AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS 20.i - Audit - Register of... · AUDIT COMMITTEE...
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Page 1 AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS Date Minute No. Action Owner Status 10.03.09/ 20.04.09 10.11.09 20.04.10 20.07.10 14.i LCFS update – removal of fraud related taxi firm from future tenders - clarification of position to July meeting The taxi firm in question had gone bankrupt, however it was reported they had merged with another taxi firm. NEAS would be going to tender for taxi services and all tenders would be examined to see if the (ex) taxi firm in question had merged with any of the taxi firms submitting a tender to the Trust. Tenders had been received and would be opened w/c 19 th April 2010. The outcome of the tender was unknown and it would be reported at the next meeting R D French B/Fwd April 2010 B/Fwd July 2010 B/Fwd Oct 2010 10.11.09 12.01.10 20.04.10 20.07.10 16.i Ambulance Station Visits – Security of Drugs An update (re assurances, plans, and pro-active audits) would be provided at the next meeting Outstanding Outstanding (A Fox not present at this point of the meeting) It was reported that the Medicines Management Group had an exception report system in place and that a new tender for the provision of drugs security was underway. AF to provide an update report at the next meeting A Fox B/Fwd Jan 2010 B/Fwd April 2010 B/Fwd July 2010 B/Fwd Oct 2010 10.11.09 20.07.10 18.i NHS Security Management Service – Strengthening Resilience DT to provide details of any action plan resulting from the CNI inspection at an appropriate point of time in the future, from which the Committee could take some assurance. It was reported that the CPNI visited the Trust in June 2010. A written report would be provided for the next Audit Committee meeting D Teasdale B/Fwd July 2010 B/Fwd Oct 2010 12.01.10 20.04.10 20.07.10 7.ii.i Audit Committee Development Action Plan: Update Sunderland Internal Audit undertook to consider the best way of developing a one page document consisting of a form of words to say that internal and external audit are able to speak to one another and that direct access to the Audit Committee Chairman It was agreed that the above can be incorporated into the Internal Audit Terms of Reference. These would be presented in July 2010 The Terms of Reference would be presented at the next Audit Committee meeting A Oswald B/Fwd April 2010 B/Fwd July 2010 B/Fwd Oct 2010
Transcript of AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS 20.i - Audit - Register of... · AUDIT COMMITTEE...
Page 1
AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
10.03.09/ 20.04.09 10.11.09 20.04.10 20.07.10
14.i
LCFS update – removal of fraud related taxi firm from future tenders - clarification of position to July meeting The taxi firm in question had gone bankrupt, however it was reported they had merged with another taxi firm. NEAS would be going to tender for taxi services and all tenders would be examined to see if the (ex) taxi firm in question had merged with any of the taxi firms submitting a tender to the Trust. Tenders had been received and would be opened w/c 19
th April
2010. The outcome of the tender was unknown and it would be reported at the next meeting
R D French
B/Fwd April 2010 B/Fwd July 2010 B/Fwd Oct 2010
10.11.09 12.01.10 20.04.10 20.07.10
16.i Ambulance Station Visits – Security of Drugs An update (re assurances, plans, and pro-active audits) would be provided at the next meeting Outstanding Outstanding (A Fox not present at this point of the meeting) It was reported that the Medicines Management Group had an exception report system in place and that a new tender for the provision of drugs security was underway. AF to provide an update report at the next meeting
A Fox
B/Fwd Jan 2010 B/Fwd April 2010 B/Fwd July 2010 B/Fwd Oct 2010
10.11.09 20.07.10
18.i NHS Security Management Service – Strengthening Resilience DT to provide details of any action plan resulting from the CNI inspection at an appropriate point of time in the future, from which the Committee could take some assurance. It was reported that the CPNI visited the Trust in June 2010. A written report would be provided for the next Audit Committee meeting
D Teasdale
B/Fwd July 2010 B/Fwd Oct 2010
12.01.10 20.04.10 20.07.10
7.ii.i Audit Committee Development Action Plan: Update Sunderland Internal Audit undertook to consider the best way of developing a one page document consisting of a form of words to say that internal and external audit are able to speak to one another and that direct access to the Audit Committee Chairman It was agreed that the above can be incorporated into the Internal Audit Terms of Reference. These would be presented in July 2010 The Terms of Reference would be presented at the next Audit Committee meeting
A Oswald
B/Fwd April 2010 B/Fwd July 2010 B/Fwd Oct 2010
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
20.04.10 20.07.10
20.ii Claims & Liability – Overview of Systems & Processes In noting the change in practice by the NHS Litigation Authority in that it now classifies slips, trips and falls as „Clinical‟ claims, reference was made to the targets that are set for the Acute sector and it was questioned whether the Ambulance Service would be brought into that monitoring regime. AF agreed to investigate this with Acute sector colleagues. Update to be provided at next meeting
A Fox
B/Fwd July 2010 B/Fwd Oct 2010
20.04.10 20.07.10
20.ii Claims & Liability – Overview of Systems & Processes reference was made to the 19 questions detailed within the report that would continue to be a source of enquiry until full assurances are provided, and AG informed that the risk management team would continue to work with HR until such a time as assurance against each question was in place. Given the concerns expressed by the Committee around the risk currently being carried by the Trust, it was questioned whether this featured on the Risk Register and if not the Committee expressed the view that it be included and requested confirmation at the next meeting. Added to Directorate Risk Register. Members were advised that the system for storing training records was being developed in to a more robust system and that this issue was now featured on the Board Assurance Framework and would be included in the Internal Audit Plan for later in the year. It was pleasing to note that all claims against the Trust were being rigorously challenged. The 19 questions to be answered from HR remained outstanding and AG would provide an update at the next meeting.
A Gallagher A Gallagher
B/Fwd July 2010 B/Fwd Oct 2010
20.04.10 20.07.10
23.i Progress Report & Briefing work relating to back-office benchmarking would be submitted to the Committee upon completion. The final version would be presented at the next Audit Committee meeting
C Waddell B/Fwd July 2010 B/Fwd Oct 2010
20.04.10 20.07.10
23.iii 12
Review of Business Continuity Arrangements PLL was unable to be present at this meeting to give assurance that the weaknesses identified in the report were being addressed thoroughly and would be invited to attend the next meeting in June. The Committee recognised the importance of completion of directorate-level business continuity plans and in noting the low-level of response to the request to identify leads, JP agreed to pick this issue up as a matter of urgency and to report back at the next Audit Committee meeting. PB to attend next meeting.
P L Liversidge J Pescott
June 2010 B/Fwd Oct 2010
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
20.07.10 6 Annual Equipment Audit (Stations & Vehicles) a progress report would be brought to the Audit Committee meeting to be held on 18
th January 2011. Furthermore, it was considered
prudent to ensure that the Committee include a representative of operational management at each of its future meetings.
S Edusai-Basra
B/Fwd Jan 2011
20.07.10 8.2 Infection Prevention & Control Annual Report 2009/10 With regard to the deep cleaning programme that was underway, it was concerning to note that it had only been completed to 45% against target so far. This had been raised with the contractor commissioned and assurance was given that the position could be recovered.
A Fox B/Fwd Oct 2010
20.07.10 9.1 Organisational Risk Register 2010/11 it was agreed that an additional risk would be added to the Organisational Risk Register; the potential implications to the Trust of the White Paper „Equity & Excellence: Liberating the NHS (2010)‟.
A Gallagher B/Fwd Oct 2010
20.07.10 9.2 Board Assurance Framework 2010 + aide memoir DT & JP to investigate the Trust‟s priorities within the Board Assurance Framework cross-referencing with the Internal Audit Plan, and to select the two most pressing items for inclusion in the agenda for the next meeting to be held on 19
th October 2010.
Those Directors responsible for the two items to be raised would be asked to attend the next meeting.
D Teasdale/ J Pescott
B/Fwd Oct 2010
20.07.10 9.2 Board Assurance Framework 2010 + aide memoir Members were encouraged to advise DT or JP by mid August, if there were any items within the Assurance Framework which warranted investigation by Sunderland Internal Audit, for inclusion in its Tactical Internal Audit Plan.
All B/Fwd Oct 2010
20.07.10 9.2 Board Assurance Framework 2010 + aide memoir AG to circulate the complete version to Members by email
A Gallagher B/Fwd Oct 2010
20.07.10 9.3 Risk / Incident Trend Analysis Following a question, it was confirmed that „near misses‟ were not classed as being clinical incidents. AF agreed to meet with AG to discuss this to ensure there was a consistent approach.
A Fox A Gallagher
B/Fwd Oct 2010
20.07.10 13 Final Annual Report 2009/10 (including Financial Statements excerpt) As the Annual Report was tabled, the Committee was asked to review the document outwith the meeting and to advise JP and JH by 2
nd August 2010 as to any
required changes.
All B/Fwd 2010
20.07.10 13 Final Annual Report 2009/10 (including Financial Statements excerpt) MC to devise a timetable (for example, as used for the Trust‟s Annual Accounts) in order to account for the additional demands on time that the Plain English Campaign would likely impose upon the production of the Annual Report, for future years
M Cotton B/Fwd Oct 2010
20.07.10 13 Final Annual Report 2009/10 (including Financial Statements excerpt) It was noted within the checklist that no information had been submitted for Equality & Diversity. It was agreed that JP and JH would pick up this point with the HR Department.
J Pescott J Hurrell
B/Fwd Oct 2010
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
20.07.10 13 Final Annual Report 2009/10 (including Financial Statements excerpt) The 3 year appointment periods detailed on page 58 of the Annual Report for John Pescott and Peter Wood, Non-Executive Directors, were highlighted as being out of date, JH to investigate and amend.
J Hurrell B/Fwd Oct 2010
20.07.10 14.2 Internal Audit 2010/11 Position Statement Disappointment was expressed at the repeated delays in implementation for lone worker arrangements and the Committee was informed that this would be followed-up with the AG in order to achieve a revised implementation date of August 2010.
A Oswald B/Fwd Oct 2010
20.07.10 14.3 Tactical Internal Audit Plans 2010/11 Members were asked to consider the report and forward any suggestions to Sunderland Internal Audit, through RDF, by mid August 2010, prior to the final draft which would be presented to the Audit Committee meeting to be held on 19
th October 2010
All B/Fwd Oct 2010
20.07.10 16.1 Royal College of Physicians: Implementing NICE Guidance for Health and Work: a National Organisational Audit It was agreed that the audit would be an ideal agenda item for the Workforce & Equality Committee to address, and the outcome would be monitored via the minutes of said Committee.
H Tucker B/Fwd Oct 2010
20.07.10 17.1 Trust Assurance Committee - Minutes of the Meeting held on 26
th May 2010 & 6
th July 2010 Concern was raised
regarding the failure to close out non-conformances as identified by internal and external audits. Whilst this issue was reported to have been improved, AF agreed to follow up the issue with JC.
A Fox B/Fwd Oct 2010
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
COMPLETED ACTIONS
11.11.08 3.i/08 Equipment Audit – if not carried out in December, PLL to attend the January meeting.
R D French Closed-out
11.11.08 3.ii/08 Scotswood House – update at Jan meeting & loss to be reflected in CIP.
R D French Closed-out
11.11.08 3.vi/08 Financial Risk Scenario & CIP – to be raised at Nov Board. J M Pescott Closed-out
11.11.08 4/08 Losses, Special Payments & Claims report – Equipment Officer to attend Jan meeting to explain the information contained in regular report.
G Gray/ G Craik
Closed-out
11.11.08 6/08 Copy of BIS minutes to be circulated with AC minutes. T Mullen Closed-out
11.11.08 7/08 High Level Risks – to revisit Register and update prior to next meeting
R D French Closed-out
11.11.08 9/08 Annual Health Check 07/08 outcome – issue of staff recognition to be raised at Nov pre-Board mtg
A Hitchman Closed-out
11.11.08 11.iv/08 Re R1 of Air Ambulance Partnership Audit – comments to be fed to appropriate Forum
G Marley Closed-out
11.11.08 12.ii/08 Follow-up of IA Recs (Re section 5.1) – benchmarking procurement – update re PRONE at Jan mtg
R D French Closed-out
11.11.08 15.i/08 Clinical Governance Committee Minutes – long-sleeved uniform update after Nov CGC meeting at Jan mtg
H Tucker Closed out
11.11.08 16.i&ii/08 TAC & BIS minutes to be circulated with AC minutes T Mullen Closed-out
11.11.08 18/08 Trust-wide adoption of Action Register (AC) T Mullen Closed-out
13.01.09 08.09.09
06/09 National Asthma patients target – Committee to be kept informed of progress Committee updated
C Cessford Outstanding Closed out
13.01.09 07/09 Organisational Risk Register – font size to be increased R D French Closed-out
13.01.09 08.09.09
07/09 Additional top 10 strategic risks report to be presented bi-annually. Cover sheet summarising movement within the Risk Register to be provided.
R D French R D French
Ongoing Closed out
13.01.09 08/09 Risk and Trends Report – Clarification sought re ill health section – feedback due at next meeting.
J Hurrell Closed-out
13.01.09 12.i/09 Strategic Internal Audit Plan - List of identifiable systems ascertaining national risk rating brought to March meeting
V Peacock Closed-out
13.01.09 12.i/09 Tactical Audit Plan to be presented for approval at April meeting
V Peacock Closed out
13.01.09 12.ii/iii/09 Position Statements / Internal Audit Recommendations – Financial Ledger section clarification on timescale and wording to be discussed outside of the meeting.
R D French/ A Oswald
Closed-out
13.01.09 13.i/09 Local Counter Fraud Specialist update – work plan presented at next meeting
V Peacock Closed-out
13.01.09 14.i/09 PriceWaterhouseCoopers Business Case Assessment and Approval Report – Work plan to be presented at next meeting
R D French Closed-out
13.01.09 18/09 Non-Compliance of Equipment Audit – Committee asked for a default system to be in place when managers on annual leave etc. – concern to be appropriately relayed.
D Teasdale Closed-out
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
10.03.09 5/09 Capital Schemes Business Case – further development of business case process
D Sellers Closed-out
10.03.09 7/09 March equipment audit outcome – hopefully collated in time for next (April) meeting
J Hurrell Closed-out
10.03.09 08.09.09
08/09 Clinical Governance Report – Monkton expenses identified for discussion with SHA On agenda
J Hurrell/ R D French
B/F Sept 09 Closed out
10.03.09 08/09 HCAI – KPIs used – clarification sought D Teasdale Closed-out
10.03.09 11/09 Review of Trust Protocols – clarification on Chairman responding to media enquires
D Teasdale Closed out at Mar Bd Mtg
10.03.09 12.i/09 Audit Committee Development Action Plan – on next agenda J Pescott/T Mullen
Closed out
10.03.09 13.iii Removal of Project Management Audit – clarification at next meeting
J Hurrell Closed out
10.03.09 10/09 CAA Framework – once embedded bring back
T Mullen Closed out
20.04.09 4 / 15.i/08 Clinical Governance Committee Meeting (relating to Monkton – details of costs incurred by Trust to be presented at July meeting
R D French Closed-out
20.04.09 5 Losses, Claims & Special Payments – drugs contract update R D French Closed-out
20.04.09 6 Draft Annual Report 2008/09 – reformat checklist (SH), revamp financial sections re Directors & NEDs salary and pensions (RDF), amend terminology in Chairman‟s forward (SH)
S Hassen R D French
Closed-out
20.04.09 8 Draft Statement on Internal Controls (SIC) - amend and add column as detailed in minutes
R D French Closed out
20.04.09 9 Annual Report of the Audit Committee 2008/09 – Revise wording in „Effectiveness‟ section
D Teasdale Closed-out
20.04.09 11 Draft Action Plan – to circulate revised draft to Committee members for comment before presenting final draft at July meeting
D Teasdale Closed-out
20.04.09 13.ii Risk Management & Organisational Controls Framework 2009/10 – final version to be presented at July meeting
R D French Closed-out
20.04.09 13.iii Organisational Risk Register 2008/09 – close out R D French/ A Gallagher
Closed-out
20.04.09 13.iv Assurance Framework 2008/09 – To raise issues detailed in the minutes with the Assurance Committee
J M Pescott Closed-out
20.04.09 08.09.09
14.iv Review of Internal Audit – Revise timing of future reviews of Internal Audit AC advised that this process happens every 3 years and therefore will be ongoing for a number of years (and should therefore be considered closed out)
G Roberts Ongoing Closed out
20.04.09 15.i Internal Audit Position Statement 2008/09 - Internal Audit „opinion‟ to follow in due course
A Oswald Closed-out
20.04.09 15.iv Draft Tactical Audit Plan 2009/10 - wording of section „Provision of Assurance on Core Financial Systems‟ to be amended.
V Peacock Closed-out
20.04.09 15.v Draft Head of Internal Audit Opinion 2008/09 – raise issue of third-party assurances outstanding in respect of the Oracle system, at forthcoming Directors of Finance meeting
R D French Closed-out
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
20.04.09 08.09.09
18.i Trust Assurance Committee: Minutes of the Meeting held on 06.03.09 - to investigate the schedules of other Trusts and to report back to Director of Finance & Performance This would be covered by the Audit Commission Governance review
G Roberts Ongoing Closed out
20.04.09 18.i Trust Assurance Committee: Minutes of the Meeting held on 06.03.09: review of volume of minutes forwarded to Audit Committee to be addressed in the Audit Committee Development Workshop in due course.
J M Pescott/ D Teasdale
Closed-out
20.04.09 19.ii Clinical Governance Committee (23.03.09) - to seek clarification at the next Clinical Governance Committee regarding the latest position on Thrombolysis –v- PPCI.
H Tucker Closed-out
14.07.09 08.09.09
(4)15.i//08 Clinical Governance Committee Meeting (relating to Monkton) Costs incurred by the Trust, resulting from the delayed occupation of Monkton On agenda
R D French B/F – Sept 09 Closed out
14.07.09 08.09.09
8.ii Organisational Risk Register 2009/10 post Directorate Risk Registers on the intranet. It was expected that this would be complete by 11.09.09
R D French/ A Gallagher
B/F Sept 09 Closed out
14.07.09 08.09.09
8.ii Organisational Risk Register 2009/10 It was highlighted that the covering report (template) had been inaccurately completed, citing the Audit Committee as undertaking an (equality) impact assessment.
A Gallagher July 2009 Closed out
14.07.09 8.iii Assurance Framework 2009/10 the Risk & Claims Manager would undertake a final consistency check between the Organisational Register and the Assurance Framework, prior to July Board meeting
A Gallagher Closed-out
14.07.09 08.09.09
10.ii Clinical Governance Committee (09.07.09) - The minutes were requested to be circulated to the Committee once completed.
C Cessford July 2009 Closed out
14.07.09 08.09.09
10.iii Patient Involvement & Complaints Committee (10.07.09) - to update the Audit Committee at its next meeting regarding the large volume of complaints being dealt with in the complaints office On agenda
P Wood B/F Sept 09 Closed out
14.07.09 08.09.09
11 Final Annual Report 2008/09 the profile for Mr Joel Byers, JCC Representative, was included under the Non-Executive Directors section of the Annual Report, and in order to avoid confusion it was decided that this profile would be moved to a different section of the report. Not achieved due to Annual Report already gone through printing process
R D French
July 2009 Closed out
14.07.09 11 Final Annual Report 2008/09 It was highlighted that the R D French July 2009
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
08.09.09
schedule of „Salary and Pension Entitlements of Senior Managers‟ had not been populated with this year‟s figures and the Director of Finance & Performance was asked to ensure this was updated prior to the publication of the Annual Report. The Engagement Manager confirmed that auditors had been provided with a fully-populated schedule as part of the annual accounts audit process. It was agreed that the information should be circulated to members.
Closed out
14.07.09 08.09.09
11 Final Annual Report 2008/09 Bonus payments to remain in the report - an Audit Opinion had been made on this, based on the content of the schedule which was prescriptive, and this could not be changed at this stage.
R D French July 2009 Closed out
14.07.09 08.09.09
13.i Internal Audit 2009/10 Position Statement - address the issues of E&D re online recruitment with the Trust‟s Equality and Diversity Officer in order to explore further and report back to the Committee. It was confirmed that a process was in operation to received paper based applications
H Tucker B/F Sept 09 Closed out
14.07.09 08.09.09
14.i External Audit Progress Report - The final report of Taking Healthcare to the Patient‟ to be presented to the Committee at its next meeting. On agenda
G Roberts B/F Sept 09 Closed out
14.07.09 08.09.09
15.iii Care Quality Commission (Healthcare Associated Infections & following the supporting Code of Practice) a report would be prepared within 7 days of the visit and this would be presented to the Audit Committee in due course. On agenda
C Cessford B/F Sept 09 Closed out
14.07.09 08.09.09
16.i Minutes of Trust Assurance Committee Meeting held on 7th
July 2009 An Annual Report on Effectiveness would be presented at the next Assurance Committee meeting. On agenda
R D French B/F Sept 09 Closed out
10.03.09 10.11.09
5/09
Capital Schemes Business Case – Progress report to be presented to the Committee 6-9 months after implementation
D Sellers/ R D French
B/F – Nov 2009 Closed out
14.07.09 08.09.09
10.11.09
5
Outcome of Equipment (March) Audit – To check if calibration of equipment featured in risk registers - the PF undertook to relay this to CC and raise through the Clinical Governance Committee. Outstanding, to have been closed out by Nov 2009 meeting It was confirmed that this issue was raised at the clinical Governance Committee and that the issue of collaboration is included in the Organisational Risk Register
P Fell C Cessford H Tucker D Teasdale
B/F – Sept 09 B/F – Nov 09 Closed out
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
14.07.09 10.11.09
6 Medicines Management - Out of Date Drugs contract review meeting with Lloyds due to take place on 5
th August 2009.
G Marley B/F Sept 09 Closed out
14.07.09 10.11.09
14.ii Follow-up of 2007/08 Recommendations outstanding recommendations relating to 2007/08 Annual Governance Report and 2007/08 Auditors‟ Local Evaluation would be completed by November 2009 and the findings would be reported to the Committee in due course.
G Roberts
B/F Nov 09 Closed out
14.07.09 10.11.09
14.ii Follow-up of 2007/08 Recommendations It was noted that a follow-up of the other 2007/08 recommendations would be undertaken before November 2009 and the findings would be reported to the Committee thereafter. On agenda
G Roberts B/F Nov 09 Closed out
08.09.09 10.11.09
3.i Medicines Management – feedback from Lloyds Contract Review Meeting CC agreed to provide an update at the next Audit Committee meeting including details of costs associated with developments (outlined fully in the minutes) of the Lloyds Contract Review minutes
C Cessford B/F Nov 09 Closed out
08.09.09 10.11.09
3.ii External Audit: Follow-up of 2007/08 Recommendations – IM&T audit – resourcing requirements recommendation on data security – Deferred; item to be presented at next meeting
C Cessford
B/F Nov 09 Closed out
08.09.09 10.11.09
5 Losses, Claims & Special Payments Report – The Quarter 1 submission was incomplete however, members were assured that a composite report would be provided to the next meeting.
M Rutter B/F Nov 09 Closed out
08.09.09 10.11.09
7.i Business Investment & Strategy (BIC) Committee (02.09.09) The Terms of Reference were being reviewed to reflect that discussion and once agreed by members, these would be presented to the Board at its next meeting.
R D French Board Sept 09 Closed out
08.09.09 10.11.09
7.ii Clinical Governance Committee (09.07.09) The Clinical Governance Committee had undertaken its Annual Review of Effectiveness which would be presented to the Board at its next meeting.
C Cessford Board Sept 09 Closed out
08.09.09 10.11.09
7.iii Patient Involvement & Complaints Committee (10.07.09) Members asked that an update on the issue of the complaints department resources be provided for the next Audit Committee meeting to be held on 10 November 2009.
P Wood / C Cessford
B/F Nov 09 Closed out
08.09.09 10.11.09
9 Revised Audit Committee Terms of Reference The Revised Audit Committee Terms of Reference were agreed, subject to an amendment detailed in the minutes on section 12.1.4 and these would be presented to the Board for approval.
D Teasdale Board Sept 09 Closed out
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
08.09.09 10.11.09
11 Standards of Business Conduct Policy – Review The Policy was agreed subject to an amendment under section 16 – Relationship with other documents. There was a need to include reference to the Professional Codes of Conduct in the list of key documents.
D Teasdale Sept 09 Closed out
08.09.09 10.11.09
14.i Internal Audit 2009/10 Position Statement A report to be produced for the next Audit Committee meeting on clarification and assurances re the drugs management issue
A Oswald B/F Nov 09 Closed out
08.09.09 10.11.09
15.i External Audit Progress Report & Briefing Final version of the ALE Report to be presented at next Audit Committee meeting Presented at meeting
G Roberts B/F Nov 09 Closed out
08.09.09 10.11.09
14.i Internal Audit 2009/10 Position Statement The Chairman of the Committee undertook to raise this issue drugs management at the September 2009 Trust Board meeting.
J Pescott Board Sept 09 Closed out
08.09.09 10.11.09
15.i External Audit Progress Report & Briefing DT to advise NEDs of forthcoming High Performing Boards events
D Teasdale Sept 09 Closed out
08.09.09 10.11.09
15.ii ‘Taking Healthcare to the Patient’ Audit DT to: Ask the CWH to undertake Recommendation 1: - Identify capacity requirements for maintaining forecast levels of job training / updating ensuring that plans are documents and resourced.
D Teasdale Sept 09 Closed out
08.09.09 10.11.09
15.ii ‘Taking Healthcare to the Patient’ Audit DT to: Ask SB to undertake Recommendation 2: - Develop and resource a comprehensive plan for developing PTS services, including links to other Trust functions, such as commissioning, covering: service development projects, staff engagement plans, management reconfiguration, and commissioner liaison.
D Teasdale Sept 09 Closed out
08.09.09 10.11.09
16.i Care Quality Commission – Inspection Report on the Prevention and Control of Infections DT undertook to relay information (re measurable standards) in relation to criteria 2(f) of the CQC report to the Infection, Prevention and Control Manager
D Teasdale Sept 09 Closed out
08.09.09 10.11.09
16.i Care Quality Commission – Inspection Report on the Prevention and Control of Infections It was agreed that DT would – in an effort to avoid duplication between the various committees – liaise with CC to determine how best to communicate issues of internal controls and assurances.
D Teasdale Sept 09 Closed out
08.09.09
16.ii DoH Flu Resilience Team – Audit of Ambulance Trust Preparedness Any outstanding items would be provided at the next meeting. No outstanding actions
D Teasdale B/F Nov 09 Closed out
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
10.11.09
10.11.09 10.11.09
3.ii External Audit: Follow-up of 2007/08 Recommendations – IM&T audit – resourcing requirements recommendation on data security A Paper was tabled. Members were asked to review and forward any questions to CC prior to the next Audit Committee meeting to be held on 12
th January 2010.
All B/Fwd Jan 2010 Closed out
10.11.09 13 Capital Monitoring Group Terms of Reference the first point listed in the „purpose‟ section of the Terms of Reference regarding the formulation of the Capital Programme should also feature as a duty. Subject to this amendment the ToR were approved.
D Sellers Closed out
13.01.09 12.iv/09 Internal Audit Performance – Report to be brought on annual basis unless reporting by exception was considered.
R D French Closed out
14.07.09 08.09.09 10.11.09 12.01.10
8.iv Risk / Incident Trend Analysis Two additional columns were to be added to the trend frequency chart; to show the comparative figure for the six months previous and a total for the months in question. Outstanding DT confirmed that this had been requested, and would report back to the January meeting Complete
R D French B/F Sept 09 B/F Nov 09 B/Fwd – Jan 2010 Closed out
14.07.09 12.01.10
12 International Financial Reporting Standards (IFRS) Project Update - Members were advised that all outstanding requirements would be progressed in line with the original project timetable and that a further update report would be received in six months time. Complete
R D French January 2010 Closed out
08.09.09 10.11.09 12.01.10
10 Policy for the Engagement of the External Auditor to Supply Non-Audit Services The proposed policy was considered and agreed by the Committee and this would be further developed and produced by DT Complete
D Teasdale B/F Nov 09 B/Fwd Jan 10 Closed out
08.09.09 10.11.09 12.01.10
16.i Care Quality Commission – Inspection Report on the Prevention and Control of Infections this item would be presented at the Clinical Governance Committee meeting to be held on 10 September 2009 and any outstanding issues would be raised at the next Audit Committee meeting AF agreed to provide a report on infection control issues for the next meeting in order to provide assurance Complete
C Cessford A Fox
B/F Nov 09 B/Fwd Jan 2010 Closed out
10.11.09
3.i
Medicines Management – feedback from Lloyds Contract Review Meeting A number of actions were outlined that would
A Fox B/Fwd Jan 2010
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Date Minute
No. Action Owner Status
12.01.10
result in better management of the drugs and the contract, including the preparation of a regular management report which would be presented to the Committee at its next meeting. The above was presented as part of the composite Losses, Claims & Special Payments report
Closed out
10.11.09 12.01.09
5 Losses, Claims & Special Payments Report RDF to present details of a significantly high personal injury payment to the November Trust Board meeting
R D French 26th November
2009 Closed out
10.11.09 12.01.10
5 Losses, Claims & Special Payments Report the Committee agreed it would be possible to combine the management information report (referred to in Minute 3.i.) and this appendix in future to produce a composite report detailing drugs management as part of the Losses, Claims & Special Payments Report, in light of the high costs of drugs associated losses. On agenda
A Fox / M Rutter
B/Fwd Jan 2010 Closed out
10.11.09 12.01.10
5 Losses, Claims & Special Payments Report it was agreed it would be useful to receive, for the next meeting a summary of employers‟ liability claims. Complete
M Rutter B/Fwd Jan 2010 Closed out
10.11.09 12.01.10
5 Losses, Claims & Special Payments Report It was queried what action was being undertaken in order to address the losses of equipment detailed in the report. Action undertaken as detailed in the minutes
A Fox B/Fwd Jan 2010 Closed out
10.11.09 12.01.10
5 Losses, Claims & Special Payments Report, AF undertook to investigate vehicles being deployed without equipment and report to the Committee at its next meeting and also feed into the Clinical Governance Committee where such matters would be monitored. Action undertaken as detailed in the minutes
A Fox B/Fwd Jan 2010 Closed out
10.11.09 12.01.10
7.ii Action Plan Progress Report It was highlighted that there were approximately 16 areas whereby the Trust Secretary was seeking the views of the Committee before either closing-out the actions or agreeing the course of action to be taken. Members agreed that an informal session should be held in the near future, in order to further review the document Complete
D Teasdale B/Fwd Jan 2010 Closed out
10.11.09 12.01.10
8 Risk Register – Process and Guidance details of the key risks to be incorporated into the Integrated Performance Report Complete
A Gallagher B/Fwd Jan 2010 Closed out
10.11.09
11 Capital Business Care Evaluation & Approval Process Update DS undertook to incorporate expectations of a minimum rate of return for developmental business cases into
D Sellers B/Fwd Jan 2010
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
12.01.10
the Business Case Guidelines. RDF advised that this action nad been completed and would now be reviewed at a forthcoming Capital Monitoring Group meeting for approval.
Closed out
10.11.09 12.01.10
11 Capital Business Care Evaluation & Approval Process Update Reference was made to the checklist detailed in Appendix 1 and it was suggested that Equality and Diversity (impact assessment) should also be added. This was agreed. Complete
D Sellers B/Fwd Jan 2010 Closed out
10.11.09 12.01.10
12.ii 2009/10 Mid-Year Submission Re Core Standard C14 (b) “Patient Focus” regarding the Trust‟s duty to respond to complaints in a timely manner. The Director of Finance agreed to review this in some detail and discuss as appropriate. Subject to outcome of the above, the Committee agreed that there was sufficient evidence upon which to be satisfied that the Mid-Year Health Check Statement of Compliance could be forwarded to the Trust Board for approval at its meeting to be held on 26
th November 2009.
R D French 26th Nov 2009
Closed out
10.11.09 12.01.10
16.ii Internal Audit 2009/10 Position Statement It was agreed that the findings (IG / audit review) i.e., the areas reviewed, the risk identified and the recommendation – together with management‟s response – would be presented in the next Position Statement Report and the close-out of those recommendations would be monitored in the same way as other audit findings. Complete
V Peacock B/Fwd Jan 2010 Closed out
10.11.09 12.01.10
16.ii Internal Audit 2009/10 Position Statement A request was raised that future Internal Audit Position Statements provide more detail under the Current Position column in order to give members an idea (i.e. what month/year) a specified area of work would be undertaken. Sunderland Internal Audit agreed to incorporate the additional information as requested for future reports and this would be reviewed at the next meeting. Complete
V Peacock B/Fwd Jan 2010 Closed out
10.11.09 12.01.10
23 Assurances Gained from Business Conducted – External Audit Report from the external auditors on their own internal quality procedures. It was confirmed that this report was due for presentation at the next meeting Presented at meeting
G Roberts B/Fwd Jan 2010 Closed out
11.11.08 08.09.09
11.iv/08 Air Ambulance Partnership Audit – to be viewed by PLL Discussions were ongoing with lawyers and a meeting was due to pursue this item w/c 14.09.09
R D French R D French
Still under review Update due Nov Meeting
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AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
10.11.09 12.01.10 20.04.10
An Air Ambulance review was expected to be held on w/c 5th December 2009. Whilst the draft agreement had been seen by RDF, an appendix was outstanding which would detail who would take clinical responsibility on scene. RDF to update at next meeting. The agreement had been signed off. Anyone wishing to view a note detailing the understanding, or indeed a copy, was asked to contact RDF
R D French R D French
B/Fwd Jan 2010 B/Fwd April 2010 Closed out
13.01.09 20.04.10
05/09 Audit Committee agreed that the Equipment Audit should be conducted on an annual basis (year-end period) – Operational Support Manager to ensure information sent to the Head of Financial Services, Risks & Claims thereafter. Annual Equipment Audit presented (earlier)
G Craik/ J Hurrell
Bring forward for July 2010 Closed out
14.07.09 08.09.09 10.11.09 20.04.10
5 Outcome of Equipment (March) Audit – An „equipment amnesty‟ be held in the near future. An article for the Pulse would be prepared to advise staff of this issue. Outstanding, to have been closed out by Nov 2009 meeting Covered on Organisation Risk Register & DT to check situation with the Equipment Officer & email members to advise On agenda
G Gray D Teasdale
B/F – Sept 09 B/F – Nov 09 B/Fwd – Jan 2010 Closed out
10.11.09 12.01.10 20.04.10
5 Losses, Claims & Special Payments Report It was highlighted that employers‟ liability formed only one element of the total claims made against the Trust and it was questioned whether the Committee should – acknowledging the work of the Accident Reduction Committee in reviewing and analysing all claims – seek details either by way of a „one-off‟ report for the first six months of 2009/10 or inviting the Risk & Claims Manager to a future meeting to give an overview of the systems and processes in place and where the Trust could improve these in defending future claims. The Committee Chairman agreed to consider this suggestion further. AG to produce report for April 2010 meeting On Agenda
J M Pescott A Gallagher
B/Fwd Jan 2010 B/Fwd April 2010 Closed out
14.07.09 20.04.10
5 Outcome of Equipment (March) Audit – To include details of cost of the equipment losses in the next report on the annual Audit.
G Gray July 2010 Closed out
14.07.09
14.ii Follow-up of 2007/08 Recommendations Following scrutiny of the action plan follow-up documentation, attention was drawn to „R5‟ (page 6), following the Information Management & Governance Audit which was now seeking the Trust to „urgently‟ consider the resourcing requirements to address the recommendation on data security. This would be highlighted to
R D French
July 2010
Page 15
AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
20.04.10
the parties concerned.
Closed out
10.11.09 12.01.10
17.ii Auditors Local Evaluation 2008/09 Outcome RDF agreed to circulate the Trust‟s restatement position in due course.
R D French B/Fwd Jan 2010 Closed out
10.11.09 12.01.09 20.04.10
17.iv Audit Committee – Fee Scales 2010/11 Information on the proposed fee reduction would be circulated during the fee planning round, in due course. On agenda
G Roberts B/Fwd Jan 2010 B/Fwd April Closed out
10.11.09 12.01.10 20.04.10
23 Assurances Gained from Business Conducted – Whistle Blowing DT to produce a composite report for the next meeting. On agenda
D Teasdale B/Fwd Jan 2010 B/Fwd April 2010 Closed out
12.01.10 20.04.10
5 Losses, Claims & Special Payments Report AF agreed to present the Medicines Management Group Terms of Reference (ToR) to the Committee, for information, at its next meeting to be held on 20
th April 2009.
ToR to be circulated with April Minutes
A Fox T Mullen
B/Fwd April 2010 Closed-out
12.01.10 20.04.10
7.ii.i Audit Committee Development Action Plan: Update NEAS Accounting Policy to be brought to next meeting for review, then thereafter only if significant change Chair of Audit Committee met with Director of Finance to review
R D French B/Fwd April 2010 Closed out
12.01.10 20.04.10
8 Clinical Governance Update AF to give update of developments (i.e. what assurances could be given at future meetings) at next meeting Confirmed that a draft Clinical Governance Strategy had been prepared and would be submitted to the Board in due course
A Fox B/Fwd April 2010 Closed-out
12.01.10 20.04.10
10 Annual Account Timetable RDF to advise JP on developments re Annual Accounts submission throughout 2009/10 Q4, if necessary Verbal report given at meeting
R D French Jan – April 2010 Closed out
12.01.10 20.04.10
14.ii Clinical Governance & Patient Safety Committee (12.11.09) DT to ensure that a NETS progress update be included in a forthcoming Board agenda for 2010. Progress report presented to the Board.
D Teasdale
B/Fwd April 2010 Closed-out
12.01.10
15.ii Internal Audit Position Statement 2009/10 Sunderland Internal Audit undertook to update Internal Audit 2009/10 Position Statement (as at 31
st December 2009), in order to
reflect the changes in the Clinical Care & Patient Safety directorate.
V Peacock B/Fwd April 2010
Page 16
AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
20.04.10 Confirmed as complete Closed out
12.01.10 20.04.10
17.1 Whistle Blowing – Assurances to be Gained DT was asked to provide details of the number of whistleblowing cases (for 2008/09, and to date) Furthermore, an explanation of how members of staff are protected, should they use the whistleblowing policy was requested. Additional details provided at meeting together with an e:mail to members (DT)
D Teasdale B/Fwd April 2010 Closed-out
12.01.10 20.07.10
13 Infection, Prevention & Control Audits – Assurance bi-annual report to be produced for future Audit Committee meetings; the next report would be presented 20th July 2009 meeting. On agenda
A Fox B/Fwd July 2010 Closed-out
20.04.10 20.07.10
7 WQA and (Quality) Internal Audit Process and Plan Procedures were being set in place to ensure that internal and external work was not duplicated re ISO:9001 and to ensure that accreditation was not lost. Upon completion of a full review, an update would be brought back to a future meeting.
A Fox B/Fwd July 2010 Closed-out
20.04.10 20.07.10
12 Draft Trust Annual Report 2009/10 All of the financial figures should be in the report by 23 April after which it would be electronically circulated to members for final comments – members had until mid-May to respond.
R D French ALL
May 2010 Closed-out
20.04.10 20.07.10
13 Draft Statement on Internal Controls 2009/10 Reference was made to section 5 of the report and after a brief discussion regarding the consistency of wording across reports (in respect of gap reporting in this instance), it was agreed that VP and RDF would meet outside of the meeting to discuss in more detail.
V Peacock R D French
B/Fwd July 2010 Closed-out
20.04.10 20.07.10
13 Draft Statement on Internal Controls 2009/10 Members expressed the view that the report should include reference to the Trust‟s active involvement with LINks organisations. This point would be considered.
R D French B/Fwd July 2010 Closed-out
20.04.10 20.07.10
13 Draft Statement on Internal Controls 2009/10 Members were asked to provide the Director of Finance with any comments on the draft report and the final version would be submitted at the June Audit Committee meeting.
All R D French
June 2010 Closed-out
20.04.10 20.07.10
18 Schedule of Audit Committee Business 2010/11 NEDs informed that they had attended a course on risk and the possibility of engaging the speaker (Professor Stanton) to address the whole Board, was being looked in to. Professor Stanton had been invited to the October Board Seminar
A Gallagher D Teasdale
B/Fwd July 2010 Closed-out
20.04.10
22.i Internal Audit Position Statement 2009/10 The exception to the assurance (in respect of the audit reviews against the 2009/10 Tactical Internal Audit) related to an additional area of
P L Liversidge
B/Fwd July 2010
Page 17
AUDIT COMMITTEE – REGISTER OF OUTSTANDING ITEMS
Date Minute
No. Action Owner Status
20.07.10
work that had been requested concerning pneumatic power tools. Weaknesses in the operation of the maintenance contract had been identified and as a result an alternative supplier had been sought. In noting the reported „weaknesses‟, the Committee requested that PLL provide an update at the next meeting. On agenda
Closed out
20.04.10 20.07.10
22.iii Updated Strategic Internal Audit Plan The final report will be presented at the June 2010 Audit Committee meeting for consideration and approval. The Committee agreed to the changes outlined in Appendix B of the paper.
V Peacock June 2010 Closed out
20.04.10 20.07.10
22.iv Draft Tactical Internal Audit Plan 2010/11 A final draft of the report will be presented to the June Audit Committee meeting for consideration and approval.
V Peacock June 2010 Closed out
20.04.10 20.07.10
22.v Draft Head of Internal Audit Opinion 2009/10 Some discussion took place on the wording, in particular the „generally being applied consistently‟ and whilst it was thought to be standard wording, VP agreed to revisit
V Peacock B/Fwd July 2010 Closed out
20.04.10 20.07.10
23.ii 2009/10 Audit Opinion Plan CW explained the „modern equivalent asset revaluation‟ method to the Committee and agreed to provide SMF with a summary of the principles.
C Waddell B/Fwd July 2010 Closed out
20.04.10 20.07.10
24 Medicines Management Group Terms of Reference Update Members were advised that the Terms of Reference would be circulated to the Committee with the minutes of this meeting.
T Mullen May 2010 Closed out
20.04.10 20.04.10
25.i Whistle-blowing The Committee requested details of the number of whistle-blowing cases for 2008/09 to-date in order to gain assurance of the number of cases reported. This information was available and would be circulated after the meeting
D Teasdale April / May 2010 Closed out
20.04.10 20.07.10
25.vii National Audit Office – Progress in Improving Stroke Care The Clinical Care & Patient Safety directorate were discussing the National Audit Office‟s Feedback Report and would report back on any issues that had an impact on the Trust.
A Fox B/Fwd July 2010 Closed out
