Annual Governance Statement

Scope of Responsibility

As 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 2022 and up to the date of approval of the annual report and accounts.

Capacity to handle risk

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 discussed in assurance groups and trust Committees prior to ratification by the trust Board in March 2022. This included a full review and realignment of the trust’s Risk Appetite Statement following board development sessions in-year and testing the 2021-22 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.

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 Corporate Governance Code and the Orange Book, principles and concepts of risk management. 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 Corporate Operational Risk Register for risks holding an overall score of 4 to 11, monitored through the trust Leadership Team on a monthly basis and informed by local risk registers held by divisions with support from Quality Assurance Managers and/ or risk owners for corporate functions. Robust mechanisms are in place to ensure risks are managed effectively, moved between registers appropriately and to 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 are able to identify, assess and develop mitigating action plans to reduce and manage each risk or issue effectively. 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. The Deputy Directors, Divisional Leads, Heads of Service, Specialist Advisors and Quality Assurance Managers 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.

The risk and control framework

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. The organisation’s Risk Appetite Statement is published on the website and reviewed periodically while 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 within best practice and is regularly reviewed and assessed through internal processes. While the Strategy was collaboratively rewritten and published in March 2022 regular reports at every meeting of the trust Board reflect developments, movement 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. A significant development during 2021-22 has been the development and investment to strengthen local risk registers for digital and information governance and consolidation of the clinical services local risk registers with the corporate operational risk register (May-July 2021). 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.

Among the key high-scoring risks on the Corporate Risk Register during 2021-22 were:

1. Risk to community nursing and capacity due to vacancy gaps, the time between recruitment and start dates, sickness and self-isolating alongside an increase in demand for the service which could result in possible failures to identify and monitor deterioration in patients leading to an impact on patient safety.
2. Risk that staffing levels are not sufficient to meet demand in urgent care services due to increase in demand for the service, staff sickness, self-isolation and vacancies that could result in a negative patient experience and potential for patient harm as well as loss of staff moral and possible closure of departments.
3. Risk to service sustainability and deliverability due to future changes to commissioning, with the potential to result in reduction in income or opportunity to invest, affecting financial viability of the trust and its services.
4. 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.
5. Risk of delay in providing initial health assessments for looked after children and children in care in Lincolnshire caused by a lack of consistent General Practice resource with suitable training to undertake assessments, resulting in health and safeguarding implications on the children and potential impact on their wellbeing and future development
6. Risk that the delivery of the two large vaccination sites in Lincolnshire under the trust’s Care Quality Commission’s registration may impact negatively on quality governance reporting and the trust’s reputation due to the organisation working with Lincolnshire partners differently and where the trust is not the leading operational provider or employing organisation and could result in loss of oversight assurance for patient safety, potential patient harm and reputational damage. urgent and emergency care services across Lincolnshire could become overwhelmed due to periods of high activity, resulting in patient safety issues.

Of the high-scoring risks from 2021-22 detailed above, mitigating actions for each risk continue to be implemented, such as the significant recruitment of additional staff in community nursing and urgent care teams. Nonetheless, additional programmes such have also seen investment from teams, such as the urgent community response programme. The remaining risks continue to be managed and reviewed regularly.

1. Additional high-rating risks during 2021-22 that were closed or mitigated to the extent of movement to corporate operational or local risk registers were:
2. Risks relating to the trust and system response to Covid-19, such as the provision of personal protective equipment, the restoration of services and the trust’s lead provider role for the two Lincolnshire large vaccination centres based in Boston and Lincoln.
3. Risk that the inadequate maintenance of the NHS Property Services-owned estate could result in a loss of service and/or damage to persons.
4. Risk that urgent and emergency care services across Lincolnshire could become overwhelmed due to periods of high activity, resulting in patient safety issues.
5. Risk that patients treated within LCHS services could deteriorate due to delays while awaiting ambulance transfer, resulting in patient harm.
6. Risk that the UK left the EU with either ‘no deal’ or a deal and the possible impact upon LCHS activity, with potential to result in significant disruption to services, supply, business delay and logistics. This was revised post securing an exit agreement.
7. Risk that the trust will not have the capacity or competencies within teams to effectively respond to the anticipated Children and Young People (CYP) Respiratory Surge in Winter 2021/22 due to respiratory viral infection, identified anticipated challenges of an increased prevalence of paediatric respiratory viral infections that could impact of patient safety of children and young people.

LCHS is passionate about learning from risk management and during the 2021-22 year the deputy director of corporate governance has been working with teams and leaders across the organisation to provide advice about risk management, develop understanding of definitions of risks and issues, the differences between controls for a 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 and local risk registers and the trust Board Assurance Framework frame 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 2022-23 as a further risk management training programme is piloted 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 to 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 each and every business item against the Board Assurance Framework. This enables direct assessment against compliance on all fronts, including CQC requirements. The committees review the corporate risk register monthly, with an overall score of 12 or above, in addition to risks on the corporate 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 risk appetite that upward reporting from committees to Board will identify such risks that require Board’s attention on the corporate 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 trust Board. Operational management and oversight for the Corporate Operational Risk Register (CORR) resides 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 progress reports, assurance reports and updates risks and work-plans to FPPIC. All policies approved by this forum are able to be escalated to Board for endorsement and/or challenge. Quality and Equality Impact Assessments are completed to assess substantive changes to workforce or services and are reviewed and approved through the Quality and Equality Impact Assessments Panel, which reports into QRC.

Sharing the learning gained through risks and issues, incidents, complaints and claims management processes is an essential component to 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 into 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 which include:

• analysis of incidents, complaints, claims and acting on the findings of investigations
• quality impact assessments
• equality impact assessments
• external Inspections
• internal and external audit reports
• clinical audits
• outcome of investigations and inspections relating to other organisations.

Freedom to speak up

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 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 matters and issues that are raised by people who are speaking up.
• Safety and quality are assured.

The results of the 2021 NHS Staff Survey – four Speak up questions are as follows:

• Question 17a, I would feel secure raising concerns about unsafe practice – 82.6% slight increase from 82.5% in 2020, UK average 83.1%.
• Question 17b, I am confident my organisation would address my concerns - 72.5% decrease from 74.8% in 2020, UK average 72.4%.
• Question 21e, I feel safe to speak up about anything that concerns me in this organisation – 73.3% a decrease from 74.2% in 2020, UK average 71.4%.
• Question 21f, (new question for 2021) If I spoke up about something in my organisation I am confident my organisation would address my concerns - 63.1% - highest being 69.2% and lowest 48.6%.

Analysis enables targeted work in areas identified and has resulted in additional FTSUG hours.

introduced and utilised by the FTSUG.

NGO Principles for Responding to Speaking Up

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

Annual contact numbers

The number of contacts continue to increase year on year as the role has become embedded, and senior leaders across the trust are referring to the guardian as part of everyday communications where relevant.

As with previous years the greatest number of contacts were pertaining to staff experience. Any patient safety or quality issues were small in number, detailed later in the report and related to staffing levels, which were rapidly escalated.

Themes of contacts

bullying, relationships and working conditions.

Worker safety includes health and safety at work and emotional wellbeing issues.

Only one contact was pertaining to COVID-19 and that was resulting from redeployment issues.

Staff role

Of the 48 nurse contacts 21 were band 7 or above. From the above contacts the majority came directly to the FTSUG other areas that signposted or directed contacts to the FTSUG are:

• Leavers questionnaire 7
• Champions network 7
• Staffside 3
• Staff networks 2

One case expressed detriment which has been rapidly escalated.

Service area breakdown

Fulfilling the wider objectives of the trust requires effective partnership working in addition to the internal governance and control framework. As the Chief Executive, I am accountable to the trust Board, the Chair and NHS England and Improvement. I am also accountable, along with the trust Board, to the Secretary of State via NHS Improvement. Increasingly the trust will be assessed on how well it works with and through the system it is part of to tackle problems as regulators including the Care Quality Commission and NHS England and Improvement 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. Key partnerships include:

• NHS Lincolnshire Clinical Commissioning Group and CCGs in adjoining counties
• The Integrated Care Board designate which will be formally established on 1 July as the CCGs are dissolved and their duties taken into the ICB
• Other health commissioners including the local authority and NHS England
• Lincolnshire Health Scrutiny Committee which reviews and scrutinises health and wellbeing services and their outcomes
• Unions including through the Joint Consultation and Negotiation Committee (JCNC)
• Lincolnshire County Council including adult social care and children’s services
• The 15 Primary Care Networks in Lincolnshire and the Primary Care Network Alliance
• The voluntary, community, and social enterprise sector via the Voluntary Engagement Team
• The independent sector including care home and nursing home providers through Lincolnshire Care Association (LinCA)
• Community and patient representative bodies including Lincolnshire Healthwatch
• Regulators including NHS England and NHS Improvement (NHSEI) and Care Quality Commission
• Infrastructure bodies including NHS Providers and NHS Confederation
• The Better Lives Lincolnshire Executive Team made up of the top leaders from among Lincolnshire health and care providers
• Lincolnshire Health and Care Collaborative, an alliance of health and care providers who will take responsibility for delivering key functions on behalf of the ICB, of which I am co-chair
• Lincolnshire NHS Leaders Group of NHS provider chief executives and chairs and the CCG (ICB after 1 July).

Better Lives Lincolnshire

Better Lives Lincolnshire is the name used for the Integrated Care System (ICS) in our county. From 1 April 2021 this new partnership brings together organisations across the NHS, primary care, local authority, the voluntary, community and social enterprise sector, and independent sector to collectively improve services and the health and wellbeing of the people of Lincolnshire. In line with the 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 development of the Lincolnshire Integrated Care System has also progressed ahead of it formally coming into effect in July 2022 through the Health and Social Care Act 2022. The ICS includes the NHS Lincolnshire Integrated Care Board (ICB) and the Integrated Care Partnership (ICP).

The ICB is a statutory board responsible for developing a plan to meet the health needs of the population, managing the NHS budget and arranging for the provision of health services in the defined area. The ICB will replace the Lincolnshire Clinical Commissioning Group.

The ICB work continues on developing the governance arrangements for the Lincolnshire Integrated Care Board and Integrated Care Partnership. The Integrated Care Partnership is a statutory committee of the ICS whose members support integrated working at a system level and develop a strategy that describes the changes it wants to achieve.

Provider collaboratives

Provider collaboratives are a key component of system working. They are the main way for providers to work together to plan, deliver and transform services in an ICS by working at scale to tackle unwarranted variation, make improvements and deliver the best care for patients and communities.

The Lincolnshire Health and Care Collaborative (LHCC) has been established as the provider collaborative for the county that will drive the improvements in quality of care while ensuring services are integrated and cost effective. While there may be more than one provider partnership in Lincolnshire, LHCC is the provider collaborative for Lincolnshire. The context, supported by new legislation, is changing from competition to partnerships, closer integration and local collaboration.

This collaborative will be enabled by legislation on 1 July 2022, setting a platform for driving forward increased collaboration, putting the health and care needs of residents as priority and taking the opportunity to think differently, work closer and more efficiently than ever.

The commitment to the residents of Lincolnshire remains the same:

• A healthy population with better information for people to manage their own health, earlier prevention and making sure we tackle inequalities with equitable provision supporting health and wellbeing.
• Strong communities with people and their families included in health and care management, ensuring no one is disadvantaged with good advocacy and support, and ensuring we contribute to making a difference to wider aspects of daily life that can improve people’s health and wellbeing.
• Accessible, integrated, and responsive care, listening to people and treating them holistically, working together in much more joined up approach, fully developing care closer to home. And reducing waiting times for diagnosis, appointment, and test results.

An Alliance Agreement describes how partners will work together to establish more robust mutual accountability and break down barriers between our separate organisations.

In the immediate term, the provider collaborative deliverables include three key transformation programmes that will contribute to the delivery of the Strategic Delivery Plan which will take Lincolnshire out of SOF 4. The phase 1 projects are:

• Prescribing including for mental health conditions
• Muscular skeletal problems
• Care closer to home, providing co-ordinated care for patients in their homes or in their local communities that enables residents and patients to keep themselves well, take charge of their own health, whilst maintaining access to high quality care at the right time, with the right specialist support.

As the Integrated Care Board becomes established it will look to delegate responsibility for specific functions to the provider collaborative. We anticipate that these will be:

• Data and digital
• People and culture
• Service delivery, redesign and transformation.

In 2022, the provider collaborative will focus on developing the next phase of transformation projects that will help Lincolnshire to deliver its Strategic Delivery Plan to exit SOF 4, and the programmes under the two other functions.

Organisation’s statutory obligations

The trust is fully compliant with the registration requirements of the Care Quality Commission.

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.

As an employer with staff entitled to membership of 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 (ICO) during 2021/22.

Information Governance Management Assurance Group (IGMAG), following significant review through 2021-22 to reflect digital and cyber programmes, data, assurance and risk, has been renamed to the Digital Executive Group (DEG). The group 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 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 rate.

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 information governance risks. These are supported by Information asset administrators who provide assistance at a local level.

The submission for the Data Security and Protection Toolkit was published 11 June 2021 with all standards met and achieved ‘significant assurance with some improvement required’ from the auditors.

Data quality and governance

The Performance and Information team, 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.

A Data Quality Group provides the trust with assurance that the trust’s data and information, provided both internally and externally, is being carefully monitored and that improvements are being identified and implemented where necessary. It also enables the trust to demonstrate its commitment to encouraging a culture of continuous improvement and accountability. The Finance, People, Performance and Innovation Committee has oversight for the Data Quality Group (FPPIC) and receives a report from them every 6-8 weeks on data quality assurance and in relation to the significant work to develop power business intelligence across the trust. In February 2022 the national ‘Make Data Count’ team presented trust data using statistical process control tool to simplify and improve data quality and reporting and reduce spuddling in assurance meetings, enabling the trust to focus on trends that require action. FPPIC reports bimonthly into trust Board.

Performance data and reporting is a key component of FPPIC and Quality and Rick Committee (QRC) assurance, highlighting areas where key performance indicators and metrics are being achieved and can be celebrated, or to 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 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
• Ceri Lennon, Director of People and Innovation
• Sam Wilde, Director of Finance and Business Intelligence
• Dr Yvonne Owen, Medical Director

Non-Executive Directors

• Alan Kent
• Liz Libiszewski (01/04/2021 – 31/10/2021)
• Kevin Lockyer (01/04/2021 – 30/04/2021)
• Gail Shadlock
• Malcolm Burch (from 01/05/2021)
• Murray Macdonald (from 01/07/2021)
• Jim Connolly (from 01/11/2021)

Also in attendance:

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

The board met monthly throughout 2021-22 alternating between formal public and private meetings one month and informal meetings and Board training sessions the next. A programme of monthly Board development sessions were also rolled out, evolving in format through the year which resulted in numerous products being developed, such as an enabling visual graphic, case studies for collaboration and a Board-approved Board Assurance Framework for 2022-23 by the close of the financial year. Several of the products developed supported system conversations and pace in the progression of the Lincolnshire Health and Care Collaborative. The Board’s main committees – the Quality and Risk Committee and the Finance, Performance and Investment Committee, whose title was updated in-year to reflect the transformational nature of the committee to the Finance, Performance, People and Innovation Committee – also met monthly. The Remuneration Committee met five times during the year. The Board of Trustees for Charitable Funds met three times during the year.

Through the Board development programme senior leaders reviewed the trust well-led board, deputy directors and heads of service ratings from the previous financial year in light of the CQC strategy released in May 2021. The session enabled the trust to confirm alignment of the trust strategic aims and objectives to the four areas outlined by the CQC of people and communities, smarter regulation, safety through learning and accelerating improvement. Sessions were rolled out across the trust by the Deputy Director of Nursing and Quality.

Changes to the Board membership in-year were:

• Kevin Lockyer, Non-Executive Director and interim chair of finance, performance and investment committee, left the trust on 30 April 2021
• Liz Libiszewski, Non-Executive Director and chair of quality and risk committee, left the trust on 31 October 2021.
• Malcolm Burch, Non-Executive Director, commenced on 1 May
• Murray MacDonald, Non-Executive Director, commenced on 1 July
• Jim Connolly, Non-Executive Director, commenced on 1 November 2021.

In line with the nationally released guidance in December 2021, LCHS Non-Executive Director Champion roles were reviewed and agreed in March 2022, excluding the Maternity Safety Champion role which is not applicable to LCHS:

• Wellbeing Guardian – Gail Shadlock.
• Freedom to Speak Up – Jim Connolly has taken over this role from Liz Libiszewski as previous Quality and Risk Committee Chair related role.
• Doctors Disciplinary –Gail Shadlock.
• Security Management – Malcolm Burch.

Register of directors’ interests

As Accountable Officer, I have 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 gave particular consideration to the development of fraud prevention and incorporating nationally identified fraud risks into the trust risk management processes, actions identified through internal audits and governance and assurance of vaccination sites and processes. LCHS continued to undertake the role of lead provider and the trust’s CQC registration for the provision of covid vaccinations through the two large vaccination centres, in collaboration with system partners, and for the roll out of vaccinations to school aged children and young people, as per the nationally stipulated cohorts.

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 2021-22. 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 a 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
• Gail Shadlock – non-executive director
• Malcolm Burch – non-executive director (from 1 May 2021)
• 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 (Q&RC)

The Quality and Risk Committee met each month by virtual means, inclusive of a development session in December 2021. The Committee provides assurance to the trust Board that appropriate and effective 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, 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.

Finance, Performance, People and Innovation Committee (FPPIC)

The committee, with the arrival of a new chair in July 2021, reviewed and updated the committee name to more closely reflect the scope of the committee’s accountabilities and priorities of the committee and organisation to be people-centred and innovative as well as driving excellent financial management and performance. The name was updated from the Finance, Performance and Investment Committee to the Finance, Performance, People and Innovation Committee. The committee met monthly throughout the year, with a development session in December 2021.

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, management and reporting, 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.

Trust Leadership Team

The Trust Leadership Team (TLT) continued to meet throughout the year, reducing meetings to twice monthly. TLT comprises of the Maz Fosh (Chief Executive and chair), all executive directors (Tracy Pilcher, Sam Wilde, Ceri Lennon and Yvonne Owen) all deputy directors and for extended meetings divisional leads and heads of service join meetings. TLT oversee the running of trust business and connect into committees and trust Board as required. The team also hold responsibility for the corporate operational risk register.

Emergency Arrangements

On 24 December 2021 NHS England and NHS Improvement issued guidance to NHS trusts in light of the new Omicron Covid variant, the rapid spread and increase in covid positive presentations and the announcement on 13 December to significantly step-up the roll-out of covid vaccinations across the country. LCHS did not step committees or trust Board meetings down at this time, although in the January 2022 board session reducing the burden interim governance arrangements were approved to step down non-essential assurance groups and operate condensed agendas. From the beginning of March meetings and functions that had been temporarily suspended progressed to re-commencing.

In conclusion, I am assured that no significant control issues existed within Lincolnshire Community Health Services NHS Trust during the 2021-22 year.

Maz Fosh, Chief Executive

Lincolnshire Community Health Services NHS Trust

Date: 16 June 2022