TRUST BOARD HIGHLIGHT REPORT FROM THE CHAIR OF THE AUDIT COMMITTEE

Transcription

1 TRUST BOARD HIGHLIGHT REPORT FROM THE CHAIR OF THE AUDIT COMMITTEE Meeting Date: 30 th November 2017 Author: Sponsoring Executive Director: Report Presented by: Claire Bowden, Interim Deputy Director of Finance Mark Osland, Executive Director of Finance & Informatics Martin Veale, Trust Independent Member and Chair of the Audit Committee Trust Resolution to: (please tick) Approve: REVIEW: INFORM: ASSURE: Recommendation: This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well ACRONYMS NWIS - NHS Wales Informatics Service

2 2 Highlight Report Executive Summary: This paper has been prepared to provide the Board with details of the key issues considered by the Audit Committee at its meeting on the 3 rd October The Board is requested to NOTE the contents of the report and actions being taken. Key highlights from the meeting are reported below: NHS Wales Informatics Service (NWIS): Independent Review & Internal Audit Plan ALERT/ ESCALATE Mr Cookson from Internal Audit presented the report on a complex audit which had taken almost 2 years to complete. Most of the recommendations made are to be taken forward by NWIS, with a few to be taken forward by the Trust who are preparing responses. Mrs Galletly advised that work was ongoing with Welsh Government to provide clarity on what was meant by the hosting of NWIS. A piece of work on the governance of NWIS had been completed and subsequently approved by the Chief Executive. The views of NWIS will be sought and then the document shared with a wider audience including the Chair of the Audit Committee. Mrs Galletly advised a paper would be brought to the December 2017 Audit Committee. Internal Audit Of the 4 audits completed since the last Committee meeting, 2 had received limited assurance ratings and are detailed below: ADVISE Management of Sickness & Absence Follow Up Report The original audit was undertaken in November 2016 and received the same rating. However, it was noted that there have been some improvements with the follow up of sickness triggers in the areas reviewed, and access to the ESR system across the Trust. Cyber Security Report Mr Lewis from Internal Audit noted that this is such a large area to cover, it is difficult for any organisation to achieve a better rating. Areas of good practice were identified, along with some key areas of concern. It was noted that all NHS organisations are experiencing the same risks as the Trust. Internal Audit ASSURE INFORM In addition to the 2 audits outlined in the section above, 2 further audits had been completed since the last Committee meeting and their assurance ratings are detailed below: Annual Quality Statement This had received a substantial assurance rating. IT Strategy Statement This had received a reasonable assurance rating. The Committee agreed it should receive Annual Reports for all other Committees for further assurance. Appendices Report History None The Audit Committee highlight report is a standing quarterly agenda item. Page 2

3 PUBLIC TRUST BOARD PART A HIGHLIGHT REPORT FROM THE CHAIR OF THE CHARITABLE FUNDS COMMITTEE Meeting Date: 30 th November 2017 Author(s): Sponsoring Director: Report Presented by: Mrs Cally Hamblyn, Head of Corporate Governance Mr Mark Osland, Executive Director of Finance & Informatics Professor Rosemary Kennedy, Chairman Trust Resolution to: (please tick) APPROVE REVIEW: INFORM: ASSURE: Recommendation: The Board is requested to receive the highlight report on the activity considered at the Charitable Funds Committee on the 14 th November This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well ACRONYMS CFC Charitable Funds Committee This report supports the following Health & Care Standards: Governance, Leadership & Accountability, Effective Care, Dignified Care, Timely Care, Staff and Resources

4 2 Highlight Report Charitable Funds Committee 14 th November 2017 EXECUTIVE SUMMARY: This paper had been prepared to provide the Board with details of the key issues considered by the Charitable Funds Committee at its meeting on the 14 th November The Board is requested to NOTE the contents of the report and actions being taken Key highlights from the meeting are reported below: ALERT There were no items considered for escalation to the Board under this section. Velindre NHS Trust Charity Reserves Policy The reserves are a part of the charity s unrestricted funds that are available to spend on any of the charity s purposes. Reserves need to be maintained at a level which is sufficient to meet planned and unplanned commitments, but without holding funds which should be spent in a timely manner on charitable activities. The Trustees have previously considered that reserves should be set at a level which is equivalent to estimated commitments covering a period of 4 months. At, this level and in the event of a significant reduction in funding, the Trustees feel that they can manage the current programme of activity for such a time to allow for a managed change in activity and/ or the generation of additional income streams. ADVISE In the light of the above and following a significant increase in income over a period of 2 years the reserve variance was over achieving by 1,579k as at the end of March In order to bring the reserve down a number of expenditure proposals which aligned with the charities aims and objectives were received by the Charitable Funds Committee for approval. In accordance with the Trustees wishes this program of work has helped bring down the reserve variance to a reduced over achievement of 348k as at 30th September Fundraising Income The CFC acknowledged and reflected upon the impact the current economic climate has had on potential fundraising income not only for the Velindre NHS Trust Charity but the wider charity network. In light of this the Velindre NHS Trust Charity fundraising target will continue to be monitored and reviewed particularly when setting the target for Risk Management: The CFC scrutinised the two current risks and one new risk on the Charity Risk Register and considered the mitigating actions for managing these risks are within the acceptable organisational risk tolerance level, the three risks are: Risk item Lack of Charity Strategy & Business Plan Risk item Potential impact on Velindre NHS Trust Charity Fundraising Income due to competing onsite charities Risk item Failure to appoint a Charity Director

5 3 Highlight Report Charitable Funds Committee 14 th November 2017 Velindre NHS Trust Chartable Funds (Trustee) Annual Report The Charitable Funds Committee: Approved the Charitable Funds (Trustee) Annual Report Duly Authorised the Chairman, Chief Executive and Executive Director of Finance to sign the letter of representation contained within the audit report and the accounts as appropriate. The report will be submitted to the Charity Commission by the deadline of the 31 st January Audit ISA 260 Report (Wales Audit Office) The CFC approved and noted the following key points from this report: ASSURE The Auditor General for Wales intends issuing an unqualified audit report on the financial statements once the charity has provided a Letter of representation (included in the report). The Auditor General has provided the following opinion the on the financial statements give a true and fair view of the state of the charity as at 31 st March and its incoming resources and application of resources for the year then ended: and have been properly prepared in accordance with the United Kingdom Generally Accepted practice and the charities act 2011 Business Case & Fundraising Evaluation Reports The committee considered a number of Business Case and Fundraising Evaluation Reports which provide assurance that projects funded by the Charity are clearly measured in terms of their outputs and success. The Committee received a presentation from the Therapies Manager in relation to the Acupuncture service currently funded by the Charity. This presentation was in lieu of a written business case evaluation report and was received positively by the Committee in providing assurance that the activity funded was realising benefits for patients and the service. Moondance Programme Board The Moondance Programme Board were commended by the CFC for the well-defined process and governance structure it has established to manage funding applications and the positive feedback received by those involved. In this context the CFC agreed to extend the scope of responsibilities of the Programme Board to include the management of a substantial legacy for radiotherapy research that has recently been notified to the Charity. Business Case Request for Charitable Funding The CFC determined the following action on the business cases outlined below, received by the Committee for charity funding: INFORM Approved: Funding for a pilot of a Patient Portal (Patient held Records). Approved in principle subject to R&D approval: Funding for a PhD student to work on the project Developing radiomics as an imaging biomarker in High Grade Glioma.

6 4 Highlight Report Charitable Funds Committee 14 th November 2017 Fundraising Proposals The CFC approved the following fundraising proposals: Grand Slam Anniversary Lunch March 2018 Nepal Trek 2019 Highlight Report from the Investment Performance Review (IPR) Committee It was noted that the IPR Committee will be undertaking some comparative work in relation to its investment risk categories and will also be exploring potential social economical investments. Appendices Report History None identified. The Charitable Funds Committee highlight report is a standing quarterly agenda item.

7 PUBLIC TRUST BOARD REPORT PART A BOARD ASSURANCE FRAMEWORK (BAF) UPDATE Meeting Date: 30 th November 2017 Author: Cally Hamblyn, Head of Corporate Governance Sponsoring Executive Director: Georgina Galletly, Director of Corporate Governance Report Presented by: Georgina Galletly, Director of Corporate Governance Committee/Group who have received or considered this paper: Nil. Trust Resolution to: (please tick) Approve: REVIEW: INFORM: ASSURE: Recommendation: The Trust Board is asked to NOTE the update in respect of the BAF development. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well ACRONYMS BAF Board Assurance Framework KPI s Key Performance Indicators IMTP Integrated Medium Term Plan This report supports the following Health & Care Standards: Governance Leadership & Accountability, Safe Care, Effective Care, Staff and Resources, Dignified Care

8 2 BAF Project Update 1. Introduction / Background The need to develop and agree a mapped Board Assurance Framework (BAF) for the Trust has been identified and supported by the Trust Board, with the BAF Project Initiation Document being approved at the June 2017 Executive Management Board. A robust and meaningful BAF cuts across planning, performance management, governance and risk. Bringing them together, to allow a robust and informed discussion at Board on areas of risk and poor performance will support the achievement of the Trust s overarching goals and objectives. A project management approach is being taken to design and implement a solution, working with colleagues from across the Trust and at Board as outlined in section 3. This report provides an update on the progress of the project to date. 2. Timing: The key milestone within the implementation plan is to introduce a new mapped BAF for the Trust Board by April Description: 3.1 Research & Options appraisal At the first meeting, the group researched existing BAF approaches adopted in NHS Wales and NHS England to assist in agreeing a preferred approach. This benchmarking allowed the group to develop a template which captures a number of areas of good practice from a number of sources. The project group has also considered the reports published by Wales Audit Office in relation to WAO s comparative findings. 3.2 Collaborative Working and Engagement Project Team membership is as follows: Role Project Director/Director of Corporate Governance Project Manager/Head of Corporate Governance Quality & Safety Manager Associate Director of Informatics Assistant Director of Organisational Development Planning and Service Development Manager Finance Representative Head of Strategic Planning & Performance Head of Business Support Planning & Performance Manager Organisation/Area Trust Governance Trust Governance Trust Risk Trust Informatics Trust Workforce & OF Trust Planning Trust Finance Welsh Blood Service Welsh Blood Service Velindre Cancer Centre Page 2

9 3 BAF Project Update Programme Approach: In August 2017, the Executive Management Board endorsed a programme approach which supported the engagement and alignment of the following groups to contribute to the overall BAF development. This approach gains benefits from the developing work programmes of each of the work streams, minimise duplication and provide a collaborative approach to the overall desired outputs. BOARD ASSURANCE PROGRAMME Enhanced Performance Report and Analysis Group Lead: Planning & Service Development Manager Business Intelligence Task & Finish Group Lead: Associate Director of Informatics Risk Project Group Lead: Quality & Safety Manager Board Assurance Framework (BAF) Project Group Lead: Head of Corporate Governance ACTIVITY: Performance Data What to Report KPI s / Metrics. Aligned to IMTP ACTIVITY: Mechanics How to report/use the information/ data Incorporating Data Quality. Structure and Resource. ACTIVITY: Risk Tolerance How strategic risks will be reflected in the framework Alignment with the Trust Risk Register ACTIVITY: Presentation How the information/data will be presented to provide assurance on achievements Data Quality Assurance Each of the above work stream leads provides an update on progress at each BAF project meeting. Independent Member Lead: Mr Martin Veale, Independent Member (IM) has been agreed to be the projects IM lead and will work with the group at various test points in the development of the BAF. 3.3 Progress to date The project group meets on a monthly basis and is making significant progress as outlined below: o An Implementation plan has been approved and agreed, with all group members actively leading on their respective areas such as Business Intelligence, Performance Analysis, and Risk etc. o A Draft BAF Template has been developed based on an approach adopted in a Trust in NHS England and adapted to meet the requirements of the Trust. Page 3

10 4 BAF Project Update o Presentational Objective Statements for use with the BAF have been developed and mapped against existing strategic risks to ensure the approach aligns effectively. o The November 2017 Project Group will focus predominantly on risk, mapping the organisations strategic risks to the proposed framework incorporating the recently approved risk appetite statements. 4. Financial Impact: There are no direct significant financial implications to the Trust identified, but significant resources (colleagues time) will be essential in realising the success of the programme. Should a software solution be identified to support the timely management and reporting of data, this would be subject to consideration by the EMB in a separate business case and should not be a critical success factor to the project. 5. Quality, Equality, Safety and Patient Experience Impact: The role of the BAF is to provide evidence and structure to support effective management of Risk within the organisation. The BAF provides this totality of assurance and identifies which of the organisation s strategic objectives are at risk of not being delivered. At the same time, it provides positive assurance where risks are being managed effectively and objectives are being delivered. This allows the Board to determine where to make most efficient use of their resources and address the issues identified in order to improve the quality and safety of care. 6. Considerations for Board / Committee: The Trust Board is asked to NOTE the update in respect of the BAF development. 7. Next Steps: A further update will be provided at the January 2018 Trust Board. Page 4