions). During the year leadershipfor risk management and governance has changedfrom the Executive Director of Nursing and IntegratedGovernance (current title Chief Operating Officer/Chief Nurse) to joint leadership between the DeputyDan Jarvis MP, Artsand WellbeingConference 2012Chief Executive and the Medical Director. Thisprovides assurance on the Trust’s capacity to handlerisk through the various reports that are providedto the Quality Assurance Committee, the Audit andAssurance Committee and the Board of Directors itself.Roles and responsibilities for risk management aredescribed in detail in the Trust’s Risk ManagementStrategy. Responsibilities include:• All directors are operationally responsible forsafety and the effective management of riskwithin their areas of responsibility• All managers including team managers/leadersand heads of departments are responsible forhealth and safety and the effective managementof risks within their teams, services or departments• All staff in the Trust, including those ontemporary contracts, placements or secondments,and contractors must keep themselves and otherssafe. All staff have a duty of care to provide safeservices and do no harm. All health and socialcare staff working directly with service users andcarers are responsible for ensuring that their workis safe and that they use systematic clinical riskassessment and management processes in thedelivery of care and treatment.13.3.2 Staff Training and DevelopmentStaff training and development needs with regardto risk management and safety are described in theTrust’s Mandatory Training Policy. This policy wasrevised and approved by the Executive Directors’Group (in accordance with the Trust’s Policy onPolicies) in January 2011.Development for the Board and senior managersin 2012/13 has included various workshops onannual planning, looking at the external andinternal environment, service and financial planning,financial challenges, optimising value in care and theimplications of the Health and Social Care Bill 2012.Training provided by the Trust for its staff includes:• Corporate Welcome – An introduction tothe organisation• Core Training – An intensive 4 day trainingpackage for all new starters, which includes riskmanagement, health and safety, equality andhuman rights, information governance, infectioncontrol etc. Training is tailored, dependent uponthe individual’s job role• Incident Reporting and Investigation (includingroot cause analysis);• Mental Health Act• Mental Capacity Act• Health, Safety and Security, including Fire Safety• Equality & Human Rights• Respect (Managing Violence and Aggression)• First Aid and Life Support (including Resuscitation)• Root Cause Analysis• Clinical Risk Assessment and Management• Medicines Management• Safeguarding Children and Vulnerable Adults• Infection Control• Care Programme Approach.The service directorates and the professional groupsalso provided a range of regular training up-datesfor their staff during the year.National Institute for Health and Clinical Excellence(NICE) guidance and evidence-based practicecontinue to be incorporated into clinical practice.NICE guideline implementation groups are establishedfor all mental health guidelines, progress is reportedthrough the Quality Improvement Group and quarterlyto the Quality Assurance Committee of the Boardof Directors. Performance on implementation ismonitored by the Medical Director and also by NHSSheffield. All relevant NICE Technical Appraisals havebeen implemented within timescales.The Trust employs a range of suitably qualifiedand experienced persons who are accessible to allstaff to advise on risk issues, such as clinical risk,infection control, risk assessment, health and safety,litigation, liability, fire and security, environmental,estate management, medicines management,psychological therapies governance, safeguardingchildren and vulnerable adults, human resourcesand finance among others.137138