report summary sheet_board_committees.pdfmr j murray, internal audit, bso ms l neill, external...

Quality care – for you, with you

REPORT SUMMARY SHEET

Meeting: Date:

Trust Board 26th May 2016

Title:

Governance Committee Minutes - 4th February 2016

Lead Director:

Chairman, Governance Committee

Corporate Objective:

N/A

Purpose:

For Approval

Summary of Key Issues for Trust Board

High level context:

- The Minutes contain an overview of the key discussion points and decisions from the Governance Committee meeting on 4th February 2016.

Key issues/risks for discussion:

- Key issues/risks discussed at the meeting on 10th May 2016.

- Corporate Risk Register - Medicines Governance - Incident/Complaints/Patient Safety Report - Mortality & Morbidity - Draft Governance Statement - Controls Assurance Standards – Report on

Compliance 2015/16 - The Committee endorsed the following policies

i) Draft Gifts, Hospitality and Sponsorship Policy ii) Draft Conflicts of Interest Policy

- Members endorsed the Governance Committee

Annual Business Cycle 2016

The following presentation was given:

- Managing deteriorating patients

Governance Committee

Schedule of Reporting 2016

Governance Area Report details Lead Person Frequency Month

Clinical and Social Care Governance

Clinical and Social Care Governance Dashboard

a) Incidents/Complaints/Patient

Safety Report b) Ombudsman Cases c) Serious Adverse Incidents d) Standards and Guidelines e) RQIA Reviews & Inspections

ADC&SCG/ Medical Director

Quarterly

February 2016 May 2016 September 2016 December 2016

Risk Corporate Risk Register Chief Executive/ Board Assurance Manager

Quarterly February 2016 May 2016 September 2016 December 2016

Professional Governance

Allied Health Professionals Social Work and Social Care Governance

Executive Director of Nursing Executive Director of Social Work

Six-monthly Six-monthly

February 2016 September 2016 September 2016

Medicines Governance

Medicines Governance Report Report from the Accountable Officer responsible for Controlled Drugs

Director of Pharmacy Director of Pharmacy

Quarterly Annually

February 2016 May 2016 September 2016 December 2016 February 2016

Information Governance

Freedom of Information, Environmental Information

and Subject Access Requests

SIRO Information Governance Report

Director of P&R “

Quarterly Annually

February 2016 May 2016 September 2016 December 2016 December 2016

External/Internal Inspections/Independent Reviews

Annual Mortality Review As and when reports are available

Medical Director Directors

Annually

May 2016

Controls Assurance Standards

Report on Compliance Chief Executive/ Board Assurance Manager

Annually May 2016

Governance Statement Draft Governance Statement

Chief Executive Annually

May 2016

Health and Safety Governance

Health and Safety Report Director of HR & Organisational Development

Annually September 2016

Service User Involvement Update from Patient and Client Experience Committee

Mr E. Graham

Quarterly February 2016 May 2016 September 2016 December 2016

Leadership Walkabouts Summary Report Dr Mullan Six Monthly May 2016 December 2016

Non-Executive Director’s visits to Children’s Homes Report

Summary Report Mr P Morgan Six Monthly May 2016 December 2016

Effectiveness of Governance Committee

Self-Assessment

Review and update the Committee’s Terms of Reference

Draft Annual Report of the Governance Committee

Schedule of Reporting

Members Members Committee Chair/Board Assurance Manager Board Assurance Manager

Annually Annually/ as required Annually Annually

September 2016 February 2016 September 2016 May 2016

Other reports presented for assurance as and when required

Carers Action Plan

Non Executive Director/Director of Older People and Primary Care

Six Monthly May 2016 December 2016

Quality care – for you, with you

REPORT SUMMARY SHEET

Meeting: Date:

Trust Board 26th May 2016

Title:

Audit Committee Minutes – 11th February, 3rd March & 7th April 2016

Lead Director:

Chair, Audit Committee

Corporate Objective:

All

Purpose:

For Approval

Summary of Key Issues for Trust Board

High level context: - The Minutes contain an overview of the key discussion points

and decisions from the Audit Committee meetings on 11th February, 3rd March and 7th April 2016.

Key issues/risks for discussion: Key issues/risks discussed at the meeting on 5th May 2016

- IA Report for Management of Estates Contracts 2015/16 Director attended to provide an update on progress where unacceptable assurance was provided.

- BSO Shared Services Reports

Representatives from BSO attended to provide an update on progress in the following areas:-

- Payroll 2015/16 (Limited Assurance) - Recruitment 2015/16 (Unacceptable Assurance)

- Draft Annual Accounts for the year ended 31 March 2016 - Draft Governance Statement 2015/16 - Controls Assurance Standards – Report of Compliance 2015/16

- Internal Audit Progress Report

- Head of Internal Audit Annual Report

Audit Committee Minutes – 11th February 2016 Page 1

Minutes of a meeting of the Audit Committee held on Thursday, 11th February 2016 at 9.30 a.m. in the Boardroom, Trust Headquarters

PRESENT: Mrs E Mahood, Non Executive Director (Chair) Mr E Graham , Non-Executive Director IN ATTENDANCE: Mr S McNally, Director of Finance and Procurement, SHSCT Mrs A Rutherford, Assistant Director of Finance, SHSCT Mrs F Jones, Corporate Financial Accountant and Fraud Liaison Officer Mrs C McKeown, Head of Internal Audit, BSO Mr J Murray, Internal Audit, BSO Ms L Neill, External Audit, KPMG Mr J Poole, External Audit, KPMG Mr T Wilkinson, Northern Ireland Audit Office (NIAO) Mrs E Gishkori, Director of Acute Services, SHSCT (Item 6i and 6ii only) Mr P Morgan, Director of Children and Young People’s Services/ Executive Director of Social Work, SHSCT (Item 6i and 6ii only) Mrs S Judt, Board Assurance Manager, SHSCT Mrs S McCormick, Committee Secretary (Minutes), SHSCT APOLOGIES Dr Mullan, Non Executive Director. 1. CHAIRMAN’S WELCOME Mrs Mahood welcomed those present to the meeting.


2. DECLARATION OF INTERESTS

Mrs Mahood asked members to declare any potential conflict of interests in relation to items on the agenda. None were received and the business of the meeting proceeded.

3. CHAIRMAN’S BUSINESS

Mrs Mahood advised that she had attended the Departmental Audit Committee Chairs’ Forum on 1st December 2015.

4. MINUTES OF MEETING HELD ON 15th OCTOBER 2015 The minutes of the meeting held on 15th October 2015, were agreed as

an accurate record and duly signed by the Chairman, subject to the following amendment;

Page 9 – Replace following paragraph – ‘Mrs Rutherford updated members on a number of issues from the Trust’s perspective and Mrs McKeown assured members that issues were being managed’.

with the following -

‘Mrs Rutherford updated members on a number of issues from the Trust’s perspective and Mrs McKeown advised that any recommendations would form part of the Internal Audit year end follow up’.

5. MATTERS ARISING FROM PREVIOUS MINUTES

Members noted the progress updates from the relevant Directors to issues raised at the previous meeting.

Corporate Mandatory Training and Appraisal Mrs Mahood advised that she had raised this matter at a recent Governance Committee meeting and welcomed the number of in-year actions being considered by the Trust to seek to significantly improve mandatory training compliance and specifically target areas of higher risk.


Mrs Mahood referred members back to page 2 of the draft minutes from the previous meeting held on 15th October 2015 and asked for clarification as to whether an overall level of assurance, specifically for shared services audits would be provided at year end from a BSO management perspective. Mrs McKeown stated that she would be including Shared Services in her end year report to SHSCT, but undertook to clarify the position from a BSO management perspective.

Action: Mrs C McKeown

6. INTERNAL AUDIT REPORTS WITH LIMITED ASSURANCE

Mrs Mahood welcomed both Mr Morgan and Mrs Gishkori to the meeting to speak to the following limited assurance reports for their areas of responsibility. i) Fostering & Adoption Payments 2015/16

Mr Morgan presented an update report, providing assurance on progress on a number of control weaknesses in relation to Fostering and Adoption Payments. He reminded members that the limited assurance had been awarded on the basis that a high level of errors had been identified from samples tested across all payments. Mr Morgan provided assurance that a review of adoption allowances will be undertaken in April each year and advised of a meeting scheduled for March 2016 with the Finance Department to verify that payments calculated by the Family Placement Teams have been accurately calculated. Mr Morgan stated that the review process would be undertaken over a period of 3 months, January – March 2016 and he would envisage the final process being implemented by the beginning of the new financial year. Mrs Mahood referred to 2010/11 when an audit of this topic was last undertaken and limited assurance was provided. She recorded her disappointment at the low level of progress made and sought assurance that a robust strategy was being put in place to achieve progress. In responding, Mr Morgan advised


that an overhaul of fostering structures had been undertaken by the Head of Family Support and Safeguarding and auditing practices within the division would also be implemented and taken forward. In referring to page 13, Mrs Mahood welcomed the formation of a working group with representation from family placement service, 16 plus and HSCB to progress and develop a set of practice guidance notes on finance for staff working in Adoption and Fostering teams. Following a question from Mrs Mahood regarding workforce concerns, Mr Morgan confirmed that he had no such concerns and the issues highlighted through the audit process were as a result of the correct practices not being in place. Members noted the recommendation around the SOSCARE payment report and the challenges this may present in terms of implementation given the exceptionally short turnaround time for payments verification. Mr Morgan acknowledged the challenges referred to. He assured members that further work internally has been undertaken post audit that the responsible managers are confident compliance can be achieved. In conclusion, Mrs Mahood emphasized the importance of ensuring much stronger processes are put in place moving forward and she welcomed the comprehensive update provided by Mr Morgan.

ii) Laboratory Procurement and Contracts Management 2015/16 Mrs Gishkori presented an update report, providing assurance on progress on a number of control weaknesses in relation to the Management of Laboratory Procurement and Contracts Management. Limited assurance had been awarded on the basis that effective controls are not in place within the Trust to monitor and verify laboratory expenditure. Mrs Gishkori reminded members this was the first regional audit carried out on this topic. She began by addressing the six priority 2 weaknesses and advised these could be internally managed and she referred members to the associated action plan. Mrs Gishkori spoke of the challenge in implementing the 2 Priority 1


recommendations. She advised that a Regional Laboratory Procurement Group is in place to ensure that a list of all laboratories contracts is maintained. Members discussed in detail the Belfast Block Contract and concerns were raised in terms of financial control gaps, due to no signed agreement being in place with the BHSCT for the provision of its service and the costs being charged. Mr McNally agreed to raise the Committee’s concerns at the Regional Audit Forum meeting the following day. Action – Mr McNally Mrs Mahood referred to page 11 of the report and sought clarity on the wording ‘analytical integrity of samples’. Following some discussion, Mrs Gishkori undertook to clarify this statement. Action – Mrs Gishkori

In terms of clinical issues, members sought assurance that systems are in place to alert the Trust of any missing results. Mrs Gishkori agreed to provide further assurance on this under matters arising at the next meeting. Action – Mrs Gishkori In concluding discussion, Mrs Mahood recognized that a number of recommendations required regional agreement and welcomed the update provided by Mrs Gishkori and the progress made post audit. Mrs Gishkori and Mr Morgan left the meeting at 10.10 a.m.

7. FRAUD

i) Fraud Update

Mrs Jones provided a detailed update on reported fraud cases during 2015/16, together with an update on cases from previous


years. Mrs Mahood asked about lessons learned and if this was being disseminated throughout the Trust. Mrs Jones advised that this will continue to be reinforced to staff through Fraud Awareness sessions and sampling would also take place. At this point in the meeting, Mrs Mahood referred to Item 8i on the agenda, IA Progress Report and asked Mrs Jones a number of questions regarding the IA Report on Whistleblowing and Fraud Processes 2015/16. Mrs Jones confirmed that the revised Fraud Policy including Fraud Response Plan would be presented to Audit Committee at its scheduled meeting on 3rd March 2016. Mrs Jones highlighted the Priority 2 recommendation that the Trust should give consideration to making the Fraud e-learning module compulsory for some staff groups and building this into the Mandatory Training Programme. Mrs Mahood asked Mrs Jones to present the following Departmental Finance Circular at this point in the meeting. Annual Theft & Fraud Report 2014/15. Ref: HSC(F) 12-2016 Members noted receipt of the above. Mrs Jones advised that the report in full would be an agenda item at the next Audit Committee meeting on 3rd March 2016. Action – Mrs Jones

ii) National Fraud Initiative Update

Mrs Rutherford advised that data matching exercises were nearing completion and a written report would be presented to the next Audit Committee meeting on 3rd March 2016.

8. INTERNAL AUDIT

i) Internal Audit Progress Report Mrs McKeown gave a detailed report on progress to date against the 2015/16 Audit Plan. She advised that the Trust had requested that the audit assignment into Clinical Audit be deferred until


2016/17, to allow changes currently underway in how the service is operated and delivered to be implemented. Mrs McKeown sought approval for this proposed adjustment, to which members agreed. Mr Murray stated he would envisage the re-scheduled assignment to take place in the Autumn of 2016. Mrs McKeown presented her Progress Report drawing attention to nine final audit reports issued since the previous Audit Committee meeting. She stated that five further reports remain in draft form at present. All work will be completed by the end of March 2016 for review by the Committee within the required timeframes. Non Pay Expenditure 2015/16 A Satisfactory level of assurance was provided on the system of internal control over Management of Non Pay Expenditure. One Priority 1 and five Priority 2 weaknesses were identified. Mrs Mahood referred to the issues around Service Level Agreements (SLA) and in particular the need for clarity around roles and responsibilities between BSO Shared Services and the Trust. Mr McNally updated members on the current position and Mrs Rutherford advised that the Trust had signed the 2015/16 SLA but envisaged changes moving into the 2016/17 period. Mrs Mahood asked Mr McNally to consider raising the matter at the Regional Audit Forum meeting. Budgetary Control 2015/16 A Satisfactory level of assurance was provided on the system of internal control over Budgetary Control in the SHSCT. No Priority 1 and four Priority 2 weaknesses were identified. Members noted the recommendation, rejected by management that zero based budgeting should be more fully utilized by the Trust. Mrs Mahood welcomed the detailed management comment and pointed out that there was potential for the Trust to move forward but acknowledged the workforce challenges involved.


Adult Supported Living, MHLD 2015/16 A Satisfactory level of assurance was provided on the system of internal control over Adult Supported Living in those facilities visited within the Mental Health and Learning Disability (MHLD) Directorate. Financial controls were broadly found to be operating effectively in these homes, however, controls over monitoring of balances in tenants’ and budget bank accounts need strengthening. Two Priority 1 and seven Priority 2 weaknesses were identified. Members recorded disappointment at the Priority 1 issues, specifically in relation to large amounts of monies held in household budget accounts, particularly in Glanree. Concern was expressed that this was a slip in process and that the good practice messages and processes agreed following the 2013/14 audit assignment, when the Trust Chief Executive and Director of Finance met each facility, were not being applied. Mrs Mahood emphasized the importance of implementing universal ways of working across the Trust and stated that she would raise the issue along with Audit Committee concerns, at the next Chair feedback meeting. Mr Murray advised that this issue would be included in the IA follow up process in due course. Action – Mrs Mahood Haven Transport 2015/16 Mrs McKeown reminded members of the background to this exercise, which exclusively focused on confirming the accuracy of reimbursement amounts, calculated by the home for transport charges paid by service users. She explained that as part of their work, IA had sampled 5 residents for the period January 2009 to May 2012 and found that in all 5 instances the reimbursement amount calculated by IA was greater than the amount calculated by the Haven facility. Mrs McKeown advised that a number of recommendations have been identified and all accepted by management. Mrs Mahood welcomed the robust process deployed by the Trust in seeking to move forward with this issue.


Mr Murray confirmed that monies have been repaid to all 34 current/past residents. Performance Management 2015/16 A Satisfactory level of assurance was provided on the system of internal control over Performance Management. No Priority 1 and five Priority 2 weaknesses were identified. Mrs Mahood drew attention to the Priority 2 recommendation, rejected by management, that the Trust should continue to work with Commissioners and DHSSPS to further develop its action plans to i) closely monitor progress against Commissioning Plan (CP) targets in areas of under-performance, (ii) Identify additional resources, targeting same to services areas which will have greatest impact on service delivery/performance and (iii) Identify innovative approaches to service delivery in challenged areas. In alluding to regular discussions at Board level where Trust performance is rigorously scrutinized, Mrs Mahood referred to the Trust Delivery Plan (TDP) and the Trust response to the Commissioning Plan targets both of which have been accepted by the Commissioner and stated that she could clearly see the rationale behind the rejection of this recommendation. Members noted that the Trust continue to target any internal resources to areas of greatest priority and highlight issues related to manpower to HSCB and DHSSPSNI via its accountability mechanism. Management of Licenses & Accreditations 2015/16 A Satisfactory level of assurance was provided on the system of internal control surrounding the Trust Management of Licenses and Mandatory Accreditations within the four areas visited. One Priority 1 and one Priority 2 weaknesses were identified. Mrs McKeown advised that all recommendations had been accepted by management. Mrs Mahood welcomed the report and emphasized the need for the establishment of a corporate system for the Trust coordination, management and reporting of licenses and accreditations.


Risk Management 2015/16 A Satisfactory level of assurance was provided on the system of internal control in relation to Risk Management. No Priority 1 and four Priority 2 weaknesses were identified. Mrs McKeown stated that a number of the Priority 2 recommendations remain outstanding from previous years. Mrs Mahood drew members attention to page 81 and raised concern at a number of risk registers held in different formats. Following a brief discussion, Mrs Mahood stated that she would raise this at the next Audit Committee Chair feedback meeting. Action – Mrs Mahood Whistleblowing & Fraud Processes 2015/16 A Satisfactory level of assurance was provided on the system of internal control over Whistleblowing and Fraud Processes. One Priority 1 and nine Priority 2 weaknesses were identified. At the outset, Mrs McKeown made reference to the Trusts own internal Whistleblowing Survey undertaken in April 2015 from which a number of recommendations had evolved and welcomed same. She guided members through the detail of the IA report and pointed out the issues identified in the main related to awareness and staff training. All recommendations have been accepted by management. Members raised concern that no specific whistleblowing training was available to staff in general or staff undertaking whistleblowing investigations. A brief discussion ensued. Mr McNally pointed out that the Trust had a skill set of staff in place but direction was required on the specifics and content of appropriate training. In seeking to move forward, Mr Wilkinson suggested that representatives from the NIAO would be happy to engage with the Trust on this issue. Members welcomed this suggestion. Mr Graham commented that he felt the management comment in relation to an awareness raising programme was weak and Mrs Mahood advised that she would raise the issue of whistleblowing training/awareness at the next Audit Committee Chair feedback meeting.


Action – Mrs Mahood

ii) Update on Shared Services Reports Mrs McKeown referred to the detail included within the summary sheet and reminded members that as part of the BSO Internal Audit Plan a programme of Shared Services audits was being conducted. The following report has been finalized and presented to the BSO Governance and Audit Committee since the last Southern Trust Audit Committee: - Income Shared Services – Satisfactory Assurance One Priority 1 finding was reported in relation to credit notes. Mrs Rutherford reported that the Financial systems team within the Southern Trust have been working to rectify the issues raised and this work is nearing completion. Following some discussion as to whether the BSO reports in full should be shared with Audit Committee members, agreement was reached that only reports with less than satisfactory assurance should be presented in full for Audit Committee discussion. Mrs Rutherford presented the Shared Services (SS) Assurance report for the Southern Health and Social Care Trust covering the quarter ended 31 December 2015. For the period, SS had 13 key performance indicators (KPIs) for SHSCT per month, 4 of which did not meet the required standard as at December 2015 and members noted the detail included within the report. Members agreed that in future quarterly Shared Services assurance reports should be shared with Audit Committee members and any issues or concerns would be discussed at the following Audit Committee meeting.


9. EXTERNAL AUDIT STRATEGY 2015/16

Mrs Mahood welcomed representatives from the Trust’s Audit Partners, KPMG and the Northern Ireland Audit Office (NIAO) to speak to the above named paper. Mr Poole, KPMG, guided members through the detail of the External Audit Strategy for the Trust’s 2015/16 Accounts. He stated that the audit approach is risk based and referred members to two significant risks, namely i) the ability of the Trust to breakeven in tight funding environment; and ii) operation of BSO shared services centre in relation to key financial controls. Mrs Mahood asked if the Trust’s Corporate Risk Register (CRR) had been reviewed to inform the audit plan. In responding, Mr Poole advised that detail gathered from the CRR along with various other sources had been taken into account. Mr Poole further advised that no specific risks in terms of Charitable Trust Fund Accounts have been identified. Members noted page 9 of the document, outlining the departmental timetable for producing and laying audited accounts for 2015/16. Mr Wilkinson, NIAO drew members attention to page 15, Annex 2 and a number of Value for Money (VFM) studies undertaken by the NIAO across the public sector. He referred to 2 health relevant studies nearing publication, namely i) Emergency Admissions and ii) Transforming Your Care (TYC).

Mrs Mahood thanked Mr Poole for his detailed report of the work and members approved the External Audit Strategy for 2015/16 Accounts.

10. AUDIT COMMITTEE CORE WORK PROGRAMME 2016

Mrs Mahood presented the Audit Committee Core Work Programme for the calendar year 2016 and recorded thanks to Mrs Judt for her work in compiling the paper. Mrs Judt advised that following the Committee’s endorsement, the work plan would be submitted to Trust Board for approval. Members endorsed the work plan for onward submission to Trust Board approval.


11. FINANCE CIRCULARS:

i) NIAO Publication Managing Fraud Risk in a Changing

Environment: A Good Practice Guide. Ref: HSC(F) 57-2015 Mrs Rutherford presented the above named Finance Circular for members’ information.

ii) Timetable for 2015/16 Annual Accounts. Ref: HSC(F) 04-2016

Members noted receipt of the above named Finance Circular, advising of the timescales for 2015/16 Annual Accounts. Mrs Rutherford pointed out that the submission date for Draft Accounts to NIAO and Department was 3rd May 2016. Members were reminded that Trust’s Charitable Funds account, will again be consolidated with the Public Funds as a result of a change in accounting policy.

iii) Annual Theft & Fraud Report 2014/15. Ref: HSC(F) 12-2016

The above named Finance Circular was presented by Mrs Jones under Item 7 of the agenda.

12. ANY OTHER BUSINESS

None.

The meeting concluded at 12.10 p.m.

The next Audit Committee meeting will be held on Thursday, 7th April 2016, in the Boardroom, Trust Headquarters,

commencing at 10.00 a.m.

SIGNED: _____________________ DATED: ______________________

Audit Committee Minutes 3 March 2016 1 | P a g e

Minutes of a meeting of the Audit Committee held on Thursday, 3rd March 2016 at 9.30 a.m. in the Boardroom, Trust Headquarters

PRESENT: Mrs E Mahood, Non-Executive Director (Chair) Dr R Mullan, Non-Executive Director Mr E Graham, Non-Executive Director Mr J Wilkinson, Non-Executive Director IN ATTENDANCE: Mr S McNally, Director of Finance and Procurement, SHSCT Mrs A Rutherford, Assistant Director of Finance, SHSCT Mrs F Jones, Corporate Financial Accountant/Fraud Liaison Officer, SHSCT Ms J McCaw, Internal Audit, BSO Mr J Murray, Internal Audit, BSO Ms L Neill, External Audit, KPMG Mrs S Judt, Board Assurance Manager, SHSCT Mrs S McCormick, Committee Secretary, SHSCT (Minutes) 1. CHAIRMAN’S WELCOME AND APOLOGIES

Mrs Mahood welcomed everyone to the meeting. She particularly welcomed Mr J Wilkinson, newly appointed Non Executive Director to the Trust. Mrs Mahood advised that three Non Executive Director appointments had recently been made, but unfortunately due to prior diary commitments, two were unable to attend today’s meeting.

Apologies were recorded from Mrs C McKeown, Head of Internal Audit, BSO, Mr J Poole, External Audit, KPMG and Mr T Wilkinson, N.I. Audit Office.




3. UPDATE ON OUTSTANDING INTERNAL AUDIT RECOMMENDATIONS

Mrs Mahood welcomed and thanked Directors for attending the Committee meeting for discussion on this item. She reminded members that following the update provided for the mid-year position in October 2015, it had been agreed that any Director with outstanding internal audit recommendations relating to 2013/14 or prior would be asked to attend the Audit Committee meeting to agree a final position on these with Audit Committee members.

Each Director spoke to their written response to each recommendation which detailed:-

i) Where the recommendation was now complete. Internal Audit

confirmed that they will verify this in their year-end work. ii) Where the recommendation is no longer appropriate, details

were provided as to why. iii) A reasonable explanation as to why the recommendation cannot

be carried out.

A detailed discussion ensued in which members asked Directors a number of questions. Mrs Mahood welcomed this process and discussion to bring final closure on long standing internal audit recommendations for 2013/14 and prior.

4. CHAIR’S BUSINESS

There was no business to report. 5. MATTERS ARISING FROM PREVIOUS MEETING

Mrs Mahood drew member’s attention to the progress updates.


6. FRAUD UPDATE

i) Department of Finance and Personnel Annual Theft and Fraud Report 2014/15 Mrs Jones highlighted the key aspects of the above-named report. In response to a question from Dr Mullan regarding breaches of internet security, Mrs Jones undertook to find out how the Trust addresses potential breaches of I.T. security. Mrs Mahood also undertook to raise this matter at the next Information Governance Committee meeting. Mrs Jones highlighted the fact that a total of 285 referrals were dealt with by the Counter Fraud and Probity Services (CFPS) in 2014/15. Members discussed the fact that health service specific cases was the most common category of cases reported, recording a total of 117 cases. Mrs Jones spoke of the Trust’s risk of exposure to fraud, not only internally, but also externally given the wide range of people the Trust is in contact with. Action: Mrs Jones and Mrs Mahood

ii) Draft Anti-Fraud Policy and Fraud Response Plan Mrs Jones presented the updated Anti-Fraud Policy and Fraud Response Plan. She explained that the policy is intended to provide advice to all Trust staff on their responsibilities to prevent and detect fraud and to report all cases of actual, suspected or potential fraud.

iii) Draft Bribery Policy and Bribery Response Plan Mrs Jones in presenting the above-named documents, stated that the purpose of these is to set out the Trust’s position on bribery and the measures in place to comply with the provisions of the Bribery Act 2010. Mrs Mahood asked about plans to communicate these documents to staff to which Mrs Jones advised that a communication strategy will be put in place.

iv) National Fraud Initiative Update

Mrs Rutherford spoke to the report which summaries the findings of the 2014/15 NFI exercise which was completed on 29 February 2016. Members noted a total of 1,237 matches,


851 of which were reviewed and within that, 18 errors were notified and corrective action taken. One duplicate payment was identified for £2,791 which has been recovered. Mrs Rutherford advised that a new NFI exercise is due to commence in Autumn 2016.

7. UPDATE ON EXTERNAL RECOMMENDATIONS

Mrs Rutherford presented this report and stated there were three priority one issues, all of which require regional input. She referred to the first priority one issue and stated that the Trust remains fully engaged with BSO Payroll Shared Services and have raised a number of issues of concern through various fora with BSO but progress on resolution of these has been very slow. Mrs Rutherford advised this recommendation is not expected to be complete by March 2016. With regards to the priority one recommendation that the Trust works with PaLS to actively monitor contracts so that those which are due to expire are identified on a timely basis, Mrs Rutherford advised that the position remains the same with regard to Trust contract management arrangements and the establishment of a central contracts database. This will be reflected within the Trust Governance Statement. Members noted the update provided on a number of priority two issues. Mrs Rutherford stated that she had received an update from Human Resources advising that from 1 April 2016 the HRPTS system would be amended to ensure that the appropriate pay is calculated when a member of staff is on sick leave, in accordance with the Terms and Conditions of Service. Mrs Mahood welcomed the report and asked Ms Neill if these outstanding recommendations would be reflected within the external audit process at year end. In responding, Ms Neill confirmed that the aforementioned recommendations would be noted.

8. INTERNAL AUDIT

i) Progress Report

Ms McCaw provided a detailed account of progress to date against the 2015/16 Audit Plan. Members noted that four final audit reports had been issued since the previous Audit Committee meeting on


11th February 2016. Ms McCaw stated that five further reports will be presented at the next Audit Committee meeting with the exception of the year end follow up report and the Controls Assurance Standards report. Ms McCaw also stated that four outstanding BSO Shared Service audit reports for 2015/16 will be presented to the Audit Committee at the next meeting on 7th April 2016. Domiciliary Care – Enablecare

Mrs Mahood welcomed Mrs A McVeigh, Director of Older People and Primary Care Services, to the meeting for discussion on the internal audit report on a domiciliary care provider (Enablecare). At the outset, Mrs Mahood recorded her disappointment at the unacceptable level of assurance provided on the system of internal control in Enablecare. At this point, Mrs Mahood requested an amendment to the Committee’s Terms of Reference to reflect that in the event of an Internal Audit Report having an unacceptable level of assurance, the relevant Director will be invited to attend the meeting when the final report is being presented to the Audit Committee for the first time. Members agreed to this proposed amendment.

Mrs McVeigh provided assurance that work was progressing with this provider to address weaknesses identified and confirmed that they have provided an action plan for the Trust’s consideration. Mrs McVeigh spoke of the various mechanisms within the Trust to address the issues and concerns identified. Mrs Mahood stated that she found the comment on page 12 of the report unacceptable in that the Bessbrook office was not aware of the requirement to retain rotas. She also queried who the responsible officer in the Bessbrook office was. Mrs McVeigh undertook to clarify.

In response to a question from Mrs Mahood as to how serious the provider was taking the issues, Mrs Rutherford advised that an unsatisfactory performance notice had been issued to the provider prior to Christmas, followed by the Internal Audit report. The provider was given three weeks to respond to both which they did. A meeting with the provider had been scheduled for 9th March 2016, but this date no longer suits the provider and will be re-arranged. Mr McNally suggested to the Audit Committee that it may be appropriate to apply sanctions if the provider does not resolve the issues to the Trust’s satisfaction within a specified timescale. He


suggested considering an immediate hold on new business with the threat that if no progress is made over 3 months/6 months, then the Trust would move to termination of contract.

Mrs Mahood concluded the discussion by advising that this matter will be further discussed at the next meeting when Mrs McVeigh will be attending to provide an update on progress.

Income & Debt Management 2015/16 A Satisfactory level of assurance was provided on the system of internal control over Income and Debt Management. One priority two weakness was identified. However, a Limited level of assurance was provided on the system of internal control over Income: Provision of Health Services to persons not ordinarily resident. This is on the basis that the process for identifying non UK patients is not sufficiently robust to ensure that all chargeable patients are identified and billed. Discussion ensued around the total value of invoices raised and the responsibility upon General Practitioners (GPs) in the primary sector in conjunction with BSO Medical Registration to ensure such patients are appropriately identified. Mrs Mahood stated the importance of getting the message out to GPs that their current registration processes need to be strengthened. Mr McNally advised that it would be appropriate for the Health and Social Care Board (HSCB) to take the lead on this matter as they have responsibility for commissioning GP services. Mrs Mahood asked about the SHSCT Access to Healthcare Pilot which had commenced in July 2015. In response, Mrs Rutherford advised that the evaluation report covering the initial 6 month period of the pilot would be submitted to the HSCB and Counter Fraud for review.

Management of Complaints 2015/16

A Satisfactory level of assurance was provided on the system of internal control over the Management of Complaints. Two priority one and six priority two weaknesses were identified. Dr Mullan referred to the ongoing work being undertaken by the Assistant Director for Clinical and Social Care Governance and the evolving report to Governance Committee which sets out trends over time in respect of Incidents, Serious Adverse Incidents and Complaints. He pointed out that this report was based on recommendations made in


the Francis report and in line with DHSSPS direction. Mrs Mahood concurred with Dr Mullan’s comments and added the report was a work in progress and improvements continue to be looked at with regards trending and analysis.

Payments to Staff 2015/16 A Limited level of assurance was provided on the system of internal control over Payments to Staff. Three priority one and seven priority two weaknesses were identified. Mrs Mahood expressed her disappointment at the limited assurance and the lack of progress made given that this area was previously audited in 2014/15 when limited assurance was also provided. Members discussed the issues that require regional system solutions and noted that these are being addressed via the regional groups.

ii) Update on Shared Services Reports

There were no reports for discussion under this item.

iii) Internal Audit Plan 2016/17 to 2018/19

Ms McCaw spoke to the above named paper presented to Audit Committee for approval. She explained that the paper sets out the Internal Audit Plan for the next 3 years and was developed to be risk-based, in line with the Trust’s Corporate Risk Register and Board Assurance Framework. Members considered the proposed Internal Audit Plan for 2016/17 on page 20 and the topics to be addressed under i) Finance Audits, (ii) Corporate Risk Audits and (iii) Governance Audits. Mrs Mahood welcomed the scope of topics to be audited within the plan. Members approved the Internal Audit Strategy and Audit Plan for 2016/17 to 2018/19

9. APPROVAL FOR WRITE OFF OF LOSSES

Mrs Jones presented the schedule of losses totalling £2,157,468 for the 10 months ended 31 January 2016, together with a brief narrative. Mrs Jones provided assurance that the losses have


been subjected to and controlled by the Trust’s detailed procedures and will be subject to External Audit as part of the audit of the annual accounts. Mrs Jones drew attention to the figure of £163,689 recorded as Health Centres – GPs debt. She explained that this was an error and should not have been included within the report. Members noted the write off figure for Clinical Negligence payments for the period 1 April 2015 to 31 January 2016 was calculated at £1,397,618. In conclusion, Mrs Mahood reminded members this was a preliminary paper and a final report on the Write Off of Losses 2015/16 would be considered by Audit Committee at the meeting scheduled for 7th June 2016 for onward submission to Trust Board for formal approval.

10. REVIEW TERMS OF REFERENCE

Members reviewed the Terms of Reference and approved the proposed changes. Mrs Mahood referred to the earlier discussion regarding internal audit reports with an unsatisfactory level of assurance and requested an additional amendment reflecting the requirement for Directors to attend Audit Committee when these reports were being presented for the first time. Mrs Judt agreed to further amend the Terms of Reference and bring back to the next meeting on 7th April 2016 for approval. Action – Mrs Judt


At this point, Mr McNally referred to earlier discussion in the meeting with regards to outstanding audit recommendations relating to 2013/14 or prior and asked for clarity that the Committee were content with the update provided and are happy that old Internal Audit recommendations are accepted as closed. It was agreed that subject to confirmation by Internal Audit as part of the year end follow up work, Audit Committee members would accept the recommendations as closed. Ms McCaw confirmed that this would be included as part of the Internal Audit follow up and reported on at the Audit Committee meeting, scheduled for October 2016.


Mrs Mahood referred to the next meeting scheduled to take place on Thursday, 7th April 2016. She referred to the recent appointment of three new Non-Executive Directors to the Trust and advised that an Audit Committee Induction session would take place from 9.00 a.m. – 10.00 am prior to the commencement of the Audit Committee meeting. Mrs Mahood advised that this would be Mr Graham’s last Audit Committee meeting as he would be taking up membership of the Remuneration Committee. Mrs Mahood recorded her thanks to Mr Graham for this contribution and support to the Audit Committee in the past.

The meeting concluded at 1.00pm

SIGNED: ____________________ DATED: ____________________

Audit Committee Minutes – 7th

April 2016 1 | P a g e

Minutes of a meeting of the Audit Committee held on Thursday, 7th April 2016 at 9.30 a.m. in the Boardroom,

Trust Headquarters

PRESENT: Mrs E Mahood, Non-Executive Director (Chair) Dr R Mullan, Non-Executive Director Ms E Mullan, Non-Executive Director Mrs H McCartan, Non-Executive Director Mr J Wilkinson, Non-Executive Director IN ATTENDANCE: Mr S McNally, Director of Finance and Procurement, SHSCT Mrs A Rutherford, Assistant Director of Finance, SHSCT Mrs F Jones, Corporate Financial Accountant/Fraud Liaison Officer Mrs C McKeown, Internal Audit, BSO Ms L Neill, External Audit, KPMG Mr J Poole, External Audit, KPMG Mr R Ross, External Audit, NIAO Mrs A McVeigh, Director of Older People & Primary Care, SHSCT (item 4) Mrs M McClements, Assistant Director of Older Peoples Services (item 4) Mr B Beattie, Assistant Director of Primary Care, SHSCT (item 4) Mrs S Judt, Board Assurance Manager, SHSCT Mrs S McCormick, Committee Secretary, SHSCT (Minutes) APOLOGIES None. 1. CHAIRMAN’S WELCOME

Mrs Mahood welcomed everyone to the meeting. She particularly welcomed new Non-Executive Directors, Ms E Mullan and Mrs H McCartan to their first Audit Committee meeting.





3. CHAIRMAN’S BUSINESS

None.

4. INTERNAL AUDIT REPORTS WITH UNACCEPTABLE ASSURANCE

Older People & Primary Care Directorate – Enable Care 2015/16

Mrs Mahood welcomed Mrs McVeigh, Director of Older People and Primary Care to the meeting along with colleagues, Mrs McClements and Mr Beattie. Mrs Mahood reminded members that Mrs McVeigh had attended the previous Audit Committee meeting following the release of the Internal Audit Report on domiciliary care provider (Enable Care) when an unacceptable level of assurance was provided. She emphasized the seriousness of the issues raised within the IA report and welcomed the update report provided by Mrs McVeigh which demonstrated a lot of work had been undertaken to achieve progress and facilitate better controls. Mrs McVeigh thanked Mrs Mahood for the opportunity to address the Committee and stated that it was important to note that Enable Care is one of a number of independent sector providers with whom the Trust have domiciliary care contracts in place. She referred to the presentation to follow and added that it would provide assurance to members that the Trust has good systems and processes in place that assist the work with all of its independent agencies. At this point, Mrs McClements provided a comprehensive update on Enable Care. She began by assuring members that although a number of control weaknesses had been identified regarding, communication/monitoring and poor schemes and processes, it should be noted that the provider had a high client satisfaction level with care delivery being well received in the most part. Members considered the detailed timeline of relevant events and the update on recent progress.



In answer to a question from Mrs McCartan regarding the gaps identified around hours worked and paid for, Mrs McClements acknowledged this to be a concern as many agencies only pay workers for care deliver time, not travel time or mileage costs. Mrs Mahood referred to the performance management strategy and asked, when concerns were raised, what was the time frame before a performance management notice would be issued to the provider. Mrs McClements advised that this was dependent on the seriousness of the issues identified rather than a specific time frame. Members spent some time discussing the contractual options available to the Trust and legal advice received from DLS. Mrs McClements advised that the Trust would continue along the performance management route however some sanctions can only be imposed following default by the provider on total failure to provide services. Members were advised that the HSCB have agreed to review this regionally within the contract review. Mr McNally advised that he would take the matter up regionally with Directors of Finance to establish if the current contract terms created difficulty for the other Trusts. Ms Mullan asked for clarity on the ownership of the contract to which Mr McNally advised that the contract was owned by the Trust, however he was of the opinion that the period of time which had elapsed before the Trust could demand action was too long and therefore restricted the options available. Mr McNally referred to the timeline of events from July 2013 – April 2016 and the issue of the length of time it had taken for the provider to respond to the Trust and asked at what point was it appropriate to apply sanctions if issues not resolved. Mr Wilkinson concurred with Mr McNally’s comments and asked for clarification as to the next steps. Mrs McVeigh referred to the performance management approach as outlined earlier by Mrs McClements and then if necessary progress to sanctions, however concrete evidence of breach or failure to remedy would be required. She stated that in line with advice from legal services the matter would be managed on a day to day basis between the Trust and the Independent Sector. A detailed action plan has been submitted which is acceptable to the Trust. Mrs McVeigh spoke of the daily challenges in balancing the provision of high quality care with capacity issues and she referred



to Trust contingency planning and the recent tender for additional providers and Trust recruitment. A full Trust procurement of domiciliary care contracts will take place within the new financial year. She pointed out that the Trust had no care issues with the provider, they continue to evidence improvements and are working with RQIA. Ms Mullan asked if performance management had related to care delivery would the same approach have been taken. Mrs McVeigh provided assurance that all care issues are followed up and dependent on their nature, may require investigation under adult safeguarding. Non-Executive Directors recorded their concern at the amount of in-house resource required to support this level of Governance and they found this to be unacceptable. Mr Poole asked if there were lessons to be learned from the length of time this process has taken and pointed out a new contract would offer the Trust greater scope in terms of being able to move more quickly. In concluding discussion, Mrs Mahood emphasized that it was important performance management should continue and she asked for reassurance that the provider is taking the issues seriously and progress is being achieved. In responding, Mrs McClements assured members that Invoicing and Contract compliance rates are improving and the provider is aware of their obligations. Mr Beattie assured members that the Trust had acted immediately once gaps had been identified at monitoring level and improvements are being made regarding picking up issues in a timely way. Mrs McVeigh added that the Trust has good checks and balances in place for monitoring in-house provision as well as independent provision and work remains ongoing as to how the monitoring of independent sector provision can be strengthened. Mrs McKeown advised that IA would return to Enable Care and carry out some follow up work around July/August 2016.

5. MINUTES OF MEETINGS HELD ON 11TH FEBRUARY 2016 AND

3RD MARCH 2016

The minutes of meetings held on 11th February 2016 and 3rd March 2016 were agreed as an accurate record and duly signed by the Chairman.



6. MATTERS ARISING Mrs Mahood drew member’s attention to the progress updates.

Mrs Jones referred to previous discussion at the meeting of 3rd March 2016 when Dr Mullan raised breaches of internet security. Mrs Jones stated that she had spoken with the Trust IT security manager in the context of email phishing who had advised her that the Trust have an email gateway in place to assist in the detection of such virus. The Trust Cyber Incident Response team is also in place. Mrs Jones assured members that staff are reminded to be vigilant and referred to a recent global email that was communicated alerting them to one such scam. Mrs McKeown referred to a previous action from the meeting of 11th February and advised that she had sought clarification from BSO as to whether they would provide an overall level of assurance, specifically for shared services audits at year end. Mrs McKeown stated that any assurance would be included in a letter to the Trust detailing Internal Audit and External assurance audit opinion but overall opinion would not be received from BSO management.

7. FRAUD UPDATE

Mrs Jones spoke to a detailed update which included 22 reported fraud cases during 2015/16. She advised that this list provides a flavor of some of the cases Access to Healthcare has been picking up. Mr McNally referred to earlier comments by Mrs McCartan regarding the strain that is put on resources/manpower generating time to investigate some issues. He alluded to a pilot scheme undertaken recently and stated that moving forward some consideration would be given to how some of these suspected fraud cases are investigated in the future. Mr McNally referred to case no. 4 within the report and advised that this was an Estates minor works issue. He stated that Internal Audit had undertaken an audit of Estates Contracts and their report would be reviewed by Audit Committee at the next meeting in May 2016. Mrs McKeown added that the IA report mentioned by Mr McNally does not refer specifically to this case but there are similarities. Ms Mullan asked if the number of fraud cases reported were consistent across the Trust’s and if so suggested that it may be



worth considering raising options on how to best manage this process across the region. Mrs McCartan suggested that it would be helpful if a quantifiable value could be included within future reports to establish the materiality of some of the cases under investigation by the Trust. Mrs Jones agreed to take this suggestion on board. Action – Mrs Jones

8. INTERNAL AUDIT

i) Internal Audit Progress Report

Mrs McKeown reported on progress to date against the 2015/16 Audit Plan and 1 final audit report issued since the Audit Committee last met on 3rd March 2016. Members noted that the remaining 6 outstanding reports will be presented ahead of the next Audit Committee meeting on 5th May 2016. Mrs McKeown referenced the BSO Shared Service Audits and reminded members that Mr McNally will receive the full report once finalised and Audit Committee will review a summary report. Asset Management 2015/16 A Satisfactory level of assurance was provided in relation to Asset Management on the basis that records in relation to procedures, asset additions to RAMS and depreciation and indexation calculations were complete and accurate. However, controls require strengthening over physical verification of assets by Estates team and annual checks on assets by their Asset Controllers. One priority 1 and 4 priority 2 issues were identified. Members briefly discussed the 2 system approach currently being used to manage and track assets across the Trust, (BackTraq and RAMS) and the challenge this presents. Dr Mullan asked about the disposal of assets and pointed out that this information should automatically pass from Estates to Finance colleagues. Mrs Rutherford acknowledged a breakdown in communication had been identified through audit testing. She stated that mechanisms had been put into place to improve this and referred to the new monthly report process established by Estates to inform disposals to Finance. This



process will be reflected in the updated Capital assets procedures manual to be completed by March 2016.

ii) Update on Shared Services Reports No reports were presented for consideration under this item.

9. REVISED TERMS OF REFERENCE

Members reviewed the Committee’s Terms of Reference. Mrs Mahood pointed out the proposed amendment regarding IA report’s presenting with an unacceptable level of assurance. Members agreed to the proposed amendment.


Mrs Mahood noted that the interim external audit work was completed and asked KMPG if they had anything to report. Ms Neill advised that they had nothing to report at this stage and would be on site from 3rd May 2016. Mrs Mahood reminded members that in keeping with good practice procedures, Audit Committee would review the draft accounts for the year ending 31 March 2016, at the next meeting on 5th May 2016.

The meeting concluded at 12.10 p.m.

SIGNED: __________________ DATED: __________________

report summary sheet_board_committees.pdfmr j murray, internal audit, bso ms l neill, external...

Documents