WELSH AMBULANCE SERVICES NHS TRUST

MINUTES OF THE OPEN MEETING OF THE AUDIT COMMITTEE OF THE WELSH AMBULANCE SERVICES NHS TRUST HELD ON THURSDAY 27

FEBRUARY 2014 AT VANTAGE POINT HOUSE, CWMBRAN WITH A VIDEO CONFERENCING LINK TO TRUST HEADQUARTERS, ST ASAPH, CEFN COED, SWANSEA AND THE PRE HOSPITAL EMERGENCY UNIT (PERU)

PRESENT :
Stuart Castledine
Dilwyn Evans
Mary Powell
David Scott
/
Non Executive Director and Chair
Non Executive Director (Via VC)
Interim Non Executive Director
Interim Non Executive Director
NON EXECUTIVE DIRECTORS/EXECUTIVE DIRECTORS
Mick Giannasi
Patsy Roseblade
Dr Jonathan Whelan / Chairman of the Board
Director of Finance and ICT
Interim Medical Director
IN ATTENDANCE :
Terry Eckley
Jillian Gill
David Harries
Lynne Haddow
John Huxley
John Jones
Ossama Lotfy
Steve Owen
Virginia Stevens
Kevin Webb
Julie Winspear /
National Risk and Health and Safety Manager (Via VC)
Financial Accountant (Via VC)
Internal Audit (Via VC)
Local Counter Fraud Specialist (Via VC)
Assistant Corporate Secretary
Corporate Accountant (Via VC)
Principal Auditor (Via VC)
Corporate Governance Officer
KPMG
Clinical Effectiveness Manager (Via VC)
Head of Business Management and Concerns
APOLOGIES:
Dawn Sharp / Corporate Secretary
01/14
02/14 / PROCEDURAL MATTERS
The Chairman opened the meeting by confirming the attendance of all those present. He welcomed Mary Powell, Interim Non Executive Director as a member of the Audit Committee who, in accordance with the requirements of the Quality Delivery Committee (QDC) Terms of Reference (TOR) had been nominated from the QDC membership.
The Chairman of the Board announced that the resignation letter of Dr Kevin Fitzpatrick had now been approved by the Minister for Health and Social Services and therefore the Committee was holding a vacancy in its membership until the Trust Board had approved a replacement member.
The Assistant Corporate Secretary updated the Members on the schedule of Non Executive Director (NED) expenses which had recently been sent to NEDs under separate cover. It was explained that the current format in which the expenses are annotated would be revised and re-sent in a more user friendly version. It was noted that those NEDs who were able to view their expenses, Stuart Castledine and John Morgan were in agreement with its contents.
Members were updated by the Assistant Corporate Secretary on the arrangements for processing and finalising the Annual Governance Statement (AGS) and the Standards for Health Services assessment. The AGS would be presented to this Committee on 29 May 2014 and then presented to the Trust Board following any amendments on 5 June 2014. It was anticipated that a draft of the Standards for Health would be presented to this Committee on 24 April 2014 and then presented to the Trust Board on 15 May 2014 for consideration.
The Assistant Corporate Secretary briefed Members on the position regarding the change of date for the Trust Board Annual Meeting from 17 July 2014 to 18 September 2014. Welsh Government (WG) had originally intended to realign the submission of the Annual Quality Statement (AQS) in line with preparation of the AGS which would have meant the Trust’s Annual General Meeting taking place on 17 July 2014. Unfortunately WG have not responded in this regard and consequently the ratification of the Trust’s Annual report (of which the AQS forms part) cannot be done at the Annual Board Meeting scheduled for 17 July 2014 and therefore that meeting needs to be rescheduled for 18 September 2014.
Members were informed by the Assistant Corporate Secretary that there was to be a change in the process for staff to declare an interest under the Gifts and Hospitality Policy in that the responsibility for ensuring completion and retention of the forms would fall to Line Managers.
Members had been asked to comment on the annual plan of business for the Committee. The Head of Concerns and Business Management asked that the Author/Lead on the meeting date of 26 April 2014 at paragraph 9 be amended to read Director of Quality and Nursing.
RESOLVED: That
(1) it be noted that there were no declarations made under the Code of Conduct;
(2) the minutes of the meeting (open and closed) of the Committee held on 20 November 2013 be confirmed as a correct record;
(3) the membership, including the Chair, and the Terms of Reference (TOR) be noted and that the resignation of Dr Kevin Fitzpatrick as a Non Executive Director of the Board be confirmed;
(4) the arrangements for the production of the Annual Quality Statement, as described in the minute, be noted;
(5) the Trust Board be recommended to move the date of the Annual General Meeting from the Board meeting to be held on 17 July to the scheduled meeting on 18 September 2014 to enable the AQS to be produced in line with the timetable for the production of the Trust’s Annual Report;
(6) the change to the process for holding completed staff declaration of interest forms, as described, be agreed; and
(7) the amendment to the annual plan of business as described above be noted.
MATTERS ARISING
RESOLVED:
That the following matters arising from the minutes were considered and the position reached by the Committee in each case be noted:-
(a)  Minute 22/13 (2b) (Open) – Medical Device Management
Position: The Director of Finance and ICT reported that the process in employing a Medical Devices Manager was progressing but as someone was already in post on an interim basis the substantive post was not being pursued vigorously at this moment in time.
(b)  Minute 22/13 (2e) (Open) – Patient Care Services Contract
Position: The Director of Finance and ICT to provide further clarification to the Chairman on the arrangements for signing the PCS contracts and the date when all Health Boards signed up to the contracts.
(c)  Minute 22/13 (3c) (Open) – Wales Air Ambulance (Service Level Agreement (SLA))
Position: The Director of Finance and ICT provided a report on progress at the meeting which confirmed that, although progress had been made, it had not been possible to finalise the agreement at this time.
(d)  Minute 22/13 (4) (Open) – Schedule of Expenses
Position: The current format was unreadable. The Corporate Secretary agreed to obtain an improved format and circulate to members for clearance.
(e)  Audit Tracker Tool – The Committee noted that the template was not being updated and that without this being done regularly the Committee could not monitor the actions effectively.
Position: The Chairman of the Trust Board agreed to discuss options with the Chief Executive in terms of facilitating improved use of the tracker tool.
(f)  Phase One – Audit Inspection Regulation Consultation
The Committee agreed not to provide comments as part of the consultation on Phase one and to consider comments on Phases two and three at the appropriate time.
Position: The Corporate Secretary to inform Welsh Government that no comments will be provided on Phase one on behalf of the Trust.
03/14 / EXTERNAL AUDIT PROGRESS REPORT
Virginia Stevens of KPMG provided the Members with an update report which included the Audit timeline for 2014.
Non Executive Director Dilwyn Evans asked if the new HMRC ruling regarding VAT charges would result in VAT being applied to the Welsh Audit Office invoices received by the Trust. The Chairman agreed to send under separate cover a letter to the Non Executive Directors he had received which would explain the new HRMC ruling.
RESOLVED: That
(1)  the update report and timeline for 2014 be received; and
(2)  the Chairman to forward the letter from HMRC to all members of the Committee for information.
04/14 / CORPORATE RISK REGISTER/DATIX MANAGEMENT SYSTEM
The National Risk and Health and Safety Manager provided Members with an update on the Corporate Risk Register which included information on the Datix Management System. He indicated that at this time there were 10 risks which required consideration by the Executive Management Team and explained that the review of the register was an ongoing process. Members were informed that within the Datix Web Risk Register Module a facility was available which allowed for the monitoring of progress on any action plans. The Chairman of the Board asked if this module could be used and adapted to the information provided within the Audit Tracker Tool.
Members were further advised that it was incumbent upon Directors to ensure that the register was accurately completed within their area of responsibility with particular focus being paid to the risks associated with the transformation agenda and the Integrated Business Plan.
The Head of Business Management and Concerns updated Members regarding the Datix Administrator post which had been evaluated and was banded at level five; however at this stage there was no funding available for the further recruitment to this post.
RESOLVED: That
(1)  the update be noted;
(2) subject to the clearance of the Director of Finance and ICT,
the National Risk and Health & Safety Manager send the
current Corporate Risk Register to all members of
the Committee; and
(3) executive Directors be asked to ensure the register is up to
date in their particular area of responsibility.
05/14 / CLINICAL AUDIT & EFFECTIVENESS UPDATE
The Clinical Effectiveness Manager informed Members on progress made with the Clinical Audit and Effectiveness Programme. He highlighted issues which had impacted on the department’s efficiency and effectiveness which included:
·  delays in Patient Clinical Records (PCR) arriving at the Department;
·  a reduction in scanning capability; and
·  insufficient server storage capacity.
These issues had been investigated and initiatives to improve the systems in place had been implemented.
Non Executive Director, Dilwyn Evans enquired as to whether the introduction of Digital Pens (data storage of PCR) would speed up the process of obtaining and passing on patient information to the required receiving body. Members were informed that if these pens were introduced, the data capture would be significantly improved.
Members held a discussion concerning the backlog of PCR’s which had yet to be stored within the electronic system and the security surrounding the hard copies being held at ambulance stations. It was agreed that the Director of Finance and ICT would conduct an investigation to consider the risks surrounding this issue and report back the findings to the Committee.
RESOLVED: That
(1) the position be noted;
(2) the Director of Finance and ICT be asked to investigate the risks involving the control and security of Patient Clinical Records on ambulance stations and other Trust locations and report back to the Committee in due course; and
(3) a report be presented to the next meeting of the Committee covering the scope and resources of the Clinical Audit Plan.
06/14 / 2013/14 ANNUAL ACCOUNTS – INTERIM EXTERNAL AUDIT ARRANGEMENTS
The Corporate Accountant provided members with an update report which included key dates within the Final Accounts Timetable.
RESOLVED:
That the position be noted.

RESOLUTION TO MEET IN CLOSED SESSION

Representatives of the press and other members of the public were excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted in accordance with the requirements of Section 1(2) of the Public Bodies (Admissions to Meetings) Act 1960.

NOTE: Reports supporting the information contained in these minutes can be found on the Trust’s website: www.ambulance.wales.nhs.uk