final internal audit report hywel dda university … · hywel dda university health board physical...

FINAL INTERNAL AUDIT REPORT

Hywel Dda University Health Board

Physical Verification of Fixed Assets

2013/14

Private and Confidential

NHS Wales Shared Services Partnership

Audit and Assurance Services



Executive Summary

NWSSP: Audit & Assurance

2

CONTENTS

1. EXECUTIVE SUMMARY ..................................................................3 1.1 Introduction and Scope ............................................................3

1.2 Opinion and Key Findings .........................................................3 2. INTRODUCTION...........................................................................4

3. AUDIT APPROACH AND SCOPE ......................................................4 4. SIGNIFICANT AUDIT FINDINGS .....................................................5

4.1 Assurance Summary................................................................5

4.2 Design of System / Controls .....................................................5 4.3 Operation of System / Controls .................................................5

4.4 Summary of Audit Findings.......................................................6 5. CONCLUSION AND RECOMMENDATIONS....................................... 11

5.1 Overall Assurance Opinion...................................................... 11 5.2 Audit Recommendations......................................................... 13

Review reference: HDHB1322 Report status: Final

Fieldwork commencement: 31st January 2014 Fieldwork completion:

Management debrief meeting:

Draft report issued:

10th March 2014

17th March 2014

25th March 2014 Management response received: 8th April 2014

Final report issued: 8th April 2014 Auditors: Kevin Seward/Rhian Williams

Executive sign off: Director of Finance & Economic Reform.

Distribution: Director of Finance & Economic Reform,

Head and Assistant Head of Service Modernisation.

Committee: Audit Committee.

Appendix A Appendix B

Management Action Plan Physical Verification Lists

Appendix C Audit Assurance Ratings Appendix D Recommendation Priorities

Appendix E Responsibility Statement



Executive Summary

NWSSP: Audit & Assurance

3

ACKNOWLEDGEMENT

NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course

of this review.

1. EXECUTIVE SUMMARY

1.1 Introduction and Scope

Internal Audit conducted a physical verification of fixed assets across the

three counties of Hywel Dda University Health Board (HDUHB). All other aspects relating to the reviewing of fixed assets are being considered by

the Wales Audit Office (WAO).

The overall objective is to ensure that the fixed assets of the Health Board exist and are located in the departments stated on the asset list.

1.2 Opinion and Key Findings

Some errors on the asset register were noted during the physical verification of the assets sampled, resulting in a reasonable assurance

audit rating.

Reasonable

assurance

- +

Yellow

The Board can take reasonable

assurance that arrangements to secure governance, risk management and

internal control, within those areas under review, are suitably designed and applied effectively. Some matters require

management attention in control design or compliance with low to moderate

impact on residual risk exposure until resolved.

(Rating for previous audit HDHB1231 - ).



Main Report

NWSSP: Audit & Assurance Page | 4

2. INTRODUCTION

Internal Audit conducted a physical verification of fixed assets across the three counties of Hywel Dda University Health Board (HDUHB).

Internal Audit has previously discussed the coverage of fixed assets with

the WAO, and it was agreed at that time Internal Audit would only physically verify fixed assets, with WAO reviewing all other aspects. In

addition to this the Health Board has a three year cyclical verification programme in place, agreed by the Audit Committee.

To help contextualise the Health Board’s holdings; as at 31 December 2013

the net book value of the Health Board’s tangible assets stood at approximately £223 million. The table below shows how this is made up:

The importance of notifying the Finance department, upon the disposal or

transfer of an asset, has been reiterated to Health Board staff on a quarterly basis, via global e-mails. Discussions with the Service

Modernisation Team highlighted that whilst significant steps have been taken to improve system compliance, the team remains reliant on

departmental managers keeping them informed of asset movements.

The overall objective is to ensure that the fixed assets of the Health Board exist and are located in the departments stated on the asset list.

3. AUDIT APPROACH AND SCOPE

120 fixed assets were randomly picked for physical verification, the sample

covering the four main hospitals of the Health Board. The details can be seen in Appendix B of this report, with only the exceptions being noted in

the main body of the report.

Category of Asset Net Book

Valuation @ 31/12/12

%

Land, buildings, dwellings & assets

under construction 205 90

Plant & machinery 17 7

IM&T 4 2

Furniture & Fittings 2 1

Transport - -

Total 228 100



Main Report


4. SIGNIFICANT AUDIT FINDINGS

4.1 Assurance Summary

The summary of assurance given against the individual areas tested is outlined in the table below:

4.2 Design of System / Controls

No findings were identified that are classified as a weakness in the system

/ control design for the management of fixed assets.

4.3 Operation of System / Controls

All the findings from the review are classified as a weakness in the

operation of the designed system / control for the management of fixed assets.

ASSURANCE SUMMARY

Audit Scope

1 Follow up ��

2 BGH Physical Verification ��

3 GGH Physical Verification ��

4 PPH Physical Verification ��

5 WGH Physical Verification ��



Main Report


4.4 Summary of Audit Findings

The key findings by the individual areas tested are reported in the section below with full details in Appendix A:

• Follow up

The following areas of good practice were noted:

� The asset register

has been significantly updated to show all departments and progress has been made in updating asset details such as serial

number/make/model.

� Quarterly global

email messages are being sent out to remind departments of their responsibilities to inform Finance of any disposals of

made.

� Stronger communications have been developed with EBME and IT.

The following findings were noted:

� No commonality between EBME and finance registers; if finance register

numbers were included in the EBME database the process of locating assets would be improved.

� From the anomalies noted in last year’s audit; 5 of the assets (no’s 4486,

4700, 4704, 4092 and 4283) had not satisfactorily been addressed as was stated in the ‘Management Response’.

• Physical

Verification

20 assets of the 120 sampled, could not be physically verified at the location listed. Details of each exception are listed in the table below:



Main Report


Department Asset # Asset Description NBV Findings Management Response

Location: Bronglais General Hospital

Meurig Ward 8146 Scalp Cooler £9395.68 Asset has been relocated to Leri

Day Unit.

Confirmed as present in Leri Day Unit

- asset register updated.

Location: Glangwili General Hospital

Endoscopy 4040 Surgical Diathermy £0.00 Asset has been disposed of. Agreed - asset now disposed on

register.

Endoscopy 4195 Colour Video Printer £0.00 Asset has been disposed of.

Awaiting confirmation of disposal by

EBME – asset register will be updated

accordingly.

OPD 7402 Flexible Cystoscope £731.74 Asset has been relocated to PPH.

Awaiting confirmation of relocation –

asset register will be updated

accordingly.



Main Report



OPD 7415 Flexible Cystoscope £789.37 Asset has been relocated to PPH. Awaiting confirmation of relocation –

asset will be updated accordingly.

Physio 6219 PUVA Treatment

Lamp £0.00 Asset no longer in department.

Asset confirmed as disposed –

register updated accordingly.

Radiology 4959 Ultrasound £0.00 Asset no longer in department.

Location of asset is being

investigated. Asset register will be

updated accordingly.

Radiology 4992 Urology Ultrasound £0.00 Asset no longer in department. Asset traced to Urology. Register

updated accordingly.

Location: Prince Philip Hospital

Diabetic 8406 Fundus Camera &

3D Monitor £24,234.12 Asset has been relocated to OPD.

Location of asset 008406 has verified

as OPD. Asset register updated

accordingly (Older camera previously

located in the Diabetic Centre sent to

Swansea).



Main Report



EBME 6973 Smart Cycler

Diagnostics £0.00 Asset no longer in department.

Asset confirmed as being located in

Histology – Location amended on

register.

EBME 7405 19inch HD LCD

Monitor £339.10 Asset not located in department.

EBME confirm asset location as

Endoscopy. Location amended on

register.

Endoscopy 4066 Autodisinfector £0.00 Asset has been decommissioned. Asset disposed.

Endoscopy 007754-

01

Height Adjustable

Sink £2799.20 Asset has been decommissioned.

Asset present in HSDU. Location

amended on register.

Ophth OPD 5547 HRT3 Platform with

PC £11225.39 Asset has been disposed of.

Asset disposed – register updated

accordingly.



Main Report



PPH Ortho TH 4043 ARJO Hoist £0.00 Asset not located in department. Enquiry on going into location of

asset.

Theatre 8944

Instrum. Set for

Rhinoplasy &

Septoplasy

£5334.44 Asset has moved to Day Theatre. Asset confirmed as being present in

Day Theatre. Register updated.

Location: Withybush

Endoscopy 5387 Colposcope £0.00 Asset not located in department. Enquiries on going into location of

asset.

Theatre 5550 Hyper-Hypothermia

Unit £0.00 Asset has been condemned.

Enquiries on going into status of

asset.

X-Ray 4455 Gamma Camera

Siemans E-Cam £0.00 Asset has been decommissioned.

Asset in process of being replaced

and disposed. Asset to be disposed

on register.



Main Report



Ward 1 4282 Defib £0.00 Asset not located in department. To be confirmed.



Main Report


The exceptions reported can be categorised as follows:

5. CONCLUSION AND RECOMMENDATIONS

5.1 Overall Assurance Opinion

We are required to provide an opinion as to the adequacy and

effectiveness of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives

within this report. An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the

identified risks associated with the objectives covered in this review.

Reasonable

assurance

- +

Yellow

The Board can take reasonable assurance that arrangements to secure

governance, risk management and internal control, within those areas under review, are suitably designed and applied

effectively. Some matters require management attention in control design

or compliance with low to moderate impact on residual risk exposure until resolved.

The overall level of assurance that can be assigned to a review is

dependent on the severity of the findings as applied against the specific review objectives and should therefore be considered in that context.

Reason Number NBV

Incorrect location on the Register 11 £43,623.65

Asset has been/requires disposal 9 £11,225.39

Grand Total 20 £54,849.04



Main Report


5.2 Audit Recommendations

We have recommended that the organisation address the issues identified

and management have accepted these. A summary of these recommendations by priority is outlined below:

Priority H M L Total

Number of recommendations

0 2 1 3

The full audit findings and recommendations are detailed in Appendix A

together with the management action plan and implementation timetable.



Appendix A

Management Action Plan

NHS Wales Audit & Assurance Services Page | 1

Area 1: Follow up

Finding Impact

No commonality between EBME and Finance registers; if Finance register numbers were included in the EBME database the process of locating assets

would be improved.

Possibility of not being able to locate assets.

Recommendation 1 Priority

The feasibility of linking the two registers should be investigated.

Management Response Responsible Officer/ Deadline

The EBME department has their own systems to record and manage the assets that they are responsible for. Finance is not directly responsible for these

systems and relies upon the EBME department to keep adequate records of the

assets in question, including the asset location. Greater communication and integration will be sought with both departments to ensure that the Finance

asset register is updated with any changes in location and to ensure that any disposals are duly notified.

We will give consideration to the plausibility of including the Finance register

numbers into the EBME database.

Service Modernisation Department December 2014

Low



Appendix A



Finding Impact

5 anomalies listed in the previous audit have not been satisfactorily addressed as per the ‘Management Response’.

The assets of the Health Board could be under/over stated.


The anomalies brought forward from the previous audit for asset numbers 4486, 4700, 4704, 4092 and 4283 should be investigated, and the asset

register adjusted appropriately, to reflect the true position.


All actions have now been taken. All of the named assets have nil value.

Service Modernisation Department

April 2014

Medium



Appendix A



Area 2: Physical Verification

Finding Impact

Anomalies were found in 20 out of the 120 assets physically verified, as described in the tables above.

The assets of the Health Board could be under/over stated.


The anomalies listed in the tables above should be investigated and the asset

register adjusted appropriately, to reflect the true position.


The anomalies noted in the report will be investigated and the asset register has been amended, where appropriate in 2013/14, all other amendments will

be made in the first quarter of 2014/15.

Service Modernisation Department July 2014

Medium



Appendix B

Physical Verification Lists


Complete Sample Lists of Assets Verified Across the Health Board Bronglais General Hospital

Sample

Ref

Department Asset # Asset Description

Asset

Physically

Verified?

Date Auditor Comments

B01 A & E 5408 Light Monitor � 26.2.14 RW/KS

Asset disposed of between

report being produced and

fieldwork carried out.

B02 A & E 5409 Light Monitor � 26.2.14 RW/KS

Asset disposed of between

report being produced and

fieldwork carried out.

B03 BIOCHEM 5360 Blood Gas Analyser � 26.2.14 RW/KS

B04 BIOCHEM 5477 Double Channel HPLC � 26.2.14 RW/KS

B05 CATERING 8436 COMBI COOKER � 26.2.14 RW/KS

B06 CEREDIG 008057-03 CARDIAC PAGEWRITER � 26.2.14 RW/KS

B07 CMU 5573 Patient Monitor � 26.2.14 RW/KS

B08 DSU 008884-02 PATIENT MONITORING SYSTEM � 26.2.14 RW/KS

B09 ENDOSCOPY 7130 Video Duodenoscope � 26.2.14 RW/KS

B10 ESTATES 3215 Transit 280M Van (Reg No: CP05 � 26.2.14 RW/KS

B11 GWENLLIAN 005660-02 INFUSION PUMP � 26.2.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


B12 GWENLLIAN 7012 Incubator � 26.2.14 RW/KS

B13 HOTEL SER 3138 Tug (Food Trolley Mover) � 26.2.14 RW/KS

B14 HOTEL SER 8936 FRANKING MACHINE � 26.2.14 RW/KS

B15 HSDU 8968 AH FAN & COMPRESSOR � 26.2.14 RW/KS

B16 HSDU 5836 Washer Disinfector D/E � 26.2.14 RW/KS

B17 IORWERTH 8548 BLADDER SCANNER WITH

TROLLEY � 26.2.14 RW/KS

B18 MEURIG 8146 SCALP COOLER � 26.2.14 RW/KS

Item is located in Leri Day

Unit. Meurig ward has

relocated here

B19 RADIOLOGY 5519 Fluoroscopy System � 26.2.14 RW/KS

B20 RADIOLOGY 5559 Image Intensifier BV 300 � 26.2.14 RW/KS

B21 RHIANNON 5845 Xario Prime Ultrasound Scanner � 26.2.14 RW/KS

B22 THEATRE 7847 THEATRE ELITE STIRRUPS � 26.2.14 RW/KS

B23 THEATRE 8668 ARTHROSCOPIC (BONE) SHAVER � 26.2.14 RW/KS

B24 THEATRE 8377 CELL SAVER � 26.2.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


B25 YSTWYTH 7653 ECG Diagnosis System � 26.2.14 RW/KS Ystwyth has been renamed -

Acute Stroke Unit

Glangwili General Hospital

Sample

Ref


Asset

Physically

Verified?


G1 A & E 5859 SLIT LMP BQ900 & RELIANCE

7000 � 5.3.14 RW/KS

G2 A & E 5510 FABIUS TIRO � 5.3.14 RW/KS

G3 CERI 005285-01 SUCTION MACHINE � 5.3.14 RW/KS

G4 CILGERRAN 4674 PATIENT MONITOR (MULTI

PARAM) � 5.3.14 RW/KS

G5 CILGERRAN 8319 VENTILATOR - INFANT FLOW � 5.3.14 RW/KS

G6 CILGERRAN 8320 VENTILATOR - INFANT FLOW � 5.3.14 RW/KS

G7 CLINICDECISI 008494-01-04 WALL SYSTEM WITH COAXIAL

OPHTHAL OTOSCOP � 5.3.14 RW/KS

G8 CLINICDECISI 008494-01-04-01 WALL SETS WITH OPTHAL

OTOSCOPES x 14 � 5.3.14 RW/KS

G9 CRITICAL C U 8131 HOIST WITH SCALE � 5.3.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


G10 CRITICAL C U 8132 HOIST WITH SCALE � 5.3.14 RW/KS

G11 DISCHARGE 4599 BARIATRIC HOIST WITH SCALE � 5.3.14 RW/KS

G12 ENDOSCOPY 3966 19" HD LCD MONITOR � 10.3.14 RW/KS

G13 ENDOSCOPY 4040 SURGICAL DIATHERMY � 10.3.14 RW/KS Asset has been disposed of

and replaced

G14 ENDOSCOPY 4195 COLOUR VIDEO PRINTER � 10.3.14 RW/KS Asset has been disposed of

and replaced

G15 GWENLLIAN 005173-09 DEFIBRILLATOR � 5.3.14 RW/KS

G16 HOTEL SER 003008-03 WASTE DISPOSER � 5.3.14 RW/KS

G17 HOTEL SER 3033 RAPID THAW CABINETS � 5.3.14 RW/KS

G18 ICU 5216 LIDCOPLUS HEMODYNAMIC

MONITOR � 5.3.14 RW/KS Asset is in storage

G19 MERLIN 7718 PORTABLE NASO-PHARYNGO-

LARYNGO � 5.3.14 RW/KS

G20 MORTUARY 7927 WASHER DRYER � 5.3.14 RW/KS

G21 OPD 7402 FLEXIBLE CYSTOSCOPE � 10.3.14 RW/KS Asset has been relocated to

PPH

G22 OPD 7415 FLEXIBLE CYSTOSCOPE � 10.3.14 RW/KS Asset has been relocated to

PPH

G23 PADARN 5173 DEFIBRILLATOR � 5.3.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


G24 PHARMACY 3070 BIOSAFETY CABINET � 5.3.14 RW/KS

G25 PHYSIO 5549 HYDROTHERAPY HOIST � 5.3.14 RW/KS

G26 PHYSIO 6219 PUVA TREATMENT LAMP � 5.3.14 RW/KS No longer in department asset

has been disposed of.

G27 PICTON 4583 LIGHT SOURCE CAMERA STACK � 5.3.14 RW/KS

G28 RADIOLOGY 4959 Ultrasound � 5.3.14 RW/KS No longer in department.

G29 RADIOLOGY 4992 Urology Ultrasound � 5.3.14 RW/KS No longer in department.

G30 RADIOLOGY 8023 CT SCANNER � 5.3.14 RW/KS

G31 SCBU 7465 CEREBRAL FUNCTION MONITOR � 5.3.14 RW/KS

G32 SCBU 8674 GAS MEASUREMENT MODULE � 5.3.14 RW/KS

G33 TEIFI

ORTHOPAEDIC 8034

ORTHOPAEDIC TRACTION

SYSTEM � 5.3.14 RW/KS

G34 THEATRE 5616 MAQUET NAILING SYSTEM � 5.3.14 RW/KS

G35 THEATRE 007622-02 OTOLOGIC DRILL � 5.3.14 RW/KS Asset located in Theatre 2

G36 THEATRE 007994-01 BI-POLAR TRAY SYSTEM � 5.3.14 RW/KS

G37 THEATRE 8015 ORTHOPAEDIC DRILL � 5.3.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


G38 THEATRE 4573 INTUBATING FIBERSCOPE � 5.3.14 RW/KS

G39 TYSUL 3988 ULTRA-SONIC SCANNER � 5.3.14 RW/KS

G40 TYSUL 4537 IOL MASTER � 5.3.14 RW/KS

G41 UROLOGY 8365 TRANSRECTAL PROBE � 5.3.14 RW/KS

G42 UROLOGY 9070 VIDEO URETEROSCOPE � 5.3.14 RW/KS

G43 X RAY 7991 APLIO XG NEXT GENERATION

SCANNER � 5.3.14 RW/KS

G44 X RAY 007991-02 APLIO XG NEXT GENERATION

SCANNER � 5.3.14 RW/KS

G45 X RAY 8694 REMOTE CONSOLE � 5.3.14 RW/KS

Prince Philip Hospital

Sample

Ref


Asset

Physically

Verified?


P01 X RAY PPH 006193-01 MOBILE X RAY � 21.2.14 RW/KS

P02 BLOOD BANK 3111 LABCOLD PLASMA FREEZER � 21.2.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


P03 CATERING 3123 OVEN PPH � 21.2.14 RW/KS

P04 DAY THEATRE 004574-01 LIFEGUARD TROLLEY � 21.2.14 RW/KS Asset located in Endoscopy

recovery in Day Theatre.

P05 DIABETIC 8406 FUNDUS CAMERA & 3D

MONITOR � 21.2.14 RW/KS

Item has been relocated to

OPD.

P06 EBME 6973 SMART CYCLER DIAGNOSTICS � 21.2.14 RW/KS Asset no longer in

department.

P07 EBME 7405 19INCH HD LCD MONITOR � 21.2.14 RW/KS Item not located in

department.

P08 EBME 7411 ELECTRICAL SAFETY ANALYSIS � 21.2.14 RW/KS

P09 ENDOSCOPY 4066 AUTODISINFECTOR � 21.2.14 RW/KS Item has been

decommissioned.

P10 ENDOSCOPY 5029 VIDEOCYSTOSCOPE � 21.2.14 RW/KS

P11 ENDOSCOPY 007754-01 Height Adjustable Sink � 21.2.14 RW/KS Item has been

decommissioned.

P12 ESTATES 008045-03 SNOW CLEARANCE RIDE ON

MACHINE � 21.2.14 RW/KS

P13 HOTEL SER 8935 FRANKING MACHINE � 21.2.14 RW/KS

P14 HSDU 007758-04 T-DOC SYSTEM � 21.2.14 RW/KS System is on a dedicated PC

which is still in use.

P15 OPD 7410 PPH REPL HI/LO HYDRAULIC

COUCH � 21.2.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


P16 OPHTH OPD 5547 HRT3 PLATFORM WITH PC � 21.2.14 RW/KS Item has been disposed of.

P17 PHARMACY 2747 PHARMACY ROBOTICS � 21.2.14 RW/KS

P18 PPH ORTHO TH 4043 ARJO HOIST � 21.2.14 RW/KS Asset not located in

department.

P19 PPH ORTHO TH 4893 ELECTROSURGICAL UNIT WITH

TROLLEY � 21.2.14 RW/KS

P20 THEATRE 4019 ANAESTHETIC MACHINE � 21.2.14 RW/KS

P21 THEATRE 8944 INSTRUM. SET FOR RHINOPLASY

& SEPTOPLASY � 21.2.14 RW/KS Item is located in Day Theatre

P22 THEATRE 006979-01 PRECISION OSCILLATING TIP

SAW � 21.2.14 RW/KS

P23 TY BRYNGWYN 7934 MAXI MOVE HOIST (POWR &

SCALE) � 21.2.14 RW/KS

P24 WARD 4 8903 PORTABLE FIBROSCAN& PROBE � 21.2.14 RW/KS

P25 WARD 9 008426-01 TELESTROKE CART � 21.2.14 RW/KS



Appendix B



Withybush General Hospital

Sample

Ref


Asset

Physically

Verified?


W1 A & E 7907 GYNNIE OB/GYN STRECHER � 4.3.14 RW/KS

W2 AUDIOLOGY 4369 Echoport Clinical System � 4.3.14 RW/KS

W3 CORONARY 4271 DEFIBRILLATOR � 4.3.14 RW/KS

W4 ENDOSCOPY 5387 Colposcope � 4.3.14 RW/KS Not in Department

W5 ENDOSCOPY 9052 V3 CASSETTE & CONNECTOR � 4.3.14 RW/KS

W6 ITU 4495 HAEMFILTRATION UNIT � 4.3.14 RW/KS

W7 MATERNITY 4971 Ultrasound Scanner - digital high

resolu � 4.3.14 RW/KS

W8 MICROBIOLOGY 4628 Microscope - Fluroscent � 4.3.14 RW/KS

W9 PHARMACY 8007 FRIDGE MONITORING SYSTEM � 4.3.14 RW/KS

W10 THEATRE 5480 Drill & Accessories � 4.3.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


W11 THEATRE 5550 Hyper-Hypothermia Unit � 4.3.14 RW/KS Condemned

W12 THEATRE 7899 METRO RACKING SYSTEM � 4.3.14 RW/KS

W13 THEATRE 5671 Operating Table � 4.3.14 RW/KS

W14 WARD 1 4282 DEFIBRILLATOR � 4.3.14 RW/KS Not in Department

W15 WARD 11 5706 Patients Hoist � 4.3.14 RW/KS

W16 WARD 4 5537 Hi Lo Bath � 4.3.14 RW/KS

W17 WARD 8 5708 Patients Hoist � 4.3.14 RW/KS

W18 X RAY 4289 Defibrillator � 4.3.14 RW/KS

W19 X RAY 4455 Gamma Camera Siemens E-Cam � 4.3.14 RW/KS Decommissioned

W20 X RAY 5370 Capintec Dose Calibrator � 4.3.14 RW/KS

W21 PODIATRY 4427 Footscan � 4.3.14 RW/KS



Appendix B



Sample

Ref


Asset

Physically

Verified?


W22 OPD 5963 Laser With Slit Lamp � 4.3.14 RW/KS

W23 OPD 4510 HUMPHREY FIELD ANALYSER � 4.3.14 RW/KS

W24 HOTEL SER 5546 Hot Food Servery � 4.3.14 RW/KS

W25 ESTATES 8464 UPS BATTERIES � 4.3.14 RW/KS



Appendix C

Audit Assurance Ratings

NHS Wales Audit & Assurance Services

2013/14 Audit Assurance Ratings

RATING INDICATOR DEFINITION

Substa

ntial

assurance

- +

Green

The Board can take substantial assurance that arrangements to secure

governance, risk management and internal control, within those areas under review, are suitably designed and applied

effectively. Few matters require attention and are compliance or advisory

in nature with low impact on residual risk exposure.

Reasonable

assurance

- +

Yellow

The Board can take reasonable

assurance that arrangements to secure governance, risk management and internal control, within those areas under

review, are suitably designed and applied effectively. Some matters require

management attention in control design or compliance with low to moderate impact on residual risk exposure until

resolved.

Lim

ited a

ssurance

- +

Amber

The Board can take limited assurance that arrangements to secure governance,

risk management and internal control, within those areas under review, are

suitably designed and applied effectively. More significant matters require management attention with moderate

impact on residual risk exposure until resolved.

No a

ssurance

- +

Red

The Board has no assurance that

arrangements to secure governance, risk management and internal control, within

those areas under review, are suitably designed and applied effectively. Action is required to address the whole control

framework in this area with high impact on residual risk exposure until resolved.



Appendix D

Recommendation Priorities


Prioritisation of Recommendations In order to assist management in using our reports, we categorise our recommendations according to their level of priority as follows:

Priority

Level

Explanation

Timeframe for

commencement of management action

Poor key control design OR widespread non-compliance

with key controls

PLUS

Significant risk to achievement of a system objective OR evidence present of material

loss, error or mis-statement

Immediate*

Minor weakness in control

design OR limited non-compliance with established

controls

PLUS

Some risk to achievement of a

system objective

Within One Month*

Potential to enhance system

design to improve efficiency or effectiveness of controls

These are generally issues of good practice for management consideration

Within Three Months*

* unless a more appropriate timescale is identified / agreed at the

assignment.

High

Medium

Low

Hywel Dda Univeristy Health Board


Appendix E

Responsibility Statement


Confidentiality

This report is supplied on the understanding that it is for the sole use of

the persons to whom it is addressed and for the purposes set out herein. No persons other than those to whom it is addressed may rely on it for

any purposes whatsoever. Copies may be made available to the addressee's other advisers provided it is clearly understood by the

recipients that we accept no responsibility to them in respect thereof. The report must not be made available or copied in whole or in part to

any other person without our express written permission.

In the event that, pursuant to a request which the client has received

under the Freedom of Information Act 2000, it is required to disclose any information contained in this report, it will notify the Head of Internal

Audit promptly and consult with the Head of Internal Audit and Director of Corporate Services prior to disclosing such report.

The Health Board shall apply any relevant exemptions which may exist under the Act. If, following consultation with the Head of Internal Audit

this report or any part thereof is disclosed, management shall ensure that

any disclaimer which NHS Wales Audit & Assurance Services has included or may subsequently wish to include in the information is reproduced in

full in any copies disclosed.

Audit

The audit was undertaken using a risk-based auditing methodology. An evaluation was undertaken in relation to priority areas established after

discussion and agreement with the Health Board. Following interviews with relevant personnel and a review of key documents, files and

computer data, an evaluation was made against applicable policies, procedures and regulatory requirements and guidance as appropriate.

Internal control, no matter how well designed and operated, can provide only reasonable and not absolute assurance regarding the achievement of

an organisation’s objectives. The likelihood of achievement is affected by limitations inherent in all internal control systems. These include the

possibility of poor judgement in decision-making, human error, control

processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable

circumstances.

Where a control objective has not been achieved, or where it is viewed

that improvements to the current internal control systems can be attained, recommendations have been made that if implemented, should

ensure that the control objectives are realised/ strengthened in future.

A basic aim is to provide proactive advice, identifying good practice and

any systems weaknesses for management consideration.

Hywel Dda Univeristy Health Board


Appendix E

Responsibility Statement


Responsibilities

Responsibilities of management and internal auditors:

It is management’s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the

prevention and detection of irregularities and fraud. Internal audit work should not be seen as a substitute for management’s responsibilities for

the design and operation of these systems.

We plan our work so that we have a reasonable expectation of detecting

significant control weaknesses and, if detected, we may carry out additional work directed towards identification of fraud or other

irregularities. However, internal audit procedures alone, even when carried out with due professional care, cannot ensure fraud will be

detected. The organisation’s Local Counter Fraud Officer should provide support for these processes.




Office details St. Bride’s, Hafan Derwen, Carmarthen SA31 3HB Contact details Tel: 01267 239780

final internal audit report hywel dda university … · hywel dda university health board physical...

Documents