Appendix-2009-150 Audit Committee Mins 260509
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Appendix-2009-150 Audit Committee Mins 260509

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Appendix-2009-150 Borders NHS Board thMinutes of a Meeting of Borders NHS Board Audit Committee held on Tuesday, 26 May 2009 at 2.30 p.m. in the Committee Room, BGH. Present: Mrs J Edey (Chair) Mr A Lucas Mrs D Steele In Attendance: Mrs M Wilson Mr R Kemp R Pearson Mrs S Swan C Gillie Mr D WoodsM Campbell-Smith Mr M Ferguson Mrs B Everitt 1. Apologies and Announcements Julia Edey welcomed those present to the meeting, especially to Doreen Steele who will replace Geraldine Strickland on the Committee. Apologies were received from Mr J Glennie, Mr G O’Brien and Mr C Revie. 2. Minutes of Previous Meeting: 30 March 2009 Martin Campbell-Smith asked for a minor change to item 8 (Progress Report). The minutes also to be forwarded to Alison Ferahi for comment. The minutes were noted and would come back to the next meeting if any changes were notified by Alison. 3. Matters Arising • Fraud Awareness Day – 16 March 2009 Julia Edey asked when feedback from the staff questionnaires was expected. The timing of this was not known at present. • Action Tracker Julia Edey advised that item 10 (Interim Management Letter 2008/09) was now complete. Robbie Pearson referred to item 14 (Information Governance Annual Report 2007/08) where he suggested that this be a substantive item on the agenda at the September meeting. This was agreed. • Bank Staff Update Robert Kemp advised that sentencing of the individual ...

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Appendix-2009-150
1
Borders NHS Board
Minutes of a Meeting of
Borders
NHS Board Audit Committee
held on Tuesday, 26
th
May 2009 at
2.30 p.m. in the Committee Room, BGH.
Present
:
Mrs J Edey (Chair)
Mr A Lucas
Mrs D Steele
In Attendance
:
Mrs M Wilson
Mr R Kemp
Mr R Pearson
Mrs S Swan
Mrs C Gillie
Mr D Woods
Mr M Campbell-Smith
Mr M Ferguson
Mrs B Everitt
1.
Apologies and Announcements
Julia Edey welcomed those present to the meeting, especially to Doreen Steele who will replace
Geraldine Strickland on the Committee.
Apologies were received from Mr J Glennie, Mr G O’Brien
and Mr C Revie.
2.
Minutes of Previous Meeting: 30 March 2009
Martin Campbell-Smith asked for a minor change to item 8 (Progress Report).
The minutes also
to be forwarded to Alison Ferahi for comment.
The minutes were noted and would come back to the next meeting if any changes were notified by
Alison.
3.
Matters Arising
Fraud Awareness Day – 16 March 2009
Julia Edey asked when feedback from the staff questionnaires was expected.
The timing of
this was not known at present.
Action Tracker
Julia Edey advised that item 10 (Interim Management Letter 2008/09) was now complete.
Robbie Pearson referred to item 14 (Information Governance Annual Report 2007/08) where
he suggested that this be a substantive item on the agenda at the September meeting.
This
was agreed.
Bank Staff Update
Robert Kemp advised that sentencing of the individual concerned had been deferred as
approximately £1,500 has now been repaid with a further £6,000 expected.
Audit Scotland Fee
The Committee noted the fee payable to Audit Scotland in addition to that paid to
PricewaterhouseCoopers.
Appendix-2009-150
2
National Fraud Initiative Update
Susan Swan referred to the two outstanding issues discussed at the last meeting.
It was
noted that it had been a timing issue for the three members of staff who did not have a
current visa at the time of the exercise.
In the case of invalid NI numbers this was still being
pursued but this was linked to the issuing of NI numbers by Inland Revenue.
Julia Edey
asked if having a current visa was not part of the pre-employment checks.
Robert Kemp
advised that this would come under Human Resource’s remit and agreed to speak to Louise
Hamilton-Welsh and report back.
4.
Counter Fraud Services
CFS Quarterly Report to 31
st
March 2009
Susan Swan advised that there was one new case which is currently being investigated.
The Committee noted the report.
5.
Internal Audit
Progress Report
Martin Campbell-Smith advised that the plan for 2008/09, as agreed by the Audit Committee,
was now complete with the exception of one exercise, Board and Senior Committee
Benchmarking, which is currently in its second draft and would be presented at the June
meeting.
It was noted that two exercises from the 2009/10 plan are now complete.
Mary Wilson asked about the timings of the two audits that had been postponed, namely
Staff Governance and Appraisal.
Robert Kemp advised that Louise Hamilton-Welsh had
attended the December meeting and given a comprehensive update.
The postponement of
these audits had also been discussed and it had been agreed that Louise would attend a
future meeting for further update.
Martin Campbell-Smith added that a broad HR audit is
scheduled for later in the year and this would pick up some of these elements.
The Committee noted the report.
Executive Summaries Report
Martin Campbell-Smith took the Committee through the executive summaries of audits
completed during May 2009 but not selected for detailed review by the Committee.
Adrian Lucas asked who had overall responsibility for the Consultants’ Contract.
Robert
Kemp answered that this lies with the Medical Director and Director of Workforce and as the
issues in question related primarily to Acute it was for the Chair of the BGH Clinical Board to
take forward.
Doreen Steele asked how information on job plans and appraisals are reported
to the local Discretionary Awards Committee.
Following discussion it was agreed that there
would be merit in seeing the full audit report and asking Ross Cameron to attend the June
meeting to speak to this.
Julia Edey queried the issue in the summary for “Capital Projects – Financial Management”
that the Scheme of Delegation is not up-to-date.
Robert Kemp advised that this had been
taken forward by Neil Strother prior to his retiral but completion had been postponed
following receipt of a comprehensive document from NHS Tayside picking up this and other
key governance documents and NHS Borders intention to replicate this format of
presentation.
The Committee noted the report.
Patients’ Funds
Martin Campbell-Smith spoke to this item which had a “requires improvement” rating.
Martin
explained that the reason for this rating was due to different sets of documentation being
Appendix-2009-150
3
used post amalgamation in 2003.
It was noted however that the issue around interest has
now been actioned by Finance.
Mary Wilson referred to the recommendation to have one set of forms and asked if this had
been progressed.
Susan Swan explained that an attempt had been made to amalgamate
these but had not proved possible due to the amount of detail required to be included.
Susan advised that it is the intention to re-issue the policy with the new documentation and to
include as part of staff induction training.
The Committee noted the report.
6.
Audit Follow-Up
Internal Audit Reports
Robert Kemp spoke to this item which was a regular update on progress with Internal Audit
recommendations.
It was noted that 86 recommendations from 2007/08 have now been
implemented which is a significant increase from the last report.
From the remaining
recommendations it was noted that none of these are critical and Louise Hamilton-Welsh is
currently working through them as the majority fall within her remit.
Robert also added that
there are no critical recommendations from those outstanding for 2008/09.
Mary Wilson referred to the outstanding recommendations relating to disaster recovery in IT
and asked if there were any concerns around this.
Robbie Pearson said work on this was
continuing and confirmed that Service Continuity plans have now gone to the Clinical Boards
and they had given feedback .
The Committee noted the report and the significant improvement made.
7.
National Audit Reports
Practitioner Services
National Information Technology Services
National Procurement Logistics
David Woods advised the Committee that these reports provide assurance to Boards on
services provided by NSS.
It was noted that the full reports have been presented to NSS’s
Audit Committee which gives an added assurance.
David confirmed that all reports had
received an unqualified opinion and that action has been taken on any weaknesses
identified.
Mary Wilson declared that Bill Matthews also chairs two other Audit Committees which she is
a member of, namely the Crown Office & Procurator Fiscal Service and the Corporate
Services of Scottish Government.
The Committee noted the reports.
Financial Management System Computer Services
Robert Kemp spoke to the report from NHS Tayside’s External Auditor, Audit Scotland, on
the services provided to the Tayside Shared Financial Services Consortium.
Robert
highlighted the issue around disaster recovery testing and explained the reason this had not
taken place was due to a timing issue.
This was being developed to take place during 2009.
The Committee noted the report.
8.
External Audit
Michael Ferguson reported that they are now in the third week of the audit and everything so far
has gone smoothly.
Noted that a clearance meeting has been arranged for 17
th
June and the
Annual Report would be presented to the Audit Committee on 22
nd
June.
Appendix-2009-150
4
9.
Payment Verification
Report to 31
st
December 2008
Carol Gillie advised that there were no major issues to note from these reports.
Carol
highlighted that the information for Pharmacy is only to 30
th
September and for other
contractors to 31
st
December.
She explained that NHS Borders are working with colleagues
at PSD on improving the timing of these report.
The Committee noted the report.
10.
Draft Annual Accounts 2008/09
Robert Kemp explained that the accounts are currently in draft and are still subject to audit.
The
final version would be presented at the next meeting before going to the Board for sign-off on 25
th
June.
Robert advised that the audit has gone well so far and thanked his finance team involved in
producing the accounts.
Robert highlighted that it has been a difficult year for NHS Borders and
noted the achievements made by the Clinical Boards and support service departments in securing
challenging efficiency savings.
Robert reminded the Committee of the introduction of IFRS and
that a shadow set of accounts in this new format will require to be produced by the end of the
summer.
Susan Swan went on to give a presentation highlighting the key issues within the accounts.
It was
noted that NHS Borders had achieved its three financial targets,
namely remain within the
revenue and capital resource limits and cash target
.
Robert highlighted that there had not been
the same flexibility as in previous years and discussions are still to take place with SGHD about
the £93K carry forward.
Mary Wilson enquired about what was happening with equal pay across NHS Scotland.
Robert
replied that this should remain as a contingent liability within the accounts and he understood that
Audit Scotland are considering with other auditors regarding the wording of the audit opinion.
The Committee then went through the detailed accounts, asking for clarification on a number of
points and agreed footnotes where required.
The Committee noted the answers provided and approved the draft annual accounts.
11.
Reports from Other Governance Committees
Clinical Governance
Julia Edey referred to the Clinical Governance Committee which Martin Campbell-Smith had
attended.
This had proved useful in looking at year-end arrangements on what is required
for supporting the Statement on Internal Control.
Julia highlighted that the format is
significantly different to previous years.
It was noted that the report had not been formally
signed-off at a Clinical Governance Committee meeting but had been circulated by e-mail for
comment.
Julia advised that she still had a point to pick up and the report would be re-
submitted if there were any changes to the June meeting.
The Committee noted the report.
Public Governance
Robbie Pearson reported that the recent meeting of the Public Governance Committee had
not been quorate.
Robbie advised that a draft was currently out for comment and he would
ensure that a copy of this be circulated around the Audit Committee prior to the June
meeting.
Mary Wilson highlighted that this is not a statutory committee but one which NHS
Borders chose to have and stressed the importance of recognising the work undertaken.
The Committee noted the update.
Appendix-2009-150
5
Risk Management Board
Robbie Pearson spoke to this report produced by Joanne Weir.
Robbie highlighted that this
is the first year for an annual report of the Risk Management Board as requested by the audit
committee
in addition to the minutes received by the Committee.
It was noted that the report
still had to go to BET.
Martin Campbell-Smith referred to the sentence under Internal Audit Reports which stated
that the Risk Management Board oversees Internal Audit and highlighted that this is actually
within the remit of this Committee.
Robbie agreed to have this amended.
The Committee noted the report.
Julia Edey referred to the recent facilitated session with Scott-Moncrieff and asked if the
results of this would be fed back to the Board.
Robbie confirmed that it is planned to do a
session with the Board at a future meeting.
Staff Governance
The Committee discussed the report and agreed that to ensure consistency some areas
could be further developed and a sentence added by the Chair of the Committee to give the
Audit Committee assurance that it had fulfilled its role.
Mary Wilson advised that she had met with Edwina Cameron and Louise Hamilton-Welsh to
discuss the reporting arrangements of the Remuneration Committee into Staff Governance.
It had been agreed that a report would be submitted twice a year.
The Committee noted the report.
12.
Statement on Internal Control
Draft Statement on Internal Control (SIC)
Robert Kemp introduced this item.
The Committee went over the draft statement which
is
one of the key statements within the accounts
.
Adrian Lucas asked if it would be
appropriate to add a paragraph detailing the challenges encountered with the Strategic
Change Programme.
Michael Ferguson replied that the SIC usually concentrates on internal
controls and the wider issues sit better within the Directors’ Report.
It was agreed that the necessary changes be made for the June meeting.
Chief Internal Auditor’s Annual Report 2008/09
David Woods spoke to this item where it was noted that no reports had been issued during
2008/09 with an unsatisfactory rating.
David highlighted that Internal Audit complies with
NHS Internal Audit Standards as well as the International Standards for the Professional
Practice of Internal Auditing.
The Committee noted the report.
Letter from SGHD re Corporate Governance
The Committee noted the letter detailing the corporate governance criteria when preparing
the SIC.
13.
Draft Audit Committee Annual Assurance Statement
David Woods introduced this item that would be presented to the Board by the Audit Committee
Chair at the June Board meeting.
It was noted that the statement was in the same format as
previous years.
The Committee discussed the statement and the only area of concern was the
lack of an annual report for Information Governance for 2008/09.
Robbie Pearson reminded the
Appendix-2009-150
6
Committee that the Information Governance Committee is not a standing committee of the Board
and that it actually reports to the Risk Management Board.
Appendix-2009-150
7
Mary Wilson commented that there was no reference of the Audit Committee minutes being
routinely presented to the Board.
David agreed to add this.
14.
Letter to Chair of Scottish Government Health & Wellbeing Audit Committee
The Committee agreed that there were no governance issues arising in 2008/09 that required to
be reported to the Chair of the Scottish Government Health & Wellbeing Audit Committee.
15.
Risk
Risk Management Board Minutes – 16
th
December 2008
Julia Edey referred to item 4.5 – Audit Scotland Report: Review of NHS Diagnostic Services
which stated that this would presented to the March Audit Committee.
Julia highlighted that
this had not been on the agenda for the March meeting.
Agreed that this would be put on the
agenda for a future meeting.
Mary Wilson suggested that the Risk Management Board use
the action tracker to support the minutes as is being done by other governance committees.
Robbie Pearson agreed to action this.
The Committee noted the minutes.
16.
Technical Bulletin (2009/1)
David Woods highlighted areas of interest within the Technical Bulletin.
The Committee noted the report.
17.
AOCB
None.
18.
Date of Next Meeting
22
nd
June 2009 @ 2 p.m., Board Room, Newstead
BE
10/6/09