Workforce Planning. Internal Audit Report 2017/18. Powys Teaching Health Board. NHS Wales Shared Services Partnership. Audit and Assurance Service

Transcription

1 Workforce Planning Internal Audit Report 2017/18 Powys Teaching Health Board NHS Wales Shared Services Partnership Audit and Assurance Service

2 Workforce Planning Powys Teaching Health Board Report Contents CONTENTS Page 1. Introduction and Background 4 2. Scope and Objectives 4 3. Associated Risks 5 Opinion and key findings 4. Overall Assurance Opinion 5 5. Assurance Summary 6 6. Summary of Audit Findings 6 7. Summary of Recommendations 7 Appendix A Appendix B Appendix C Management Action Plan Assurance opinion and action plan risk rating Responsibility Statement Review reference: PTHB/1718/25 Report status: Final Fieldwork commencement: 3 July 2017 Fieldwork completion: 21 July 2017 Draft report issued: 26 July 2017 Management response received: 30 August 2017 Final report issued: 30 August 2017 Auditors: Helen Higgs, Head of Internal Audit Osian Lloyd, Deputy Head of Internal Audit Chris Scott, Principal Auditor Executive sign off Julie Rowles, Director of Workforce and Organisational Development Distribution Mark McIntyre, Head of Operational Workforce & Organisational Development, Workforce and Organisational Development. Sarah Powell, Professional Lead Culture & Leadership Development, Culture and Leadership Committee Audit Committee, Workforce and Organisational Development Committee NHS Wales Audit & Assurance Services Page 2

3 Workforce Planning Report Contents Powys Teaching Health Board ACKNOWLEDGEMENT NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this review. Please note: This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee. Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership Audit and Assurance Services, and addressed to Independent Members or officers including those designated as Accountable Officer. They are prepared for the sole use of Powys Teaching Health Board and no responsibility is taken by the Audit and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third party. NHS Wales Audit & Assurance Services Page 3

4 Workforce Planning Powys Teaching Health Board Internal Audit Report 1. Introduction and Background The review of Workforce Planning has been completed in line with the Health Board s 2017/18 Internal Audit Plan. Powys Teaching Health Board s (the Health Board ) Integrated Medium Term Plan (IMTP) for was approved by Welsh Government in June The IMTP provides the Health Board with a process to review and articulate its values, future strategy, key priorities and delivery actions for the period up to The plan reflects current pressures and priorities and outlines the service and system change required to deliver the strategic objectives so that the Health Board realises its vision of truly integrated care centred on the needs of the individual. The delivery of the IMTP is focussed around a number of Delivery Plans (or service delivery plans ). The Delivery Plans are designed to deliver the Health Board s key priorities in the first year of the IMTP, while also delivering service, workforce, and financial targets in the medium term. 2. Scope and Objectives The overall objective of this review is to ensure that the workforce elements within the IMTP service plans that have been developed by directorates are aligned to longer term service planning. In undertaking the audit, we have sought to gain assurance over the following areas: the Health Board has a comprehensive workforce strategy embedded within the IMTP driven by the senior executive; staff levels required in the Health Board are derived from a detailed resource plan and reflected in a clear establishment model; vacancy analysis is conducted and feeds into the development of recruitment and retention initiatives. where resources are scarce, deployment is based on a risk assessment so that the most critical areas are resourced first; on-going analysis is conducted to identify gaps where resources are short and this feeds into the operational plan; staff levels in clinical areas are not permitted to fall below those required for safe working practice; workforce performance is constantly reviewed / assessed through a framework of delivery measurement and individual appraisal; and ways of working are periodically reviewed to identify potential for benefit yielding changes. NHS Wales Audit & Assurance Services Page 4

5 REASONABLE ASSURANCE Workforce Planning Powys Teaching Health Board Internal Audit Report 3. Associated Risks The risks associated with this review were: negative impact on patient safety/ care and service delivery as a result of low staff resources; breaches of legislation where resource levels are below statutory minimum; failure to achieve the most efficient and effective use of resources; failure to recruit and retain sufficient staff; and failure to plan effectively to address persistent key staff shortfall. OPINION AND KEY FINDINGS 4. Overall Assurance Opinion We are required to provide an opinion as to the adequacy and effectiveness of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives within this report. An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the identified risks associated with the objectives covered in this review. The level of assurance given as to the effectiveness of the system of internal control in place to manage the risks associated with Workforce Planning is Reasonable Assurance. RATING INDICATOR DEFINITION The Board can take reasonable assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Some matters require management attention in control design or compliance with low to moderate impact on residual risk exposure until resolved. The overall level of assurance that can be assigned to a review is dependent on the severity of the findings as applied against the specific review objectives and should therefore be considered in that context. NHS Wales Audit & Assurance Services Page 5

6 Workforce Planning Powys Teaching Health Board Internal Audit Report 5. Assurance Summary The summary of assurance given against the individual objectives is described in the table below: Assurance Summary 1 Workforce strategy 2 3 Staff levels derived from detailed resource plans Vacancy analysis and resource deployment 4 Performance reporting * The above ratings are not necessarily given equal weighting when generating the audit opinion Design of Systems/Controls The findings from the review have highlighted 2 issues that are classified as weakness in the system control/design for Workforce Planning. Operation of System/Controls The findings from the review have not highlighted any issues that are classified as weakness in the operation of the designed system/control for Workforce Planning. 6. Summary of Audit Findings Issues identified, which require attention, have been discussed with management. The detailed findings with recommendations are detailed in Appendix A. We identified 1 high priority issue and 1 medium priority issue for the Powys Teaching Health Board which we consider require management s attention and provide scope for improvements to be made. These concerned: 1) Resource Planning and the IMTP (High) We understand that resource plans submitted by directorates for the IMTP were based on current establishment levels although the NHS Wales Audit & Assurance Services Page 6

7 Workforce Planning Powys Teaching Health Board Internal Audit Report intention to transition to a needs basis model is signalled in that document. Work toward transitioning all area / directorate staff establishments to a need basis and revising head counts accordingly is now in progress and has to date been completed for the ward based nursing staff complement where a significant volume of work has been undertaken by the Nursing Directorate to determine the establishments in line with the All Wales Chief Nursing Officer Principles. There are standards for School Health Nursing, which the Health Board is compliant with and in addition, the model for Midwifery is based on Birthrate Plus and again Midwifery is compliant. However, the timelines for formal workforce review and analysis for the other areas of the Health Board staffing groups, including the therapies staff group and other directorates including facilities, primary care and management capacity could not be established. 2) Vacancy monitoring across the Health Board (Medium) We noted that vacancy reporting is well developed for the nursing cohort in the Health Board but that for the remainder of the workforce there are no central reports available that report variance / vacancy. We are advised that to achieve vacancy reporting across other areas, heads of service need to validate whole time equivalents (WTEs) in their areas in order that they can be entered into the Electronic Staff Record (ESR) against the posts. That said, headcount and staff turnover is monitored routinely through the Workforce and Organisational Development Committee. 7. Summary of Recommendations The audit findings, recommendations are detailed in Appendix A together with the management action plan and implementation timetable. A summary of these recommendations by priority is outlined below. Priority H M L Total Number of recommendations NHS Wales Audit & Assurance Services Page 7

8 Powys Teaching Health Board Workforce Planning Action Plan Finding 1 - Resource planning and the IMTP (Design) We understand that resource plans submitted by directorates for the IMTP were based on current establishment levels although the intention to transition to a needs basis model is signalled in that document. Work toward transitioning all area / directorate staff establishments to a need basis and revising head counts accordingly is now in progress and has to date been completed for the ward based nursing staff complement where the establishments were determined based on the All Wales Chief Nursing Officer Principles. We understand that a significant volume of work has been undertaken by the Nursing Directorate in order to address staffing needs in hospitals, school health nursing, district nursing teams and also in midwifery in order to comply with Birthrate Plus. In regard to mental health and district nursing, these areas are bound by national work streams with the extension of the Welsh Staffing Act. However, the timelines for transition for the remainder of the directorates in the Health Board including the therapies staff group and other directorates including facilities, primary care and management capacity could not be established. Recommendation 1 We recommend that the Health Board determine a timeline for all remaining areas, outside of the Nursing Directorate, to develop and complete agreed establishments and headroom (where applicable) in order to develop this approach across the whole organisation. Each Directorate will in the first instance be required to determine and agree detailed service plans before the workforce needs and head counts can be established. We would also suggest that each Directorate should adopt the methodology and approach applied by colleagues within the Nursing Directorate, as appropriate. Risk Risk of mis-statement of resource head count and cost Risk of operating below optimum efficiency in working practices Failure to develop and take advantage of potential savings through joint working initiatives Priority level High NHS Wales Audit & Assurance Services Appendix A Page 8

9 Powys Teaching Health Board Workforce Planning Action Plan Management Response 1 The Nursing staffing group is complete and the Facilities staffing group demand exercise has also now been completed. The Medical Director has confirmed a December deadline for the completion of a staffing review and the Director of Therapies and Health Science has confirmed that the staffing review for Allied Health Professionals will also be completed by January Responsible Officer/ Deadline Director of Primary and Community Care for Facilities completed. Medical Director December Director of Therapies and Health Science January NHS Wales Audit & Assurance Services Appendix A Page 9

10 Powys Teaching Health Board Workforce Planning Action Plan Finding 2 Vacancy monitoring across the Health Board (Design) We noted that vacancy reporting is well developed for the nursing cohort in the Health Board but for the remainder of the workforce there are no central reports available that report variance / vacancy. This is further supported by the workforce performance report which was presented at the June 2017 Workforce and Organisational Development Committee which stated that; Work is ongoing to ensure that accurate information in relation to vacancies is provided in the workforce performance report. Inaccuracies in data due to recording of information and differing parameters of what is considered as a vacancy is causing Trac data to be inaccurate. The work detailed in the Workforce Productivity & Efficiency report, regarding setting establishments will enable accurate vacancy data to be reported, a timeline for this work will be agreed via Delivery & Performance. Risk Increased risk that patient care may suffer Increased risk that patient safety is compromised Risk of failure to meet treatment targets We are advised that to achieve vacancy reporting across other areas, heads of service need to validate whole time equivalents (WTEs) in their areas in order that they can be entered into the Electronic Staff Record (ESR) against the posts. Work to do this has been progressed in the nursing staff group and proposed across the next area being facilities but schedule and timelines to complete this work across the remainder of the areas could not be established. Recommendation 2 We recommend that the Health Board determine a timeline for all heads of service to validate WTEs in their areas to facilitate full and accurate reporting of vacancies. Priority level Medium NHS Wales Audit & Assurance Services Appendix A Page 10

11 Powys Teaching Health Board Workforce Planning Action Plan Management Response 2 Work to review the current reporting mechanisms for vacancies is being undertaken. The Nursing establishment has been reflected in ESR and the reporting mechanism for this will be agreed by October ESR will reflect the agreed demands for Facilities by November 2017, subject to an agreement to the approach with the Directorate and WOD. For other staffing groups, the timeframes for reflecting the demands in ESR is dependent on completion of recommendation 1. Therefore, it is anticipated that these timeframes can be agreed by October 2017 with all remaining Directorates. Responsible Officer/ Deadline Director of Nursing October Director of Primary and Community Care for Facilities November 2017 Medical Director and Director of Therapies and Health Science October 2017 NHS Wales Audit & Assurance Services Appendix A Page 11

12 Powys Teaching Health Board Workforce Planning Audit Assurance Ratings Substantial assurance - The Board can take substantial assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Few matters require attention and are compliance or advisory in nature with low impact on residual risk exposure. Reasonable assurance - The Board can take reasonable assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Some matters require management attention in control design or compliance with low to moderate impact on residual risk exposure until resolved. Limited assurance - The Board can take limited assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. More significant matters require management attention with moderate impact on residual risk exposure until resolved. No Assurance - The Board has no assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Action is required to address the whole control framework in this area with high impact on residual risk exposure until resolved Prioritisation of Recommendations In order to assist management in using our reports, we categorise our recommendations according to their level of priority as follows. Priority Level Explanation Management action High Medium Low Poor key control design OR widespread non-compliance with key controls. PLUS Significant risk to achievement of a system objective OR evidence present of material loss, error or misstatement. Minor weakness in control design OR limited noncompliance with established controls. PLUS Some risk to achievement of a system objective. Potential to enhance system design to improve efficiency or effectiveness of controls. These are generally issues of good practice for management consideration. Immediate* Within One Month* Within Three Months* * Unless a more appropriate timescale is identified/agreed at the assignment. NHS Wales Audit & Assurance Services Appendix B

13 Powys Teaching Health Board Workforce Planning Confidentiality This report is supplied on the understanding that it is for the sole use of the persons to whom it is addressed and for the purposes set out herein. No persons other than those to whom it is addressed may rely on it for any purposes whatsoever. Copies may be made available to the addressee's other advisers provided it is clearly understood by the recipients that we accept no responsibility to them in respect thereof. The report must not be made available or copied in whole or in part to any other person without our express written permission. In the event that, pursuant to a request which the client has received under the Freedom of Information Act 2000, it is required to disclose any information contained in this report, it will notify the Head of Internal Audit promptly and consult with the Head of Internal Audit and Board Secretary prior to disclosing such report. The Health Board shall apply any relevant exemptions which may exist under the Act. If, following consultation with the Head of Internal Audit this report or any part thereof is disclosed, management shall ensure that any disclaimer which NHS Wales Audit & Assurance Services has included or may subsequently wish to include in the information is reproduced in full in any copies disclosed. Audit The audit was undertaken using a risk-based auditing methodology. An evaluation was undertaken in relation to priority areas established after discussion and agreement with the Health Board. Following interviews with relevant personnel and a review of key documents, files and computer data, an evaluation was made against applicable policies procedures and regulatory requirements and guidance as appropriate. Internal control, no matter how well designed and operated, can provide only reasonable and not absolute assurance regarding the achievement of an organisation s objectives. The likelihood of achievement is affected by limitations inherent in all internal control systems. These include the possibility of poor judgement in decision-making, human error, control processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable circumstances. Where a control objective has not been achieved, or where it is viewed that improvements to the current internal control systems can be attained, recommendations have been made that if implemented, should ensure that the control objectives are realised/ strengthened in future. NHS Wales Audit & Assurance Services Appendix C

14 Powys Teaching Health Board Workforce Planning A basic aim is to provide proactive advice, identifying good practice and any systems weaknesses for management consideration. Responsibilities Responsibilities of management and internal auditors: It is management s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the prevention and detection of irregularities and fraud. Internal audit work should not be seen as a substitute for management s responsibilities for the design and operation of these systems. We plan our work so that we have a reasonable expectation of detecting significant control weaknesses and, if detected, we may carry out additional work directed towards identification of fraud or other irregularities. However, internal audit procedures alone, even when carried out with due professional care, cannot ensure fraud will be detected. The organisation s Local Counter Fraud Officer should provide support for these processes. NHS Wales Audit & Assurance Services Appendix C

15 Powys Teaching Health Board Workforce Planning Office details: POWYS Office Audit and Assurance Hafren Ward Bronllys Hospital Powys LD3 0LS MAMHILAD Office Audit and Assurance Cwmbran House (First Floor) Mamhilad Park Estate Pontypool, Gwent NP4 0XS Contact details Helen Higgs (Head of Internal Audit) Osian Lloyd (Deputy Head of Internal Audit) Chris Scott (Principal Auditor) NHS Wales Audit & Assurance Services