ITEM 1: WELCOME AND APOLOGIES Apologies were received from Huw Williams and Heather Ancient

Transcription

1 TAUNTON AND SOMERSET NHS OUNDATION TRUST Audit Committee Minutes of the meeting held on Wednesday 2 March 2016 at 14:00 In Boardroom 1, Old Building, Musgrove Park Hospital Present: Gavin Gracie (GG) Non-Executive Director: Chair Dr Kate allon (K) Non-Executive Director Stephen Harrison (SH) Non-Executive Director In attendance: Joined at 14:55 Peter Lewis (PL) Deputy Chief Executive and Acting inance Director David Allwright (DA) Director of Corporate Planning & Performance Nathan Coughlin (NC) PricewaterhouseCoopers (External Auditor) Joined at 15:00 Neil Murray (NM) Head of inancial Services Joined at 15:00 Mark Hocking (MH) Deputy Director of inance Aimee Newton (AN) Counter raud Greg Rubins (GR) BDO (Internal Auditor) Adam Spires (AS) BDO (Internal Auditor) Steve Thomson (ST) Head of Integrated Governance Carol Lydiate (CL) PA to the Trust Secretary (Note taker) Apologies: Min 012/03.16 Huw Williams and Heather Ancient ITEM 1: WELCOME AND APOLOGIES Apologies were received from Huw Williams and Heather Ancient 013/03.16 ITEM 2: MINUTES O THE MEETING HELD ON 2 MARCH 2016 The minutes of the meeting held on 2 March 2016 were approved as an accurate record of the meeting. 014/03.16 ITEM 3: REVIEW O THE ACTION LOG AND MATTERS ARISING Matters Arising: Page 2: Mortality Review It was agreed that this item should be included in the audit plan for consideration and the decision made later in the year as to whether this should be undertaken. Page 3: Estates Contract Management The AC emphasised the need to strengthen the procurement processes in the Trust by bringing all the current stand alone procurement areas (ie IT and Estates) under general procurement to ensure that all departments are compliant with the current procurement process. ollowing discussion, ST agreed to speak to DA regards why both IT and Estates are not part of the overall procurement process, and to identify both a lead and agree a timescale for completion. ST to also confirm the issue on the extension period for the estates contract. A paper to come to the May AC meeting. A timeframe and lead to be identified to bring IT and Estates into the general procurement process. ST to confirm the issue on the extension period for the contract. A paper to come to the May AC TSTA/03.16 Page 1 of 6

2 meeting (ST). Action Log: 073/11.15 Medical Agency Staff Costs: AS reported that BDO will be undertaking some additional testing on a new agency system. Dates are to be arranged. 008/01.16 Safer Staffing: This item is tied in with work currently ongoing with BDO on the European Working Time Directive. IC agreed to bring a formal response to the May Audit Committee following the completion of this work. A report on the status of the Safer Staffing: European Working Time Directive to be submitted to the May AC (IC/ST). 015/03.16 ITEM 4: REPORTS ROM BOARD SUB-COMMITTEES: Governance Committee 2 March 2016 No report was presented. 016/03.16 ITEM 5: REERENCE COST SUBMISSION APPROVAL The Audit Committee approved the costing process that supports the Trust s Reference Cost submission for 2015/16, as outlined in the report. 017/03.16 ITEM 6: REVIEW O STANDING INANCIAL INSTRUCTIONS The updated Standing inancial Instructions were presented to the AC. ollowing a short discussion the AC agreed to adopt the updated SIs with one amendment to 2.4 (41.10) Reinforcement of Information Governance The role of Senior Information Risk Owner (SIRO) is covered by the Director of Corporate Planning & Performance, not the Deputy Chief Executive. The SIs will be circulated to all budget holders in early April following the approval of the Trust s budget at the March Trust Board. Section 2.4 (41.10) to be amended to state the role of SIRO is covered by the Director of Corporate Planning & Performance (PL/ST). 018/03.16 ITEM 7: PwC INANCIAL BASELINE REVIEW NC reported that following the audit plan approval at the January AC meeting PwC are continuing their planning processes and will be out on site undertaking interim audits from next week. They will be looking at progress with control accounts, following concern in this area last year. This will be reported on at the May AC. PwC are also currently undertaking a detailed stocktake for year-end to ensure all stock balances are captured on the balance sheet and that a formal stock system is in place to capture stock movements to year end. Year End Planning: The finance team confirmed that they had sufficient resource to prepare for year end and had a detailed timetable to work to. The audit will commence next week. NM and the finance team have recently attended an HMA training day in preparation for year end. TSTA/03.16 Page 2 of 6

3 019/03.16 ITEM 8: INTERNAL AUDIT March Progress Report AS summarised the current position with the audit plan noting that they are through the vast majority of the work for this year. The consultant job planning has been discussed and they are close to completing the duty of candour work. The governance draft report will be arriving this week. Time has been allocated next year for the EPR work. This will be a joint piece of work using a data quality specialist and a BDO IT auditor, and will appear more like a consultation than an auditing view. K asked for clarification as to what is to be audited as EPR was not up and running yet. In response, PL advised that the audit will focus on the MAXIMS system. The delayed discharge report (which is a cross county report) is out in draft and awaiting final comments from all parties, including the Clinical Commissioning Group (CCG). The wording on the report has been agreed with the CCG and GR confirmed that if comments don t come back in time he will finalise it and bring it to the next AC. or the Trust, PL has forwarded the report to Matthew Bryant, Chief Operating Offiicer, for comment. GG asked for our response to be chased up. PL agreed to follow this up. The Trust s response to the delayed discharge report to be chased up (PL). March ollow-up Report AS reported that out of the 11 recommendations, seven have been fully implemented. The budget control recommendation has a revised due date, but good progress is being made. In relation to the risk maturity recommendation, some responses were due at the end of ebruary, but due to the timing of today s meeting this will now be closed off for the May Audit Committee. There are no concerns. Updated Strategic and Operational Audit Plan GR advised that the plan includes the changes agreed at the last Audit Committee. To be included: Main financial systems - payroll Clinical coding Staff appraisals Removed: Staff retention Outcome based commissioning Patient level costing GR noted that the plan will need to be flexible due to the changes being experienced by the Trust at this time, particular with the requirements of the CQC and Monitor. PL raised a concern that the audit description in the plan can change by the time it reaches the scope stage and asked if more needed to be done to ensure that there was more control of the scope. AS confirmed that there is an executive lead for TSTA/03.16 Page 3 of 6

4 each scope. ST agreed to be the coordinator to ensure that the scope meets the need and will check with the Executive lead before progressing the audit and escalate to GG if there are concerns. ST to be the coordinator to ensure that the scope meets the need of the audit requested in the plan (ST). Key inancial systems and Working Capital Management (Limited Assurance) GR reported on the findings in the above audit: Reference costs: Detailed testing was undertaken around reference costs and no issues/errors were found. BDO confirmed that there is a very good process in place. Accounts payable: This area is generally good although it was noted that bank reconciliations were not up to date. It was acknowledged that at the time there had been absences in the team due to sickness. These issues have now been dealt with. Changes to supplier bank details: No evidence of problems, but advised to ensure that we evidence where changes have been made. This has been agreed with the finance team. Working capital (limited assurance: The key issue with this audit was the gap in processes in terms of cash flow and cash balance looking into next year. No detailed plan in place at the time, which resulted in the limited opinion. This is now being addressed. Cash flow forecasting was also highlighted as an issue, this also has been agreed and taken forward. (Information Redacted: Section 43(2) of OI Commercially Sensitive) Pre-employment checks report (Limited Assurance) In Attendance: Isobel Clements, Director of People IC had been invited to attend the AC to respond to the Limited Assurance opinion for the pre-employment check audit recently undertaken by BDO. GG informed the AC that IC and Chris Perry, Director of Change had expressed concern about the timing of the audit due to the fact that the HR department had just implemented a new recruitment process when it began. IC advised the meeting that they were aware of the gaps in pre-employment checks and are already progressing on these having introduced a Trac system in October Although IC acknowledged some of the areas that were red rated, she was not in agreement with others that had been highlighted as a high risk in the report. Three months after implementing Trac, IC reports that benefits are already being seen and that the time to hire time has been halved. She is confident that the processes now in place will alleviate some off the issues raised in the report. IC offered for BDO to reaudit against the checks in 3-6 months time, if they so wished. IC confirmed that she has taken every action recommended in the report which will TSTA/03.16 Page 4 of 6

5 be delivered by the end of the month. Other areas in red included right to work and immigration activity. Local Counter raud Serice (LCS) have been very helpful in providing training for the recruitment advisors and software has been installed to enable checks on passports. In response, GR stated that some of the issues that the audit highlighted were basic things that he would have expected a trust to do from the start. This had been a joint piece of work with the LCS and that management response to the recommendations is positive. AS informed the AC that with regards the timing of the audit the plan had been agreed a year in advance and that due to the NHS Protect standard it had to be undertaken at this time. AN reported that this issue will come out as red on the NHS Protect self-assessment toolkit. The AC accepted the report and progress being made. 020/03.16 ITEM 9: EXTERNAL AUDIT: SECTOR UPDATE The Sector Update paper was noted. 021/03.16 ITEM 10: LOCAL COUNTER RAUD SERVICE Investigation Report: (Information Redacted: Section 43(2) of OI Commercially Sensitive) Workplan for 2016/17: The LCS presented a draft work plan for 2016/17 to the last Audit Committee. This plan was based on the 2015/16 standards as no standards had been issued at this time. To date the standards in full still have not been issued. However, NHS Protect has produced a summary of the changes they are due to publish. This will result in only very minor changes to the plan. The AC agreed to accept any minor changes to the plan following the publication of the 2016/17 standards and that the final plan would come to the May meeting. inal LCS Work Plan 2016/17 to be presented to the May AC meeting (AN). Invoice raud Risk Assessment: This risk assessment used guidance issued by NHS Protect in order to assess the Trust s compliance with NHS Protect standard 3.7. Key points from the review are: Training for budget holders Recommendations re Gensis and Oracle systems segregation of duties in finance and procurement Ensuring leavers are removed from the system Purchasing cards this has been addressed. The highest risk areas were: Duplication of invoices for agency staff (high volume and high number) Changes to supplier bank account details (also addressed by Internal Audit) P9; ailure to implement the P9 may mean that the Trust is unable to demonstrate Green rating in this area. TSTA/03.16 Page 5 of 6

6 During discussion the AC agreed that it was vitally important that the Trust has a robust universal process for its invoice checking; without it the Trust could open itself up to challenge from Monitor. It was noted that a strong purchase order system would eliminate a lot of these issues. 022/03.16 ITEM 11: ITEM YEAR END PLANNING Covered above 023/03.16 ITEM 12: ATTENDANCE REGISTER The attendance register was noted. 024/03.16 ITEM 13: ANY OTHER BUSINESS There was no further business. Date of next meeting: Wednesday 23 May, 2016 at 11:30 in Meeting Room 6, Barton House South TSTA/03.16 Page 6 of 6