MINUTEs OF THE NHS fife audit AND RISK committee HELD AT 09:30 AMON FRIDAY 17 MARCHIN CONFERENCE ROOM2, LYNEBANK Hospital.

Present:

Mr S Little (Chairperson) / Ms M Adams, Non-Executive Director
Mr M Black, Non-Executive Director / Ms C Cooper, Non-Executive Director
Ms Janette Owens, Associate Director of Nursing

In Attendance:

Mrs C Potter, Director of Finance

Mr P Hawkins, Chief Executive

Mr M Doyle, Assistant Director of Finance

Mr B Hudson, Regional Audit Manager

Ms P Tate, Audit Scotland

Mrs F McLeary (Minutes)

ACTION
01/17 / APOLOGIES FOR ABSENCE
H Wright.
02/17 / DECLARATION OF MEMBERS’ INTERESTS
There were no declarations of interest.
03/17 / MINUTES OF PREVIOUS MEETING HELD ON 15DECEMBER 2016
The Minutes of the meeting of the 15December 2016 were approved as a true record.
04/17 / MATTERS ARISING
There were no matter arising.
05/17 / INTERNAL AUDIT
(a) / PROGRESS REPORT
Mr Hudson said this report shows the progress that has been made since the previous meeting around the ongoing delivery of the 2016/17 plan. 5 reports have been finalised and the last report is currently being finalised.
Mr Hudson drew attention to section 7 of the report and stated that following discussions with the Director of Finance and reflection of External Audit plan that 6 audit plans were being removed from the 2016/17 plan and will be incorporated into future audit plans.
Mrs Potter noted that she had asked the Chief Internal Auditor to discuss with the Chair of this Committee.
Mr Hudson agreed to circulate a more detailed paper to Audit and Risk Members. / BH
The Audit and Risk Committee noted the ongoing delivery of the 2016/17 Audit Plan.
(b) / SUMMARY OF INTERNAL AUDIT REPORTS
Mr Hudson explained that the report provided was self explanatory. It now had the inclusion of management responses were applicable. He highlighted the following points from his report;
B09/17 – Audit Follow Up – Grade B
No recommendations, some issues found have been discussed with Management.
B10/17 – Strategic Planning – Grade B
This review focused on the process around the Clinical Strategy. There were 2 priority 2 recommendations. Management responses have been included in the paper.
B21/17 – Recruitment Processes – Grade B
This report is self explanatory.
Mrs Adams asked if there processes in place for unsuccessful applicants. Mr Hudson confirmed that this had not been looked at.
Mr Hawkins suggested that it is good practice to follow up with a phone call and asked Mrs Adam to follow this up through Staff Governance.
B23/17 – Financial Processes Compliance- Grade N/A
B26/17 – eHealth Project Management – Grade B
This report is self explanatory.
Mr Little commended Ms Owens and her Team on this huge impressive piece of work.
B28B/17 – Departmental Review – Endoscopy QMH – Grade B
This report is self explanatory. There was 1 priority 2 recommendation. A management response has been included in the paper. / MA
The Audit and Risk Committee noted the report.
(c) / Interim Review
Action Plan – Ref 1, page 10 –IJB
Mrs Potter confirmed that since the last meeting of Audit and Risk a meeting had taken place between NHS Fife and IJB to discuss the assurances for 2016/17. A response has been provided to the Chief Internal Auditor and a reply is awaited.
Ms Tate added that when everything is clear it should be included in the Annual Governance Statement.
Action Plan – Ref 9 – Page 14 –Information Governance Group
Mr Little asked if there has been a date agreed on when this review will be complete. Ms Potter said she would pick this action up with the Medical Director. / CP
The Audit and Risk Committee noted the report.
(d) / Internal Audit Charter
Mr Hudson stated that the Audit Charter paper provided was a mandatory requirement for all NHS Scotland Health Boards. The draft paper provided has been produced in line with the Internal Audit Standards requirements.
Ms Owens stated that there were a few minor typo’s in Annex 1.
Mr Hawkins stated that the paper will need to be considered through EDG and will come back to the May Audit and Risk Committee. / PH
The Audit and Risk Committee noted the paper.
06/17 / EXTERNAL AUDIT
Ms Tate advised that the interim work was underway and on target. A report would be brought to the next meeting.
The Audit and Risk Committee noted the update.
07/17 / CODE OF CORPORATE GOVERNANCE
Mrs Potter stated that the Code of Corporate Governance (COCG), approved in February 2016 was due for review.This review is more complex than initially anticipated, in view of the issues raised by internal audit with regards to assurances and roles/responsibilities between the NHS Board and IJB.
The COCG needs to be reviewed alongside the Integration Scheme.
Each of the remaining Governance Committee Lead will be asked to review their governance sections.
An update on the progress will be provided at the May meeting.
The Audit and Risk Committee noted the report
08/17 / BOARD ASSURANCE FRAMEWORK (BAF)
Board Assurance Framework
Mr Hawkins said since the previous meeting a further Board Development Session was held in January 2017. Following discussions it was agreed that the potential list of risks should be reduced from 9 to 5. A report will be presented to the NHS Fife Board in April.
Mr Little asked if the NHS Board have overall say with the agreed key structures and headlines.
Mr Hawkins said that all Governance Committees have an oversight of the BAF and the Audit and Riskgive assurances to the Board that there is a robust system in place.
Mr Little stated that he was surprised that Quality and Safety had been taken off the potential risks list and was concerned that consequentially some issues might not being sighted.
Mr Hawkins said that the BAF goes to the NHS Board. The Clinical Governance reviews the Risk Register and would advise the Board if there were any significant risks. He stated that the BAF was an evolving document and could change as and when required.
Corporate Risk Register
Mr Little asked for clarity on the role of the Audit and Risk Committee in respect to the Risk Register and whether the Committee were allowed to give their views and make observations. He also asked where it gets its assurances from.
Mrs Potter said that the paper was here for information. She referred to the COGC and stated that “The Committee has no executive authority, and has no role in the executive decision-making in relation to the management of risk. The Committee is charged with ensuring that there is an appropriate publicised Risk Management Framework with all roles identified and fulfilled.”
Mr Hawkins stated that the Risk Register sits below the BAF, The Risk Register has recently all been reassessed with scores being reviewed, the report provided is the most current Risk Register. Each Committee see their own elements of the register.
Mr Little referred to page 7 – Risk 529 Information Governance - and asked why the risk had changed from moderate to high and couldn’t see why this had happened and was not assured that this was being articulated well.
Mr Hawkins stated that it was an imminent risk but not 100%.
Mr Little added that he trusts that Committees are dealing with these risks and the Audit and Risk Committee can be assured of the processes that are in place.
The Audit and Risk Committee noted the reports.
09/17 / FIFE HEALTH BOARD ANNUAL ACCOUNTS – ACCOUNTING POLICIES 2016/17
Mrs Potter advised that this paper outlined the main changes to the 2016/17 Annual Accounts and the proposed 2016/17 Accounting Policies.
The Audit and Risk Committee noted the report.
10/17 / DRAFT STATEMENT OF ASSURANCE FOR THE AUDIT AND RISK COMMITTEE
Mr Little stated that all Committees of the Board were required to provide an Annual Statement of Assurance for the NHS Board.
After some discussion Mrs Potter said that the report would be updated to include today’s business and incorporate a couple of recommendations that were suggested.
The Audit and Risk agreed the Draft Statement of Assurance subject to minor amendments.
11/17 / FOLLOW UP MONITORING REPORT
Mrs Potter said that since the previous meeting a total of 38 actions remained outstanding, with the majority of actions being priority 3. A number of the actions have been added fairly recently, however, a few go back as far as May 2016.
Mr Little stated that he would like to see an additional column giving some insight into the long standing actions that have been outstanding for 6 months or more. Ms Potter stated that she would be meeting with each of the Directors and ask them to supply a narrative.
Mr Hawkins added that he would be taking this list to EDG to try and accelerate the outstanding actions.
12/17 / DRAFT ANNUAL WORKPLAN 2017/18
Mr Little noted that the Corporate Risk Register was not currently included on the Workplan for 2017/18 and asked for it to be included. / CP
The Audit and Risk Committee noted the Workplan for 2017/18
13/17 / EFFECTIVENESS REVIEW OF AUDIT & RISK COMMITTEE (DRAFT)
Mrs Potter said this was an annual assessment which is completed by the Chair of the Committee in discussion with its members.
Mr Little asked the Members for their view on the checklist and asked them to complete the provided checklist and send to himself before he completes the final version. / ALL
The Audit and Risk Committee Members agreed to complete the checklist.
14/17 / UPDATE ON GGI GOVERNANCE REVIEW
Mr Hawkins stated that the new NHS Fife Chair is currently reviewing this process and has some ideas of her own. The Chair will share her thoughts at the March Development Session and a paper will go to the April Board Meeting.
The Audit and Risk Committee noted the update.
15/17 / IJB DRAFT RESERVES POLICY
Mrs Potter said that this paper was here for information and awareness of the legislation and the requirement for all integration authorities to have a formal reserves policy.
The Audit and Risk Committee noted the report.
16/17 / ITEMS FOR NOTING
(a) / Technical Bulleting 12/4
The Audit and Risk Committee noted the report.
17/17 / ANY OTHER COMPETENT BUSINESS
There was no other competent business.
18/16 / DATE OF NEXT MEETING
Thursday, 18 May 2017 at 0930a.m. within Meeting Room 2, Ward 6, Victoria Hospital
File Name: Audit 030317 / Issue 1
Originator: Fiona McLeary / Page 1 of 7 / Date: