Agenda Item Significant Issues of Interest to the Board

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1 Audit Committee Chair s Report Public Board Presented for: Presented by: Author: List of meeting dates 28 May 2015 Information Caroline Johnstone, Chair of Audit Committee Caroline Johnstone, Chair of Audit Committee 7 May 2015 Trust Goals The best for patient safety, quality and experience The best place to work A centre for excellence for research, education and innovation Seamless integrated care across organisational boundaries Financial sustainability Key points 1. To provide an overview of significant issues of interest to the Board, highlight key risks discussed, key decisions taken and key actions agreed. For information 1

2 1. Introduction The audit committee ( AC ) has met twice since the last Board meeting in March On 7 May 2015, our major item of business was in reviewing annual governance reports and an overview of the Trust s Risk Assurance Framework. I note key points below. On 27 May 2015, we will meet to review the annual accounts and audit thereof for the year ended 31 March I will report orally to the Board on this meeting. 2. Significant Issues of Interest to the Board Annual governance documents o Standards of business conduct reporting gifts and hospitality. Significant progress and over 2,000 declarations (compared to 200 last year). AC to review declarations regularly. o Data governance the AC has focused on this over the past two years and this is the first report of its kind. It is a huge step forward for the Trust and board members should review a summary of all the many datasets and reports which go outside the Trust. We now have a much improved understanding, clarity of purpose and are implementing controls but there is still work to do on the many ad hoc systems and processes which had been allowed to develop. We will review progress on this regularly. o Counter Fraud very low level of reported cases. The AC will undertake a review of this work in the coming year. We will look for the plan to be fully aligned to key fraud risks. o Head of Internal Audit s opinion no issues for the board - see comments below on internal audit. o Annual Governance Statement we commended the team on a very comprehensive document and we asked the team to confirm all factual statements. We suggested that further reference to the financial challenges be added to the statement. o The Board should review and agree an up to date risk appetite statement. Annual accounts: o No major issues reported by auditors (full and final review 27 May 2015) o Auditors will make reference and reports will reflect the Trust s deficit position and projections as well as immaterial (less than 1,000) payments made outwith terms of contracts o Two members of the AC undertook a more detailed review of accounts with the team outside the formal AC meetings o Year end reporting and audit moving in line with plan 2

3 3. Key Risks Discussed Reviewed the Risk Assurance Framework interacts with the Risk Register in managing risk across the Trust. We were impressed with the progress but challenged if the level of detail in both documents might inhibit its day to day use. Also, to review weighting of controls in assessing the level of assurance on which were effective. Internal audit ( IA ) reports and plans. We challenged the number of high assurance reports and the team will benchmark this going forward. We also encouraged the IA team to align its planning to the risks and objectives of the Trust and to develop a longer term (typically 3 year) audit plan. We also reflected on the scope and overall cost of the IA plan, given the financial challenges of the Trust. Losses and compensations report we need to do more work around non NHS income and debt collection. 4. Key Decisions Taken Reviewed the AC annual report and agreed to revise certain statements having reflected on other reports to the meeting. 5. Agreed Key Actions Replacement to Bryan Gill on the committee required To interact with Quality Committee in reviewing success of Leeds Institute of Quality Healthcare (LIQH) Others see above 6. Future Business Review of Risk Assurance Framework Review of specific risks Overview of governance arrangements with new arrangements in place We are considering an overview of private work undertaken across the Trust 7. Recommendation The Board is asked to receive and note the Report. Name of Committee Chair: Caroline Johnstone Committee Name: Audit Date paper written: 17 May

4 Audit Committee 7 May 2015 Draft Minutes Present: In attendance: Observer: Apologies: Caroline Johnstone Non-Executive Director (Chair) Allison Page Non-Executive Director Jo Bray Trust Board Secretary Craig Brigg Director of Quality Head of Internal Audit Julian Hartley - Chief Executive (from item 3.1) Phil Jones - Grant Thornton Paul Moore - Consultant Risk Manager Perminder Sethi Grant Thornton Melanie Simmonds Associate Director of Finance (representing Tony Whitfield) Andy Thomas - Director of Informatics (item 5.1) Lucy Riach - Executive Support Officer Nadeem Hussein - Graduate Management Trainee - Finance Carl Chambers - Non-Executive Director Tony Whitfield - Director of Finance 0.1 Head of Internal Audit There was a private meeting with Members and the External Auditors. 1 Standing Items 1.1 Welcome and Introductions; Apologies for Absence; Declarations of Interest Apologies for absence were received from Carl Chambers and Tony Whitfield who it was noted had been invited to sit on a national Board, chaired by Lord Carter to address procurement and efficiency across the NHS. Caroline Johnstone noted that Bryan Gill had not yet been replaced as an attendee of the Committee and reminded the Committee of the benefit of having this operational perspective she noted that this was in hand with the executive team. There were no declarations of interest. 4

5 The meeting was quorate. 1.2 Patient and Clinical Focus: Director of Quality Briefing Craig Brigg, making reference to his briefing to the last meeting, explained more about the agreement with the local CCGs to continue to address CQUINs without additional levies within the contract agreed for 2015/16 (as a result of the tariff option chosen by LTHT). He reported that there were national CQUINs for 2015/16 for sepsis and acute kidney injury, and noted that these were likely to be carried forward into future years. He explained more about the programmes of work and confirmed that some of these would be addressed in the Leeds Institute of Quality Healthcare (LIQH) that involved collaborative work with partners in health and social care. This included pathways relating to heart disease, chronic chest disease (COPD), fractured neck of femur, and three additional pathways introduced in 2014/15 focusing on cancer, diabetes and dementia. Craig Brigg made reference to his recent attendance at the annual LIQH conference with partner organisations, the aim of which was to review achievements to date to improve quality and productivity with pan-city solutions for the specific care pathways identified. Craig Brigg, responding to a question raised by Caroline Johnstone, confirmed that assurance on progress regarding the LIQH work programme would be addressed through the Quality Assurance Committee and Quality Management group. Caroline Johnstone requested that this be re-visited by the Audit Committee in the autumn; Craig Brigg would include this in the Director of Quality briefing at this time. Caroline Johnstone & In concluding his update, Craig Brigg confirmed the Trust had received no recent visits from the CQC, but had received some specific communications regarding individual patient or family concerns involving individual wards. These had been investigated and concluded with the CQC in line with the processes in place. He advised the Committee of the CQC recent publications following Hospital Inspection visits to Leeds Community Healthcare NHS Trust, which had received an overall rating of requires improvement. The Trust had sent a representative to the Quality Summit that had been arranged before publication of the report. 1.3 Draft Minutes of Last Meeting held on 11 March 2015 Page 7 item 3.3, final sentence of the second paragraph which read; She challenged Paul Moore in continuing the development that had been made and was keen to see further progress. 5

6 To be amended to read; She challenged the whole Board and Executive Team in continuing the development that had been made and was keen to see further progress. Caroline Johnstone asked Jo Bray to review the minutes further to ensure that there was clarity in the record to distinguish comments made by herself as the Committee Chair and those of the Trust Chair. With the above amendments the minutes of the last meeting were confirmed as an accurate record. 1.4 Matters Arising and Review of Action Tracker: Standards for Business Conduct Policy Items from the Tracker Item 11 Policy for external auditors carrying out non-audit work - Caroline Johnstone requested that follow this up to confirm if the Trust did need such a policy, and if so to confirm when one could be written, and requested that this action be resolved by the next meeting. Item 16 Revalidation of Datix system with regard to content and recording of risk Caroline Johnstone enquired if the system was fit for purpose. Paul Moore confirmed the progress that had taken place. Information could now be reported out of the Datix system and it was agreed that this action was completed and could be removed from the tracker. Items 39, 53, 54 all were to do with aspects of consultant private practice Caroline Johnstone reported that she had discussed with the Trust Chair and agreed to define the scope of a review which would look into and provide greater understanding of consultants carrying out private practice. Caroline Johnstone and Craig Brigg agreed to discuss this further with Dr Yvette Oade for the report to be brought to the July meeting. Item 70 Risk appetite discussion to be held with the full Board Caroline Johnstone reported that this was not addressed at the recent Board timeout meeting and asked Paul Moore to discuss with Julian Hartley and report back to the Committee. Jo Bray Caroline Johnstone, Craig Brigg and Dr Yvette Oade Paul Moore Item 75 Critical plant failure review at the May Audit Committee meeting Paul Moore reported that this was to be discussed further at the Risk Management Committee (RMC) that afternoon, with the recommendation that this be downgraded, thus it was agreed to remove from the tracker. Post meeting note the RMC supported the downgrade of this risk to a score of 8 to be recommended to the May Board meeting. 6

7 Standards for Business Conduct Policy Jo Bray highlighted from the paper the actions that had taken place to amend the policy (which had been discussed and approved at the December 2014 Audit Committee meeting) by the Executive Team. This was supported by the Committee. She was pleased to report that as a result of the implementation of the new online system, supported by a number of Trust wide key communication messages, there had been a significant increase in the number of declarations made to date. A total of 2,468 had been received nil and positive declarations compared to 286 positive declarations made at the same point in the previous financial year. She reported that these were still being received as a result of ongoing communication messages to encourage year end declarations. Caroline Johnstone commented positively about the simplicity of the system when making her own declaration and commended the work that had taken place. It was agreed that a report on the number and details of declarations would be received by the Audit Committee in September and March. Jo Bray & Responding to a question from Perminder Sethi, Jo Bray confirmed that the ownership of this would be with the triumvirate management teams of the CSUs, as the new system would support the production of quarterly reports on compliance by CSU for greater scrutiny which was now defined in the policy. 2 Briefings 2.1 Chair of the Audit Committee Caroline Johnstone provided an outline of the Committee and Board meetings she had attended since the last Audit Committee meeting. She made reference to the recent meeting where she and Carl Chambers had reviewed the draft year-end accounts in some detail. 2.2 Director of Finance Mel Simmonds reported positively about the new style Finance & Performance Committee meeting that had been held the previous week. She made reference to the draft procurement strategy that had been reviewed and linked this to the national work that Tony Whitfield was contributing to, which aimed to address savings to procurement and efficiency across the NHS. In responding to Caroline Johnstone, she explained that good progress been made in preparing the year-end accounts and that the final financial plan for 2015/16 would be submitted to the TDA the following week within the specified deadline. 3 Strategic Risk and Governance 7

8 3.1 Strategic Risk Area: Framework of Assurance (Standing Item) Andy Thomas and Julian Hartley joined the meeting. Caroline Johnstone provided an introduction to the discussion referring to the various mechanisms the Trust now has to manage risk - the Risk Assurance Framework (RAF), the Corporate Risk Register (CRR) and the role of the Risk Management Committee (RMC). She concluded by reflecting that the role of Audit Committee was to provide an overview of the effectiveness of the whole process. Paul Moore supported the summary from Caroline Johnstone adding that the RAF was intended to provide a greater understanding of the effectiveness of the controls and the three lines of defence and was built upon the information within the CRR, based on a number of facets; Board objectives, controls and effectiveness. He explained the role of the RMC was to challenge the mitigation of risks and reflected that the role of the Audit Committee was to review the effectiveness of the risk management process, and to question if this was under a level of control that was acceptable for the Trust. He concluded that the document aimed to summarise this. Caroline Johnstone noted the helpful content of the RAF document but reflected on the detailed information in the full document and some duplication between the RAF and the CRR. In responding to her question, Paul Moore confirmed that there was no current weighting associated to the controls. Julian Hartley reflected on paediatric congenital screening, noting that half the controls had been effective in addressing this risk where the effective controls would be much more important than those controls that were not yet effective and reported that he did see the benefits of weighting the controls. Mel Simmonds also supported the discussion reflecting on delivery of the financial plan as controls were in place to deliver the year-end results, and supported the benefits of weighting these controls. It was agreed that weighting of controls would be an important consideration moving forward. Paul Moore confirmed that if 100% of the control was effective, then the objective would be achieved. Caroline Johnstone reflected that in developing this further she would call on some of the Executive team to attend the Audit Committee to test out its use and effectiveness. She asked to note and plan the invitation to the Committee. Caroline Johnstone & Paul Moore confirmed that the full document would be refreshed half way through the year and reported to the September Audit Committee and at the year-end to support the development of the AGS. Caroline Johnstone commended the RAF, however questioned if the Executive Team were using 8

9 this document and noted its benefits and further refinement. She supported the proposed biannual reporting of the full document with the overview summary to be presented at each meeting. The Audit Committee received and noted the information set out within the RAF to support the assurance outlined in the framework for 2014/15. 4 Audit and Counter Fraud 4.1 Grant Thornton: External Audit Progress Report Perminder Sethi provided a verbal update on the year-end work of the External Auditors in reviewing the accounts for 2014/15. Making reference to Section 19 of the Audit Commission Act and the required report to Secretary of State, he outlined they would provide an except for opinion as the statement against value for money. He highlighted they would report the Trust is forecasting a deficit for the next three years, however did have detailed plans to address this. He also reported that a payment issue would be noted and that members of the Audit Committee had been fully briefed on this in their private discussion at the start of the meeting. Post meeting note The Trust Chair had met with the External Auditors, regarding payments received by Non-Executive Directors to fulfil the requirement for lay representation to Chair of consultant interview panels. Grant Thornton had deemed the sum of ( 875) to be immaterial and noted this had been declared to the chair of the TDA, and there was no additional cost to the Trust. Perminder Sethi reported he understood the uncertainties for the Trust (in common with other NHS bodies) regarding projections for 2017/18 and confirmed the auditors would require to review the latest projections as part of the year-end process. Mel Simmonds highlighted the Trust had submitted a five year plan to the TDA but explained more about the uncertainties about (for example) the tariff moving forward into 2017/18. Perminder Sethi confirmed to Caroline Johnstone there was good support and compliance with the finance team. 4.2 Grant Thornton: Benchmarking your annual report Perminder Sethi explained the context to the report, as Grant Thornton had benchmarked some 200 Annual Reports from CCGs, Foundation Trusts and Non-Foundation Trusts. The report summarised the best practice in 2014 annual reports and compared LTHT with its peers. It was confirmed that the benchmarking was against the annual report for 2013/14 and Jo Bray confirmed she had met with Perminder Sethi in March and had reflected this feedback into the production of the current annual report for 2014/15. Caroline 9

10 Johnstone confirmed she had also reflected on this when reviewing an early draft of the annual report for 2014/15. A discussion focussed on the summary of benchmarking outlined on page 12 of the report, highlighting areas the Trust had reported perhaps less than other peer trusts in It was noted that in most areas, the Trust was either in line or ahead of its peers in reporting in Caroline Johnstone requested; Mel Simmonds to ensure the published annual report has appropriate commentary around the preparation of the annual accounts on a going concern basis. Caroline Johnstone and Jo Bray would consider the extract from the full audit committee report which is inserted into the published annual report as in previous years this extract did not include reference to the audit committee undertaking an annual assessment of its own effectiveness. It was noted that this assessment is indeed undertaken and reported in the full report of the audit committee to the board. A one page summary which cross-referenced the areas that were not addressed within the Annual Report for 2013/14 be addressed in the current 2014/15 Annual Report. Mel Simmonds Caroline Johnstone & Jo Bray Jo Bray The Audit Committee received and noted the Trust positon in the Grant Thornton report for benchmarking the 2013/14 Annual Report. 4.3 Emerging Issues and Developments highlighted in External Audit Reports Mel Simmonds highlighted the report was for information and summarised external emerging issues and developments. Caroline Johnstone noted this would be reported to each Audit Committee moving forward. This report was received and noted by the Committee. 4.4 Internal Audit Progress Report The report described the Internal Audit activities from 1 March to 17 April Audit reports issued; one with full assurance and five with significant assurance. confirmed that the draft reports issues had been confirmed; one with full assurance and a further five with significant assurance. There was a debate about the terminology used to grade levels of assurance in other public sector organisations, noting the use of Substantial Assurance and Moderate Assurance as descriptions. A wider discussion highlighted the four defined categories within the guidelines for the NHS; Full Assurance, Significant Assurance, Limited Assurance and No Assurance and the 10

11 interpretation of these. Mel Simmonds reflected on her own experience noted she had seen few reports stating full assurance within other Trusts. Paul Moore noted that providing Limited Assurance was good for progression and learning. Allison Page suggested that this document would benefit from the definitions being added to provide greater understanding. It was noted that the Internal Audit team were currently benchmarking work in this area and would report to the July meeting. The discussion moved on to reflect that the Audit Plan should be more overtly aligned to the risks identified in the Trust, as this would support the Trust with more learning opportunities. The Committee received and noted the Internal Audit Progress report and noted the level of assurance provided, as described within the report. 4.5 Internal Audit Strategic and Annual Plans at detailed level The report was re-presented to the Committee with more detail within the appendices to provide greater level of detail for consideration. reported that he would seek further consultation on the plan with a wider audience as described within the report. Caroline Johnstone questioned the alignment with the Trust Annual Plan, Corporate Objectives and the CRR to ensure that Internal Audit was focusing on the biggest risk areas. There was a wider discussion relating to the number of days of work by the Internal Audit Team set out in the programme, noting the productivity challenge for the whole Trust. Caroline Johnstone enquired if the team would consider what could be done differently and wanted to discuss this further at the Audit Committee meeting in July and she suggested that the work plan might include greater consideration to the people agenda, for instance the quality of appraisals. updated the Committee on his recent discussions with Dean Royles to address aspects of HR within the work plan of Internal Audit. Paul Moore recommended the benefits of a longer term planning, thus moving from an annual plan to a three year cycle and Andy Thomas suggested the advantages of less audits but with greater detail. The Committee received, noted and approved the detailed plans with the proposed consultation to support the Internal Audit Strategic Annual Plans 2015/16, and were keen to see this develop to cover a three year period as discussed. 11

12 4.6 Mazars: 2015/16 External Audit Fee Planning Letter The letter from Mazars, referring to the Audit Commission s appointment of an External Auditor to the Trust and confirming audit fees for the coming year, was received and noted by the Committee. 5 Annual Governance Reports Annual Data Governance Report Andy Thomas introduced the report which set out to update the Committee on the work during 2014/15 in relation to the Data Governance and Assurance action plan and to report on the current levels of assurance and outline the key actions planned for 2015/16. Andy Thomas noted this was a comprehensive baseline report to the Audit Committee and would want to move to a summary style report moving forward. He set out there was a two year work plan, and the data warehouse was fundamental to underpinning the work plan. He reported the ongoing work with the communication team to better inform the organisation that no data was to be release externally unless it had been screened by IT team and approved by an appropriate executive member. He reported on the information that was to be routinely supplied to the Quality Management Committee. He spoke about the value of benchmarking and the understanding gained from other organisations. He emphasised the drive for internal analysis with support from the IT team and aimed for the reduction of out-sourcing to external organisations for analysis which was currently common practice. Caroline Johnstone reflected how impressed the Committee was with the report and the appendices and congratulated the team. She recommended that this report or a summary be presented to the Board as she felt there was value in a wider understanding of the large volume of external reports and data prepared by the Trust. Andy Thomas recommended a detailed review by the Executive Team which would assess the benefit of the external reporting by the Trust for specific issues within the report and suggested where possible could this be streamlined. Julian Hartley provided more context to the evolution of the supply of data from key clinicians, often to their professional colleges/ societies, which had been used in benchmarking publications and noted the growth of this which may not provide any benefit to the Trust or reported data that the Board would be even sighted on. Andy Thomas & Jo Bray Andy Thomas & Exec Team Paul Moore commended the quality of the report and reported that he was 12

13 already using aspects of the data within his own work. It was agreed that once a year this detailed report would to be represented to the Audit Committee in March with an update report in September and in year the summary would be reviewed by the Quality Management Committee. agreed to update the audit work plan. The Committee received and noted the comprehensive update report on Data Governance and Assurance. Andy Thomas left the meeting. 5.2 Counter Fraud Annual Report The report updated the Audit Committee with details of the anti-fraud, bribery and corruption activities during 2014/15. responded to a question from Caroline Johnstone and confirmed that the costs set out in appendix 2 were a statutory requirement of the annual report. Comments raised during the discussion expressed surprise that there were not a greater number of cases of fraud or bribery, noting the overall size of the Trust. It was highlighted that the Committee had received regular reports from the Local Counter Fraud Specialists but would welcome a presentation from the team and Caroline Johnstone requested that they be added to the work programme. Mel Simmonds suggested that there would be benefits from risk rating specific areas of the Trust that should be addressed within the plan. explained more about the networking that was taking place to understanding more from others Trusts fraud cases. This resulted in a wider discussion to explore the return on the 20,000 investment in the team, Caroline Johnstone perceived this as a low costs and prorata suggested that this may be a low level of investment in contrast to the overall audit days which was supported by Mel Simmonds. Phil Jones noted in his experience the largest three areas of fraud within the NHS were; contracting issues, agency staffing and change of payment details (mandate). Allison Page enquired about the processes of assurances against fraud with agency staffing both at an individual level and corporate level, which was explained in more detail by. Caroline Johnstone reflected on the discussion and the requested further work to define the highest areas of risk within the Trust and wanted to review this during the year. 13

14 The Committee received and noted the Annual Report 2014/15 for anti-fraud, bribery and corruption. 5.3 Internal Audit Annual Report and Head of Internal Audit Opinion Statement The report summarised the Head of Internal Audits Opinion Statement for 2014/15 which reported significant assurance which was described as a generally sound system of internal control, designed to meet the organisation s objectives and that controls are generally being applied consistently. However some weakness in the design and/or inconsistent application of controls put the achievement of particular objectives at risk. drew attention to the improvement in the level assurance provided compared to last year. The Committee discussed the definitions set out in page two of the report and Allison Page gave her advice regarding the interpretation of these definitions. Caroline Johnstone sought confirmation, which was provided from, that three Internal Audit reports were assigned a rating of three triangles was not inconsistent with a statement of significant assurance. In cross referencing to the Annual Governance Statement it was confirmed to Caroline Johnstone that s statement was in keeping with the assurance provided to underpin this governance self-assessment. The Committee received and noted the Head of Internal Audit s Opinion Statement for 2014/15 set out in the Internal Audit Annual Report. 5.4 Annual Governance Statement and Supporting Letters of Representation The Annual Governance Statement (AGS) is a statutory disclosure from the Chief Executive in his role as Accounting Officer of the Trust, to describe the Trust s risk and control framework on behalf of the Board, to support a formal declaration to the regulator, the TDA, within the Annual Report. The draft AGS was presented to the Committee for consideration. Paul Moore explained more context, as described in the cover paper, to the annual letters of declarations from the Chief Executive s direct reports, the Clinical Directors of the CSUs and the Chairs of Committees of the Board. He reported the responses had informed the Chief Executive to draft the content of the AGS and in due course his letter of assurance to the Trust Chair. He noted that Tony Whitfield was yet to supply a letter, as the year-end accounts process needed to be concluded before he could report assurance to the Chief Executive. He also explained that the draft letter of assurance from the Chief Executive to the Trust Chair would be presented to the RMC later in the day 14

15 for endorsement by the Committee. Response letters from the Executive Team were provided to the Committee for information. Julian Hartley reflected the robust approach that had covered both strategic and operational issues during the year which had been debated in full at the Board and the RMC. Caroline Johnstone commended the detail of the draft AGS and enquired if during the process anything had been reported as a surprise. Responding Paul Moore reported there was nothing material or new to the Executive Team. Julian Hartley reflected on the volume of information set out in the returns to the letters of representation which had had a personal impact on him and went on to explain this had helped in reviewing the organisation s objectives. He summarised; one vision, five goals and ten objectives with targets and measurements, the process had helped fine tune the specific objectives for the coming year. Caroline Johnstone enquired if there would be a paper presented by the Executive Team to define a short summary of the objectives for 2015/16 with goals and measurable outcomes for the Board to debate and agree. Julian Hartley provided an overview of the measures that were within the final submission of the annual plan to the TDA, for each of the objectives across the CSUs. Post meeting note information to be discussed at May Board Workshop. Jo Bray Specific detailed points were raised as feedback to the AGS; The wider context of risk management policies was confirmed The statement on mandatory training was confirmed as factually correct The figure for Serious Incidents could be reduced by one to 94 reported in year It was agreed that more context would be provided to the financial plan in section 9.2 The concluding paragraph to improve the description of the stage 4 escalation with the TDA Mel Simmonds and Paul Moore to reflect on section 15 wider discussion regarding the achievement of the financial plan to explain the delivery of the deficit plan The benefit of inclusion of a diagram to describe the Trust governance arrangements would be considered next year 15

16 In concluding the discussion the Committee received and noted the current draft of the AGS and Caroline Johnstone reported she would welcome a further version of the AGS to be presented to the Audit Committee meeting at the end of May and the Board the next day. Paul Moore 5.5 Draft Annual Report The draft Annual Report was considered by the Committee. It was noted that this would be proof read further by the Trust Chair and Chief Executive the following week. Caroline Johnstone commended Jo Bray and the team on the progress to date. Specific comments were noted and would be addressed in the next version of the report. This would be presented to the Board at the end of May for final approval. The Committee received, noted and were assured on progress to date with the drafting of the Trust s annual report. 5.6 Draft Quality Account The draft Quality Account was considered by the Committee. It was noted that this was to be published by 30 June 2015 on NHS Choices website and would be presented to the Board at the end of May. Craig Brigg reported on the oversight by both the Quality Management Committee and the Quality Assurance Committee and the statutory duty of review by the External Auditors. Perminder Sethi responding to a question from Caroline Johnstone confirmed the timeline and information supplied by the Quality Team It was noted that in future revisions to both the Annual Report and the Quality Account cross-referencing would be made by the Communication Team. Julian Hartley drew attention to page 30 of the draft Quality Account which provided and overview of the work that had taken place within the Trust towards improvements in quality and safety. It was suggested that this could be used at the start of the document. Craig Brigg The Committee received, noted and were assured on the progress to date with the drafting of the Trust s Quality Account. 5.7 Audit Committee Annual Report Caroline Johnstone explained that drew attention to the Committee that the Audit Committees Annual Report was in two parts short summary and fuller 16

17 report. It was noted that a review of the effectiveness of the Audit Committee should be included in the short summary included in the Annual Report. Caroline Johnstone Caroline Johnstone invited feedback from Mel Simmonds and Tony Whitfield to the report. Julian Hartley, noting page 4 of the report, supported the concept of reviewing the Trust s risk appetite. He went on to reflect on the RMC and used examples of risks that had been discussed that were common across all CSUs. Caroline Johnstone enquired if there were risks that were small in CSUs but were common across them, as a result of the discussion she agreed to reflect on comments within the report. It was agreed to consider benchmarking the audit committee against other audit committees in the coming year. The Committee received and noted the draft review of the Annual Report. Julian Hartley & Paul Moore Caroline Johnstone & 6 Matters for the Audit Committee 6.1 Losses and Compensations Report The report set out to the Committee the losses and compensation payments made in the year to 31 March Mel Simmonds explained more context to the work that had taken place to improve systems and processes and a cleaning up exercise to clear many very small balances due to the Trust. She provided assurance to the Committee that debt beyond 90 days was recovered using an external agency. Responding to a question raised by Allison Page, Mel Simmonds reported on the success of working with this agency with some positive examples but also noted that this was a relatively new change in practice. The Committee received and noted the report but expected further work in the area of debt management in the coming year. 6.2 Applications for waiver to invite tender / quotations from Contractors not on the Approved Supplier List The report confirmed that there had been no applications for waiver to invite tender/ quotations from contractors not on the approved supplier list. Caroline Johnstone requested that this be explored further and be reported back to the Committee in July. She also wanted assurance that the process 17

18 was understood by key purchasers across the organisation e.g. Andy Thomas and Brettle. The Committee received the report and requested further assurance. 6.3 Record of Use of the Seal The use of the Seal for 2014/15 was set out in a summary report as required by Standing Orders. This was received and noted by the Committee. It was agreed that next year this information would be set out over a three year period to better reflect patterns and trends. Jo Bray 6.4 Nothing to Declare A review of Gifts, Hospitality and Sponsorship Registers. LTH MIAA Partnership report The report was a benchmarking report produced in partnership with LTHT Internal Audit Service and MIAA. This was received and noted by the Committee. Jo Bray commented that the presentation of the categories would be reviewed in producing the compliance at LTHT against the Code of Conduct Policy to be reported at the September Audit Committee meeting. Caroline Johnstone asked for the Committee to view declarations across the Trust on a regular basis going forward. 6.5 Self-Assessment of Audit Committee s Effectiveness using latest Audit Committee Handbook Checklists Caroline Johnstone noted that the process was reported on at the last meeting using the self-assessment of the Audit Committee Effectiveness. She confirmed that she was to hold a meeting with Alison Page and Carl Chambers to discuss this further and would report back to the next meeting. Caroline Johnstone 7 Standing Concluding Items 7.1 Any Other Business There was no other business. 7.2 Round up of the matters to be drawn to the Board s attention by the Chair In the interests of time Caroline Johnstone reflected that she would consider items to be reported to the Board and would invite members to add additional issues at the May Board meeting. 7.3 Workplan and Calendar of Key Events The workplan of the Committee was noted, it had been updated to reflect the new terms of committee reference and would be updated to reflect a number of actions from the meeting. 18

19 7.4 Dates of future meetings: 27 May 2015 (p.m.), 29 July 2015 (Risk Focus) (p.m.), 17 September 2015 (p.m.), 3 December 2015 (a.m.), 6 April 2016 (p.m.) Future dates were noted by the Committee. 19

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