Poole Hospital NHS Foundation Trust Report template

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1 Report template Audit and Governance Committee Meeting Date of meeting: 11/11/2015 Chairman: Jean Lang Deloitte Audit Plan 2015/2016 Internal Audit Progress Report Risk Register new reds and amber risks Annual review of Standing Financial Instructions SIRO Information Governance Report Register of Authorisation of Tenders Losses & Special Payments Register by exception Re-audit of Clinical and Non- Clinical Policies Policy on use of External Auditors for non-audit reports Audit Notification Monitor Reference Cost Assurance Situation Change of internal audit plan Background At request of Committee Internal audit had been asked to revise their plan to address an issue raised through the Governors (clinical coding) and to carry out further work on IT after an audit report of only limited assurance Assessment Consideration was given to the two issues raised and whether they should replace other topics ie Regulatory Compliance and Excluded Drug and Device Cost Monitoring Recommendation To accept the changes proposed N/A 1. The Director of Finance will schedule an annual IT Investment Strategy Review which will go to FIC and the Board and check the Energy Performance Contract is also part of the annual review process. 2. The level of Fraud Training (85%) across the Trust will be reviewed as part of Mandatory training by the Workforce and OD Committee. 3. Metrics to be reviewed that are being reported to the CCG and Unify that are not currently covered as part of the DQAF process. Internal Audit to pick up as part of next year s Data Quality Audit.

2 4. Non-executive Directors to contact performance manager and pick an area of data collection and follow the data stream process to end product for their information. 5. The drug fridge temperature processes will be reviewed as part of an audit in quarter The Director of Finance will confirm the timing of property valuations. 7. The Director of Nursing to provide a verbal update at the next meeting in relation to the satellite site bowel screening risk on the risk register. 8. The Internal Audit Report will be circulated to Board members. 9. The revised SFI s will come to March s Audit and Governance Committee with tracked changes included. 10. The Director of Finance to send a copy of the current SFIs to Mr Green. 11. The Director of Finance to confirm the term ADO in the Register of Authorisations of Tender report. 12. The Director of Finance will include a waiver pro forma as part of the next Register of Authorisations of Tender Report. 13. The definitions section in the Policy on the Use of External Auditors for Non-Audit Services will read..other than the audit of financial statements and Quality Accounts within the Annual Report. 14. Thanks to be sent to Mr Plant for his work as the Trust s LCFS.

3 Report Title Finance and Investment Committee Meeting Date of meeting: 23/11/2105 Chairman: Ian Marshall Financial Report Capex Report Debtors Medical agency staff costs Supplier payments Domestic services contract retendering Electronic Prescribing Medicines Admininistration update Monitor monthly return 1. Financial performances still on budget but dependent on managing key issues including: contract income; agency costs; level of winter activity / investment; CIP. 2. Capital expenditure a number of capex slippages; The Director of Finance is keen to tighten reporting. NB: Monitor looking to take advantage from slippages. 3. IT a slippage on projects due to delayed approvals and shortage of infrastructure staff. We need to be closer to project progress; project prioritisation and reason for delays. 4. EPMA project delayed by complex approvals; it will be important to have a clear project structure. N/A Management of IT may be an issue Actions arising from the meeting: 1. The Director of Finance to provide the committee with an update on the Trust s I&E position in December s meeting. 2. A brief report outlining the potential fines/penalties from the CCG to come to the next meeting. 3. A brief outline of overruns on non-pay to come to the next meeting. 4. A report outlining the issues with the ITSLA will come to the next meeting. 5. A realistic estimate of IT projects and managing the implications of a reduced IT programme will be reviewed as part of the ITSLA review in February. 6. Confirmation of capital expenditure, slippage etc. for the next few years will be picked up as part of the budget setting process. 7. All members to confirm that they are able to attend the Finance and Investment Committee meeting on Monday 18 April The EPMA clinical team will come to the committee once the Trust is ready to implement the new system a project lead is to be identified.

4 Report template Quality, Safety and Performance Committee Date of meeting: 23Nov 15 Chairman: Dr Calum McArthur Medicine Governance, Management and Optimisation Update CD Update Prescribing Errors EM Directorate Quality CQC Preparedness Update Annual NICE Compliance Annual Clinical Audit Management of Pressure Ulcers Management of Sharps & dermatitis Maternity Women s Experience of Maternity Care 2015 Survey Results National Hip Fracture annual report 2015 Review BAF and Risks Relating to Quality and Safety IPR SIR SIR 6 Monthly Complaints Good progress on a range of pharmacy issues despite 30 % vacancy in Pharmacy. Action plan in place to deal with various CD issues and prescribing errors. Chf Pharmacist working on a Pharmacy dashboard. To be in place by Dec? Will be included in IPR. EM Quality report reassuring. Main issue staff shortages: ED down 8 WTE RNs, Ansty down 4 WTE RNs; 7 th consultant post gapped; 2.5 wte middle grades left and not replaced (no suitable applicants0; 1 x SHO off sick. Excellent compliance with NICE guidelines. Good progress in meeting recommendations made in Dr Kirkup s report on maternity services. Good results in National Maternity Survey Very good standards achieved in National Hip Fracture Database Nos of complaints declining. 87 this quarter; 102 for same quarter last year. Positive impact from merging PALS and complaints process. Clinical audit annual Report 2014/15 noted. Useful information for all directorates. Updated QSP Committee Governance Cycle approved Pharmacy dashboard being developed One new risk in Q2 relating to delayed reporting of CT and MRI scans. Situation now improved.

5 New, improved SIR policy noted. A new template (Learning Panel Report) has been developed to enhance and share learning from incidents. 1. The Medicines Optimisation dashboard will be completed and relevant sections will be included in the IPR. 2. The Medicines Governance, Management and Optimisation report will be added to the governance cycle as a regular report. 3. Data relating to Controlled Drug incidents by ward should be included in future Ward to Board reports. 4. The Medical Director proposed that wards should publish their controlled drug incidents for staff to see. 5. Medicines Optimisation to be included in the Quality Account. 6. The directorate Quarterly Quality Reports to include more info relating to mortality and info relating to workforce. 7. The Chief Operating Officer to visit Maternity and review the delivery suite. This relates to a risk which is on the risk register. 8. The mortality rates relating to the National Hip Fracture Database Annual Report are currently unavailable and will be included as an exception report in a future IPR. 9. The National Hip Fracture Database Annual Report needs to be received as part of the Quarterly Performance Reviews for Quarter A report to come to January s Board detailing a Trauma and Orthopaedic action plan relating to the NOF (Fracture Neck of Femur) target the Chief Operating Officer will take into account a wider context of performance indicators. 11. The will be updated to reflect improvements in CT/MR reporting 12. An update on stroke services performance will come back through an exception report in the next IPR. 13. Future QSPC meetings to receive all Serious Incident Reports reported to the Board. 14. A 6 monthly mortality report to come to the committee to be added to governance cycle

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