DRAFT ANNEX 1

WELSH AMBULANCE SERVICES NHS TRUST

MINUTES OF THE OPEN MEETING OF THE AUDIT COMMITTEE OF THE WELSH AMBULANCE SERVICES NHS TRUST HELD ON THURSDAY 8

JANUARY 2015 AT TRUST HEADQUARTERS, ST ASAPH WITH A VIDEO CONFERENCING LINK TO VANTAGE POINT HOUSE, CWMBRAN AND

AMBULANCE CONTROL, LLANFAIRFECHAN PRESENT :

David ScottPam Hall John MorganMartin Woodford

Non Executive Director and ChairNon Executive Director Non Executive Director (VC, VPH)Non Executive Director (VC, VPH)

DScPHJMMWo

IN ATTENDANCE :

Rees BatleySimon CooksonJillian GillDave HarriesJohn JonesMichael JoseOssama LotfyPatsy RosebladeDawn SharpVirginia StevensJonathan SweetDavid ThomasMelanie Watson

KPMG (VC, VPH)Director of Audit and Assurance (ABM, NWSSP) (VC, VPH)Financial Accountant Head of Internal Audit Corporate Accountant Staff Side representative (UNISON) (VC, VPH)Principal Auditor Director of Finance and ICT (VC, VPH)Corporate Secretary KPMG (VC, VPH)Staff Officer (VC, Control at Llanfairfechan)Engagement Director, Wales Audit Office (VC, VPH)KPMG (VC, VPH)

RBSCJGDHJJMJOLPRDShVSJSDTMWa

APOLOGIES:

Mike CollinsEmrys DaviesLynne Haddow

Director of Service DeliveryNon Executive Director Counter Fraud Specialist

MCEDLH

1/15 PROCEDURAL MATTERS

DSc welcomed all to the meeting and confirmed that the meeting was being recorded. The Minutes of the meeting of the Open and Closed sessions of the Audit Committee held on 23 October 2014 were confirmed as a correct record subject to the following observations:

PH referred to Minute 26/14 and sought clarity in terms of whether the reference to ‘current ratings system being reviewed’ should be annotated within the Action Log. DH confirmed that the risk ratings were based on individual recommendations and would be reviewed on an individual and case by case basis.

In terms of the Counter Fraud report PR explained that due to the Christmas break and as there was nothing significant to report it had been decided not to submit a late paper to this meeting.

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DSc referred to the Action Log and Members were provided with the following updates:

DSh explained that the Infection Prevention Control update had been transferred onto the Audit Tracker Tool and it was agreed there was no requirement for the Director of Quality and Nursing to attend the meeting. In future it was agreed that should there be limited progress within a particular area being audited, the appropriate Director would be asked to attend and provide an explanation.

DSh informed the Committee that the Corporate Risk Register (CRR) had been presented to the Executive Team on 7 January 2015 where after a detailed discussion it was updated. However, due to a technical problem with opening the CRR it had not been possible for Members to view it. PR informed the Committee that the CRR had been updated to reflect details following her meeting with the Ambulance Services Commissioner yesterday with regard to the Trust’s forecast deficit.

RESOLVED: That

(1) the Minutes of the meeting of the open and closed sessions of the Committee held on 23 October 2014 be confirmed as a correct record; and

(2) a copy of the updated CRR be circulated to Members of the Committee as soon as possible.

2/15 INTERNAL AUDIT PROGRESS REPORT

DH provided the Committee with an overview of the findings from the following reviews:

Environmental Sustainability - Minor issues with regard to the accuracy of information in terms of fuel consumption and waste had been highlighted which had subsequently been corrected for the annual report. Furthermore, the report fell within the remit of Estates but it was much wider than that and he wanted to see greater input from other areas on the development of greater sustainability which would be used for input into the annual report.

The following comments were raised by Members as follows:

MWo queried whether, in terms of the Trust’s overall approach to sustainability should the Board give further consideration to the issue, given that it appeared to be heavily orientated towards Estates areas only. PR advised the Committee that the Trust employed a person for one day a week who had completed a significant amount of work at BCU in this area. PR was satisfied that as many different areas as possible were being captured, however felt that more exposure on this matter was still required.

DSc referred to fuel consumption and sought clarity on the amount used being reported. DH advised that this was simply an administrative error which had since been rectified and reported correctly within the Annual report.

DSc brought Members’ attention to paragraph 8.iii of the report and asked for clarity in understanding what was meant. DH agreed to re-word to make it more understandable.

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Community First Responder

DH explained that the policy had been reviewed and added that within it there had been some significant challenges set by the Trust for it to deliver against the requirements contained in it. The review had identified significant issues in terms of the Trust’s ability to show that correct processes in the following areas had been followed:

Training Assessments Identification cards Vehicle Driving checks Equipment Disclosure and Barring Service Inappropriate Despatches to patients

DSc welcomed questions and comments from Members of the Committee:

PH asked whether checks were carried out on other Trust policies to identify if they were challenging. DH confirmed that this undertaking was not routinely carried out, however, should the Trust require it this could be arranged. JS agreed that this was a challenging policy in terms of the governance in managing CFR’s and should it be compared to other Trusts it would be on par.

JM commented that the management response had been very good and welcomed the fact that JS was in the process of implementing a CFR development programme which would incorporate measures to address the issues brought forward from the review.

JS provided the Committee with an update on the action/s each of the recommendations: Recommendation 1 - a draft interim policy was being developed and would be submitted to the next QDC meeting for consideration. DSh queried whether the policy would be available for presentation to the Trust Board on 23 January 2015 and whether the policy would have followed the necessary governance procedures. It was confirmed that the interim policy would be presented at QDC on 27 January 2015 and would be implemented by that Committee.

Recommendation 2 - a standardised refresher training package had been developed which included the checking and capturing of all the required documentation.

Recommendation 3 - the standardisation of the Safeguarding and Violence and Aggression training was currently being developed and as an interim measure, handbooks had been distributed to CFR scheme coordinators to those areas where training had not been delivered. Furthermore, online training modules were under implementation and it was anticipated these would be live in March 2015.

Recommendation 4 - the refresher training packages were being completed and the formal assessments were taking place.

Recommendation 5 – a new CFR database had been developed which 3

included a pre- alert set up warning when documentation and/or equipment required renewal. PH asked why ID cards were re-issued on a 12 monthly basis. JH explained that a significant number of CFR’s fall out of the scheme within 12 months and do not re-apply. If there was no expiry date on the ID the CFR, essentially, would still be active. In terms of process checking, after six months of the CFR’s inactivity a letter was sent to them asking if they still wished to remain on the scheme.

Recommendation 6 - information relating to CFR’s vehicle documentation was now captured as part of the refresher training.

Recommendation 7 - the new database was being used as a form of asset register which highlighted when equipment required servicing. PH queried how the servicing of the additional equipment purchased by CFR’s was administered. JS explained that any additional equipment was required to be entered onto the database to ensure the servicing intervals were met, however, this relied upon individuals providing the Trust with the relevant information. Once the new policy was implemented CFR’s would, through workshops, be made aware of this and other issues.

Recommendation 8 - the new policy would reflect that no CFR would become effective until Occupational Health screening and Disclosure Barring Service (DBS) clearance had been substantiated. PH sought clarification with how the Trust could confirm that all existing CFR’s had DBS clearance. JS confirmed it was his understanding that all checks on CFR’s had been completed either using the previous method (Criminal Records Bureau) or the new DBS system.

Recommendation 9 - in terms of inappropriate despatches of CFR’s, processes had been put in place to monitor these. PR provided Members with a brief explanation in terms of how despatch codes were generated upon the information provided by the caller. These codes dictated whether a CFR would be suitable to attend.

JM commented that the recommendations depended upon the successful completion and continuation of the new database which was critical to the effective and safe management of CFR’s. He expressed concern that with the limited resources available, it must raise questions in terms of data quality. In addition, JM requested assurance be given at the next QDC meeting that the database was up to date and robust arrangements ensuring its continual monitoring were in place.

In terms of the management structure JS indicated that as part of the information being provided to the QDC, there would be a revised management structure proposal which would improve and make the CFR schemes more sustainable.

MWo reiterated the consensus of the Committee in welcoming the work being carried out by JS but expressed concern with regard to the limited resources available to maintain the CFR database.

DSc thanked JS for his work and the reassurance provided and acknowledged that progress was being made in a positive manner.

RESOLVED: That

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(1) the assurance levels provided on the two reviews finalised on the two reviews finalised in the period and progress on other planned reviews be noted; and

(2) the CFR Interim policy be presented to QDC on 27 January 2015.

3/15 EXTERNAL AUDIT ANNUAL REPORT

Members were given a brief overview of the report by VS and the following key areas were highlighted by MWa:

further progress where possible was required in terms of Integrated Medium Term Plans.

the improvement in performance reporting was recognised.

positive progress had clearly been made in senior management capacity.

recognition of the progress in terms of the work concerning the development of workforce policies was acknowledged.

Early indications of the relationships building between Non Executive Directors and Local Health Boards had been noted.

MWo referred to the financial aspect, in particular savings delivery and how this could be improved, and asked for this comment to be expanded upon. VS explained that there had been a mismatch with the level of financial input in terms of what the individual Directorate, when planning their savings wanted and what they could achieve. PR explained that the savings plan, which was discussed at the last Board level meeting, contained the full year value, the planned year to date value and the actual achievement against the year to date plan and this was recognised as a true reflection of the high level of financial reporting.

MWo asked for further expansion on the comment within the report which related to strengthening the focus on capital projects particularly where there would be an ongoing financial benefit. VS explained that working to a one year plan was not the most effective method of conducting business in terms of forecasting capital related developments as this was very challenging. PR added that the ongoing review of the committee structure would incorporate a forum whereby the issue of capital development would be discussed.

MWo added that the report was very useful in that it provided a checklist for the Board to be made aware of when considering plans for the future.

RESOLVED: That

(1) the report be acknowledged and presented to Trust Board for approval;

(2) the audit tracker be updated to reflect the recommendations contained within the report; and

(3) a note of thanks to KPMG be recorded.RESOLUTION TO MEET IN CLOSED SESSION

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Representatives of the press and other members of the public were excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted in accordance with the requirements of Section 1(2) of the Public Bodies (Admissions to Meetings) Act 1960.

Reports relating to the items of business in these minutes can be found on the Trust’s website, www.ambulance.wales.nhs.uk

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