Archived decisions

Appendix 2

Annual Governance Statement

Self-assessment matrix (recommended by the CIPFA Finance Advisory Network - rough guide for practitioners)

Last updated: June 2008

Notes: _ = evidence available/compliant with good practice; _ = evidence not available and/or not fully compliant

Score of 10 = overall good practice and good evidence for the element


Step 1: In support of objective 1 - Mechanism established to identify principal statutory obligations

	Examples of assurance	Examples of evidence		Evidence	Score	Action for improvement
1	Responsibilities for statutory obligations are formally established	· Documents (e.g. constitution) recording individual officer and member responsibilities · Minutes of delegations to officers and committees · Committee terms of reference · Job descriptions of key officers · Structure charts · Member/officer protocols	_ _ _ _ _ _	· Hampshire Combination Order 1996 · Scheme of Delegation · Terms of Reference updated in 2008 · Job Descriptions updated as part of Rank to Role and Job evaluation exercises · Protocols approved by Standards Committee	10
2	Record held of statutory obligations	· Accessible record of statutory obligations (e.g. central registry or legal library, intranet)	_	· Fire and Rescue Services Act 2004 and Regulatory Reform Order (RRO) accessible from website.	10
3	Effective procedures to identify, evaluate, communicate, implement, comply with and monitor legislative change exist and are used	· Review of established processes in place · Appointment of suitably qualified and experienced employees, selected against accurate and specific job descriptions and person specifications · Evidence of effective arrangements for internal and external communications (e.g. by review of communication of recent legislation to relevant officers and members) · Appropriate induction training has been given to specific post holders · Awareness training tailored to job profiles has been provided · Inspection of reports to members on implications of new legislation · Evidence that assurance has been given to Chief Executive (or equivalent) that all relevant legislative changes have been reported and addressed	_ _ _ _ _ _ _	· `STEELPE' review carried out annually (to identify emerging legislation · Participation in Fire Lawyers Network - sharing good practice · Legal expertise `bought in' from Hampshire County Council and two private sector law firms · Specialist training on (RRO) has been delivered to relevant staff. · Gap analyses on implications of National Framework presented to the HFRA	10
4	Effective action is taken where areas of non-compliance are found in either mechanism or legislation	· Review of evidence to demonstrate that action has been taken to overcome identified areas of non-compliance, for example: o Internal / external audit reports to audit committee or equivalent o Monitoring reports on progress on delivering action plans in response to identified legal/statutory risks in risk register (e.g. on implementation of Freedom of Information Act 2000) o Evidence of corrective action being taken in response to upheld complaints against the authority o	_	· Findings and recommendations of all external and internal audit reports and assessments presented to the Governance Committee / Performance Review and Scrutiny Committees - agreed actions are progress-chased by these committees	10


Step 2: In support of Objective 1 - Mechanism in place to establish organisational objectives

	Examples of assurance	Examples of evidence		Comments	Score	Action for improvement
1	Consultation with stakeholders on priorities and objectives	· Results from internal and/or external consultation exercises have been analysed and published	_	· Extensive consultation undertaken annually on IRMP · Findings and recommendations of all external and internal audit reports and assessments presented to the Governance Committee / Performance Review and Scrutiny Committees - agreed actions are progress-chased by these committees	10
2	The Authority's priorities and organisational objectives have been agreed (taking into account feedback from consultation),	· Authority's approved and published strategic plan takes account of all consultation and local national priorities · Priorities and objectives in strategic partnerships are aligned with corporate priorities and objectives	_ _	· Our rolling 3-year IRMP (now Fire and Rescue Plan) is reviewed, updated with new proposals, subjected to extensive consultation with stakeholders (including partners), and then approved by the HFRA, prior to publication in March each year. · SWOT & STEEPLE analyses take partnership working fully into account · Active attendance at strategic LAA meetings	10
3	Priorities and objectives are aligned to principal statutory obligations and relate to available funding	· Corporate priorities and objectives are clearly set out in the strategic plan · Strategic plan takes account of annual budget and medium term financial plan · Financial plans take account of strategic partnership contributions and income streams	_ _ _	· Clear aims and smart targets set out in IRMP · Decisions on IRMP and Budget taken to same HFRA meeting (February) to ensure consideration of resource implications · Draft budget highlights funding pressures and efficiency expectations as well as resource implications of IRMP proposals	10
4	Objectives are reflected in departmental plans and are clearly matched with associated budgets	· Clear terms of reference are set for the preparation of departmental and/or service plans · Departmental and/or service plans clearly reflect corporate objectives and match approved funding · Annual reports are produced on the outcome of departmental and/or service plans	_ _ _	· Corporate templates & guidelines for committee reports and business/service plans ensure consistency of approach · Group/Station/Departmental plans both influence and reflect corporate aims and objectives (bottom-up & top-down approach) · Resource implications are identified for all objectives and actions · Progress on actions monitored via HFRA and its committees	8	_ Plans in place to improve evaluation processes (including post-implementation reviews. _ Performance review and Scrutiny Committee has had its terms of reference strengthened (June 2008) to enable this
5	The authority's objectives are clearly communicated to staff and to all stakeholders, including partners.	· A communication strategy in respect of the corporate objectives has been developed, approved and implemented · Evidence of consultation with stakeholders (e.g. public and internal surveys etc) and strategic partners on service provision against cost · Documented meetings across departments to discuss key objectives in corporate and departmental and/or service plans · Corporate objectives and aims are set out in key documents (annual plans, Local Area Agreements etc) on the authority's website and intranet site	_ _ _ _	Extensive and well-established communications strategies in place for both internal and external communications (particularly for IRMP - where specific events are arranged to maximise opportunities for stakeholder input). Notes of all consultation meetings are made - sometimes recorded on video. IRMP and related documentation is available on public website	10


Step 3: In support of objective 1 - Effective corporate governance arrangements are embedded within the authority

	Examples of assurance	Examples of evidence		Comments	Score	Action for improvement
1	Code of corporate governance established	· A code of Corporate Governance in line with CIPFA/SOLACE guidance relevant to the type of authority has been adopted by the authority · A communication strategy in relation to the Code has been developed, approved and implemented	_ _	· Code first published in 2005 and used as the basis for the review of corporate governance arrangements and production of the former Statements of Internal Control · A specific communications exercise to publish the code has not been undertaken to date.	8	_ Code needs updating in the light of the latest advice. The use of this matrix is part of that review process. _ Once updated it will be more positively promoted.
2	Review and monitoring arrangements in place	· The Code itself incorporates a review date and/or a system for continuous update in response to changed requirement · There are clear arrangements for continuously monitoring compliance with the Code e.g. reports on compliance are regularly submitted to the committee charged with corporate governance responsibility · An annual report on compliance with the Code of Corporate Governance is prepared and submitted to members (i.e. the Annual Governance Statement) · Internal/external audit reports on adequacy of corporate governance arrangements · An action plan is prepared to address any significant identified weaknesses in complying with the Code and is continuously monitored by the authority or committee charged with corporate governance responsibility (i.e. the AGS action plan)	_ _ _ _ _	· Not yet fully and formally established. · The AGS (and previous the SIC) has been considered and approved by the Governance Committee annually · Internal Audit Report on corporate governance undertaken in 2007/08 - findings reported to Governance Committee · This matrix forms part of the AGS and includes `actions for improvement'	8	_ On the basis of recommendations of good practice in the CIPFA `Rough Guide', the opportunity will be taken to establish better processes and timing of formal reviews of the Code (and this AGS) by the Governance Committee and the HFRA.
3	Committee charged with governance responsibilities	· Responsibility for overseeing corporate governance has been formally delegated to an appropriate committee · Committee terms of reference clearly demonstrating responsibility for corporate governance issues have been approved by the authority · Terms of reference are sufficiently comprehensive to ensure that all appropriate aspects of corporate governance are covered · Agendas and minutes from the committee charged with corporate governance responsibility indicate that the responsibility is being discharged adequately in accordance with terms of reference	_ _ _ _	· Terms of reference recently extended to include reviews and consideration of all external and internal audit reports.	10
4	Governance training provided to key officers and all members	· Induction training for key new officers and all new members incorporate suitable coverage on corporate governance issues according to responsibilities · Ongoing awareness training is provided as appropriate to key staff and all members to ensure that changes in the Code are made known within the authority	_ _	· Corporate induction programme for all new staff is delivered frequently, but more emphasis needs to be given to the code itself - especially for Group Managers and above (and equivalent Green Book staff) · HFRA members receive training on general governance issues the constituent authorities, but more could be done to promote the code for HFRA.	6	_ Use existing meetings and communications structure to deliver occasional updates on the Code. _ Arrange ongoing awareness training for members of the Authority (use existing training and awareness events following HFRA meetings)
5	Staff, public and other stakeholder awareness of corporate governance	· There is a general staff awareness programme · The Code has been published and is accessible to all staff, the public and other stakeholders	_ _	· Corporate induction programme for all new staff is delivered frequently with general introduction about how the Authority operates - including officer/member relationships.	7	_ Once updated the Code will be more positively promoted.


Step 4: In support of objective 1 - Performance management arrangements are in place

	Examples of assurance	Examples of evidence		Comments	Score	Action for improvement
1	Comprehensive and effective performance management systems operate routinely	· There is a clearly defined performance management framework that identifies: o all sources of performance measures; o who is responsible for achieving each performance measure; o who is responsible for collating the data for each one; o who determines and approves the performance measures; o who receives reports on performance and how often; o how data quality is assured; o how performance data is captured and its integrity maintained; o how poor performance is addressed; o how performance is driven upwards over time · Reports resulting from internal or external reviews of performance managements · Year-on-year comparison of achievement against performance targets (e.g. in annual reports) · Best value reviews, including benchmarking results · Departmental and/or service benchmarking results · Annual reports issued by, or in relation to, strategic partnerships.	_ _ _ _ _ _	· Every performance indicator has been assigned an `owner' responsible for providing interpretation and commentary - updates made at least quarterly. · Well-established system for `progress-chasing' managers responsible for actions and reporting - reported to Performance Review & Scrutiny and Governance Committees. Benchmarking undertaken wherever practically possible. · To date, reports on partnerships have been ad hoc	9	_ Consideration will be given to producing a regular report on partnerships.
2	Key performance indicators are established and monitored	· Appropriate key performance indicators (KPIs) have been established and approved for each service element and are included in departmental and service business/annual plans · KPIs have been developed and are monitored in respect of key partnerships · A robust monitoring system has been approved and implemented · There are regular reports on progress on delivering approved KPIs · There is an approved mechanism for reviewing the continuing suitability if KPIs and for securing continuous improvement.	_ _ _ _ _	· Well-established processes in place to monitor and report on performance. A standing item on the Performance Review & Scrutiny Committee agenda. · Indicators and targets reviewed each year as part of IRMP update. · Actions aimed at continuous improvement monitored via Improvement Planning Register.	10
3	The authority knows how well it is performing against its planned outcomes	· Regular reports are presented to members on the delivery of national, authority, departmental and partnership performance targets · Internal and external auditor's reports on key performance indicators · Key performance indicator risk scorecards · Use of Resources reviews and progress reviews against the action plans · Monitoring reports on the achievement of local performance targets in the Local Policing Plan · Best Value Performance Indicators · Internal performance indicators · Regular budget monitoring reports (capital and revenue, current year and medium-term) · Voluntary benchmarking exercise with peer groups · National comparative performance measures against comparable authorities · Local Area Agreements and other strategic partnerships · Balanced score card · EFQM model adopted · External audit/agency reports on performance	_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _	· Well-established processes in place to monitor and report on performance. Standing items on the Performance Review & Scrutiny Committee and the Governance Committee agenda. Risk Register and Improvement Planning Register reviewed by CMT quarterly and formally by the HFRA annually. · Balanced Scorecard and EFQM models are not used routinely, although EFQM has been used in the past on specific projects. A new evaluation toolkit (produced by Family Group 4 FRSs) will strengthen our performance management processes.	8	_ Roll-out evaluation toolkit during 2008/09
4	Knowledge of absolute and relative performances achieved is used to support decisions that drive improvements in outcomes	· Monitoring reports are regularly presented to the appropriate committee · The reports include detailed performance results, both absolute and relative to peer authorities, a clear indication of below target, on target and at, or above, target results, highlighting areas where corrective action is necessary · Committee reports on below par performance include `SMART' action plans to improve performance · Performance targets in subsequent corporate and departmental and/or service business plans are revised in the light of actual performance · Continuous improvement is strived for by increasing the difficulty of performance targets when they have been met over a period (e.g. movements on KPI results) · Performance trends are established and reported upon over the medium term and are fed into the corporate and departmental and/or service planning process and into the planning process of key partnerships · Performance targets are adjusted in the light of the performances of peer authorities	_ _ _ _ _ _ _	· Well-established processes in place to monitor and report on performance. Standing items on the Performance Review & Scrutiny Committee and the Governance Committee agenda. · `Views' software is used to provide consistency in reporting on performance. · Targets are reviewed annually. · Comparative data used to identify good practice elsewhere and to help determine whether HFRA is maintaining its position as a high-performing FRA.	9	_ May need to revisit scope for benchmarking in light of changing PIs
5	The authority continuously improves its performance management	· The performance management systems are reviewed and updated to take account of changes in organisational structure, new performance measurement frameworks (i.e. new Government initiatives, new internal performance measures etc) and other factors · The performance management arrangements are revised in line with external or internal review of the arrangements · Performance management arrangements are reviewed to assimilate new techniques and/or technology e.g. developments in performance management information systems · Performance management arrangements are developed and monitored in relation to key partnerships	_ _ _ _	· SWOT & STEEPLE analyses are reviewed and updated annually. · Gap analyses undertaken following publication of National Framework · Work well underway in improving risk management information (e.g. use of Mosaic software) · Regular attendance at strategic partnership steering bodies (e.g. LAAs, SEIP)	10


Step 1 - In support of Objective 1 - Apply the Six CIPFA/SOLACE Core Principles
Focusing on the purpose of the authority and on outcomes for the community and creating and implementing a vision for the local area

	The local code should reflect the requirement for local authorities to:	Examples of source documents / good practice / other means that may be used to demonstrate compliance		Evidence	Score	Action for improvement

1	Develop and promote the authority's purpose and vision	The Code is used as a basis for: · corporate and service planning · shaping the community strategy · local area or performance agreements	_	· Our strategic planning framework - with its emphasis on review and consultation, ensures that many aspects of good governance are considered in our planning, but we do not overtly use the Code itself as a primary driver of our planning process.	6	_ We need to make explicit reference to the Code (and update the Code itself) as part of our established corporate planning process.
2	Review on a regular basis the authority's vision for the local area and its impact on the authority's governance arrangements		_	· In our SWOT & STEEPLE analyses we do take account of local risk information - and are striving to improve this intelligence · Our extensive consultation arrangements (in IRMP process) are an important element of our governance arrangements.	8	_ (as 1 above)
3	Ensure that partnerships are underpinned by a common vision of their work that is understood and agreed by all parties	· The Code is made available to key partnerships	_	· It is available on or website, but we do not promote its existence to our partners.	7	_ Once updated it will be more positively promoted.
4	Publish an annual report on a timely basis to communicate the authority's activities and achievements, its financial position and performance	· annual financial statements · annual business plan · formal annual report	_ _ _	· We publish our rolling 3-year IRMP annually which provides a review of our achievements. Financial statements are published. We have chosen not to publish a separate formal annual report.	7	_ Consider the costs and benefits of producing a formal annual report and/or provide more retrospective analysis of performance in our IRMP.
5	Decide how the quality of service for users is to be measured and make sure that the information needed to review service quality effectively and regularly is available	This information is reflected in the authority's: · corporate plan · medium term strategy · resourcing plan	_ _ _	· Our corporate plan (IRMP) is both supported and influenced by a number of medium-term business and service plans - including our financial plan and asset management strategy.	9
6	Put in place effective arrangements to identify and deal with failure in service delivery	· satisfaction surveys · complaints procedure	_ _	· Frequent stakeholder satisfaction surveys are carried out - both at the corporate and departmental levels. · We have a complaints procedure in place. We do not get many complaints, but we could do more to make the procedure more accessible.	9	_ Provide a more visible link to our complaints procedure on our website home page.
7	Decide how value for money is to be measured and make sure that the authority or partnership has the information needed to review value for money and performance effectively. Measure the environmental impact of policies, plans and decisions.	· The results are reflected in authority's performance plans and in reviewing the work of the authority · Publish environmental strategy and policy, incorporating monitoring and reporting arrangements	_ _	· Our annual efficiency plan is reviewed each year in the light of Government expectations and our own resource needs it is part of our budget strategy. · A 2-year environmental impact review is began in 2007/08. It will inform our environmental strategy.	6	_ Publish environmental strategy/plan from 2009/10 onwards


Step 2 - In support of Objective 1 - Apply the Six CIPFA/SOLACE Core Principles
Members and officers working together to achieve a common purpose with clearly defined functions and roles

	The local code should reflect the requirement for local authorities to:	Examples of source documents / good practice / other means that may be used to demonstrate compliance		Evidence	Score	Action for improvement

1	Set out a clear statement of the respective roles and responsibilities of the executive and of the executive's members individually and the authority's approach towards putting this into practice	· Constitution (where appropriate)	_	· Derives from Combination Order 1996	10
2	Set out a clear statement of the respective roles and responsibilities of other authority members, members generally and of senior officers	· Constitution (where appropriate) · conditions of employment	_	· Derives from Combination Order 1996 · national Conditions of Service apply (Grey & Green, Gold Book staff) · Scheme for memebrs' allowances in place (reviewed annually)	10
3	Determine a scheme of delegation and reserve powers within the constitution, including a formal schedule of those matters specifically reserved for collective decision of the authority taking account of relevant legislation and ensure that it is monitored and updated when required	· scheme of delegation · statutory provisions	_ _	· Scheme of Delegation to Officers in place and update in respect of estates matters in 2007 · Fire and Rescue Services Act (as supplemented by Regulatory Reform Order) sets out most statutory duties.	10
4	Make a chief executive or equivalent responsible and accountable to the authority for all aspects of operational management	· job descriptions/specification · performance management system	_ _	· Job descriptions/role maps in place for all staff. Charter adopted for members of the Authority · Annual appraisal system in place for all staff. Chief Officer is appraised annually by panel of leading members. Chief Officer is responsible for day-to-day operational management.	10
5	Develop protocols to ensure that the leader and chief executive (or equivalent) negotiate their respective roles early in the relationship and that a shared understanding of roles and objectives is maintained	· new chief executive and leader pairing consider how best to establish and maintain effective communication	_	· Chief Officer meet frequently and regularly on a one-to-one basis. Leading members and officers meet regularly at CMT meeting (6-weekly)	10
6	Make a senior officer (usually the section 151 officer) responsible to the authority for ensuring that appropriate advice is given on all financial matters, for keeping proper financial records and accounts, and for maintaining an effective system of internal financial control	· Section 151 responsibilities · S112/114 Local Gov't Finance Act 1988 · Statutory provision · Statutory reports · budget documentation · job description/specification	_ _ _ _ _	· Treasurer is appointed as Section 151 Officer. Role is bought in from HCC to give greater level of independence from day-to-day management of Service. Role described in SLA with HCC	10
7	Make a senior officer (other than the Responsible Financial Officer) responsible to the authority for ensuring that agreed procedures are followed and that all applicable statutes, regulations are complied with	· monitoring officer provisions · Statutory provision · job description/specification	_ _ _	· Clerk is appointed as Monitoring Officer and Treasurer is appointed as Section 151 Officer. Roles are bought in from HCC to give greater level of independence from day-to-day management of Service. Roles described in SLA with HCC	10
8	Develop protocols to ensure effective communication between members and officers in their respective roles	· Member/officer protocol	_	· Protocol approved and reviewed by Standards Committee; and also the Codes of Conduct for members and officers.	8	_ Need to communicate the protocols to staff and members more frequently
9	Set out the terms and conditions for remuneration of members and officers and an effective structure for managing the process including an effective remuneration panel (if applicable)	· Pay and conditions policies and practices · Member allowances/remuneration scheme	_ _	· Members' allowances reviewed by Remuneration Panel of Standards Committee each year. Details of scheme published on website.	10
10	Ensure that effective mechanisms exist to monitor service delivery		_	· Apart from a comprehensive performance management regime with the Service, the Authority receives an Activity Report (and performance management reports via the respective Committees) at each meeting.	10
11	Ensure that the organisation's vision, strategic plans, priorities and targets are developed through robust mechanisms, and in consultation with the local community and other key stakeholders, and that they are clearly articulated and disseminated	· Vision, strategy, corporate plans, budgets, performance plan/regime · Communication/consultation strategies	_ _	· Our rolling 3-year IRMP (now Fire and Rescue Plan) is reviewed, updated with new proposals, subjected to extensive consultation with stakeholders (including partners), and then approved by the HFRA, prior to publication in March each year. · SWOT & STEEPLE analyses take partnership working fully into account · Active attendance at strategic LAA meetings · All this activity is carried out using our well-established (since 2000) corporate planning process, which has been modified to take account of changing national expectations regarding audit and inspection.	10
12	When working in partnership ensure that members are clear about their roles and responsibilities both individually and collectively in relation to the partnership and to the authority	· Protocols for partnership working. For each partnership there is: o a clear statement of the partnership principles and objectives o clarity of each partner's role within the partnership o definition of roles of partnership board members o line management responsibilities for staff who support the partnership o a statement of funding sources for joint projects and clear accountability for proper financial administration o a protocol for dispute resolution within the partnership (NB from special report ` Local Partnerships and Citizen Redress by LGO ) · Code of Corporate Governance is made available to all key partner organisations	_ _	· Best Value Review of Partnerships undertaken in 2005/06. Toolkit established and being used to review effectiveness of specific schemes. · Specific Best Value Review undertaken in respect of major `partnership' -via SLAs for support services - with HCC. Arrangements now on a more formal footing. · Not actively promoted.	7	_ Need to establish a more structured programme of reviews of existing partnerships. This will link well with roll-out of new evaluation model/toolkit. _ Need to actively promote Code once it has been updated.
13	When working in partnership: ensure that there is clarity about the legal status of the partnership; ensure that representatives or organisations both understand and make clear to all other partners the extent of their authority to bind their organisation to partner decisions	· Partnership agreement sets out legal status and authority to make binding decisions and/or financial commitments · Key partnership agreements are in line with codes of corporate governance	_ _	· Toolkit available, but needs to be applied more widely across all major partnerships before we can be confident about our arrangements.	5	_ Need to establish a more structured programme of reviews of existing partnerships. This will link well with roll-out of new evaluation model/toolkit.


Step 3 - In support of Objective 1 - Apply the Six CIPFA/SOLACE Core Principles
Promoting values for the authority and demonstrating the values of good governance through upholding high standards of conduct and behaviour

	The local code should reflect the requirement for local authorities to:	Examples of source documents / good practice / other means that may be used to demonstrate compliance		Evidence	Score	Action for improvement
1	Ensure that the authority's leadership sets a tone for the organisation by creating a climate of openness, support and respect	· Reports are compliant with statute re what can be deemed to be confidential · Decisions are made openly by the authority	_ _	· Established procedure for determining whether reports to the HFRA need to be confidential. · CMT is not open to the public, but it is not a decision-making committee.	10
2	Ensure that standards of conduct and personal behaviour expected of members and staff, of work between members and staff and between the authority, its partners and the community are defined and communicated through codes of conduct and protocols	· members/officers code of conduct performance management system · performance appraisal · complaints procedures · antifraud and corruption policy · member/officer protocols · protocols and codes shared with key partners	_ _ _ _ _ _	· Codes of Conduct in place for members and officers. · Appraisal system in place (recently enhanced) · IiP accreditation achieved in 2007/08 · Anti-fraud policy in place and monitored by Internal & External Audit. · Protocols reviewed and approved by Standards Committee · Information-sharing protocol ion place with key strategic partners.	9	_ Need to do more to promote anti-fraud policy to staff an stakeholders.
3	Put in place arrangements to ensure that members and employees of the authority are not influenced by prejudice, bias or conflicts of interest in dealing with different stakeholders and put in place appropriate processes to ensure that they continue to operate in practice	· standing orders · codes of conduct · financial regulations · "whistle-blowing" or equivalent confidential reporting facility	_ _ _ _	· All established: financial regulations / scheme of delegation to officers reviewed within last two years,	9	_ Need to do more to promote whistle-blowing policy to staff.
4	Develop and maintain shared values including leadership values both for the organisation and staff reflecting public expectations and communicate these with members, staff, the community and partners	· codes of conduct	_	· In place	9	_ Need to do more to promote codes of conduct for staff and members at induction sessions - both in formal and in informal one-to-one sessions
5	Put in place arrangements to ensure that procedures and operations are designed in conformity with appropriate ethical standards, and monitor their continuing effectiveness in practice	· codes of conduct	_	· In place	9
6	Develop and maintain an effective standards committee	· terms of reference · regular reporting to the authority	_ _	· In place	10
7	Use the organisations shared values to act as a guide for decision making and as a basis for developing positive and trusting relationships within the authority	· decision making practices, including QA of reports to committees and authority	_	· Corporate template and guidance for reports to HFRA and Committees widely used, but QA procedures need to be improved.	7	_ Report writing skills need to be improved, a programme of short course tutorials being arranged from 2008/09
8	In pursuing the vision of a partnership, agree a set of values against which decision making and actions can be judged. Such values must be demonstrated by partners' behaviour both individually and collectively	· protocols for partnership working · code of corporate governance made available to all key partners	_ _	· Partnership toolkit and information sharing protocol are available, but more progress needs to be made in utilising the toolkit more widely.		_ Once Code has been updated it will be more positively promoted.


Step 4 - In support of Objective 1 - Apply the Six CIPFA/SOLACE Core Principles
Taking informed and transparent decisions which are subject to effective scrutiny and managing risk

		Examples of source documents / good practice / other means that may be used to demonstrate compliance		Evidence	Score	Action for improvement

1	Develop and maintain an effective scrutiny function which encourages constructive challenge and enhances the organisation's performance overall and of any organisation for which it is responsible.	· Scrutiny is supported by robust evidence and data analysis	_	· Performance Review Committee terms of reference enhanced in 2007/08 to specifically undertake a more robust scrutiny role. I has become `PR & Scrutiny Committee'	8
2	Develop and maintain open and effective mechanisms for documenting evidence for decisions and recording the criteria, rationale and considerations on which decisions are based	· decision making protocols record of decisions and supporting materials · reports on which decisions are to be made go through a robust QA process	_ _	· Standard report template puts more rigour into decision-making process. Resource implications, risk analysis, equality impact statement, contribution to corporate aims and objectives, consultation process are all included in template. · Quality of report writing style needs to be improved.	8	_ Report writing skills need to be improved, a programme of short course tutorials being arranged from 2008/09
3	Put in place arrangements to safeguard members and employees against conflicts of interest and put in place appropriate processes to ensure that they continue to operate in practice	· Members Code of Conduct · Register of gifts and hospitality · Financial regulations · Standing orders	_ _ _ _	· All in place	9	_ Scope for more staff to receive awareness training = especially on financial regulations
4	Develop and maintain an effective audit committee ( or equivalent ) which is independent or make other appropriate arrangements for the discharge of the functions of such a committee	· terms of reference · membership · training for committee members	_ _ _	· The Governance Committee now receives all audit report findings and recommendations and monitors implementation of progress · Although members receive training is some aspects from their `home' authority, more could be done to enhance members' knowledge of HFRS/HFRA processes.	8	_ Scope for more members to receive awareness training - especially on financial regulations
5	Put in place effective transparent and accessible arrangements for dealing with complaints	· complaints procedure · Communication of ways of referring complaints to external bodies e.g. Ombudsman	_ _	· Procedure in place, but not well promoted	8	_ Provide a more visible link to our complaints procedure on our website home page.
6	Ensure that those making decisions whether for the authority or partnership are provided with information that is fit for the purpose - relevant, timely and gives clear explanations of technical issues and their implications	· members' induction scheme · training for committee chairs · robust QA process for all reports	_ _ _	· Chief Officer meets on a one-to-one basis with all new members. SMT brief Members on specific issues on an ad hoc basis. At least 3 members' awareness sessions are arranged per annum on rising of HFRA meetings. CMT provides a more informal joint member/office forum/sounding board. Regular "members' update" bulletins are issued by Chief Officer. · While Directors sign off reports to the HFRA, there's scope to improve report-writing style skill set.	8	_ Report writing skills need to be improved, a programme of short course tutorials being arranged from 2008/09
7	Ensure that professional advice on matters that have legal or financial implications is available and recorded well in advance of decision making and used appropriately	· record of decision making and supporting materials · robust QA process for all reports · protocol re reporting deadlines	_ _ _	· Report template encourages resource and risk issues to be consider by authors of reports. · Timetable for production of reports to HFRA is established well in advance (and public notices of meeting appear in local press). SMT formally considers reports that need to go to HFRA for information and/or decision.	9
8	Ensure that risk management is embedded into the culture of the organisation , with members and managers at all levels recognising that risk management is part of their job	· risk management strategy/protocol · financial standards and regulations · job descriptions reflect risk management responsibilities · reports leading to key decisions and/or requiring major resources include risk assessment	_ _ _ _	· Strategic risk policy and register well-established with regular reports to officers and members. · Job descriptions detail accountabilities and expectations of postholders · Report template provides authors/decision-makers with checklist of items to consider including risk and resource implications.	10
9	Ensure that arrangements are in place for whistle blowing to which staff and all those contracting with the authority have access	· Whistle-blowing policy · publication of policy	_ _	· Policy in place, but needs more frequent publicity.	9	_ Need to do more to promote whistle-blowing policy to staff.
10	Actively recognise the limits of lawful activity placed on them by, for example the ultra vires doctrine but also strive to utilise powers to the full benefit of their communities	· Constitution (where appropriate) · monitoring officer provisions · Statutory provision · robust QA process for all reports	_ _ _	Clerk acts as Monitoring officer and is responsible for raising any concerns about HFRA/HFRS powers. Counsel's onion sought whenever there's doubt about powers.	9	_ Report QA process could be improved.
11	Recognise the limits of lawful action and observe both the specific requirements of legislation and the general responsibilities placed on local authorities by public law	· robust QA process for all reports	_	Report template widely used, but QA role by relevant line manager needs strengthening - possibly by training some existing managers on how to do this.	9	_ Report QA process could be improved.
12	Observe all specific legislative requirements placed upon them, as well as the requirements of general law, and in particular to integrate the key principles of good administrative law - rationality, legality and natural justice into their procedures and decision making processes	· monitoring officer provisions · job description/specification · Statutory provision · robust QA process for all reports	_ _ _ _	Clerk acts as Monitoring officer and is responsible for raising any concerns about HFRA/HFRS powers and advising on legal implications of new and emerging laws and regulations.	9	_ Report QA process could be improved.


Step 5 - In support of Objective 1 - Apply the Six CIPFA/SOLACE Core Principles
Developing the capacity and capability of members and officers to be effective

		Examples of source documents / good practice / other means that may be used to demonstrate compliance		Evidence	Score	Action for improvement
1	Provide induction programmes tailored to individual needs and opportunities for members and officers to update their knowledge on a regular basis	· training and development plan · induction programme · update courses/information	_ _ _	· Members' Charter sets out expectations regarding training and development needs. · Chief Officer meets on a one-to-one basis with all new members. SMT brief Members on specific issues on an ad hoc basis. At least 3 members' awareness sessions are arranged per annum on rising of HFRA meetings. CMT provides a more informal joint member/office forum/sounding board. Regular "members' update" bulletins are issued by Chief Officer. · Members invited to attend conferences and short courses/awareness events. Regional collaboration used to provide specific training and development opportunities.	8	_ Scope for better coordination of training needs with members' `home' authorities.
2	Ensure that the statutory officers have the skills, resources and support necessary to perform effectively in their roles and that these roles are properly understood throughout the organisation	· job description/personal specifications · appointment process · membership of top management team	_ _ _	· PDRS system identifies individual training and development needs. · Expertise also bought in - e.g. appointment of Clerk and Treasurer from HCC under SLA. · Directors' and SMT team-building/development events arranged two/three times per year.	10
3	Assess the skills required by members and officers and make a commitment to develop those skills to enable roles to be carried out effectively	· appraisal · training development plan	_ _	· Both well-established.	10
4	Develop skills on a continuing basis to improve performance including the ability to scrutinise and challenge and to recognise when outside expert advice is needed	· Training and development plan reflects requirements of a modern councillor or member including: o the ability to scrutinise and challenge o the ability to recognise when outside advice is required o advice on how to act as an ambassador for the community o leadership and influencing skills	_	· Members' Charter adopted. Awareness/update sessions incorporated on agenda of meetings of HFRA and its committees.	8
5	Ensure that effective arrangements are in place for reviewing the performance of the authority as a whole and of individual members and agreeing an action plan which might for example aim to address any training or development needs	· performance management system	_	· System well-established. Members of Performance Review and Scrutiny Committee engaged in officer/member review teams.	9
6	Ensure that effective arrangements designed to encourage individuals from all sections of the community to engage with, contribute to and participate in the work of the authority	· strategic partnership framework stakeholders forums' terms of reference · area forums' roles and responsibilities · residents panel structure · targeted advertising	_	· Active participation on local crime and disorder / community safety panels, as well as at strategic partnerships (e.g. LPSA2, LAA). · Focus groups / ideas week used to develop IRMP	8
7	Ensure that career structures are in place for members and officers to encourage participation and development	· succession planning	_	· Use of assessment and development centres for staff promotion; PDRS appraisal system. · No succession planning used for member development.	7


Step 6 - In support of Objective 1 - Apply the Six CIPFA/SOLACE Core Principles
Engaging with local people and other stakeholders to ensure robust public accountability

	The local code should reflect the requirements to:	Examples of source documents / good practice / other means that may be used to demonstrate compliance		Evidence	Score	Action for improvement
1	Make clear to themselves, all staff and the community, to whom they are accountable and for what	· community strategy · engagement strategy	_ _	· IRMP supplemented by Service Delivery medium term plan; Group and Station plans focus on local geographic areas. Active on local crime and disorder panels.	8
2	Consider those stakeholder bodies to whom the organisation is accountable and assess the effectiveness of the relationships and any changes required		_	· Excellent feedback received over last five years from representatives of residents' associations and business community representatives at budget consultation meetings.	9
3	Produce an annual report on scrutiny function activity (where relevant)	· annual report	_	· A separate annual report is not published. Information on past performance contained in IRMP and financial reports.	7	_ Consider the costs and benefits of producing a formal annual report and/or provide more retrospective analysis of performance in our IRMP.
4	Ensure that clear channels of communication are in place with all sections of the community and other stakeholders including monitoring arrangements to ensure that they operate effectively	· community strategy · engagement strategy · processes for dealing with competing demands within the community	_ _ _	· IRMP and Service Delivery medium-term plan supported by Group and Station plans. · Communications Strategy and Marketing & Communications Strategy updated annually. · HFRA is a single-purpose organisation, but works effectively with other partners. · Team of out-reach workers.	9
5	Hold meetings in public unless there are good reasons for confidentiality.	· Compliance with statute regarding the determination of confidential issues	_	· Fully compliant with principles of open government.	10
6	Ensure arrangements are in place to enable the authority to engage with all sections of the community effectively. These arrangements should recognise that different sections of the community have different priorities and establish explicit processes for dealing with these competing demands	· Engagement strategy · Communication strategy	_ _	· Both strategies in place, but we feel that we are not always reaching all groups in our communities. This is evidenced by the fact that our workforce does not yet reflect the diversity of the communities it serves.	7	_ Specific objectives in 2008-2011 Plan to improve levels of community engagement.
7	Establish a clear policy on the types of issues they will meaningfully consult on or engage with the public and service users including a feedback mechanism for those consultees to demonstrate what has changed as a result	· partnership framework · communication strategy · engagement strategy	_ _ _	· Our communications strategy and programme of activities are reviewed annually to ensure that they are fit for purpose (e.g. in 2007/08 more events arranged in communities likely to be most affected by IRMP proposals). · Focus groups and open meetings arranged to debate proposals from a local community perspective (e.g. in 2007/08 open meetings held in Copnor and Winchester)	9
8	On an annual basis, publish a performance plan giving information on the authority's vision, strategy, plans and financial statements as well as information about its outcomes, achievements and the satisfaction of service users in the previous period.	· annual report · annual financial statements · annual business plan	_ _ _	· See 3 above · Financial statements published annually · IRMP and supporting plans updated and widely published in March each year.	7	_ See 3 above
9	Ensure that the authority as a whole is open and accessible to the community, service users and its staff and ensure that it has made a commitment to openness and transparency in all its dealings, including partnerships subject only to the need to preserve confidentiality in those specific circumstances where it is proper and appropriate to do so	· Constitution (where applicable) · Communication strategy · Engagement strategy	_ _ _	· Combination Order 1996 · In place · In place	9
10	Develop and maintain a clear policy on how staff and their representatives are consulted and involved in decision making.	· Constitution (where appropriate) · Consultation policy, identifying recognised staff representatives and the extent to which they are consulted and involved in decision making	_	· Well-established and regular meetings held with staff representative bodies. Formally consulted on future plans (e.g. IRMP and Budget proposals)	10


Objective 2: Identify principal risks to achievement of objectives:
Step 1: In support of objective 2 - The authority has robust systems and processes in place for the identification and management of strategic and operational risk

	Examples of assurance:	Examples of evidence		Evidence	Score	Action for improvement
1	There is a written strategy and policy in place for managing risk which: · Has been formally approved at political and risk management board (or equivalent) level · Is reviewed on a regular basis · Has been communicated to all relevant staff Includes partnership risks	· Existence of approved strategy and policy document · Evidence of formal approval (e.g. management board/committee minutes) · Evidence of formal review (e.g. management board/committee minutes, document version number and date) · Evidence of communication strategy, possibly covered in strategy document · Examples of dissemination e.g. induction, briefings, awareness sessions, policy and strategy published on intranet, strategic diagnostic questionnaire results · Partnership risk registers	_ _ _ _ _ _	· Risk Management Policy and Strategic Risk Register well-established. · Regularly reviewed by SMT/CMT/Finance and General Purposes Committee and annually by HFRA. · Used to inform future plans. · Used in team briefings. · Partnership tool kit includes need to consider risk.	10
2	The authority has implemented clear structures and processes for risk management which are successfully implemented and: · Management board and elected members see risk management as a priority and support it by personal interest and input · Decision making considers risk · A senior manager has been appointed to "champion" risk management · Roles and responsibilities for risk management have been defined · Risk management systems are subject to independent assessment · Risk management is considered in the annual business planning process · Risk management extends to partnership risk	· Management board/committee minutes · Job descriptions of senior and operational managers and corporate risk manager · Internal audit reports and external audit comments on risk management system · Use of resources, CPA or PPAF review comments on risk management · Annual business plans · Link between internal audit and risk management functions is clearly defined in terms of reference of internal audit · Responsibility for risk management function, including partnership risk management, is set at appropriate senior level · Committee reports setting out options for change include an appropriate risk assessment, including the `no change' option · The corporate business plan and financial plan assess risks as appropriate and in particular take account of new and emerging risks facing the authority · Partnership risks are assessed before agreements are signed	_ _ _ _ _ _ _ _ _ _	· Regular reviews by SMT and CMT minutes - HFRA and F&GP minutes. · Relevant job descriptions include references. · UoR assessment examined Register. · Register used by auditors to determine programme of work · `Ownership' for managing risk · At SMT level. · Register used in formulating future IRMP objectives. · SWOT & STEEPLE analyses used to update Register and pick up on emerging risks. · Partnership tool kit includes need to assess risk.	9
3	The authority has developed a corporate approach to the identification and evaluation of risk which is understood by all staff	· Systematic procedures for risk identification and evaluation have been agreed and published in a policy document and are consistently applied across all business units and partnerships · Examples of dissemination e.g. induction, briefings, awareness sessions, strategic diagnostic questionnaire results	_ _	· Standard template for describing risks well-established and format improved in 2007/08. Actions `progress-chased' by Performance Review Team.	8	_ Consider scope for producing a more accessible summary of strategic risk register for use in induction and other briefings
4	The authority has well defined procedures for recording and reporting risk	· Evidenced by review of risk management strategy and policy · Examination of corporate and partnership risk registers · Key risk indicators have been determined and there is evidence of monitoring against these risks · Evidence of regular and frequent reporting of risk to political and management board level · Evidence of risk based auditing being carried out · Evidence of risks not properly addressed identified in internal audit reports etc being fed into the risk management process · Environmental scanning reports are fed into the risk management process so as to identify new and emerging risks	_ _ _ _ _ _ _	Established reporting process by SMT/CMT/F&GP Committee/HFA. · Monitoring / progress-chasing established as a routine. · Minutes of meetings of the above. · Internal Audit plan assesses risk when prioritising programme. · SWOT & STEEPLE analyses.	10
5	The authority has well-established and clear arrangements for financing risk	· Evidence that the authority's policy for risk financing is regularly reviewed in the light of costs and alternative risk mitigation strategies · All legal requirements for insurance are met · Evidence that self-insurance provisions are subject to annual independent actuarial valuation and that contributions to the fund are adjusted accordingly · Insurance claims being managed in accordance with `Woolf' principles · Evidence of monitoring the incidence of successful and unsuccessful claims and of feeding the results back into the policy for risk financing accordingly	_ _ _ _ _	· During 2007/08 HFRA took a leading role in establishing an Insurance Mutual (FRAML) specifically for fire and rescue authorities. This was widely recognised as an innovative collaborative procurement venture. Following a recent legal challenge (being appealed) in respect of the London Boroughs Mutual, it has been determined that FRAs cannot rely on powers in FRS Act 2004 to participate in an insurance mutual. This has highlighted an anomaly/inconsistency in the law: i.e. lack of powers of well-being for CFAs. FRAML has had to obtain alternative cover until the legal position is clarified. In the meantime, adequate cover is being provided.	10	_ Alternative methods of providing insurance cover in short- to medium-term through a consortium arrangement (using conventional marketplace) currently being explored.
6	The authority has developed a programme of risk management training for relevant staff	· Training programme for risk management · Training needs analysis (both specialist staff development and general awareness) · Regular newsletter or other means of communicating risk management issues to staff · Induction programme includes risk management · Appropriate responsibilities for risk management incorporated into job descriptions and appraisals	_ _ _ _ _	· Key staff are members of, and actively participate in events organised by, the Association of Local Authority Risk Managers (ALARM). · Training has been delivered to middle and senior managers and leading members (used external consultant initially). · Corporate Induction programme does not include a specific session on risk management.	7	_ Consider scope for producing a more accessible summary of strategic risk register for use in induction and other briefings
7	The corporate risk management board (or equivalent) adds value to the risk management process by: · Advising and supporting corporate management team on risk strategies · Identifying areas of overlapping risk · Driving new risk management initiatives · Communicating risk management and sharing good practice · Providing and reviewing risk management training · Regularly reviewing the risk register(s) · Coordinating the results for risk reporting	· Corporate risk management board or equivalent terms of reference · Minutes of corporate risk management board · Reports to corporate management team · Low incidence of avoidable risk events occurring	_ _ _ _	· SMT acts as the primary risk management board. · Good audit trail (through version control of Strategic Risk Register) demonstrates general success of preventing/mitigating identified risks. · Evidenced through annual sign-off by HFRA of `green' (low) risks.	10
8	A corporate risk officer has been appointed with the necessary skills to analyse issues and offer options and advice and: · Support decision making and policy formulation · Provides support in the risk identification and analysis process · Provides support in prioritising risk mitigation action · Provides advice and support in determining risk treatments · Inspires confidence in managers	· Job description of corporate risk officer · Key task matrix of corporate risk officer · Evidence of the corporate risk officer reporting to corporate management team on risk management issues · Evidence of training on current risk management topics / membership of appropriate organisations (e.g. ALARM) · Use of consultancy as appropriate	_ _ _ _ _	· Role currently assigned to Director of Corporate Services (supported by Performance Review Team). · Member of that Team (specifically trained) coordinates risk management activity and presents Register at meetings of SMT/CMT/HFRA. Active member of ALARM (and Fire & Rescue special interest group). Training at post-graduate level. · Consultancy used initially until staff trained and confident in managing process, Consultants used to assess specific risks (e.g. data/information security)	10
9	Managers are accountable for managing their risks	· Evidence of manager involvement in risk identification and analysis process · Risk owners detailed in corporate /departmental risk register(s) · Risk owners assigned in relation to key partnerships · Job descriptions of managers outline their risk management responsibilities · Evidence of (at least) annual review of risk at service/operational levels and of partnership risks · Analysis of completed control and risk self-assessment questionnaires	_ _ _ _ _ _	· Owners (SMT level) assigned and named in Risk Register. · Lead officers of partnerships responsible for risk analysis. · Risk Register formally reviewed at least quarterly.	10
10	Risk management is embedded throughout the organisation	· Evidence of a general risk management culture at all levels · Risk management training programme · Evidence of managers involvement in risk management aspects of business planning · Results of strategic diagnostic survey to ascertain the extent to which risk management is understood by each category of officer (senior management, operational managers etc) and members	_ _ _ _	· Risk assessment is part of the day-to-day responsibility and culture of front-line staff; but business/corporate risk management requires a different knowledge/skill set. Needs to be considered as an integral part of corporate planning process. · Training programme delivered to middle managers, need to undertake refresher/repeat programme for newly appointed managers. · A diagnostic survey has been undertaken, but needs to be repeated owing to staff turnover.	8	_ Risk management diagnostic and training programme for managers needs to be repeated at least every three years.
11	Risks in partnership working are fully considered	· Evidence of risk assessments being undertaken before the commencement of major partnerships, preferably in the report on which the decision to proceed is based · Evidence that risk assessment are regularly reviewed and updated during the partnership period · Evidence that potential partners are required to produce and submit risk assessments · Evidence that partnership arrangements are reviewed in terms of risk before they are entered into and, subsequently, that the risks are reviewed · Evidence that there are effective arrangements in place for risk sharing (e.g. in the partnership contract terms and conditions or agreement)	_ _ _ _ _	· Part of partnerships tool kit. · Insufficient evidence so far to be certain that risk analysis is fully embedded in management of existing partnerships. · New partnerships are subjected to rigour of tool kit assessment.	6	_ Need to establish a programme of risk management of existing strategic partnerships.
12	Where employed, risk management information systems meet users' needs	· Evidence of risk information being updated promptly · Review of accuracy and usefulness of output from information systems · Evidence that users were/are consulted on initial implementation and further development · Interviews with users to assess suitability of the system for their needs		· Not applicable	n/a


Objective 3: Identify and evaluate key controls to manage principal risks:
Step 1: In support of objective 3 - The authority has robust system of internal control which includes systems and procedures to mitigate principal risks

	Examples of assurance:	Examples of evidence		Evidence	Score	Action for improvement
1	There are written financial regulations in place which have been formally approved, regularly reviewed and widely communicated to all relevant staff: · Authority has adopted CIPFA code on Treasury Management · Compliance with the Prudential Code	· Financial regulations and instructions exist & are reviewed & updated regularly · Evidence of formal approval · Examples of dissemination e.g. induction, briefings, awareness sessions, accessible in finance manuals and/or on intranet site · Reports to audit committee or equivalent confirming compliance or identifying extent of non-compliance with regulations and instructions · Report approving annual treasury management and investment strategy · Outturn report on treasury mgt. · External audit assessment of compliance with Prudential Code · Results of Use of Resources (or PURE) assessment of internal control KLOEs	_ _ _ _ _ _ _	· All in place	10
2	There are written contract standing orders in place which have been formally approved, regularly reviewed and widely communicated to all relevant staff	· Standing orders exist, are reviewed and updated regularly to cover new procedures such as partnering arrangements and on-line tendering · Evidence of formal approval · Examples of communication and dissemination e.g. induction, briefings, awareness sessions, accessible in finance manuals and/or on intranet site	_ _ _	· All in place, accessibility could be improved.	9	_ Consider scope to improve website navigation/searching of key documents
3	There is a whistle blowing policy in place which has been formally approved, regularly reviewed and widely communicated to all relevant staff	· Whistle blowing policy exists and has been reviewed and updated regularly · Evidence of formal approval · Examples of communication and dissemination e.g. induction, briefings, awareness sessions, accessible on website and intranet site · Evidence of effectiveness of policy (e.g. reports on incidence of usage, evidence on annual declarations on fraud to Audit Commission)	_ _ _ _	· In place, but could be more frequently communicated and accessibility improved on website. · No verifiable evidence of policy being accessed or used in reporting matters of concern.	8	_ Publicise whistle-blowing policy and procedure at least annually. _ Consider cost/benefit of monitoring use of, or access to, policy.
4	There is a counter fraud and corruption policy in place which has been formally approved, regularly reviewed and widely communicated to all relevant staff	· Counter fraud and corruption policy exists and has been reviewed and updated regularly · Evidence of formal approval · Examples of dissemination (briefings, induction, awareness sessions, accessible on website and intranet site) · Evidence of effectiveness of policy (e.g. reports on identified frauds; annual AF70 returns to Audit Commission, reports on results of National Fraud Initiatives) · Review of register of gifts and hospitality · Examples of dissemination e.g. induction, briefings, awareness sessions, accessible on intranet site	_ _ _ _ _ _	· Policy approved and audit work undertaken. · On website, but not widely promoted. · Only one example of potential fraud reported in last three years. · Gifts and hospitality register maintained, but needs to be promoted at least annually.	8	_ Publicise counter fraud policy and procedure at least annually. _ Publicise gifts and hospitality policy and procedure at least annually.
5	There are codes of conduct in place which have been formally approved and widely communicated to all relevant staff	· Codes of conduct have been agreed, including national schemes (e.g. police officers) · Evidence of formal approval · Examples of dissemination e.g. induction, briefings, awareness sessions, accessible on intranet site	_ _ _	· Codes need to publicised and made more accessible on website.	7	_ Publicise codes of conduct at least annually - improve website access.
6	A register of interests is maintained, regularly updated and reviewed	· Inspection of register of interests (members and staff) · Evidence of regular updating and review by senior officer(s)	_ _	· Well-established with evidence of updates having been made.	9
7	Where a scheme of delegation has been drawn up, it has been formally approved and communicated to all relevant staff	· Scheme of delegation incorporates adequate controls and sanctions · Evidence of formal approval · Examples of communication and dissemination e.g. induction, briefings, awareness sessions, accessible on intranet site · Regular reports on the operation of the scheme (e.g. compliance, budget monitoring, year-end balances)	_ _ _ _	· Scheme of Delegation to Officers last updated (regarding minor estates issues) in 2007/08). Has not been specifically communicated widely.	8	_ Publicise in managers training events the Scheme of Delegation to Officers and improve website access.
8	A corporate procurement policy has been drawn up, formally approved and communicated to all relevant staff	· Procurement policy exists and has been reviewed and updated regularly to take account of new initiatives e.g. drive towards wider consortia arrangements, shared services · Evidence of formal approval · Examples of dissemination e.g. induction, briefings, awareness sessions, accessible on intranet site · Evidence of effectiveness of policy (e.g. benchmarking results, best value review, internal/ external audit review)	_ _ _ _	· Published - with practitioner guidelines - in 2005. · Day-today procedures work well; training given to appropriate staff; but a best value review of procurement policy and processes has not been undertaken.	5	_ Consider undertaking a best value review of current policy and processes.
9	Business/service continuity plans have been drawn up for all critical service areas and the plans: · Are subject to regular testing · Are subject to regular review	· Current business/service continuity plans exist covering all critical service areas and are readily accessible · Evidence of regular testing · Evidence of regular review in the light of the results of testing and for changes in structures, procedures, information systems, responsibilities etc	_ _ _	· Exercise of business continuity (involving all departments) carried out in December 2007. · Operational business continuity well-established and regularly tested. · Some individual support departments have tested fall-back arrangements (e.g. Performance Review Team)	9
10	The corporate/departmental risk register(s) includes expected key controls to manage principal risks	· Risk register sets out principal risks and sets out appropriate key controls to manage them. · Key controls are monitored, reviewed and updated regularly · Use of risk management workshops to underpin the process and review of register and key controls · Risk owners are assigned to manage principal risks · Partnership risks are considered	_ _ _ _ _	· See detailed comments in Objective 2 above.	9	_ Need to establish a programme of risk management of existing strategic partnerships.
11	Key risk indicators have been drawn up to track the movement of key risks and are regularly monitored and reviewed.	· Appropriate key risk indicators are documented · Evidence of regular monitoring · Evidence of changes in risk indicators (and reasons for change) emanating from appropriate information sources (e.g. where internal audit findings are used to change the perceived level of risk)	_ _ _	· Standard template used giving direction of travel on management of individual strategic risks. Good version control of documentation in place.	10
12	The authority's internal control framework is subject to regular independent assessment	· Internal audit plans and reports · Annual report/opinion of Head of Internal Audit · External audit reports · Use of Resources/PURE assessment reports	_ _ _ _	· All undertaken and fully reported to Governance Committee / Performance Review and Scrutiny Committee and to HFRA meetings	10
13	A corporate health and safety policy has been drawn up, formally approved, is subject to regular review and has been communicated to all relevant staff	· Health & safety policy exists and has been reviewed and updated regularly · Policy covers partnerships · Evidence of formal approval · Examples of dissemination e.g. induction, briefings, awareness sessions, inclusion of policy on website and intranet site · Evidence of effectiveness of policy e.g. number of cases investigated by Health & Safety Executive - and the number of cases proven · Review of number of reported incidences and `near misses'	_ _ _ _ _	· All in place and day-to-day management process and reporting overseen by Health and Safety Committee (involves employee representative).	10
14	A corporate complaints policy/procedure has been drawn up, formally approved, communicated to all relevant staff, the public and other stakeholders is regularly reviewed	· Complaints policy/procedure exists and has been reviewed and updated regularly · Procedure is compliant with all relevant statutory requirements · Evidence of formal approval · Examples of dissemination e.g. induction, briefings, awareness sessions, inclusion of policy on website and intranet site · Leaflets/posters highlighting complaints procedure · Complaints files · Committee reports summarising complaints dealt with analysed by outcome	_ _ _ _ _ __	· Approved policy compliant with statutory requirements; but it has not been sufficiently and regularly promoted, nor has analysis of complaints been reported recently to relevant committees.		_ Need to re-present policy to Perfomance Review and Scrutiny Committee together with analysis of complaints received and handled over preceding 12 months. _ Provide a more visible link to our complaints procedure on our website home page.


Objective 4: Obtain assurance on the effectiveness of key controls:
Step 1: In support of objective 4 - Appropriate assurance statements are received from designated internal and external assurance providers: the authority has identified appropriate sources of assurance; appropriate external assurances are identified and obtained

	Examples of assurance:	Examples of evidence		Evidence	Score	Action for improvement
1	The authority has determined appropriate internal and external sources of assurance	· Minutes of committee at which report on assurances was considered · Sources of assurance are appropriate to the authority	_ _	· All audit and Inspection reports taken to Governance Committee and/or HFRA	10
2	Appropriate key controls on which assurance is to be given have been identified and agreed	· Briefing notes, guidance, instructions etc given to appropriate managers regarding what is expected of them	_	· Management action plans (identifying ownership) produced for each recommendation. Progress on implementation of controls rigorously monitored. · Cross-referenced in Improvement Planning Register.	10
3	Departmental assurances are provided	· Departmental heads sign off on adequacy of controls (i.e. provide annual governance assurance statements) · Supporting documentation provided by departmental heads re review and monitoring arrangements that key controls have been in operation for the period and will continue to operate until accounts signed off. (Structured process and standard documentation to ensure consistency of coverage and common understanding of level of assurance given) · Completed Control & Risk Self-Assessment questionnaires · Annual governance assurance statements evaluated by officer team or committee charged with the responsibility of preparing the AGS. Evaluation to include `reality checking' of sample of assurance statements	_ _ _ _	· Issue owner provides statement on progress of implementation of control (e.g. in Risk Register and on regular reports on audit recommendations). · This is the first AGS self-assessment that has been undertaken. · The new AGS replaces the former Statement of Internal Control (which were previously approved by Governance Committee)	8
4	External assurance reports are collated centrally · Reports are reviewed by relevant senior management team and reported to appropriate committee · Action plans are prepared and approved as appropriate · Follow up reports on recommendations are requested and reviewed by relevant senior management team and progress is regularly reported to relevant committee	· Sources of external assurance relevant to authority are identified and agreed, including partnerships · External assurance reports will vary according to type of authority and could include comment and input from the following (the list is not exhaustive): · Audit Commission · External Auditor (either from direct audit work or from work jointly commissioned) · Social Services Inspectorate · Use of Resources assessment · PURE assessment (police service) · Best Value Reviews · HMIC · Police Standards Unit · Home Office commissioned reports · Senior management team minutes · Follow up reports to appropriate committee	_ _ _ _ _ _	· Relevant reports always taken to committee and HFRA. Where appropriate, improvement actions recorded in Improvement Register which is monitored by CMT.	10
5	Internal Audit Arrangements	· Reports of Head of Internal Audit to audit committee or equivalent throughout the year · Annual report of Head of Internal Audit, including opinion on internal control and risk management framework	_ _	· All presented to Governance Committee.	10
6	Corporate Governance Arrangements	· Annual corporate governance assurance statement · Internal or external audit review of corporate governance arrangements · Monitoring reports to committee on delivery of action plans in response to reviews of corporate governance	_ _ _	· This matrix forms part of the first AGS presented to the Governance Committee under the new Framework. · All audit findings presented to Governance Committee (previously to Performance Review Committee)	9
7	Performance monitoring arrangements	· Annual and in-year reports on delivery of key performance indicators by internal and/or external review agencies	_	· SMT and Performance Review and Scrutiny Committee review key performance indicators at least quarterly.	10


Objective 5: Evaluate assurances and identify gaps in control/ assurances:
Step 1: In support of objective 5 - The authority has made adequate arrangements to identify, receive and evaluate reports from the defined internal and external assurance providers to identify areas of weakness in controls

	Examples of assurance:	Examples of evidence		Evidence	Score	Action for improvement
1	Responsibilities for the evaluation of assurances are clearly defined throughout the organisation.	· Minutes of committee meetings · Training plans · Job descriptions · Committee terms of reference	_ _ _ _	· Progress reports on implementation of evaluation of assurances regularly report (see Objective 4 above). Unsure about the relevance of `training plans' in this context, except that if a training need is identified to enable issue to be addressed it will be provided.	9	_ Need to consider relevance of `training plans' in this context.
2	Mechanism established for collecting governance assurances · Overall responsibility allocated to governance senior officer group · Required assurances are agreed and recorded · Central record of all assurances (either evidence file, or showing clear link to where evidence is held) · Clear guidance as to evaluation procedure including assurance over risks, independence and objectivity of assurances · Defined evaluation mechanism · Timetable for completion by statutory deadline · Gap assessment - performed and challenged	· Terms of reference and key responsibilities · Record of assurances required and received is held and is complete · Approved written guidance re evaluation procedure · Scoring matrix/methodology (Not all assurances are suitable for grading; many will be subjective anyway. Key points are that there is a consistent and reliable assessment process and that the conclusions drawn are in line with the evidence produced) · An agreed timetable, allowing for in-year evidence gathering and assessment and for the period between the year-end and the date of the governance assurance statement (timetable driven by that for the production of the annual statement of accounts) · Gap assessment results and actions arising · Minutes of meetings · Annual report of Head of Internal Audit - including opinion on internal control and risk management framework · Reports of external auditor and other external review agencies	_ _ _ _ _ _	· Oversight assigned to Director of Corporate Services. · Processes under new Framework still being developed in the light of this first year of implementation. Rough guide arrived too late to implement at start of 2007/08. · Gap analysis arises from this self-assessment on which the AGS is based. · Reported to Governance Committee.	6	_ Procedure and timetable for implementing good practice under the new framework is still under development. The intention is to use this matrix as a dynamic document which will be presented to SMT and updated during the year. It will be reported as a draft assessment to the Governance Committee at its April meeting in future. It will form basis of an action plan for improving arrangements.


Objective 6: Action plan to address weaknesses and ensure continuous improvement of the system of corporate governance:
Step 1: In support of objective 6 - There is a robust mechanism to ensure that an appropriate action plan is agreed to address identified control weaknesses and is implemented and monitored

	Examples of assurance:	Examples of evidence		Evidence	Score	Action for improvement
1	An action plan is drawn up and approved	· Prioritised action plan, setting out actions, responsibilities and timescales, approved at appropriate level · Minutes	_	· Following presentation to the Governance Committee, a prioritised action plan will be produced from actions identified in the right-hand column of this self-assessment. · NOTE scores of 5 given on first four elements of this Objective as the self-assessment process has at least identified the scale of the work that needs to be undertaken - the scores on all other elements providing a basis for prioritisation.	5	_ Use this matrix to prioritise actions to improve governance arrangements.
2	All actions are `SMART': · Specific · Measurable · Achievable · Realistic · Time-bound	· Each action on prioritised action plan is compliant with `SMART' test	_	· Most actions will simply require timescales for implementation.	5	_ The aim will be to achieve scores of 9 and above for all elements of the evaluation by end of 2010/11.
3	Actions communicated and responsibilities assigned	· Responsibilities for each action are defined in action plan · Evidence of distribution of action plan to those who require it	_	· This matrix will be reviewed at least twice per year by SMT (July/March preferred).	5	_ Owners yet to be assigned for each action - this will be undertaken by SMT.
4	Implementation timescales agreed	· Target dates included in action plan	_	· This will be determined when priorities agreed and owners identified.	5	_ Need to agree timescales for implementing improvements when ownership and priorities agreed.
5	Ongoing review of progress and of continuing appropriateness of action	· Timetabled reviews · Minutes · Progress reports · Internal audit or other review of implementation of agreed actions	_	· These will be determined when priorities agreed and owners identified.	0	_ Ensure a robust audit-trail of reporting from 2008/09


Objective 7: Annual Governance Statement:
Step 1: In support of objective 7 - An Annual Governance Statement has been drafted in accordance with the statutory requirements and timetable set out in the Accounts and Audit Regulations 2003, as revised by the Accounts and Audit (Amendment) (England) Regulations 2006, and is in accordance with CIPFA guidance.

	Examples of assurance:	Examples of evidence		Evidence	Score	Action for improvement
1	Responsibility for the compilation of the Annual Governance Statement has been assigned to a team drawn from appropriate disciplines and having sufficient seniority	· Documented key responsibilities · Minutes	_	· SMT will undertake the review of the matrix.. CMT will be used as a joint officer/member sounding board of the draft AGS.	5	_ SMT / CMT to be responsible for reviewing self-assessment matrix.
2	There is an Annual Governance Statement production timetable that meets the statutory deadline	· Annual Governance Statement timetable is linked to that for the preparation of statutory accounts	_	· In future the AGS will be presented to the Governance Committee ahead of its consideration of the Annual Statement of Accounts to give more time for formal member input.	5	_ Produce AGS and supporting matrix at April/May meeting of Governance Committee.
3	The Annual Governance Statement is reviewed, challenged and approved by the authority	· Terms of reference assigned to senior officers group · Annual Governance Statement is compliant with CIPFA guidance · Minutes	_ _		0	_ Consider whether SMT /CMT terms of reference need to be updated to reflect this role. _ Governance Committee to make recommendations to the HFRA on any strategic issues/risks that emerge from its consideration of governance arrangements.
4	The Annual Governance Statement incorporates all the required elements of the statement on internal control	· Format of Annual Governance Statement clearly incorporates required elements of the statement on internal control · Annual Governance Statement is prepared by a senior officer group under terms of reference defined by the authority · Statutory timetable is followed	_ _ _	· New AGS subsumes the former requirements of the Statement of Internal Control and uses the gap analysis from this first self-assessment to meet the new requirements.	7	_ Timetabling needs to be improved to provide more time for Governance Committee input.


Objective 8: Report to cabinet / executive committee:
Step 1: In support of objective 8 - An annual report to the authority (or delegated committee) on the Annual Governance Statement is presented, in accordance with the CIPFA pro forma

	Examples of assurance:	Examples of evidence		Evidence	Score	Action for improvement
1	Responsibility for reporting is clearly defined	· Initial report explaining the requirement to produce an annual governance statement incorporating the SIC should establish the reporting arrangements / responsibilities of all involved and set out who should sign the annual governance assurance statement after approval by the authority or designated committee · Reports identifying any changes to initial arrangements	_ _	· Reported to Governance Committee June 2008.	8
2	The signatories to the annual governance statement and SIC are defined and are appropriate in accordance with statutory requirements (i.e. Most senior officer and most senior member of the organisation)	· As above	_	· Chairman and Chief Officer sign the AGS.	8
3	The report is likely to be published in a timely fashion with the statutory accounts	· Assessment of the current position in relation to the statutory deadline	_	Needs to be reported earlier in future.	5	_ AGS needs to be reported to Governance Committee in April/May each year in future.

Secretarial/WP/Corporate/HFRA/Governance HFRA Gov 26 6 08 Annual Gov Statement Matrix Appx 2 DH/JMW/18/6/08

This content is archived

Annual Governance Statement