VEHICLES PRIVATS

As Accounting 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 Foundation Trust who have responsibility for the development and maintenance of the internal control framework. 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. The Head of Internal Audit Opinion confirms overall as significant assurance. Executive Directors and Senior Managers within the Trust who have responsibility for the development and maintenance of the system of internal control provide me with assurance. I have drawn on the content of the quality report attached to 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 of Directors, the Audit Committee, Finance and Investment Committee, and Quality and Governance Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place.

My review is also informed by:

❙ Reports from external auditors;

❙ Assurances on process provided by the Audit Committee and its officers;

❙ Internal Audit reports on arrangements within key Trust functions;

❙ Full compliance with the Care Quality Commission essential standards for quality and safety for all regulated activities across all locations;

❙ Care Quality Commission Quality and Risk Profile;

❙ NHS Litigation Authority reassessment of the Trust risk management standards at Level 1;

❙ Commissioner feedback;

❙ Corporate performance reports;

❙ Quarterly assurance reports to the Board of Directors for submission to Monitor;

❙ Investigation reports and action plans following serious incidents.

The Board of Directors regularly reviews its governance reporting structure. The Board of Directors, Audit and Quality and Governance committees also undertake annual self assessment of their own effectiveness. Each forum has an annual cycle of business and a record is maintained throughout the year of all business discussed.

The Governance Committee has been in place for four and a half years (renamed as the Quality and Governance Committee with effect from September 2010), evolving into a valuable forum for development and review of governance systems and quality improvements including: quality governance policy and strategy; governance framework; patient experience; patient safety; health and safety reports; risk

management; identification of new risks; NHSLA implementation; identification of new legislation; learning from experience; infection prevention and control; implementation of National Institute for Clinical Excellence (NICE) guidelines; clinical audit and effectiveness; information governance; communications and public relations; membership; HR activity; clinical and non clinical training; policy register; compliance; safeguarding updates; and feedback from sub groups.

The Audit Committee and Internal Audit have developed, approved, and monitored a programme for the year to assess the effectiveness and fitness for purpose of key assurance processes and systems of internal control, including assessment of evidence of compliance with Care Quality Commission outcome regulation, and the evidence collection process established for that registration from 1 April 2010; review of the Board Assurance Framework; and review of risk management arrangements. The outcome of the areas monitored as part of the internal audit programme for 2011/12 did not identify any significant issues. Where scope for improvement was identified, recommendations were made and appropriate action plans agreed which are monitored by the Audit Committee. To enhance the existing process in place for the management of internal audits, additional scrutiny by the Governance Team was implemented during the year to ensure there is a corporate overview of all reports considering quality and consistency.

The Trust has a Health, Safety and Security Manager in post who is the Trust’s Local Security Management Service lead. She leads the Trust Health and Safety Group and associated work programme, under the line management of the Head of Logistics. The Trust Audit Committee includes a Local Counter Fraud Specialist who reports to the Deputy Chief Executive/Director of Finance and Performance any matters of concern which are reported to the Audit Committee and myself as the Accountable Officer.

Although no significant weaknesses in internal controls have been identified for 2011/12, a plan to address weaknesses and ensure continuous improvement of the system is in place through continual review of the risk management and assurance processes and development of the Governance Framework including checklists for key functions. Risk based governance checklists were undertaken of three functions during 2011/12: the Transaction project for a proposed acquisition; the NHS 111 tender project; and Equality and Diversity. A programme has been developed for the completion of further governance checklists during 2012/13. The system of internal control has been managed at Board level through scrutiny of the Board Assurance Framework and management of the Trust committees. Action plans are monitored by the appropriate committee which receives exception reports and monitors progress. Escalation is applied where it is felt that a higher level of focus is required eg reports required by the Directors to ensure that issues are being fully managed and that any risk to the Trust is mitigated. The Corporate Performance Report is also monitored at each Board of Directors meeting and provides exception reports and action plans where necessary.

Conclusion

No breaches or significant control issues have been identified. My review confirms that South Western Ambulance Service NHS Foundation Trust has a generally sound system of internal control that supports the achievement of its policies, aims and objectives.

Signed

Chief Executive Date: 24 May 2012

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