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, 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 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 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 our policies, aims and objectives , 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 Trust for the year ended 31 March 2026 and up to the date of approval of the Annual Report and accounts.  

Capacity to handle risk

The Trust has a range of ways in which risks are identified which include:

• I ncident and accident reporting, including near misses
• Outcomes of complaints, investigations and deep dive reviews
• Performance systems and dashboards
• Routine internal and external audits, such as annual safety audits
• External reviews, such as those by the Care Quality Commission 
• Benchmarking, including through the NHS Benchmarking Network
• Utilisation of intelligence from system working with our partners in the South West London Integrated Care System and the South London Community and Mental Health Partnership, as well as input from Health Overview and Scrutiny Committees and local Healthwatch organisations
• Through the work of committees and groups
• Quality, equality and privacy impact assessments of change programmes
• Staff, patient, carer and stakeholder feedback.

  The Trust recognises the importance of making available appropriate resources and infrastructure to successfully manage risk, so that it can effectively deliver its plans and on-going risk management activities. 

These resources include:

• People  - Making sure our staff have the skills, capability, knowledge and support they need to deliver their risk management responsibilities and have the capacity to do so.  Training and coaching will be provided to those who need it.  Assessing and providing development needs of staff is integral to our risk management annual plan. The Trust promotes an open learning culture where staff have the space and opportunities to develop.
• Tools  – Making sure that people have the tools they need to deliver their risk management responsibilities.  This includes access to guidance, risk forms, risk register software, incident reporting software, analytical tools, decision support tools (e.g., a risk matrix), etc. Our plan will include on-going development/improvement of supporting tools and information.
• Co-operation   – Commitment to support each other in managing our risks.  To be successful we all need to work together.  Something could potentially ‘go wrong’ in one part of our organisation or health system; however, the causal factors may originate in another part of our organisation or be external.  Our risk management processes will include arrangements to promote work across disciplines and service lines and the means to handle mitigation and management of risk across the organisation and externally where required. 

All identified risks are required to be assessed and recorded in the Trust’s risk register system and escalated to executive (high risk) risk registers or the Board Assurance Framework (BAF) as appropriate.  Ward/Departmental managers (and above) are authorised to add risks to the risk register system (Ulysses) and must ensure that the risk is properly and fully completed, recognising that once the risk is submitted, the system will send automatic notifications to a number of staff members. These notifications will invite the receiver to view and/or review the risks and will typically be sent to the risk owners (depending on risks levels) and those who have been assigned actions in the system.   

At each stage risks and the risk scoring are formally reviewed through the applicable groups and committees, in line with the Board’s agreed Risk Appetite. This provides levels of risk moderation and challenge to help ensure risks are appropriately articulated, assessed, managed and are escalated in line with defined risks levels and escalation processes. 

We ensure that adequate training is provided to help equip our staff to understand and apply our systems and processes in the successful management of risk. The risk management strategy is being delivered by linking the Trust’s strategic objectives to local objectives and by delivering a focused training programme.             

The current risks on the BAF at the end of 2025 — 2026 were:

• Failure to deliver a great place to work to enable the delivery of great care for our patients and service users.
• A failure to achieve financial targets
• A failure to deliver transformed models of care, working practices and environments within available resources
• Failure to consistently deliver high-quality, safe, and equitable care, alongside a positive experience for patients, families, and carers
• A failure to meet the increasing demand on services relating to adult care pathways while maintaining safe, timely and high-quality care. 

Work has been done this year to refresh and streamline the BAF alongside updating the assurance map.  

The risk and control framework

The Trust adopted an updated Risk Management Framework in 2021. The Framework combines the risk strategy, policy and procedures into one document. This avoids unnecessary duplication and provides a single document detailing the Trust’s aims, approach and arrangements for managing risk throughout the organisation. The Framework is reviewed annually via (RSM) Internal Audit and overseen by the Audit Committee.  

The Risk Management Framework sets a clear organisational policy for the management of risk and a strategy to deliver effective risk management through the organisation’s architecture, systems and processes to ensure objectives are met, and includes full reference to the risk appetite agreed by the Board.  

The Framework covers the strategic elements for risk and extends to describe the key processes and procedures staff at specific levels are required to follow. These cover risk identification through to assessment, mitigation, actions and assurances. The framework clearly establishes the responsibilities for various committees and individuals.  

The scope of the framework is, by its nature, wide, covering areas such as operational management, performance and finance. The Trust also has a clinical risk policy which covers clinical risk assessment and management. The Board has adopted the following risk policy statement:

  The Board is committed to ensuring that:

• Effective frameworks, structures and accountabilities are in place for the effective management of risk at all levels throughout the Trust, achieving a clear line of sight of risks from board to floor. 
• Risk is considered, co-ordinated and managed in an integrated way and not in silos.
• Sufficient resources, people, training and other arrangements are in place to successfully implement the risk management policy, though service line management and corporate structures.
• A culture exists where staff feel empowered to report risk and have the systems and tools to formally assess and escalate risk where necessary.
• Risks are managed in a positive, sensible and proportionate way to maximise opportunities to achieve objectives and the delivery of services, although recognising the Trust has a low-risk appetite to risks in regard to the safety and wellbeing of patients, staff and visitors.
• When risks are realised, there are resilience plans and arrangements to respond and recover, particularly in regard to patient care.
• The Trust focuses upon experience and learning to eliminate or reduce all risks to an acceptable level.
• There is a clear risk management system is in place to enable staff to identify, assess and escalate risks to the appropriate level of management with the necessary authority to appropriately respond to the risk. 

The Trust has the following risk management objectives:

• Ensure effective structures are in place to enable and provide the leadership support needed for staff to undertake their risk management responsibilities, and to build their risk management capabilities.
• Minimise the potential for harm to patients, staff and visitors  to as low as is reasonably practicable, thereby providing a safe environment in which patients can be cared for, staff can work, and the public can visit.
• Promote an open and just culture that makes risk visible, adapts to protect everything of value, providing organisational resilience. 
• Raise abilities of all staff through ongoing training and awareness that is appropriate to specific roles and their responsibilities, ensuring that the benefits of risk management are championed, and systems and processes are understood.
• Systematic processes are used to learn lessons from our successes, best practice, errors and failures.
• Support innovation by enabling initiatives where the management of risk is part of success and not an obstacle. 
• Risks are identified and managed protecting the reputation of the Trust and items of value.
• Risks are regularly reviewed and updated by accountable managers, supported by robust action plans.
• Assurance on the effectiveness of controls / mitigations is provided with gaps in controls identified and proactively managed.
• Maintain high levels of organisational compliance, particularly in relation to standards and requirements associated with safety, assurance and legislation.
• Our approach to risk and opportunity taking and how that affects our decisions is communicated with internal and external stakeholders. 
• Maximise opportunities  by adapting to changing risk factors and learning experience when things go wrong, to continually improve our processes and the way we undertake our activities.
• Measurement to monitor risk performance and provide necessary assurances.

The Risk Management Framework is summarised in this diagram.

The Chief Nurse has overall leadership responsibilities for risk, including the delivery of the risk management framework. The Associate Director of Quality Governance and Risk manages the risk and governance functions on behalf of the Chief Nurse Alongside this, as set out in the Trust’s risk management strategy, the BAF is managed by the Director of Corporate Governance. In addition, the Trust has been subject to a review of the process by Internal Audit to provide assurance on the appropriateness of the process and its operation.

All Executive Directors of the Trust have collective responsibility for the overview and monitoring of risk registers relating to their areas of responsibility, through their management lines.  

The BAF underpins the risk management process by setting out the risks to the Trust achieving its strategic objectives and how these will be managed. 

The BAF lists each principal objective, the risks to achieving each objective and current controls and sources of assurance. Where either control or assurance gaps are identified through internal or external scrutiny, action plans are put in place. The BAF is also informed by risk registers held at corporate levels as defined above. 

All projects are undertaken in line with Project Management principles and process and risks relating to the achievement of the project are recorded within project risk registers. The Executive Leadership Team receives regular monthly updates on the Executive Risk Register and BAF. The Trust submits routine and accurate information on a timely basis through routine reporting and exception reporting.  

A quarterly report incorporating the executive risk register and BAF is produced which is presented to the Audit Committee and then Trust Board. The Audit Committee reviews the risk register and BAF to be assured of the process by which the risk register has been developed and to assure itself that the overall assessment of risk is congruent with its own work programme. In addition, each Board Committee reviews its own section of the BAF.

The Executive Risk Register is also reviewed each month by the Executive Leadership Team and the Quality and Safety Assurance Committee. This committee is charged with looking in particular at risks associated with the quality of care and safety of those who use Trust services. It also helps identify which risks could impact on the strategic objectives, where the committee would recommend, a risk is escalated to the BAF. Report templates all include a section on risk to ensure appropriate profile and diligence for risks.  

Project management arrangements are in place to identify, assess and mitigate any risks to achieve project outcomes safety and without any deterioration in quality. 

The Trust has a range of policies and control frameworks, particularly for high-risk areas and for ensuring compliance with legislation. All policies are available on the Trust intranet site and reviews are undertaken in line with defined timescales and reported through the relevant committees and groups. The Executive Leadership Team receives monthly assurance reports on the Trust’s policies.  

The Trust’s mandatory and statutory training (MAST) policy identifies the key areas of training which staff must undertake to be able to manage key risks within the organisation.

Risk management is a vital part of our governance and quality frameworks and is underpinned by the risk management policy approved by the Trust Board. The policy is subject to periodic review. Performance is subject to regular senior level scrutiny as part of the service line performance reviews.  

The Trust uses a standard risk assessment and scoring matrix typical to most NHS providers, which helps ensure risks are appropriately and consistently assessed and escalated. Through robust executive and service line governance arrangements, all services are required to systematically review risks on their risk registers and provide assurance that the risks are being managed through their local governance group/team meetings.

Risks that reach a certain level are escalated throughout the organisation, meaning there is a clear line of sight from board to floor in relation to risk. 

Visibility on where risks could impact on the delivery of the corporate objectives and business plan are mapped on to the BAF, which is presented quarterly in full to the Audit Committee and then reported to the Trust Board. 

Each Executive Director holds overall accountability for maintaining the risk register and BAF for their area of responsibility.  

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.  

The Audit Committee receives regular and detailed counter fraud reports. The Trust’s self-assessed rating which will be submitted to the NHS Counter Fraud Authority in May 2026, covering the period 2025 — 2026, is as follows: 

The proposed high level overview of the Counter Fraud Functional Standard Return (CFFSR) rating at the end of the 2025 — 2026 financial year. Overall, the Trust has been rated ‘Green’.

• Green – 11 components
• Amber – 1 component
• Red – 0 components

The Trust has appointed a Director of Corporate Governance who is responsible for overseeing appropriate arrangements to ensure that the Trust is able to discharge its statutory functions.  

The Board has regard to such guidance on good corporate governance as may be issued from time to time. The Trust is required to self-certify on compliance with certain conditions equivalent to the NHS provider license. The Trust Board can confirm that, under Condition FT4(8) it has reviewed the governance systems, as outlined in section two of the Annual Governance Statement, and that the Trust Board is satisfied that the Trust has established and implemented: 

·        An effective Board and committee structure;

·        Clear responsibilities for its Board, for committee reporting to the Board and for staff reporting to the Board and those committees; and

·        Clear reporting lines and accountabilities throughout the organisation.

The Trust Board is satisfied that the Trust has established and effectively implemented systems and/or processes to ensure compliance with the Trust’s duty to operate efficiently, economically and effectively:

·        For timely and effective scrutiny and oversight by the Trust Board of the Trust’s operations; and

·        To ensure compliance with health care standards binding on the Trust including but not restricted to standards specified by the Secretary of State, the CQC, NHS England and statutory regulators of health care professions.

The Trust is ensuring that short, medium and long-term workforce strategies and staffing systems are in place which assure the Board that staffing processes are safe, sustainable and effective by putting in place several measures. These include:

·        the operation of a Board committee, the People Committee, chaired by a Non-Executive Director, which provides the Board with assurance on a range of workforce and organisational development (OD) issues and a remit around workforce equality diversity and inclusion matters.

·        a People Matters Group personally led by the Chief People Officer, to provide a monthly forum for key senior staff in the Trust to have direct involvement with, and influence over, Trust recruitment, retention and development of staff, and to ensure that staff resourcing is maximised to focus on the delivery of the workforce plans to support the Trust’s strategy.

·        working through the South London Partnership to explore, design and share best practice and implement models of work aligned to recruit, retain and develop staff. 

·        systematic analysis of the results of the staff survey, supported by comprehensive action plans and structures to provide assurance on the delivery of those plans.

·        putting in place a robust action plan for the Workforce Race Equality Standard.

·        the development of a strong action plan for the Workforce Disability Equality Standard.

·        developing a training needs analysis and apprenticeship strategy for the equitable distribution of apprenticeships throughout the Service Lines and departments to ensure the organisation meets its overall targets.

·        working to ensure inclusive recruitment, retention, learning and development and employee relation practices are in place for the Trust to operate in a fair non-discriminatory manner, to reduce inequalities and to promote the Trust in being an inclusive organisation.

·        ensuring all service lines have workforce plans in place reflecting skill mix changes, role redesign and organisational change programmes / operating models.

·        ensuring that services are supported in delivering their recruitment and workforce plans.

Staffing levels are reported monthly in the Quality and Performance report received by the Executive Leadership Team, the Quality and Safety Assurance Committee and the Board.

The Trust complies with the ‘Developing Workforce Safeguards’ recommendations by:

·        deploying sufficient suitably qualified, competent, skilled and experienced staff to meet care and treatment needs safely and effectively.

·        a systematic approach to determining the number of staff and range of skills required to meet the needs of people using the service and keep them safe at all times.

·        using an approach that reflects current legislation and guidance where it is available.

The Trust continues with its Better Communities programme. All healthcare development at Springfield (Phase 1) has now concluded with Phase 2 focusing on the delivery of inpatient facilities at Tolworth and new outpatient facilities at Barnes and Richmond Royal. This programme has been largely funded by asset sales of surplus estate. The programme is supported by NHS England and the Department of Health and Social Care (DHSC), and a loan was agreed with DHSC to cover the temporary shortfall in cash that occurred during the building phase.  The Trust’s governance processes, through the monthly Better Communities Improvement Group meeting, and the bi-monthly Modernisation Committee provide regular structured assurance to the Board on the delivery of the programme and the mitigation of the programme risks including Chair’s Reports.  

The Trust is fully compliant with the registration requirements of the Care Quality Commission (CQC). The Trust’s ‘good’ rating with the CQC remains in place.  

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) as required by the ‘Managing Conflicts of Interest in the NHS’ guidance. The register of interests is regularly updated and published on the Trust website and a link is also included on all Board agendas.  

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 Board reaffirms on an annual basis its commitment to the NHSE statement on Modern Slavery which is published on the NHS England website

Green plan

The Trust has undertaken risk assessments on the effects of climate change and severe weather and has developed a Green Plan following the guidance of the Greener NHS programme.The Trust ensures that its obligations under the Climate Change Act and the Adaption Reporting requirements are complied with.setting out how we are reducing our environmental impact and supporting a more sustainable NHS.  

We are committed to meeting our responsibilities under the Climate Change Act and national climate adaptation requirements. This means taking action not only to reduce carbon emissions, but also to prepare for the effects of climate change, such as extreme weather.

As part of our Modernisation Programme, the Trust is working towards a 20% reduction in our carbon footprint over four years. This work is delivered through key Green Plan workstreams, including clinical models of care, procurement, estates and facilities, adaptation, travel and transport, and education and engagement. Together, these workstreams support more sustainable ways of delivering care, reduce our environmental impact, and help ensure resources are used efficiently while maintaining high‑quality services for patients and communities.  

The Trust also takes climate‑related risks seriously. We have completed a severe weather risk assessment, which forms part of our Severe Weather Plan. This assessment is informed by the London Risk Register and considers risks such as extreme heat, flooding and severe weather events. Plans are in place to reduce disruption, protect patient and staff safety, and maintain services during adverse weather.

Together, these actions reflect the Trust’s commitment to protecting the environment, future‑proofing services and supporting the health and wellbeing of our patients, staff and local communities.

Severe Weather Risk

The London Risk Register, version 14 published January 2025, rates severe weather as follows:

Under the NHS Oversight Framework, the Board has received positive assurance of the Trust’s compliance with the oversight metrics and as at June 2026, the Trust has been rated in Segment 2, meaning that there are no areas where there is need of specific support – the Trust is seen as an organisation that would be encouraged to offer peer support to other providers. 

Review of economy, efficiency and effectiveness of the use of resources 

The Trust has in place a number of processes and controls aimed to ensure that the best value for money from the taxpayers’ purse is obtained and it is through these controls that the Trust Board ensures that economy, efficiency and effectiveness are prevalent in our use of resources.

Through our Standing Orders we require all orders above prescribed thresholds to be subject to either written quotation or formal tender before being placed. Any exceptions to these limits must be reported to Audit Committee to provide rationale and evidence for the waiver.

The Trust undertakes monthly budget monitoring where actual spend compared to planned spend is reviewed and forecasts scrutinised. This takes place at the Executive Leadership Team and the Finance and Performance Committee. Key drivers for variation are identified and reported through to the Trust Board. There is also a monthly Operational Finance Management Group which is chaired by the Chief Finance and Performance Officer.

In addition, the Audit Committee annually reviews the Scheme of Delegation and authorised spending limits. It is through this that the Trust Board assures itself that decision making is at an appropriate level and equally that staff are empowered to manage their services.

The Trust risk management processes continue to be strengthened and risk management contributes to this.

The Trust Board has a Risk Appetite statement and measures to ensure that risks are managed and escalated in line with the agreed appetite. The Board sets aside time each year for a focused discussion on risk appetite and the BAF, including risk descriptions and scores. The Board confirmed that they had a low appetite for risks relating to the safety of patients and staff. 

As Accountable Officer, I have responsibility for reviewing the effectiveness in practice of the system of internal control. My review is informed in a number of ways. 

The Head of Internal Audit provides an opinion on the overall arrangements for gaining assurance through the BAF and on the controls reviewed as part of the internal audit work. Executive Directors have responsibility for the development and maintenance of specific elements of the system of internal control.

The BAF itself provides evidence that the effectiveness of controls to manage the risks to the organisation achieving its principal objectives have been regularly reviewed. 

The improvement of processes and the use of the BAF itself are regularly reported to the Audit Committee and the Trust Board. The effectiveness of the system of internal control is maintained through review of the BAF, corporate and service line risk registers and associated action plans. These are monitored by Executive Directors though the committees of the Board.

My review is also informed by the outcome of internal and external audits and reviews. Our external auditor, Bishop Fleming, has provided us with their Value for Money opinion for 2025/26 which has concluded that they are satisfied that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ending 31 March 2026, based upon the criteria of financial sustainability, governance and improving economy, efficiency and effectiveness. 

This table shows the auditor’s conclusions against each domain of value for money:

The external auditors did not identify any significant risks that do not have appropriate arrangements in place. They did not raise any recommendations as a result of their work.

The Head of Internal Audit Opinion for the period 2025 — 2026 was rated overall as ‘amber’ – reasonable assurance and states that: the auditors are satisfied that, for the areas reviewed during the year, Southwest London and St George’s Mental Health NHS Trust has an adequate and effective framework for risk management, governance and internal control. However, their work has identified further enhancements to the framework of risk management, governance and internal control, to ensure that it remains adequate and effective. The formation of the opinion is achieved through a risk-based plan of work, agreed with management and approved by the Audit Committee. The Trust remained at level two (positive) for internal controls. 

Internal audit carried out eight reviews in 2025 — 2026, which were designed to ascertain the extent to which the internal controls in the system are adequate, to ensure that activities and procedures are operating to achieve the Trust’s objectives. For each completed assurance review, an assessment of the combined effectiveness of the controls in mitigating the key control risks was provided.

The areas on which the assurance assessments have been provided can only provide reasonable and not absolute assurance against misstatement or loss and their effectiveness is reduced if the internal audit recommendations made during the year have not been fully implemented.

The following total number of recommendations were made on internal audit work carried out in 2025 — 2026. The numbers in brackets relate to 2024 — 2025 recommendations.