SOUTH EASTERN HEALTH & SOCIAL CARE TRUST

Transcription

1 SOUTH EASTERN HEALTH & SOCIAL CARE TRUST Minutes of a meeting of the Audit Committee held on Thursday 3 December 2015 at noon in the Boardroom, Trust Headquarters, Ulster Hospital PRESENT: IN ATTENDANCE: APOLOGIES: ABSENT: Mr J Trethowan, Non-Executive Director (Chairman) Miss F Graham, Non-Executive Director Mr N Mansley, Non-Executive Director Mr N Guckian, Director of Finance & Estates Miss I Low, Board Secretary & Assistant Director, Risk Management & Governance Mr P Morgan, Assistant Director, Financial Services Mrs C McKeown, Head of Internal Audit, Business Services Organisation (BSO) Ms P Blair, Senior Auditor, Northern Ireland Audit Office (NIAO) Ms M Maginnis, Grant Thornton None received None ACTION CHAIRMAN S BUSINESS At the outset, Mr Trethowan referred to the letter dated 27 November 2015 from Mr Wilkinson, Director, NIAO, a copy of which had been shared with members via in advance of the meeting. The letter confirmed the appointment of Grant Thornton as the firm who won the tender for the audit of the annual accounts for the South Eastern HSC Trust. Members noted that the contract is for a period of three years commencing with the 2015/16 accounts, with the possibility for a further two years. The engagement partner in Grant Thornton is Ms Louise Kelly. Mr Trethowan then welcomed Ms Michelle Maginnis who was representing Grant Thornton during Ms Kelly s maternity leave. Mr Trethowan advised members that the bi-lateral meeting with representatives from NIAO had been held immediately prior to today s meeting. Representatives from NIAO were Ms Mason and Ms Blair and Ms Maginnis was also present. A copy of the note of the meeting will be circulated with the papers for the Audit Committee meeting to be held on 4 February IL 1.0 DECLARATION OF POTENTIAL CONFLICT OF INTERESTS WITH ANY BUSINESS ITEMS ON THE AGENDA Mr Trethowan invited members to declare any items of potential conflict of interest with business items on the agenda. None were received and the business of the meeting proceeded 1

2 2.0 MINUTES OF THE PREVIOUS MEETING The minutes of the previous meeting held on 12 October 2015, having been previously circulated, were taken as read and agreed as a true and accurate record. 3.0 MATTERS ARISING FROM THE MINUTES 3.1 Update BSTP Project Mr Guckian updated members in respect of the BSTP Project since the last meeting. Regional meetings continue to take place and provide a forum for discussion on emerging issues. Both Payments/Income functions are stable and the service provided is excellent. However, whilst the Payroll function for this Trust is good there are problems in other Trusts which are being addressed. Mr Guckian has formally written to the Chair of the Regional Project Board in this regard. Assurances in respect of performance issues have been provided and a detailed project plan is in place. A short discussion ensued in respect of this project and Mr Guckian and Mr Morgan responded to members queries. Mr Guckian confirmed that a detailed plan was in place to ensure all monthly over payments would be identified with a repayment plan in place by year end. In response to Mr Trethowan s query, Mrs McKeown confirmed that she had no comments to add other than progress was in line with the Briefing Paper on Shared Services which had previously been shared with members and the audit findings would be reviewed at year end 31 March Update Stewart Memorial Mr Trethowan provided a short briefing on the background to this item for the benefit of Ms Maginnis who had joined the meeting today. Mr Morgan confirmed that Ms Mongan, Director of Adult Services & Prison Healthcare, continued to have regular meetings with Stewart Memorial representatives to try and resolve the issues concerning this home. In addition, the audit findings had been raised with the recently appointed new Chief Executive, by Trust staff. However the implementation of the audit findings is dependent on the whether the home will close (or not, as the case may be). A decision on this matter is still awaited. Miss Graham said that she was concerned about this matter. Detailed discussions had taken place on this item at the October Audit Committee meeting and from the information presented today there is still no firm decision as to whether the home will or will not close. In response, Mr Guckian reassured members that operational staff are working very closely with families/carers to ensure continuity of services and that Ms 2

3 Mongan is actively working to get a suitable resolution to the issues hopefully without residents having to move. He confirmed that should the House close, it would be extremely challenging to find alternative arrangements for all clients. Following discussion, it was agreed that Mr Guckian would ask Ms Mongan for a position report in respect of Stewart Memorial detailing the current position and way forward for consideration at the next meeting. NG 3.3 Update Succession Planning for Non-Executive Directors (training for new Audit Committee members) Mr Guckian updated members in respect of the above item. He confirmed that the issue of regional training for new Audit Committee members had been raised at the recent Ground Clearing meeting prior to the DHSSPS Accountability Meeting. In addition, Mr Mansley advised that he had also raised this issue at the recent Audit Committee Chairs Forum held on 1 December 2015 and it was noted that Trusts were expected to provide this internally (as opposed to regional training events). Mr Morgan advised that he had recently contacted CIPFA, Northern Ireland, regarding training for new Non-Executive Directors and, in particular, in respect of Audit Committee courses. It was noted that their 2016 schedule was not yet released but there would be a number of one day courses available in the new year suitable for Audit Committee members. Miss Low confirmed that bespoken training for new Non-Executive Directors in respect of all Trust Board sub committees was included in the new Induction Programme for Non-Executive Directors. 3.4 Update GP OOH Mr Guckian confirmed that the recommendations contained within the above internal audit report were the responsibility of the service area to complete. A review of progress will be included in the year end follow up report by Internal Audit. 3.4 Update Dental Service Contract in Magilligan Mr Guckian reported that it is likely that the extant contract for Dental Services in Magilligan will cease as there are plans under discussion to bring the service in-house. Expected date is end of March 2016, at this stage. 4.0 NEW BUSINESS ITEMS For Approval and/or Discussion 4.1 Update on Audit Committee Chairs Forum held on 1 December 2015 Members received, for information, copies of the four 3

4 presentations discussed at the Audit Committee Chairs Forum held on 1 December Details as listed below:- DHSSPS and Strategic Procurement Mr Peter Toogood, Director of Finance, DHSSPS; NIAO Strategic Planning of Value for Money Audits Mr Sean McKay, Director of Health VFM; Review of Assurance & Accountability Arrangements Ms Linda Devlin, DHSSPS Shared Learning Across HSC BSO Internal Audit Perspective, Mrs McKeown, Head of Internal Audit Mr Mansley provided a brief synopsis of each session and a general discussion ensued. In response, Mr Guckian responded to members queries raised during the meeting. Mr Mansley stated that this was a very valuable forum to attend and hoped that the incoming chair of the Audit Committee would continue supporting this forum. All members agreed with this view. In addition, Mr Trethowan asked Mr Guckian to ensure that the profile of the work of both Internal and External Audit is raised with his EMT colleagues and continued to be supported when a new Audit Committee is formed. It was suggested that this matter could be raised at a future Senior Staff Briefing session. NG For Information/Noting 4.2 Update P1 findings from Report to those Charged with Governance (RTTCWG) 2014/15 Members received, for information, a copy of an update report in respect of the P1 findings (5 in total) arising out of the RTTCWG 2014/15 which was received by the Trust on 3 September In presenting the report, Mr Morgan said that the paper contained a current position report in respect of each item together with a revised status comment two items were implemented, one confirmed no action required and the remaining 2 had agreed implementation dates of March and April 206 respectively. 4.3 Mid-Year Assurance Statement Members received, for information, a copy of the final version of the Mid-Year Assurance Statement dated 16 October 2015 which was submitted to the Department of Health, Social Services & Public Safety in accordance with the agreed timetable. 4.4 Update International Fraud Week November 2015 Mr Morgan gave a brief synopsis of activity undertaken during 4

5 International Fraud Week which was held on November Circular HSC (F) FD (DFP) NIAO Publication Managing Fraud Risk in a Changing Environment: A Good Practice Guide Members received, for information, a copy of the above circular dated 26 November 2015 which advises staff on the latest NIAO publication Managing Fraud Risk in a Changing Environment: A Good Practice Guide (including a checklist, for completion). Hard copies of both documents were circulated by NIAO representatives at the meeting, for information. A short discussion ensued and it was agreed that Mr Morgan should review the extant Fraud Policy to ensure it complies with the good practice detailed in the checklist and report back at the next meeting. PM 5.0 REPORT FROM INTERNAL AUDITORS 5.1 Progress Report to Audit Committee dated 3 December 2015 Members received, for consideration, the Progress Report to Audit Committee dated 3 December 2015 which had been circulated with the papers for the meeting. In presenting the report, Mrs McKeown highlighted page 2 of the report which detailed the audit assignment, current status, date of consideration by the Audit Committee and overall level of assurance. She confirmed that the audit programme was on target for completion by the year end. The following reports were reviewed and discussed during the meeting Financial Assessments including direct payments 2015/16 Satisfactory Assurance (in relation to Financial Assessments) and Limited Assurance (in relation to Direct Payments) A lengthy discussion took place in respect of this report. A number of queries were raised by members and Mr Guckian duly responded to all. He reassured members that all reassessments of financial assessments were up to date and the delay was primarily due to staffing issues which had now been resolved. With regard to the issue of Direct Payments, he advised that he had discussed this matter with the NIAO and it is likely that this payment method may change in the future due to the developments with self directed support. However, the report details a number of recommendations which have been accepted by management and these will be implemented and followed up at year end by Internal Audit. 5

6 Reference was also made by Mr Mansley to the issue of retrieving monies in respect of formal charges to properties and the use of RX1 forms currently used in England. In response, Mr Guckian said that the Trust do pursue property charges on a case by case basis; RX1 forms do not apply in Northern Ireland, although there may be an equivalent form in use. Mr Morgan agreed to check the position in advance of the next meeting Management of Waiting Lists Satisfactory Assurance PM Mrs McKeown presented the findings in respect of the above report which was noted to have received satisfactory assurance. Management had accepted the recommendations. Mr Trethowan said that he had ed Miss Low on 30 November 2015 (with cc to members) indicating his concern with the Priority 1 finding on page 24 and the more detailed report on page 28. He considered that this was at variance with assurances given at more than one Trust Board that whilst waiting lists were lengthening, that no-one who urgently needed to be seen was being delayed? In response to this , Mr Guckian advised that he had sought clarification from Mr McGoran and he duly responded to Mr Trethowan s queries at the meeting. Mr Guckian confirmed that whilst administratively, waiting lists are not reviewed weekly, due to the minimal changes week to week, clinical teams will reflect clinical priorities as well as waiting times in addressing waiting lists, when resources are available. There is a risk, however, due to delays in outpatients waiting times, that patients could deteriorate during this wait, without clinical assessment. This risk was highlighted in the mid-year governance statement. In respect of urgent patients generally (ie non cancer patients) there is no target waiting time. The target waiting times only relate to suspect cancer patients, confirmed cancer patients and all other patients (both urgent and routine who are not meant to exceed maximum waiting times). Clearly, these patients are waiting longer than the maximum waiting time as we report every month. The reason for this is the HSCB has not commissioned sufficient services for these patients. Finally, the key risks are included in both the mid and end of year Governance Statement, as appropriate, which members of the Audit Committee actively comment on the draft when being prepared. Mr Trethowan thanked Mr Guckian for the detailed response in respect of this issue but indicated that he would like to discuss 6

7 the matter further with Mr McGoran/Mr Guckian outside this meeting and, if necessary, highlight the key issues at the next Trust Board meeting. Mr Guckian agreed to speak with Mr Trethowan at the end of today s meeting. NG Discussion also took place in relation to page 30 of the report. This related to several lapses in Information Governance whilst visiting wards at the Ulster Hospital; medical files left unattended at workstations and rooms containing medical files left unlocked and unattended. Mr Guckian reported that this was due to a reduction in admin staff combined with lack of storage space. Members indicated they were supportive of the action taken by management post the report and recognised that the longer term solution to resolve the problem was linked to the completion of the Phase B project. There was acceptance that this issue was common to all hospitals given the need to update Patient Admin Systems from files, etc. Following detailed discussion, it was agreed that this matter should be highlighted to the Governance Assurance Committee at their meeting on 16 December 2015, noting that management were doing everything within their power to resolve the issue pending the completion of Phase B project. IL Laboratory Procurement and Contract Management 2015/16 Limited Assurance A discussion in relation to the above report took place which also included regional aspects across all 5 HSC Trusts (page 36 details the outcome of this aspect). Findings were largely consistent across the Trusts and common weaknesses were identified in respect of: The management and monitoring of the Belfast block contract activity; Non contract activity through non-pop route with both NHS providers and private sector suppliers; and Formal contract management and monitoring arrangements. Mr Guckian said he was pleased to see the recommendation in relation to the finding about the SLA with Belfast H&SC Trust which was welcomed. 6.0 REPORT FROM THE EXTERNAL AUDITORS There was no formal report from NIAO or Grant Thornton at the meeting. 7

8 7.0 REPORT ON INCIDENTS OF THEFT / FRAUD AND WHISTLEBLOWING AND NFI MATCHES Members received, for consideration a report on Incidents of Theft/Fraud and Whistleblowing since the last meeting held on 12 October 2015 together with an update report on NFI Matches. Members noted that there were no new incidents of whistleblowing reported via the BSO hotline since the previous update. The Trust has received one indirectly via the HSCB and is currently considering the action required. A report will be made at the next Audit Committee meeting in this regard. It was also noted that there were no new incidents of theft or fraud reported since the last meeting; an update was provided on all open cases. With regard to NFI matches, Mr Morgan reported that this issue will be taken forward by Shared Services in the future and he will update members on progress at the next meeting. PM 8.0 REQUEST FOR A CLOSED MEETING Mr Trethowan invited members to declare any requests for a closed meeting. None were received and the business of the meeting proceeded. 9.0 ANY OTHER BUSINESS 9.1 Compliments of the Season Mr Trethowan concluded the meeting by wishing all members a Happy Christmas and best wishes for DATE AND VENUE OF NEXT MEETING It was agreed that the next meeting should be held on Thursday 4 February 2016 at 12 noon in the Boardroom, Trust Headquarters, Ulster Hospital. IL Minutes Audit Committee 3 Dec