GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST MINUTES OF THE AUDIT by SayreW

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									               GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

                        MINUTES OF THE AUDIT COMMITTEE
             HELD IN THE BOARDROOM, 1 COLLEGE LAWN, CHELTENHAM
                          ON TUESDAY 8 FEBRUARY 2005

      THESE MINUTES MAY BE MADE AVAILABLE TO THE PUBLIC AND PERSONS OUTSIDE
              OF THE TRUST AS PART OF THE TRUST’S COMPLIANCE WITH THE
                         FREEDOM OF INFORMATION ACT 2000

PRESENT
Ian Phillips               IP      Chairman (Non-Executive Director *GHNHSFT)
John Henry                 JH      Non-Executive Director *GHNHSFT
Margaret Greenwood         MG      Non-Executive Director *GHNHSFT

IN ATTENDANCE
David Westcott             DW      Deputy Director of Finance, *GHNHSFT
Diane Cresswell            DC      Governor
Jane Hewin                 JH      Governor
Sallie Cheung              SC      Local Counter Fraud Service
Lee Sheridan               LS      Local Counter Fraud Service
Barrie Morris              BM      RSM Robson Rhodes LLP
Richard Tremeer            RT      RSM Robson Rhodes LLP
John Micklewright          JM      Deloitte & Touche Public Sector Internal Audit Ltd
Alexander Lee              AL      Deloitte & Touche Public Sector Internal Audit Ltd

APOLOGIES
Terry Smith                TS      Director of Finance, *GHNHSFT
David Miller               DM      Governor
Mike Clarkson              MC      Deloitte & Touche Public Sector Internal Audit Ltd

ABSENT
None                       *GHNHSFT – Gloucestershire Hospitals NHS Foundation Trust


ITEM       DETAILS                                                                  ACTION

1.         OPEN FORUM BETWEEN AUDIT COMMITTEE AND INTERNAL
           AUDITORS
1.1        The Internal Auditors had no matters to raise with the Committee in
           private.


2.         APOLOGIES / INTRODUCTION
2.1        Terry Smith, David Miller (Governor) and Mike Clarkson were unable to
           attend.
2.2        The Chairman welcomed the two Governors to the meeting. He
           explained that David Miller was unable to be present because of an
           important PCT meeting. He also explained that whilst the three
           Governors had been delegated at their last meeting to attend the Audit
           Committee to discuss the question of appointment of external auditors,
           they should feel welcome to contribute and to ask questions about
           anything on the agenda.




Audit Committee Minutes                                                                 Page 1
Main Board February 2005
3.         MINUTES OF THE PREVIOUS MEETING HELD ON 9 NOVEMBER
           2004
3.1        MG to be removed from the list of absentees to reflect that MG notified HJM
           the Committee she would be unable to attend.


4.         MATTERS ARISING:
4.1        There were no matters arising other than those covered under Minute 5
           (Action Plan).


5.         ACTION PLAN FROM THE MEETING HELD ON 9 NOVEMBER 2004
5.1        IP addressed the previous Action Plan dated 9 November 2004
5.1.1      The appointment of external auditors (TS). See minute 7.1 below.
5.1.2      Recommendation relating to Password Control to be referred to other
           Trusts and PCTs. JM confirmed that this had been raised with the
           Partnership Trust’s Audit Committee.
5.1.3      Liaison with Sallie Cheung on the closure reports (TS) – See minute 10.1
           below
5.1.4      Liaison with Sallie Cheung on resource for local proactive work (TS) –
           See minute 10.1 below.


6.         EXTERNAL AUDIT REPORTS (RSM ROBSON RHODES)
6.1        BM gave a verbal update on the 3 month accounts to the 30 June 2004.
           The SAS610 report should be complete in time for the next Committee
           and although no major issues have been raised, some significant issues
           so far relate to the accounting for residential accommodation, consultants
           back-pay and various miscellaneous changes (e.g. clinical excellence
           awards) resulting in a surplus movement from £17k to £25k. Two notes
           remain outstanding; the first relating to the disclosure of pensions
           information for Directors and the second to the average number of Trust
           employees. BM confirmed that they should be able to sign off the
           accounts in April 2005.
6.2        BM gave a verbal update on the 9 month audit on the accounts to the 31
           March 2005. Field work starts in the week commencing 14 February
           2005. Some work is needed on the structure of reporting as there are
           currently no rules or guidance on this other than from UK GAAP.
6.3        BM gave a verbal update on the Charitable Funds accounts and
           informed the Committee that these do not need to be produced until 31
           January 2006. DC raised a question surrounding the controls over the
           treatment of charitable donations with respect to donor’s wishes. IP
           explained that individual funds are set up for specific wards or equipment
           but the Committee agreed that procedures surrounding tracking
           donations would need to be checked. It was agreed that this matter TS
           should be added to the next Charitable Funds Committee meeting with a
           view to informing the Governors of the controls and processes in place.




Audit Committee Minutes                                                                 Page 2
Main Board February 2005
6.4        BM gave an update for undertaking “spot checks” on data quality, and
           presented a summary document on the risk assessment results, and how
           the performance work related to data quality.
           The Trust gained an overall excellent rating for the risk assessment phase
           of the spot checks. Two minor areas of improvement have been identified
           surrounding the monitoring of returns between quarters and the
           introduction of a formal program of data quality audits.
           Work is now underway on the data quality review phase of the spot
           checks. No significant concerns have been raised so far and BM intends
           to issue a draft report within the next 2 weeks.


7.         REAPPOINTMENT OF EXTERNAL AUDITORS
7.1        IP suggested moving this item to the end of the meeting as it would have
           to be conducted without the presence of RSM Robson Rhodes. This was
           agreed by the Committee. Refer to minute 15.


8.         PROTOCOL FOR RECEIVING REPORTS FROM EXTERNAL AUDIT
8.1        IP summarized the protocol. JH raised the issue that Terry Smith is both DW
           the author and sponsor for authorisation of reports. It was decided that the
           protocol should be updated to reflect the Audit Committee as sponsor.
           DW agreed to make this change, and subject to this the Committee
           endorsed the protocol.


9.         INTERNAL AUDIT PROGRESS REPORT (DELOITTE & TOUCHE
           PUBLIC SECTOR INTERNAL AUDIT LTD)
9.1        JM presented a progress report; 58% of the 2004/05 audit plan has now
           been completed. All remaining audits are planned and scheduled with the
           exception of some controls assurance work that traditionally takes place
           in April.   JM highlighted some problems with finalising the draft
           recruitment audit report, but confirmed that management had found
           information to change the initial limited assurance opinion to satisfactory
           assurance. The Committee agreed that internal audit was making good
           progress with the audit plan.


10.        LOCAL COUNTER FRAUD SPECIALIST
10.1       SC presented a progress report. She confirmed that LCFS are falling
           short on their planned pro-active prevention and detection work because
           more time has had to be spent on counter fraud investigations. Of the 90
           days allocated to prevention and detection work, only 54 have been
           completed. SC stated that the LCFS team is planning to recruit a third
           part time person to handle administrative tasks.
10.2       SC discussed the impact of the Freedom of Information Act on counter SC
           fraud work. She explained that active investigations are excluded from
           the Act. However, when an investigation is closed it may become
           available to the public but exactly how much information should be made
           available is unclear. There is no national guidance on this and as yet no
           such request for information has been made. SC would update the
           Committee at the next meeting on the impact of the Freedom of
           Information Act on LCFS work.


Audit Committee Minutes                                                                  Page 3
Main Board February 2005
10.3       SC presented the Revised Secretary of State Directions. SC remarked
           that there have been no significant changes and just two issues require
           attention. The first is the nomination of a non-executive Director to
           undertake specific responsibility for the promotion of counter fraud
           measures. The second is a review and update of the current service level
           agreement and supporting counter fraud policy and response plan. This
           will be completed when the revised counter fraud manual is issued. The
           Committee agreed that, subject to the Board's wishes, IP should act as
           non executive Director for LCFS.
10.4       SC updated the Committee on outstanding cases previously reported to
           the Audit Committee.


11.        ITEMS MONITORED BY THE COMMITTEE
11.1       DW presented three cases where the Chief Executive has not accepted DW
           the lowest tender/purchase as per Standing Order arrangements. DW
           agreed to change the format of the report to make clearer the cost of not
           accepting the lowest tender.      Otherwise, all were agreed by the
           Committee.
11.2       DW presented nine occasions where single tender action has had to be
           taken. DW clarified two items.
11.3       DW presented the losses and compensations approved by the Chief
           Executive. IP suggested that steps should be taken to ensure private
           patients are credit worthy.


12         ANY OTHER BUSINESS
12.1       IP presented an IT report produced by Steve Edwards Head of JM
           Information Technology which outlined progress made in response to
           internal audit recommendations (discussed in the last Audit Committee).
           IP stated that it was clear that significant issues had now been dealt with
           and the Audit Committee expressed satisfaction with the progress made.
           However, there remain problems with the implementation of a Disaster
           Recovery Plan, hindered primarily by resource issues. MG stated that the
           fact the IT department had produced this update report demonstrated
           their commitment to addressing the issues raised by internal audit. IP
           suggested that progress by the IT Department should become a standing
           item monitored by the Audit Committee.


13.        CONFIRMATION OF MEETINGS FOR 2005
13.1       Tuesday 26 April.
           Tuesday 5 July (to be moved forward to June to enable consideration of
           the audit report on the accounts for the period 1 July 2004 to 31 March
           2005 in accordance with the timetable for subsequent presentation to
           Monitor and Parliament).
           Post meeting note - Date confirmed as Wednesday 22nd June 9.30 am.
           Tuesday 8 November




Audit Committee Minutes                                                               Page 4
Main Board February 2005
14.        OPEN FORUM BETWEEN AUDIT COMMITTEE AND EXTERNAL
           AUDITORS
14.1       The External Auditors did not raise any matters with the Committee in
           private.


15.        REAPPOINTMENT OF EXTERNAL AUDITORS
15.1       RT explained the audit practicalities and timings involved with any re-
           appointment decision. He stated that RSM Robson Rhodes were in place
           for the 2004/05 accounts, auditing both the old Trust (year ending 30 June
           2004) and the new Foundation Trust (year ending 31 March 2005).
           The Trust has not appointed auditors for the 2005/06 accounts. If RSM
           Robson Rhodes were not appointed for the 2005/06 accounts, they would
           end their relationship with the Trust in approximately June 2005 and issue
           their last audit letter by November 2005. If RSM Robson Rhodes were to
           continue as auditors, they would start audit work for 2005/06 in the late
           summertime, although other work, such as the performance audits, would
           be ongoing.
           RSM Robson Rhodes representatives RT and BM left the meeting along
           with LCFS representatives.
15.2       IP presented the process of appointing/reappointing external auditors to IP
           the Committee, noting in particular that this was formally a matter for the
                                                                                       DW
           Governors. IP stated that although RSM Robson Rhodes have done a
           good job as external auditors for a number of years, it would be TS
           appropriate for the Trust to market test. IP recommended this course of
           action to the Governors but warned that the process could take up to 6
           months. JH stated that the Governors had not had the time or the
           necessary information to fully understand the process. DC agreed that
           the preferred course might be for RSM Robson Rhodes to be re-
           appointed for the 2005/06 accounts, giving the Committee and the
           Governors time to market test for appointment/re-appointment for the
           2006/07 accounts. IP stated that a decision should really be reached by
           April 2005, and that DW, IP and TS would discuss and present a detailed
           paper to the Governors.


16.        DATE, VENUE AND TIME OF THE NEXT MEETING
16.1       The next Committee meeting will be 26 April 2004.
           The meeting finished at 11.30 am.




Audit Committee Minutes                                                                 Page 5
Main Board February 2005
                                                                            APPENDIX B

Action Plan from meeting of 8 February 2005


Ref.      Action                                 Responsibility   Target date

6.3       Place on the agenda for the next       Terry Smith      Next Charitable Funds
          Charitable Funds Committee Meeting                      Committee Meeting
          the controls over donor’s wishes for
          informing the Governors.

8.1       To update the protocol for receiving   David Westcott   Next meeting
          reports from external to reflect the
          Audit Committee as sponsor.

10.2      To update the Committee on the         Sallie Cheung    Next meeting
          impact of the Freedom of Information
          Act on LCFS work.

15.2      To present a paper on the process for Ian Philips       As soon as possible, and
          the re-appointment of the external    Terry Smith       before the next Council
          auditors to the Governors.                              of Governors




Audit Committee Minutes                                                            Page 6
Main Board February 2005

								
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