Fife NHS Board
Audit Committee – 21st March 2013

INTERNAL AUDIT

SUMMARY OF INTERNAL AUDIT REPORTS

PURPOSE OF THE REPORT

1.This paper summarises the key issues from the internal audit reports issued since the last Audit Committee that do not appear elsewhere on the Audit Committee agenda. It provides a note of progress on audit activities ongoing throughout the year and on work undertaken as part of the contingency arrangements.

SUMMARY OF REPORTS ISSUED

Job No. / Report Title / Summary / Grade
B10/13 / NHS Board, Operational Committees and Accountable Officer / C
The scope of this audit was to compare the arrangements in place against the duties laid out in the Accountable Officer memorandum. We also considered whether relevant best practice outlined by the Institute of Chartered Secretaries and Administrators regarding the role of Board Secretary is being followed in NHS Fife.
The Governance Statement guidance for 2012-13 includes a requirement for the Board to undertake a formal and rigorous annual evaluation of its own performance and that of its committees and individual directors. A Board Diagnostic self assessment tool was issued to Board chairs for this purpose but the NHS Fife Board have not yet undertaken a self assessment of performance for 2012-13.
The role and responsibilities of the Accountable Officer are clearly defined in the memorandum issued by the Scottish Government in 2003 and most recently updated in May 2012. The only change to Board arrangements since 2011/12 is in the deputising arrangements for the Chief Executive. In 2011/12 the Chief Executive of the Operational Division acted as the Deputy Chief Executive for NHS Fife. In 2012/13 this has been revised to a Deputy Chief Executive being appointed from the Strategic Management Team to cover each period of absence with the fall back position being that the Medical Director acts in this capacity. However, this new arrangement is not formalised within the Scheme of Delegation in the latest version of the Code of Corporate Governance (Version 10).
B16/13 / Staff and Patient Safety / N/A
This audit followed up previous audit review B15/12 Patient and Staff Safety, which reviewed the framework and processes in place for delivering improvements in the occupational health and safety of NHSScotland staff to comply with CEL (2011)13 Occupational Health and Safety Strategic Framework for NHSScotland. This review concentrated on confirming the status of agreed actions on recommendations on B15/12, as well as establishing the plans in place to build on the improvements made in order to address future challenges.
Our follow up review confirmed that action has now been taken to consider each of the action points raised in our previous report and work is ongoing to deliver on the commitments set out in the Occupational Health and Safety Strategic Framework for Scotland CEL (2011) 13.
A draft Health & Safety Policy Statement has recently been prepared. The draft Health & Safety Policy Statement is an overarching statement explaining the action being taken by NHS Fife to meet its health and safety obligations. The Policy Statement will be supported by a framework document, detailing the relevant aspects of the previous Health & Safety Strategy
TheSafe and Well at Workaction plan has been reviewed and now covers all aspects of CEL (2011) 13. Individual managers responsible for implementing each of the actions are now identified within the action plan.
As part of the process to ensure thatall NHS Fife locations receive an OHSAS Health and Safety audit,plans to deliver 20 distinct audits are now included within the Health & Safety Work Plan 2013-15.
A review of the procedures for processing RIDDOR incidents has been completed, with mechanisms introduced to notify OHSAS of all reported incidents and “not knowns”. A five day turnaround target for completion of actions has also been introduced.
B20/13 / Service Redesign / B
NHS Fife has introduced a Programme Management approach to support the delivery of its target efficiency savings for 2012/13 and beyond. The scope of this review was to evaluate and report on controls established to manage the risks relating to the new programme management approach.
A programme management system, specifically designed to record and monitor all individual savings projects, is now fully operational. The system incorporates a formal process with defined documentation and tools which must be utilised in the initiation of all projects. A project initiation document (PID) is prepared for all projects this is a prerequisite for the approval of each project and is entered on the project tracking database for full monitoring and reporting to relevant committees.
From a review of a sample of PIDs and a demonstration of the project tracking database, the systems in place are considered adequate to enable the individual savings programmes to be adequately monitored by the Programme Management Office (PMO).
A monthly reporting mechanism exists to ensure the Efficiency and Productivity Group (E&PG) of SMT, is fully informed of target savings achievement to date and what the forecast outcome is for the year end. The minutes of the E&PG go to the Finance and Resources Committee so it is kept fully informed on the current achievement of the target savings and the action being taken to meet the year-end target.
The approach to identification of Directorate savings schemes was considered for two directorates. Their approach to progressing savings schemes was in accordance with that set by the PMO.
Individual savings schemes are identified by the service managers within each Directorate from their own review of areas where they believe savings can be made. Identification of the delivery risk associated with efficiency savings schemes is an integral part of the PID process and is recorded on the PMO tracker system as high, medium or low.
B26/13 / NHS Resilience / N/A
This audit followed up the previous audit review B25/12 - Business Continuity Planning. Our follow up review confirmed that action has now been taken to consider each of the action points raised in the previous report.
The Business Continuity Database has now been revised to include further information fields which will enable additional statistical data to be reported showing progress in establishing and improving business continuity arrangements.
The reporting of statistical information to the relevant NHS Fife Resilience Forum and SMT has not yet been provided. However, plans are in place for this reporting to commence in May 2013, once all Business Continuity Plans have been collated.
A new Business Continuity Risk template has been prepared to enable departments/wards to record business continuity risks in a consistent manner
Action has been taken to remind nominated leads responsible for BCP to complete all necessary stages in the BCP process. Annual BCP returns are due for submission at the beginning of May 2013.
B28/13 / Staff Performance Management / B
Internal audit report B08/13 highlighted the fact that NHS Fife’s figure for Development Reviews for 2012/13 was 55% as at October 2012. Subsequent departmental reviews of wards has highlighted a recurring pattern of competing priorities which have contributed to a lack of up to date KSF personal development plans. This review examined the current level of up to date KSF reviews across NHS Fife and through a series of sample areas explored the underlying reasons for low completion of annual KSF reviews, in an effort to improve overall performance towards the 80% target.
Knowledge & Skills Framework (KSF) outlines have been developed for all posts within NHS Fife, any new posts require the generation of a job description and associated KSF outline. The latest figure reported to the Strategic Management Team (SMT) showed that as at 1 March 2013 only 41% of reviews due were completed within the previous 12 months. This indicates a progressively worsening situation.
A sample of 10 managers with responsibility for performing KSF reviews were questioned on completion of such reviews. Of those questioned 8 are behind with their reviews and 2 are fully up to date.
KSF reviewers whose reviews are fully up to date have a procedure in place whereby at the beginning of the year dates for KSF reviews are put in reviewee diaries to ensure they are completed by the required date. None of the KSF reviewers with behind schedule KSF reviews has a timetable in place to complete reviews as part of a set annual process. Most confirmed they are dependant on the automated email alert as a prompt to complete reviews
Of the managers with behind schedule reviews, 3 already have plans in place to bring their reviews up to date and the remaining 5 confirmed that following the audit questionnaire they would now make a conscious effort to bring those overdue up to date.
The majority of reviewers (70%) spoken to confirmed that they are aware that the removal of the HEAT target has not removed the expectation on the Board to achieve the previous 80% target for up to date KSF reviews and PDPs being in place.
The majority of managers confirmed that they have retained the necessary skills to update the KSF system efficiently and consider themselves sufficiently trained and confident enough to use it for completing KSF reviews. A small number indicated refresher training would be useful and will now arrange to complete such. None indicated a lack of staff awareness about the KSF system as being a reason for reviews not being completed.
B29/13 / Human Resources / N/A
This audit followed up previous audit review B25/10, which evaluated the systems, procedures and controls in place for the recruitment of staff across NHS Fife.
Our follow up review confirmed that action has now been taken to consider each of the action points raised in our previous report. However, a number of significant changes have come about since the publication of report B25/10 and these changes have presented additional challenges which were not envisaged at the time that the management actions for report B25/10 were agreed.
The process for applying for work permits has changed in the intervening period since publication of report B25/10 and NHS Fife now apply online on an annual basis for an allocation of 15 Tier 2 certificates of sponsorship from the Home Office. The Home Office carry out an evaluation of all licensed employers to establish the level of compliance with Home Office regulations. NHS Fife has recently been advised that the category ‘A’ licence will be retained for the period from March 2013 to November 2016.
In February 2011 the Scottish Government introduced the Protecting Vulnerable Groups (PVG) scheme to replace and improve upon the previous disclosure arrangements for people who work with vulnerable groups.The PVG Scheme is managed and delivered by Disclosure Scotland, which is an executive agency of the Scottish Government and now covers children and protected adults. NHS Fife recruitment policies have been updated to reflect the introduction of the PVG Scheme and all new starts in regulated work are now required to be PVG registered. The PVG Scheme also contained a retrospective element for existing staff and in response to this requirement a plan was considered by SMT and the Area Partnership Forum, which showed the activity required to achieve the throughput needed to achieve the required checks by 2015. A tracker spreadsheet is in place which allows detailed monitoring of the PVG process as an integral part of the recruitment process. NHS Fife now funds all membership fees for the PVG scheme. Previously some new starts were required to self fund this membership fee but plans are now in place to deal with the issue of refunds and this has been reported to both the SMT and APF.
Report B25/10 recommended that consideration should be given to using HR.net for all recruitment and that staff should be reminded to ensure that all data is being properly recorded on HR.net. However, the eESS (Electronic Employee Support System) project aims to introduce a single national HR system for all boards in NHS Scotland and once implemented this will replace HR.net within NHS Fife as the workforce information system responsible for holding and managing employee information. The final production version of eESS has been received which includes iRec which is a module dealing with recruitment. The eESS Local Project Board will continue to oversee the implementation and roll out phases of eESS. The local implementation group will be re-established to consider any practical issues arising. A pilot approach will be adopted for implementation in NHS Fife with subsequent rollout in line with an agreed phasing plan.
B30/13 / Efficiency Savings / N/A
This review concentrated on gathering the evidence required to allow us to confirm that the processes examined in report B28/12 are capable of delivering the budgeted recurring and non-recurring savings set out within the LDP 2012/13 and that reporting of progress against savings trajectories is sufficiently comprehensive and detailed to meet the needs of senior management and Board members. From the work conducted we have concluded that Board arrangements to deliver efficiency savings are working effectively and that the reporting to management and to Board members is sufficient to allow effective monitoring and challenge
Detailed reports on the delivery of the efficiency programme 2012/13 are considered monthly by the Efficiency and Productivity Group. The monthly updates on the Efficiency Programme 2012/13 are underpinned by monthly reports produced by the Programme Management Office (PMO). The PMO monthly report provides a breakdown of individual savings plans across each of the business units.
The Finance Report submitted to each meeting of the Finance and Resources Committee and then the Board contains the key tables from the Efficiency Programme 2012/13 report considered by the Efficiency and Productivity Group. This provides the members of the Finance and Resources Committee, and then subsequently all Board members, with an overview of progress against trajectory and provides a projected year end position against the savings target set out within the financial plan.
B31/13 / PFI-PPP Hub / B
The contract for the provision of PFI/PPP services was agreed with the service provider, Consort Healthcare, in April 2009 and NHS Fife has been paying for services provided under this contract since the keys to the new wing at VictoriaHospital were handed over in October 2011. These contractual arrangements include provision for financial claw back should the service provider fail to deliver services within the agreed quality and time parameters. Contractual arrangements are monitored by the service provider whose representatives meet with NHS Fife on a monthly basis to discuss contractual performance. Our review considered the processes in place for monitoring service provision by the service provider and for ensuring that financial claw back due to NHS Fife is recovered.
An Executive Summary of the Pay and Performance report is passed to the Head of Estates on a monthly basis but there is currently no direct reporting to SMT or a Governance Committee on the performance of the GH&MS contract with the service provider. However, we have been advised that any request for an alteration or addition to the Project Agreement would require consideration and approval by the Board. Such an alteration or addition would be discussed at the Quarterly Liaison meeting in the first instance as would any issues arising with the contractual performance of the service provider requiring the attention of a Governance Committee or Fife NHS Board. A narrative update on the performance of the PPP contracts at VictoriaHospital and St AndrewsCommunityHospitalshould be included as part of the Efficiency and Productivity update reports which are subsequently presented to the Finance and Resources Committee.
The Executive Summary to the Pay and Performance report is appended with more detailed information in tables and graphs including information regarding financial deductions and service failure points applicable. Our testing of this information revealed some differences between the deductions reported in the Pay and Performance report compared to the amounts invoiced and some differences with deductions and service failure points report within different sections of the Pay and Performance report (eg Section 2 and Appendix 1). Although, following further investigation, the unexplained amounts not invoiced was not material the fact that these sections of the Pay and Performance Report are not in agreement should be raised with the service provider as the reconciliation of these different sections may reveal errors in reporting.
There have been changes to the planned building layout since the Project Agreement was signed in April 2009. The net effect of these changes is an increase of 4 store rooms. Some terminology regarding locations has also changed since the Project Agreement was signed (eg the Acute Medical Admissions Unit (AMAU) is now referred to as Admissions Unit 1). A spreadsheet is used to map between the new terminology and the old. As the changes have no material impact on the Payment Mechanism, project risk or the Annual Service Payment, it was agreed that the changes should be captured in a nil cost variation. This variation is currently being written and once finalised and formally agreed this will result in an update to Section 18 of the Project Agreement.