SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

Transcription

1 at 9.00am in the Brooke Suite, Warwick Hospital Present: Rosemary Hyde (RH) Non-Executive Director (NED) and Committee Chair Bruce Paxton (BP) NED Simon Page (SP) NED In attendance: Glen Burley (GB) Chief Executive (Present until Minute ) Anne Coyle (AC) Associate Director of Operations Integrated and Community Care Division (Present until Minute ) Jane Ives (JI) Director of Operations (Present for Minute only) Meg Lambert (ML) Trust Secretary Kim Li () Director of Finance Gus Miah (GM) Partner, Deloitte LLP (Present until Minute ) Mary Powell (MP) Communications Manager (Present until Minute ) Sarah Swan (SS) Assistant Director, CW Audit Services Karun Thaper (KT) Trust Assurance Manager (Deputising for Director of Nursing) Present until Minute ) Colleen Tooze (CT) Committee Administrator MINUTE APOLOGIES FOR ABSENCE Apologies were received from the Director of Nursing and Mr Boorman (NED) DECLARATIONS OF INTEREST No declarations of interest were made DRAFT ANNUAL GOVERNANCE STATEMENT The Chief Executive presented the draft Annual Governance Statement. The report covered a number of areas and the Chief Executive wanted to ensure that it provided an appropriate level of assurance, in particular around the risk register, how the Board Assurance Framework (BAF) worked and included reference to the Care Quality Commission (CQC) inspection. The Chief Executive highlighted the reference made to the outsourced payroll service providers which was on the agenda for this meeting (Minute refers) and provided assurance to the Committee. He also made reference to the concerns around 18 weeks referral to treatment (RTT) data which had been identified by Deloitte LLP as part of the Quality Report review (Minute refers). The Partner, Deloitte, LLP explained that testing was done on a sample basis for RTT which showed that the error rate had increased when compared to last year. The next testing involved the sample increasing to 40 and the error rate was still high. This was disappointing as RTT data quality was very good last year. It was noted that towards the end of the year there was much improvement with lower error rates. The Director of Page 1 of 9

2 Operations confirmed that all three pathways were reviewed. The Partner, Deloitte, LLP stated that he did not expect any difficulties this year as the issues were related to the implementation of a new system (Lorenzo) at the beginning of the new year.. The Director of Operations concurred with training and support for staff. Random checks had not been done but would now be a part of an action plan to ensure monthly checks were undertaken to improve the data quality. The Partner, Deloitte, LLP stated that getting the data right before it went into the system would help improve data quality. It was agreed the Director of Operations would develop an action plan to improve RTT data quality based on Deloitte, LLP findings. The Director of Finance would liaise with Internal Audit to determine if time was available in the internal audit plan to help with any further audit work. Mr Page, NED sought assurance around whether the RTT data quality issues impacted on patient safety and wellbeing. The Director of Operations provided assurance that as the pathways were checked, it was confirmed that there was no impact on patient safety. The Partner, Deloitte, LLP stated that only 1 error was found in the sample for A&E. The Director of Operations stated that it was an excellent result for A&E. Mr Page, NED addressed the extreme risks listed on the Trust s Risk Register and suggested that a measure of emergency/timescale was identified to the extreme risks. The Chief Executive stated that the level of risk was identified in the risk register but would add a sentence in the report to ensure it was clearly identified. The Committee Chair mentioned the paperless clinics and queried if Spring 2016 was a bit optimistic for full implementation. The Chief Executive stated that an amendment would be made to the Annual Governance Statement to reflect the revised timescale to Summer Resolved that (A) subject to the amendments above, the draft Annual Governance Statement be considered, and (B) the Director of Operations develop an action plan to improve RTT data quality based on Deloitte, LLP findings. (C) The Director of Finance would liaise with Internal Audit to determine if time was available in the internal audit plan to help with any further audit work. JI JI EXTERNAL AUDIT External Audit Update Report The Partner, Deloitte, LLP explained that testing of the RTT indicator had identified issues with accuracy of reporting, particularly in the early months Page 2 of 9

3 of the year when Lorenzo was newly implemented. It was suggested that an action plan be put in place to ensure improvement in the resilience of the data. Better training with initial data input, as well as additional data validation checks were advised. It was reported that the A&E and Falls Indicators showed a high level of compliance. The Committee Chair reported that the Audit Committee would monitor the implementation of these actions over the coming months DRAFT ANNUAL REPORT 2015/16 INCLUDING DRAFT QUALITY REPORT The Communications Manager and Trust Assurance Manager presented the draft Annual Report 2015/16 including the draft Quality Report and explained that there had been a significant amount of changes since the report was circulated. The Committee Chair expressed concern with a number of points/errors observed in the document and that changes were required to ensure the wording was appropriate for public circulation. Discussion took place on the length of the document and it was suggested that the Communications Manager and the Trust Assurance Manager reviewed the document with a view to shortening the document for future years. The Communications Manager and the Trust Assurance Manager noted the comments and would make the necessary changes to the draft Annual Report 2015/16 including the draft Quality Report and submit a revised version to the Audit Committee and Board meetings on 25 May 2016 for final approval. Resolved - that (A) the draft Annual Report 2015/16 be received and noted and the Committee s comments be included in the final version; (B) the content of the Strategic Report to contain a fair review of the Trust s business be approved; and (C) the Draft Quality Report be received and noted and the Committee s comments included in the final version. MP/KT MP/KT UPDATE ON PLAN CONTINENCE SERVICE The Associate Director of Operations Integrated and Community Division provided an update on the action plan for the Continence Service. The Associate Director of Operations Integrated and Community Division explained that the Continence Service had been a work in progress over a number of years. It was highlighted that a significant number of changes had been made which included: Page 3 of 9

4 MINUTE (a) better management of stores/warehouses and delivery; (b) big improvement on working within the continence budget of 875k with no overspend; (c) guidelines had been ratified including catheterisation; (d) yearly re-evaluation of continence products; (e) supporting patients through clinics instead of in a domiciliary setting; (f) working with patients appropriately, so that those who did not attend twice had to be re-referred by their GP; (g) SWFT Clinical Services Ltd had devised a template with the help of Richard Loydall, Anti-Fraud Specialist whereby there was an audit trail to ensure residential homes could prove patients were alive and well and in need of prescribed products, and (h) New external provider identified (Abena) who would help with work with Social Care and Warwickshire County Council (WCC). The Assistant Director, CW Audit Services suggested that the Associate Director of Operations, Integrated and Community Division be added to the internal audit tracker. Mr Paxton, NED requested that this update was included in the Audit and Operational Governance Group (AOGG) report for emphasis as a report would help galvanise the efforts. Resolved - that (A) the Assistant Director, CW Audit Services ensure the Associate Director of Operations, Integrated and Community Division be added to the internal audit tracker, and (B) the Associate Director of Operations, Integrated and Community Division ensure the Continence Service Updates be included in the AOGG report. SS AC DRAFT ANNUAL ACCOUNTS AND COMMENTARY 2015/16 (PRE-AUDIT SIGN OFF) The Director of Finance presented the draft Annual Accounts and Commentary 2015/16 (pre-audit sign off) and highlighted the key issues. Of particular note was that the Trust had produced a 244k surplus. The audit team had finished their auditing work and would provide a report on 23 May Mr Page, NED queried if there would be a plan to address the level of costs that the Trust was incurring. The Director of Finance stated that the Trust continued to reduce the amount of agency costs and that further opportunities continued to be explored related to the Cost Improvement Programme (CIP) and the Carter Review to reduce costs. Mr Page, NED noted that it was always good to ensure the Trust produced a surplus but costs would need to be addressed. The Director of Finance stated that there had been issues with South Page 4 of 9

5 Warwickshire Clinical Commissioning Group (SWCCG) last year and the Trust had held back paying creditors in order to manage cash. The Director of Finance anticipated another 4 million receipt from the SWCCG shortly. The Committee Chair commented that the balance sheet looked stronger than in the past. Mr Page, NED queried if the volume of activity was growing faster than the value. The Director of Finance stated that there had been activity growth as well as tariff changes and commented that the formula on income was complex. Discussion took place on some of the categories in the report which included property construction, the public dividend received and the details of the loan on the Stratford Ward Block. Resolved that the Draft Annual Accounts 2015/16 and Commentary be received and noted MINUTES OF THE MEETING HELD ON 13 APRIL 2016 Interim Report on the Financial Statement Audit for the Year Ended 31 March 2016 (Minute refers) Page 12, paragraph 3 be re-worded to read: The Partner, Deloitte, LLP stated that the Trust had its CQC visit and that the CQC inspection report was due mid May Subject to this amendment, the Minutes of the meeting held on 13 April 2016 were confirmed as an accurate record of the meeting. Resolved that, subject to the amendment above, the Minutes of the meeting held on 13 April 2016 be confirmed as an accurate record of the meeting MATTERS ARISING AND PROGRESS MONITORING REPORT Actions Listed as Complete The actions listed as complete or on today s agenda in the Actions Update Report were noted and would now be removed from the report Doctors Accommodation (Minute and refers) The Director of Finance stated that a credit card facility had not been expedited. The issue was with out of hours cover, switchboard would be contacted and any risks would be identified. The process was still on-going. The Director of Finance also added that the Debt Controller wanted to make further attempts to collect debts before they were written off which was also on-going. Page 5 of 9

6 MINUTE Resolved - that the position be noted Internal Audit Report Patient Discharges (Minute refers) Mr Paxton, NED confirmed that the clinical Internal Audit Report for Patient Discharges had been shared with the Clinical Governance Committee Internal Audit Progress Report Patient Consent for Significant Procedures (Minute refers) Mr Paxton, NED confirmed that the clinical Internal Audit Report for Patient Consent for Significant Procedures had been shared with the Clinical Governance Committee Interim Report on the Financial Statement Audit for the Year Ended 31 March 2016 (Minute refers) The Director of Finance confirmed that feedback of the mediation result had been shared with the Partner, Deloitte, LLP Accounting Policies 2015/16 (Minute refers) The Director of Finance confirmed that the historic notes to the accounts had been reviewed /17 SCHEDULE OF BUSINESS (UPDATE) The Schedule of Business (Update) was noted and the Trust Secretary clarified that a Lorenzo Delivery Benefits Realisation Report was added as a general item for a future date of September The Committee Chair requested that the Internal Audit Progress Report be included for the April 2017 meeting and for the Annual Internal Audit Report including Head of Internal Audit Opinion be included in the first May 2017 meeting. Resolved that (A) the 2016/17 Schedule of Business be received and noted, and (B) the Internal Audit Progress Report be included for the April 2017 meeting and (C) the Annual Internal Audit Report including Head of Internal Audit Opinion be included in the first May 2017 meeting. ML/CT ML/CT ML/CT Page 6 of 9

7 MINUTE INTERNAL AUDIT Annual Internal Audit Report 2015/16 including Head of Internal Audit Opinion (Revised) The Assistant Director, CW Audit Services presented this report and highlighted the key issues. Of particular note was the paragraph on Reliance on Third Party Assurances on page 10. There had been a gap in third party assurance but it did not change the overall opinion and no weakness had been identified with the independent service auditor s report on the new payroll service provider. Mr Paxton, NED acknowledged his support for the Executives choices on the reports being audited. Resolved that the Annual Internal Audit Report 2015/16 including Head of Internal Audit Opinion (Revised) be received and noted NHS SBS Report The Assistant Director, CW Audit Services presented this report and highlighted the key issues. Of particular note was that comments made by Grant Thornton in relation to Payroll, Pensions and associated general IT controls for the period 1 April 2015 to 31 March 2016 to ensure the Payroll Provider applied consistently high standards of control and identified eleven control objectives that were key to assurance. The Director of Finance stated that the eleven objectives would be reviewed and a decision would be made if action had to be taken. Mr Paxton, NED suggested that clarification or an explicit statement from Grant Thornton should be made to the Trust for any actions to be carried out. The Director of Finance stated that she would liaise with the Director of Human Resources on clarification of an action plan from Grant Thornton if required. Resolved that (A) the NHS SBS Report be received and noted, and (B) the Director of Finance liaise with the Director of Human Resources around clarification of an action plan from Grant Thornton if required Outstanding Recommendations as at 30 April 2016 The Assistant Director, CW Audit Services tabled the Outstanding Recommendations as at 30 April 2016 report. The Committee reviewed the estimated and revised implementation dates of reports. Mr Paxton, NED observed that there was a general delay with some reports. The Committee Chair suggested that the focus had been taken off the reports due to the number of changes in personnel. Page 7 of 9

8 The Committee Chair suggested that the Assistant Director, CW Audit Services arrange to meet with Lead Executives to follow up on the outstanding reports. The Director of Finance agreed to arrange for the Assistant Director, CW Audit Services to meet with the Lead Executives at a future Executive Team Meeting. Resolved (A) that the Outstanding Recommendations as at 30 April 2016 be received and noted, and (B) the Director of Finance arranged for the Assistant Director, CW Audit services to meet with the Lead Executives at a future Executive Team Meeting JOINT AUDIT AND CLINICAL GOVERNANCE ASSURANCE STATEMENT The Committee Chair presented this report and explained that the Audit Committee and Clinical Governance Committee had published this joint statement of assurance which aimed to give the Board satisfaction that through the two committees there was assurance of their work. Since the last Clinical Governance Committee meeting and the distribution of the Audit Committee meeting papers, a new version of the Joint Audit and Clinical Governance Assurance Statement was tabled. The Committee reviewed the tabled report. The Trust Secretary clarified that the updated Joint Assurance Statement 2015/16 and Appendix 1 would be appended to the Committee Chair s report to the Board. Resolved that (A) the tabled Joint Audit and Clinical Governance Assurance Statement be received and noted, and (B) the Trust Secretary ensure the updated Joint Assurance Statement 2015/16 be appended to the Committee Chair s report to Board. ML ML AUDIT COMMITTEE SELF ASSESSMENT OF PERFORMANCE 2016 The Committee Chair presented this report and thanked those who completed the questionnaire on Self Assessment of Performance Discussion took place on some points of Checklist A on how NEDs were made aware of issues. The Trust Secretary explained that there was a quarterly BAF which was considered by the Risk Management Board and any high risk scores were identified for the organisation. Mr Paxton, NED suggested that even if high risk issues were resolved then they should be cascaded where appropriate. He also suggested the same approach with business cases as not all decisions were cascaded. The Director of Finance suggested that a review Page 8 of 9

9 date was created with criteria to measure benefits and delivery. The Committee agreed that there was a need to improve the process. Discussion took place on some points of Checklist B around whether the Committee summarised enough at the end of each meeting and if a reflection was made on what had worked well. It was agreed to trial this on the agenda for future meetings. The Committee Chair stated that having three NEDs as heads of Committees would be very useful. CT REFERENCE COSTING METHODOLOGY 2015/16 The Director of Finance presented the Reference Costing Methodology 2015/16 which outlined that the Department of Health had extended its requirement to the Board to both approve the reference cost process and methodology and to sign a statement of Directors responsibilities for the reference cost return. The Committee reviewed the methodology, along with a self assessment of the control in place to ensure data reliability. Discussion took place on the on-going work in relation to reference costing and the feedback loop with the new Business Performance and Investment Committee to commence in June 2016 which would be chaired by Mr Page, NED. Resolved that the Reference Costing Methodology 2015/16 be approved and noted. The Audit Committee chair would request the Board to delegate responsibility to the Audit Committee to approve the methodology on behalf of the Board, and for the statement to be signed off by the Director of Finance. RH ANY OTHER BUSINESS There was no further business DATE OF NEXT MEETING The next meeting to be held on Wednesday, 25 May 2016 at 9.00am in the Brooke Suite, Warwick Hospital. Signed (Chair) Date 25 May 2016 Page 9 of 9