How To Write An Audit Committee Report

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1 WEST HERTFORDSHIRE HOSPITALS NHS TRUST AUDIT COMMITTEE Minutes of the Audit Committee Meeting held on 14 November 2013 West Herts Meeting Room Watford General Hospital Chair: Present: In attendance Sarah Connor (SC), Non Executive Director Phil Townsend (PT), Non Executive Director Robin Douglas (RD), Non Executive Director Malcolm Dennett (MD), Interim Director of Finance Clare Stafford (CS), Deputy Director of Finance Dr Mike Van Der Watt (MVDW), Medical Director Amy Thorpe (AT), Grant Thornton Greg Rubins (GR), BDO Antony Tiernan (AT), Director of Corporate Affairs and Communications Georgia Denegri (GD), Interim Trust Secretary Page 1 of 6

2 MEETING MINUTES 1. Chairman s Introduction 1.1 SC welcomed everyone to the meeting 2. Apologies for absence 2.1 None were received 3. Declarations of Interest Action Who When 3.1 There were no new interests declared other than those previously recorded in the Trust register. 4. Minutes Of The Audit Committees Held On (a) 10 September 2013 (b) revised minutes of 16 May (a) The minutes of the meeting held on 10 September 2013 were approved as a true record subject to a comment that PT had passed to CS. 4.2 (b) The revised minutes of the meeting held on 16 May minutes were approved as a true record. 5. Action Logs 5.1 The Committee considered a report on historic outstanding actions from 2012 and agreed that all actions except those relating to the waiver arrangements can be closed. The outstanding actions relating to the waiver would remain open in view of ongoing concerns. 5.2 The Committee further considered the action log for the meeting (arising from the meeting held on 18 July 2013) and agreed: Minutes of May meeting: actions were complete. To be removed from action log. Previous action logs: A report consolidating all outstanding actions was on the agenda. To be removed from action log. Clinical Audit: Scheduled on the agenda. To be removed for action log. Losses and compensation report Standing item and future reports to have analysis of what has been agreed year to date with an annual overview at year end. To remain on action log to ensure continuity. Salary Overpayments: Internal audit would look at this as part of the payroll audit. To be Page 2 of 6

3 removed from action log. Gifts and Hospitality Register: All actions complete. To be removed from action log. Audit Committee Annual Report: Action complete. To be removed from action log. Terms of Reference: The Committee agreed its Terms of Reference and these would be scheduled on the Board agenda for approval. To be removed from the action log. Care Quality Commission Report exception reporting verbally at future meetings. Action ongoing. To remain on action log for continuity. Performance Measure Report (Internal Audit) follow up report on actions to be scheduled at forthcoming meeting. To remain on action log. Counter fraud plan. Complete. To be removed from action log. Overdue recommendations. Scheduled on the agenda. To be removed from action log. Annual Work Programme. To be scheduled on Board agenda together with the Committee s Terms of Reference. To be removed from action log. 6. Terms Of Reference 6.1 The Committee considered its revised draft Terms of Reference (ToR) prior to their approval by the Board. The following further comments and amendments were noted: The format of the ToR of all the Committees would be reviewed to ensure that it is consistent. Paragraph 4.1: Frequency of attendance will increase to 70% in line with the requirement of the Foundation Trust Code of Governance reflecting best practice. Paragraph 4.3: To be deleted (duplication with paragraph 4.4). 7. Patient Safety and Risk Committee feedback on items for Audit Committee attention 7.1 MVDW updated the Committee about a possible never event which was being looked into. He further reported four elevated risks relating to: orthopaedics; concerns with staff training, lack of staff awareness of the whistleblowing policy; and Georgia Denegri March 2014 Page 3 of 6

4 an incident with a cardiologist. 8. CQC Registration update 8.2 MVDW introduced the report which updated the Committee on the new inspection approach of the Care Quality Commission. 8.3 The Committee noted the report. 9. Clinical Audit 9.1 MVDW informed the Committee that a new Assistant Director (AD) for Clinical Audit started in the beginning of November with immediate priority to develop a centralised system for logging all clinical audits. An internal audit on the clinical audit processes was scheduled for the beginning of the new year and would be brought to the committee on completion. 9.2 RD commended the swift progress. 9.3 The Committee noted the report. 10. Board Assurance Framework (BAF) 10.1 The Committee acknowledged that the BAF was not fit for purpose. A new interim Assistant Director for Quality and Risk was starting the following week with immediate priority to look into the risk management arrangements across the Trust. At this stage no assurance could be provided to the Board with regard to the appropriate escalation of risks from the divisional risk registers PT updated the Committee on the work of the Risk Summit and commented that all major risks both clinical and non clinical - had been identified and were being monitored closely by the Executive team. He further noted that the Clinical Commissioning Group (CCG) and the NHS Trust Development Authority (TDA) were aware of the outcomes of the Risk Summits. A structured approach for reviewing risk management across the Trust was required. 11. Finance Update 11.1 MD updated the Committee on the approach for developing the 2014/15 annual plan due for final submission in the beginning of March. Meetings with the CCG and the TDA were scheduled for the forthcoming weeks. A Board development session was also scheduled at the end of February to give Page 4 of 6

5 the opportunity to the Board to discuss the annual plan The Committee noted the update. 12. Losses and Compensation Register 12.1 The report was noted. 13. Waiver Register 13.1 Following on from discussion at the previous meeting, the Committee felt that stronger controls should be put in place. The Committee further noted that it was agreed that the waiver register is a standing item on the agenda and that in addition the committee will receive an annual summary and report at May meetings, with context to whether the position was acceptable and in line with practice elsewhere The report was noted. 14. Gifts And Hospitality 14.1 In light of discussion at the previous meeting, the Register of Gifts and Hospitality had been updated with a notional amount for daily conference rates provided by the Medical Director. MVDW further added that many doctors are obliged to attend conferences The report was noted. 15. Internal Audit Report and LCFS progress Report 15.1 The Committee noted the progress update from the internal auditors and the timeline for completion of the internal audits under way. 16. Internal Audit Follow Up of Recommendations report 16.1 The Committee noted the number of outstanding recommendations yet to be delivered and asked BDO to provide a report detailing which actions could be closed and which required further follow up. 17. External Audit Report 17.1 The Committee discussed and noted the external auditors progress update. Internal Audit January Audit Committee Annual Report 2012/13 Page 5 of 6

6 18.1 SC introduced the report. The Committee discussed at length its effectiveness, with PT and RD expressing their concern that the Committee was in a position to provide assurance to the Board that the internal control systems are fit for purpose as stated in the conclusion and recommendation of the report. 19. Annual Work Programme 19.1 The Committee s work programme had been revised following discussion at the previous meeting. The Committee noted its forward work programme. 20. Any Other Business 20.1 SC said that this was her and RD s last meeting. She wished to thank RD for his support and wished every success to the new auditors and staff. 21. Date of Next Meeting 21.1 The next meeting of the Audit Committee will be on 16 January 2014, at 11.00, in the West Herts Meeting Room, Watford General Hospital. Page 6 of 6