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Chairpersons Report Chairpersons Name Carole Hudson Committee Name Audit Committee Date of Meeting 07.12.16 Name of Receiving Committee Trust Board Date of Receiving Committee meeting December 2016 Strategic Items for referral to Trust Board Na. Items for escalation? Na.

Please detail the key successes or achievements discussed at the meeting 1. Quality and progress of work undertaken by legal services 2. Quality of risk management process and continuing identification of risk and mitigation 3. Maintenance and monitoring of the Raising Concerns policy and register by HR 4. Progress on audit recommendations

Details of the top risks identified during the course of the meeting and initials of primary member of staff actioning 1. No accurate repository for the replacement of assets (both medical and non-

medical). The process explained gave some comfort but was not comprehensive or consistent

DH / DE

2. Concern about asset registers being sufficiently maintained with reference to the Trusts SFI’s

DH / DE

3. Lease agreement for assets not routinely entered on systems but the policy was now being updated

DH / DE

4. Risks associated with HIS e.g. Consultant use SA 5. Gaps identified in the policy for compliance with conflicts of interests and the

requirement for an overarching policy as described DN / CR

6. Laser safety report and the lack of assurance that this was being operated and maintained safely

Surgery

Attendance at the meeting (please highlight):

Excellent (well attended)

Acceptable (some apologies)

x

Unacceptable (quorate)

Unacceptable (not quorate)

Was the agenda fit for purpose and reflective of the Committees terms of reference?

Yes

Narrative report of the key issues of the meeting

Discussion as per the detail contained in the Audit Committee minutes below.

Key outcomes from the reports taken at the meeting Agreement by the Committee that there would be the following taken at the next meeting:

Deep dive of the IT Disposal policy, monitoring of IT Disposal Policy and compliance with SFI’s Progress on updating the SLA register Chief Executive attendance to demonstrate his compliance with best value Review of how assets are replaced in accordance with section 13.3.3 of SFIs

Agreed actions from the meeting Name of primary lead for the actions The Committee to be updated with regard to the GS1 application in terms of timescales for delivery

D Hughes

D Hughes / D Evans to give consideration to the inclusion of a risk around the fragmented process to the risk register

D Hughes / D Evans

S Arya to raise issues around identification of the lead Consultant on the documentation on the HIS system

S Arya

D Evans to check E&F involvement in the maintenance of the laser equipment and whether this was on the RAM

D Evans

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system D Pullen to include C Ryan on the distribution for the PARC agendas

D Pullen

D Hughes to speak with Procurement regarding the detail to be added to the waiver report

D Hughes

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MINUTES OF A MEETING OF THE AUDIT COMMITTEE HELD ON WEDNESDAY, 7 DECEMBER 2016 AT 9.30AM

IN THE THQ BOARDROOM

1. COMMITTEE CHAIRS OPENING REMARKS

C Hudson welcomed all to the meeting. She noted that the agenda was busy but felt that the Committee would be able to stay within time constraints.

2. APOLOGIES As noted above.

3. DECLARATION OF INTERESTS

None declared.

4. APPROVAL OF MINUTES OF MEETING ON 05.10.16 The minutes were agreed to be an accurate record.

PRESENT 2016

03 02

02 03

04 05

18 05

03 08

05 10

07 12

Mrs C Hudson (Chair) NED √ √ √ √ √ √ √ Mr N Turner NED √ √ √ √ √ APOLS APOLS Mr N Campbell NED APOLS √ √ APOLS APOLS √ √ Mr M Guymer, NED √ APOLS √ √ √ √ √ IN ATTENDANCE

Mr R Forster, Director of Finance / Deputy CEO APOLS APOLS APOLS √ APOLS APOLS APOLS

D

Hughes

Mrs Pauline Law, Acting Director of Nursing √ √ Not

required √ Not

required

Not

required

Not required

Mrs H Hand, Trust Board Secretary √ APOLS APOLS APOLS APOLS APOLS - Mrs C Ryan, Counter Fraud √ √ √ APOLS √ √ √ Ms D Wright, Deloitte √ √ APOLS √ APOLS - - Ms L Warner, Internal Audit Manager √ √ √ √ √ √ √

Mrs L Hancock, Corporate Services Administrator √ √ √ √ √ √ √

Claire Alexander, Head of Governance and Assurance √ √ √ √ √ √ APOLS

Shirley Martland, Financial Controller √ √ √ √ √ √ APOLS

Alison Balson, Director of HR APOLS

VM √ √ APOLS

SM

APOLS

VM

Not

required

Not

required

Umesh Prabhu, Medical Director √ APOLS √ APOLS

MF

APOLS - -

Steve Connor, Deputy Director MIAA √ √ APOLS APOLS √ APOLS APOLS

Carolyn Wood, Deputy Director of Finance √ √ √ √ APOLS √ APOLS Mary Fleming, Interim Director of Performance and Ops

√ APOLS

DE

Not

required Not

required

Not

required

Not

required

Not

required

Richard Mundon, Director of Strategy and Planning √ APOLS APOLS APOLS √ √ √ Deborah Pullen, Compliance Lead √ √ √ √ APOLS √ √ Paul Thompson, Deloitte - √ √ √ √ √ √ Paul Hewitson, Deloitte - - - - - √ √ David Evans, E&F - - - - - - √ Dave Nunns, Interim Board Liaison Officer - - - - - - √

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5. MATTERS ARISING

a. Action log 05.10.16

Action updates were received and noted. The WHO safety checklist update was received and the progress noted by the Committee

b. Work plan 16/17 The work plan was received and noted.

6. DEEP DIVE INTO COMPLIANCE WITH THE MEDICAL EQUIPMENT DISPOSAL POLICY

C Hudson noted that the requirement for this had arisen at the last meeting due to the sale of some scopes that were on lease. The Committee were seeking assurances that the SFIs were being complied with when equipment was sold. The Committee had also requested a review of compliance with the IT disposal policy which hadn’t been available for this meeting and had been deferred to the next. D Hughes advised that the specific issue around the sale of the leased scopes had been due to human error. It had been believed that these were owned by the Trust and the error only came to light when the lease company contacted the Trust with regard to the return of the equipment. He noted that steps were now being taken to amend the disposal policy to include checks with both Finance and Procurement to fully clarify whether the items were leased or owned before sale.

D Evans advised that the items had been leased some years ago and hadn’t been recorded. Even the Endoscopy department hadn’t been aware that the items were leased. This had highlighted a gap which was now being addressed by the amendment of the policy. He noted that, in the past, the Trust had never leased equipment but, with capital constraints, the need to lease items would increase so it would be important to address this issue. D Hughes noted that an asset register (RAM system) was held in Finance but this was only for items purchased via the capital route. Historically this had not been well maintained with items grouped together. This had been raised by Deloitte and internal audit reviews and action had been taken to improve the position. There was not a complete process in place to enable a central view of asset end of life and the replacement requirements however; D Hughes noted that there were a number of different processes and procedures in place to try to capture this information:

The newly formed Capital Committee – this reports into F&I and is attended by operational owners of capital items. It holds responsibility for looking after the capital programme throughout the year

Capital Medical Equipment Group – this looked after the three clinical Divisions and enabled a feed through of requirements

Capital planning and risk assessments – this was a detailed process that fed into the 5 year

plan. Each capital requirement was required to go through a risk assessment which then went to Management Board for agreement on the capital priorities for the year

Policies – policies were in place Asset tagging - this had not been done well previously but improvements were now being

made

External reports – the Trust had external assistance from Deloitte MIAA. There had also been a review by a company called Getinge and the report was expected soon

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Medical Electronics – a RAM system was also in place for this. The registering of devices was now much better than it was historically with over 21,000 items of equipment now on the system. The system picked up both revenue and capital purchases

Medical equipment management group – currently each ward and department are responsible

for replacing their own equipment and it is also their responsibility to notify medical electronics. Therefore asset tracking was very challenging. A working group had been established with a view to centralising this but it would require additional resourcing and a business case was being produced

M Guymer queried if there was the possibility of the two RAM systems linking together. D Hughes advised that it could be linked but there would be a cost implication. D Hughes added that the majority of IT assets were on the capital system. C Hudson queried how it was possible to fulfil Health & Safety expectations if wards were responsible for ordering their own equipment. D Evans advised that anything purchased via procurement was notified to the medical electronics team for pre-testing. All PAT testing was carried out by an external supplier on a schedule.

D Evans further noted that there was a central loan store which was responsible for the loan of key pieces of equipment. This worked well and ensured that the necessary checks to the equipment could be made. C Hudson advised that she heard the loan store being commended by staff. M Guymer felt assured that all reasonable endeavours were being made to mitigate the risks to the fragmented nature of the process. He felt it would be useful for the Committee to have an understanding of when the GS1 application was expected. He felt this would bring a step change in the ability to track assets and to understand risks. D Hughes advised that there were also solutions provided by Teletracking and Allscripts that could help with this. P Thomson agreed that Deloitte had raised some issues in the past but these had been considered by management. External Audit was happy from a fixed asset accounting view and were satisfied that reasonable steps were being taken. The Committee thanked D Hughes and D Evans for their report and were content with the actions being taken. It was noted that the process was very fragmented and there were some risks arising from this, even though mitigating steps were being taken. The Committee agreed that it would be useful for these to be included on the risk register.

ACTION: The Committee to be updated with regard to the GS1 application in terms of

timescales for delivery D Hughes / D Evans to give consideration to the inclusion of a risk around the

fragmented process to the risk register

7. CORPORATE GOVERNANCE

a. Legal Services Half Year Report N Halpin was in attendance to present the report and advised the Committee of the following key points:

There continued to be a trend of decreasing claims being brought against the Trust The number of clinical negligence claims had reduced but Surgery continued to have

the most claims. Work was being undertaken with the Division to learn lessons Whilst there had been a reduction in claims, there had been a slight rise in the

number of claims resulting in payments but these were not at the level of previous years

There had been a reduction in non-clinical claims with reduced employers liability claims; only one claim had been settled in the first half of the year. There had been no public liability claims

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There had been a rise in the number of inquests and a change in the Coroner A meeting had taken place with the Coroner in June. This had been a positive

meeting and the Trusts concerns with regard to the number of clinicians called to attend inquests had been noted

The Trust had received a PFD in the first half of the year due to concerns around weekend staffing and care at the weekends. There had also been some concerns around MEWs scoring. An action plan had been drawn up and was being monitored via Q&S Committee

There had been a rise in the number of ex gratia payments in the first half of the year. This mainly related to mix ups and cancellation of appointments. Work was being undertaken with the Divisions on this

The NHSLA contributions had increased slightly The Implementation of HIS had been a concern as coroners were not willing to

access the system and still requested hard copies of the case notes which impacted on resources and finances. This would be discussed with the Coroner in the New Year

C Hudson noted the reference to some clinicians not using HIS and advised that she had not seen this raised as a risk. N Halpin advised that a lot of the notes on the system were being typed by junior doctors and they were not always identifying the lead clinician. This had been raised with Consultants. S Arya advised that he would raise the point at the CAB meeting later that afternoon. R Mundon advised that he would be happy to pick up behavioural issues in relation to HIS as part of the overall HIS risks. D Pullen was pleased to note the reduction in clinical negligence claims and thanked E&F for their hard work on managing the estate to reduce the non-clinical claims. She queried whether ex gratia payments were paid centrally or by the Divisions. N Halpin advised that the Divisions paid these. The Committee thanked N Halpin for an excellent report which contained a great level of assurance. ACTION: S Arya to raise issues around identification of the lead Consultant on

the documentation on the HIS system

b. Losses and compensations ending September 2016 The report was received and noted by the Committee.

c. Schedule of Matters

D Nunns presented the paper to the Committee. He advised that this was a document that required updating every year and which formally defined the decision making powers held by the Board and the Governors. C Alexander had reviewed the document and made amendments as necessary. She had identified a gap around the arrangements for the Shared Services Board. R Mundon had since clarified that there were some changes taking place with regard to this meeting which would be included once finalised. The Committee were asked to approve the schedule of matters pending this amendment. The revised Schedule of Matters was approved.

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d. Gifts and Hospitality Register / Conflicts of Interests D Nunns presented the latest version of the Gifts and Hospitality Register to the Committee. This was received and noted for information. The Committee were pleased to note the improving position although it was noted that there was still work to be done around the pharmaceutical declarations.

The Committee also received and noted the paper submitted by D Nunns and C Ryan in relation to the G&H Policy and Practice Update. The paper provided an update on progress against the recommendations made by MIAA during their review and outlined the work being undertaken to produce a revised G&H policy and SOP for approval in early 2017. The paper further made the recommendation for work towards a Trust wide Conflicts of Interest policy and SOP which would encompass Gifts and Hospitality, Corporate Sponsorship, Secondary Employment and Private Practice.

The Committee noted its support of the proposals outlined and the belief that the processes would be much stronger with a combined policy.

e. Monitor Q2 return The report was received and noted. This would be the last report of this kind to be produced as NHSI had revised their monitoring requirements.

f. Update on the medical cover at Wrightington risk S Arya noted that this matter had been a cause for concern for some time due to the impact on patient care. Care of the Elderly Consultants continued to provide cover Monday to Friday, despite staff shortages, but there were gaps at weekends and out of hours. Medicine had given Wrightington one of their Ortho - geriatrician posts to advertise but this had not attracted any candidates yet. Alternative models of care were being considered including the use of Anaesthetists and the critical care outreach team. The Committee thanked S Arya for his update and noted the requirement for further updates in the future.

8. RISK MANAGEMENT

a. Review changes in policy which may affect compliance (for information)

No items this meeting.

b. Consider adequacy of all policies

No items this meeting.

c. Risk escalations / referrals No items this meeting.

d. REMC minutes The REMC minutes were received and noted. R Mundon noted that there was robust discussion around the risk register each month. He noted that the risk around APLS training was on track and the risks around paediatric staffing and child safeguarding training were making good progress. New risks had been added in relation to asbestos in subways and basements across the Trust and adolescent and child

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mental health beds. R Mundon highlighted that there hadn’t been an IM&T representative present. He felt that this was a risk due to the level of HIS risks. The SLA process had also been discussed. C Hudson was pleased to note the discussion around the SLA register and noted that the Committee would need to understand the solution and timescales. R Mundon agreed that a full report would be provided in due course. C Hudson noted the risk around the reliability of mammogram equipment. She noted that this was an area the Trust was keen to expand. R Mundon agreed and advised that the risk was being taken very seriously. The Committee thanked R Mundon for his report.

9. INTERNAL AUDIT

a. Internal Audit progress report

The report was received and noted. L Warner noted that there was only one report this time with regard to laser safety which had provided limited assurance. The Trust had requested that MIAA undertake this review as they were aware of the potential issues in the area. The review had highlighted issues around a lack of evidence of training, lack of evidence that regular maintenance checks were undertaken and the frequency and quality of the Laser Safety Committee meetings. Responses had been received back from management to address this and MIAA would follow up in due course. The Committee were concerned that the report did not give assurance that procedure was being followed correctly.

D Evans was not aware that E&F had been involved in this and felt that this was in relation to the local checks that were carried out by the team involved. However, he noted that he would look to see if there was anything that E&F should have been undertaking around this and whether it was recorded on the RAM system. L Warner noted that Surgery were leading on the management response. D Pullen noted that the issues around this had been escalated by the H&S Manager of the Trust which demonstrated that the escalation procedures were working well. She advised that all actions in relation to Boston House had been undertaken and that the issues raised in the report were around the use of the equipment rather than the maintenance of it. The Committee felt that the process seemed fragmented and were seeking assurance that equipment in its totality was being maintained and used in conjunction with Trust rules. They would be seeking assurance around this. The Committee felt that the report was good and thorough, albeit that the outcome had now been positive. ACTION: D Evans to check E&F involvement in the maintenance of the laser

equipment and whether this was on the RAM system

b. Internal Audit tracking report The report was received and noted. The Committee were pleased to note the good progress being made in clearing actions, particularly the closure of the actions around car parking.

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c. MIAA Insight Audit Committee update paper The paper was received and noted.

10. EXTERNAL AUDIT The draft External Audit plan was received and noted. P Thompson noted that this was the first draft of the plan and would be amended to take account of NHSI guidance when this was received. Guidance in relation to Quality Accounts was still awaited. He felt that, in comparison to other Trusts, WWL was in a stronger position but Deloitte would continue to keep the Trust under close review. P Hewitson noted that the estimate of materiality for the year had increased to £5.7m for the year. This had not been increased in other organisations and it was felt that WWL presented less of an audit risk than others. He queried if the Committee were comfortable with this. The Committee approved the materiality level. P Hewitson then went on to describe the main areas of focus for audit. These were supported by the Committee. C Hudson believed the plan to be very thorough and challenging. The Committee agreed that it was happy with the proposed approach and the report provided.

11. COUNTER FRAUD PROGRESS REPORT

The report was received and noted. C Ryan advised that there continued to be an increase in referrals and there had been a third whistle blowing allegation for the year. She would be working with the Trust to fraud proof relevant policies. D Pullen advised that she would forward PARC agendas to C Ryan to enable access to policies as they came through for approval. ACTION: D Pullen to include C Ryan on the distribution for the PARC agendas

12. CHAIRS REPORTS OF OTHER SUB COMMITTEES

The Committee received and noted the reporting Committee Chairs reports.

13. SINGLE TENDER WAIVER REQUESTS

The single tender waiver requests were received and noted. M Guymer noted the appointment of a clinical independent medical review outside of normal procedure due to timescales and queried the rationale for this. D Pullen explained that this was in relation to a serious complaint that would be subject to a Coroner’s inquest. The review had been expedited to satisfy the family and to tie in with the Coroner’s court. A list of experts had been provided to the family for them to choose from. M Guymer accepted the explanation and felt that it would be useful to include this detail in future reports.

The report on the tender waiver limit was received and noted. The Committee accepted the recommendation that this should remain at £5k. ACTION: D Hughes to speak with Procurement regarding the detail to be added to the

waiver report

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14. ANY OTHER BUSINESS There were no further items raised for discussion.

15. KEY SUCCESSES / RISKS

Key successes were agreed to be:

Quality and progress of work undertaken by legal services Quality of risk management process and continuing identification of risk and mitigation Maintenance and monitoring of the Raising Concerns policy and register by HR Progress on audit recommendations

Key risks were agreed to be:

No accurate repository for the replacement of assets (both medical and non-medical). The process explained gave some comfort but was not comprehensive or consistent

Concern about asset registers being sufficiently maintained with reference to the Trusts SFI’s Lease agreement for assets not routinely entered on systems but the policy was now being

updated Risks associated with HIS e.g. Consultant use Gaps identified in the policy for compliance with conflicts of interests and the requirement for

an overarching policy as described Laser safety report and the lack of assurance that this was being operated and maintained

safely

C Hudson queried whether the amount of training given to medical staff with regard to Trust SFI’s was satisfactory. S Arya provided assurance to the Committee that every Clinical Director was being involved in the management of their budgets. He would be looking to ensure a Consultant wide understanding of finance and assured the Committee that this would be taken forward.

Items for consideration at the next meeting would be:

Deep dive into compliance with the IT Disposal Policy Progress report on the SLA register IA Audit plan

C Hudson was also giving consideration to inviting the CEO to attend the next meeting.

16. COMMITTEE EFFECTIVENESS FEEDBACK

C Hudson thanked all for their attendance and input into what had been some excellent discussions.

17. DATE AND TIME OF NEXT MEETING

1st February 2017, 9.45am, THQ Boardroom.