CONFIRMED MINUTES OF A MEETING OF THE AUDIT COMMITTEE, HELD ON THURSDAY 5 JUNE 2013 AT 9.30 AM IN THE MEETING ROOM CORPORATE HEADQUARTERS, WHITCHURCH

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1 AGENDA ITEM 7.1a CONFIRMED MINUTES OF A MEETING OF THE AUDIT COMMITTEE, HELD ON THURSDAY 5 JUNE 2013 AT 9.30 AM IN THE MEETING ROOM CORPORATE HEADQUARTERS, WHITCHURCH Present: Ivar Grey Stuart Egan Brendan Sadka In attendance: Charlotte Moar Alison Gerrard Abigail Harris James Johns Alison Butler John Herniman Tracy Myhill Louise Driscoll Joanne McCarthy Independent Member Finance (Chair) Independent Member Trade Union Independent Member - Capital Executive Director of Finance Board Secretary Director of Planning Head of Internal Audit External Audit Client Manager Wales Audit Office (WAO) External Audit Engagement Partner, WAO Deputy Chief Executive/Director of Workforce and Organisational Development PPV Manager, Shared Services Partnership WAO Board Members invited to attend the meeting: Maria Battle Chair Marcus Longley Vice Chair Adam Cairns Chief Executive Margaret McLaughlin Independent Member Third Sector Other Officers invited to attend the meeting: Christopher Lewis Assistant Director of Finance Corporate and Strategy Richard Hurton Head of Financial Accounting Apologies: Craig Greenstock Counter Fraud Manager Anne Beegan Performance Audit Manager - WAO Elizabeth Treasure Independent Member - University Carol Evans Assistant Director of Patient Safety and Quality Nigel Gibbs Staff Representative Alice Casey Chief Operating Officer (from agenda item AC 13/183) Martyn Waygood Independent Member Legal Cllr Chris Elmore Independent Member Local Authority Secretariat Confirmed Minutes of the Audit Committee 5 June of 7 9 September 2014

2 Rachel Armitage AC 14/067 Corporate Administrator WELCOME AND INTRODUCTIONS The Chair welcomed all present to the meeting which had been convened specifically to consider the Cardiff and Vale University Health Board (the UHB) Annual Accounts (and associated documents) for 2013/14 for recommendation to the Board. A number of Board Members, in addition to Committee members, had been invited to inform discussions at the Board meeting that would take place immediately following the Committee meeting. AC 14/068 APOLOGIES FOR ABSENCE Apologies for absence were noted. AC 14/069 DECLARATIONS OF INTEREST The Chair invited Members to declare any interests in the proceedings on the agenda. No interests were declared. AC 14/070 ANY OTHER URGENT BUSINESS There were no items of urgent business. AC 14/072 POST PAYMENT VERIFICATION ANNUAL REPORT 2013/14 AND PLAN 2014/15 (BROUGHT FORWARD FROM MAY MEETING) The Committee RECEIVED the report of the PPV Manager who summarised the key points, in particular that meetings have been held with primary care contractors where repeated errors and recoveries have occurred where the zero tolerance approach has been emphasised. Positive results have followed the increased amount of training delivered to primary care providers. The UHB error rates are now below the All Wales average and significantly below the South East Wales average. It was confirmed that there is no adverse impact on the quality of treatment to patients; errors have been found to be related to poor administrative processes and record keeping within Practices. It was noted that such processes are currently manual and could be improved with improved technologies. It was emphasised that there is a need for increased scrutiny across all contractors, to include dental and prescribing, to provide a more accurate picture of the UHB position. It was noted that a protocol is now in place to audit Pharmacists, to commence in August 2014; plans are under development to undertake dental PPV in APPROVED the post payment verification annual report 2013/14 and plan 2014/15 Confirmed Minutes of the Audit Committee 5 June of 7 9 September 2014

3 AC 14/073 LOSSES AND SPECIAL PAYMENTS The Committee RECEIVED the report of the Deputy Director of Finance who highlighted the areas for Audit Committee approval as set out in the report. It was noted that the total cost of clinical negligence and permanent injury to the NHS for the UHB has reduced but the cost to the UHB itself has increased owing to the increased number of smaller cases that were not met by the Welsh Risk Pool. It was highlighted that the losses of items belonging to visitors and staff are greater than thefts etc of UHB property. There has been a reduction from the previous year in obsolete stock. There was discussion on the increasing amounts of high value IT equipment brought by patients to hospital increasing the risks of loss and increased claims. There is a work programme in place to address this. It was recognised that the increased availability of WiFi and removal of televisions across UHB estate has also resulted in increased risk of losses of personal equipment. Assurance was provided that the Health and Safety Committee receives regular updates on manual handling and violence and aggression incidents. It was confirmed that the new procedure for concerns will be monitored to establish its impact on the numbers of small claims. There was discussion on the level of risk to the UHB associated with the devolution of the Welsh Risk Pool (WRP), noting that the allocation will be on a population basis and that the Welsh Government has allocated an additional allowance to the UHB in recognition of its a tertiary provider status. It was noted that the new arrangements will encourage improved scrutiny and highlight opportunities for incentivising improved practice. There was discussion on the need for the WRP to clarify the position on thefts from the UHB asset base, noting risks over controls of equipment and the need for a higher level of staff awareness and personal responsibility for property. NOTED the minutes of the 21st May 2014 meeting of the Losses and Special payments Panel APPROVED the losses, special payments and write-offs set out in the report. AC 14/074 MANAGEMENT UPDATE AGAINST WALES AUDIT OFFICE RECOMMENDATIONS IN THE ANNUAL AUDIT LETTER The Committee RECEIVED the report of the Board Secretary. There were no exceptions to highlight. The WAO confirmed that it supports the UHB approach to addressing the matters raised in the Annual Audit Letter. Confirmed Minutes of the Audit Committee 5 June of 7 9 September 2014

4 NOTED progress against the recommendations in the WAO Annual Audit Letter AC 14/075 AUDIT COMMITTEE DRAFT WORK PROGRAMME The Committee RECEIVED the report of the Board Secretary, noting that the work plan is indicative. This will be approved by the Board at its July meeting. RECOMMENDED the programme to the Board for approval in July AC 14/076 ANNUAL ACCOUNTS AND YEAR END STATEMENTS 2013/14 The Chair introduced the five items that required consideration by the Committee prior to the approval of the Accounts by the Board. The Committee had met in workshop mode on the 16 May 2013 which had allowed the opportunity for the detailed discussion of these items, which were: Draft Annual Accounts The Annual Governance Statement Draft Remuneration Report The Draft Letter of Representation WAO ISA 260 Report All items would be discussed as separate items with the Draft Letter of Representation considered alongside the WAO Audit of Financial Statements/ISA 260 Report. AC 14/077 REPORT ON THE ANNUAL ACCOUNTS 2013/14 The Committee RECEIVED and NOTED the report of the Director of Finance on the Annual Financial Accounts for the year ending 31 March Chris Lewis, Deputy Director of Finance introduced the Annual Accounts and associated documentation and set out the responsibilities of Committee members in considering these prior to recommending approval to the Board. The report should be read in conjunction with WAO ISA 260 report (AC 14/081 refers). He also highlighted reported performance against the UHB s statutory financial duties i.e. remaining within its revenue and capital resource limits. It was highlighted that the UHB will be reporting an end of year deficit, in breach of statutory duty, leading to qualified accounts. It was noted that there is a three year plan in place to stabilise the UHB financial position. The cash position was summarised, noting that against the duty to pay 95% of all non-nhs invoices within 30 days, the UHB performance has deteriorated but arrangements have been made to ensure timely payments in 2014/15. The report was NOTED. The Chair thanked the Executive for the efforts that had been made to reach the reported year-end financial position. Confirmed Minutes of the Audit Committee 5 June of 7 9 September 2014

5 AC 14/078 ANNUAL GOVERNANCE STATEMENT The Committee RECEIVED and NOTED the Annual Governance Statement. The Board Secretary outlined the contents of the Statement and informed the Committee that it is a personal statement of the Chief Executive as Accountable Officer setting out governance arrangements within the UHB and areas where there have been challenges within the year. The draft document had previously been shared with colleagues, Welsh Government and Wales Audit Office and had been amended to reflect comments/observations made. It had been discussed in detail at a workshop of the Committee on 22 May 2014 and had also been subject to Internal Audit scrutiny. The Statement describes overall improvement on 2012/13, as evidenced by the Internal Audit rating from Limited to Reasonable assurance. The assurance ratings for individual internal audit reports and for performance against Doing Well, Dong Better: Standards for Health Services in Wales were also detailed within the Statement. The Committee Chair acknowledged that once again the organisation had been very open and honest regarding its strengths and weaknesses. The improvements made were recognised. AC 14/079 DRAFT REMUNERATION REPORT The Committee RECEIVED and NOTED the Draft Remuneration Report. It will be issued as part of the accounts and published within the Annual Report. Committee members attention was drawn to the WG-prescribed revised format for the report and the accompanying explanatory notes. AC 14/080 LETTER OF REPRESENTATION The Committee RECEIVED and NOTED the Draft Letter of Representation. Attention was drawn to the specific representations on contracts and contract extensions exceeding 1m but not approved by Welsh Government. There was discussion on the need to reduce the levels of stock held in Theatres and on the challenges associated with prices for stock and consignment stock, noting the associated storage issue. It was recognised that the Surgery team have carried out significant improvement work on the stock position. It was decided to defer recommending approval of the Letter of Representation until the WAO ISA 260 report had been discussed. AC 14/081 WALES AUDIT OFFICE AUDIT OF FINANCIAL STATEMENTS REPORT - ISA 260 The Committee RECEIVED and NOTED the draft WAO Audit of Financial Statements Report ISA 260 tabled by External Audit Engagement Partner, WAO. He provided a detailed summary of the issues arising from the audit of financial accounts. Attention was drawn to the qualified opinion on the annual accounts owing to the overspend against the resource limit. The full reasons for qualification of the accounts were included in the report. The UHB was commended for being one of Confirmed Minutes of the Audit Committee 5 June of 7 9 September 2014

6 only 2 Health Boards that have set out a 3-year plan in line with the NHS Act It was confirmed that there are no further adjustments to the statements. It was highlighted that UHB accounting practices are good, with good co-operation, good working papers, a good set of accounts and good review by Independent Members. It was highlighted that there are some procedural issues to resolve in the system for payments to primary care providers to ensure accurate reporting in future. It was confirmed that some of the guidance on the treatment of asset impairment in the accounts has been clarified, but that there remain issues which will need to be addressed in 2014/15, noting that the current position is not material and will not result in further qualification of the accounts. It was emphasised that procedures have not been followed for gaining Ministerial approval for all contracts of over 1m value, resulting in the UHB breaching requirements. One case has been referred to the Minister. Note was made that on Executive Director remuneration, the terms of the Chief Executive s Lease Car will be reviewed as they do not currently comply with UHB policy. A report will be made to the Remuneration and Terms of Service Committee setting out remedial and corrective action. ACTION: T Myhill Material weakness has been identified relating to the procurement system, some of which have been raised previously, and recommendations for improvement are included in the report. The Director of Finance supported the recommendations and highlighted the need for clarification of the position in relation to Shared Services. It was confirmed by the Board Secretary that the weaknesses identified have not been highlighted to the Shared Services Committee. The WAO have raised the matter with colleagues auditing Shared Services and the Committee Chair agreed to write formally to the Chair of the Shared Services Audit Committee. ACTION: I Grey It was highlighted that on page 18, the figure of 21.85m representing the UHB share of additional resource to meet new demands and pressures in the current financial year will be updated to reflect the additional 300k awarded to the UHB by WG. In summary, the WAO recommended that the Committee note the specific representations and the qualified opinion. NOTED and ACCEPTED the WAO ISA 260 Report. RECOMMENDED that the Letter of Representation is APPROVED and signed. Confirmed Minutes of the Audit Committee 5 June of 7 9 September 2014

7 AC 14/082 DRAFT AUDIT COMMITTEE ANNUAL REPORT 2013/14 The Committee RECEIVED and APPROVED the Audit Committee Annual Report to the Board. AC 14/083 RECOMMENDATION TO THE BOARD On the basis of the preceding discussions, the Committee AGREED to recommend to the Board APPROVAL of the Accounts, the Remuneration Report Governance Statement and Letter of Representation. AC 14/084 DATE OF NEXT MEETING Members NOTED the next meeting of the Audit Committee to be held in the Meeting Room, Headquarters, University Hospital of Wales at 9.30 am on 12 August 2014, Meeting Room, Headquarters Signed: Date: Confirmed Minutes of the Audit Committee 5 June of 7 9 September 2014

8 . AGENDA ITEM 7.1b UNCONFIRMED MINUTES OF A MEETING OF THE AUDIT COMMITTEE HELD AT 09.30AM ON TUESDAY 12 AUGUST 2014 CORPORATE MEETING ROOM, HEADQUARTERS UHW Present: Ivar Grey Brendan Sadka Stuart Egan Elizabeth Treasure Chair Independent Member - Capital Independent Member -Trade Union Independent Member - University In attendance: Craig Greenstock Counter Fraud Manager Abigail Harris Director of Planning Charlotte Moar Director of Finance Graham Shortland Medical Director (for agenda item 2.1) James Johns Head of Internal Audit John Herniman External Audit Engagement Partner, WAO Alison Gerrard Board Secretary Martyn Lewis Internal Audit Manager Tracy Myhill Deputy Chief Executive/Director of Workforce & Organisational Development Carol Evans Assistant Director Patient Safety, Quality Geoff Walsh Assistant Director of Capital and Asset Planning (for agenda items 2.1 and 5.1) Apologies Anne Beegan Nigel Gibbs Joe Monks Louise Driscoll Alison Butler Secretariat Rachel Armitage AC 14/085 Performance Audit Manager, WAO Staff Representative Staff Representative Post-Payment Verification Manager External Audit Client Manager, WAO Corporate Administrator WELCOME AND INTRODUCTIONS The Chair opened the meeting and welcomed everyone present. AC 14/086 APOLOGIES FOR ABSENCE Apologies for absence were noted. 12 August 2014 Page 1 of 8 9 September 2014

9 . AC 14/087 DECLARATIONS OF INTEREST The Chair invited Members to declare any interests in the proceedings on the agenda. No interests were declared. AC 14/088 MINUTES OF THE PREVIOUS MEETING OF THE AUDIT COMMITTEE The Committee RECEIVED and APPROVED the minutes of the Audit Committee Meetings held on 22 May 2014 and 5 June AC 14/089 ACTION LOG REVIEW The Audit Committee RECEIVED the Action Log from the meetings of 22 May and 5 June 2014 and NOTED the following: AC 13/255 AC 14/036 AC 14/037 AC 14/041 Audit and Assurance Services Outcome of Wales Audit Office Assessment: Amend UHB Declarations of Interests Policy. Following initial consultation the Policy needs to be re-written and will be submitted to the Audit Committee in October 2014 Internal Audit Position Report (Public Health Improvement Targets) prepare a summary of where each Clinical Board s IMTP is mapped against the Public Health plan. This item has been completed. Overpayments of Salaries: the Director of Finance will discuss this matter with the Director of Workforce and Organisational Development. Committee was asked to note that this should read AC 14/061. Internal Audit Position Report and Head of Internal Audit Opinion and Annual Report 2013/14 Artificial Limb and Appliance Service (Reasonable Assurance): discussion on the reduction in the number of assessment days available owing to the reduced number of staff, and the consequent increase in waiting times and drop in RTT achievement, and on the identified high error rate in stock accounting. The Chair will write to the Chief Operating Officer. AC 14/081 Wales Audit Office Audit of Financial Statements Report ISA 260: Material weaknesses relating to the procurement system. Agenda item 2.2. AC 14/090 ANY OTHER URGENT BUSINESS The Director of Finance and the Director of Planning have commissioned an Internal Audit report to examine the processes related to the procurement and commissioning of the Urology robot. 12 August 2014 Page 2 of 8 9 September 2014

10 . AC 14/091 INTERNAL AUDIT POSITION REPORT The Committee RECEIVED and NOTED the report. The Head of Internal Audit provided a summary of the following internal audit reports: Authorised Signatories Full Report Prison Service Review Reasonable Assurance Rookwood Catering Review Reasonable Assurance Community Pharmacy Data Analysis 1 Emergency Unit Follow Up Limited Assurance E-Rostering Reasonable Assurance Hazardous Waste Reasonable Assurance Heathfields Catering (advisory) Prison Service Review Reasonable Assurance Good progress has been made since the service transferred to the UHB and there is evidence of greater compliance with UHB procedures. Some areas for improvement have been identified, notably the recording of sickness and annual leave and the need to update Service Level Agreements. It was noted that the number of vacancies is expected to impact on service provision. It was noted that there have been issues associated with attempted resuscitation at the Prison, which interface with both the Audit and Quality, Safety and Patient Experience (QSE) Committees; it was agreed that the Lead Executives will jointly agree the Terms of Reference with Internal Audit. (9.50 am Tracy Myhill and Geoff Walsh joined the meeting.) There was discussion regarding the recurrent theme relating to the management of annual leave, training, and other HR, noting that whilst there is an overall improvement across the UHB, there are some pockets of concern. It was highlighted that some non-compliance relates to the transfer of staff to the UHB from other organisations and the change in administrative systems. It was confirmed that there is a standard spreadsheet available on the UHB intranet to provide guidance on annual leave calculations to managers. The rollout of the Electronic Staff Record (ESR) across the organisation will increase consistency in practice. The Director of Workforce and Organisational Development agreed to investigate the correlation of training, sickness and annual leave, noting that the Prison Service has not had its training needs updated since Action T Myhill There was discussion on the position regarding the resolution of repayments of salary (see Action Log update above). It was confirmed that overpayments information is regularly provided to managers and are reviewed by the Clinical Board Heads of Workforce and Organisational Development; the data are also regularly reviewed with the Shared Services Partnership (SSP). 12 August 2014 Page 3 of 8 9 September 2014

11 . It was noted that effective workforce controls are necessary to ensure that managers recruit and terminate individuals employment efficiently. It was acknowledged that there is a requirement for a central framework to ensure that standard processes occur, releasing managers to perform other responsibilities, such as training needs analysis. It was recommended that disclosure of the level of sickness absence should be added to future reports as a key indicator. Rookwood Catering Review Reasonable Assurance The audit had been requested by the management team at Rookwood to support work under way to improve staff management and recording of leave and overtime, following some previously identified concerns. The Management actions and new systems put in place have enabled a finding of reasonable assurance. There was discussion on the inconsistent use of clocking in systems across the organisation, and the need for a consistent approach for all staff groups. The Director of Workforce and Organisational Development agreed to take this matter forward to reach anorganisation-wide decision. ACTION: T Myhill Emergency Unit Follow Up Limited Assurance (full report provided) The report followed up on recommendations from previous reviews; only three of the previous recommendations have been followed up. Committee was asked to note that there is an error in paragraph 3 of the report (Audit Recommendations) indicating that there is Reasonable Assurance; Limited Assurance is the correct finding. The report listed a number of actions as still outstanding where the agreed action could not have taken place e.g. where new policies were agreed but until a new capital project is developed compliance cannot be demonstrated. Also Internal Audit: in one case the Capital team followed WG guidance but were still criticised. The Committee considered that the limited assurance given in the report did not fairly reflect the position. The original report gave limited assurance and this should not be carried forward just because there were no new capital projects that would enable the UHB to demonstrate improvements. Therefore the Committee DID NOT ACCEPT the report and asked the Directors of Finance and Planning to meet with the internal auditors in order to correct the report. ACTION: C Moar/A Harris The Committee AGREED to receive an update report at its next meeting in October E-rostering Reasonable Assurance It was highlighted that a high priority finding had been that Ward Managers and Deputy Ward Managers are enabled by the system to authorise their own shifts for payment. It was confirmed that one such case is under investigation by the Counter Fraud team and that user access rights will be amended. It was confirmed that e-rostering and establishment figures match. 12 August 2014 Page 4 of 8 9 September 2014

12 . Hazardous Waste Reasonable Assurance Some isolated areas of non-compliance have been identified and more work is required to strengthen duty of care audits. It was confirmed that management has taken some actions to address the findings. It was confirmed that waste management is considered regularly by the Health and Safety Committee. The Chair agreed to write to the Chair of the Health and Safety Committee to request assurance that waste management systems are robust. ACTION: I Grey There was discussion on realising the economic value of waste, noting the need to separate this from the contamination issues associated with clinical waste. It was agreed to submit a paper on the maximising of the economic value of waste to the People Performance and Delivery Committee in November ACTION: A Harris Heathfields Catering Advisory Internal Audit had been invited by the management team at Heathfields to advise on cash management processes. Authorised Signatories (full report provided) It had been found that there are no centralised or consistent systems for the management of authorised signatories. The issues are now being fully addressed by the Finance Department. Community Pharmacy Data Analysis 1 This report is the first detailed data analysis of Community Pharmacy carried out by Internal Audit and it identified many areas where there is incomplete information and where further work is necessary to ensure that inappropriate claims are not being submitted. It was confirmed that the Primary, Community and Intermediate Care (PCIC) Clinical Board has reviewed the report and has agreed to participate with Betsi Cadwaladr University Health Board to pilot with the SSP a systematic approach to Pharmacy Post-Payment Verification audit. This will enable the UHB to influence the commissioning of appropriate technological solutions. The issues raised by this audit report will enable PCIC to engage more fully on discussions regarding changes to the national framework. There was discussion on the timescale for the provision of data, the improvements possible using electronic systems and the availability internal to the organisation of expertise in data analysis. There was discussion on the need to match patient level with repeat prescription data and the interface with clinical governance and patient safety issues. It was noted that the matching of primary with secondary care prescriptions would inform the wastage debate (see above). 12 August 2014 Page 5 of 8 9 September 2014

13 . CONSIDERED the Progress Report ACCEPTED the findings and conclusions from the individual audit reports on Authorised Signatories, Prison Service Review, Rookwood Catering Review, Community Pharmacy Data Analysis 1, E-Rostering, Hazardous Waste and Heathfields Catering DID NOT ACCEPT the findings from the Emergency Unit Follow Up report. The Chair recommended re-ordering of the agenda. AC 14/092 PROCEDURE FOR THE MANAGEMENT OF UNIVERSITY HEALTH BOARD CAPITAL The Committee RECEIVED and NOTED the report submitted by the Director of Finance who provided a summary and set the context for the Procedure. The Board Secretary confirmed that there had been further discussion at the People, Performance and Delivery Committee regarding the arrangements of sub- Committees. It was highlighted that the Terms of Reference (ToRs) for the Information Technology Programme Board have not yet been ratified, while the ToRs for the Medical Equipment Group have been re-written, including identifying the Director of Therapies and Health Sciences as Chair. The appendices will require to be updated once approved by the September PPD Committee. It was recommended that the Procedure should include WG provision of funds at short notice and other types of funding. DELEGATED minor amendments to Procedure to the Director of Finance and the Director of Planning APPROVED the procedure confirming that it is in line with the UHB s Scheme of Delegation in respect of capital expenditure governance and management. NOTED the current hierarchy of capital governance groups that sit below the People, Performance and Delivery Committee and the ongoing discussions in discharging its duty in respect of capital governance. APPROVED the inclusion of any subsequent amendments to terms of reference etc within this procedure. APPROVED the full publication of the Capital Management Procedure in accordance with the UHB Publication Scheme. AC 14/093 WAO AUDIT FINDINGS AND RECOMMENDATIONS The Committee RECEIVED and NOTED the report of the Director of Finance, highlighting that the WAO C&V UHB Annual Audit letter for 2013/14 identified some deficiencies in the contracts approval process both internally at the Health Board and within NWSSP, and ministerial consent for contracts that cumulatively exceed 1m. Following this the Finance Director wrote to NWSSP asking them to review the findings of the audit and confirm how they would strengthen their management processes to ensure that this did not occur again, and the Committee Chair wrote to the Chair of the Velindre Audit Committee (as the host of NWSSP) to ask for assurance that their Audit Committee were considering this 12 August 2014 Page 6 of 8 9 September 2014

14 . matter and developing assurance mechanisms. The response to the Chair from the Chair of the Velindre Audit Committee had been tabled to the Independent Members. It was agreed that this issue requires ongoing monitoring and it was suggested that a re-audit should be carried out in January The Chair agreed to write again to the Chair of the Velindre Audit Committee. ACTION: I Grey CONSIDERED the response from NWSSP CONSIDERED the response from the Chair of the Velindre Audit Committee and agreed the further actions to be taken AC 14/094 WAO AUDIT COMMITTEE UPDATE The Committee RECEIVED and NOTED the report of the Wales Audit Office. It was confirmed that the financial information contained within the Annual Report is acceptable and that work is continuing on the Welsh version. Committee was asked to note that the lead Executive for medicines management is Charlotte Moar, Director of Finance, and for the tracking programme is Alison Gerrard, Board Secretary. AC 14/095 WAO RECOMMENDATIONS TRACKING REPORT- APRIL 2014 The Committee RECEIVED and NOTED the report of the Board Secretary. It was noted that there will be an additional WAO review of the operating theatres; this item will therefore be closed and a new theatres item will be opened. It was highlighted that chronic conditions will be reported to the People, Performance and Delivery Committee in September 2014 and the Consultant contract report will be a regular feature of reports to the same Committee; QSE will receive regular reports on hospital catering as part of its work plan and medical equipment will comprise part of the capital report to Board in September NOTED this report and the arrangements for ensuring that all WAO Actions had been tracked. AC 14/096 POST-PAYMENT VERIFICATION PROGRESS REPORT: DENTAL AND PHARMACY UPDATE The Committee AGREED that this subject had been adequately discussed under agenda item 2.1 (see minute AC 14/091). AC 14/097 REGULATORY AND INSPECTION VISITS TRACKING REPORT 1 FEBRUARY 30 JUNE 2014 The Committee RECEIVED and NOTED the report of the Board Secretary, highlighting that the report excludes the Trusted to Care visits undertaken by 12 August 2014 Page 7 of 8 9 September 2014

15 Health Inspectorate Wales (HIW) and WG; these will be included in a report to QSE in September It has been identified that there is one area of noncompliance with the central recording arrangements relating to an HIW inspection of Mental Health facilities. This item has now been closed appropriately. There was discussion on the HIW timescales for providing reports. It was confirmed that HIW has recently issued new, more robust protocols on the work programme, the issuing of reports and receipt of responses. There was discussion on the Health and Safety Executive (HSE) inspection of Cellular Pathology. It was confirmed that the HSE had been invited to inspect to provide reassurance on actions taken to respond to concerns raised by staff.. AC 14/098 TO NOTE ANY RELEVANT DEVELOPMENTS DISCUSSED AT OTHER COMMITTEES There were no items to note. AC 14/099 REVIEW OF THE MEETING The Chair highlighted the following key points from the meeting: The Director of Workforce and Organisational Development will take forward work on sickness, annual leave and training The Chair will write to the Chair of the Health and Safety Committee about procurement. AC 14/100 DATE, TIME AND VENUE OF THE NEXT MEETING OF THE COMMITTEE 9.30 am on Tuesday 14 October 2014, Corporate Meeting Room, Headquarters UHW Signed Date.. 12 August 2014 Page 8 of 8 9 September 2014