Tel: 0208 8370 8100
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Minutes of the meeting held on 16th September 2009 at 10:00am
Contact: Jack Manashe Tel No 020 8370 8187
David Harbott NED and Chair DH
Darriane Garrett LCFS Bentley-Jennison DG
Sophie Castell NED EPCT SC
Nick Atkinson Partner Bentley-Jennison NA
Darren Cattell Finance Director DC
Paul Dossett Grant Thornton PD
Julia Brown Chief Operating Officer Providerside JB
Paul Hughes Grant Thornton PH
Ian Winning Interim Deputy Director of Finance IW
Jack Manashe Interim Financial Controller JM
David Maloney Head of Finance DM
Kristy Leach Director of Nursing & Corporate Governance KL
Lynn Pope Assistant Director of Corporate Governance LP
1 Welcome and Introductions
DH welcomed everyone to the meeting.
DH stated that he was disappointed that some AC members had not
received the AC papers and therefore the meeting would lose its
effectiveness. It was agreed that all papers should be received one week
before the meeting if they were to be discussed. DC stated that this matter
would be resolved for the next meeting.
Apologies were received on behalf of John Simons. Paul Dosset gave
apologies in advance for having to leave early.
PART A: Provider Side
A1 Business Readiness Update
IW updated the Committee regarding the progress being made by the APO
with respect to Business Readiness and confirmed that the Provider side
was on track with the timetable. This had been confirmed by NHS London.
IW pointed out that SLA with EPCT and the Provider side had been signed
IW discussed I M & T strategy and Finance Structure. All on schedule
Draft 5 year business plan sent to NHS London. This has yet to be approved
A2 Clinical Audit Plan
DH stated that the AC should have a Clinical Plan with regular progress
updates. DH wanted to have included things like GP control, Not for Profit
KL stated that she would have off line discussions to decide what to include
and what format to adopt.
DH action point to agree format in advance of next AC meeting.
A3 Any Other Business
DC raised the point of having separate agendas and formal meetings for
Providerside not just for Commissioningside.
NA said he would share a draft format with IW
IW said he would review the terms of reference as to what to be included in
Parts A and B of future agendas.
PART B: Audit & Risk Committee
B1 Minutes of previous meeting June 2009
DH stated that he wanted included in the agenda a single Action
Point List which had been requested at the June AC meeting and
included in the Minutes. DM said he would resolve this matter with
B2 Health & Safety Draft Annual report.
This document was presented to the Committee as part of the assurance for
the coverage for 2009/10 for the deficits identified in the CQC inspection on
core standard 20a (Estates & environment). The final report will go to the
trust board in November. The Committee noted:
Formalisation of the fire risk procedures and expert advice through an
SLA with Barnet PCT.
The provision of security management advice and support from
1.04.09 through an SLA with Parkhill
The NEDs meeting later this month will formalise the NED lead for HSE
issues, though all formal challenge on risks sits with the Chair of the Audit
GOVERNANCE AND RISK
B3&4 Governance Update
KL presented this report.
CQC Inspection: Action plans in place for the 3 standards that the
EPCT reported partial compliance on and these are predicted to be
green for 2009/10. The outcome of the CQC inspection on the 4
standards they identified as being “at risk of unreported non-
compliance” will be feedback to the PCT on 22.09.09
CQC Registration Process: All NHS providers will be required to
register with the CQC from 1st April 2010. The Standards for Better
Health will be reported from April to September 2009 for providers as
well. This is risk-based assessment and the level of risk will
determine the frequency of inspections in the future. Commissioners
will be assessed via the CAA process and World Class
Commissioning. The Audit Committee will be kept appraised of the
developing registration process and the impact on our providers.
Mortality rates assurance: NHS London signed off the evidence
reported. More work is required to develop an assurance framework
for use within the contract quality review process with all providers to
alert the PCT to issues relating to quality and patient safety.
Information Governance: The baseline assessment against the IG
Toolkit has been completed. There are approximately 15 standards
that require work to move them from level 2 to 3. Internal Audit are
doing a piece of assurance work based on the DH letter on
information security that will be fed back to the Committee.
Use of Resources 2009/10: Work will be required to evidence actions
in reducing “carbon footprint” as part of the submission for KLoE 3 on
Use of Resources
SUIs for Q1: Data for key providers presented. NHS London has
published their revised guidance and the PCT performance
management role is formalised in this. The focus is specifically on
safeguarding children SUIs.
B5&6 Clinical Governance Annual Report
KL led on the report. This summarises the clinical governance activity and
for the commissioner is on line with the areas highlighted through the Darzi
High Quality Care for All. The key areas are:
SC raised the issues of the link between patient feedback and service
change. This is an area that requires some development to ensure that all
sources of feedback are collected and collated to inform service redesign
etc. and will be taken forward by the Quality Standards & Patient Experience
Action: KL and DH to meet to discuss how the Committee will receive on
going assurance on clinical quality.
B7 DRAFT SINGLE EQUALITY SCHEME
The draft SES was presented. This is working document and the action
plans are currently being reviewed by local stakeholders. The actions will
include how the PCT will monitor activity and impact of change on the 6
strands of the Equalities legislation.
HR Annual report
This was not discussed fully as the papers had not been received by all. The
Costs of the increasing numbers of Employment Tribunals in the
Current sickness absence rates are over the public services
benchmark from the Dame Carol Black review
Management of sickness absence is an issue for the Better Value Plan as
per the Boorman review.
B8 Progress Report
PH led on the progress report. A further update would be received at the
B9 2008/09 Annual Audit Letter
PH led on this.
The AC discussion focussed on Financial Underperformance and the current
financial risk value of £15.7m.
PH mentioned that GT would have to send a S.19 Referral Letter to the
Secretary of state because of the significant risk to the breach in statutory
duty of break even for 2009-10.
PH mentioned that GT were considering a Public Interest Report due to the
size of the financial risk but have seen enough evidence that the PCT was
taking action to control and reduce its expenditure to defer the decision for
three months. Specific evidence included:-
Appointment of an Interim director of Finance with significant
experience of financially challenged NHS bodies.
Moves to clarify management responsibilities to best support the
Better Value Programme.
Meetings with Barnet and Chase Farm Hospitals to plan to resolve
the financial issues.
Appointment of a Better Value Director charged with changing ways
of doing things across the PCT.
DH and other AC members asked for a section to be inserted in the Audit
Letter to put the expected financial risk in context having achieved a break
even position in 2008/09. DH asked that the following factors should be
Change in MFF contributed £15m to the financial risk value
Repayment of £7m loans to the SHA
DC said he would draft the words and arrange with PH to change the letter.
B10 Updated Internal Audit Providerside Plan
The report was not received. Action point. NA to provide this to AC for next
B11 Internal Audit Progress Report
NA led on this report:
A 3 year profile was discussed showing good improvement in Financial
Systems when comparing 2008/09 with the 2 preceding years. The numbers
of Internal Audit (IA) “Significant” and “Merits Attention” recommendations
NA discussed report on Estates which appeared to require a significant
amount of attention. It was noted that Neil Farrell the new Estates Manager
would work with IA on the report findings.
DH asked that an update on historical Action Plans proposed by IA should
be shown as an agenda item under Section B I/A
Action Point: DC.
LOCAL COUNTER FRAUD SERVICE
B12 DG led on this.
2 new staff investigations were detailed
QOF falsification investigation was discussed following an
anonymous tip off.
UPDATE FROM HIS
B13 Data Security Recommendations
MA led on this report
An Audit and Risk Working Group has been set up with KL as chair. It met
It will report back in December.
Plan to cover risks to be agreed with DOF.
Good progress had been made on 28 projects shown on the report.
4 Projects had not been started.
DH asked about the project to replace old servers and the risk if any went
MA said that oldest were being replaced first and that he assessed the risk
of failure as extremely low.
B14 HIS Audit Recommendations
MA led on the report detailing progress on HIS recommendations.
Question raised in respect of the single points of failure not resolved until
2011. This is in hand and risk assessment being done.
Full Business Continuity Plans are in place.
Fire Suppression available in data centre but concerns are for remainder of
Wenlock House. These risks are high and are to be carried through to the
Capital Review Group.
DC asked the question, whether there are there sufficient resources to
manage the key risks?
KL: Plans are in place to manage the transfer of the data centre to reduce
the current instances of IT remaining on non NHS premises.
Director of Finance
B15 IFRS Restated Accounts
These were noted.
B16 Updated Accounting Policies
These were approved by the AC
B17 Debtors/Creditors Report
These were noted.
DH asked for summary headlines on these reports highlighting items of risk.
DC said he would work with JM to arrange this for next AC
B18 Losses and Special Payments
DM presented. This report was noted.
Requests to Waive Standing Orders
LR explained why the AC were being asked to waive standing orders. The
main reason was timing and the potential saving arising from the speedy
resolution for this project was estimated to be £500k. Quotations were being
sought. The Committee agreed to waive the standing order for this tender
B19 Annual work Plan
DM presented the work plan and this was noted.
B20 Analysis of Claim Based payments
DH requested a more comprehensive coverage.
DC agreed to work with DM on this to present enhanced report to next AC.
B21 Waiver of Competitive Quotations
The waiver relating to the Estate Valuation was accepted by the AC.
B22 Policies for Ratification
Retention of Staff beyond Retirement Age
Long Service gifts to Staff Policy
Care Programme Approach Policy
Clinical Assessment & Management Policy
Controlled Access Policy
Email Use Policy
Missing Informal Patient Policy
Observation & Engagement Policy
Prevention of management of Violence and Aggression Policy
The Conveyance and Escort of Patient Policy
Action following a sudden/unexpected death policy
HR Policy for approval – Financial Implication
The AC agreed the policies as presented.
B23 to These reports not received.
KL to meet with DH to discuss what need to go to the next AC
DH thanked DM for his work at Enfield.
DC informed the AC that the new Associate Director of Finance, Lesley
Macleod would be starting on Monday21st of September 2009.