GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

Transcription

1 GLOUCEERSHIRE HOSPITALS NHS FOUNDATION TRU MINUTES OF THE AUDIT COMMITTEE HELD IN THE MEETING ROOM, No 2 COLLEGE LAWN, CHELTENHAM ON TUESDAY 3 RD APRIL 2012 THESE MINUTES MAY BE MADE AVAILABLE TO THE PUBLIC AND PERSONS OUTSIDE OF THE TRU AS PART OF THE TRU S COMPLIANCE WITH THE FREEDOM OF INFORMATION ACT 2000 PRESENT (Members) Mr Mike Evans ME Chairman and Non-Executive Director Mr Clive Lewis CL Non-Executive Director IN ATTENDANCE (By invitation) Mrs Sarah Truelove Director of Finance Mr Simon Cookson SC Price Waterhouse Coopers, Internal Audit Mr John Golding JG Grant Thornton (GT), External Audit Ms Julie Masci JM Grant Thornton (GT), External Audit Mrs Sallie Cheung SCh Local Counter Fraud Specialist Mr Paul Edwards PE Governor, Appointed, NHS Herefordshire Prof Chris Dunn CD Governor, Public, Stroud District Mrs Hilary Millington Personal Assistant to Director of Finance APOLOGIES Mrs Helen Munro HM Non-Executive Director Mr Peter Stephenson PS Price Waterhouse Coopers (PWC), Internal Audit Mr Andrew Seaton AS Director of Safety Mr Andrew Collis AC Trust Secretary 01/12 Apologies were received from HM, AS, AC and PS. The Chair allowed SCh to present her Local Counter Fraud reports first as she had another meeting to attend ACTION 02/12 MINUTES OF THE MEETING HELD ON 7 FEBRUARY 2012 The minutes were agreed as a correct record. 03/12 MATTERS ARISING See Matters Arising paper. 04/12 LOCAL COUNTER FRAUD SERVICE COUNTER FRAUD REPORT SCh presented the regular quarterly report asking the Committee to tear out page 3 of Appendix 2 which should not have been included in the Committee papers. Appendix 1 Additional Paid Sessions:- All managers are involved in checking to ensure there are no duplicate claims for paid sessions for FWI (Funding Waiting Initiative) and APS (Additional Paid Sessions). No staff had been paid for sessions twice. There had been a surge in the number of referrals to the Counter Fraud Service since the beginning of this year. SC agreed that numbers seemed to have increased in all Trusts. ME asked for any questions PE expressed his surprise at how long staff Audit Committee Minutes Page 1 of 7

2 took to put in payment claims, making it easier to duplicate claims. SCh reported that finding duplications had to be done manually by going back into the archives; staff were supposed to send their claims in regularly. ME asked to speak to DS to see if this situation could be improved. explained to the Committee that a company had been appointed to look into duplicate claims on a no-win, no-fee basis and nothing had been found over the last 5 years. Recommendations:- ME commented that he was surprised that managers had not acted upon Counter Fraud s recommendations from last year. SCh reported that she hadn t raised this issue at a higher level. ME commented that it was unacceptable for recommendations once accepted to then not be implemented. ME agreed that in future managers may be asked to attend the Audit Committee if recommendations had not been implemented (depending on the circumstances). Appendix 3 Bribery Act 2011 Risk Assessment:- SCh reported that she would be presenting to the Main Board in April. COUNTER FRAUD ANNUAL REPORT SCh tabled the annual report, making the following points:- Item 1.2 Counter Fraud activity these figures were to be updated. Item 2.5 Detection Over 7.5k had been recovered from the National Fraud Initiative There were some queries over next year which SCh would talk over with. SCh/ The Committee noted the Progress Report, was happy with the Action Plan and agreed the Annual Report. SCh left the meeting at this point. 05/12 EXTERNAL AUDIT INTERIM AUDIT REPORT JG introduced the Interim Audit Report which looked at the Trust s financial systems and the outcome of that work. JM reported that there were some risk areas to be updated at the Final Accounts stage and this would be reported at the next meeting. The Trust was forecasting a breakeven between income and expenditure. There were some specific accounting issues re the multi-storey car park it was a PFI scheme so transactions have to be accurately reported in the accounts as per Monitor s Annual Reporting Manual. Restatement entries there was a change in accounting policy set out by HM Treasury; GT will review the accounting treatment of government grants and donated assets. Results of Interim audit work key areas JM reported GT had looked at the Internal Audit function. They carried out a full review every 3 years with an update every year. This year they had completed a full review and were satisfied that good arrangements had been maintained. GT was happy with the closedown timetable for final accounts with GT starting their audit on 2. Property, Plant and Equipment JM reported that the Trust had commissioned the District Valuer to undertake a desk top revaluation exercise of its assets for the final accounts. Any assets which are to be sold must be classified correctly in the final accounts. Audit Committee Minutes Page 2 of 7

3 Pharmacy Stock position. GT had attended an inventory count at CGH Pharmacy which had raised a number of issues. A selection of random samples of 20 items had included 12 discontinued items, leaving only 8 for checking (these were very small in value). A full count on 24 th March revealed that initial reservations were unfounded. However, JM will report back to the Committee. CD agreed it was difficult to keep accurate counts on low value, high volume drugs but would not expect this to be the case for expensive drugs. He also commented that drugs from different suppliers had used different codes which could cause duplication in counting. ME commented that there had been a problem last year with the reporting. Discussion confirmed that the Head of Pharmacy had overall responsibility and there must be a sound process / system; Audit Committee would await their follow up report in May and review the findings closely. ME reported that the basic systems and control of Pharmacy was important particularly with regard to controlled drugs. Appendix B General overall IT control Password Complexity this recommendation had taken time to implement. This had now been agreed and would be put in place over the next couple of months. Database Management this recommendation was looking at alternatives to see who was logging into the system. GT was keeping a close eye on this. IT Security this was to be updated. Network intrusion detection and prevention GT had recommended a regular third party testing to prevent intrusion. explained to PE that the Trust provided IT services to the PCT and 2gether Trust. It had been agreed to run a pilot for single sign on. The pilot had been successful and was now being rolled out. Once this was in place increased password complexity will be introduced. ME commented that GT s report evaluating Internal Audit formally was very useful for the Audit Committee and vitally in confirming quality of this important service. commented that since Zack Pandor, Countywide Director for IT, had been recruited he had positively been taking things forward and IT had settled down. ME commented on Leaver s Checklist IT was now receiving regular report from HR, so the recommendation was complete. 06/12 INTERNAL AUDIT 2011/12 INTERNAL AUDIT PROGRESS REPORT SC presented the progress report, apologising for the mistake in the numbering on page 4 (numbers 6 and 12 were missing). He commented on the following:- Risk Management & Governance this review was now complete and the report would be with the Trust by Tuesday 10 th April. IT Strategy this review had now been completed and the report would be issued for the May Audit Committee meeting. Ward Rostering this review was in draft at present. Clinical Audit this review was being undertaken later this month. Audit Committee Minutes Page 3 of 7

4 SELF CERTIFICATION REVIEW SC presented the Self Certification Review and was pleased and very impressed to report a low risk assurance on this report; the Trust had implemented all the recommendations from the last review conducted in 2009 by Deloitte. It was a very difficult area and subject to change. Monitor was putting more emphasis on Self Certification and may introduce a more formal process. ME was very pleased with the result. SC commented that Monitor has to trust the Non executives (NEDs). ME commented that much NED challenge and resolution of issues takes place outside of the meetings which would not be reported in meeting minutes. SC commented that resolution of issues should be reflected in minutes; informal discussions should be recorded formally at some point. The key for NEDs is if there is a cause for concern then it should be brought into formal meetings. ME would mention this to inform NEDs. ME WINTER PLANNING REVIEW SC presented the report which was classified as Medium risk. He had discussed the review with Gloucestershire Care Services (GCS) and found that the process was working pretty well. Four issues were raised:- Daily conference calls were held and recorded between GHNHSFT and GCS it was not always clear what the pressure level was nor the agreed actions Evidence was not available to demonstrate that the Trust Management Board is monitoring and implementing actions within the Winter Plan The Trust s internal escalation plan does not match the escalation plan monitored by the Bed Management Team Follow up work will be done next year to monitor each organisation in relation to times of high pressure. ME thanked SC for the report; it was a difficult time. commented that although it had been a mild winter there had been a lot of patients suffering from Norovirus. ME reported that the Board was aware of the report and that the escalation process is there, added that the escalation plan needed regular review. 07/12 UPDATE ON THE SETTLEMENT OF OUTANDING DEBT WITH NHS BODIES presented the report which was a follow up from the first report last year. Generally the Trust has made good progress in settling debt. However, there remain some outstanding issues with Wales. reported a significantly lower NHS debt this year. The Trust had been working with the Commissioner, NHS Glos and GCS and the overall contract sum has been agreed for 2011/12. JG commented that the Welsh Health Board will not accept debt unless the activity has previously been agreed. reported that she had recently met with a cancer specialist regarding this and some real ethical problems had arisen. Audit Committee Minutes Page 4 of 7

5 PAYMENT BY RESULTS DATA ASSURANCE FRAMEWORK AND FOLLOW UP presented the report to the Audit Committee for completeness. This work was carried out for NHS Gloucestershire and looked at Inpatients, Outpatients and Reference Costs. The recommendations of the report are being picked up by Service Line Reporting (SLR) project. The report deals with coding and accounting issues and shows good clinical engagement regarding coding. SC commented that there was no such thing as no errors on coding, keeping it under review is acceptable. CD asked about the Medium and High priorities in the Recommendations in Appendix 1 of the Follow Up Report. responded that the Team Leader did not have the formal qualification but was taking the exam in March. Other members of the team are qualified. was happy that other arrangements were in place to ensure good cover; this situation did not give her any concerns. 08/12 ITEMS FOR THE RISK REGIER The Committee agreed that they needed to see the result of GT s final report on the Pharmacy stock position. This might be an item for the Risk Register although JM s initial review suggested it would not be an issue. reported that she had asked SC to review stock control in theatres. 09/12 ANNUAL REPORT OF THE AUDIT COMMITTEE FOR THE YEAR 2011/12 ME presented the report, commenting that he thought that it reflected well on the Committee s work. He asked to have a look at the spacing. 10/12 SELF ASSESSMENT CHECKLI presented the Checklists, explaining that they were to ensure that people understood the work of the Audit Committee. ME commented that it was a fairly good result. ME went through the Nos and Don t knows with the Committee:- Has the Committee formally assessed whether there is a need for the support of a Company Secretary role or its equivalent? This had been discussed in December The Committee agreed that it was not formally assessed but to stick with the existing arrangements. Do the Terms of Reference adequately specify the relationship between the Head of Internal Audit and the Audit Committee? SC reported that this had been looked into before and addressed. Are the key principles of the terms of reference set out in the Standing Financial Instructions? reported that she thought so but would check. Are any scope restrictions placed on Internal Audit and, if so, what are they and who establishes them? SC responded that he would tell the Committee if there were. Does the Committee hold periodic private discussions with the Head of Internal Audit Audit Committee Minutes Page 5 of 7

6 SC responded that this happens at every meeting. Are members, particularly those new to the Committee provided with training? ME reported that they don t actually provide training. CL reported that had kindly helped him and he had attended an external course on finance. CD had received an from the FT which he would have another look at. SC and JG offered to tailor a presentation to the Governors and NEDs after the September Audit Committee meeting; would also present on the role of Governors and Governance of the Trust. offered to ask SCh whether she could do a presentation on Counter Fraud. to arrange extended meeting. Has the Committee established a process whereby it reviews any material objection to the plans and associated assignments that cannot be resolved through negotiation? SC responded that it would be included in their reports. Are changes to the Committee s current and future workload discussed and approved at Board level? ME responded No, but if there was a problem then initially he would talk to the Chair. Has the Committee formally considered how it integrates with other committees that are reviewing risk e.g. risk management and clinical governance? ME responded that AS is on the Committee to ensure this is covered. Has the Committee formally considered how its work integrates with wider performance management and standards compliance? ME responded that the Audit Committee and Finance & Performance Committee operate independently. Has the Committee reviewed whether the reports it receives are timely and have the right format and content to ensure its internal control and risk management responsibilities are discharged? ME responded that the Committee does that every time. Has the Committee determined the appropriate level of detail it wishes to receive from Internal Audit? ME responded Yes, through draft and final reports Does the Committee review the effectiveness of Internal Audit and the adequacy of staffing and resources within Internal Audit? ME responded that he is not sure that the Audit Committee does, but it is not an issue. A meeting with would be the appropriate place for discussion. JG reviews this every 3 years anyway. ME and to have another look at the Self Assessment Checklist to review the questions. CD SC & JG ME/ 11/12 AUDIT COMMITTEE WORKPLAN 2012 ME noted that FH was attending the next Audit Committee meeting re Annual Governance Statement (previously named the Statement of Internal Control). to amend. JG reported a potential problem re timing for the Quality Accounts report in May. ME responded that he was not too worried about this. Amendment required for October column, meeting rearranged for 21 st September. 12/12 ANY OTHER BUSINESS There was none. Audit Committee Minutes Page 6 of 7

7 OPPORTUNITY FOR DISCUSSION BETWEEN AUDIT COMMITTEE MEMBERS AND EXTERNAL / INTERNAL AUDITORS All others left the meeting at this point. 13/12 DATE OF THE NEXT MEETING The next meeting will be held on Friday 25 th May 2012 at 2.00 pm in the Boardroom, 1 College Lawn, Cheltenham Further meetings Friday 21 st September at 9.15 am in the Boardroom, 1 College Lawn, Cheltenham, extended by 1 ½ hours for presentations by, JG, SC and possibly SCh for the Governors and NEDs and All involved Audit Committee Minutes Page 7 of 7