Aneurin Bevan Health Board

Audit Committee Agenda item 1.3 Aneurin Bevan Health Board AUDIT COMMITTEE MEETING Draft Minutes of the meeting held on Wednesday 17 th November 2010, at 9a.m. in the Boardroom, Mamhilad House Present: Chris Koehli - Chair Peter Sampson - Vice Chair Prof Helen Houston - Independent Member (University) Prof Janet Wademan - Independent Member (ICT) In Attendance: Kay Baker - Corporate Services Manager Richard Bevan - Board Secretary Alan Brace - Director of Finance Louise Driscoll - Post Payment Verification Manager Martyn Edwards - Head of Counter Fraud Dr Andrew Goodall - Chief Executive John Herniman - Wales Audit Office Ian Howse - Head of Internal Audit Andy Jones - Assistant Director, Workforce Development Jamie Marchant - Divisional Director of Facilities Andrew Naylor - Assistant Director, Corporate Finance Dr Grant Robinson - Medical Director Margaret Rutledge - Catering & Cleanliness Manager Dave Thomas - Wales Audit Office Paul Thomas -? Steve Wood - Internal Audit, Capital & PFI Audit & Consultancy Claire Worrall - Wales Audit Office Apologies: Wendy Bourton - Independent Member (Third Sector) David Jenkins - Chair, Aneurin Bevan Health Board Status: DRAFT 1

Audit 11/10/01 Declarations of Interest There were no declarations of interest made by Members of the Committee Audit 11/10/02 Minutes of the Meeting on 13 September 2010 The minutes of the meeting on 13 September 2010 were approved as a true record. Audit 11/10/03 Matters Arising There were no matters arising not covered on the agenda. Audit 11/10/04 Action Sheet 01/10/06, 03/10/04, 03/10/07, and 03/10/15 Financial Recovery Committee to receive a presentation on the current position against these action points in early December 2010. 05/10/18 The Board Secretary explained that discussions had been held regarding a consolidated tracking mechanism for external and internal audit actions. This will form part of the corporate function through the reporting of all agreed actions to Executive Team; the Board Secretary will monitor Executive actions and report by exception. 09/10/12 The error on the Capital & PFI Progress Report for Energy Management was accepted and, as per the original audit report, was noted as a 1 star report. A management response to the limited assurance to be provided at the next meeting scheduled for 18 February 2011. 09/10/15 The Finance Director advised that mechanisms for supplying timely information to WAO have been discussed and reviewed. Audit 11/10/05 Report of payments where value exceeds 100,000 The Assistant Director (Corporate Finance) stated Status: DRAFT 2

that the revised Scheme of Delegation now incorporates all the pre-existing contracts for SLA s or related items that regularly exceed approval limits e.g. energy supplies, and that the exceptions would be indicated in the future. An explanation was provided for the following outstanding issues: Monmouthshire County Council Section 28a payment: This arrangement was set up to support the residential and community needs of the people resettled from Llanfrechfa and to ensure community and residential services are available in Monmouthshire for people with a learning disability. These arrangements are continuously monitored. Kensington Court Clinic: This agreement was setup to assess the need and suitability for general anaesthesia (GA) and dental treatment for children between the ages of 3 and 16 years. The Chair asked whether the safety issues of providing GA at the clinic had been reviewed in light of Royal College guidance. Following a discussion of the issue it was agreed that the patient quality and safety issues of the agreement be referred to the Quality & Patient Safety Committee for review. Action: A Goodall/G Robinson Audit 11/10/06 Single Tender and Single Quotation Actions The Assistant Director (Corporate Finance) provided an update on single tender and single tender actions that had been considered by the Chief Executive. It was highlighted that the Head of Procurement has contacted WAG to ensure that the Health Board is involved in all centrally funded projects at an early stage to ensure that scenarios do not develop where the Health Board is forced to put through Single Tender actions to accommodate pre-determined outcomes. Status: DRAFT 3

The Vice Chair asked for further details on the reasons for Orthopaedic Service provision by St Josephs to be provided. AG agreed to circulate a more detailed explanation from the Executive Team meeting discussions. Action: A Goodall The Independent Member (ICT) asked that items relating to IT have more detailed descriptions of requirements and reasons for provision. AB agreed to provide fuller explanations for any IT related items. Action: A Brace The Chair asked that capital purchases made via the WHE All Wales procurement framework be tested to ensure they are still providing value for money. AN agreed to take this action forward with the Head of Procurement. Action: A Naylor Jamie Marchant, Divisional Director of Facilities and Andy Jones, Assistant Director (Workforce Development) joined the meeting. Audit 11/10/07 Review of Accident & Emergency Department Medical Staffing David Thomas advised that in response to a Whistle-blowing protected disclosure, the Wales Audit Office undertook a review of the A&E medical staffing. Following a preliminary review the WAO decided that certain value-for-money and performance issues warranted further examination. The report sets out the results of the investigation of those issues and recommendations intended to help secure further improvement of the Health Boards A&E medical staffing arrangements. WAO advised that a management response to the report had been received. The Medical Director advised that progress is being made on addressing the recommendations. He advised that the A&E refurbishment has been completed and the issues around medical staffing recruitment are being progressed. The Committee considered the report and discussions ensued and the following points and actions were noted: Status: DRAFT 4

The 5 Year Plan Framework to incorporate and address the short, medium and long term issues. Action: A Goodall Financial Recovery Committee to address the control and financial issues around medical staffing. Action: G Robinson The response to the report recommendations and the follow up monitoring to be picked up by the Quality & Patient Safety Committee. Action: G Robinson Grant Robinson, Medical Director left the meeting. Audit 11/10/08 Losses and Special Payments The Assistant Director (Corporate Finance) provided an update in relation to losses and special payments made by the Health Board for the quarter ending 30 September 2010. The report covers: clinical negligence personal injury and other payments write offs that constitute a loss to the organisation minor losses incurred from 1 July to 30 September 2010 benchmarking with other Health Boards The Audit Committee noted the payments made. The Director of Finance advised that an in depth trend analysis is being undertaken and will be presented to the Audit Committee following Executive Team discussion. Action: A Brace Concerns were raised around the appropriateness and decision making process around awarding compensation payments and in particular the providing of financial support to a bereaved family to visit their daughters grave on an annual basis. It was agreed that a Losses and Special Payments guidance framework document be developed for discussion at the next meeting. Action: A Naylor Status: DRAFT 5

Audit 11/10/09 Counter Fraud The Head of Counter Fraud provided an update on the work undertaken by the Local Counter Fraud Specialists (LCFS) during 2010/11 and advised that unfortunately WARO/10/00068 was found not guilty at Newport Crown Court but has subsequently lost their professional status. It was noted that there was currently an investigation ongoing involving a member of the LCFS team. The Director of Finance raised concerns around the dental cases and asked that either colleagues in Counter Fraud or Internal Audit check the performers lists to make sure that those dentists issuing prescriptions for reimbursement by the Health Board are authorised to do so. Action: M Edwards/I Howse The Chair asked that timescales be added to the report to indicate the period of time taken for cases once notified to be concluded. Action: M Edwards Martyn Edwards, Head of Counter Fraud left the meeting Audit 11/10/10 Report on GMS Post Payment Verification The Post Payment Verification Manager provided information on the PPV findings and trends following visits in 2009/10 and provided information regarding error rate performance for specified enhanced services. The PPV Manager clarified that the Y axis on the graph was the percentage of claim errors and that the sample size also varied between practices dependent on their size. The PPV Manager advised that this initial stage has been a learning exercise as not all practices interpret the service specifications in the same way and this has led to some of the errors. Status: DRAFT 6

The PPV Manager advised that following the visits, she had met with Locality Clinical Directors to highlight key issues and discuss the next steps. The Director of Finance queried what lessons had been learnt and what actions have resulted from the visits and discussions ensued. It was agreed that the Assistant Director (Primary, Community and Mental Health) provide a report for discussion at the next meeting detailing the results from the visits and the actions being undertaken to address any issues. Action: R Holcombe The Chief Executive asked that the LMC be made aware of the concerns raised and the Chair agreed to write to the LMC on behalf of the Health Board. Action: Chair Audit 11/10/11 Audit Committee Annual Evaluation The Committee considered the Annual Evaluation Report. The Chair advised that the purpose of the report was to summarise the results of the evaluation of the Committee s first year of operation, which was based on the requirements of the NHS Audit Committee Handbook. The main purpose of the exercise was to assess the effectiveness of the Committee and to identify improvement for the future. The Independent Member (ICT) questioned whether the evaluation questionnaire format had deterred completion, as it was in a different format to the usual document and difficult to open? It was agreed that a consistent document format be used that all members are familiar with. Action: Secretariat The Vice Chair questioned the differing responses of the Audit Committee members and discussions took place around the results of the evaluation. It was agreed that the WAO develop a training and development session for Committee members to Status: DRAFT 7

be undertaken sometime during February/March 2011. Action: D Thomas The Board Secretary advised that the Audit Committee Annual Evaluation would need to be presented to the Governance and Assurance Committee to discuss and agree the suggested actions to improve the effectiveness of the Audit Committee. Action: R Bevan Audit 11/10/12 Audit Committee Annual Report The draft template for the Audit Committee Annual Report was received for information and noted. Audit 11/10/13 Mid Year Assessment Against the National Audit Office Guidance on the Statement of Internal Control: A Guide for Audit Committee The Committee considered the paper setting out the mid year assessment of the Health Board s current position against the best practice identified by the National Audit Office (NAO) in order for the Audit Committee to identify any areas where further actions could be taken to prepare for the development of the Health Board s Statement of Internal Control at year end. The Board Secretary advised that progress had been made but wider work needed to be undertaken with clinical colleagues and the Health Board were considering a core of Risk Champions within Divisions and Localities to help with this work and to disseminate key messages to staff. The Board Secretary advised that the Mid Year Assessment would need to be presented to the Governance and Assurance Committee to discuss and agree the further actions or development work which could be undertaken to increase the Health Board s compliance with the identified best practice. Action: R Bevan Status: DRAFT 8

Audit 11/10/14 Audit Committee Work Plan 2010/2011 The draft Audit Committee Work Plan for 2010/2011 was received for information and noted. It was agreed to review the Work Plan at every meeting. Action: Secretariat The Board Secretary advised that the Audit Committee Work Plan for 2010/2011 would need to be presented at the Governance and Assurance Committee for ratification. Action: R Bevan Audit 11/10/15 Internal Audit Progress Report The Head of Internal Audit provided an update on the current status of the Internal Audit work and the plan for the remainder of the financial year. The Committee received and noted the report for information. Audit 11/10/16 Audit Recommendation Tracking 2009/10 The Committee considered the Internal Audit Tracking Status Report. The Head of Internal Audit provided a summary of the implementation status of the recommendations agreed in the 2009/2010 Internal Audit Reports which had not been implemented within the agreed timescales. The Director of Finance advised that given the current financial climate the Health Board would need to be clear about what recommendations were necessary and what were nice to do. It was agreed that all recommendations need to identify what actions are to do or nice to do and that all reports are submitted to the Executive Team for review prior to submission to Audit Committee. Action: I Howse Audit 11/10/17 Summary of Creditors CAATs Activity The Committee considered the Summary of Status: DRAFT 9

Creditors CAATs Activity Report. The Head of Internal Audit advised that the purpose of the paper was to provide a summary of the use of CAATs during 2009/10 and 2010/11 in relation to creditor accounts and payments. The CAATs used are based on those suggested by the Wales Audit Office. These include tests to identify duplicate creditor payments, inactive creditor accounts, and high/low value creditor payments. The Chair asked that future reports include the number, reason, and value of any duplicates. Action: I Howse Audit 11/10/18 Capital and PFI Progress Report Steve Wood (Capital and PFI) provided an update on progress against the Capital and PFI Audit Services Plan 2009/10. It was highlighted that the 2009/10 audit plan was substantially complete. The sign off meeting for Ysbyty Ystrad Fawr was to be held week commencing 22 November 2010. The Director of Finance advised that discussions were ongoing within the All Wales Directors of Finance forum on the Health Board s contributions and usage of this audit resource. It was agreed that feedback from these discussions would be provided at the next meeting. Action: A Brace Audit 11/10/19 External Audit Update John Herniman, Wales Audit Office, provided an update on the current and planned Wales Audit Office work, highlighting work which had been completed to date and stating that the majority of the current workload was focused on the Structured Assessment process. The Committee considered the report and the following points and actions were agreed: A Protocol focussing on the working arrangements between the Health Board and external audit Status: DRAFT 10

function to be presented at the next meeting. Action: A Brace/J Herniman The Chief Executive informed the Committee that the Legacy Report had been discussed at the Board and asked for the narrative to be updated to reflect this. Action: J Herniman Recent media coverage of the management of continuing healthcare and the cost pressures were discussed. It was noted that Internal Audit are meeting with staff to discuss the Terms of Reference and the date to commence the audit. The Independent Member (ICT) asked that the Terms of Reference for the IT Security audit be reviewed prior to the start of the audit fieldwork. Action: J Herniman Audit 11/10/20 Audit of Financial Statements Report to the Trustees Claire Worrall, Wales Audit Office, provided a summary of the report outlining the key recommendations, draft Letter of Representation and summary corrections to the financial statements. She indicated that the final date for closure was the end of January 2011. The Assistant Director (Corporate Finance) confirmed the following: All the former LHB accounts were in the process of being closed off and will be concluded prior to the end of January 2011. The T P Price Estate property values are now shown as the rental values. A Charitable Fund Expenditure policy has been approved and implemented within the Health Board. The Chair asked for the draft Letter of Representation to be amended to reflect the management response to the recommendations. Action: C Worrall Status: DRAFT 11

The Committee considered and approved the Audit of Financial Statements Report to the Trustees and the management response. The Vice Chair advised that the Charitable Funds Committee will consider the final accounts at its next meeting. Action: P Sampson Audit 11/10/21 Review of Hospital Catering The Committee considered the WAO Review of Hospital Catering and the summary report highlighting the good practice and the areas for improvement. David Thomas, Wales Audit Office advised that the national review of hospital catering was carried out in tandem with the Internal Audit review of the Health Board s compliance with the All Wales Nutritional Pathway introduced in November 2009. The findings and recommendations of both reviews were compiled to form one report. The final report was received in October 2010. Jamie Marchant, Divisional Director of Facilities and Margaret Rutledge, Head of Catering provided the following update since the fieldwork was undertaken: The budget for patient catering is 2.9m. The food waste percentage is down from 17% to 10% but requires further reduction. There needs to be a balance between having the right amount of food to meet patient needs with as little waste as practicably possible. Nevill Hall Hospital catering service offer small, medium and large portion sizes to provide flexibility according to a patient s nutritional needs. Partnership working between catering/dietetics and wards is key to achieving nutritional and food waste targets. The Non-Patient Catering Subsidy and Tariffs Policy is on target for an implementation date of February 2011. The Nutritional Training Programme is ready for implementation. Status: DRAFT 12

Staff are adhering to the Protected Mealtimes Policy. The Chair, Chief Executive and Director of Finance commended the excellent work undertaken by the Division. In response to a query raised by the Independent Member (ICT), Margaret Rutledge confirmed that the wards audited were chosen by the WAO. The Independent Member (University) raised concerns around the nutritional elements of the report. Discussions ensued and the Committee agreed to the following recommendations: To receive the report, acknowledge the good practice and areas for improvement. To sign off the Action Plan To agree that the Action Plan be monitored via the Clinical Nutrition Steering Group, with performance reports to the Quality & Patient Safety Committee. Action: R Bevan/G Robinson Jamie Marchant and Margaret Rutledge left the meeting. Audit 11/10/22 Planning Process for 2010/11 Annual Accounts The Committee considered the report on the Planning Process for 2010/11 Annual Accounts which summarises and addresses the issues raised during the 2009/10 accounts audit, lessons learnt and highlights the key dates where the Audit Committee are required to review and approve the draft and final accounts respectively. The Director of Finance advised that the timetable risk is planned for discussion at the All Wales Directors of Finance forum and would feedback at the next meeting. Action: A Brace It was noted that the CHC risk was the subject of an Ombudsman Review. Status: DRAFT 13

The Committee received and noted the report. Audit 11/10/23 Over Payments of On-Call Allowances and Salary Over Payments The Committee considered the report on Over Payments of On-Call Allowances and Salary Over Payments. The Assistant Director (Corporate Finance) summarised the purpose of the paper in relation to a recent discovery of over payment of on-call allowances to medical staff over a number of years. Associated with this issue is the review and improvement of the existing policy relating to the recovery of over payments to staff. It was noted that the on-call over payments related initially to intensity payments being received by orthopaedic staff who were not on the on-call rota. The review within this Directorate was subsequently broadened to include an organisation wide review thus resulting in the identification of other over payments. Discussions ensued and the Chair asked that the management controls be addressed and assurance required that managers and payroll adhere to Health Board policies and procedures. The Assistant Director (Corporate Finance) advised that in response to the review the Recovery of Over Payments Policy is being revised and due to be finalised for submission for Executive Team approval by the end of November 2010. Action: A Naylor Audit 11/10/24 Compliance Report on the Use of Oracle The Committee considered the Compliance Report on the Use of Oracle which detailed the current position in relation to the use of Oracle in relation to the payment of invoices being supported by an official order from Oracle, and a brief update on the Order Management Rollout and Hierarchy Implementation Project. Status: DRAFT 14

The Assistant Director (Corporate Finance) reported that progress is being made but the most significant issue being addressed currently is the implementation into Continuing Healthcare with other outstanding areas being rolled out. The Chair raised concerns and asked for considerable progress to be reported at the next meeting. Action: A Naylor Audit 11/10/25 Model Standing Financial Instructions The Committee received and noted the revised Standing Financial Instructions. Audit 11/10/26 Budgetary Control Policy The Committee received and noted the progress with the development of a new Budgetary Control Policy. Audit 11/10/27 Schedule of Meeting Dates for 2011 The Schedule of Meeting Dates for the Audit Committee for 2011 were received and noted. The date of the next meeting is scheduled for 18 February 2011 at 10.00am in the Board Room, Block A, Mamhilad House. Status: DRAFT 15