AUDIT & GOVERNANCE COMMITTEE Part 1 Minutes of the meeting held on Thursday 14 January 2010 in the Board Room of Poole Hospital NHS Foundation Trust. Present: Mrs Jean Lang, Chairman (JL) Non-Executive Director Mrs Elizabeth Hall (EH) Non-Executive Director Dame Yvonne Moores (YM) Non-Executive Director Mr Guy Spencer (GS) Non-Executive Director In Attendance: Mr Noel Arnott (NA) Internal Audit Mr Michael Beswick (MB) Company Secretary Mr Dave Griffin (DG) PricewaterhouseCoopers Mr Peter Harvey (PH) Trust Chairman Mr Steve Plant (SP) Counter Fraud Service Mr Greg Rubins (GR) PricewaterhouseCoopers Mr Mark Stabb (MSt) Internal Audit Mrs Sue Sutherland (SS) Chief Executive Mr David Taylor (DT) Director of Finance Mrs Sara Elkin (SE) (Secretary) A&G 01/10 Apologies for Absence Apologies for absence were received from Mr Charles Cunningham and Mr John Knowles. A&G 02/10 Minutes of the Meeting held on 12 November 2009 (Paper A) 104/09 Internal Audit Monitoring Report The last paragraph and action point were corrected to read Mr Stabb. 119/09 Dates and Times of Next Meetings The Chairman noted that the date of the November 2010 meeting had been changed to Thursday 18 November. The minutes were then AGREED as an accurate record of the meeting. A&G 03/10 Matters Arising 102/09 Matters Arising 29/09 Internal Audit Monitoring Report Mrs Sutherland said she had discussed the KSF with the Director of Human Resources and was satisfied that progress was on track. A progress report would be brought to the Committee. Action: SS 1
105/09 Implementation of Internal Audit Recommendations: Summary Report Mr Stabb said he had met with the Director of Operations to discuss data quality assurance following which he was to undertake some follow-up work. He would be looking at some of the targets within the quality framework. Mr Taylor said high risk areas had been covered off. Mr Spencer noted that external incident reviews generally found poor data assurance and said the Trust needed to be sure this had been covered off. 116/09 Minutes of Hospital Executive Committee: September 2009 Minute 163/09 Mrs Sutherland reported there had been one hoist on Sandbanks Ward that was not working, however, the hoist was under warranty so the manufacturers were coming to deal with the problem. In the meantime, patients were being lifted safely with manual hoists. 117/09 Draft Minutes of Infection Control Committee: September & October 2009 Mrs Sutherland said the Infection Control Committee membership was to be reviewed in March. In the meantime, the Committee chairman had written to all members about poor attendance. Mrs Lang noted that one meeting had been cancelled as it had not been quorate. 117/09 Draft Minutes of Risk Management & Safety Committee: September 2009 (Minute 160/09) Mrs Sutherland explained there had been a number of incidents relating to poor handover communication, however, these were now declining. A&G 04/10 Risk Register: New Red and Amber Risks (Paper B) Mrs Sutherland noted there had been three new amber risks added to the Risk Register in November and December 2009: i) Non-compliance with the 4-hour A&E waiting time target: This had been the subject of an exception report to Monitor; performance was now back on track. The national Intensive Support Team had now visited the Trust their report had been received on 13 January; ii) Risk of injury to patients on Portland Ward: A number of recommendations had been put in place, some of which had already been actioned; iii) Ward staffing issue: The controls in place were the best that could be achieved as it was no longer possible to move nursing staff around due to specialist working. However, this was not likely to be a Mr Spencer asked whether the medicines reconciliation issue discussed at the Board of Directors meeting had been added to the Risk Register. Mrs Sutherland explained that the Risk Management & Safety Committee had not yet met to discuss the issue and formally add it to the Register. 2
A&G 05/10 External Audit Progress Report (Paper C) Mr Griffin spoke to the report, noting the following: i) PWC had given an unqualified opinion on the Trust s Charitable Funds; ii) There had been an issue of verifying the balance owed to the hospital and a recommendation had been made in this respect. However, PWC was satisfied that the balance was correct; iii) Monitor was consulting on some important issues which would affect the Trust. These included quality accounts and their external validation, and sustainability. Sustainability in particular was a priority for Monitor. Mr Taylor noted the Trust was well on track regarding carbon emissions and had set its baseline. A&G 06/10 Internal Audit Monitoring Report (Paper D) Mr Stabb spoke to his report, noting the following: Capital Contracts Pre-contract stage i) There had been two significant areas of non-compliance: the Trust had no authorised list of contractors; procedure for opening tenders: Internal Audit had recommended a definitive central location for the receipt of tenders. The Associate Director of Capital was reviewing authorisation limits as these may need updating. Mr Taylor said the Purchasing Department was to organise receipt of all tenders which would be opened by two executive directors in future. He said he was not prepared to recommend changes in authorisation values at present due to the Trust s financial situation. Junior Doctor Rota Monitoring ii) iii) iv) There were a number of factors contributing to non-compliance with EWTD. Internal Audit was to try to propose an early warning system for non-compliance; The legal view was that the Trust would have to pay staff at the same rate until the end of their contract; Diary collection was all manual. The number of diary collection exercises could be increased if conducted electronically this should also improve uptake. The Director of HR was to look into this; v) Diary cards were not monitored and there was no peer review this could be introduced with an electronic system. Mr Taylor noted that an electronic system had just been introduced in anaesthetics. Mrs Sutherland said it was important that managers really understood the system. 3
The Chairman asked Internal Audit to review the system in a year s time. It was agreed this should be undertaken in conjunction with the Royal Bournemouth and Dorset County Hospitals. Mr Taylor noted this would be a big piece of work. Action: Internal Audit Central Alert System Follow Up vi) There had been a significant improvement since the last audit for example, the establishment of an audit trail and the reporting status of alerts. However, alerts were still dispersed and not always robustly managed. The Director of Nursing & Patient Services was to centralise the process through the Risk Management Team and hoped to have this in place by 1 April. Information Governance Toolkit vii) viii) ix) At the time of the audit, just fewer than half the Information Governance policies had been approved. Internal Audit was to provide Mr Taylor with details so he could progress them, especially with regard to making them accessible to staff; In future the Information Committee would receive full reports on Information Governance; There was no detailed action plan in place to improve the Trust s information governance assessment level. Mr Taylor noted there had previously been an Information Governance subcommittee but this had been disbanded once the Trust s information governance scores improved. Contract Agreements x) The main issue had been whether there were SLAs in place rather than reliance on historic agreements. There was no central SLA register. The Deputy Director of Finance had agreed to review all income streams at budget setting to ensure SLAs were in place. Main Accounting System xi) There had been good continuation of controls. However, the sickness absence of the Capital Accountant had impacted on the system there was a need for longer term cover to be arranged. A&G 07/10 Implementation of Internal Audit Recommendations: Summary Report (Paper E) A&G 08/10 Counter Fraud Interim Report (Paper F) Mr Plant spoke to his report, noting the following: i) The Trust had no contract with any agency for the provision of temporary staff so could not enforce the PASA price. He suggested the Trust should consider entering into a multi-agency contract to 4
ii) iii) ensure the National Framework Agreement prices would apply. Mr Taylor said the process of negotiating such a contract would take about 12 months. Mrs Sutherland said he should talk to the Director of HR about using NHS Professionals. Action: DT The Deputy Director of HR was to arrange training for HR staff with the UK Borders Agency in respect of staff/applicants with no right to work in the UK. Document scrutiny was to be centralised within HR; The Bank HCA who had been forging signatures on her timesheets had now been dismissed for gross misconduct - the Finance Department was to recover the overpayment. A series of procedural failures had allowed this fraud to occur, for example, timesheets had not been signed off at the end of each shift. He was to talk to ward sisters about the potential for fraud if procedures were not followed. A&G 09/10 Review of ALE Standards Mr Taylor said he had reviewed the current ALE standards and felt it would not be useful for the Trust to follow these. Mr Rubins said it was unusual for Trusts to undertake ALE once they became a foundation trust. Mr Rubins noted there may be an issue of sustainability and suggested the Committee may want some assurance on this in future. A&G 11/10 Backdated Register of Authorisation of Tenders (Paper H) Mr Taylor said the processes followed for the authorisation of tenders had not been correct. He said he had tried to cover off those that had not been properly authorized processes were now in place to ensure this could not happen again. He said he did not believe managers had been trying to get round the system but had believed that if items had been approved as part of the detail of the capital budget it was not necessary to follow the usual procedure. Mr Taylor said he would bring a report to the committee on those items that were technically beyond his limit so they could be signed off appropriately. Action: DT A&G 12/09 Register of Authorisation of Tenders (Paper I) Mr Taylor said he would confirm there had been no tenders to be entered on the Register since the previous Committee meeting. Action: DT A&G 13/10 Draft Counter Fraud Work Plan 2010/11 (Paper J) The Chairman said she had met with Mr Plant, Mr Taylor and the Head of Dorset and Somerset Counter Fraud Service. She said the LCFS was aware that the Trust wanted some specific work undertaken at Poole instead of following the national template. 5
Mr Plant said the LCFS had retained some items from the template, as they were considered to be worthwhile, but had reduced the number of days to free up time for ad hoc work. The number of investigation days had been increased and 60 days had been allocated for local work. Mt Taylor said the cost would be agreed with Mr Plant after the Plan was agreed and brought to the next Committee meeting. Mr Plant estimated the cost at 29,360 for the 100 days work. Action: SP/DT Mr Taylor said the Trust had been more proactive on counter fraud over the last few years and had consequently detected more cases. Dame Yvonne Moores said the Committee needed to think how to best monitor outcome. The Draft Counter Fraud Work Plan 2010/11 was APPROVED. A&G 14/10 Timeline for Annual Report & Accounts (Paper L) Mr Beswick noted the timeline had been to the Board of Directors and shared with the auditors but was awaiting final confirmation from Monitor. He drew attention to the extraordinary Board meeting to be held on 3 June. The Timeline was NOTED. A&G 15/10 Case Record Tracking (CRT) Update (Paper G) Martyn Penn, Associate Director, attended to present his paper. He explained that the numbers in the attached tables were the number of records returned untracked to the Medical Records Library after being received by the consultant named. He noted: i) The frequency of CRT audits had been increased with a better breakdown of information. The Medical Records Manager was endeavouring to run more audits as they had improved performance; ii) All Bank staff were now CRT trained as part of their induction; iii) Breaches of CRT were highlighted at the Quarterly Performance Reviews; iv) Persistent high offenders were being targeted by the Medical Records Manager; v) It would not be possible to achieve zero due to records being moved out of hours; vi) All staff would be trained to use the new electronic CRT which was to be introduced from April 2010. This would be a much simpler process so should improve CRT rates. The Chairman asked for the CRT Quick Reference Guide to be circulated with the minutes. Action: MP/SE Mr Taylor said he would provide absolute numbers to show the percentage improvement in performance. Action: DT 6
A&G 16/10 Register of Losses and Special Payments (Paper K) A&G 17/10 Notes of Strategic & Corporate Risk Meeting: November 2009 (Paper M) Mr Spencer said the objective of the meeting had been to gain views on how the Trust identified and monitored strategic risk. He said he had been satisfied with outcome of the meeting. Mrs Sutherland said a paper on refreshing the Trust s strategy would be taken to the January meeting of the Board of Directors. The Chairman thanked Mr Spencer for chairing the Strategic & Corporate Risk Meeting. A&G 18/10 Draft Minutes of Hospital Executive Committee: November 2009 (Paper N) Mr Spencer asked about the reference to dermatology being a concern in minute 195/09 (G2). Mrs Sutherland explained that the PCT had failed to reduce the increasing number of dermatology referrals so there were capacity issues for the hospital. In addition, the Care Group had been unable to recruit to a consultant dermatologist post. There was concern about meeting targets and the Trust had given notice to the PCT that it would have to move to a maximum 18-week referral to treatment time. The underlying issue was the level of demand. The Chairman asked about the reference to Newtons work in minute 195/09 (G3). Mrs Sutherland explained that Newtons was a consultancy firm working on a no win, no fee basis looking at theatres and anaesthetics with a view to making savings and releasing capacity. Newtons was very process oriented and had identified some 700k recurrent savings to date. A&G 19/10 Draft Minutes and Minutes of Executive Committees: Academic Committee: November 2009 (Paper O) Dame Yvonne Moores noted the target date of October 2010 for the Trust to achieve university status. Cancer Committee: November 2009 (Paper P) Clinical Governance Committee: December 2009 (Paper Q) The Chairman asked about Matching Michigan in minute 97/09. Mrs Sutherland explained that this was a global project that set standards for patients in intensive care, for example incidence of pneumonia in ventilated patients. The Trust was using Matching Michigan in preference to the NHS South West system. 7
The Chairman asked about the issue of compliance with NICE guidelines. Mrs Sutherland said some guidance was not relevant to the Trust or was not considered appropriate. In addition, it was difficult to implement some guidance at present due to the financial situation. She said the trick was to be clear what was really important to patient safety and care. The Chairman said the Trust needed to be clear through the Board of Directors what decisions were made about implementing NICE guidance. Dame Yvonne Moores said the Trust needed a framework within decisions were made. Mr Stabb said Internal Audit would be reviewing evidence behind implementation and why NICE advice had not been followed (if that was the case). Mr Spencer said the Trust needed to be explicit about what it did in response to NICE guidance. Mrs Hall noted the need to be sure that compliance was maintained if there were changes to services or procedures. Infection Control Committee: November & December 2009 (Paper R) Dame Yvonne Moores noted there appeared to be problems with the domestic contract. Mrs Sutherland said she would ask the Director of Nursing & Patient Services to produce a more detailed paper on the domestic contract. She said the overall standard of cleaning was good but the contract had not taken account of some issues such as escalation and pay. Action: SS Information Committee: December 2009 (Paper S) Risk Management & Safety: October, November & December 2009 (Paper T) The Chairman raised the continuing issue of poor attendance at meetings and noted that the December meeting had not been quorate. Mrs Hall noted that the Committee s Terms of Reference stated that members could send a deputy in their absence. Mrs Sutherland reported that the Committee s membership was being reviewed. The Chairman noted there did not appear to have been any follow up to minute 171/09 (143/09) when it was stated that a report on drug errors would be taken to the next meeting. Mrs Sutherland said she would follow this up. Action: SS A&G 20/10 Any Other Business There was no other business. A&G 21/10 Dates and Times of Next Meetings Thursday 18 March 2010 Thursday 3 June 2010 Thursday 9 September 2010 Thursday 18 November 2010 (Please note change of date) 8