Chairpersons Report Chairpersons Name Carole Hudson Committee Name Audit Committee Date of Meeting 03.08.16 Name of Receiving Committee Trust Board Date of Receiving Committee meeting September 2016 Strategic Items for referral to Trust Board Na. Items for escalation? Na. Please detail the key successes or achievements discussed at the meeting 1. Positive progress and assurance from the Annual Clinical Audit report and outcomes 2. Assurance given from the Internal Audit report on nursing handovers 3. Positive outcomes from the Charitable Funds draft annual report and accounts 4. Good conversion rates from the Counter Fraud work to revised policies 5. Considerable assurance given by the work of REMC now regularly updating the Risk Register Details of the top risks identified during the course of the meeting and initials of primary member of staff actioning 1. Although good assurance given by Internal Audit on the process established for recording of Gifts and Hospitality, this remains a concern based on the recent data provided by the Pharmaceutical Industry and the lack of recording at WWL in this area C Alexander / C Ryan 2. A lack of a standard operating procedure in terms of Estates stock use or D Evans withdrawals on each of the hospital sites. 3. The lack of qualified coding auditors R Forster 4. Potential delays for patients in the risk identified on the renewal of decontamination equipment for endoscopes M Fleming Attendance at the meeting (please highlight): Excellent (well attended) Acceptable (some apologies) x Unacceptable (quorate) Unacceptable (not quorate) Was the agenda fit for purpose and reflective of the Committees terms of reference? Yes Narrative report of the key issues of the meeting The Audit Committee reviewed the draft Charitable Funds accounts for 2015/16 which were approved. The Committee considered the revised policies for salary advances and overpayments and SLAs. The above policies demonstrate a good conversion rate from the Counter Fraud work undertaken to the policy generation which gives considerable assurance. The Audit Committee reviewed the losses and compensations report from April to June which was approved. The Audit Committee reviewed the reference costs audit report and noted the recommendations included in the report which have been accepted. The Audit Committee noted the need for qualified coding auditors to be in place and work is currently being undertaken to address this. The Audit Committee thanked the finance team for the assurance given on the reference cost audit. The Audit Committee reviewed the process of declaring Gifts and Hospitality and quality of the current register. The Counter Fraud team have identified concerns with the recording of Gifts and Hospitality with respect to information provided for 2015 by the UK Pharmaceutical companies, who are now required to disclose and publicise details of payments and benefits to organisations or individuals. 92 disclosures were made in respect of WWL by the pharmaceutical companies in 2015 but only three had been formally recorded in the Trust register. The remaining information is currently being dealt with by the Counter Fraud team and the Associate Director of Governance and Assurance. There is lack of assurance on the recording of Gifts and Hospitality despite a robust system being in place. The Audit Committee reviewed the Monitor Q1 return together with the Committee Effectiveness reports all of which gave considerable assurance on reporting and transparency. 1
The Audit Committee reviewed the annual report on clinical audit and effectiveness for 2015/16. This report gave the Committee considerable assurance on the following: The Trust is participating in National audits and is performing as well as or better than other Trusts The Trust is able to demonstrate robust patient pathways; the delivery of safe and effective care; a culture of learning from mistakes and good clinical outcomes The Trust continues to benchmark its practice against National and Regional providers and can evidence compliance with NICE guidelines The Trust can evidence a methodical process for continuously monitoring and evaluating the level of care and service provided to patients and service users, in order to sustain quality improvement Action plans are in place and are regularly followed up. The Audit Committee may choose to receive presentations on individual, current clinical audits during 2016/17 to consider progress against action plans The Audit Committee noted the excellent work now being undertaken to regularly update the risk register and conducted a deep dive into three risks; The action plan associated with the SHMI risk The concerns about the future of the post mortem service The replacement of the decontamination unit for endoscopy on the RAEI site. Discussions took place about the robustness of the replacement schedule for medical devices and its impact on the budget The work of REMC now gives assurance to the Audit Committee and the minutes of REMC will be included in all future Audit agendas. Internal Audit provided report which gave assurances on; Nursing handovers The process for recording Gifts and Hospitality Internal Audit also highlighted two areas for future consideration, these include security concerns identified on the first level of protection for the authentication of HIS users and the absence of a standard operation procedure by the Estates department for controlling stock use and withdrawals of stock on each hospital site. The Counter Fraud lead updated progress on problems with regard to Declarations of Interest, working whilst off sick and the use of self-certification for recording sickness. Counter Fraud will bring forward reports on the review of Travel Policy and E-Expenses to the next Audit Committee. Key outcomes from the reports taken at the meeting Good compliance with the updating and monitoring of the Risk Register Good conversion rates from Counter Fraud work to policy updating Concerns remain about the level of recording of information for Gifts and Hospitality despite the Trusts process being judged to be good The Clinical Audit report provided good evidence of a methodical process for continuously monitoring and evaluating the level of care and service provided to patients and service users Agreed actions from the meeting Quarterly reports from Clinical Audit to be taken to provide assurance on outstanding actions from the annual report S Holt and S Connor to link with regard to the MIAA clinical coding academy The SLA register to be circulated to the Audit Committee for information S Martland to include the requirement for monitoring into Name of primary lead for the actions C Alexander / L Farnworth S Holt / S Connor C Alexander / S Martland S Martland 2
the SLA Process Policy An update on the follow up of the Pharmaceutical Company list to be given at the next meeting (C Ryan) Deep dive of three corporate risks per meeting to be added to the work plan Deep dive of sections of the business continuity plan to be added to the work plan MIAA to provide an update on the car parking permits action for the October meeting Audit Committee to review a retrospective waiver above 10k at a future meeting A review of the controls for monitoring overtime working to be undertaken at the next meeting C Ryan / C Alexander L Hancock L Hancock L Warner C Wood A Balson 3
MINUTES OF A MEETING OF THE AUDIT COMMITTEE HELD ON WEDNESDAY, 3 AUGUST 2016 AT 9.30AM IN THE THQ BOARDROOM 2016 PRESENT 03 02 02 03 04 05 18 05 03 08 Mrs C Hudson (Chair) NED Mr N Turner NED Mr N Campbell NED Mr M Guymer, NED IN ATTENDANCE Mr R Forster, Director of Finance / Deputy CEO Mrs Pauline Law, Acting Director of Nursing Mrs H Hand, Trust Board Secretary Mrs C Ryan, Counter Fraud Ms D Wright, Deloitte Ms L Warner, Internal Audit Manager Mrs L Hancock, Corporate Services Administrator Claire Alexander, Head of Governance and Assurance Shirley Martland, Financial Controller Alison Balson, Director of HR Umesh Prabhu, Medical Director 1. COMMITTEE CHAIRS OPENING REMARKS C Hudson welcomed all to the meeting. 2. APOLOGIES As noted in the table above. 3. DECLARATION OF INTERESTS None declared. 4. APPROVAL OF MINUTES OF MEETING ON 18.05.16 The minutes were agreed to be an accurate record. 5. MATTERS ARISING a. ACTION LOG VM All action updates were received and noted. SM Steve Connor, Deputy Director MIAA Carolyn Wood, Deputy Director of Finance Mary Fleming, Interim Director of Performance and Ops DE Richard Mundon, Director of Strategy and Planning Deborah Pullen, Compliance Lead Paul Thompson, Deloitte - MF VM 4
b. Work plan 16/17 This was received and noted. c. ToR The amended Terms of Reference were approved by the Committee. 6. CORPORATE GOVERNANCE a. CLINICAL AUDIT ANNUAL REPORT L Farnworth was in attendance to present this report to the Committee. C Hudson thanked L Farnworth and the team for a very thorough and excellent report. The Audit Committee could take assurance from the report that it gave considerable coverage and that best practice was being followed. The Audit Committee commended the team for their work on this. It was agreed to take quarterly updates on outstanding actions so that the Audit Committee could be assured that actions from the annual report were being dealt with. Quarterly reports from Clinical Audit to be taken to provide assurance on actions from the annual report b. REFERENCE COST AUDIT REPORT S Holt was in attendance to present the report on the PWC audit of the 14/15 reference costs. WWL had performed well in this and had been materially compliant. Three particular areas had been identified as requiring consideration: The lack of an overall procedure for reference costs The lack of a qualified auditor for the clinical coding function S Holt noted that a number of staff members had been sent for training on this but had failed the assessment process. At this time the Trust had to buy in this service Activity reconciliation it was felt that the move to HIS would help to resolve this M Guymer noted the issues around a coding auditor and noted that this was a tough area to recruit in. He felt that other ways of filling this gap needed to be considered. S Connor noted that MIAA had a separate function that offered training and support in this area. He would be happy to link with S Holt to discuss this further. The Audit Committee thanked S Holt for an excellent report and looked forward the actions around the recommendations being delivered. S Holt and S Connor to link with regard to the MIAA clinical coding academy c. DRAFT CHARITABLE FUNDS ACCOUNTS S Martland presented the first draft of the Charitable Funds which had been audited by Deloitte. The final Deloitte report was awaited and the accounts would return to Audit Committee in October for approval and these would then be signed off by Charitable Trust Board. S Martland noted that Deloitte had made some suggested amendments which would be included in the final draft. P Thompson advised that there were still some elements for review but the core of the audit undertaken had raised no issues. 5
The Audit Committee noted that draft position and looked forward to receiving the final version for approval in October. d. LOSSES AND COMPENSATIONS FROM APRIL TO JUNE The report was received and approved by the Audit Committee. e. DRAFT POLICIES FOR SALARY ADVANCES AND OVERPAYMENTS S Martland presented the draft policies which had been produced in response to a recommendation from the MIAA report on payroll and ESR. The Audit Committee approved the policies and noted that some workshop events would be held for managers around this. f. APPROVAL OF SLA PROCESS POLICY S Martland had worked with H Hand to put in place a policy and procedure for the central collation of SLAs. The policy was now presented to the Committee for approval. L Warner noted that MIAA was currently undertaking an audit around this so she would forward the policy on to the auditors for their reference. C Hudson queried whether there was a monitoring process in place for SLAs to ensure that the Trust wasn t providing services to others at a loss. S Martland advised that SLAs were fully reviewed by finance to ensure viability. R Mundon advised that it was the responsibility of the individual department holding the SLA to monitor and they held the accountability for this. The Audit Committee considered the potential to review the monitoring arrangements of SLAs in terms of quality and finance and to undertake some deep dives to gain assurance. The Audit Committee asked that the register of SLA s was circulated to the Audit Committee for information with a view to some deep dives being undertaken periodically. The Audit Committee approved the SLA Process Policy but noted the need for monitoring to be built more explicitly into the policy. The SLA register to be circulated to the Audit Committee for information g. GIFTS AND HOSPITALITY REGISTER S Martland to include monitoring into the SLA Process Policy The Gifts and Hospitality register was received and noted. C Ryan and L Warner reported back on the audit that had taken place around this. They advised that significant assurance had been provided overall but some recommendations had been made which were being followed up. They felt that there were still potential gaps on the register and, despite the system and process in place, it would always be difficult to ensure that staff had declared everything. They suggested that an electronic form or annual reporting might make it easier for staff. C Hudson was pleased that the Trust had a good policy in place and that the Audit Committee had received assurance around the process but she noted the issues being raised by the Auditors. C Ryan advised that UK Pharmaceutical companies now had to publish details of gifts / benefits to organisations. In the recent published list, there had been 92 WWL employees that had received a benefit of some kind. Of these 92, only 3 had declared this in 2015/16. 6
She advised that M Parks would be discussing this at the Medicines Management Board and that follow up with the staff that had not declared would be undertaken. The Audit Committee accepted the update but acknowledged that based on the additional information provided by the Pharmaceutical Industry, the policy was not being fully complied with. The Audit Committee requested an update on the follow up action being taken at the next meeting. An update on the Pharmaceutical Company list to be given at the next meeting (C Ryan) h. MONITOR Q1 RETURN The return was received and noted. It had been approved at the Board meeting the previous week. i. COMMITTEE EFFECTIVENESS REPORTS The effectiveness reports for the following Committees were received and noted: Q&S F&I HR IM&T These had been prepared by the Chairs of the Sub Committees and the Audit Committee thanked the Sub Committee chairs for the detail. j. DEEP DIVE OF POLICIES, PROCEDURES AND APPLICATION A deep dive of the three oldest risks on the CRR was undertaken as part of the CRR review (further down in the minutes). 7. RISK MANAGEMENT a. REVIEW CHANGES IN POLICY WHICH MAY AFFECT COMPLIANCE (FOR INFORMATION) No items this meeting. b. CONSIDER ADEQUACY OF ALL POLICIES No items this meeting. c. RISK ESCALATIONS / REFERRALS No items this meeting. d. REVIEW OF CORPORATE RISK REGISTER AND DEEP DIVE OF THREE OLDEST RISKS SHMI C Alexander advised that this had been a risk since July 2015. WWL was still an outlier in terms of SHMI although improvement had been made. WWL was one of 18 Trusts that were below expected. An action plan had been put in place but the actions would need to be refreshed and this would be taken via the Q&S Committee. The issues around SHMI were noted such as; old data and lack of consideration for deprivation but it was noted that, as the Trust remained an outlier, it was not possible to reduce the risk. 7
The Audit Committee accepted the update given around this risk and accepted the assurance provided that this was constantly reviewed and monitored. POST MORTEM SERVICE R Mundon advised that this risk was about the relationship between WWL and the coroner and the demands placed upon Pathologists in terms of hearings. This had been on the register for some time and was an ongoing issue. However, there had been some senior level discussions which had been constructive and it was hoped that the situation around this would improve. The Audit Committee noted that this remained a risk but noted the ongoing discussions. ENDOSCOPY R Mundon advised that this had been a long standing issue with the machines beginning to break down on a more frequent basis. The availability of capital had been an issue also but capital investment for a centralised service had now been approved. A business case for the running costs was currently going through the approvals process and, once this had been approved, this could be removed as a risk. He advised that the risk was being well managed and patients continued to get their treatment. The Audit Committee were concerned that this had been a long standing risk but were pleased to note the assurances that this was being dealt with in the best possible way given the capital constraints. RISK REGISTER The risk register was received and noted. This was now reviewed, discussed and updated monthly at REMC. C Hudson noted the responsibility of the Audit Committee to assure the Board that the process around risk management was robust and thanked REMC for the improved risk register. It was agreed that the Audit Committee would continue to deep dive risks of particular concern. The Committee would also continue to deep dive elements of the business continuity plan. The Committee accepted the risk register. Corporate risk register and the minutes of REMC to be included on the agenda of the Audit Committee Deep dive of elements of the business continuity plan to be added to the work plan 8. INTERNAL AUDIT a. INTERNAL AUDIT PROGRESS REPORT Patient Handover significant assurance The audit looked at Trust processes for medical and nursing handovers. Handovers had been observed and some evidence of good practice had been found but it had been identified that there was not a policy in place to cover shift to shift handovers. There were also some variances in practice. The recommendations and the report had been accepted by P Law and U Prabhu. 8
Briefing note on HIS MIAA had been providing support around this in terms of advice on governance, security and resilience. Some issues had been identified in the report around the security of the system and the team are looking into this. A further review is planned for later in the year. Estates stock briefing note It was noted that this piece of work had arisen from an allegation of theft from the Estates stock. MIAA had found some issues in relation to the management of stock and a number of recommendations were made which were accepted by management. The Audit Committee were pleased to note the link between Anti-Fraud and Internal Audit which demonstrated that important issues were being highlighted and the gaps were being closed. b. INTERNAL AUDIT TRACKING REPORT L Warner felt that the follow up of actions had improved significantly in the last 12 months. The regular review at ECC had helped with this. There were only 2 outstanding recommendations from 13/14 and 15/16; these were in relation to R&D and car parking permits. The Audit Committee asked that the position on car parking permits was updated at the October meeting but was pleased to note the good progress in general MIAA to provide an update on the car parking permits action for the October meeting c. AUDIT COMMITTEE INSIGHT BRIEFING 9. EXTERNAL AUDIT The report was received and noted by the Committee for information. There were no reports from External Audit on this occasion. 10. COUNTER FRAUD PROGRESS REPORT C Ryan provided her progress report to the Audit Committee. She noted that there had been an increase in investigations, particularly around working whilst off sick. The Audit Committee were pleased to see the culture of reporting and that the work for Anti-Fraud was being taken forward and being used to strengthen policies within the Trust, particularly in HR. The Audit Committee accepted the report and thanked C Ryan for her continued hard work. 11. CHAIRS REPORTS OF OTHER SUB COMMITTEES The chairs reports from reporting Committees were received and noted. 12. SINGLE TENDER WAIVER REQUESTS The report was received and noted. The Audit Committee expressed concern of retrospective waivers which would not receive approval and will look at this next time one comes through. Audit Committee to review a retrospective waiver at future meetings 9
13. ANY OTHER BUSINESS P Thompson noted that WWL was one of the few Trusts nationally to have received no qualifications to their annual accounts and quality accounts. He felt this was a significant achievement. He highlighted a number of challenges facing Trusts in 2016/17 which would be considered during 16/17 14. KEY SUCCESSES / RISKS Key successes were agreed to be: Positive progress and assurance from the Annual Clinical Audit report and outcomes Assurance given from the Internal Audit report on nursing handovers Positive outcomes from the Charitable Funds draft annual report and accounts Good conversion rates from the Counter Fraud work to revised policies Considerable assurance given by the work of REMC regularly updating the Risk Register Key risks were agreed to be: Although good assurance given by Internal Audit on the process established for recording of Gifts and Hospitality, this remains a concern based on the recent data provided by the Pharmaceutical Industry and the lack of recording at WWL in this area A lack of a standard operating procedure in terms of Estates stock use or withdrawals on each of the hospital sites. The lack of qualified coding auditors Potential delays for patients in the risk identified on the renewal of decontamination equipment for endoscopes 15. COMMITTEE EFFECTIVENESS FEEDBACK C Hudson thanked all for their attendance and participation in what had been a full meeting. 16. DATE AND TIME OF NEXT MEETING 5 th October 2016, 9.30am, THQ Boardroom. 10