SOMERSET PARTNERSHIP NHS FOUNDATION TRUST RATIFED MINUTES OF THE AUDIT COMMITTEE MEETING HELD ON 15 OCTOBER 2014

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1 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST RATIFED MINUTES OF THE AUDIT COMMITTEE MEETING HELD ON 15 OCTOBER 2014 Report to the Trust Board 24 March 2015 Sponsoring Director: Author: Purpose of the report: Director of Finance and Business Development/Director of Governance and Corporate Development/Chairman of the Audit Committee. Secretary to the Trust. The purpose of the report is to present the ratified minutes of the Audit Committee meeting held on 15 October 2014 to the Board for information. Key Issues and Recommendations: the report set out the discussions held at the Audit Committee meeting held on 15 October 2014; particular issues discussed were: Counter Fraud work plan for 2014/15; concluding counter fraud report relating to an allegation of working for another organisation whilst in receipt of sick pay from the Trust; concluding counter fraud report relating to non payment of out of date and excess toners; patient fraud counter fraud report relating to prescription charges; progress report on the implementation of counter fraud audit recommendations; internal audit 2014/15 progress report; estates strategy audit report; progress report on the implementation of internal audit recommendations; March 2015 Public Board - 1

2 2014/15 external audit progress report; report on A Safer NHS The Evolving Focus on Governance in the NHS ; Information Commissioners Audit Report; 2014/15 Assurance Framework; review of the effectiveness of the Audit Committee; review of the effectiveness of Internal Audit services; review of the effectiveness of external audit services; review of the effectiveness of counter fraud services; Terms of Reference progress report; losses and special payments report; hospitality and sponsorship report. The Committee identified a risk in relation to the late completion of audit recommendations and agreed that Executive Directors will be invited to attend Audit Committee meetings if recommendations are not completed by the target date. The Committee did not identify any lessons learned. The Committee reviewed the Terms of Reference and approved the change in the number of Non-Executive Director members from five to four to take account of the reduction in the number of Non-Executive Directors from 1 December These changes were approved at the January 2015 Confidential Board meeting. Actions required by the Board: The Board is asked to note the ratified minutes of the Audit Committee meeting held on 15 October March 2015 Public Board - 2

3 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST MINUTES OF THE AUDIT COMMITTEE MEETING HELD ON 15 OCTOBER 2014 AT FOUNDATION HOUSE, CHEDDON ROAD, TAUNTON PRESENT: Jane Townson Non-Executive Director (Chair) Tim Guernsey Non-Executive Director Roger Powell Non-Executive Director Judith Newman Non-Executive Director IN ATTENDANCE: Ian Davies Price Waterhouse Coopers Greg Rubins BDO (from item 4) Andy Knight Dorset and Somerset Counter Fraud Service Phil Brice Director of Governance and Corporate Development Pippa Moger Director of Finance and Business Development Ria Zandvliet Secretary to the Trust 1. APOLOGIES There were no apologies. 2. DECLARATION OF INTERESTS RELATING TO ITEMS ON THE AGENDA There were no declarations of interests relating to items on the agenda. 3. MINUTES OF MEETING HELD ON 3 JULY 2014 The minutes of the meeting held on 3 July 2014 were approved as a true and accurate record. Roger Powell proposed, Tim Guernsey seconded and the Audit Committee approved the minutes of the meeting held on 3 July COUNTER FRAUD UPDATE Workplan 2014/15 Andy Knight provided an overview of the progress made against the 2014/15 Counter Fraud Workplan and highlighted progress in relation to the strategic governance, inform and involve, prevent and deter, and hold to account areas. March 2015 Public Board - 3

4 It was noted that good progress was being made and one of the three pro-active exercises in relation to overtime payments and expenses claims had been completed. The Counter Fraud Service had received three fraud referrals, one of which was not deemed to be a fraud matter and the findings of the other two referrals were included on the agenda as separate reports. In relation to Op Maddox, the allegation of altering agency timesheets had been raised by the Head of Medical Services and the investigation had concluded that the timesheets had been fraudulently altered after they had been signed. It was noted that the Locum Consultant Psychiatrist was no longer working for the Trust at the time the fraud had been identified. As the Trust had withheld payment of the agency invoices pending the investigation, the loss of 15, was carried by the locum s agency. The Audit Committee agreed that timesheets once signed should not be handed back to agency staff and noted that the process had been amended. The Audit Committee agreed that this investigation clearly showed that processes to identify fraud were in place and functioned well. Greg Rubins joined the meeting. The investigation into a specific care home had not progressed as sufficient information had not yet been submitted by the Trust. It was noted that this related to an out of area placement and the Out of Area Panel was aware of the concerns. Concluding Report Op MADLYN Andy Knight advised that this investigation related to an allegation that a member of staff may have been working whilst in receipt of sick pay from the Trust. The investigation concluded that the allegation of fraud could not be substantiated, however, the employee s contract with the Trust had been terminated due to a failure to provide sick certificates or engage with or respond to the Trust in relation to the sickness absence. Concluding Report Op MADARA Andy Knight advised that this investigation related to non payment for out of date and excess toners collected from the Trust. The value of the toners was 300 and Pippa Moger advised that in view of the low value, the recommendation to seek redress through the civil courts will not be taken forward. Pippa Moger advised that the toners concerned were no longer compatible with the current printers. A new print contract was March 2015 Public Board - 4

5 being procured and as part of this contract, the supplier will take the responsibility for toners. Patient Fraud Report Follow Up Review Andy Knight advised that a review of the Trust s response to patient fraud had been undertaken in 2013 and a follow up review had been undertaken in The recommendation in relation to prescription charges had not been implemented and patients attending Minor Injury Units were not routinely asked whether they were exempt from prescription charges and patients who were eligible to pay prescription charges were not routinely issued with promissory notes. Andy Knight advised that on occasions when patients had been issued with a promissory note, the relevant prescription charge had been recovered. Pippa Moger advised that the prescription charge issue had been followed up with the Heads of Services and guidance had been placed in all Minor Injury Units. A local compliance audit will be undertaken at Bridgwater Minor Injury Unit in January Phil Brice advised that the recommendation in relation to the identification of an overseas visitors manager had been implemented. Andrew Sinclair had been identified as the lead manager and guidance had been issued to staff. Pippa Moger advised that a large part of the services provided by the Trust were exempt from charges and the number of overseas visitors to whom charges applied was very small. Counter Fraud Recommendation Tracker The Audit Committee discussed the recommendation tracker and commented/noted that: recommendation one travel expenses this recommendation had been completed; recommendation two Managing Absence Policy the policy will be presented to the Senior Managers Operational Group meeting on 20 November 2014 for ratification and this recommendation will then be completed; recommendation five integration of the Bank, Agency and Locum Policy the approval of the integrated policy had been delayed due to further changes required to take account of the Safer Staffing requirements. The review of the policy was scheduled to be completed by 31 December It was queried why it had taken a long time for recommendations two and five to be implemented and it was March 2015 Public Board - 5

6 noted that implementation had been delayed due to the need to take account of national changes and legal implications and in addition, the policy approval process required consultation with staff side; recommendation one prescription charges progress had been already discussed; recommendation three travel expenses a follow up audit will be undertaken in 2014/15; recommendation four travel expenses the overpayments to three members of staff will be followed up by the Human Resources and Workforce Development Directorate on an individual basis; recommendation two concluding investigation report this recommendation had now been completed. 5. BDO INTERNAL AUDIT REPORT 2014/15 Progress Report Greg Rubins presented the progress report and advised that the estates strategy had been finalised and included on the agenda as a separate report. The Human Resources audit report had been issued in draft and this report provided moderate assurance. The full report will be presented to the January 2015 Audit Committee meeting. The Committee noted that the majority of the audits were scheduled towards the end of 2014/15. In relation to the follow up audit, it was noted that the implementation of the recommendations was reviewed on an ongoing basis but a follow up audit report will be issued later in the financial year. Greg Rubins advised that the business development audit was scheduled for December 2014 and the focus of this audit will be on contract management. Estates Strategy Audit Report Greg Rubins presented the report and advised that the report provided moderate assurance for both design and effectiveness. One high priority, three medium priority and two low priority recommendations had been made and the recommendations related to the linking of individual objectives to the Trust s strategic objectives; the lack of an overarching annual estates plan to show the individual actions to be achieved in the current financial year; the completion of the Protect Initiation Document prior to the March 2015 Public Board - 6

7 approval of the business case; and the need to clarify the roles of the different estates groups. Jane Townson advised that it had been difficult to link the Five Year Estate Strategy to the overall strategy due to national changes and policies. The Committee noted that the estate strategy will be reviewed on an annual basis to take account of any strategic changes. Internal Audit Recommendation Tracker Greg Rubins presented the recommendation tracker and advised that six of the 17 recommendations had been assessed as having been implemented. Six recommendations had been partially implemented and the implementation of these recommendations will be further reviewed in January 2015 to ensure that processes were embedded. Five recommendations had not yet been implemented. Some delays were felt to have been due to the target dates being set at unrealistic timescales. The Committee discussed the recommendations and commented/ noted that: cost improvement programmes (one, two) - the cost improvement programmes presented to the Board included lead Directors for each of the cost improvement programmes and progress was reported to the operational finance and performance group meetings. The Committee agreed that progress was being monitored. It was agreed to amend the target dates to April Pippa Moger commented that it was not expected that individual project plans will need to be developed for every cost improvement programme and a balanced view will need to be taken. The Integration Phase 2 cost improvement programme will be the overarching cost improvement programme from 2015/16 onwards and a three year integration phase 2 cost improvement programme will be developed by the IP2 Project Board. This will be accompanied by robust project plans on how the savings will be achieved; cost improvement programmes (three) performance management strategy this recommendation could be implemented at an earlier stage as it was not dependent on the 2015/16 cost improvement programmes; overall it was felt that the progress reported should be more detailed and should reflect the actions taken; March 2015 Public Board - 7

8 recommendation four was a duplication from recommendation two and should be removed; recommendation five payroll the manual checking of payslips will continue until the electronic rostering system has been put in place. The electronic rostering system will be rolled out to all inpatient areas by 30 November 2014 and to all other area by 31 March It was agreed to amend the target date to April 2015; recommendation six sickness absence the Human Resources Directorate identified teams with the highest level of sickness and worked with these teams to identify and address specific issues. However, the recommendation related more to sharing best practice from teams with low levels of sickness. It was queried whether the Board should be provided with information relating to sickness hot spots and actions taken to address any areas of high sickness, but it was felt that it was not the role of the Board to consider detailed information. In terms of monitoring sickness, monthly reports were presented to the Senior Managers Operational Group meetings. In relation to the specific recommendation, the Audit Committee should be provided with evidence that the recommendation has been implemented and that best practice data was being shared. The Audit Committee agreed that robust sickness monitoring systems were in place but that more information on the sharing of best practice should be included in the quarterly human resources and workforce development report to the Board. Greg Rubins agreed to liaise with Andre Frullo in relation to the data to be included in the quarterly Board report; Greg Rubins was asked to include the dates of the audit reports in the recommendation tracker; recommendation seven/eight medicines management a report had been presented to a recent Executive Team meeting and an action plan will be developed. The Audit Committee agreed that if these recommendations were not implemented by January 2015, Andrew Dayani will be invited to attend the January 2015 Audit Committee meeting; recommendation nine cost improvement programme - the residual issues in relation to the sign off of all budgets will be resolved by 31 January There had been some delay due to budgetary issues in relation to the ILT service and these will be resolved by 30 November 2014; March 2015 Public Board - 8

9 recommendation ten sickness absence the ratification process for the integrated sickness absence policy will be completed by 31 January The Audit Committee commented that not all overdue recommendations had been included on the audit log and the log also did not include recommendations not yet due, even though some of these may have been completed before the due date.. Greg Rubins advised that some overdue recommendations had not been included in the audit log for this meeting as recommendations were grouped by subject rather than included as individual recommendations based solely on their due date and these recommendations will be included on the audit log for the January 2015 Audit Committee meeting. Including all recommendations would make the audit log unmanageable and would have resource implications. Greg Rubins advised that internal audit did not have any major concerns about the implementation of recommendations in general and the Trust compared well with other organisations. Pippa Moger confirmed that when audits were completed, Directors did identify their recommendations and monitored progress on an ongoing basis, and this included progress on recommendations not yet due. The Audit Committee agreed that it was important to take a balanced view as to the information to be included in the audit log. As Judith Newman will be taking on the chairmanship of the Audit Committee from 1 November 2014, the Committee asked Judith Newman to discuss the audit log process with Pippa Moger, Phil Brice and internal audit. The Audit Committee stressed that the lead Directors should be setting realistic target dates, but if a date had been agreed with internal audit, it was the lead Director s responsibility to ensure that the recommendations were implemented within the timescale agreed. The relevant Director will in future be requested to attend the Audit Committee meeting to provide an explanation as to the reasons for any delay in implementing recommendations. 6. EXTERNAL AUDIT REPORT Progress Report Ian Davies presented the progress report and advised that the annual accounts audit will be undertaken in line with the NHS Foundation Trust Annual Reporting Manuel (ARM), statutory and other relevant requirements. Monitor was currently consulting on a number of changes to the Reporting Manual and the key change related to enhanced audit reporting, which required a statement to March 2015 Public Board - 9

10 be included in the accounts whether the Trust had adopted the NHS Foundation Trust Code of Governance on a comply or explain basis. External audit were looking at the implications of this additional requirement on the audit process. Possible implications were an increased audit fee and additional audit time. The audit plan will be produced as soon as the additional requirements had been clarified. A Safer NHS The Evolving Focus on Governance in the NHS Ian Davies presented the report which had been included for information. Phil Brice advised that the report had not identified any issues which had not already been identified by the Trust and which were being taken forward. This included feedback from patients and staff. Phil Brice agreed to present the report to a future Integrated Governance Committee meeting for discussion. In relation to commissioning an external review of governance arrangements, this could be carried out in a number of different ways, including Peer Review, and options were being considered. It was noted that the review will be carried out in 2015/ INFORMATION COMMISSIONERS REPORT Phil Brice presented the findings of the Data Protection audit report conducted by the Information Commissioner s Office and advised that the audit had been undertaken on a voluntary consensual basis. The audit was undertaken over a three day period and included visits to a mental health inpatient ward, community hospital and community team. The audit process had been positive and helpful in terms of sharing best practice. The audit concluded that there was reasonable assurance that processes and procedures were in place and that they delivered data protection compliance. The audit identified one limited and two reasonable assurance assessments where controls could be enhanced to reduce the risk of non compliance. The areas for improvement related to the storage, disposal and transfer of paper records; regular updating of the Information Asset Register; consideration of data protection risks when commencing new projects; and third party processing of personal data on behalf of the Trust. March 2015 Public Board - 10

11 In relation to paper records, the longer term solution was the roll out of the electronic patient record system (RiO) to all community services. Phil Brice advised that an action plan had been developed and the dates for implementing the recommendations have been agreed with the Information Commissioner s Office. The implementation of some of the recommendations had been delayed due to internal capacity issues. The action plan will be presented to the October 2014 Caldicott and Information Governance meeting and will be represented to the Information Commissioner s Office in April The Audit Committee discussed the report and agreed with the recommendation that patient records should not be kept indefinitely. Phil Brice advised that patient records were held for a specified number of years in accordance with the national records retention schedule. The Audit Committee queried what actions were being taken in relation to cross shredders and noted that a confidential waste procurement process was currently being undertaken which will address the cross shredder issues. The Audit Committee agreed that the audit report provided positive assurance to the Committee /15 ASSURANCE FRAMEWORK Phil Brice presented the 2014/15 Assurance Framework and advised that all risks had been grouped under the Five Year Plan s Strategic Themes and Strategic Objectives and the objectives for 2014/15 and provided a clear link to the strategic goals and Business Action Plan. It was noted that the Assurance Framework had been presented to the September 2014 Integrated Governance Committee and Roger Powell advised that the Integrated Governance Committee was assured that the Assurance Framework took account of internal audit s recommendations in relation to clear risk identification and actions. The Audit Committee discussed the Assurance Framework and commented/noted that: the value of the dental contract set out on page four should read 3 million ; March 2015 Public Board - 11

12 the Assurance Framework had been cross referenced and was consistent with the Business Action Plan and the plan on a page ; a Associate Director of Commercial and Business Development will be recruited and this post had been approved by the Executive Team; the residual risk for the business development risk still showed as red as the Trust only had limited control over this risk and the mitigating actions it could take as these related largely to the actions of other organisations and this remained a high risk to the organisation; the Trust had received notification from the Clinical Commissioning Group about the services they were potentially intending to put out to tender in 2015/16 and a review of these services was being undertaken by the Trust; cultural diagnostic approach it was felt that further assurance was required in relation to the findings from the pulse survey. Phil Brice advised that the pulse survey was being rolled out to staff on a phased basis and all staff will be given the opportunity to complete the survey. The feedback from the quarter one data was positive but was from a small number of staff and by December 2014 a higher percentage of staff will have been able to provide feedback. 9. AUDIT COMMITTEE REVIEW OF EFFECTIVENESS The Audit Committee carried out the annual self assessment based on the HFMA s Self Assessment Checklist. The Committee discussed the check list and noted that: changes to the Committee s current and future workload were discussed and approved at Board level Stephen Ladyman had undertaken a review of the Board Committees and their Terms of Reference in 2014 and the revised Terms of References had been approved by the Board. The Committee agreed that any significant changes to the workload would be highlighted to the Board as part of the submission of the minutes to the Board; new members were offered appropriate induction it was noted that Barbara Clift had attended the HFMA finance and audit two day course; March 2015 Public Board - 12

13 Audit Committee members having sufficient knowledge of the organisation s business to identify key risk areas the Committee agreed that current members met this criteria. In relation to new members joining the Audit Committee, it was recognised that new members would require a period of learning; the robustness and content of the draft Statement on Internal Control was reviewed prior to it being presented to the Board; internal audit plan - it was queried how involved the Chairman of the Audit Committee was in deciding the scope of audits as i.e. the focus of the business development audit will be on contract management and it was queried whether the scope of the audit should be decided by the Audit Committee. Pippa Moger advised that the scope of the business development audit had been set out in the internal audit plan approved by the Audit Committee. Greg Rubins commented that it was not expected that the Audit Committee or Chairman of the Audit Committee would be involved in deciding the scope for all audits. In relation to the approval of the internal audit plan, the Audit Committee reviewed and approved the internal audit plan at the beginning of the financial year. If any new risks were identified after the internal audit plan had been agreed, there was sufficient flexibility to amend the plan in year; the Committee has not established a process for reviewing any material objections to the plan that cannot be resolved through negotiation as there had been no requirement for this process. If required a process will be developed; performance against key performance indicators was included in the internal audit progress report. Feedback reports from audits had not yet been presented to the Audit Committee, but it was noted that feedback was included in the progress reports. The individual feedback forms will be presented to the Audit Committee; in relation to quality assurance procedures to ensure that the work of the internal auditors was properly planned, completed, supervised and reviewed - progress against the internal audit plan was reviewed at every meeting. The internal audit tendering process had been undertaken on a community wide basis and quality assurance procedures had been part of that process. Additional assurance was March 2015 Public Board - 13

14 received through external audit as they relied on the work of internal audit when conducting the annual accounts audit; the Committee had not reviewed the nature and value of non audit work carried out by the external auditors as no non audit work had been carried out. Ian Davies confirmed that if any such work had been carried out this would be reported through the annual audit report; the Committee had received a detailed update on the clinical audit process at its September 2014 meeting and felt assured that proper clinical audit processes were in place and that the Clinical and Social Care Effectiveness Group reported into the Clinical Governance Group, which in turn reported to the Integrated Governance Committee; reviewing of draft annual accounts the Committee did not review the draft accounts prior to the external annual accounts audit being undertaken due to the tight timescales; the Committee did not receive and review the evidence required to demonstrate fitness to register with the Care Quality Commission as this was within the scope of the Integrated Governance Committee. If required the Audit Committee will receive a report from the Integrated Governance Committee. The Audit Committee agreed that it was compliant with the check list for all other areas not set out above. Greg Rubins commented that the Audit Committee met the criteria well but there was scope for improvement in relation to the value for money aspect of the Audit Committee. The Audit Committee sometimes tended to focus on small elements of audit reports and it was important to stand back from those small issues and focus on particularly large issues. 10. INTERNAL AUDIT REVIEW OF EFFECTIVENESS Greg Rubins, Ian Davies and Andy Knight left the meeting. The Committee carried out the review of effectiveness as part of a confidential session and it was agreed that Judith Newman, as the Chairman of the Audit Committee from 1 November 2014, will arrange to meet with internal auditors (and Pippa Moger) to provide feedback. March 2015 Public Board - 14

15 11. EXTERNAL AUDIT REVIEW OF EFFECTIVENESS AND EXTERNAL AUDIT CONTRACT The Committee carried out the review of effectiveness as part of a confidential session and it was agreed that Judith Newman, as the Chairman of the Audit Committee from 1 November 2014, will arrange to meet with external auditors (and Pippa Moger) to provide feedback. 12. COUNTER FRAUD REVIEW OF EFFECTIVENESS The Committee carried out the review of effectiveness as part of a confidential session and it was agreed that Judith Newman, as the Chairman of the Audit Committee from 1 November 2014, will arrange to meet with the counter fraud service (and Pippa Moger) to provide feedback. Greg Rubins, Ian Davies and Andy Knight rejoined the meeting and were informed that individual feedback will be provided outside of the meeting. 13. TERMS OF REFERENCE PROGRESS REPORT The Audit Committee had agreed to use its Terms of References as the Committee s work programme and the progress made had been highlighted in the Terms of Reference progress report. The Audit Committee discussed the Terms of Reference and agreed that the report accurately reflected the progress made. The Audit Committee reviewed the Terms of Reference and approved the change in the number of Non-Executive Director members from five to four to take account of the reduction in the number of Non-Executive Directors from 1 December The Audit Committee agreed that the quorum of three Non- Executive Directors should remain unchanged. 14. LOSSES AND SPECIAL PAYMENTS Hilary Corcoran presented the summary of losses and special payments report. The format of the report had been amended to set out the number of losses and special payments and value by subject. The Audit Committee noted the report. March 2015 Public Board - 15

16 15. HOSPITALITY/SPONSORSHIP REGISTER Hilary Corcoran presented the hospitality/sponsorship register and highlighted the two entries on the register. The Audit Committee noted the report. 16. MATTERS ARISING Internal Audit Examples of Good Practice of Partnership Working Greg Rubins advised that the BDO s advisory team had been asked to advise him when examples of good practice become available. Patient and Public Involvement benchmarking information Phil Brice advised that Rachael Tomlinson had provided some benchmarking information. Safeguarding Training The names of the four individuals who had not undertaken level one safeguarding training had been passed on to Andre Frullo. 17. RISKS IDENTIFIED AND LESSONS LEARNED The Audit Committee identified a risk in relation to the late completion of audit recommendations. Phil Brice agreed to follow this up with the Executive Team and to advise that lead Directors will be asked to attend the Audit Committee meeting if recommendations were not completed by the target date. Lessons Learned The Audit Committee did not identify any lessons learned. 18. ANY OTHER BUSINESS Jane Townson advised that this was her last Audit Committee meeting and wished all well for the future. Judith Newman thanked both Jane Townson and Tim Guernsey for their significant contributions to the work of the Audit Committee and the wider governance agenda. 19. DATE AND TIME OF NEXT MEETING The dates for 2015 were confirmed as follows: Wednesday 15 April 2015 Wednesday 27 May 2015 (annual accounts) Wednesday 1 July 2015 (Foundation House) (Room 4, BCH) (Room 4, BCH) March 2015 Public Board - 16

17 Wednesday 14 October 2015 Wednesday 13 January 2016 Wednesday 20 April 2016 (Foundation House) (Foundation House) (Foundation House) 20. INFORMAL SESSION FOR AUDITORS/NON-EXECUTIVE DIRECTORS March 2015 Public Board - 17

18 Links to Strategic Themes: Identify to which of the Somerset Partnership NHS Foundation Trust strategic themes this report relates by including a cross behind the relevant theme(s) Quality and Safety X Innovation X Viability and Growth X Integration X Service Delivery X Culture and People X Links to the Assurance Framework: Links to the NHS Constitution and Trust Values: Links to CQC Domains: Identify to which risks of the Assurance Framework this report relates strong governance processes support all the areas of the Assurance Framework. Identify the Values to which the issues raised in this report relate by including a cross behind the relevant value(s) Working together for X Compassion X patients Respect and dignity X Improving lives X Commitment to quality of care X Everyone counts Identify which of the CQC domains are covered by this report by including a cross behind the relevant domain(s) X Is it safe? X Is it caring? X Is it well-led? X Is it effective? X Is it responsive to people s needs? X Legal or statutory implications/ requirements: Public/Staff Involvement History: Previous Consideration: under its terms of authorisation and Monitor s compliance framework the Trust is required to ensure the existence of appropriate arrangements to provide representative and comprehensive governance in accordance with the Act. not applicable. the minutes of the Audit Committee meetings are presented to the Board after every Audit Committee meeting. March 2015 Public Board - 18

19 March 2015 Public Board - 19 O