WELSH AMBULANCE SERVICES NHS TRUST

Transcription

1 WELSH AMBULANCE SERVICES NHS TRUST Minutes of a meeting of the Audit Committee held on 14 September 2010 at Newtown Ambulance Station and via Video Conference from HQ, St Asaph and Vantage Point House, Cwmbran. Present: Mr P James Mr D Evans Mr S Castledine Non Executive Director (Chair) Non Executive Director Non Executive Director In Attendance: Mr S Bower KPMG Mr D Davies Audit Manager, MIAA Mrs J Gill Financial Accountant Mrs L Haddow Local Counter Fraud Specialist Mr W Harris Interim Finance Director (for Minute Numbers 31 and 32/10) Mr J Jones Corporate Accountant Mr R Lee Regional Director, Central and West (for Minute Number 39/10) Mr O Lotfy Principal Auditor Ms J Palmer Category Manager, BSP (for Minute Numbers 31,32 and 39/10) Mrs D Sharp Corporate Secretary Apologies: Mr M Cassidy Ms K Evans Mr E Price-Morris Mr B Roberts Deputy Chief Executive KPMG Interim Chief Executive Staff side Representative (Unite) 31/10 PROCEDURAL MATTERS NHS Audit Committee Handbook Self Assessment Checklist Members of the Committee were asked to complete the self assessment and submit it to the Corporate Secretary by the end of September who would compile a feedback report for the next meeting. Referrals to the Audit Committee The Committee noted that no referrals had been received during the last cycle and requested that the Corporate Secretary to remind all Committees in the new structure of this process. This will encouraging referrals, whilst making it clear that it would be a matter for the Audit Committee itself to determine those matters it may wish to pursue further.

2 Committee Structure Review/Scheme of Delegation/Standing Orders (SOs) /Standing Financial Instructions (SFIs) Work on the Committee Structure review was almost complete and adjustments were being made to the model SOs/SFI issued by the Welsh Assembly Government. A further meeting of the Committee Structure Working Group was being convened to consider final proposals and would be presented to the Audit Committee at its next meeting for submission to the December Board as opposed to the September Board which had been the original intention. In view of the deferral the Committee agreed to recommend to the Board that the Corporate Secretary should update the current Scheme of Delegation to reflect recent management structure changes in consultation with the Chairman and Chief Executive. RESOLVED: That (1) The minutes of the meeting of the Committee held on 16 June 2010 be confirmed as a correct record and the update and action relating to the following minutes be noted:- Minute 01/10 (d) and 10/10 Provision of Taxi Services Following discussion between the Chairman and the Deputy Chief Executive it had been agreed to defer the comprehensive review report on PCS to the next meeting in view of recent reports to the Board detailing progress. This would also enable the report when presented to provide further clarity on the progress of the modernisation and the pilot arrangements. Minute 11/10 (3) Vehicle Maintenance Position within Central and West and Minute 30/10 Fleet Management Arrangements. The Committee noted the appointment of Robert Raistrick as Interim Fleet Manager from 14 September, pending the return of the substantive postholder. The Fleet Management report to the Committee was therefore postponed to the next meeting. Minute 22/10 Serious Adverse Incidents (SAIs)/ Adverse Incidents (AI) Reports Members of the Committee were aware of the progress to date on the transfer of the Complaints and Claims to the Clinical Directorate and the scoping exercise and review being undertaken, to fully implement the new Welsh Assembly Government (WAG) Guidance Putting Things Right. This document proposed an integrated structure to support best practice in the handling and investigation of concerns, encompassing complaints, incidents and claims.

3 Integral to the review would be the establishment of systems, and processes at local and regional levels, and consequently a review and streamlining of associated key policies and procedures. This work clearly formed a key element of the Trust s governance and accountability framework. The Committee emphasised the importance of it being provided with the necessary assurances that the work was both progressing at a satisfactory pace but more importantly that the new systems and processes would provide the necessary assurances for the Board from a governance perspective. The Trust had completed an extensive gap analysis resulting in the production of an action plan, which was currently being progressed. The Committee asked to be kept updated in terms of progress with regard to establishment of new systems and processes but also requested a detailed breakdown in terms of the current profile, status, clearance rates and outcomes in relation to Complaints management at its next meeting. (2) the Committee received a progress report on the implementation and streamlining of structures and processes to support the Putting Things Right guidance in addition to a detailed breakdown in terms of the current profile, status, clearance rates and outcomes in relation to complaints management at its next meeting; (3) Committee members complete the self assessment, as detailed in Appendix 2 to the report, and submit it to the Corporate Secretary by the end of September for onward report and consideration of findings at the next meeting; (4) all Committees in the new structure be reminded of the process for referrals to the Audit Committee; and (5) the position with regard to the revised Committee Structures, SOs and SFIs be noted. It is recommended that the Board instructs the Corporate Secretary to update the current scheme to reflect recent management structure changes in consultation with the Chairman and Chief Executive. 32/10 TENDER UPDATE REPORT AND SINGLE TENDER WAIVER REGISTER The Committee considered an update report on tender activity and a summary of single tender waivers for the period June to August Members raised some issues surrounding individual tender arrangements to which a response was given. The Committee requested further background information from the Deputy Chief Executive to be provided at the next meeting with regard to T.0163 Provision of

4 Courier Services with regard to the make up of the contract, clarity of service provision etc including an analysis of cost of current provision of services versus income. With regard to T.0073 Maintenance and repair of emergency vehicles, the Committee emphasised the importance of ensuring contract duration was aligned to the direction of travel envisaged as part of the overall estates strategy. The Corporate Secretary referred to the model SFIs, emphasizing the need to review the overall format and presentation of future reports and documentation to the Committee to ensure SFI requirements were met. RESOLVED: That (1) the report be noted; (2) a detailed report on T.0163 as set out above be prepared for the next meeting; (3) before the award of T.0073 regard be paid to the overall draft estates strategy and timescales within; and (4) presentation and content of future reports to the Committee be reviewed in light of the revised model SFIs issued by WAG. 33/10 FINANCE REPORT FOR THE PERIOD ENDED 31 JULY 2010 (MONTH /11) The Chairman agreed to vary the order of business and take this item earlier in the proceedings in order to facilitate the release of the Interim Director of Finance to attend another important meeting. The reported outturn performance at Month 4 was a retained deficit for period of 1.42m. The most significant reason for the deficit position was the delay in the actions required to deliver the savings schemes required to achieve a balanced budget, although the Trust had also experienced non-pay related adverse variances, which were being addressed by the Executive Team and local Trust management. At the time the report had been written figures relating to Month 5, ending 31 August, had not been available. However, they were reported orally at the meeting and the overall deficit had worsened slightly to 1,634,000. This was mainly attributable to issues within the Central and West Region. The Management Team were taking active steps collectively to address the problem and the Interim Director of Finance outlined the arrangements. The Committee expressed concern at the ongoing vacancy of a Director of Emergency Services, and noted that arrangements were in hand to recruit to this position. A detailed report on the Month 5 position would be provided to the September Board.

5 RESOLVED: That the position be noted and the corrective actionbeing taken to address the deficit be endorsed. 34/10 RISK MANAGEMENT FRAMEWORK The Committee were informed of the progress in developing the Trust s Risk Management Framework, which was being undertaken in conjunction with the Trust s Management Structure Review, the review of the Committee Structure and the revision of the Scheme of Reservation and Delegation and taking account of WAG s draft consultation document Your Risk and Assurance Framework: A Structured Approach. It was proposed that, within the context of the revised Management and Committee Structures and the revised Scheme of Reservation and Delegation, the Risk Management Framework would be broadly as follows (subject to further discussion at Executive Level): a) The Board would determine and interpret strategic aims and objectives, whether externally imposed or internally adopted, and approve Trust policies, advised by the Management Team. b) The Management Team would ensure that there was clarity of objectives and aims at all levels of management, together with clarity about roles, responsibilities and accountabilities to ensure effective decision-making at all appropriate levels. The Management Team would be responsible for reviewing and determining the Corporate Risk Register as an integral part of the Corporate Planning process. c) Risk profiling and the development of Risk Registers would be developed at Directorate level and appropriate Departmental and functional levels, with risks being managed at the lowest effective level. d) Directorate, Departmental and functional Risk Registers would be considered by the appropriate Business Delivery Group (Level 3). e) The Management Team would review each of the Risk Registers on a regular basis and consider which risks were significant enough to merit inclusion on the Trust s Corporate Risk Register. f) The Management Team would agree the draft Corporate Risk Register for submission to the appropriate committee for consideration. g) The draft Corporate Risk Register would be submitted to the Board for consideration at regular intervals and the Board will require progress reports on Actions Plans to address the risks on the Corporate Risk Register.

6 The above process had already begun, with Directorates engaged in the process of reviewing and revising their Risk Registers. The Risk Management Policy and Strategy was being revised to take account of the revised Management and Committee Structures and the revised Scheme of Delegation and would be presented to this Committee in due course. A comprehensive review of the Corporate Risk Register was taking place within the context of an overall review of the Risk Management process. RESOLVED: That the position be noted and ongoing work be supported. 35/10 MIAA INTERNAL AUDIT PROGRESS REPORT The Audit Manager (MIAA) presented the Committee with the Internal Audit Progress Report, which provided an update in respect of the assurances, key issues and progress against the Internal Audit Plan for 2009/10 and 2010/11. Comprehensive reports detailing findings, recommendations and key actions had been provided to the Committee. The Committee requested that finalised audit reports in addition to being ed to Committee members at the point of finalising the report, be included within future agenda papers. The Committee also requested a detailed table showing all high level scorings irrespective of the classification of the final report. It was also agreed that Directors would be asked to be present when reports relating to their area were presented. The Chairman and Corporate Secretary agreed to agree attendances prior to each meeting. Reference was made to the ongoing WAG All Wales shared service project which from April 2010 was proposing to incorporate Internal Audit provision. The effect on current position of service by MIAA was as yet unclear. RESOLVED: That detailed action in relation to future internal audit reports be progressed by the Audit Manager, Corporate Secretary and Chairman as outlined above. 36/10 EXTERNAL AUDIT PROGRESS REPORT The External Auditor briefed the Committee on progress with regard to the external audit plan. KPMG had verified the audit of accounts for the Trust s Charitable Funds, which had been presented to the Charitable Funds Committee on 26 August and were due to be presented to the Trust Board on 29 September prior to submission to the Charity Commission by the prescribed deadline of 31 January Reference was also made to the ongoing work relating to the Structured Assessment. It was recognised that the process underpinning the assessment was

7 not as smooth as would be desired due to the introduction of the change late in the year. RESOLVED: That the position be noted. 37/10 COUNTER FRAUD PROGRESS REPORT JUNE TO AUGUST 2010 The Committee considered a report which summarised the work being undertaken by the Local Counter Fraud Specialist for the period June to August 2010 and also providing details of ongoing and future counter fraud work. The report made reference to proactive work undertaken in relation to the awareness raising. Suggestions put forward for future activity included make a presentation at the NJC, team briefings and allocated time at induction events. The Committee requested that future reports on investigations include details of the date on which the matter arose. The Committee also encouraged the Local Counter Fraud Specialist to raise any difficulties that might be experienced in progressing investigations with the Committee. RESOLVED: That (1) the report be received; and (2) the recommendations put forward by the Committee and outlined above be actioned by the Local Counter Fraud Specialist and an update on progress/response be included within the next Counter Fraud Progress Report. 38/10 SUMMARY OF INCOME AND EXPENDITURE FOR 2009/10 RELATING TO AMBULANCE RADIO REPLACEMENT PROJECT (ARRP) The Interim Director of Finance provided a written response to Minute 23/10 (3), summarising the income and expenditure for 2009/10 relating to ARRP. The Committee requested further detail setting out the full breakdown of figures over the life of the project as a whole. RESOLVED: That the full breakdown of income and expenditure over the life of the project be provided to the Committee.

8 39/10 IMPROVING THE MANAGEMENT OF OXYGEN SUPPLIES ACROSS THE WELSH AMBULANCE SERVICES NHS TRUST The Regional Director, Central and West provided an update regarding the progress made following the report to the June Committee. Since the last meeting the following actions had been completed and a detailed report on each aspect was provided to the Committee. a full audit of the Trust s oxygen cylinder holdings and reconciliation with the supplier; a position statement following this audit in relation to the way forward; and revision of delivery and storage arrangements with the Central and West Region. The Committee noted the ongoing discussions with the supplier regarding the reconciliation of lost cylinders and expressed concern that these discussions had not been concluded. The Committee requested that the matter be resolved as soon as possible with discussions taking place at Chief Executive level or equivalent between the Trust, the Supplier, Welsh Health Supplies and the North Wales Business Support Partnership. A full report on the financial implications would be included within the next report to the Committee. RESOLVED: That (1) ongoing negotiations with the supplier continue as outlined above; and (2) further detail with regard to the financial implications be included in the next report to thecommittee.