Bundle Audit Committee (Open) 13 September 2018...Bundle Audit Committee (Open) 13 September 2018 1...
Transcript of Bundle Audit Committee (Open) 13 September 2018...Bundle Audit Committee (Open) 13 September 2018 1...
Bundle Audit Committee (Open) 13 September 2018
1 PROCEDURAL MATTERS1.1 13:00 - Welcome and Apologies For Absence1.2 13:04 - Declarations of Interest
Members are reminded that they should declare any personal or business interests which they have in anymatter or item to be considered at the meeting which may influence, or may be perceived to influence theirjudgement, including interests relating to the receipt of any gifts or hospitality received. Declarations shouldincluded as a minimum, personal direct and indirect financial interests, and normally also include suchinterests in the case of close family members. Any declaration must be made before the matter is consideredor as soon as the Member becomes aware that a declaration is required.
1.3 13:05 - Minutes/Action LogTo confirm as a correct record the Minutes of the Committee and review the Action Log.
ITEM 1.3a Audit Committee OPEN Minutes 24 May 2018 ver 3.doc
ITEM 1.3b Audit Minutes CLOSED Minutes 24 May 2018 chair ver 2.doc
ITEM 1.3c Audit Committee Action Log.xlsx
ITEM 1.3d handover report status update.docx
2 INTERNAL AUDIT AND EXTERNAL AUDIT REPORTS2.1 13:20 - Internal Audit Reports (Head of Internal Audit)
To note update and note Internal Audit Reports:
a. Fleetwave Systemb. Annual Quality Statement reviewc. Continuous Professional Development Managementd. Volunteers – Governance Arrangementse. Environmental Sustainability
ITEM 2.1 WAST Audit & Assurance Progress Report.pdf
ITEM 2.1a WAST_18-19_Fleetwave II_FINAL Internal Audit Report_ FOR CLIENT ISSUE.pdf
ITEM 2.1b WAST_2018-19_AQS_Final Internal Audit Report _for Trust issue.pdf
ITEM 2.1c WAST_2018-19_CPD Management_Final Internal Audit Report_for client issue....pdf
ITEM 2.1d WAST_2018-19_Volunteer Car Drivers' - Governance Arrangements_Final Internal AuditReport_for client issue.pdf
ITEM 2.1e WAST_2018-19_Environmental Sustainability Reporting_Final Internal Audit Report_forclient issue.pdf
2.2 14:20 - External Audit Reports (Head of External Audit)To Note update
ITEM 2.2 426A2018-19_WAST_Audit_Committee_Update_September2018.pdf
ITEM 2.2a 565A2018-19_Embedding the sustainable development principle into ways ofworking_final.pdf
ITEM 2.2b 565A2018-19_Embedding the sustainable development principle into ways ofworking_final_Welsh.pdf
3 BUSINESS MATTERS3.1 14:50 - Losses and Special Payments Update (Interim Director of Finance and ICT)
Note the contents as per SFI’sITEM 3.1 SBAR Losses and Special Payments Sept 2018.docx
ITEM 3.1a Annex 1 - Losses Special Payments 2018-19 M1-4 Final.pdf
3.2 15:05 - Trust procedures for Internal and External Recommendations (Corporate Governance Manager))Presentation
3.3 15:20 - Audit Recommendation Trackers (Corporate Governance Manager)To inform Audit Committee of the progress made by the Trust in responding to recommendations fromInternal Audit and Wales Audit Office.
ITEM 3.3 Audit Recommendation Tracker Report September 2018.docx
3.4 15:30 - Corporate Risk Register Quarterly Report (Assistant Director of Quality and Asurance) (TOFOLLOW)To receive an update
3.5 15:45 - Gifts and Hospitality Policy (Board Secretary)To approve the policy.
ITEM 3.5 SBAR Gifts and Hospitality 130918.docx
ITEM 3.5a Gifts and Hospitality Policy 170418 final.pdf
3.6 15:50 - Research and Innovation Non-Executives Directors Report (TO FOLLOW)4 ANY OTHER BUSINESS
To consider any other business to the agenda items listed above.5 DATE OF NEXT MEETING
6 December 2018
1.3 Minutes/Action Log
1 ITEM 1.3a Audit Committee OPEN Minutes 24 May 2018 ver 3.doc
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ANNEX 1
WELSH AMBULANCE SERVICES NHS TRUST
UNCONFIRMED MINUTES OF THE OPEN MEETING OF THE AUDIT COMMITTEE OF THE WELSH AMBULANCE SERVICES NHS TRUST HELD ON
THURSDAY 24 MAY 2018 AT VANTAGE POINT HOUSE, CWMBRAN with VIDEO CONFERENCING FROM ST ASAPH
PRESENT :
Pam Hall Emrys Davies Paul Hollard
Non Executive Director and Chair Non Executive Director Non Executive Director
PH ED PHo
IN ATTENDANCE : Mike Armstrong Claire Bevan Keith Cox Jill Gill Helen Higgs Fflur Jones Gwen Kohler Ossian Lloyd Steve Owen Michelle Phoenix Claire Roche Patsy Roseblade Paul Seppman Chris Turley Claire Vaughan Anthony Veale Judith White Carl Window
Assistant Board Secretary (Via VC St Asaph) (Part) Director of Quality, Safety and Patient Experience and Nursing (Part) Board Secretary Financial Accountant (Via VC St Asaph) Head of Internal Audit NWSSP Wales Audit Office (Via VC St Asaph) Interim Deputy Director of Finance Internal Audit Corporate Governance Officer Wales Audit Office (Via VC St Asaph) Assistant Director of Quality, Governance & Assurance (Part) Chief Executive (Interim) (Part) Trade Union Partner Interim Director of Finance and ICT Director of Workforce and OD (Part) Wales Audit Office Area Manager South East (Part) Counter Fraud Manager
MA CB KC JG HH FJ GK OL SO MP CR PR PS CT CV AV JW CW
APOLOGIES: Helen Birtwhistle Julie Boalch Richard Lee Damon Turner
Non Executive Director Corporate Governance Manager Director of Operations Trade Union Partner
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13/18
PROCEDURAL MATTERS The Chair welcomed all to the meeting and advised that the meeting was being audio recorded. Members were informed that the meeting consisted of a joint agenda which included the annual accounts/accountability report and normal committee business. Declarations of Interest The Committee noted the standing declaration of interest of Mr Emrys Davies being a retired Member of UNITE. Minutes The Minutes of the open and closed sessions of the Audit Committee meeting held on 8 March 2018 were confirmed as a correct record. Action Log The items within the log were considered and actioned accordingly. Action numbers: 12 and 13 – To remain open Action number: 14 (Weir report) - CT explained that the Executive Management Team had received an update and a further update would be provided at the Audit Committee meeting in September. Action number: 25 - Control of drugs policy, completion date to be shown as 13 Sep 2018. Action number: 27 - Fire Drills and Fire Logs. JW explained that the Assistant Director of Operations (Louise Platt) had sought assurance from operational colleagues confirming that local processes had been implemented. JW advised that an update would be provided at the next Audit Committee meeting. Action numbers: 31 and 32 - to be annotated as completed. RESOLVED: That (1) the declaration of interest of Mr Emrys Davies being a retired member
of UNITE made under the Code of Conduct was noted;
(2) the Minutes of the meeting of the open and closed sessions of the Committee held on 8 March 2018 were confirmed as a correct record; and
(3) the items within the Action Log as described above were actioned
accordingly and it was noted that the action log would be presented to the Executive Management Team on a monthly basis.
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14/18 WAO – AUDIT OF FINANCIAL STATEMENTS REPORT 2017/18 AV in presenting the report gave an overview of the process involved which in the case of the Trust’s accounts had used the sample checking method. This looked at key transactions within the accounts. This report had set out the findings from the extensive audit work that had been undertaken. There were however some further queries regarding property, plant and equipment which required resolving and some final administration checks regarding the remuneration report; there would also be an overall final check of the accounts. AV reported that he was not anticipating any significant issues. AV confirmed that the WAO intended to issue an unqualified audit report noting that the accounts represented a true and fair position subject to receiving a letter of representation from the Trust. As part of the audit work, no misstatements had been identified that remained uncorrected. There were corrections which AV drew the Committee’s attention to and these had been reported in Appendix one of the report. In terms of the issues arising from the audit work there were no concerns about the quality and aspects of accounting and financial reporting procedures; the accounting policies and estimates were appropriate and the financial disclosures were unbiased, fair and clear. AV added there had been a significant improvement regarding the audit process and asked that note of thanks be recorded for all the Trust staff involved. There were no significant matters to report and there were no material weaknesses in terms of internal control. In concluding, AV reported there had been a particular issue with fixed assets and the coordination of the fixed asset register; this had been highlighted within the report. He added that WAO would be working closely with the Trust regarding the implementation of the asset register. Members raised the following:
1. Clarity was sought on the timescales involved regarding the asset register. CT advised that the Finances and Resources Committee were monitoring the situation and agreed to provide an update on progress to the Audit Committee on 13 September 2018. CT explained the asset register was a new system of managing assets and was NHS recognised. The benefits involved would include a significant increase in business intelligence and would allow the managing and verification of assets in a much improved and efficient manner
2. HH reminded the Committee that an internal audit reviewed was planned in quarter two on asset management
3. It was requested that the proper title of health boards was used in the report in order for clarity going forward
4. PR referred to the West Midlands Ambulance Service (WMAS) invoice regarding cross border issues received by the Trust which was contained within the report. Members recognised that the WMAS understood that the Trust had no intention of
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paying and were no longer pursuing the Trust for payment. PR added there was no agreement in place with any other ambulance service with cross border activity to charge for attending to an incident.
5. RESOLVED: That the report was noted.
15/18
ANNUAL ACCOUNTS AND ACCOUNTABILITY REPORTS Draft Annual Accounts 2017/18 The Committee gave detailed consideration to the Trust’s accounts for the year ended 31 March 2018 which had been prepared by the Trust to comply with International Financial Reporting Standards under Schedule 9, Section 178, Paragraph 3 (1) of the National Health Service (Wales) Act 2006.
CT, the Interim Director of Finance and ICT, introduced specific areas in the accounts and highlighted where changes had occurred to income and expenditure when compared to the previous year’s accounts. He added that no adjustments had been made to the draft accounts and delivery of financial targets had been fully achieved. The following questions and comments were raised by the Committee:
1. Welsh Risk Pool (WRP) sharing agreement – why hasn’t this been renewed and what were the consequences? PR advised that when the risk share for funding the WRP was initially re-evaluated a few years ago, the Trust was not included in this as it wasn’t liable for any of the services which gave rise to the increasing costs. These were predominantly hospital based services including Obstetrics. A more recent potential risk share update has included the need for the Trust to potentially pick up a small share of increased WRP contributions, but this hasn’t been invoked in 2017/18, to which this note in the accounts refers. Carbon reduction scheme - why was the Trust not a member? KC advised that it was his understanding that the size of the organisation determined membership
2. Risk pool reimbursements – there appeared to be an anomaly where in one instance it was shown as zero and another instance there was a value. CT explained that the receipts from the Welsh Risk Pool were netted off as expenditure as opposed to income
3. Following a query regarding Patient Transport funding – CT explained that this was funded through Health Boards
4. Staff costs reconciliation – following a brief discussion, JG agreed to circulate the reconciliation paper to the Chair which provided further clarity
5. Was the significant increase in the cost of clinical negligence and personal injury claims a one off or was it a likely trend? JG explained that it was possible to predict payments by monitoring the Personal Injury Benefits Scheme (PIBS); however in terms of clinical negligence and personal injury cases, the timing of pay out was not always predictable hence a prudent approach was taken in estimating the times of payment. PR added that a session on clinical negligence claims at a future Board Development day had been planned
6. Related party transactions – JG would check to see if these were still in existence
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7. Clarity was sought on the impairment of £861k within the accounts. CT gave an explanation into the term ‘financial impairment’ which was in essence accelerated depreciation of an asset. JG advised the amount of £861k related to the element of impairments which had gone against the revaluation reserve
8. There had been a large increase in intangible assets and trade and other receivables, why was this the case? CT explained that the new Computer Aided Dispatch system had been a significant element of intangible assets.
9. Why had Directors’ costs increase by circa 20% year on year? - CT advised this would be clarified and detailed in the report mentioned in paragraph five above
10. An explanation was requested with regard to the year on year movement in losses/special payments and irrecoverable debts chargeable to operating expenses. JG explained there had been a downturn in PIBS, compared to the previous year which had resulted in a £1.3m difference in personal injury costs
11. An explanation was asked regarding the movement in provisions. JG informed the Committee there had been two large cases which related to both a personal injury and a clinical negligence case
12. Regarding the cash and cash equivalent table within the report, what were ‘current investments?’ CT explained that these referred to national loans which essentially was where the Trust invested the balance of cash at the end of the year
13. Property, plant and equipment table, what were the reclassifications? JG explained that these were assets coming into the Trust that were then reclassified in to the correct category. AV added that once the new asset register had been implemented, registering of assets would be improved.
Draft Accountability Report 2017/18 KC drew the Committee’s attention to the Accountability Report and advised that it consisted of three main elements; a Corporate Governance Report (which included the Annual Governance Statement (AGS) that historically had been produced as a standalone document), a Remuneration and Staff Report and a Parliamentary Accountability and Audit Report. He gave further details in terms of what each element consisted of and commented that the AGS was the most significant document. He further added that the AGS contained information relating to the Trust’s risk management and provided details on how the Trust was managing its governance arrangements. Having considered the report in more detail, Members raised the following:
1. In terms of the breach of standing orders, a clear description of the breach should be included within the report
2. With regard to limited assurance in terms of the Handover of Care internal audit report, the narrative should be strengthened to reflect the Trust’s view of the report and the responsibilities of health boards
3. Board membership – details of Champion roles should be included as part of the Non Executive Directors roles.
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RESOLVED: That (1) the Committee gave formal approval for the annual accounts 2017/18 to
be recommended to the Trust Board for adoption;
(2) it was noted that the monitoring of the implementation of the asset register was deferred to the Finance and Resources Committee;
(3) the accountability report 2017/18 was recommended for approval by the Trust Board; and
(4) a note of thanks was recorded for all those involved in the production of the reports especially in view of the staff shortage and tight timescales.
16/18
HEAD OF INTERNAL AUDIT OPINION AND REPORT 2017/18 The Head of Internal Audit HH, gave an overview of the work submitted to the Audit Committee throughout the year. A total of 24 audits had been carried out during the last year and the overall opinion was of a reasonable assurance. Members recognised the significant progress being made in terms of internal audit response from management going forward and acknowledged that more focus should be given to the Audit Tracker. RESOLVED: That the report was received.
17/18 INTERNAL AUDIT PROGRESS REPORTS
1) Rest Breaks Follow up - Limited Assurance. OL explained this was a second follow up report; management had accepted the recommendations. CV acknowledged this was an unacceptable position and commented that further work was being undertaken to address this issue. This included tightening up and implementing a new rostering system and the implementation of electronic time sheets going forward. This would eliminate the need for manual checks to be carried out. CV added that clear lines of accountability had been identified and gave assurance that the actions within the report would be implemented. Members noted that the new rostering system would be trialled on a rolling process and piloted in one particular area prior to full implementation. It was also noted that monitoring of the project would be overseen by the Finance and Resources Committee; and that no further follow up reports would be issued by Internal Audit. The Committee noted the inequity across Wales in terms of rest breaks, particularly in Pembrokeshire and stressed the importance of implementing a consistent approach going forward. The Committee discussed rest breaks in further detail and debated whether it would be useful for the partnership forum to be made aware of limited assurance audit reports; CV agreed to facilitate this going forward.
2) Health and Safety - Limited Assurance. In providing an overview of the
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report OL explained that management had accepted the findings and had provided a response. The Director of Quality, Safety and Patient Experience and Nursing CB, in giving an update informed the Committee that significant improvements had been made in terms of health and safety, however there were still milestones to be achieved. In terms of the report, three areas within it had been identified as high:
I. Intranet site – work was underway to improve the design and enable better access to Health and Safety information
II. Datix facility for reporting – a review was being undertaken to improve the reporting capability within Datix
III. Risk Assessments – in terms of the health and safety aspect, these were being reviewed prior to uploading on to the Intranet
The Committee were informed that a health and safety assurance framework was being scoped which would identify roles and responsibilities from a health and safety perspective. Members, in discussing the report in further detail were encouraged by the improvements in health and safety going forward. The following comments were raised:
I. It would be helpful, in terms of the objectives, that more detail was included
II. In terms of development of the Intranet, clarity was sought regarding responsibility of Health and Safety input. The Head of Health and Safety would be responsible for the input
The Committee understood that all the recommendations within the report should be completed by the end of the financial year.
3) Handovers at Emergency Departments - Limited Assurance. HH, in presenting the report, informed the Committee that responses from health boards were still outstanding noting input from the Trust’s Director of Operations had been included within the report. The Board Secretary KC, agreed to circulate the final report to health boards and would arrange to keep a log of any responses where the report had been visible and should include the Trust’s response. The log/tracker could be used as evidence to support any escalation going forward. The Committee discussed the matter in greater detail recognising the issues and expressed concern that unless there were radical changes, the status quo would remain and another limited assurance would be issued. AV added that WAO would be focussing on the issues going forward.
4) Non-Emergency Patient Transport Services - Reasonable Assurance. OL advised that management had accepted the comments.
5) Health and Care Standards - Substantial Assurance. OL informed the Committee this was a very positive report.
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6) Staff Engagement and Communication - Reasonable Assurance. OL
briefed the Committee that the initial findings had been shared with the WAO. Recommendations had been agreed by management and the appropriate response was in place. There were however challenges to be overcome and this was due to the operational nature of the workforce.
7) Welsh Risk Pool - Claims Management Standard - Substantial Assurance. OL explained this had been a very positive report and had been accepted by management with the appropriate response in place.
RESOLVED: That the updates were noted.
18/18 INTERNAL AUDIT PLAN 2018/19 An overview of the plan was provided by HH. KC provided an explanation in terms of the process involved with regard to the Executive Management Team being updated on progress with internal audits; follow up audits were at the forefront. The Chair added that a process was underway in order to keep all Non Executive Directors well-informed of future internal audit plans going forward. RESOLVED: That the updated action plan was approved.
19/18 AUDIT RECOMMENDATION TRACKERS The Board Secretary KC, provided the Audit Committee with a progress report in respect of the work undertaken to address recommendations made as a result of internal and external audit reviews. In presenting the report, KC referred to the two annexes; Internal Audit (IA) reviews and Wales Audit Office reviews attached to the report which described the actions taken by the Trust to address outstanding recommendations. Members considered the report further and asked that further clarity be provided on the reasons why there were delays in receiving responses, especially with the higher rated audits. Members also considered whether the relevant Executive Director be requested to attend the Audit Committee should there be no progress regarding IA reports relevant to their directorate. KC and CT agreed to alert the Executive Management Team of this request. The Committee expressed concern that the rest break audit review did not appear on the tracker. KC advised that he would investigate the matter and update the Committee at its next meeting. RESOLVED: That the progress made by the Trust in addressing the Internal and External Audit Report recommendations as outlined in each of the Annexes was reviewed.
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20/18 LOSSES AND SPECIAL PAYMENTS – PAYMENTS FOR THE PERIOD 1 APRIL 2017 TO 30 APRIL 2018 CT gave an overview of the report which detailed Losses and Special Payments made during the twelve months from 1st April 2017 to 31st March 2018. Members considered the report in more detail and queried whether the Trust would no longer charge a fee for accessing medical records; CT explained that as part of the new General Data Protection Regulations (GDPR) the fee would no longer be chargeable. RESOLVED: That the Losses and Special Payments Report for 2017/18 was received.
21/18 CORPORATE RISK REGISTER (CRR) QUARTERLY REPORT 2017/18 The Assistant Director of Quality, Governance & Assurance CR, in presenting the CRR Quarterly Report (Annex 1) advised the Committee it had been approved by the Executive Management Team on 16 May 2018 and was presented to the Audit Committee for endorsement. The quarterly report provided a platform to demonstrate how the Trust was continually improving the Trust’s risk maturity in sourcing and controlling risks, in addition to providing strong internal and external assurances over the lifespan of the Risk Management Strategy & Framework 2016/19. It was confirmed that the strategy would be presented to the Board at its meeting in July. The Trust Risk Management Development Group continued to build the capacity and capability across the organisation to support its risk maturity. During Quarter 4 the Risk Management Development Group meeting reviewed the Risk Management Strategy and this had recently been approved at the last Quality, Patient Experience and Safety Committee meeting. Following the update the Committee raised the following:
1. Members recognised that the next report would contain details of the risk regarding handover delays
2. A method of expressing the fact that not all the risks were the Trust’s overall responsibility would be worthwhile
3. In accessing the risk, the risk score should relate practically to the issue in question
In summarising, the Chair acknowledged there was further work to be undertaken in terms of the description of the risk and noted the significant improvement with the register going forward. RESOLVED: That the Corporate Risk Register Quarterly Report for Quarter 4 was endorsed by the Audit Committee, recognising there were additional actions to be taken forward to support the Trust risk maturity.
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22/18 MONTHLY FREEDOM OF INFORMATION IMPROVEMENT PLAN MONITORING REPORT
KC gave the Committee an overview of the report which contained information on the Trust’s performance in meeting its obligations under the Freedom of Information (FoI) Act 2000. There had been a marked improvement in the Trust’s performance in responding to FoIs for the period 1 January to 31 March 2018 compared to the same period for 2017. The Trust had received 62 requests during this period which was an increase of 11 requests received in 2018 compared to the same period last year. The Trust exceeded the ICO target of 90% consecutively for November 17 – February 18. The Committee recognised that unless there was a significant decrease in FOI reporting performance no further updates would be provided to the Committee; it was noted that FoIs were monitored by the Quality Steering Group. CT provided an overview of the themes and trends in terms of FoI requests. It was not known at this stage whether the implementation of GDPR would have an effect on the number of FoI requests. RESOLVED: That the update was noted.
23/18 GOVERNANCE IN RECRUITMENT The Committee were presented with the report by KC who drew their attention to the updated action plan which had been designed to track progress in addressing the actions contained within the Welsh Government’s letter following the Welsh Audit Office (WAO) report into recruitment and procurement issues at Cardiff & Vale Health Board. Members noted progress in which they were informed that all actions had been completed and it was agreed that no further updates were required going forward. RESOLVED: That the Audit Committee received the action plan and agreed the closure of the actions
24/18 WALES AUDIT OFFICE (WAO) REPORT – INFORMATICS SYSTEMS IN NHS WALES
CT briefed the Committee on the recent WAO report into informatics in NHS Wales and the future impact on the Trust. In briefing the Committee CT added that the arrangements for delivering national informatics services had been reviewed and focused on whether NHS Wales was well placed to achieve the intended benefits from investment in updated clinical informatics systems. The review had focussed on the arrangements within NHS Wales Informatics Services to deliver national systems, looking at six specific systems in more detail as indicators of the wider approach to informatics. It had also included looking at the engagement of health boards with the delivery of national systems.
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At this stage Paul Hollard declared an interest as he provided support to NWIS in terms of governance issues. Members discussed the report in more detail and noted that the report appeared to be more system focused as opposed to clinical; this could raise problems with coding systems going forward. RESOLVED: That the report was noted.
25/18 NO PURCHASE ORDER, NO PAYMENT CT provided the Committee with an explanation on the agreement to implement a national No Purchase Order/No Payment approach within all NHS Wales organisations, as agreed through the NHS Wales Finance Academy, NWSSP Committee and all Wales NHS Directors’ of Finance. He added that following implementation, the process should be seamless. RESOLVED: That the proposed national implementation of an agreed No
PO/No Pay approach by NWSSP, to be implemented in a shadow form from 1
June with full implementation from 1 September 2018 was noted.
26/18 POLICIES Counter Fraud, Corruption and Bribery Policy The policy was presented as read and approved by the Committee. A note of thanks was recorded for all those involved in its production. RESOLVED: That the Counter Fraud, Corruption and Bribery policy was approved in line with the Trust process.
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. Reports relating to the items of business in these minutes can be found on the Trust’s website, www.ambulance.wales.nhs.uk
1 ITEM 1.3b Audit Minutes CLOSED Minutes 24 May 2018 chair ver 2.doc
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WELSH AMBULANCE SERVICES NHS TRUST
UNCONFIRMED MINUTES OF THE CLOSED MEETING OF THE AUDIT COMMITTEE OF THE WELSH AMBULANCE SERVICES NHS TRUST HELD ON
THURSDAY 24 May 2018 AT VANTAGE POINT HOUSE, CWMBRAN WITH VIDEO CONFERENCING AND AUDIO FACILITIES
PRESENT :
Pam Hall Emrys Davies Paul Hollard
Non Executive Director and Chair Non Executive Director Non Executive Director
PH ED PHo
IN ATTENDANCE: Keith Cox Jill Gill Helen Higgs Ossian Lloyd Steve Owen Chris Turley Paul Seppmann Carl Window
Board Secretary Financial Accountant (Via VC St Asaph) Head of Internal Audit NWSSP Internal Audit Corporate Governance Officer Interim Director of Finance and ICT Trade Union Partner Counter Fraud Manager
KC JG HH OL SO CT PS CW
APOLOGIES: Julie Boalch Helen Birtwhistle
Corporate Governance Officer Non Executive Director
04/18
PROCEDURAL MATTERS Declarations of Interest The Committee noted Mr Emrys Davies’ standing declaration of interest as being a retired Member of UNITE. RESOLVED: That the declaration of interest of Mr Emrys Davies being a retired member of UNITE made under the Code of Conduct was noted.
05/18
COUNTER FRAUD ANNUAL REPORT 2017/18 and COUNTER FRAUD WORK PLAN 2018/19 Prior to the update and further to the last meeting following a query in terms of whether the Counter Fraud Annual Report should be presented under closed session, CW gave an explanation as to why it was appropriate for the report to continue to be reported in the closed session. CW provided the Committee with an overview of the work being undertaken by
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Counter Fraud going forward and referred to several specific contents of the report in more detail. Members were advised of the several initiatives underway which were in place to improve the dissemination of the counter fraud message throughout the organisation. In considering the report in further detail Members recognised the excellent progress to date. They queried whether it was possible to determine the amount of money lost with fraud. CW explained that whilst it was a challenge to provide an exact figure, the general rule of the thumb was in the order of 7% of the annual budget of the organisation. In terms of the work plan, CW provided an overview with regards to its progress. He added that the plan had been broken down into four key work delivery strands:
• Inform and Involve
• Prevent and Deter
• Hold to Account
• Strategic Governance Members were given further details in terms of how each strand was adhered to going forward. RESOLVED: That the Counter Fraud Annual Report and the Counter Fraud Work plan 2018/19 was approved by the Audit Committee.
06/18 TENDER UPDATE REPORT AND SINGLE TENDER WAIVE REQUESTS
The Committee were given an overview of tenders and tender waivers since the last meeting by CT. He explained in more detail the procurement route in terms of the three single tender waivers. Following a query regarding the Electronic Patient Clinical Record contract PHo and CT updated the Committee with progress. RESOLVED: That
(1) Members of the Committee commented on the information provided and noted the contents of the report;
(2) It was noted that 3 new tenders were issued during this period, 2 of
which had been awarded; and
(3) It was noted that there were 3 requests to waive SFIs accepted during the period.
1 ITEM 1.3c Audit Committee Action Log.xlsx
No. DATERAISED
MINUTEREFERENCE ACTION ASSIGNED TO/ ACTION STATUS AND DUE DATE
12 14-Sep-17 20/17 InternalAudit reports -Safeguarding
CB added that once guidance hadbeen received from WG on theDisclosure Barring Service, furtherclarification would be provided.
Ongoing until information received. Noprogress at an All Wales level on thisissue. Paper to be tabled at ExecutiveManagement Team to discuss andassess the risk and ascertain whetherthere is a requirement for a local decisionto be made. Awaiting WG to provide anational view for Wales
Director of Quality, Safety andPatient Experience
13 14-Sep-17 20/17 InternalAudit reports -Safeguarding
CB advised that the Deputy Director ofWorkforce and OrganisationalDevelopment was currently performinga review into the issue and would berequested to provide an update on DBSchecks at the next Audit Committeemeeting with a particular focus onCommunity First Responders.
Ongoing until further information received Director of Workforce andOrganisational Development
14 14September2017 and 7December2017
20/17 InternalAudit reports –Weir report
LP agreed to liaise with the FleetManager and report back to AuditCommittee with findings. ExecutiveManagement Team would formallyclose the report at its next meeting.Director of Operations to circulatereport prior to next meeting.
13-Sep-18 Director of Operations
CT advised that a paper had been sent toEMT and an update would be provided atthe Audit Committee meeting inSeptember. Report has been circulatedto Committee (28 Aug)
25 7-Dec-17 28/17 The policy which managed the controlof drugs was developed and effectedas soon as possible.
13-Sep-18 Assistant Director of Operations
Internal Audit
27 7-Dec-17 28/17 A more robust procedure to ensure thecompletion of Fire Drills and Fire LogBooks was to be implementedimmediately.
13/09/2018All HB have assigned a Fire marshall &have a system in place regarding whotakes ownership of Fire drills & Log books
Assistant Director of OperationsInternal Audit
33 24-May-18 15/18 Members sought clarity on thetimescales involved regarding the assetregister. CT advised that the Financesand Resources Committee weremonitoring the situation and agreed toprovide an update on progress to theAudit Committee on 13 September2018
A Task and Finish group was createdand met for the first time in July 2018.Since then a significant amount of workhas been undertaken in this area and thegroup is on target to complete theimplementation by the end of September2018.
Interim Director of Finance and ICT
A paper was taken to FRC on 5th Julyoutlining progress on the implementationof the new asset register system, as thisitem had been referred to FRC from AC.This confirmed implementation to due tocompleted by Sept / Oct 2018, well inadvance of both the 2018/19 financialyear end and any planned interim2018/19 audit by WAO.
35 24-May-18 17/18Internal Audit
Rest Breaks follow up review, it wasagreed this be deferred to FRC tooversee and monitor progress
13/09/2018This related to the financial benefit likelyto be seen following the significantincrease in rest break compliance. Thiswill be picked up by FRC as part of theoverall scrutiny and monitoring of the2018/19 financial position.
Interim Director of Finance and ICT
36 24-May-18 17/18Internal Audit
Handovers at ED's. It was agreed thatthe Board Secretary arrange for thereport to be circulated to Health Boardsand that a log of discussion be kept toshow outcomes going forward. Anupdate would be provided at the nextmeeting
13/09/2018 An update is being preparedfor the meeting. See Annex d to thisaction log
Board Secretary
37 24-May-18 109/18 AuditTracker
The Committee expressed concern thatthe rest break audit review did notappear on the tracker. KC advised thathe would investigate this issue andupdate the Committee at its nextmeeting.
13/09/2018 Responsewill form part of the AuditRecommendation report on the Agenda.
Board Secretary
COMPLETED ACTIONS
11 December2016 and 9March 2017
35/16 FireSafetyComplianceFollow-up
Richard Davies, Assistant Director ofCapital and Estates would berequested to attend the next AuditCommittee meeting to provide anupdate on progress and to notify of anybarriers to the success of complyingwith the recommendations.
1-Jun-17
Director of Finance and ICT
COMPLETED
2 9-Mar-17
02/17INTERNALAUDITPROGRESSREPORT andInternal Audit(IA) Plan2017/18
Controls over the use of NHSsupplies 1-Jun-17
Director of Operations
RL confirmed that the issues raised inthe audit would be rectified by April2017
Update provided at meeting.
COMPLETED
3 9-Mar-1702/17 InternalAudit (IA) Plan2017/18
The comments regarding the plan beaddressed by HH and an updated planbe circulated by the next AuditCommittee meeting.
1-Jun-17
Head of Internal AuditRevised plan and comments circulatedto Members on 4 April 2017
COMPLETED
4 9-Mar-17 03/17 ExternalAudit
Committee requested all completiondates were to be illustrated insubsequent reports
1-Jun-17External Audit
COMPLETED
5 9-Mar-1709/17 ReportedBreach ofStanding Orders
Updated report to be presented at nextmeeting
1-Jun-17
Board SecretaryReport is included in IA reports: Item3.1g
COMPLETED
6
1 June2017 and 14/17
The specific recommendations arisingfrom the financial audit work would bereported in a separate report to theAudit Committee scheduled forSeptember 2017. At 14 Septembermeeting, this item was deferred by theWAO to December meeting.
7-Dec-17
Wales Audit Office
14-Sep-17Audit ofFinancialStatements
11 December2016 and 9March 2017
35/16 FireSafetyComplianceFollow-up
Richard Davies, Assistant Director ofCapital and Estates would berequested to attend the next AuditCommittee meeting to provide anupdate on progress and to notify of anybarriers to the success of complyingwith the recommendations.
Director of Finance and ICT
COMPLETED
7 1-Jun-17
17/17Members recognised the challengesinvolved in keeping the tracker up todate and in future would like to see theitems earmarked for closure identifiedwithin the SBAR
14-Sep-17
Board Secretary
AuditRecommendation Trackers
COMPLETED
8 1-Jun-17 13/17 ExternalAudit Report
In terms of the Remuneration Report,following a detailed discussion into theprocess, it was agreed that the issuewould be considered at the next ChairsWorking Group meeting
14-Sep-17
Board SecretaryCOMPLETED
9 14-Sep-17
Nov-17
Asset management - the Committeediscussed the processes in terms ofasset It was agreed that PR wouldarrange for this to be brought to theattention of the Finance and ResourcesCommittee for their consideration
COMPLETEDExecutive Director of Financeand Deputy Chief ExecutiveOfficer
DRAFTANNUALACCOUNTSANDACCOUNTABILITY REPORT2016/17
10 14-Sep-17
12/17 HEAD OFINTERNALAUDITOPINION ANDANNUALREPORT
It was suggested that going forward,and as part of the process, NonExecutive Directors would be madeaware of specific IA reports which couldbe discussed through their respectiveExecutive Director champions – Thiswas to be actioned at the next meetingof the CWG.
3-Oct-17
Board SecretaryCOMPLETED
6
The specific recommendations arisingfrom the financial audit work would bereported in a separate report to theAudit Committee scheduled forSeptember 2017. At 14 Septembermeeting, this item was deferred by theWAO to December meeting.
Wales Audit Office
11 14-Sep-17 Closed Session Disseminate further informationregarding Tenders and Waivers
Information e-mailed to Members ofCommittee on 18 September 2017
Deputy Director of Finance
COMPLETED
15 14-Sep-1721/17 ExternalAudit Progressreport
The charitable funds FinancialAccounts Independent Examinationwas planned to be undertaken duringOctober and once completed would bereported at the next Audit Committeemeeting
7-Dec-17
Wales Audit OfficeCOMPLETED
16 14-Sep-1722/17 Lossesand SpecialPayments
Members were keen to understand howany lessons were being learned andwere any themes or trends developinggoing forward? LP and CT agreed toconsider this further and would providethe Committee with an analysis on anylearning themes that were developing.
A full update on this area is beingincluded within the December 2017Losses and Special Payments Report.
Deputy Director of Finance and
Assistant Director of OperationsOn Agenda
COMPLETED
17 14-Sep-17
23/17 CorporateRisk Register(CRR) QuarterlyReport QuarterOne
Some of the target dates were in 2019and if these applied to high risks, wasthis timely enough? CB explained thatthese had been timelines set by WGand would refer this back to the riskregister advisory group for theirconsideration.
7-Dec-17
Director of Quality, Safety andPatient Experience
COMPLETED
18 14-Sep-17
24/17 AUDITRECOMMENDATIONTRACKERS
CB was requested to conduct a reviewon the open health and safety itemsand provide comments for the trackerfor the next Audit Committee meeting.
7-Dec-17
Director of Quality, Safety andPatient Experience
COMPLETED
19 14-Sep-17
24/17 AUDITRECOMMENDATIONTRACKERS
Members asked for further detail interms of progress with items on thetracker where completion dates hadpassed.
7-Dec-17
Corporate Governance Manager
COMPLETED
20 14-Sep-17 25/17 FoI report
The Committee requested that futureFoI update reports include requeststhat had been refused with the specificreason why.
7-Dec-17
Board SecretaryCOMPLETED
21 14-Sep-17 26/17 Items forNoting
Auditor General for Wales - Audit ofCardiff and Vale University HealthBoard’s
7-Dec-17
Board SecretaryKC briefed the Committee on thedevelopments being made following theaudit and advised that a progressreport should be forthcoming to thenext Audit Committee.
COMPLETED
22 14-Sep-17
Closed Session Members queried the process for theapproval of the Counter Fraud AnnualReport and it was agreed clarity wouldbe provided.
7-Dec-17Board Secretary and Counter FraudManagerNov-17
Counter FraudAnnual Report COMPLETED
23 7-Dec-17
29/17To review and provide the Committeewith an update on the finding includedwithin the WAO Public Procurement inWales report published in October2017
8-Mar-18
Deputy Director of Finance
External Audit
COMPLETED
24 7-Dec-17
29/17
To provide Members of the Committeewith a current update on the status ofeach of the items highlighted by WAOin their final accounts auditmemorandum 2016/17
31-Jan-18
Deputy Director of Finance
External AuditCOMPLETED
19 14-Sep-17
24/17 AUDITRECOMMENDATIONTRACKERS
Members asked for further detail interms of progress with items on thetracker where completion dates hadpassed.
Corporate Governance Manager
Circulated to Committee on 1 March 2018
26 7-Dec-17
28/17 Fleet Maintenance Costs – As part ofthe ongoing work it was agreed that abenchmarking exercise would beconducted.
8-Mar-18
Deputy Director of FinanceInternal Audit
COMPLETED
28 7-Dec-17
28/17Personal Appraisal and DevelopmentReview (PADR) process, LP gave anoverview of how these were beingconducted and how any themes andtrends identified were being mapped. Afollow up review would be presented atthe next meeting.
8-Mar-18
Assistant Director of Operations
Internal Audit
To be monitored through FRC
29 7-Dec-17
28/17Members discussed the issue ofcontrolled drugs in further detail and itwas suggested that a clinical notice toremind staff of the requirements wouldbe circulated.
8-Mar-18
Assistant Director of Operations
Internal Audit
COMPLETED
30 7-Dec-17
31/17
1. In terms of the EmergencyServices Mobile CommunicationsProgramme (EMSCP) it was queriedwhy the consequence/impact had beendowngraded?
8-Mar-18
Assistant Director of Quality,Governance and Assurance
CRRNote: Extract from CRR: ‘Followingfurther review by CEO and Director ofOperations and consultation with bluelight partners the consequence of risk hasbeen adjusted to reflect consistentapproach and assessment of risk by allpartners’.
COMPLETED
24 7-Dec-17
To provide Members of the Committeewith a current update on the status ofeach of the items highlighted by WAOin their final accounts auditmemorandum 2016/17
Deputy Director of Finance
Meeting arranged between Claire Bevan& Patsy Roseblade for 31 January 2018to discuss/agree a way forward -COMPLETED
2. New committees had beenidentified; how would any duplication ofwork be avoided going forward?
31 7-Dec-17
36/17
An update was to be provided on theactions as detailed in the attached:
8-Mar-18
Board Secretary
Governance,Recruitment andProcurement
COMPLETED
Verbal update will be provided
COMPLETED
32 13-Mar-18IA Progress Report to includeadditional information to highlight turn-round times for reports
24-May-18
Head of Internal Audit
Internal AuditReports
COMPLETED
34 24-May-18 15/18 Annual Accounts, staff costs. Jill Gill,Financial Accountant agreed tocirculate reconciliation paper to theChair
13/09/2018 Thisaction was completed with an e-mail toPam Hall from Jill Gill on 29/05/18COMPLETED
Financial Accountant
30 7-Dec-17 Assistant Director of Quality,Governance and Assurance
No. DATERAISED MINUTE REFERENCE ACTION
STATUS/ ASSIGNED TO/ACTION
DUE DATE
1 ITEM 1.3d handover report status update.docx
Handover of Care at Emergency Departments: Status Update Internal Audit Report Draft issued 5 January 2018 Final issued 15 May 2018
Date
Setting Purpose
Jan/February 2018
Chief Operating Officers
Draft report circulated for comments and management responses
Jan 2018
All-Wales NHS Chairs meeting
Draft report shared with NHS Chairs
March 2018
Board Secretaries Group meeting
Head of Internal Audit Attends Board Secretaries meeting to emphasise importance of the report and obtaining management responses
March 2018
Board Secretaries
Report distributed to Board Secretaries with the request that this is presented to their audit Committees.
April - July
Presented to Health Board Audit Committees
Cwm Taf – April Cardiff & Vale - April BCU – May Hywel Dda – June ABM – July AB - July
June 2018
Presented to EASC
Referred to JMAG
July 2018
Presented to Nurse Directors
To make aware and emphasise the need to take through Audit Committees
July 2018
Presented to Medical Directors To make aware and emphasise the need to take through Audit Committees
Handover of Care at Emergency Departments: Status Update Internal Audit Report Draft issued 5 January 2018 Final issued 15 May 2018
September 2018
On the agenda of the All- Wales Audit Chairs meeting
To remind Chairs of the need to respond and provide updates on the report
September 2018
Chair to write to NHS Chairs
Request Health Boards respond to recommendations
October 2018
CASC report to EASC Remind Health Boards to respond to recommendations
2.1 Internal Audit Reports (Head of Internal Audit)
1 ITEM 2.1 WAST Audit & Assurance Progress Report.pdf
INTERNAL AUDIT PROGRESS REPORT 2018/19
Welsh Ambulance Services NHS Trust
September Audit Committee
NHS Wales Shared Services Partnership
Audit and Assurance Service
INTERNAL AUDIT PROGRESS REPORT 2018/19 Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 2
Contents
1. INTRODUCTION........................................................................... 3
2. OUTCOMES FROM COMPLETED REVIEWS ........................................ 3 3. DELIVERY OF THE 2017/2018 AUDIT PLAN ..................................... 3
4. PROPOSED CHANGES TO 2017/18 PLAN ......................................... 5 5. ENGAGEMENT ............................................................................. 5
6. POST AUDIT QUESTIONNAIRES (PAQs) .......................................... 6 7. RECOMMENDATION ..................................................................... 6
APPENDIX A – STATUS SCHEDULE
APPENDIX B – KEY PERFORMANCE INDICATORS APPENDIX C – ASSURANCE RATINGS
INTERNAL AUDIT PROGRESS REPORT 2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 3
1. INTRODUCTION
1.1 The purpose of this report is to inform the Committee on progress of
the 2018/19 Internal Audit Plan as recorded at 6 September 2018.
1.2 Appendix A details the 2018/19 Audit plan and shows the status of work to date. At the time of this report, progress against the Plan is
as follows:
Number of Audits in plan 28
Number of audits finalised 5
Number of audits issued at draft 0
Number of audits in progress 6
Year-end reporting
2. OUTCOMES FROM COMPLETED REVIEWS
2.1 Since the May meeting of the Committee, five reports have been
finalised. These are highlighted in the table below along with the
allocated assurance rating. The full versions of these reports are
included in the committee’s papers as separate items.
3. DELIVERY OF THE 2017/2018 AUDIT PLAN
Full details are available at Appendix A.
3.1 No further reports are currently issued as draft.
Review Assurance rating
Fleetwave system Reasonable
Annual Quality Statement N/A
Continuous Professional Development Limited
Volunteers car drivers – governance arrangements
Limited
Environmental Sustainability Report N/A
INTERNAL AUDIT PROGRESS REPORT 2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 4
3.2 The following audit reviews are currently in progress:
Audit Review Objective overview
Losses and Special Payments (LASP) –
lessons learned
The review seeks to provide assurance that where losses and special payments
have been incurred by the Trust, that these are recorded and there are
adequate processes in place to ensure lessons are learned to avoid similar
costs in the future.
Travel and subsistence
expenses
The review will examine the
appropriateness of spend with a focus
on travel consciousness and seek to provide an assurance that appropriate
examples are being set by Board members and that this is emulated
throughout the Trust.
General Data
Protection Regulations The internal audit will seek to provide
assurance to the Trust that arrangements are in place and managed
appropriately within its
Departments/Directorates to ensure compliance with the requirements of the
GDPR.
Information systems
security – appropriate
access
A focus mainly on the controls around
appropriate security and access to the Trust’s information systems, specifically
in relation to leavers from the organisation. In addition, an assessment
of related salary overpayments and the return of Trust property and assets in
respect of leavers.
Escalation procedures The audit will assess the arrangements in place within the Trust for assessing
the effectiveness of the Escalation
Processes Toolkit.
Clinical Contact Centre
– hear
The review will assess the operational
performance of Hear and Treat across the Trust’s three Clinical Contact
Centres, including looking at resource
utilisation.
INTERNAL AUDIT PROGRESS REPORT 2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 5
4. PROPOSED CHANGES TO 2017/18 PLAN
4.1 Planned reviews:
At the request of the Director of Workforce & OD, the ‘trade union
release time’ review that was planned to be undertaken in Q2 and
reported to the December Audit Committee, will now be moved to Q4 and reported to the May Audit Committee.
To ensure that delivery of the Audit Plan remains on track, we have
agreed with management that the review of ‘travel and subsistence expenses’ is brought forward as a straight swap as this review was
originally scheduled for Q4.
Due to the work undertaken by Wales Audit Office on asset management, it has been agreed with management that our planned
review of ‘property, plant and equipment’ be replaced by a lessons learnt review of ‘losses and special payments’.
5. ENGAGEMENT
5.1 Meetings held and Committees attended during the reporting period:
Board/Sub Committee Attendance:
Board – 31 May; 19 July
Finance & Resources Committee – 10 May; 5 July
QUEST – 22 May; 4 September
Trust Internal Meetings:
Patsy Roseblade, Interim Chief Executive Officer – 16 July
Martin Woodford, Chairman –31 May; 21 August
Pam Hall, Chair of Audit Committee – 21 May; 5 September
Keith Cox, Board Secretary – 10 July; 10 September
Wales Audit Office Meetings:
Fflur Jones/Michelle Phoenix – 10 July
INTERNAL AUDIT PROGRESS REPORT 2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 6
Health Inspectorate Wales Meetings:
Joseph Wilton – 10 July
In addition to the above, regular meetings with Executive Directors to
discuss individual audit reviews.
6. POST AUDIT QUESTIONNAIRES (PAQs)
6.1 Following the issue of each audit report, we issue a feedback survey to the Executive lead/key contact. Feedback is important as it helps
us to improve our service and allows us to deal with any issues. Out of the five surveys issued to date, we have received one response,
which provided a satisfaction score of 10/10.
We encourage auditees to take the opportunity to feedback on their
audit experience.
7. RECOMMENDATION
7.1 The Audit Committee is invited to note the above and agree to the
proposed changes set out at 4.1.
INTERNAL AUDIT PROGRESS REPORT 2018/19
STATUS SCHEDULE Appendix A
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 7
Planned output Outline
timing
Status End of
Field
work
Draft
report
issued
Mgt
response
received
Final
report
issued
Assurance Planned
Audit
Committee
Revised
Audit
Committee
Corporate governance, risk and regulatory compliance
Head of Internal Audit Opinion &
Annual Report
Q4
Annual Governance Statement Q4
Risk Management & Assurance
Q4 May
Health & safety follow up
Q4 May
Welsh Risk Pool Claims
Management
Q4 May
Whistleblowing/Raising Concerns
Q3 March
Strategic planning, performance management and reporting
Integrated Medium Term Plan
(performance management)
Q4 May
111 service provision
Q3 March
Performance management - Local
Delivery Plans (LDPs)
Q3 March
Operational business continuity -
follow up Q4 May
INTERNAL AUDIT PROGRESS REPORT 2018/19
STATUS SCHEDULE Appendix A
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 8
Planned output Outline
timing
Status End of
Field
work
Draft
report
issued
Mgt
response
received
Final
report
issued
Assurance Planned
Audit
Committee
Revised
Audit
Committee
Financial Governance & Management
Property, plant & equipment Q2 Replaced
by LASP
review
N/A N/A N/A N/A N/A N/A N/A
Losses & special payments (LASP)
- lessons learnt
Q2 In progress December
Fleetwave system Q2 Final report
issued
25/07 25/07 17/08 29/08 Reasonable September
Travel and subsistence expenses Q4
Revised
Q2
In progress May December
Clinical Governance, Quality & Safety
Annual Quality Statement
Q1 Final report
issued
05/07 11/07 24/07 25/07 N/A September
Clinical risk
Q3 March
Clinical audit follow up
Q4 May
Research & development
governance structure
Q4 May
Information Governance & I.T. Security
GDPR
Q2 In progress December
INTERNAL AUDIT PROGRESS REPORT 2018/19
STATUS SCHEDULE Appendix A
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 9
Planned output Outline
timing
Status End of
Field
work
Draft
report
issued
Mgt
response
received
Final
report
issued
Assurance Planned
Audit
Committee
Revised
Audit
Committee
Information systems security –
cyber security
Q3 March
Information systems security –
appropriate access to system
(leavers)
Q2 In progress December
Operational Service and Functional Management
Health Board Areas/Station review
follow up
Q3 March
Hospital handovers follow up
Q4 May
Escalation procedures
Q2 In progress December
Clinical Contact Centre - Hear &
Treat
Q2 In progress December
Workforce Management
Continuous Professional
Development management
Q1 Final report
issued
30/07 10/08 02/09 05/09 Limited September
Volunteer car drivers – governance
arrangements
Q2 Final report
issued
07/08 10/08 27/08 29/08 Limited September
Trade union release time
Q2
Revised
Q4
December May
INTERNAL AUDIT PROGRESS REPORT 2018/19
STATUS SCHEDULE Appendix A
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 10
Planned output Outline
timing
Status End of
Field
work
Draft
report
issued
Mgt
response
received
Final
report
issued
Assurance Planned
Audit
Committee
Revised
Audit
Committee
Sickness absence management
follow up
Q4 May
Capital and estates management
Capital audit - Either North Wales
Headquarters and/or Vehicle
replacement programme
(dependent on available days)
QTBC TBC
Environmental sustainability
Q1 Final report
issued
05/07 20/07 15/08 30/08 N/A September
INTERNAL AUDIT PROGRESS REPORT 2018/19
KEY PERFORMANCE INDICATORS Appendix B
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 11
Indicator
Status Actual Target Red Amber Green
Report turnaround: time from fieldwork
completion to draft reporting [10 days] ● 5 out of
5
80%
v>20% 10%<v<
20%
v<10%
Report turnaround: time taken for management
response to draft report [15 days] ● 4 out of
5
80%
v>20% 10%<v<
20%
v<10%
Report turnaround: time from management
response to issue of final report [10 days] ● 5 out of
5
80%
v>20%
10%<v<
20%
v<10%
* Correct at 31/08/2018
Within agreed timescales Less than 5 days over agreed timescale More than 5 days over agreed timescale
INTERNAL AUDIT PROGRESS REPORT 2018/19 Appendix C
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services
Assurance Ratings
RATING INDICATOR DEFINITION
Su
bsta
nti
al
assu
ran
ce
- +
Green
The Board can take substantial assurance that arrangements to secure
governance, risk management and internal control, within those areas under
review, are suitably designed and applied effectively. Few matters require
attention and are compliance or advisory in nature with low impact on residual risk exposure.
Reason
ab
le
assu
ran
ce
- +
Yellow
The Board can take reasonable
assurance that arrangements to secure governance, risk management and
internal control, within those areas under review, are suitably designed and applied
effectively. Some matters require management attention in control design or compliance with low to moderate
impact on residual risk exposure until resolved.
Lim
ited
assu
ran
ce
- +
Amber
The Board can take limited assurance
that arrangements to secure governance, risk management and internal control, within those areas under review, are
suitably designed and applied effectively. More significant matters require
management attention with moderate impact on residual risk exposure until
resolved.
No
assu
ran
ce
- +
Red
The Board has no assurance that arrangements to secure governance, risk management and internal control, within
those areas under review, are suitably designed and applied effectively. Action
is required to address the whole control framework in this area with high impact on residual risk exposure until resolved.
INTERNAL AUDIT PROGRESS REPORT 2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services
Office details:
Audit and Assurance,
Cwmbran House, Mamhilad Park Estate,
Pontypool, NP4 0XS
Contact details
Helen Higgs (Head of Internal Audit) – 01495 300846
1 ITEM 2.1a WAST_18-19_Fleetwave II_FINAL Internal Audit Report_ FOR CLIENT ISSUE.pdf
Fleetwave II System
Internal Audit Report
2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Shared Services Partnership
Audit and Assurance Services
Fleetwave II System Report Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 2
CONTENTS Page
1.Introduction and Background 4
2.Scope and Objectives 4
3.Associated Risks 5
Opinion and key findings
4.Overall Assurance Opinion 5
5.Assurance Summary 6
6.Summary of Audit Findings 7
7.Summary of Recommendations 9
Review reference: WAST-1819-10
Report status: Final Fieldwork commencement: 2nd July 2018
Fieldwork completion: 25th July 2018
Draft report issued: 25th July 2018 Draft report clearance meeting: 20th / 27th July 2018
Updated draft report issued: 8th August 2018 Management response received: 17th August 2018
Final report issued: 29th August 2018
Auditors Helen Higgs, Head of Internal Audit
Osian Lloyd, Deputy Head of Internal Audit
Emma Rees, Principal Auditor Executive sign off Chris Turley, Interim Director of
Finance Distribution Gwen Kohler, Interim Deputy
Director of Finance Rob Macintosh, Regional Fleet
Manager Gareth Lloyd, Fleetwave Systems
Manager Committee Audit Committee
Finance and Resources Committee
Fleetwave User Group
Appendix A Appendix B
Appendix C
Management Action Plan Assurance Opinion and Action Plan Risk Rating
Responsibility Statement
Fleetwave II System Report Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 3
ACKNOWLEDGEMENT
NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this
review.
Please note:
This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in
accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.
Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance
Services, and addressed to Non-Executive Directors or officers including those designated as Accountable Officer.
They are prepared for the sole use of Welsh Ambulance Service Trust and no responsibility is taken by the Audit
and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third
party.
Fleetwave II System Internal Audit Report
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 4
1. Introduction and Background
The review of the Fleetwave II System was completed in line with the 2018/19 Internal Audit Plan. This covered the recently implemented
system to provide an assurance that it is working as intended. The review
included a specific focus on duplicate payments.
In 2016/17, we undertook a review of the previous Fleet Management System, 1link, to establish and test arrangements and controls in place
within the Fleet Department to ensure invoices are paid in a timely manner, and to prevent and detect duplicate payments. The scope was limited to
the process employed by the Fleet Maintenance Department, across the Trust, for the matching and payment of invoices against the ordering for
goods and services. A sample of 31 jobs was tested, highlighting multiple exceptions, including non-Purchase Order (PO) invoice, use of generic (call-
off) POs for multiple vehicles and approval numbers not being used. This resulted in limited assurance being given for the previous Fleet
Management System.
The Trust has subsequently purchased a new Fleet Management System called Fleetwave II (‘Fleetwave’). Fleetwave is a bespoke software package
designed specifically for the Trust. It supersedes the 1link system and has an automatic invoice feed into Oracle, allowing the Fleet Department to
provide suppliers with an order number from Fleetwave rather than Oracle.
Fleetwave went live on 1st April 2018.
2. Scope and Objectives
The internal audit assessed the adequacy and effectiveness of internal
controls in operation. Any weaknesses have been brought to the attention of management and advice issued on how particular problems may be
resolved and control improved to minimise future occurrence.
The audit sought to provide assurance over the following key areas to
ensure that:
payments are only made for goods or services required;
payments are only made for goods or services received (including
prevention and detection of duplicate payments); invoices are paid in a timely manner; and
the Fleet Department is ready for the full implementation of the No
PO/No Pay Policy.
Our initial scope was limited to the Fleetwave II System and payments to fleet maintenance contractors between 1st May and 30th June 2018. During
the audit, we extended this to cover the stock ordering system within
Fleetwave under the same control objectives.
Fleetwave II System Internal Audit Report
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 5
Limitations of Scope
The review only looked at expenditure on fleet maintenance contractors and stock ordering within Fleetwave. It did not cover any other areas of the
Trust’s expenditure. We also excluded the Fleet Department’s quality
assurance programme for external maintenance contractors.
3. Associated Risks
The risks considered in the review were as follows:
duplicate or overpayments being made or payments made for goods or services not received;
failure to comply with the Public Sector Prompt Payment Policy; and failure to comply with the No-PO/No Pay Policy, leading to high
numbers of invoices returned to fleet maintenance contractors – this
could be damaging to the Trust’s relationship with these contractors.
OPINION AND KEY FINDINGS
4. Overall Assurance Opinion
We are required to provide an opinion as to the adequacy and effectiveness
of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives within this report.
An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the identified risks associated
with the objectives covered in this review.
The level of assurance given as to the effectiveness of the system of internal
control in place to manage the risks associated with the Fleetwave II System (both fleet maintenance contractors and stock ordering processes)
is Reasonable assurance.
The overall level of assurance that can be assigned to a review is dependent
on the severity of the findings as applied against the specific review
objectives and should therefore be considered in that context.
RATING INDICATOR DEFINITION
Reason
ab
le
Assu
ran
ce
The Board can take reasonable assurance that arrangements to secure governance, risk
management and internal control, within those areas under review, are suitably designed and
applied effectively. Some matters require management attention in control design or
compliance with low to moderate impact on
residual risk exposure until resolved.
Fleetwave II System Internal Audit Report
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NHS Wales Audit & Assurance Services Page | 6
5. Assurance Summary
The summary of assurance given against the individual objectives is
described in the tables below:
Fleet maintenance contractors
1 Payments made only for
services required
2 Payments made only for services received **
3 Invoices are paid in a timely manner
4 Preparedness for the No PO/No Pay Policy
Stock ordering
1 Payments made only for
goods required
2 Payments made only for goods received **
3 Invoices are paid in a timely manner
4 Preparedness for the No PO/No Pay Policy
* The above ratings are not necessarily given equal weighting when generating the audit
opinion.
**Including prevention and detection of duplicate payments.
Design of Systems/Controls
The findings from the review have highlighted six issues that are classified
as weaknesses in the system control/design for the Fleetwave II System.
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Operation of System/Controls
The findings from the review highlighted one issue that is classified as a weakness in the operation of the designed system/control for the Fleetwave
II System.
6. Summary of Audit Findings
The Fleetwave Implementation Team has put a significant amount of work
into creating a system that works efficiently and effectively for the Trust. This is evidenced in the number of good practice points we have identified
below. The initial focus of this team was to address the previously identified issue with regard to duplicate payments and then to move on to
exploit the potential for Fleetwave to be a ‘one stop shop’ for all fleet
related activities. This is a longer term project and will include logging defects, lease/pool cars, monitoring driving licences with a direct link to
the DVLA, interfacing with fuel cards and linking directly with telematics for daily updates on vehicle mileage.
We understand that implementation of Fleetwave has already created
some efficiencies, for example:
the Fleet Administration Team has been reduced by two posts where it was not necessary to replace staff upon leaving;
staff within NHS Wales Shared Services Partnership Accounts
Payable division are no longer required to process fleet maintenance invoices; and
the Fleet Administration Team are processing fewer fleet maintenance invoices due to the functionality that allows contractors
to upload their invoices directly to Fleetwave.
Our work focused on a small section of the larger project, as outlined in the ‘Scope and objectives’ section (section 2) above.
Good Practice
We identified the following good practice within the Fleetwave system:
authorisation limits for stock ordering are embedded into the system,
thus preventing unauthorised approval of stock orders;
segregation of duties within the planned contract maintenance and
stock ordering processes;
Fleetwave II System Internal Audit Report
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 8
each contract maintenance job has a unique job number and only one
vehicle can be added to each job;
regular maintenance contractors upload their invoices directly to
Fleetwave, freeing up time for the Fleet Administration Team to
undertake other work;
daily emails to relevant staff detailing the contract maintenance invoices awaiting authorisation, so prompt action can be taken to
authorise or query the invoice;
the system will not allow an invoice number to be entered more than
once, thus preventing duplicate invoices being processed;
access to create new users and suppliers is limited to the Fleet
Systems Manager and Fleet Administration Team Leader and, as a result of the audit, access to add new vehicles is now also limited to
these individuals;
automated process for rejecting queried maintenance contractor
invoices, sending the invoice directly back to the contractor and
placing the onus on the contractor to promptly resolve the query; and
zero-tolerance approach to raising retrospective purchase orders
under the No PO/No Pay Policy prior to its full implementation in
September 2018.
In addition to the four recommendations that were implemented during the course of the audit (see ‘Audit findings’ section below for details), the
following enhancements were made to the system during the audit:
daily emails detailing jobs open for more than 30 days are now sent
to relevant staff to ensure that jobs are being completed promptly by
the maintenance contractors; and
password controls were strengthened so that passwords must now have a minimum of eight characters, including a minimum of one
uppercase character, one lowercase character and one number.
Audit findings
The key findings are reported in the Management Action Plan (Appendix A).
We identified seven Low priority findings, four of which were either fully
or partially implemented during the course of the audit. Given the timing of the audit and reporting process, we have been unable to test compliance
for some of these newly implemented elements of the system.
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NHS Wales Audit & Assurance Services Page | 9
It is encouraging that management have taken swift action to address some
of the issues raised by the audit. However, the weaknesses identified existed within the system from the time it went live (1st April 2018) to the
time of the audit (July 2018) and, therefore, presented a risk to the system during that time. Accordingly, all findings have been included, regardless of
their implementation status.
The Low priority issues identified for management consideration concern:
impacting both Fleet Maintenance Contractors and Stock Ordering:
undertaking Fleetwave user access reviews and approval of new
users (partly implemented during the audit);
evidencing new supplier approvals (implemented during the
audit); and
monitoring of rejected / queried invoices (partly implemented
during the audit).
impacting on Fleet Maintenance Contractors only:
potential control enhancements for monitoring of potential
duplicate contract maintenance jobs; and
invoice authorisation levels within the planned and unplanned
maintenance process (partially implemented during the audit).
impacting on Stock Ordering only:
implementing tolerance levels and approvals for variances
between stock invoice and order values; and
updating Fleetwave functionality to allow stock invoices to be
placed on hold within the system whilst queries are resolved.
We also identified one efficiency finding concerning removing duplication of effort within the contractor maintenance invoice matching process, which
was fed back to, and agreed with, management in the debrief meeting. This
finding has not been included in Appendix A.
The findings of the audit should be applied to the in-house maintenance
element of Fleetwave where relevant.
7. Summary of Recommendations
The audit findings, recommendations are detailed in Appendix A together
with the management action plan and implementation timetable.
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NHS Wales Audit & Assurance Services Page | 10
A summary of these recommendations by priority is outlined in the table
below.
Priority H M L Total
Number of
recommendations - - 7 7
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 11
Findings impacting both Fleet Maintenance Contractors and Stock Ordering
Finding 1 Fleetwave User Access (Design) Risk
We were informed that user access to Fleetwave was reviewed prior to the system going live on 1st April 2018. However, there is no evidence that this review took place. There is
also no process in place to provide ongoing monitoring of user access levels.
In the period after Fleetwave went live, i.e. 1st April 2018 to the time of the audit in July
2018, an additional 30 new users had been added to the system. We tested a sample of five new users, identifying that documented evidence of approval had not been obtained for three of them. We were able to verify with management that these three new users had
genuine need to access Fleetwave. We understand that the Fleet Department introduced a new Fleetwave user approval form just prior to the audit. A Regional Fleet Manager must
now complete and approve this form prior to new users being added to the system.
Unauthorised or inappropriate access to Fleetwave,
potentially leading to fraudulent transactions.
Recommendation 1 Priority level
We concur with the action already taken and further recommend that management
undertakes a regular review of Fleetwave users to ensure that access levels remain appropriate. The review should be performed on at least an annual basis.
Management should ensure that all staff are aware of the new user approval forms.
Low
Management Response 1 Responsible Officer/ Deadline
Agreed
A process has been put in place that will require a review of Fleetwave users on an annual basis.
Regional Fleet Manager
Completed
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 12
All staff will be made aware of the new user approval forms, this will be a formal agenda
item at the Fleet System user group on 6th September.
Will be completed by 6th
September 2018
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 13
Finding 2 New Suppliers / Contractors (Operation) Risk
Prior to Fleetwave going live, the WAST Finance department provided Chevin (the software developer) with a batch of supplier details to upload onto the system. For suppliers added after this, approval should have been obtained from a Regional Fleet Manager.
In the period after Fleetwave went live, 11 new suppliers were added to the system. Of these we tested a sample of three. For one of those three, there was no documented evidence of
approval, although we were subsequently able to confirm through NWSSP that this was a genuine supplier. As a result of the audit, the Fleet Department have now introduced a new Fleetwave supplier form, which must be completed and approved by a Regional Fleet Manager
prior to new suppliers being added to the system.
Unauthorised suppliers may be added to the system, potentially
leading to fraudulent transactions.
Recommendation 2 Priority level
We concur with the action already taken and further recommend that management undertakes a review of Fleetwave suppliers (both for contract maintenance and stock) to ensure that suppliers are appropriate and those no longer in use are removed from the system. The review
could be performed on bi-annual basis.
Management should ensure that all staff are aware of the new supplier approval forms.
Low
Management Response 2 Responsible Officer/
Deadline
Agreed
A process has been put in place that will require a review of suppliers on an annual basis.
All staff will be made aware of the new supplier approval forms, this will be a formal agenda item at the Fleet System user group on 6th September.
Regional Fleet Manager
Completed
Will be completed by 6th September 2018
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 14
Finding 3 Rejected / Queried Invoices (Design) Risk
Throughout our testing, we identified a number of contract maintenance invoices that had been rejected and returned to the supplier with queries. We noted that these queries had been dealt with on a timely basis, all within three to twelve days of the invoice being received.
Additionally, the Fleet Department are currently meeting the 95% PSPP target.
However, up to the point of the audit in July 2018, the Fleet Department had no set target
for the timely resolution of rejected or queried invoices. In addition to this, there was no monitoring of rejected / queried invoices to ensure they are issues are settled promptly. As a result of the audit, the Fleet Department has introduced a time limit of seven days from receipt
of invoice for dealing with queries. They have now also included a list of rejected contract maintenance invoices in the daily update emails to the Regional Fleet Managers to ensure that
these are being resolved on a timely basis.
Payment to suppliers may be delayed by untimely resolution of invoice
queries.
Recommendation 3 Priority level
We concur with the action already taken by management. Monitoring of queried invoices
should also be undertaken for stock orders – see finding 7 for additional issues identified within this area.
Management should ensure that all relevant staff are aware of the new time limit for dealing with queried invoices and of the requirement to monitor queried invoices to ensure timely
resolution.
Low
Management Response 3 Responsible Officer/ Deadline
Already actioned Completed
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 15
Findings impacting Fleet Maintenance Contractors only
Finding 4 Monitoring for Duplicate Jobs (Design) Risk
The Fleetwave system does not currently allow management to monitor for potential duplicate jobs (i.e. the same job raised under two different numbers). We understand that the Fleet Department desire such a report to be available.
There is a mitigating control in place, whereby users are prompted to check existing job cards raised for a vehicle prior to inputting a new job. However, users are not required to confirm
they have undertaken this check, therefore the control does not fully mitigate the risk.
Note: the risk of duplicate invoices (i.e. two invoices with the same number) being input to Fleetwave is mitigated because the system will not allow the same invoice number to be input
twice. This finding therefore relates only to the risk of duplicate jobs.
Duplicate jobs may be raised under separate numbers, potentially
leading to suppliers invoicing twice (two
different invoices) for the same job.
Recommendation 4 Priority level
Management should explore potential options to enhance the controls in this area. This could include the use of a confirmation button once the check on existing open jobs has been
completed and/or the regular monitoring of a Fleetwave report that identifies potential duplicate jobs.
Low
Management Response 4 Responsible Officer/ Deadline
Agreed
We will explore options as described and will include this as part of the regular account meeting with Chevin (System Suppliers) in early October to scope any development work that
may be required.
Regional Fleet Manager
31st October 2018
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 16
Finding 5 Invoice Authorisation (Design) Risk
Planned maintenance jobs are raised by the Fleet Administration Team (‘the Team’) based on the planned maintenance schedules. According to the planned maintenance processes, the Team are not authorised to approve invoices for payment. However, our testing on user
access levels identified that members of the Team all had access to approve contract maintenance invoices within Fleetwave. Further testing on a sample of the authorisation of
25 planned maintenance invoices showed that the Team has adhered to the required process. As a result of the audit, the Fleet Systems Manager has now removed the Team’s access to approve contract maintenance invoices on the system.
Note: this issue above only relates to contract maintenance invoices because the embedded authorisation limits within Fleetwave prevent the Team from authorising stock invoices.
During the period after Fleetwave went live until the time of the audit, the individuals authorised to approve invoices (for both planned and unplanned maintenance) also had access to add new vehicles to the system. As a result of the audit, this access was removed from
their user profiles. We tested 25 of the 83 new vehicles added since the system went live and were able to agree all vehicles tested to a V5 logbook identifying the Trust as the vehicle
owner.
We further identified that whilst authorisation levels for invoice approvals are embedded into Fleetwave for stock orders, these authorisation limits are not embedded for contract
maintenance invoices.
Potential for fraudulent transactions within Fleetwave.
Recommendation 5 Priority level
We concur with the action already taken to remove contract maintenance invoice approval access from the Fleet Administration Team and to remove the ability to add new vehicles from
the individuals authorised to approve invoices for payment.
Low
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 17
We recommend that the authorisation levels embedded into Fleetwave for approval of stock
orders should also be embedded for contract maintenance invoice approvals.
Management Response 5 Responsible Officer/ Deadline
Agreed
We will explore options as described and if this cannot be implemented internally though our own management of the system we will include this as part of the regular account meeting
with Chevin (System Suppliers) in early October 2018 to scope any development work that may be required.
Interim Deputy Director of
Finance / Regional Fleet Manager
31st October 2018
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 18
Findings impacting Stock Ordering only
Finding 6 Stock Invoice Matching Tolerance (Design) Risk
Stock orders are raised by requisitioners and must be approved by someone with an appropriate authorisation limit (embedded into Fleetwave). The goods are then receipted and electronically matched to the order within Fleetwave. The Fleet Administration Team (‘the Team’) are
responsible for matching the invoices to the related orders within the system. However, unlike the Oracle accounting system, there are no tolerances within Fleetwave for variances between
the invoice and order values. The Team are able to process all invoices without further authorisation, regardless of the value of any variances. In the period from 1st to 31st July 2018, invoices totalling £14,400 were processed by the Team. The net variance against the related
orders was £89. This included four invoices with variances over £100, the greatest of which was £780 less than the order (due to a supplier discount for a bulk purchase). Of the 107 invoices
processed during this period, 39 had variances of over 10% of the order value.
Unauthorised transactions may take place.
Payments may be made for goods not received.
Incorrect or inaccurate supplier invoices may be processed and paid.
Recommendation 6 Priority level
Management should implement tolerance levels for variances between stock invoice and order values, over which additional authorisation is required. These should be in line with, or tighter than, those used within Oracle. The tolerance levels and requirement for additional approval
should be embedded into Fleetwave.
Low
Management Response 6 Responsible Officer/ Deadline
Agreed
We will review tolerance levels in line with those used within Oracle.
Interim Deputy Director
of Finance
31st October 2018
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 19
Finding 7 Queried Stock Invoices (Design) Risk
There is currently no functionality within Fleetwave for stock invoices to be put on hold if there is a query on them. Consequently, if there is a query on a stock invoice, the invoice cannot be input to the system until the query is resolved. Furthermore, this
means that queried stock invoices cannot be monitored to ensure timely resolution.
As noted in finding 3, we noted that the Fleet Department are currently meeting the 95%
PSPP target, indicating that invoice queries are currently most likely being dealt with on a timely basis.
Payment to suppliers may be delayed by untimely resolution of invoice queries.
Paper copies of queried invoices not input to Fleewave may be
mislaid, resulting in delayed resolution of queries.
Recommendation 7 Priority level
Fleetwave should be updated with the functionality to put queried stock invoices ‘on hold’, automatically generating a notification email to the individual who approved the
related order. As noted in finding 3, queried invoices should be dealt with in the 7 day timeframe and management should monitor queried invoices to ensure timely resolution.
Low
Management Response 7 Responsible Officer/
Deadline
We will explore options as described and if this cannot be implemented internally though our own management of the system we will include this as part of the regular account meeting with Chevin (System Suppliers) in early October 2018 to scope any development
work that may be required.
Interim Deputy Director of Finance / Regional Fleet Manager
31st October 2018
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix B
Audit Assurance Ratings
Substantial assurance - The Board can take substantial assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Few matters require
attention and are compliance or advisory in nature with low impact on residual risk
exposure.
Reasonable assurance - The Board can take reasonable assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Some matters require
management attention in control design or compliance with low to moderate impact on
residual risk exposure until resolved.
Limited assurance - The Board can take limited assurance that arrangements to
secure governance, risk management and internal control, within those areas under
review, are suitably designed and applied effectively. More significant matters require
management attention with moderate impact on residual risk exposure until resolved.
No Assurance - The Board has no assurance that arrangements to secure
governance, risk management and internal control, within those areas under review, are
suitably designed and applied effectively. Action is required to address the whole control
framework in this area with high impact on residual risk exposure until resolved
Prioritisation of Recommendations
In order to assist management in using our reports, we categorise our recommendations
according to their level of priority as follows.
* Unless a more appropriate timescale is identified/agreed at the assignment.
Priority
Level
Explanation
Management
action
High
Poor key control design OR widespread non-compliance
with key controls.
PLUS
Significant risk to achievement of a system objective OR
evidence present of material loss, error or misstatement.
Immediate*
Medium
Minor weakness in control design OR limited non-
compliance with established controls.
PLUS
Some risk to achievement of a system objective.
Within One
Month*
Low
Potential to enhance system design to improve efficiency or
effectiveness of controls.
These are generally issues of good practice for
management consideration.
Within
Three
Months*
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix C
Confidentiality
This report is supplied on the understanding that it is for the sole use of the persons to whom it is addressed and for the purposes set out herein. No
persons other than those to whom it is addressed may rely on it for any purposes whatsoever. Copies may be made available to the addressee's
other advisers provided it is clearly understood by the recipients that we accept no responsibility to them in respect thereof. The report must not be
made available or copied in whole or in part to any other person without
our express written permission.
In the event that, pursuant to a request which the client has received under the Freedom of Information Act 2000, it is required to disclose any
information contained in this report, it will notify the Head of Internal Audit
promptly and consult with the Head of Internal Audit and Board Secretary
prior to disclosing such report.
WAST shall apply any relevant exemptions which may exist under the Act. If, following consultation with the Head of Internal Audit this report or any
part thereof is disclosed, management shall ensure that any disclaimer which NHS Wales Audit & Assurance Services has included or may
subsequently wish to include in the information is reproduced in full in any
copies disclosed.
Audit
The audit was undertaken using a risk-based auditing methodology. An
evaluation was undertaken in relation to priority areas established after discussion and agreement with WAST. Following interviews with relevant
personnel and a review of key documents, files and computer data, an evaluation was made against applicable policies procedures and regulatory
requirements and guidance as appropriate.
Internal control, no matter how well designed and operated, can provide only reasonable and not absolute assurance regarding the achievement of
an organisation’s objectives. The likelihood of achievement is affected by limitations inherent in all internal control systems. These include the
possibility of poor judgement in decision-making, human error, control processes being deliberately circumvented by employees and others,
management overriding controls and the occurrence of unforeseeable
circumstances.
Where a control objective has not been achieved, or where it is viewed that improvements to the current internal control systems can be attained,
recommendations have been made that if implemented, should ensure that
the control objectives are realised/ strengthened in future.
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services Appendix C
A basic aim is to provide proactive advice, identifying good practice and any
systems weaknesses for management consideration.
Responsibilities
Responsibilities of management and internal auditors:
It is management’s responsibility to develop and maintain sound systems
of risk management, internal control and governance and for the prevention and detection of irregularities and fraud. Internal audit work should not be
seen as a substitute for management’s responsibilities for the design and
operation of these systems.
We plan our work so that we have a reasonable expectation of detecting significant control weaknesses and, if detected, we may carry out additional
work directed towards identification of fraud or other irregularities.
However, internal audit procedures alone, even when carried out with due professional care, cannot ensure fraud will be detected. The organisation’s
Local Counter Fraud Officer should provide support for these processes.
Welsh Ambulance Services NHS Trust Fleetwave II System
Action Plan
NHS Wales Audit & Assurance Services
Office details:
MAMHILAD Office POWYS Office Audit and Assurance Audit and Assurance
Cwmbran House (First Floor) Hafren Ward Mamhilad Park Estate Bronllys Hospital
Pontypool, Gwent Powys NP4 0XS LD3 0LS
Contact details
Helen Higgs (Head of Internal Audit) – 01495 300846
Osian Lloyd (Deputy Head of Internal Audit) – 01495 300843 Emma Rees (Principal Auditor) – 01495 300845
1 ITEM 2.1b WAST_2018-19_AQS_Final Internal Audit Report _for Trust issue.pdf
Annual Quality Statement
Internal Audit Report
2018/19
Welsh Ambulance Services NHS Trust
Private and Confidential
NHS Wales Shared Services Partnership
Audit and Assurance Services
Annual Quality Statement Report Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 2
CONTENTS Page
1. Introduction and Background 4
2. Scope and Objectives 4
3. Associated Risks 5
Opinion and key findings
4. Overall Assurance Opinion 6
5. Assurance Summary 6
Review reference: WAST-1819-12 Report status: Final
Fieldwork commencement: 18 May 2018 Fieldwork completion: 05 July 2018
Draft report issued: 11 July 2018
Management response received: 24 July 2018 Final report issued: 25 July 2018
Auditor/s: Helen Higgs, Head of Internal Audit
Osian Lloyd, Deputy Head of Internal Audit
Rhian Gard, Principal Auditor
Executive sign off Claire Bevan, Director of
Quality, Safety & Patient Experience
Distribution Leanne Hawker, Head of
Patient Experience & Community Involvement
Appendix A Appendix B
Appendix C
Management Action Plan Matters arising from Source Documents
Prioritisation of Recommendations Appendix D
Responsibility Statement
Annual Quality Statement Report Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 3
Committee Audit Committee
Quality, Patient Experience and Safety Committee
ACKNOWLEDGEMENT NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this review.
Please note:
This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in
accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.
Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance
Services, and addressed to Non-Executive Directors or officers including those designated as Accountable Officer.
They are prepared for the sole use of Welsh Ambulance Service Trust and no responsibility is taken by the Audit
and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third
party.
Annual Quality Statement Internal Audit Report
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 4
1. Introduction and Background
Our review of the Annual Quality Statement (AQS) has been completed in line with the 2018/19 Internal Audit Plan. The review sought to provide the
Welsh Ambulance Service NHS Trust (the ‘Trust’) with assurance that the AQS is compliant with the requirements of the Welsh Government Health
Circular: The Annual Quality Statement 2017/18 (WHC/2018/011).
The AQS is a statement from the Trust to the public and represents a key
step forward in meeting the commitment set out in ‘Together for Health’ for transparency on performance and specifically, action 10 of the ‘Quality
Delivery Plan’ for the NHS in Wales.
Welsh Government had initially brought forward the submission deadline to
publish an AQS reporting on the 2017/18 year by 1st June 2018. It was announced in March 2018 that the deadline had been pushed back to 31
July 2018 in line with previous years. The Trust had been working towards the accelerated deadline up until Welsh Government’s announcement,
which posed a challenge to the Trust to both create the AQS report and
validate the underlying data within this timeframe.
The AQS is an opportunity for the public to know in an open and honest
way about what and how the Trust is doing in making the best use of resources to provide and deliver safe, effective and user/patient-centred
services and ensuring that care is dignified and compassionate.
2. Scope and Objectives
2.1 Audit approach
The overall objective was to ensure that the AQS is, based on a sample
tested, materially consistent with information reported to the Board and
other committees and meets the requirements of Welsh Government.
2.2 Scope
The scope was limited to ensuring:
that the AQS is consistent with information reported to the Board
and other committees over the period;
compliance with the 2017/18 Welsh Health Circular: The Annual
Quality Statement 2017/18; and
the previous recommendation that was raised during the 2017/18
audit of the AQS has been implemented.
Annual Quality Statement Internal Audit Report
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NHS Wales Audit & Assurance Services Page | 5
As we tested a limited sample of the AQS, the intention is not to provide assurance against the full content.
The areas that we may have considered during our review include:
Board papers for the financial year and an up to date production of
the Annual Quality Statement; Quality, Patient Experience & Safety Patient Experience Committee
papers for the financial year; Information Governance Committee papers for the financial year;
any other relevant papers;
performance Reports over the period covered by the Annual Quality Statement;
other relevant performance information/data demonstrating 2017/18 achievements and challenges;
papers relating to relevant participation in national clinical audits and clinical outcome reviews and resulting actions;
response to staff feedback; evidence to demonstrate the quality of services commissioned by the
Trust; evidence to demonstrate improving patient experience;
the Trust’s concerns, including incidents and claims, Public Services Ombudsman Wales reports, Coroner reports and actions followed;
compliance with patient safety alerts; details of any ‘Never Events’ and actions taken;
evidence of quality priorities identified for 2018/19; and
feedback from other stakeholders, such as Community Health Council, when agreeing the statement.
3. Associated Risks
The risks considered in the review were as follows:
the information detailed in the AQS is incomplete and / or incorrect;
the public is not clearly informed of any improvements and challenges experienced in the range of services being provided as
well as improvements priorities for the coming year; and
failure to follow Welsh Government guidance.
Annual Quality Statement Internal Audit Report
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NHS Wales Audit & Assurance Services Page | 6
OPINION AND KEY FINDINGS
4. Overall Assurance Conclusion
Based on the results of our procedures, for year ended 31 March 2018, we
noted that the Annual Quality Statement has been prepared in accordance with the requirements of the Welsh Health Circular: The Annual Quality
Statement 2017/18. However, amendments were required to 14 items from our testing sample of 45 in order to ensure consistency with supporting
documentation and sources. We recommend that a thorough quality review of the Annual Quality Statement is undertaken by management to ensure
completeness and accuracy before it is submitted to Board and published.
5. Assurance Summary
The summary of assurance given against the individual objectives is
described in the table below:
Assurance Summary
1
The extent to which Welsh Government
guidance has been followed.
2
The extent to which the detailed
information in the AQS is complete and correct.
3 Previous Recommendation
5.1 Summary of Audit Findings
We have reviewed various iterations of the AQS and identified to
management, issues arising from our content review. At the beginning of the audit fieldwork, we reviewed the AQS against the requirements of the
Welsh Health Circular and fed back comments and subject suggestions to the Head of Patient Experience and Community Involvement and these
were reflected in the next iteration.
Management has been informed of amendments required to 14 items from our testing sample of 45 items. The majority of the exceptions identified
were minor although there were some that were deemed material.
Annual Quality Statement Internal Audit Report
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NHS Wales Audit & Assurance Services Page | 7
Appendix B provides information on the matters arising from our review of
the source documents and the consistency of that information when compared to the AQS. These have all been addressed by management.
In line with the previous years, it was evident throughout the audit assignment that a great deal of effort and co-ordination has been put into
the production of the Annual Quality Statement by the Head of Patient Experience and Community Involvement.
During the audit of the 2016/17 AQS we raised a medium finding regarding partnership working resulting in a recommendation that the Trust should
consider nominating an officer from each Directorate with the responsibility for preparing the relevant section of the AQS for the Head of Patient
Experience and Community Involvement to then co-ordinate. We have noted an improvement in the process this year, whereby nominated officers
have provided contributions to the AQS, and more support has been given.
However, we have raised a high priority finding this year due to the increase
in the number of amendments identified from our testing, as noted above,
coupled with a number of instances where it was necessary to request additional information in order to validate statements made within the AQS.
We have raised a recommendation that a thorough quality review of the AQS is undertaken by management before it is published to ensure
completeness and accuracy.
Annual Quality Statement Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix A
Finding 1 – Quality Review of the AQS (Design) Risk
During the audit of the 2016/17 AQS we raised a medium priority finding regarding
partnership working resulting in a recommendation that the Trust should consider nominating an officer from each Directorate with the responsibility for preparing the
relevant section of the AQS for the Head of Patient Experience and Community Involvement to then co-ordinate. We have noted an improvement in the process this year, whereby nominated officers have provided contributions to the AQS, and more
support has been provided.
It is also apparent that more partnership working has taken place with less reliance on the Head of Patient Experience and Community Involvement. This year, an email was issued by the Head of Patient Experience and Community Involvement to all nominated
officers, with a blank AQS template and the 2016/17 AQS document attached, requesting statements and information for the AQS. The communication also stressed
the importance of providing the relevant information and evidence to support the statements included within the AQS.
Despite this, there has been an increase in the number of amendments identified from our testing, as shown in appendix B, coupled with a number of instances where it was
necessary to request additional information in order to validate statements made within the AQS. This suggests that nominated Directorate officers are not fully understanding what is being required of them.
The information detailed in the AQS is
incomplete and / or incorrect.
Recommendation 1 Priority level
A thorough quality review of the AQS should also be undertaken by management before
it is published to ensure completeness and accuracy. High
Annual Quality Statement Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix A
Directorates and nominated officers should ensure they provide relevant and accurate information and evidence to support the statements included within the AQS. Further
training may be necessary to ensure that requirements are fully understood.
Accurate and timely reporting will be even more important next year as it is expected that the Welsh Government will bring the submission deadline forward to 1st June 2019.
Consideration should be given to storing reports centrally to avoid inconsistent reporting.
Management Response 1 Responsible Officer/ Deadline
We acknowledge that timescales proved challenging this year with the deadline of the AQS being brought forward to July, this impacted on our own internal and audit
timescales resulting in the inability to ensure full robust verification process of the draft AQS prior to submitting the AQS to audit.
For 2018/19 we will continue with the process put in place following last year’s recommendation of using nominated individuals as ‘AQS contacts’ from within each
directorate across the Trust to ensure relevant information and evidence is available. As well as providing contacts with a blank ‘template’ for the AQS more specific guidance,
with examples of the type of evidence needed will be developed and shared to assist them in their submissions.
In order to ensure there is time for management to undertake a thorough quality review of the AQS a final ‘text’ draft will be completed in early March for management to review
with data being inserted from a centralised point of contact early April.
We will consider the suggestion of a central repository, and explore with Corporate Secretary and Health Informatics department to see how this can be achieved.
Head of Patient Experience & Community Involvement
Head of Patient Experience &
Community Involvement
Head of Patient Experience & Community Involvement
Head of Patient Experience & Community Involvement
Annual Quality Statement Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix A
The Trust is progressing the development implementation of Qliksense and this will support the Trust with the establishment of validated data on this platform going
forward.
Head of Quality Governance
Annual Quality Statement Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix B
Appendix B: Matters arising from our source document review of the Trust’s 2017/18 Annual Quality Statement that have been addressed.
Findings
Our verification of the data/information did not identify any significant findings with regard to the accuracy and completeness of data/information that fed into the Annual Quality Statement.
However, a number of inconsistencies were identified, the majority of which were minor although there were some that were deemed material. These have all been corrected by management and are detailed below:
Page 6 – “483,109 total number of 999 calls received and 22,924 number of immediately life-threatening calls to 999” – this statement needed to be changed to “540,891 total number of 999 calls received and 22,639 number of immediately life-threatening incidents resulting in an emergency response.”
Page 9 – “The Trust has been the first ambulance service in the UK to develop a process and platform to carry out our mortality reviews” – this statement needed to be changed to “The Trust has developed a
process and platform to carry out mortality reviews.”
Page 10 – “Restart a Heart Day – 16 October. There was a fantastic response with more than 200 of our staff and volunteers helping us deliver CPR training to secondary schools across Wales ‘Restart a heart day’.
Around 12,000 school children were given a lesson in life-saving CPR” – this statement needed to be changed to “There was a fantastic response with our staff and volunteers helping us deliver CPR training to 53 out of
200 secondary schools across Wales for ‘Restart a Heart Day’. Around 9,000 schoolchildren were given a
lesson in lifesaving CPR.”
Page 11 – “#Defibruary – 9,600 number of hospital visits in Wales attributed to a heart attack or cardiac arrest.” – the first figure needed to be changed to 9,800 number of hospital visits.
Annual Quality Statement Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix B
Findings
Page 14 - The impact of poor communication section – “in doing things better we have written and A-Z common diseases for staff…” – This document is still in draft format and has not yet been approved, wording
amended to this effect.
Page 22 – “Staff dementia awareness training compliance 74%” – this figure needed to be changed to 69%.
Page 24 - Responding to people’s concerns section – “Our concerns Improvement Plan has been completed and has improved the time taken to respond to peoples complaints. However, throughout the months of December (2017), January and February (2018), we experienced an increase in the number of concerns
being raised. This was largely due to the pressures experienced across the NHS. Despite this during these three months we achieved a 98% rate on our 2 day acknowledgment and 68% on our 30 day response rate
to complaints” – this section has been updated to reflect more up-to-date information being available relating to March 2018 resulting in the 2 day acknowledgement and 30 day response rate to complaints changing to 97% and 62% respectively.
Page 24 – “254 number of complaints 2017, 488 number of formal complaints 2018, 92% increase in formal complaints this year” – this statement needed to be changed to “254 number of complaints 2017, 547
number of formal complaints 2018, 115% increase in formal complaints this year.”
Page 24 - “Total complaints = 1756 including 1209 “on the spot” concerns resolved formally by phone, 488 formal complaints, and 59 joint investigations with Health Boards.” - this statement needed to be amended
to “Total complaints = 1817 including 1211 “on the spot” concerns resolved formally by phone, 547 formal complaints, and 59 joint investigations with Health Boards.”
“Incident Investigations - 2048 patient safety incidents, near misses and hazards and 51 serious adverse incidents reportable to Welsh Government” – this statement needed to be changed to “2041 patient safety incidents, near misses and hazards and 55 serious adverse incidents reportable to Welsh Government
Page 26 – “Call Route Through Medical Priority Dispatch System (MPDS) MPDS is used by 3000 communication centres worldwide, processing approximately 65 million calls” – the reference to processing
approximately 65 million calls has been removed from the AQS because there was no supporting information available to verify that statement.
Annual Quality Statement Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix B
Findings
Page 31 - Compliments section – “This year we recorded 731 compliments from members of the public and patients.” – this figure needed to be changed 705.
Page 31 - Welsh Language Section – “Welsh Speaking / Listening Levels 3-5 (intermediate to fluent) – as of 31.12.2017 Assignment count = 3035, Achieved = 453, % level 3-5 = 14.94%” – in order to reflect more
up-to-date information being available, relating to the quarter ended 31 March 2018, this statement needed to be amended to “As of 31.03.2018 out of 3,306 staff, Assignment count 3098 (have self-assessed and recorded their Welsh language skills on ESR), Achieved = 456, % Level 3-5 = 15%.”
Page 34 - Living our values and behaviours section – “During 2017/18, 6 cohorts (79 people) have commenced their learning.” – this figure needed to be changed to over 80 people.
Page 35 - Flu Campaign section – “2017/18 figures: 1295 of 3262 all staff = 39.60%. 1057 of 2707 pt facing = 39.04%” the patient facing statistic was removed from the AQS because there was no supporting information available to verify. In addition, the total number of staff needed to be changed to 3,306, in line
with the figure quoted in the Welsh Language Section above which has been agreed to ESR. Flu immunisation rates are also detailed on page 15 of the AQS, this section has also been updated by management to ensure
consistency.
Annual Quality Statement Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix C
Prioritisation of Recommendations
In order to assist management in using our reports, we categorise our recommendations
according to their level of priority as follows.
* Unless a more appropriate timescale is identified/agreed at the assignment.
Priority
Level
Explanation
Management
action
High
Poor key control design OR widespread non-compliance
with key controls.
PLUS
Significant risk to achievement of a system objective OR
evidence present of material loss, error or misstatement.
Immediate*
Medium
Minor weakness in control design OR limited non-
compliance with established controls.
PLUS
Some risk to achievement of a system objective.
Within One
Month*
Low
Potential to enhance system design to improve efficiency or
effectiveness of controls.
These are generally issues of good practice for
management consideration.
Within
Three
Months*
Annual Quality Statement Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix D
Confidentiality
This report is supplied on the understanding that it is for the sole use of the
persons to whom it is addressed and for the purposes set out herein. No persons other than those to whom it is addressed may rely on it for any
purposes whatsoever. Copies may be made available to the addressee's other advisers provided it is clearly understood by the recipients that we
accept no responsibility to them in respect thereof. The report must not be
made available or copied in whole or in part to any other person without
our express written permission.
In the event that, pursuant to a request which the client has received under the Freedom of Information Act 2000, it is required to disclose any
information contained in this report, it will notify the Head of Internal Audit promptly and consult with the Head of Internal Audit and Board Secretary
prior to disclosing such report.
The Trust shall apply any relevant exemptions which may exist under the
Act. If, following consultation with the Head of Internal Audit this report or any part thereof is disclosed, management shall ensure that any disclaimer
which NHS Wales Audit & Assurance Services has included or may subsequently wish to include in the information is reproduced in full in any
copies disclosed.
Audit
The audit was undertaken using a risk-based auditing methodology. An
evaluation was undertaken in relation to priority areas established after discussion and agreement with the Trust. Following interviews with relevant
personnel and a review of key documents, files and computer data, an evaluation was made against applicable policies procedures and regulatory
requirements and guidance as appropriate.
Internal control, no matter how well designed and operated, can provide
only reasonable and not absolute assurance regarding the achievement of an organisation’s objectives. The likelihood of achievement is affected by
limitations inherent in all internal control systems. These include the possibility of poor judgement in decision-making, human error, control
processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable
circumstances.
Where a control objective has not been achieved, or where it is viewed that
improvements to the current internal control systems can be attained,
recommendations have been made that if implemented, should ensure that
the control objectives are realised/ strengthened in future.
Annual Quality Statement Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix D
A basic aim is to provide proactive advice, identifying good practice and any
systems weaknesses for management consideration.
Responsibilities
Responsibilities of management and internal auditors:
It is management’s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the prevention
and detection of irregularities and fraud. Internal audit work should not be
seen as a substitute for management’s responsibilities for the design and
operation of these systems.
We plan our work so that we have a reasonable expectation of detecting significant control weaknesses and, if detected, we may carry out additional
work directed towards identification of fraud or other irregularities. However, internal audit procedures alone, even when carried out with due
professional care, cannot ensure fraud will be detected. The organisation’s
Local Counter Fraud Officer should provide support for these processes.
Annual Quality Statement Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services
Office details:
POWYS Office MAMHILAD Office Audit and Assurance Audit and Assurance
Hafren Ward Cwmbran House (First Floor) Bronllys Hospital Mamhilad Park Estate
Powys Pontypool, Gwent LD3 0LS NP4 0XS
Contact details
Helen Higgs (Head of Internal Audit) – 01495 300846
Osian Lloyd (Deputy Head of Internal Audit) – 01495 300843 Rhian Gard (Principal Auditor) – 01495 300840
1 ITEM 2.1c WAST_2018-19_CPD Management_Final Internal Audit Report_for client issue....pdf
Continuous Professional Development Management
Internal Audit Report
2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Shared Services Partnership
Audit and Assurance Services
Continuous Professional Development Management Report Contents
NHS Wales Audit & Assurance Services Page | 2
CONTENTS Page
1. Introduction and Background 4
2. Scope and Objectives 4
3. Associated Risks 5
Opinion and key findings
4. Overall Assurance Opinion 5
5. Assurance Summary 6
6. Summary of Audit Findings 7
7. Summary of Recommendations 10
Review reference: WAST-1819-23 Report status: Final
Fieldwork commencement: 15 June 2018 Fieldwork completion: 30 July 2018
Draft report issued: 10 August 2018
Draft report clearance meeting: 23 July 2018 Management response received: 2 September 2018
Final report issued: 5 September 2018 Auditor/s: Helen Higgs, Head of Internal
Audit Osian Lloyd, Deputy Head of
Internal Audit Rhian Gard, Principal Auditor
Executive sign off Claire Vaughan, Director of
Workforce & Organisational
Development
Distribution Andrew Challenger, Interim Head of Learning &
Development Louise Platt, Assistant Director
of Operations Sarah Davies, Learning &
Development Business Partner Siobhain Frain, Resource
Supervisor Committee Audit Committee
Appendix A Appendix B
Appendix C
Management Action Plan Assurance opinion and action plan risk rating
Responsibility Statement
Continuous Professional Development Management Report Contents
NHS Wales Audit & Assurance Services Page | 3
Finance and Resources
Committee
ACKNOWLEDGEMENT
NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this
review.
Please note:
This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in
accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.
Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance
Services, and addressed to Non-Executive Directors or officers including those designated as Accountable Officer.
They are prepared for the sole use of Welsh Ambulance Services Trust and no responsibility is taken by the Audit
and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third
party.
Continuous Professional Development Management Internal Audit Report
NHS Wales Audit & Assurance Services Page | 4
1. Introduction and Background
The review of the management of Continuous Professional Development (CPD) hours with the Trust’s Emergency Medical Service has been
completed in line with the 2018/19 Internal Audit Plan. The review sought to provide assurance that management of CPD hours is consistent and
appropriate across the Trust.
The Trust is committed to the learning and on-going personal and
professional development of all staff. The skills and expertise demonstrated by staff are central to the quality of the service delivered. The principles of
equality and fairness are fundamental to all education, learning and development activity, as a means of creating a culture of lifelong learning,
actively encouraging staff to develop, update knowledge and skills for continuous improvement, and to maintain current levels of knowledge and
skills.
Emergency Medical Services (EMS) employees are paid for 52 hours of CPD
per annum as per the contracted term (with the exception of Cwm Taf
University Health Board (CTUHB) and Aneurin Bevan University Health Board (ABUHB), however, there is a requirement for these staff to maintain
records of CPD.) The successful completion of the annual training
requirements are the responsibility of each staff member and manager.
2. Scope and Objectives
We requested CPD folders for five members of staff from each of the following four Health Board Areas / Localities: Cardiff and Vale (Barry /
Cowbridge), Aneurin Bevan (Bargoed), Abertawe Bro Morgannwg (Cwmbwrla) and Betsi Cadwaladr (Wrexham, Caernarfon and Flintshire).
The internal audit assessed the adequacy and effectiveness of the internal
controls in operation. Any weaknesses have been brought to the attention of management and advice issued on how particular problems may be
resolved and control improved to minimise future occurrence.
The objectives of this audit sought to provide assurance on the recording, tracking and monitoring of allocated time to CPD across the Trust (focussing
on EMS staff) and compliance with relevant policies and procedures:
there is appropriate guidance in place which details what is expected of all Trust staff in relation to CPD;
CPD requirements are documented in PADR records / staff logs which are regularly monitored and discussed with CTLs at 1:1 meetings and PADR discussions;
Continuous Professional Development Management Internal Audit Report
NHS Wales Audit & Assurance Services Page | 5
applications to enrol onto training courses are submitted and approved in advance;
CPD activity is captured and recorded accurately across the Trust;
adequate reporting mechanisms are in place to monitor CPD compliance throughout the Trust; and
effective initiatives are in place to improve low levels of CPD compliance and to enable local delivery of CPD, for example, Local
Learning Cells (LLCs), CPD surveys and campaigns as part of statutory & mandatory training.
3. Associated Risks
The risks considered in the review are as follows:
there is a risk of patient harm if staff do not have the appropriate
training and CPD;
where CPD compliance rates are low this could lead to directorate and organisational plans, priorities and objectives not being achieved; and
financial and productivity implications for the Trust where staff do not
complete the 52 CPD hours per annum, for which they are paid, in line with their employment contract.
OPINION AND KEY FINDINGS
4. Overall Assurance Opinion
We are required to provide an opinion as to the adequacy and effectiveness
of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives within this report.
An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the identified risks associated
with the objectives covered in this review.
The level of assurance given as to the effectiveness of the system of internal
control in place to manage the risks associated with Continuous Professional
Development Management is Limited Assurance.
Continuous Professional Development Management Internal Audit Report
NHS Wales Audit & Assurance Services Page | 6
The overall level of assurance that can be assigned to a review is dependent
on the severity of the findings as applied against the specific review
objectives and should therefore be considered in that context.
5. Assurance Summary
The summary of assurance given against the individual objectives is
described in the table below:
Assurance Summary
1 Guidance explaining to
staff what is expected
in relation to CPD
2
CPD requirements
documented in PADR
records which are
regularly monitored
3
Applications to enrol
onto training courses
are submitted and
approved in advance
4 CPD activity captured
and recorded
accurately
5 Trust reporting to
monitor CPD
compliance
6 Effective initiatives to
improve low levels of
CPD compliance
* The above ratings are not necessarily given equal weighting when
generating the audit opinion.
RATING INDICATOR DEFINITION
Lim
ited
Assu
ran
ce
Limited assurance - The Board can take
limited assurance that arrangements to secure governance, risk management and
internal control, within those areas under
review, are suitably designed and applied effectively. More significant matters require
management attention with moderate impact
on residual risk exposure until resolved.
Continuous Professional Development Management Internal Audit Report
NHS Wales Audit & Assurance Services Page | 7
Design of Systems/Controls
The findings from the review have highlighted three issues that are classified as weakness in the system control/design for Continuous
Professional Development Management
Operation of System/Controls
The findings from the review have highlighted two issues that are classified as weakness in the operation of the designed system/control for Continuous
Professional Development Management
6. Summary of Audit Findings
It is Trust policy that an annual Personal Appraisal Development Review
(PADR) is a mandatory requirement for all staff. This should be produced
jointly and agreed with their line manager based on individual, team and Trust objectives. The Trust recognises that a PADR is not a once in a year
event but an ongoing development feedback process between the reviewee and reviewer culminating in a formal review. The PADR should drive
development activities by helping to identify gaps in knowledge, skills and behaviours that individuals may have and how these will be met. The 52
paid hours, which form part of the employment contract, are expected to be utilised by staff to achieve their CPD objectives.
All staff are required to keep their own CPD records folder, which is also
used as evidence to demonstrate adherence to their Health and Care Professions Council (HCPC) registration, which they are required to
maintain in their role as a paramedic. The Learning and Development User Guide states that individuals are responsible for accessing their own
development hours and recording CPD activity appropriately to ensure
PADR requirements and Personal Development Plan (PDP) requirements are met.
As per Trust policy, staff are required to maintain two logs – a ‘Learning
and Development Learning Log’ and a ‘Learning and Development Individual Log’ recording learning activity, outcomes and evidence. Line
managers are required to approve these records along with timesheets.
The key findings are reported in the Management Action Plan (Appendix A).
Two High priority issues were identified that require prompt management
actions, which are summarised below:
Continuous Professional Development Management Internal Audit Report
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1) Compliance with CPD Requirements
As part of the audit we reviewed CPD folders for five members of staff from each of the following Health Board Areas / Localities - Cardiff & Vale (Barry
/ Cowbridge), Aneurin Bevan (Bargoed), Abertawe Bro Morgannwg (Cwmbwrla), Betsi Cadwaladr (Wrexham, Caernarfon and Flintshire), to
test compliance against the process set out above. The following issues were identified:
Learning and Development Learning Logs/Individual Logs were
either not present, not up-to-date or not signed off by line managers / CTLs;
Lack of evidence of on-going discussion regarding CPD; and Lack of evidence to demonstrate the achievement of CPD
requirements.
The records within the CPD folders reviewed were not presented in a consistent structure. Consequently, it was difficult to determine whether all
CPD and HCPC registration requirements had been achieved (although we understand there is no prescribed definition for the latter) and whether all
contracted CPD hours had been used. Staff do not appear to be taking ownership of their CPD.
2) CPD Compliance Reporting
We were advised that meetings take place regularly throughout the Trust
to discuss operational and workforce matters, including CPD compliance. Spreadsheets are maintained manually by Health Board Areas / Localities
to record and monitor CPD hours completed by staff. No central records are kept within the Resource Team, although we understand there is an
intention for a module to be added into the Global Rostering System (GRS) so that CPD hours can be recorded, monitored and reported across the
organisation.
We were informed by the Locality Managers and CTLs that the individuals in our testing sample, apart from one who is carrying over 10 hours as
permitted under the policy, had all completed 52 CPD hours. Furthermore, the compliance report provided by the Learning and Development team,
which focuses on the mandatory two day CPD programme ran by the Trust,
stated that CPD compliance for Paramedics and EMT staff for the year ended 31 March 2018 was 88.10% and 75.81% for UCS staff. However, as set out
in our test results above, in the absence of both the required Learning and Development Logs within CPD folders we were unable to agree the CPD
hours recorded.
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From review of Finance & Reporting Committee and Board papers, we can
see that CPD compliance rates are reported. However, the focus is on the mandatory two day CPD programme ran by the Trust rather than
monitoring whether staff are appropriately using the full 52 CPD hours as set out in their employment contract.
We identified three Medium priority issues which we consider require
management’s attention and provide scope for improvements to be made:
1) Training Strategy and Guidance
Whilst a Learning and Development User Guide is in place, this is dated May
2014. The current Learning and Development page on the Trust’s intranet site, which has hyperlinks to CPD information including this user guide, was
last updated in June 2015.
The Trust’s Integrated Medium Term Plan (IMTP) for 2018/19 – 2020/21
includes an action to develop an overarching Education Strategy. We were also informed by the Learning and Development Team that consideration is
being given to produce a CPD policy. This could be achieved by refreshing the user guide, where greater clarity should be provided in certain areas
such as the roles and responsibilities of staff, the consequences of not completing CPD hours and the compliance monitoring and reporting
process.
2) CPD Training Applications
We were informed that there are two routes available to apply for training,
a formal application process through the Study Leave policy, for example, to enrol onto a degree or masters course and which requires approval of
Trust funding by the Bursary Committee; and an informal route for attending CPD training events. There were no formal training applications
within the sample of CPD folders tested during this audit, therefore the observations below relate to applications to attend CPD training events
(outside the mandatory two day CPD programme run by the Trust).
The Knowledge Skills Framework Flowchart on the Learning and Development section on the Trust’s intranet page encourages discussion
between staff and their CTL / line manager or the training school about the content to ensure the CPD activity is relevant and appropriate. However, it
does not require a training application form to be completed and approved in advance of the event. In the absence of both Learning and Development
Logs within CPD folders we were unable to confirm whether CPD requirements documented on the PADR / PDP forms are regularly monitored
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to ensure that CPD and HCPC registration requirements have been
achieved, and all contracted CPD hours utilised.
3) Initiatives to increase CPD compliance
CPD training activity is currently being delivered differently across localities. Whilst some areas are looking into operating a training hub, others are
running CPD events in the evenings at local stations. This poses a challenge
for the central Learning and Development Team to ensure training is of the required quality and delivered consistently.
In line with the strategic action within the IMTP, the Local Learning
Community (LLC) initiative is being piloted in the Aneurin Bevan area to address this. We were informed that the initiative trials a new approach to
the local delivery of training including improved access. It provides support to operational staff to become tutors, with input from clinical leads. The LLC
pilot has been effective in increasing compliance with the mandatory two day CPD programme ran by the Trust in the area to 92% in 2017/18. A key
factor driving this increase is that training events are held locally, reducing the requirement to travel nationally. The tutor running the events is also a
Clinical Team Leader from the locality and is known to staff.
7. Summary of Recommendations
The audit findings, recommendations are detailed in Appendix A together
with the management action plan and implementation timetable.
A summary of these recommendations by priority is outlined below.
Priority H M L Total
Number of
recommendations 2 3 0 5
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 11
Finding 1 Compliance with CPD Requirements (Operational) Risk
We requested CPD folders for 5 members of staff from each of the following four Health
Board Areas / Localities: Cardiff and Vale (Barry / Cowbridge), Aneurin Bevan (Bargoed), Abertawe Bro Morgannwg (Cwmbwrla) and Betsi Cadwaladr (Wrexham,
Caernarfon and Flintshire), to test compliance against the process set out in section 6 above. Out of the 20 CPD folders provided, seventeen related to Paramedics, two related to Urgent Care Service (USC) staff and one to an Emergency Medical Technician
(EMT). Trust policy requires individuals to maintain PADRs, a learning log and an individual log (detailed log). The following issues were identified:
One individual did not have a PADR for 2017/18, one PADR where the CPD requirements were absent and two individuals did not have their PADRs signed by their Line Manager / CTL;
Seven CPD folders did not contain a learning log and in three folders the logs
were not up to date; Nine folders did not contain individual logs (detailed logs), although there were
certificates enclosed. In addition, we identified nine folders where there were a number of individual logs that had not been signed as approved by the Line Manager / CTL. Therefore, there was no clear evidence to demonstrate that
regular discussions are taking place; Fifteen instances where it was difficult to confirm whether CPD requirements had
been met. This was mainly because the CPD requirements within the PADRs were either too vague or it was hard to link the requirements from the PADR to the
CPD logs completed.
Low CPD compliance rates
leading to:
a risk of patient harm if staff do not have the appropriate training;
directorate and
organisational plans, priorities and objectives not being
achieved; and
financial implications to the Trust where staff do not complete the CPD
hours they are paid to undertake in line with
their employment contract.
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 12
One instance where a letter was sent to the individual because they had not
completed sufficient CPD hours. The individual subsequently completed the hours.
The records within CPD folders reviewed are not presented in a consistent structure.
Consequently, it is difficult to determine whether all CPD and HCPC registration requirements have been achieved (although we understand there is no prescribed
definition for the latter), and all contracted CPD hours used. Staff do not appear to be taking ownership of their CPD.
Recommendation 1 Priority level
Staff should be reminded of their responsibilities to complete CPD activity in line with
their PADR and maintain structured records. These records must also be reviewed and approved by line managers / CTLs.
Management should take action where individuals are not complying with CPD requirements.
High
Management Response 1 Responsible Officer/ Deadline
This recommendation is accepted and will be addressed through an updating of the current policy and guidelines, with communication to remind and reinforce
expectations with frontline staff and their team leaders.
Andrew Challenger, Interim Head of Learning &
Development 1 January 2019
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 13
Finding 2 CPD Compliance Reporting (Design) Risk
We were advised that meetings take place regularly throughout the Trust to discuss operational and workforce matters, including CPD compliance. For instance, quarterly meetings are held between the Assistant Director of Operations, Assistant Director of
Workforce and Area Managers. In addition, there is regular discussion between Area Managers, Operations Managers, Locality Managers and Clinical Team Leaders.
There is also regular contact between the Resource Team and Locality Managers. The Resource Team share a breakdown of CPD hours by individual at the end of each
financial year and there is dialogue on what actions need to be taken where there is non-compliance. Locality Managers will inform Resource where staff need to work
operational shifts to make up for unused CPD hours and Resource then let them know what shifts are available for staff to be booked onto. This is currently deemed the most effective sanction to ensure staff comply with their CPD hours.
Out of the four Health Board Areas / Localities, it was evident that compliance is
monitored through the local spreadsheets that are maintained manually to record CPD hours completed by staff. No central records are kept within the Resource Team, although we understand there is an intention for a module to be added into the Global
Rostering System (GRS) so that CPD hours can be recorded, monitored and reported across the organisation.
The spreadsheets maintained by Health Board Areas / Localities are referred to during the various update meetings mentioned above. We were informed by the Locality
Managers and CTLs that the individuals in our testing sample, apart from one who is carrying over 10 hours as permitted under the policy, had all completed 52 CPD hours.
Furthermore, the compliance report provided by the Learning and Development team,
CPD compliance issues are not appropriately escalated and addressed resulting in
financial implications to the Trust where staff do not
complete CPD hours they are paid to undertake in line with their employment contract.
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 14
which focuses on the mandatory two day CPD programme ran by the Trust, stated that
CPD compliance for Paramedics and EMT staff for the year ended 31 March 2018 was 88.10% and 75.81% for UCS staff. However, as set out in our test results above, in
the absence of both learning logs within CPD folders we were unable to agree the CPD hours recorded.
From review of Finance & Reporting Committee and Board papers, we can see that CPD compliance rates are reported. However, the focus is on the mandatory two day CPD
programme ran by the Trust rather than monitoring whether staff are appropriately using the full 52 CPD hours as set out in their employment contract. The campaign ran by the Trust regarding the mandatory two day CPD programme proved effective in
increasing compliance rates. A series of 'Blockade Days' targeted those staff with low compliance rates in order to drive improvement.
Recommendation 2 Priority level
We concur with the Trust’s proposal to add a module on GRS so that CPD hours can be
recorded, monitored and reported across the organisation, reducing the manual and resource intensive arrangements which are currently in place.
In addition to reporting on the use of CPD hours to complete mandatory two day CPD programme ran by the Trust, performance reports should be discussed at relevant sub
committees and at Board when appropriate. A measure should be included which monitors each staff member’s usage of the full 52 CPD hours set out in their employment contract.
The campaign ran by the Trust to increase attendance at the mandatory two day CPD
programme should be enhanced to ensure staff are fully aware of the requirement to complete the CPD hours provided as part of their contract of employment.
High
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 15
Management Response 2 Responsible Officer/
Deadline
The recommendation is accepted and discussions will be progressed with the Resources Department to determine whether the use of GRS to record use of CPD hours to enable
improved monitoring and reporting (as recommended) of this issue is a viable proposal.
Awareness raising of current expectations and requirements will be completed as part of the work in response to recommendation 1 above.
Stephen Clinton, Assistant Director of Operations for
Clinical Contact Centres 1 January 2019
Andrew Challenger, Interim Head of Learning &
Development 1 January 2019
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 16
Finding 3 Training Strategy and Guidance (Design) Risk
The Trust’s Integrated Medium Term Plan for 2018/19 – 2020/21 includes the following strategic action on page 25:
‘We will develop an overarching Education Strategy by the end of 2018/19, that will enable us to ensure all staff receive the highest quality education and training to
deliver their roles effectively; expanding our apprenticeship opportunities will be key.’ Whilst a Learning and Development User Guide is in place, this is dated May 2014 and
the current Learning and Development page on the Trusts intranet site, which has hyperlinks to CPD information including this user guide, was last updated in June 2015.
The user guide sets out what is expected of all Trust staff in relation to CPD requirements and includes within the appendices a ‘Learning and Development
Learning Log’ where staff should record their learning activity throughout the year, and a ‘Learning and Development Individual Log’ where staff are expected to complete for each learning activity to document details of the course they attended including its
content and certificate. The guide also states that if a member of staff has not worked or recorded their CPD hours, they will be notified by the Locality Manager / CTL and an
action plan will be put in place to ensure the hours are repaid. The actions currently available to the Trust under these circumstances is either to ask staff to lose annual leave time, a pay deduction or to work an additional operational shift. Refer to finding
2 for further detail.
We have been informed by the Learning and Development Team that consideration is being given to produce a CPD policy as one of the key deliverables of the Education Strategy. This could be achieved by refreshing the user guide, where greater clarity
should be provided in certain areas such as the roles and responsibilities of staff, the
Trust EMS staff are not clear on their roles and responsibilities concerning
CPD leading to:
a risk to patient harm if staff do not have the
appropriate training;
low CPD compliance rates leading to directorate and
organisational plans, priorities and
objectives not being achieved; and
financial implications to
the Trust where staff do not complete the CPD hours they are paid to
undertake in line with their employment
contract.
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 17
consequences of not completing CPD hours and the compliance monitoring and
reporting process.
Recommendation 3 Priority level
The Learning and Development Team should ensure clear and up-to-date guidance is in place in respect of CPD requirements. The guidance should be communicated to all staff.
Medium
Management Response 3 Responsible Officer/ Deadline
This recommendation is accepted and will be implemented in line with
recommendation 1 above.
Andrew Challenger, Interim
Head of Learning & Development 1 January 2019
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 18
Finding 4 CPD Training Applications (Operation) Risk
We were informed that there are two routes available to apply for training. There is a
formal application process through the Study Leave policy, for example to enrol onto a degree or masters course and which requires approval of Trust funding by the Bursary
Committee, and an informal route for attending CPD training events. Within the sample of CPD folders tested as part of the audit there were no formal training applications, therefore the observations below relate to applications to attend CPD training events
(outside the mandatory two day CPD programme run by the Trust).
Staff are not required to formally apply to attend a CPD event. The Knowledge Skills Framework Flowchart on the Learning and Development section on the Trust’s intranet page encourages discussion between staff and their CTL / line manager or the training
school about the content to ensure the CPD activity is relevant and appropriate. However, it does not require a training application form to be completed and approved
in advance of the event. Attendance registers are usually maintained for CPD events run by the Trust and are recorded on the Electronic Staff Record (ESR) system to enable CTLs / line managers to monitor CPD activity to ensure that they are in line with agreed
objectives and that staff accurately reflect the CPD hours on their timesheets.
As noted in section 6 above, CPD objectives and activity should be recorded through
the PADR / PDP process and approved by line managers at the start of the performance year. In addition, Trust staff are required to maintain a detailed log for each learning
activity and share with the CTL / line manager for review on a regular and ongoing basis during the performance year. In the absence of these logs within CPD folders, we
were unable to confirm that CPD requirements documented in the PADR / PDP forms are regularly monitored to ensure that CPD and HCPC registration requirements have been met and all contracted CPD hours used.
CDP objectives / requirements
are not regularly monitored to ensure that CPD and HCPC
registration requirements have been achieved and all contracted CPD hours used.
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 19
Recommendation 4 Priority level
Line managers should monitor Learning and Development Learning Logs on a regular
basis to ensure the events attended are in line with the objectives agreed in each individuals PADR / PDP forms, and that the contracted CPD hours are fully utilised.
The Trust should consider clarifying the application process for training courses when preparing the Education and Training Strategy and refreshing the Learning and
Development User Guide.
Medium
Management Response 4 Responsible Officer/ Deadline
This recommendation is accepted and will be addressed in line with the response to
recommendation 1. The current policy and guidelines will be updated, with communication to remind and reinforce expectations with frontline staff and their team leaders. This will include a review of the use of ESR for recording of locally run CPD
activity and the process for applying for CPD time.
Andrew Challenger, Interim
Head of Learning & Development 1 January 2019
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 20
Finding 5 Initiatives to increase CPD compliance (Design) Risk
CPD training is currently being delivered differently across localities. Whilst some areas are looking into operating a training hub where the Health Board Clinical Leads deliver CPD training, others are running CPD events in the evenings at local stations. This
poses a challenge for the central Learning and Development Team to ensure training is of the required quality and delivered consistently.
The Trusts Integrated Medium Term Plan for 2018/19-2020/21 includes the following strategic action in order to address this:
‘Create a hub and spoke model centred around the development of three equitable Ambulance Academies, supported by Local Learning Cells with agreement for training facilities to be included in all future operational estates developments.’
The Local Learning Community (LLC) initiative was designed nationally, the delivery
of which is currently being piloted locally in Aneurin Bevan. We were informed that the initiative trials a new approach to the local delivery of training including improved access. It provides support to operational staff to become tutors, with input from
Health Board clinical leads. The LLC pilot has been effective in increasing compliance with the mandatory two day CPD programme ran by the Trust to 92% in 2017/18. A
key factor driving this increase is that training events are held locally, reducing the requirement to travel nationally. The tutor running the events is also a Clinical Team Leader from the locality and is known to staff.
A risk of patient harm if Trust staff are not provided with the appropriate training and CPD.
Recommendation 5 Priority level
The Trust should continue rolling out the LLC initiative across all Health Board areas, so both Statutory and Mandatory and CPD training is provided locally. The roll out
Medium
Continuous Professional Development Management Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix A Page | 21
should be managed by the Training School, where tutors will be trained by the Learning
and Development Team, to ensure consistency in terms of content and quality.
Management Response 5 Responsible Officer/
Deadline
This recommendation is accepted and roll out of the LLC initiative will be progressed where suitable funding and resource is available to support this.
Andrew Challenger, Interim Head of Learning &
Development 31 March 2020 (subject to funding)
CPD Management Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix B
Audit Assurance Ratings
Substantial assurance - The Board can take substantial assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Few matters require
attention and are compliance or advisory in nature with low impact on residual risk
exposure.
Reasonable assurance - The Board can take reasonable assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Some matters require
management attention in control design or compliance with low to moderate impact on
residual risk exposure until resolved.
Limited assurance - The Board can take limited assurance that arrangements to
secure governance, risk management and internal control, within those areas under
review, are suitably designed and applied effectively. More significant matters require
management attention with moderate impact on residual risk exposure until resolved.
No Assurance - The Board has no assurance that arrangements to secure
governance, risk management and internal control, within those areas under review, are
suitably designed and applied effectively. Action is required to address the whole control
framework in this area with high impact on residual risk exposure until resolved
Prioritisation of Recommendations
In order to assist management in using our reports, we categorise our recommendations
according to their level of priority as follows.
* Unless a more appropriate timescale is identified/agreed at the assignment.
Priority
Level
Explanation
Management
action
High
Poor key control design OR widespread non-compliance
with key controls.
PLUS
Significant risk to achievement of a system objective OR
evidence present of material loss, error or misstatement.
Immediate*
Medium
Minor weakness in control design OR limited non-
compliance with established controls.
PLUS
Some risk to achievement of a system objective.
Within One
Month*
Low
Potential to enhance system design to improve efficiency or
effectiveness of controls.
These are generally issues of good practice for
management consideration.
Within
Three
Months*
CPD Management Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix C
Confidentiality
This report is supplied on the understanding that it is for the sole use of the
persons to whom it is addressed and for the purposes set out herein. No persons other than those to whom it is addressed may rely on it for any
purposes whatsoever. Copies may be made available to the addressee's other advisers provided it is clearly understood by the recipients that we
accept no responsibility to them in respect thereof. The report must not be made available or copied in whole or in part to any other person without
our express written permission.
In the event that, pursuant to a request which the client has received under
the Freedom of Information Act 2000, it is required to disclose any information contained in this report, it will notify the Head of Internal Audit
promptly and consult with the Head of Internal Audit and Board Secretary
prior to disclosing such report.
The Trust shall apply any relevant exemptions which may exist under the
Act. If, following consultation with the Head of Internal Audit this report or any part thereof is disclosed, management shall ensure that any disclaimer
which NHS Wales Audit & Assurance Services has included or may subsequently wish to include in the information is reproduced in full in any
copies disclosed.
Audit
The audit was undertaken using a risk-based auditing methodology. An evaluation was undertaken in relation to priority areas established after
discussion and agreement with the Trust. Following interviews with relevant personnel and a review of key documents, files and computer data, an
evaluation was made against applicable policies procedures and regulatory
requirements and guidance as appropriate.
Internal control, no matter how well designed and operated, can provide only reasonable and not absolute assurance regarding the achievement of
an organisation’s objectives. The likelihood of achievement is affected by
limitations inherent in all internal control systems. These include the possibility of poor judgement in decision-making, human error, control
processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable
circumstances.
Where a control objective has not been achieved, or where it is viewed that
improvements to the current internal control systems can be attained, recommendations have been made that if implemented, should ensure that
the control objectives are realised/ strengthened in future.
A basic aim is to provide proactive advice, identifying good practice and any
systems weaknesses for management consideration.
CPD Management Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix C
Responsibilities
Responsibilities of management and internal auditors:
It is management’s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the prevention
and detection of irregularities and fraud. Internal audit work should not be seen as a substitute for management’s responsibilities for the design and
operation of these systems.
We plan our work so that we have a reasonable expectation of detecting
significant control weaknesses and, if detected, we may carry out additional work directed towards identification of fraud or other irregularities.
However, internal audit procedures alone, even when carried out with due professional care, cannot ensure fraud will be detected. The organisation’s
Local Counter Fraud Officer should provide support for these processes.
CPD Management Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services
Office details:
MAMHILAD Office POWYS Office
Audit and Assurance Audit and Assurance Cwmbran House (First Floor) Hafren Ward
Mamhilad Park Estate Bronllys Hospital Pontypool, Gwent Powys
NP4 0XS LD3 0LS
Contact details
Helen Higgs (Head of Internal Audit) – 01495 300846 Osian Lloyd (Deputy Head of Internal Audit) – 01495 300843
Rhian Gard (Principal Auditor) – 01495 300840
1 ITEM 2.1d WAST_2018-19_Volunteer Car Drivers' - Governance Arrangements_Final Internal Audit Report_for client issue.pdf
Volunteer Car Drivers’ Governance Arrangements
Internal Audit Report
2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Shared Services Partnership
Audit and Assurance Services
Volunteer Car Drivers’ Governance Arrangements Report Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 2
CONTENTS Page
1. Introduction and Background 4
2. Scope and Objectives 4
3. Associated Risks 5
Opinion and key findings
4. Overall Assurance Opinion 5
5. Assurance Summary 6
6. Summary of Audit Findings 7
7. Summary of Recommendations 10
Review reference: WAST-1819-24
Report status: Final Fieldwork commencement: 4th July 2018
Fieldwork completion: 7th August 2018
Draft report issued: 10th August 2018 Management response received: 27th August 2018
Final report issued: 29th August 2018 Auditor/s: Helen Higgs, Head of Internal
Audit Osian Lloyd, Deputy Head of
Internal Audit Nicola Jones, Audit Manager
Executive sign off Claire Vaughan, Director of
Workforce & Organisational Development
Distribution Nick Smith, Deputy Director
of NEPTS,
Phill Taylor, Business Development Manager, Non-
Emergency Patient Transport Service
Committee Audit Committee
Finance and Resources Committee
Appendix A
Appendix B Appendix C
Management Action Plan
Assurance opinion and action plan risk rating Responsibility Statement
Volunteer Car Drivers’ Governance Arrangements Report Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 3
ACKNOWLEDGEMENT
NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this
review.
Please note:
This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in
accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.
Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance
Services, and addressed to Non-Executive Directors or officers including those designated as Accountable Officer.
They are prepared for the sole use of Welsh Ambulance Service Trust and no responsibility is taken by the Audit
and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third
party.
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1. Introduction and Background
The review of Volunteer Car Drivers’ Governance Arrangements was completed in line with the 2018/19 Internal Audit Plan. The review sought
to provide assurance that adequate processes are in place to manage the
volunteer workforce and that services are sustainable for the future.
Volunteers provide a valuable role in supporting frontline teams and services. These include Community First Responders (CFRs), British
Association for Immediate Care (BASICS) doctors and Volunteer Car Drivers. The WAST Integrated Medium Term Plan (IMTP) for 2018/19 –
20/21 includes the following strategic action ‘We will develop a Volunteering Strategy that will ensure we understand, value and maximise the important
contribution that volunteers can and will make to our services in the future’.
CFRs were subject to an audit review in 2014/15 (unsatisfactory assurance)
and a subsequent follow up review in 2016/17 (reasonable assurance), whilst BASICS doctors have recently been reviewed by the Commissioner’s
Office, with a report currently in draft. It was therefore agreed that this
audit would focus on the governance arrangements for Volunteer Car
Drivers across the Trust.
2. Scope and Objectives
The audit focused on how volunteers are managed within the Non-
Emergency Patient Transport Service (NEPTS). Any weaknesses have been brought to the attention of management and advice issued on how
particular problems may be resolved and control improved to minimise future occurrence.
The internal audit sought to provide assurance over the following areas:
there are policies and procedures in place which define the roles and responsibilities of volunteering and arrangements to recruit, vet, train
and supervise volunteers;
there is appropriate oversight of the deployment and utilisation of
volunteers within the Trust;
volunteer roles are subject to documented risk assessment;
volunteers are subject to enhanced Disclosure and Barring Service
(DBS) clearance, Occupational Health clearance and have suitable checks undertaken (i.e. driving licence and insurance) and references
provided;
volunteers receive adequate training for their role, including a
standard induction process and ongoing training that encompasses Trust policies, procedures and statutory and mandatory training;
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expenses claimed are in line with policy and are approved by an
appropriate person;
volunteers are provided with adequate supervision and support;
patient experience and quality of services delivered are measured and monitored to ensure services are of the expected quality; and
service sustainability is reviewed regularly by management, ensuring succession planning is in place.
3. Associated Risks
The risks considered in the review are as follows:
volunteers have not had the required employment checks undertaken
causing a risk to patient care and reputational damage to the Trust;
volunteers have not had sufficient training and are not adequately
supervised and supported to deliver their roles and may be unaware
of Trust policies and procedures; and
insufficient governance and oversight arrangements in place for the management of volunteers leading to services with a reliance on
volunteers not being sustainable in the future.
OPINION AND KEY FINDINGS
4. Overall Assurance Opinion
We are required to provide an opinion as to the adequacy and effectiveness
of the system of internal control under review. The opinion is based on the
work performed as set out in the scope and objectives within this report. An overall assurance rating is provided describing the effectiveness of the
system of internal control in place to manage the identified risks associated
with the objectives covered in this review.
The level of assurance given as to the effectiveness of the system of internal control in place to manage the risks associated with the Volunteer Car
Drivers’ Governance Arrangements is Limited Assurance.
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NHS Wales Audit & Assurance Services Page | 6
The overall level of assurance that can be assigned to a review is dependent on the severity of the findings as applied against the specific review
objectives and should therefore be considered in that context.
5. Assurance Summary
The summary of assurance given against the individual objectives is
described in the table below:
Assurance Summary
1 Policies & Procedures
2 Oversight and utilisation of
volunteers
3 Risk assessments
4 Recruitment checks
5 Induction and training
6 Expenses
7 Support and supervision
RATING INDICATOR DEFINITION Lim
ited
The Board can take limited assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and
applied effectively. More significant matters require management attention with moderate
impact on residual risk exposure until
resolved.
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Assurance Summary
8 Patient experience and quality of services
9 Service sustainability and succession
planning
* The above ratings are not necessarily given equal weighting when generating the audit
opinion.
Design of Systems/Controls
The findings from the review have highlighted five issues that are classified
as a weakness in the system control/design associated with the Volunteer
Car Drivers’ Governance arrangements.
Operation of System/Controls
The findings from the review have not highlighted any issues that are classified as a weakness in the operation of the designed system/control
associated with the Volunteer Car Drivers’ Governance Arrangements.
6. Summary of Audit Findings
The key findings are reported in the Management Action Plan.
Following approval of the NEPTS business case by Welsh Government in
January 2016, the service has been on a journey of improvement, implementing the business case recommendations. The Integrated Medium
Term Plan (IMTP) for 2017/18 recognises that a significant amount of work
has been undertaken but there is still improvement needed in the service.
The WAST Integrated Medium Term Plan (IMTP) 2018/19 - 20/21 includes the following strategic action ‘We will develop a Volunteering Strategy that
will ensure we understand, value and maximise the important contribution that volunteers can and will make to our services in future.’ We have not
reviewed the Strategy as part of this audit as it is under development.
Issues raised in this report will need to be considered within the Strategy.
We discussed arrangements with each of the regional managers (North,
Central & West and South East) before undertaking detailed testing with administrators. A common theme was the lack of a consistent approach,
which has been highlighted within the findings below. It is noted that a Volunteer Manager role within NEPTS has recently been approved, and this
person will be responsible for developing strategies and policies to ensure
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a consistent and proactive approach to the management of the volunteer
car drivers going forward.
We identified three High priority findings, which require prompt
management action:
1) Governance and oversight arrangements
The audit identified that there is a lack of oversight of the Voluntary Car Service (VCS). There is a lack of regular reporting and monitoring for a
number of the objectives covered by this audit.
Each region maintains a spreadsheet of volunteer car drivers. The CLERIC system includes the date of DBS check, induction date, occupational health
clearance, drivers licence check, insurance and MOT details. We were informed by the administrators that CLERIC is updated regularly in the
Central & West and North regions, with limited information input by the South East region. However, our review of a sample of ten volunteer records
(CLERIC and paper files) from each region identified a number of
exceptions.
2) Expenses
Volunteer car drivers are able to claim expenses for journeys undertaken,
this includes mileage (typically 39p per mile, although drivers who take wheelchairs can be paid more), phone calls (20p per call) and bridge tolls.
We note that the mileage rates differ slightly to those paid to CFRs (40p per mile in North and South East regions and 38p per mile in the Central &
West region). In addition, there is a historical agreement in place, which entitles some volunteer car drivers in the North region to claim for waiting
times at a rate of 42p per hour. Four out of the eight volunteer car drivers interviewed during the audit expressed the views that the mileage
allowance should be increased as they feel it is lower than other organisations.
The average monthly expense claims in respect of mileage for volunteer car drivers across all regions is around £190,000. There is a policy in place for
the validation of expenses and this is applied in the main by the VCS administrators, with the process differing slightly across regions as outlined
in appendix A below. We were informed that the process is resource intensive where administrators can spend a week or two per month
reviewing claims. Due to the limited time to process claims prior to the submission of details to payroll, the validation of expenses is undertaken
after all expenses have been paid.
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3) Recruitment and retention
We were informed by management that the number of volunteer car drivers has fallen over recent years and it is proving difficult to recruit. For
example, the Central & West region had 120 volunteers around ten years ago but now only have approximately 70. If this trend were to continue this
raises concerns on the sustainability of the service, which will be compounded further with an increasing demand on the service. This could
result in an increased dependency and pressure on NEPTS staff, taxi’s etc. to make up the shortfall.
A strategic approach to recruitment, retention and succession planning will
be incorporated within the Trust’s wider volunteering strategy, which is currently under development. Area managers advise that they have taken
steps to try to recruit volunteers, although this is on an ad hoc basis and is dependent on resources available. In addition, no information is reported
that quantifies the utilisation and value of volunteers to the service.
Recruitment was quick in the main, although a couple of volunteer car
drivers interviewed during the audit stated that the recruitment process was too long, taking between three to six months in total, which could put
off volunteers from joining in the future. We were also informed in the North region that the start date is often delayed due to the availability of
trainers for the driving assessments.
We identified two Medium priority findings that require management’s
attention:
1) Ambulance Car Services Policy
There is an Ambulance Car Services policy in place, which includes detailed information on the recruitment process and responsibilities of volunteers.
The approved policy is dated 2008, with an updated version, dated 2012,
in draft. A review of the policy has highlighted sections that require updating, including management of service, monitoring arrangements,
support and supervision, reward and recognition and the terminology used. We also reviewed a handbook from another UK Ambulance service and
identified additional areas that would be useful to include.
2) Training and Ongoing Supervision and Support
The induction for volunteer car drivers is provided by administrators and
training staff within the regions. The driving assessments are consistent across all regions, however the induction checklists used by administrators
varies. Whilst volunteers do not undertake statutory and mandatory training, policies they are provided with as part of the induction cover key
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areas such as Health and Safety and Safeguarding. All volunteer car drivers
interviewed confirmed they received a copy of the Trust’s policies. We are advised that there is a training programme in place for volunteers, which is
run by Learning and Development, and is currently in the process of being reviewed. Volunteer car drivers interviewed were happy to attend training;
however, four commented that they found it repetitive.
Volunteer drivers are required to undertake a driving assessment, road sign test and a driving theory assessment prior to being recruited by the Trust
as a volunteer. There is currently no requirement to repeat these tests on a regular basis.
We were informed by staff across all regions that better supervision and
support could be provided to volunteer car drivers. We are advised that previous attempts made by the Trust to support volunteers have not been
successful, with little interest shown. An explanation provided was that
volunteers would need an incentive to attend such forums and events, as they would effectively be foregoing a days’ worth of mileage expenses.
Volunteer car drivers interviewed during the audit were generally happy with the level of support and would not be interested in attending
forums/events, however four did state that more information could be provided on areas such as where they can park in certain hospitals. Overall,
the volunteer drivers we spoke with felt that they are utilised to an acceptable level and would recommend the role to other volunteers.
7. Summary of Recommendations
The audit findings, recommendations are detailed in Appendix A together with the management action plan and implementation timetable. A
summary of these recommendations by priority is outlined below.
Priority H M L Total
Number of
recommendations 3 2 0 5
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NHS Wales Audit & Assurance Services Appendix A Page | 11
Finding 1 – Governance and Oversight Arrangements (Design) Risk
The audit identified that there is a lack of oversight of the Voluntary Car Service (VCS). There is a lack of regular reporting and monitoring for a number of the
objectives covered by this audit. For example, each region highlighted a lack of support for volunteers (refer to finding 5), there is no management review to
ensure that the VCS administrators are undertaking the relevant checks such as
drivers licence, insurance, MOT expiry (refer to finding 1), and there is no review of the validation of expenses (refer to finding 2).
Each region maintains a spreadsheet of the volunteer car drivers they use. The
CLERIC system includes the date of DBS check, induction date, occupational health clearance, drivers licence check, insurance and MOT details. We were
informed by the administrators that CLERIC is updated regularly in the Central & West and North regions, with limited information input by the South East region.
Our review of a sample of ten volunteer records (CLERIC and paper files) from each region identified the following exceptions:
Central & West Region:
two volunteers have not had a drivers licence check in the last year,
although the administrator recently received details for two of these to
review;
three did not have up to date insurance details, although the insurance
documentation for one of the volunteers was received recently to check;
one volunteer did not have an occupational health clearance date, and no
occupational health form was on file;
Inappropriate governance and oversight arrangements of
volunteers leading to services with a reliance on them not being sustainable in the future.
Volunteers have not had the
required checks undertaken causing a risk to patient care and
reputational damage to the Trust.
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NHS Wales Audit & Assurance Services Appendix A Page | 12
two volunteers had either no date entered for the MOT expiry or the date
of the MOT on CLERIC had expired, although information has been
received for one of these recently to check; and
no date of induction was recorded for one volunteer.
South East: four volunteers had no date recorded for DBS clearance (a copy was on file
for one of these); ten volunteers have not had a drivers licence check in the last year;
six did not have up to date insurance details held on file, although records
on CLERIC for all but two are up to date. The insurance documentation for two has been requested by the administrator;
nine volunteers did not have an occupational health clearance date, and no occupational health form was on file for five of these;
two volunteers had either no date entered for the MOT expiry or the date of the MOT on CLERIC had expired, although information has been received
for one of these recently to check; no date of induction was recorded for seven volunteers; and
no details of driving assessments and tests were recorded for four volunteers.
North
eight volunteers had no date recorded for DBS clearance; nine volunteers have not had a drivers licence check in the last year;
one did not have up to date insurance details held on file; nine volunteers did not have an occupational health clearance date, and no
occupational health form was on file for all these;
Volunteer Car Drivers’ Governance Arrangements Welsh Ambulance Services NHS Trust
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two volunteers had an expired MOT on CLERIC, however a valid check was on file for both; and
no date of induction was recorded for four volunteers.
There is the ability to generate reports from the CLERIC system to identify the expiry date of insurance, MOT, drivers check etc. These are reviewed regularly
in the North and South East regions but only on an ad hoc basis in the Central &
West region.
In addition to WAST volunteer car drivers, we are aware of other volunteer organisations being used as well as taxi companies for transporting patients.
Whilst there is a listing of taxi companies and their terms, we have not been provided with evidence that contracts are in place for volunteer organisations.
We are advised that taxi costs are monitored by managers, however there is no evidence of regular monitoring of SLAs such as DBS checks, insurance, training
etc.
Recommendation 1 Priority level
a) The exceptions identified through audit testing should be reviewed and addressed.
b) The governance arrangements within the Trust in respect of VCS should
be reviewed to ensure that there is sufficient oversight of the volunteer car drivers, and a consistent approach is being applied throughout the
service.
High
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NHS Wales Audit & Assurance Services Appendix A Page | 14
c) This reporting function should be utilised on a regular basis to ensure details on volunteer car drivers are kept up to date in CLERIC and to
provide management with assurance that the VCS administrators are completing the necessary checks in a timely manner. Where exceptions
are identified, they should be addressed promptly.
d) Management should review external organisations used and ensure there
are relevant contracts / SLAs in place, with agreed arrangements to monitor DBS checks, insurance, training etc.
Management Response 1 Responsible Officer/ Deadline
a) This will be addressed immediately by the relevant management team.
b) The appointment of a new role, the NEPTS Volunteer Manager, will review
the existing governance arrangements and implement changes as necessary through an approved work plan.
c) The new NEPTS Volunteer Manager will ensure through the regional
coordinators that CLERIC is continually updated with all necessary information and that any issues resolved promptly.
d) Existing issues will be addressed as identified in a) and b). The contracts
and SLAs either have been addressed or we have a plan to address though
the transfer of work process led by the Head of NEPTS Transformation.
NEPTS General Managers September 2018
NEPTS Volunteer Manager
March 2019
NEPTS Volunteer Manager
March 2019
Head of NEPTS Transformation
September 2019
Volunteer Car Drivers’ Governance Arrangements Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix A Page | 15
Finding 2 – Expenses (Design) Risk
Expense claims are processed on a monthly basis by VCS administrators. The total expense claims for volunteer car drivers for the last four months (by region)
are shown below: Average
number of
claims per
month
February March April May
Central & West 66 £78,118 £67,254 £69,232 £78,090
South East 45 £40,559 £36,578 £36,868 £39,201
North 73 £80,648 £84,364 £72,202 £76,682
TOTALS 184 £199,325 £188,196 £178,302 £193,973
There is a policy in place for the validation of expenses. This is applied in the main by the VCS administrators, with the process differing slightly across regions
as outlined below. We were informed that the process is resource intensive where administrators can spend a week or two per month reviewing claims. Due to the
limited time to process claims prior to the submission of details to payroll, the validation of expenses is undertaken after expenses have been paid.
The current process in each region for expenses is that expense claims are only
reviewed to ensure the sum of the mileage recorded has been added up correctly.
The review does not confirm that the mileage is accurate for the journeys claimed. Once reviewed, the expense claims are input onto a spreadsheet and
submitted to the payroll department. A mileage checker report is generated from the CLERIC system to compare actual mileage claimed against the expected
mileage, which is based on the journeys allocated to a volunteer.
The process for validating expense claims is resource intensive, and
there is inadequate management review to confirm validation checks
have been undertaken. This could
result in inappropriate claims not being processed and paid resulting
in financial loss to the Trust.
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The ‘Auditing Expense Claims from the Volunteer Car Service’ Standard Operating Procedure (SOP 020) states: ‘The VCS Validator is to undertake a full audit on
those identified above the 10% (tolerance), ensuring that an overall total of 10% of the claims are audited for that month’. The claims are validated by the VCS
administrator with reference to google maps. The validation checks are a manual exercise, recorded on paper in the Central & West region and spreadsheets in the
South East and North regions. There is some confusion around the requirements
of the procedure in the South East and North regions. Whilst they audit 10% of total claims, they do not cover all those above the 10% tolerance. All claims over
the 10% tolerance are validated in the Central & West region, which also accounts for 10% of all claims.
In addition, in the North region there are a large number of drivers over the 10%
tolerance due to the nature of the journey. For example, the CLERIC system assumes that a driver leaves their property at the start of their shift and only
returns once all runs are completed, whereas a driver may return home several times during the day between patient journeys. All those over the 10% tolerance
are not audited, with a random approach taken to selecting the sample for audit.
The percentage of claims (and number of claims) over the 10% tolerance for the last four months (by region) is shown below: February March April May
Central & West 16% (10) 12% (9) 24% (14) 18% (12)
South East 32% (15) 24% (11) 28% (13) 31% (14)
North 49% (35) 49% (37) 47% (34) 49% (36)
Furthermore, there is no check by management to confirm that the validation of
mileage claims have been completed.
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NHS Wales Audit & Assurance Services Appendix A Page | 17
A sample of ten expense claims were tested in each region to ensure they were appropriately populated and reviewed. No issues were identified in the Central &
West and South East regions and a minor issue was identified in the North region where one claim form was not signed by the volunteer. Validation checks have
currently been completed up to February 2018 for the Central & West region and May 2018 for the South East and North regions, although they only look at a
sample of those over 10%, not all, as noted above. We reviewed the validation
checks undertaken to look at the amounts recovered, over four months £87.75 was claimed back for South East and in the North, one driver was referred to
Counter Fraud for potential incorrect claims.
There are approximately ten drivers in the North region who claim expenses for waiting times at a rate of 42p per hour. We are advised this is due to a historical
agreement, the cost of which is approximately £50 per month (March-May 2018).
We are advised that Personal Digital Assistants (PDAs), which tracks each journey, are in the process of being rolled out to all volunteers. Once
implemented the resource required to review and process expense claims should reduce.
Expense claim forms
The declaration wording on mileage claim forms used in each region varies. A
concern was raised as the driver is signing to confirm their car is taxed and insured and that their mileage is accurate, with no declaration relating to fraud
or the repayment of expenses. This may affect the ability of the Trust to reclaim overpaid expenses.
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NHS Wales Audit & Assurance Services Appendix A Page | 18
Recommendation 2 Priority level
The Trust should: a) Claims should be verified and approved prior to submission for payment.
Progress with the roll out of PDAs to volunteer drivers to reduce the resource required to process and validate expense claims. In the meantime
management should explore if the CLERIC system (and PDAs) can be configured to address issues with current mileage calculations (i.e. for
drivers returning home several times in the day), and the feasibility of using the e-expenses system, which automatically calculates mileage distances
and amounts.
b) Review the documentation used across the regions to ensure a consistent approach is applied, specifically in relation to:
the audit process, including the recording of the validation exercise
undertaken and the sample sizes tested; and expense / mileage forms - seek advice from Counter Fraud to ensure the
wording on the claim form is sufficient to protect the trust against fraud, and to be able to reclaim expenses.
c) Review the validation checks undertaken, to confirm that these are being
completed in a timely manner and relevant action is taken to recover identified overpayments.
High
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NHS Wales Audit & Assurance Services Appendix A Page | 19
Management Response 2 Responsible Officer/ Deadline
a) The new Volunteer Manager will progress the roll out of the PDAs to volunteer drivers. In the meantime the manager will identify if CLERIC can
be configured to address issues with current mileage calculations.
b) The new Volunteer Manager will review the documentation used across the regions to ensure a consistent approach is applied to the audit process,
validation process and claim forms wording.
c) Put in place a robust process to recover identified overpayments if required.
NEPTS Volunteer Manager March 2019
NEPTS Volunteer Manager March 2019
NEPTS Volunteer Manager March 2019
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NHS Wales Audit & Assurance Services Appendix A Page | 20
Finding 3 – Recruitment and Retention (Design) Risk
We were informed by management that the number of volunteer car drivers has fallen over recent years and it is proving difficult to recruit. For example, the
Central & West region had 120 volunteers around ten years ago but now only have approximately 70. If this trend were to continue this raises concerns on the
sustainability of the service, which will be compounded further with an increasing
demand on the service. This could result in an increased dependency and pressure on NEPTS staff, taxi’s etc. to make up the shortfall. The Trust generates
weekly performance reports, which detail the number of journeys and miles undertaken by volunteer car drivers within NEPTS. The table below for the week
ending 24th June 2018 highlights the high reliance placed on volunteer car drivers, especially in the North region:
ABM Hywel
Dda
Powys Cardiff Cwm
Taf
AB BCU ALL
Wales
Patient
Journeys
174 839 248 72 243 660 1880 4116
Total miles 4477 29944 10109 1111 3653 13985 50950 114229
% of
activity
done by
ACS
8% 43% 26% 4% 13% 19% 48% 26%
A strategic approach to recruitment, retention and succession planning will be
incorporated within the Trust’s wider volunteering strategy, which is currently under development. Area managers advise that they have taken steps to try to
recruit volunteers, although this is on an ad hoc basis and is dependent on resources available. Some examples that we were given include:
Without a coordinated approach to succession planning for volunteers,
there is a risk that services with a reliance on the not being
sustainable in the future.
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NHS Wales Audit & Assurance Services Appendix A Page | 21
Facebook sponsored posts; attendance at events that have been organised by other teams such as
Community First Responders, Patient Experience; and posters and leaflets.
Whilst the table above highlights the proportion of NEPTS journeys undertaken
by volunteer car drivers, no information is reported that quantifies the utilisation
and value of volunteers to the service. We were informed that there are a number of variables that would need to be taken into account in order to
determine these including dead mileage, waiting times etc.
Recruitment was quick in the main, although a couple of volunteer car drivers interviewed during the audit stated that the recruitment process was too long,
taking between three to six months in total, which could put off volunteers from joining in the future. We were also informed in the North region that the start
date is often delayed due to the availability of trainers for the driving assessments.
Recommendation 3 Priority level
a) Management should develop a succession plan for volunteers and recruitment initiatives i.e. targeted campaigns, national and local events.
b) The utilisation, value and quality of volunteers to the services should be
quantified and communicated to ensure that Trust staff and members are
aware of the importance of the service and highlight the support it needs.
High
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NHS Wales Audit & Assurance Services Appendix A Page | 22
c) Review the recruitment process in place to ensure that there are minimal delays when recruiting volunteers.
Management Response 3 Responsible Officer/ Deadline
a) The new Volunteer Manager will put in place a strategy and process for
retaining and recruiting new volunteer drivers.
b) The new Volunteer Manager will develop an engagement and communications strategy that will clearly define the performance of the
volunteer service.
c) The new Volunteer Manager will review the current recruitment process for
volunteers and make improvements to make the process quick and effective.
NEPTS Volunteer Manager
March 2019
NEPTS Volunteer Manager September 2019
NEPTS Volunteer Manager
March 2019
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NHS Wales Audit & Assurance Services Appendix A Page | 23
Finding 4 – Ambulance Car Services Policy (Design) Risk
There is an Ambulance Car Services policy in place, which includes detailed information on the recruitment process and responsibilities of volunteers. The
approved policy is dated 2008, with an updated version, dated 2012, in draft. Each region has both copies of the policy, with the 2008 copy referred to for
guidance. This version of the policy is also provided to volunteers as part of their
induction.
A review of the policy has highlighted sections that require updating, including
management of service, monitoring arrangements, support and supervision, reward and recognition and the terminology used i.e. CRB check is used instead
of DBS check. We also reviewed a handbook for the East of England Ambulance
Car Service, and identified additional areas that would be useful to include:
Guidance for non-routine / acute situations
Information on ‘passengers with a difference’, which covers considerations
and provides advice when transporting passengers with autism and
Asperger syndrome, deaf adults and children etc.
Staff and volunteers are provided with an out of date policy that does
not reflect current practices.
Recommendation 4 Priority level
The policy should be reviewed and updated as required, with the areas highlighted above considered for inclusion. Once updated, the guidance should
be communicated to relevant Trust staff and all volunteer car drivers.
Medium
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NHS Wales Audit & Assurance Services Appendix A Page | 24
Management Response 4 Responsible Officer/ Deadline
The new Volunteer Manager, in partnership with the other NEPTS Managers will review and update the VCS Policy and progress through the policy process.
NEPTS Volunteer Manager September 2019
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NHS Wales Audit & Assurance Services Appendix A Page | 25
Finding 5 - Training and Ongoing Supervision and Support (Design) Risk
Induction and Training The induction for volunteer car drivers is provided by administrators and training
staff within the regions. Administration staff will go through information such as expenses, day-to-day requirements and trainers will cover driving assessments.
The induction checklists used by the administrators varies across regions. The
driving assessments are consistent across all regions.
Whilst volunteers do not undertake Statutory and Mandatory training, policies provided to them as part of the induction cover key areas such as Health and
Safety and Safeguarding. We are advised that there is a training programme in place for volunteers, which is run by Learning and Development, and is currently
in the process of being reviewed. Ten out of 30 volunteers sampled had not confirmed they had read and understood policies and procedures.
Volunteer drivers are required to undertake a driving assessment, road sign test
and a driving theory assessment prior to being recruited by the Trust as a volunteer. There is currently no requirement to repeat these tests on a regular
basis.
Supervision and Support
We were informed by staff across all regions that better supervision and support could be provided to volunteer car drivers. A volunteer’s contact with the Trust
would typically be limited to the control centre and VCS administrators in relation to matters such as expenses, drivers licence checks, insurance checks etc.
Volunteers have not had sufficient and appropriate training and are not
adequately supported and supervised to deliver their roles.
This may also lead to low morale
amongst volunteers.
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NHS Wales Audit & Assurance Services Appendix A Page | 26
We are advised that previous attempts made by the Trust to support volunteers have not been successful, with little interest shown. An explanation provided
was that volunteers would need an incentive to attend such forums and events, as they would effectively be foregoing a days’ worth of mileage expenses. The
North region issue quarterly newsletters to volunteers, which keep drivers informed and updated on areas such as hand held devices, information
governance, toll changes etc.
Recommendation 5 Priority level
a) A training needs analysis specific to volunteer car drivers should be undertaken to ensure all required areas, including statutory and mandatory
training, are covered as part of the induction and ongoing training process. We understand that the Trust is considering adopting a consistent approach
to training across NEPTS staff.
b) Management should consider the frequency of assessments for volunteers, for example driving assessments and eyesight tests, to ensure that the
standard of driving required for the role is maintained.
c) Management should consider the support and supervision arrangements for volunteers across NEPTS and other areas within the Trust. This could
include areas such as newsletters, regular events, use of occupational health services, uniforms etc.
Medium
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NHS Wales Audit & Assurance Services Appendix A Page | 27
Management Response 5 Responsible Officer/ Deadline
a) The Volunteer Manager, in partnership with other NEPTS managers, will
undertake a training needs assessment (TNA) of the existing training against what is needed.
b) The Volunteer Manager will oversee the development of a VCS syllabus
based upon the outcome of the TNA.
c) The Volunteer Manager will work with NEPTS Operational Managers to ensure regular checks are undertaken of driving and eyesight capability.
d) The Volunteer Manager will develop better methods of engagement with
volunteers, specifically a newsletter.
NEPTS Volunteer Manager
September 2019
NEPTS Volunteer Manager
December 2019
NEPTS Volunteer Manager September 2019
NEPTS Volunteer Manager
September 2019
Volunteer Car Drivers’ Governance Arrangements
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix B
Audit Assurance Ratings
Substantial assurance - The Board can take substantial assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Few matters require
attention and are compliance or advisory in nature with low impact on residual risk
exposure.
Reasonable assurance - The Board can take reasonable assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Some matters require
management attention in control design or compliance with low to moderate impact on
residual risk exposure until resolved.
Limited assurance - The Board can take limited assurance that arrangements to
secure governance, risk management and internal control, within those areas under
review, are suitably designed and applied effectively. More significant matters require
management attention with moderate impact on residual risk exposure until resolved.
No Assurance - The Board has no assurance that arrangements to secure
governance, risk management and internal control, within those areas under review, are
suitably designed and applied effectively. Action is required to address the whole control
framework in this area with high impact on residual risk exposure until resolved
Prioritisation of Recommendations In order to assist management in using our reports, we categorise our recommendations
according to their level of priority as follows.
* Unless a more appropriate timescale is identified/agreed at the assignment.
Priority
Level
Explanation
Management
action
High
Poor key control design OR widespread non-compliance
with key controls.
PLUS
Significant risk to achievement of a system objective OR
evidence present of material loss, error or misstatement.
Immediate*
Medium
Minor weakness in control design OR limited non-
compliance with established controls.
PLUS
Some risk to achievement of a system objective.
Within One
Month*
Low
Potential to enhance system design to improve efficiency or
effectiveness of controls.
These are generally issues of good practice for
management consideration.
Within
Three
Months*
Volunteer Drivers’ Governance Arrangements
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix C
Confidentiality
This report is supplied on the understanding that it is for the sole use of the persons to whom it is addressed and for the purposes set out herein. No
persons other than those to whom it is addressed may rely on it for any purposes whatsoever. Copies may be made available to the addressee's
other advisers provided it is clearly understood by the recipients that we accept no responsibility to them in respect thereof. The report must not be
made available or copied in whole or in part to any other person without
our express written permission.
In the event that, pursuant to a request which the client has received under
the Freedom of Information Act 2000, it is required to disclose any information contained in this report, it will notify the Head of Internal Audit
promptly and consult with the Head of Internal Audit and Board Secretary
prior to disclosing such report.
The Trust shall apply any relevant exemptions which may exist under the Act. If, following consultation with the Head of Internal Audit this report or
any part thereof is disclosed, management shall ensure that any disclaimer which NHS Wales Audit & Assurance Services has included or may
subsequently wish to include in the information is reproduced in full in any
copies disclosed.
Audit
The audit was undertaken using a risk-based auditing methodology. An
evaluation was undertaken in relation to priority areas established after discussion and agreement with the Trust. Following interviews with relevant
personnel and a review of key documents, files and computer data, an
evaluation was made against applicable policies procedures and regulatory
requirements and guidance as appropriate.
Internal control, no matter how well designed and operated, can provide only reasonable and not absolute assurance regarding the achievement of
an organisation’s objectives. The likelihood of achievement is affected by limitations inherent in all internal control systems. These include the
possibility of poor judgement in decision-making, human error, control processes being deliberately circumvented by employees and others,
management overriding controls and the occurrence of unforeseeable
circumstances.
Where a control objective has not been achieved, or where it is viewed that improvements to the current internal control systems can be attained,
recommendations have been made that if implemented, should ensure that
the control objectives are realised/ strengthened in future.
A basic aim is to provide proactive advice, identifying good practice and any
systems weaknesses for management consideration.
Volunteer Drivers’ Governance Arrangements
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix C
Responsibilities
Responsibilities of management and internal auditors:
It is management’s responsibility to develop and maintain sound systems
of risk management, internal control and governance and for the prevention and detection of irregularities and fraud. Internal audit work should not be
seen as a substitute for management’s responsibilities for the design and
operation of these systems.
We plan our work so that we have a reasonable expectation of detecting significant control weaknesses and, if detected, we may carry out additional
work directed towards identification of fraud or other irregularities.
However, internal audit procedures alone, even when carried out with due professional care, cannot ensure fraud will be detected. The organisation’s
Local Counter Fraud Officer should provide support for these processes.
Volunteer Drivers’ Governance Arrangements
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services
Office details: Mamhilad
Audit and Assurance Cwmbran House (First Floor)
Mamhilad Park Estate Pontypool, Gwent
NP4 0XS
Contact details
Helen Higgs (Head of Internal Audit) – 01495 300846 Osian Lloyd (Deputy Head of Internal Audit) – 01495 300843
Nicola Jones (Audit Manager) – 01792 860592
1 ITEM 2.1e WAST_2018-19_Environmental Sustainability Reporting_Final Internal Audit Report_for client issue.pdf
Environmental Sustainability Reporting
Internal Audit Report
2018/19
Welsh Ambulance Services NHS Trust
NHS Wales Shared Services Partnership
Audit and Assurance Services
Environmental Sustainability Reporting Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 2
CONTENTS Page
1. Introduction and Background 4
2. Scope and Objectives 4
3. Associated Risks 5
Opinion and key findings
4. Overall Assurance Opinion 6
5. Assurance Summary 6
Review reference: WAST-1819-28 Report status: Final
Fieldwork commencement: 15 June 2018 Fieldwork completion: 05 July 2018
Draft report issued: 20 July 2018
Management response received: 15 August 2018 Final report issued: 30 August 2018
Auditor/s: Helen Higgs, Head of Internal Audit
Osian Lloyd, Deputy Head of Internal Audit
Chris Scott, Internal Audit Manager
Ossama Lotfy, Principal
Auditor
Executive sign off Chris Turley, Interim Director of Finance
Distribution Richard Davies, Assistant
Director of Capital and Estates
Derek Johns, National Estates
Manager
Committee Audit Committee
Appendix A Appendix B
Appendix C
Management Action Plan Matters arising from Source Documents
Prioritisation of Recommendations Appendix D
Responsibility Statement
Environmental Sustainability Reporting Contents
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 3
ACKNOWLEDGEMENT NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this review.
Please note:
This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in
accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.
Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance
Services, and addressed to Non-Executive Directors or officers including those designated as Accountable Officer.
They are prepared for the sole use of Welsh Ambulance Service Trust and no responsibility is taken by the Audit
and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third
party.
Environmental Sustainability Reporting Internal Audit Report
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 4
1. Introduction and Background
The ‘Environmental Sustainability Reporting’ review has been completed in line with the 2018/19 Internal Audit Plan. HM Treasury has released a
document: ‘Public sector annual reports: sustainability reporting guidance 2017-18’, which stipulates the importance of all organisations possessing
relevant audit or scrutiny arrangements, to ensure that the correct
procedures are in place to produce robust data on performance.
In May 2012 the Welsh Government launched the ‘Achieving Excellence: The Quality Delivery Plan for the NHS in Wales 2012-2016’. The Quality
Delivery Plan sets out the Welsh Government’s ambition to achieve a quality driven NHS, focused on providing high quality care and excellent patient
experience. The plan requires every NHS organisation from 2012 will publish an annual report. Set each year, the annual report submission
deadline for 2017/18 reports is 31st July 2018 and it is anticipated that this
will be brought forward to 30th June next year.
From 2012/13 public bodies in Wales that produce an annual report under
the Government Financial Reporting Manual (FReM) and are above the FReM de-minimis level are required to include a sustainability report. This
includes the Welsh Ambulance Services NHS Trust (the ‘Trust’).
The NHS Wales 2017-18 Manual for Accounts provides a recommended for
NHS Wales bodies’ sustainability reports, including minimum requirements
for emissions, waste and the use of resources.
2. Scope and Objectives
The internal audit assessed the adequacy and effectiveness of internal controls in operation. Any weaknesses have been brought to the attention
of management and advice issued on how particular problems may be resolved and control improved to minimise future occurrence.
The review assessed the draft version of the Environmental Sustainability
Report received from the Trust on 14th June 2018.
The overall objective of the review was to assess the adequacy of
management arrangements for the production of the Environmental Sustainability Report within the Trust’s Annual Report and in respect of the
draft as at 14th June 2018.
In particular, whether the:
format and content of the statement complies in all material aspects with the requirements of guidance published in the NHS Wales 2017-
18 Manual for Accounts;
Environmental Sustainability Reporting Internal Audit Report
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 5
information published within the draft report provides an accurate
and representative picture of the quality of services the Trust provides and the improvements it has committed to undertake.
The scope of the audit review was limited to the following aspects:
arrangements for the preparation, approval and publication of the Environmental Sustainability Report, including ensuring compliance
with relevant guidance;
management arrangements for securing data quality in reporting of
non-financial performance information;
internal controls over the collection and reporting of the data included
within the Environmental Sustainability Report, and confirmation that
these controls are working effectively in practice;
testing of selected indicators to ensure the underpinning data is robust and reliable, conforms to specified data quality standards and
prescribed definitions, and is subject to appropriate scrutiny and
review; and
the follow up of prior year recommendations.
3. Associated Risks
The risks considered in the review were as follows:
reputational risk from non-compliance with Welsh Government
guidance, breach of key public disclosure reporting requirement and
lack of transparency;
reputational risk that information within the draft report does not present a fair and balanced picture to stakeholders of the
performance in the year;
the draft report information is either incomplete or inaccurate due to
poor information governance controls overall or system controls; and
recommendations made in previous reports have not been
implemented.
Environmental Sustainability Reporting Internal Audit Report
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 6
OPINION AND KEY FINDINGS
4. Overall Assurance Conclusion
Based on the results of our procedures, for year ended 31 March 2018, we
noted that the Environmental Sustainability Report has been prepared in accordance with the minimum requirements of the NHS Wales 2017-18
Manual for Accounts.
However, there were data omissions from the stated minimum requirements, supporting source material was not available for all of the
data tested and amendments were required to the emissions numbers reported. We recommend that a thorough quality review of the
Environmental Sustainability Report is undertaken by management to ensure completeness and accuracy before it is submitted to Board and
published.
5. Assurance Summary
The summary of assurance given against the individual objectives is
described in the table below:
Assurance Summary
1
The extent to which
Welsh Government guidance has been followed.
2
The extent to which the detailed
information in the Environmental
Sustainability Report is complete and correct.
3 Previous Recommendations
5.1 Summary of Audit Findings
The review assessed the draft version of the Environmental Sustainability
Report received from the National Estates Manager by Internal Audit on 14th
June 2018.
Environmental Sustainability Reporting Internal Audit Report
Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Page | 7
The report content was in the main collated by the Trust National Estates
Manager and will be subject to approval at an appropriate level (Director of Planning and Performance). The Trust has followed the reporting format as
set out in the NHS Wales Manual for Accounts 2017-18, in particular regarding the compilation of the data for inclusion in the performance
tables. This reduces the likelihood of inconsistency between reporting years or individual subjectivity.
The review assessed compliance with only the mandatory sections of the Welsh Government guidance, which relate to (i) the format and narrative
content of the report and (ii) the disclosure within the report of numeric
data of volumes / weights / measures etc. of the following:
Greenhouse Gas Emissions;
Waste; and
Use of Resources.
Management were informed of a small number of instances of non-
compliance with Welsh Government requirements in respect of report
formats. These were addressed by management in the next iteration. Management have also been informed of amendments required to items
from our testing sample of six rows, two from each of the three tables set out above. Appendix B provides information on the matters arising from our
review of the source documents and the consistency of that information with the Environmental Sustainability Report. A material error in the
Electricity data reported was amended by management during the audit and the report was updated to address other issues found in the audit
testing.
Previous recommendations were followed up where they related to matters
which were outside of the scope of the current year audit. Those that were covered by the scope of the current year audit have been superseded by
the medium priority finding that has been raised this year due to the number of amendments identified from our testing. We have raised a
recommendation that a thorough quality review of the Environmental
Sustainability Report is undertaken by management before it is published to ensure completeness and accuracy.
Environmental Sustainability Reporting Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix A
Finding 1 –Quality Review of the Environmental Sustainability Report
(Design) Risk
Our testing of the Environmental Sustainability Report identified instances of
non-compliance with the prescribed report content set out within the NHS Wales 2017-18 Manual for Accounts. There were also a number of errors and
omissions found in the testing of the accuracy of the disclosure of numeric data of volumes / weights / measures within the mandatory emissions and usage
tables and an instance where, because current year data was not available, the
2017/18 report repeated 2016/17 values. The matters arising from our testing are set out in Appendix B below and have all been corrected by management.
The information detailed in the
Environmental Sustainability Report is not compliant with relevant
guidance and is incomplete and / or incorrect.
Recommendation 1 Priority level
A thorough quality review of the Environmental Sustainability Report should be
undertaken by management before it is published to confirm compliance with
Welsh Government guidance and to ensure completeness and accuracy. Management should also ensure that all data included within the report is up-to-
date and includes all required elements.
Directorates and nominated officers should ensure they provide relevant and accurate information and evidence to support the statements included within the
Environmental Sustainability Report. Where estimated data is reported this should be clearly stated. Further training may be necessary to ensure that
requirements are fully understood.
Medium
Environmental Sustainability Reporting Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix A
Management Response 1 Responsible Officer/ Deadline
A comprehensive management review will be undertaken which will encompass
the reporting guidance, the data collection process, the data cleansing process, communications with stakeholders, quality assurance of data sets and
calculations. An Estates standard operating procedure (eSOP) will be written on
the compilation, production and reporting of the Trust environment/sustainability report.
The management response will be completed within 3 months.
National Estates Manager
November 2018
Environmental Sustainability Reporting Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix B
Appendix B: Matters arising from our source document review of the Trust’s 2017/18 Environmental Sustainability Report that have been addressed.
Findings
Our verification of the data/information did not identify any significant findings with regard to the accuracy and
completeness of data/information that fed into the Environmental Sustainability Report.
However, a number of inconsistencies were identified, the majority of which were minor although there was one
that was deemed material. These have all been corrected by management and are detailed below.
The audit sought to determine whether the format of the Environmental Sustainability Report complied with Welsh Government guidance. Annex 5 (Sustainability Reporting) of NHS Wales 2017-18 Manual for Accounts provides a recommended structure for NHS Wales bodies’ sustainability reports, including minimum
requirements. We noted that the ‘Total Net Emissions’ figures were not included within the ‘Greenhouse Gas Emissions’ table with no explanation given to justify this omission. Management have included additional
narrative in the report explaining the reasons for this omission.
Greenhouse Gas Emissions table - Electricity
The Total Electricity Non-Renewable figure of 3,458,464 KWh presented in the draft report has been changed to 3,822,056 KWh to correctly align with the regional utility reports provided. The difference of 363,592 KWh or 0.36
million KWh has resulted in the following adjustments;
the Gross Emissions Scope 2 figure from 1,215.86 1000kgCO2e (carbon dioxide equivalent) to 1,343.68 1000kgCO2e;
the Gross Emissions Scope 3 figure from 113.68 1000kgCO2e to 125.63 1000kgCO2e;
Environmental Sustainability Reporting Welsh Ambulance Services NHS Trust
NHS Wales Audit & Assurance Services Appendix B
Findings Management advised that they had incorrectly applied 2016/17 rather than 2017/18 figures. This brings the Total of Gross Emissions Scope 2 & 3 (Indirect) to 1,469.31 1000kgCO2e rather than 1,329.54 1000kgCO2e, a
difference of 139.77 1000 kgCO2e. This in turn caused the Total Gross Emissions figure of 12,760.24 1000kgCO2e to be adjusted to 12,900.01 1000kgCO2e.
Greenhouse Gas Emissions table - Business Travel
Bus, taxi, rail and airplane business mileage emissions which Welsh Government guidance requires inclusion of were found absent from the total figure reported for business mileage emissions. Evidence provided shows that the Trust do not collect the mileage travelled if reimbursement is made for bus, taxi, rail or airplane travel. Management
have included additional narrative in the report explaining the reasons for this omission.
Waste table - Landfill
Supporting evidence was not available to verify the accuracy of Landfill and Reused/Recycled waste 2017/18
figures, and the values from the 2016/17 report were inserted. Additional commentary was provided in the report as follows: ‘Landfill and recycled waste weights and costs have been calculated on 2016-17 calculations, this was
due to amendments in contract and limited resources, these calculations are completed via DECC weight per waste stream and bin size methodology. 2017-18 calculations will be compiled by the new Trust waste contractor who is contracted to weigh all bins on collection’.
Use of Resources table - Water Consumption
Total Water Consumption (All Estate) was 23,121 m3 including 5,410 m3 for Central & West Region and 8,919 for the North. While the total figure reported was correct these regional figures should be reversed per utility reports
provided.
Environmental Sustainability Reporting Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix C
Prioritisation of Recommendations
In order to assist management in using our reports, we categorise our recommendations
according to their level of priority as follows.
* Unless a more appropriate timescale is identified/agreed at the assignment.
Priority
Level
Explanation
Management
action
High
Poor key control design OR widespread non-compliance
with key controls.
PLUS
Significant risk to achievement of a system objective OR
evidence present of material loss, error or misstatement.
Immediate*
Medium
Minor weakness in control design OR limited non-
compliance with established controls.
PLUS
Some risk to achievement of a system objective.
Within One
Month*
Low
Potential to enhance system design to improve efficiency or
effectiveness of controls.
These are generally issues of good practice for
management consideration.
Within
Three
Months*
Environmental Sustainability Reporting Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix D
Confidentiality
This report is supplied on the understanding that it is for the sole use of the
persons to whom it is addressed and for the purposes set out herein. No persons other than those to whom it is addressed may rely on it for any
purposes whatsoever. Copies may be made available to the addressee's other advisers provided it is clearly understood by the recipients that we
accept no responsibility to them in respect thereof. The report must not be
made available or copied in whole or in part to any other person without
our express written permission.
In the event that, pursuant to a request which the client has received under the Freedom of Information Act 2000, it is required to disclose any
information contained in this report, it will notify the Head of Internal Audit promptly and consult with the Head of Internal Audit and Board Secretary
prior to disclosing such report.
The Trust shall apply any relevant exemptions which may exist under the
Act. If, following consultation with the Head of Internal Audit this report or any part thereof is disclosed, management shall ensure that any disclaimer
which NHS Wales Audit & Assurance Services has included or may subsequently wish to include in the information is reproduced in full in any
copies disclosed.
Audit
The audit was undertaken using a risk-based auditing methodology. An
evaluation was undertaken in relation to priority areas established after discussion and agreement with the Trust. Following interviews with relevant
personnel and a review of key documents, files and computer data, an evaluation was made against applicable policies procedures and regulatory
requirements and guidance as appropriate.
Internal control, no matter how well designed and operated, can provide
only reasonable and not absolute assurance regarding the achievement of an organisation’s objectives. The likelihood of achievement is affected by
limitations inherent in all internal control systems. These include the possibility of poor judgement in decision-making, human error, control
processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable
circumstances.
Where a control objective has not been achieved, or where it is viewed that
improvements to the current internal control systems can be attained,
recommendations have been made that if implemented, should ensure that
the control objectives are realised/ strengthened in future.
Environmental Sustainability Reporting Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services Appendix D
A basic aim is to provide proactive advice, identifying good practice and any
systems weaknesses for management consideration.
Responsibilities
Responsibilities of management and internal auditors:
It is management’s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the prevention
and detection of irregularities and fraud. Internal audit work should not be
seen as a substitute for management’s responsibilities for the design and
operation of these systems.
We plan our work so that we have a reasonable expectation of detecting significant control weaknesses and, if detected, we may carry out additional
work directed towards identification of fraud or other irregularities. However, internal audit procedures alone, even when carried out with due
professional care, cannot ensure fraud will be detected. The organisation’s
Local Counter Fraud Officer should provide support for these processes.
Environmental Sustainability Reporting Welsh Ambulance Services NHS Trust
Action Plan
NHS Wales Audit & Assurance Services
Office details:
POWYS Office MAMHILAD Office Audit and Assurance Audit and Assurance
Hafren Ward Cwmbran House (First Floor) Bronllys Hospital Mamhilad Park Estate
Powys Pontypool, Gwent LD3 0LS NP4 0XS
Contact details
Helen Higgs (Head of Internal Audit) – 01495 300846
Osian Lloyd (Deputy Head of Internal Audit) – 01495 300843 Chris Scott (Internal Audit Manager) – 01495 300842
Ossama Lotfy (Principal Auditor)
2.2 External Audit Reports (Head of External Audit)
1 ITEM 2.2 426A2018-19_WAST_Audit_Committee_Update_September2018.pdf
Audit Committee Update – Welsh Ambulance Services NHS Trust
Date issued: September 2018
Document reference: 426A2018-19
This document has been prepared as part of work performed in accordance with statutory functions.
In the event of receiving a request for information to which this document may be relevant, attention
is drawn to the Code of Practice issued under section 45 of the Freedom of Information Act 2000.
The section 45 code sets out the practice in the handling of requests that is expected of public
authorities, including consultation with relevant third parties. In relation to this document, the Auditor
General for Wales and the Wales Audit Office are relevant third parties. Any enquiries regarding
disclosure or re-use of this document should be sent to the Wales Audit Office at
We welcome correspondence and telephone calls in Welsh and English. Corresponding in Welsh will
not lead to delay. Rydym yn croesawu gohebiaeth a galwadau ffôn yn Gymraeg a Saesneg. Ni fydd
gohebu yn Gymraeg yn arwain at oedi.
The team providing this Audit Committee update comprised Fflur Jones and Michelle Phoenix.
Contents
Page 3 of 10 - Audit Committee Update – Welsh Ambulance Services NHS Trust
Progress update
About this document 4
Audit plan 4
Financial audit update 4
Performance audit update 5
Other Auditor General studies 6
Good practice exchange 7
Progress update
Page 4 of 10 - Audit Committee Update – Welsh Ambulance Services NHS Trust
About this document
1 This document provides the Audit Committee with an update on current and
planned Wales Audit Office work as set out in our audit plan.
2 Financial and performance audit work is covered, and information is provided on
the Auditor General’s programme of national value-for-money examinations.
Audit plan
3 Details of the finalisation of our audit plan for 2018 is summarised in Exhibit 1.
Exhibit 1: audit plan
Area of work Current status
Audit Plan 2018 Presented to Audit Committee March 2018
Financial audit update
4 Our key financial audit reports for 2017 are set out in Exhibit 2. On finalisation of
the 2018 Audit Plan, details of the key reports for 2018 will be included in future
updates.
Exhibit 2: financial audit update
Area of work Current status
Accounts Audit: Audit of Financial
Statements Report 2017-18
Complete
Financial Statements Audit Letter and
Recommendations – 2017-18
Financial Statements Audit letter –
complete and presented to Audit
Committee 25 May 2017
Recommendations – in progress
Charitable Funds: Audit of Financial
Statements independent examiner’s
report 2017-18
In progress
Annual Audit Report 2018 In progress
Page 5 of 10 - Audit Committee Update – Welsh Ambulance Services NHS Trust
Performance audit update
5 The following tables set out the performance audit work included in our 2017 and
2018 audit plans. They summarise completed work (Exhibit 3); work currently
underway (Exhibit 4); and planned work that has not yet started (Exhibit 5).
Exhibit 3: work completed
Area of work Current status
NHS Structured Assessment1 (2017) Presented to Board January 2018.
Adoption of Well-being of Future
Generations (WFG) sustainable
development principle2 (2017)
For presentation to Audit Committee
September 2018
Exhibit 4: work currently in progress
Topic Focus of the work Current status Consideration
by Audit
Committee
NHS
Structured
Assessment
(2018)
This work will assess the
robustness of NHS bodies’
arrangements for corporate
governance and financial
management, and the
progress that is being made
in addressing issues and
concerns identified in
previous years’ structured
assessments.
Fieldwork
December 2018
Exhibit 5: planned work not yet started
1 Structured Assessment 2017 supplementary outputs: Comparative analyses of financial
savings due to be presented to national efficiencies groups in spring 2018, to support
learning and development.
2 The Trust is not a prescribed body under the Well-being of Future Generations (Wales)
Act 2015 but is committed to adopting the sustainable development principles. The work
will inform a picture of how the Trust is progressing with this aim. Where possible we will
compare with how prescribed bodies are responding to the Act from work done to inform
the AGW’ year-one commentary on the implementation of the Act, and highlighting areas
where the Trust’s wider contribution could be valuable.
Page 6 of 10 - Audit Committee Update – Welsh Ambulance Services NHS Trust
Topic Focus of the work Current status Consideration by
Audit Committee
Local project
(2018)
To be determined Topic and focus of
the work will be
agreed with the
Trust in September
2018
December 2018 /
March 2019
Other Auditor General studies
6 The Audit Committee may also be interested in the following studies/planned
outputs. Where the work is completed and reported, these are highlighted in red,
and include a link to the report.
Exhibit 6: other Auditor General studies
Recent publications / planned publications
Topic Update
Primary Care out of hours
services
July 2018
The report shows that despite patients being generally positive about
Out of Hours services, those services are under real strain in terms of
ability to fill shifts and maintain morale amongst staff. There are also
challenges associated with meeting national standards on timeliness,
poor quality management information, and integrating the planning of
Out of Hours services with other parts of the urgent care system.
Speak my language:
Overcoming language
and communication
barriers in public
services
April 2018
This report looks at how public bodies, particularly local government
and NHS bodies providing front-line services, provide interpretation
and translation services for BSL and other languages to enable
people facing these communication barriers to access services.
We have concluded that organisations varied in the degree to which
they understood the needs of their communities and ensured their
services were accessible to people needing interpretation and
translation services.
A summary report is also available.
Well-being of Future
Generations – reflecting
on Year One
May 2018
The report provides an assessment of how the 44 named public
bodies in Wales have responded to the Well-being of Future
Generations Act. The report found that public bodies are able to give
examples of how they have used the Act to make the changes
needed for them to effectively apply the sustainable development
principle. Public bodies now need to set out how they will continue
developing their approach to the Act so that they can deliver on the
ambition and maximise the opportunities it affords.
Page 7 of 10 - Audit Committee Update – Welsh Ambulance Services NHS Trust
Recent publications / planned publications
Topic Update
Management of follow up
outpatients
This work has considered whether health boards have fully
implemented previous audit recommendations for improving the
management of follow-up outpatient appointments, particularly in light
of the growing numbers of patients who experience delays in
receiving their follow-up treatment.
Since the publication of the local health board progress update
reports, we are bringing together the key all-Wales messages, along
with findings from supplementary work at a national level, together
into a short summary report. We are due to publish this report in
October. We are also preparing a data presentation for the national
Planned Care Programme Board.
Use of locum and agency
staff
We are currently conducting audit work on NHS agency expenditure.
This work is examining trends in staffing and expenditure, the issues
driving the use of agency staff, and initiatives aimed at helping to
control agency costs. We are aiming to report our findings during
autumn 2018, and also to explore these issues with NHS Wales
colleagues via our Good Practice Exchange events programme in
early 2019.
Good Practice Exchange
7 The Good Practice Exchange (GPX) helps public services improve by sharing
knowledge and practices that work. We run events where people can exchange
knowledge face to face and share resources online.
8 Details of past and forthcoming events, shared learning seminars and webinars
can be found on the GPX page on the Wales Audit Office’s website. The table
below lists recent and forthcoming events.
Exhibit 7: Good Practice Exchange
Recent and forthcoming events
Recent events
I’m a patient, get me out of here (public service collaboration to deliver hospital discharge
services) – March 2018.
Adverse Childhood Experiences, in partnership with ACE’s Hub at Public Health Wales
and the Future Generations Office, Online webinar 12 June.
Digital – Inspiring public services to deliver independence and well-being through
digital ambition, June 2018.
Forthcoming events
Working in partnership: Holding up the mirror, This seminar will focus on how public
bodies can hold up the mirror so that the design and delivery of a service is focused on the
‘individual’, irrespective of who is actually delivering the service.
Page 8 of 10 - Audit Committee Update – Welsh Ambulance Services NHS Trust
Cardiff: 19 September 2018 / Llanrwst: 27 September
Building Resilient Communities, A more resilient Wales is one of the seven goals of the
Well-being of the Future Generations (Wales) Act 2015, and the term resilient communities
has become a common theme over the past couple of years, but what does this mean in
reality? What is a community and how does it become resilient?.
Cardiff: 11 October 2018 / Llanrwst: 18 October 2018
Why using data effectively enables better decision making (Webinar), The Well-being of
the Future Generations Act wants us to think and act differently, and this means using
different data and thinking about the data we use differently to help drive our decision
making. 16 October 2018
9 Diary markers and details of new events are circulated in advance to the Trust,
together with information on booking delegate places. Further information on any of
our past or planned GPX events can be obtained by contacting the local audit team
or emailing [email protected].
Wales Audit Office
24 Cathedral Road
Cardiff CF11 9LJ
Tel: 029 2032 0500
Fax: 029 2032 0600
Textphone.: 029 2032 0660
E-mail: [email protected]
Website: www.audit.wales
Swyddfa Archwilio Cymru
24 Heol y Gadeirlan
Caerdydd CF11 9LJ
Ffôn: 029 2032 0500
Ffacs: 029 2032 0600
Ffôn testun: 029 2032 0660
E-bost: [email protected]
Gwefan: www.archwilio.cymru
1 ITEM 2.2a 565A2018-19_Embedding the sustainable development principle into ways of working_final.pdf
Embedding the sustainable development principle into ways of working – Welsh Ambulance Services NHS Trust Audit year: 2017
Date issued: August 2018
Document reference: 565A2018-19
Page 2 of 18 - Embedding the sustainable development principle into ways of working – Welsh Ambulance Services NHS Trust
This document has been prepared as part of work performed in accordance with statutory functions.
In the event of receiving a request for information to which this document may be relevant, attention is drawn to the Code of Practice issued under section 45 of the Freedom of Information Act 2000.
The section 45 code sets out the practice in the handling of requests that is expected of public authorities, including consultation with relevant third parties. In relation to this document, the Auditor
General for Wales and the Wales Audit Office are relevant third parties. Any enquiries regarding disclosure or re-use of this document should be sent to the Wales Audit Office at
We welcome correspondence and telephone calls in Welsh and English. Corresponding in Welsh will not lead to delay. Rydym yn croesawu gohebiaeth a galwadau ffôn yn Gymraeg a Saesneg. Ni fydd
gohebu yn Gymraeg yn arwain at oedi.
The person who delivered the work was Fflur Jones.
Contents
Page 3 of 18 - Embedding the sustainable development principle into ways of working – Welsh Ambulance Services NHS Trust
Summary report
Introduction 4
Summary of findings 5
Recommendations 6
Detailed report
The Trust has embraced the opportunities provided by the Well-being of Future Generations Act, but it knows it has more to do to embed the sustainable development principle into its ways of working 7
While not a prescribed body within the Act, the Trust recognises the advantages of integrating the sustainable development principle into its ways of working 7
The Trust can show examples of sustainable service planning, but it is not yet systematically applying the sustainable development principle 9
Despite limited capacity, the Trust and its commissioning body are developing their approaches so that the Trust maximises the Act’s opportunities 12
Appendices
Appendix 1 – our approach 14
Appendix 1 – Year One Commentary 14
Appendix 2 – the Trust’s management response to recommendations 15
Summary report
Page 4 of 18 - Embedding the sustainable development principle into ways of working – Welsh Ambulance Services NHS Trust
Introduction 1 The Well-being of Future Generations (Wales) Act 2015 (the Act) aims to create a
Wales that we all want to live in, now and in the future. The Act sets out how 44 specified public bodies must work, and work together, to improve carry out sustainable development, defined as:
‘the process of improving the economic, social, environmental and cultural well-being of Wales by taking action, in accordance with the sustainable development principle, aimed at achieving the well-being goals.’
Public bodies coved by the Act (prescribed bodies) include including national government, local government, local health boards, fire and rescue authorities, national parks and some sponsored bodies. In carrying out sustainable development, they must set well-being objectives and take all reasonable steps to meet them.
2 The Act defines the sustainable development principle as;
‘acting in a manner which seeks to ensure that the needs of the present are met without compromising the ability of future generations to meet their own needs’.
3 To act in this manner, public bodies must take account of the ‘five ways of working’. These are: • Looking to the long-term so they do not compromise the ability of future
generations to meet their own needs; • Taking an integrated approach so that they look at all the well-being goals in
deciding on their well-being objectives;
• Involving a diversity of the population in the decisions that affect them; • Working with others in a collaborative way to find shared, sustainable
solutions; and
• Understanding the root causes of issues to prevent them from occurring or getting worse.1
In this way, the Act aims to improve what public bodies do and the way they do it so that they can collectively improve the well-being of Wales.
4 The Welsh Ambulance Services NHS Trust (The Trust) operates as a commissioned service. Its services are commissioned by the seven Welsh Health Boards and the Chief Ambulance Services Commissioner. These form the Emergency Ambulance Services Committee (EASC). The seven Health Boards are prescribed bodies under the Act, the Trust is not.
1 Welsh Government, Shared Purpose: Shared Future Statutory Guidance on the Well-being of Future Generations (Wales) Act 2015, 2016
Page 5 of 18 - Embedding the sustainable development principle into ways of working – Welsh Ambulance Services NHS Trust
5 However, the Trust has is committed to working within the spirit of the Act. This includes adopting the sustainable development principle to improve the way it works, including how it can contribute to wider public service and population well-being.
6 As part of his programme of local performance audit work at the Trust, the Auditor General for Wales has carried out a review of the Trust’s approach to using the sustainable development principle to help shape its business planning and service delivery. The review provides feedback to inform the Trust’s future approach. It should be read alongside the Auditor General’s wider ‘Year One Commentary’ on the progress being made by the 44 prescribed bodies in implementing the Act’s requirements.
7 Appendix 1 provides further information on our audit approach, as well as brief details on the Auditor General’s wider Year One Commentary work.
Summary of findings 8 The Trust has acknowledged the opportunities and benefits afforded by the Act
and the sustainable development principle despite not being required to comply with it. Members of the Executive Team and the wider Board have said that the sustainable development principle provides opportunities for the organisation to work in an integrated way with partners to improve services for the people of Wales.
9 The Trust recognises it is at an early stage of framing its approach. During 2017 it has explored how it can apply the sustainable development principle. It has done this in drafting its environmental strategy, its estates strategic outline programme and in how it engages with the broader agenda of Public Service Boards.
10 The Trust is yet to apply the sustainable development principle systematically across the way it plans and runs its service. Not being a prescribed body within the Act affords the Trust more time to consider its approach. However, given its commitment to using opportunities provided by the Act, the Trust should maintain momentum ‘in taking its plans forward. The Trust has established collaborative objectives around key areas where the Trust wishes to work in partnership to achieve its goals. The Trust has also committed to review its corporate objectives in 2018-19 to take account of the sustainable development principle and the strategic plan for NHS Wales.2
11 Capacity constraints are likely to be a potential barrier for the Trust, both in adopting the sustainable development principle internally and in terms of its ability to engage meaningfully with multiple partners, for example those in the Public Service Boards (PSBs). Given its status as a non-prescribed body, the Trust will need to take a pragmatic approach that balances capacity and resource issues
2 ‘A Healthier Wales: our Plan for Health and Social Care’ published in June 2018
Page 6 of 18 - Embedding the sustainable development principle into ways of working – Welsh Ambulance Services NHS Trust
with the benefits than can be secured through adoption of the sustainable development principle and associated engagement with partner agencies.
12 The commissioning intentions that are issued to the Trust from the Emergency Ambulance Services Committee (EASC) should help shape and inform the Trust’s plans. The EASC intends to incorporate sustainable development principles in its commissioning intentions from 2019-20 and the Trust has expressed its commitment to work within these intentions.
13 These findings are explored in more detail below.
Recommendations 14 The Trust is not required to comply with the Wellbeing of Future Generations Act.
Given its stated intention to operate within the spirit of the Act, it may find it helpful to implement the following recommendations.
Exhibit 1: recommendations
Recommendations
R1 The Trust should be mindful not to simply retrofit its work and planning to the sustainable development principle. It should take reasonable steps to ensure that the sustainable development principle is considered early and throughout its planning processes. The Trust could consider embedding prompts into its internal planning templates to help achieve this.
R2 The Trust should articulate what success in working within the spirt of the Act would mean for the organisation. This could feature within some of the Trust’s key corporate documents, for example its Integrated Medium Term Plan (IMTP) and long-term strategy, which could also support the broadening of understanding of the Act amongst staff.
R3 Given capacity limitations, and its status as a non-prescribed body in the Act, the Trust should manage expectations amongst its partners about the extent to which it can meaningfully engage in discussions at the Public Service Board level. This should include clearly communicating the costs and benefits associated with such partnership working.
Detailed report
Page 7 of 18 - Embedding the sustainable development principle into ways of working – Welsh Ambulance Services NHS Trust
The Trust has embraced the opportunities provided by the Well-being of Future Generations Act, but it knows it has more to do to embed the sustainable development principle into its ways of working
While not a prescribed body within the Act, the Trust recognises the advantages of integrating the sustainable development principle into its ways of working 15 We sought to understand how the Trust perceives the Sustainable Development
principle and what it means to staff. We asked ‘How would you describe the sustainable development principle and what it means for your organisation?’ and to select the following categories that it felt applied:
• A distraction
• Unnecessary • Opportunity
• Necessity 16 In its response, the Trust clearly showed that that it sees the principle as providing
an ‘opportunity’ to help the organisation both ‘address some of the major challenges it faces’ and ‘deliver more sustainable services and better outcomes for citizens’.
17 The Trust has articulated a view that service planning in accordance with the sustainable development principle can improve service delivery. The Trust is a smaller body, which works as part of a wider public service system. It sees the sustainable development principle as helping it move beyond its traditional ways of working towards a more innovative and integrated way of delivering services which benefits the user.
18 The views of the Trust are similar to those expressed to us by many of the prescribed bodies under the Act3 as part of our evidence gathering for the Auditor General’s Year One Commentary. Overall, public bodies described the Act in positive terms with the majority viewing the Act as having the potential to improve ‘strategic planning and decision-making’ and to ‘drive positive change in culture and behaviour’.
19 Other health bodies also described how the Act can add value by encouraging a broader view of how to improve the health of the population, including by tackling health inequalities and increasing the focus on preventative work. They saw the
3 The Trust provided this response in relation to the Act, rather than its sustainable development principle specifically.
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Act as being important in driving a collective response to these challenges. Similarly, fire and rescue authorities highlighted how the Act provides an opportunity to strengthen collaboration and increase preventative work.
20 Some public bodies went further and said that they saw the Act as a ‘necessity’. Health bodies, central government and sponsored bodies and fire and rescue authorities were, proportionally, more likely to describe it in this way. This tended to be because they felt the Act could help deliver more sustainable services and better outcomes for citizens.
21 The Trust describes the changes it intends to make with regard to the sustainable development principle as ‘transformational’. It recognises that it is at an early stage of articulating and embedding its approach. The Trust is committed to using the platform created by the Act to make step changes in the way it delivers services and the way in which it works with partners.
22 The Trust knows that it is neither viable nor desirable to carry on providing services in the same way as now given the financial constraints and increasing demand facing all health bodies. The Trust has articulated a commitment to respond to the changing needs of society in a more timely way, with a focus on managing demand, improving health, maintaining independence and optimising the skills of its staff to deliver higher-level care in the community.
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The Trust can show examples of sustainable service planning, but it is not yet systematically applying the sustainable development principle 23 Within its Integrated Medium Term Plan 2017-20 (IMTP) the Trust stated its twin
ambition of being a ‘clinically-led and operationally effective service’. It also articulated a commitment to service improvement in line with its vision to become ‘a leading ambulance service providing the best possible care.’ In the IMTP, the Trust committed to engage with the Act to better develop its strategic responses to predicted population change.
24 The Trust has made progress against the plans outlined in its IMTP. For example, the Trust developed collaborative objectives in several key areas where it feels it must work with partners to achieve its goals, these were: • Estates
• Training and occupational health
• Fire and ambulance service relationships 25 The Trust has committed to pursuing these objectives over the medium to long-
term and hopes that by focussing its activity to working in partnership it will achieve better outcomes. The Trust has also committed to refining its corporate objectives by applying the sustainable development principle as well as by considering the strategic plan for NHS Wales.
26 Public bodies prescribed under the Act were required to set their first well-being objectives in 2017. Our Year One Commentary highlights a variable approach to setting objectives by the bodies prescribed under the Act. It also details an observation by the Future Generations Commissioner that ‘public bodies are committing to well-being objectives that largely resemble the corporate objectives they would have set before 2017’.
27 Other ways in which the Trust has actively made changes in pursuing its aim of working adopting the sustainable development principle include:
• The Trust’s Sustainable Development Policy: Drafted in 2017. The policy describes sustainable development as ‘one of the guiding principles in the Trust’s strategic and operational planning process’ and recognises the benefits it can have for its policies and practices; and
• Board Development Sessions: During 2017, the Trust raised awareness of the Act and the sustainable development principle among Board members and the Executive Team through two Board Development sessions. The Future Generations Commissioner attended one session and members explored the ways in which the Trust can contribute to achieving Wales’ seven well-being goals.
28 The Trust also highlighted examples of its current work in keeping with the spirit of the sustainable development principle and the five ways of working. While the sustainable development principle has not been explicitly used as a driver for these
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examples, they show consideration of some of the five ways of working including integration and prevention. Examples included:
Service Development Relevance to five ways of working Optimising of estate by working closely with the fire and rescue authorities, such as the joint Fire and Ambulance Station in Wrexham.
Collaboration, long-term
Full accreditation of the ISO14001:2004 standard Environmental Management System (EMS) in August 2016, which is intended to improve efficiency and reduce waste and energy use and cost.
Long-term, prevention
Achieving the Gold Corporate Health Standard for its commitment to improving the health and wellbeing of its staff in January 2018.
Long-term, prevention
Reducing the demand of frequent callers on the service by working with partner health and blue light organisations and the individuals themselves. This work was recognised through an NHS Wales Award in 2016.
Prevention, collaboration, involvement
Introducing the community paramedic scheme which sees paramedics working closely with primary care providers.
Prevention, collaboration, integration
Falls response teams. Prevention, collaboration Placing clinicians in police call rooms to reduce the demand on emergency ambulance services.
Collaboration, integration, prevention
29 The Trust’s service delivery is governed by the National Collaborative
Commissioning: Quality and Delivery Framework Agreement 2015-18 (the Framework) for ambulance services in Wales. The Framework is an agreement between health boards and the Trust on key areas of service provision and sets out details of what is required from the Trust and how the Trust should achieve the requirements.
30 The Framework is set within a citizen-centred pathway which describes a five-step model for the delivery of emergency ambulance services within Wales. This model is intended to encourage and enable patients to access services through other, more appropriate means before their needs become urgent and/or life-threatening, and require a response from the emergency ambulance service.
31 While the sustainable development principle and the five ways of working are not clearly stated as drivers behind the Framework and the five step model, their focus
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on outcomes and patient experience rather than on performance targets is in line with the sustainable development principle and the five ways of working, particularly involvement, integration and prevention.
32 While these examples show how the Trust is considering wider opportunities and implications during its service-planning, the Trust should be mindful not to simply retro-fit its work of the to the sustainable development principle.
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Despite limited capacity, the Trust and its commissioning body are developing their approaches so that the Trust maximises the Act’s opportunities
The Trust is continuing to develop its approach to embedding the sustainable development principle into its ways of working
33 The Trust knows its thinking in terms of applying the sustainable development principle to the way it works is at an early stage. Capacity is a significant factor for the Trust both internally and in terms of its partnership working. Given its status as a non-prescribed body, the Trust has not dedicated the same focus and level of resource to making changes to its organisational practices as prescribed members. While this has affected the pace at which the Trust has made changes, staff we spoke to were content that this approach was appropriate and proportionate.
34 The Trust is yet to articulate what success in embedding the sustainable development principle will look like. It may find that describing what success in working within the spirt of the Act would mean for the organisation a helpful exercise when shaping its approach.
35 As part of our year-one commentary, many prescribed bodies referenced changes they had made to their governance in order to change their ways of working. Many of these related to governance changes such as updating decision or committee report templates and business plan templates or updating documents such as the Constitution, Code of Corporate Governance or Code of Conduct.
36 The Trust has recognised that it could use the five ways of working in a more explicit way during service planning. The Trust is exploring options such as making greater use of planning templates to drive thinking and introducing training for staff. Such changes would encourage a shared understanding of the benefits and greater consideration of the sustainable development principle as a more visible driver for service planning and wider decision-making processes.
37 During 2018 the Trust has taken steps to ensure that its future direction aligns with the sustainable development principle by including a representative from the Wellbeing of Future Generations Commissioner’s Office on the stakeholder panel during the recruitment of its new Chief Executive. The panel sought to test each candidates’ appetite, approach and experience in respect of collaboration and partnership. This was done with the aim of ensuring that leadership within the Trust recognises and embraces the opportunities afforded by the sustainable development principle.
38 As the Trust’s commissioning body, EASC also recognises the role they have to play to ensure the services they commission from the Trust for their respective Health Board areas are in-keeping with the sustainable development principle.
39 Each year, EASC issue commissioning intentions to the Trust which they must align to the actions within their Integrated Medium Term Plan and submit to Welsh
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Government. The Chief Ambulance Services Commissioner plans for EASC to embed the sustainable development principle within the next set of strategic commissioning intentions for 2019-20. The Trust has stated its commitment to work towards new requirements within the commissioning intentions that relate to the sustainable development principle.
The Trust is continuing to explore opportunities to apply the sustainable development principle more clearly within partnership working
40 At the time of fieldwork, the Trust was considering the options available to it in terms of partnership working within the spirit of the sustainable development principle.
41 In January 2018, the Trust established an internal Strategic Planning and Partnerships Forum which meets every six weeks. Members of this forum include the Medical Director, Director of Planning and Performance and Director of Quality, Patient Safety and Experience. The forum provides a platform for key staff to discuss partnership working, including opportunities to engage with partners under the Social Services and Well-being Act and the Well-being of Future Generations Act.
42 More specifically, in March 2018 the Trust’s Executive Team agreed the organisation’s approach to engaging with Public Service Boards, in order to engage in strategic discussions about future service delivery. The Trust feels strongly that it can contribute to creative ideas for service design that could help achieve well-being objectives across Wales. However, the capacity of the Trust to engage with each of the Public Service Boards does present a significant challenge.
43 The Trust has considered how it could best use its resources in a way that provides value both to the Trust and to Public Service Boards in discharging the well-being duty. It has agreed to pilot participation at four Public Service Boards during 2018, once it has determined which four Public Service Boards present the most opportunity to add value. It aims to evaluate its approach and the benefit and impact achieved during 2019-20.
Appendix 1
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Our approach 44 For this review, we sought to understand the Trust’s views of the sustainable
development principle; what key staff think working in the spirit of the Act means for them; and how they are beginning to embed the sustainable development principle.
45 Specifically, we considered the following questions:
• To what extent does the Trust perceive the sustainable development principle to be of benefit for the organisation?
• What key actions has the Trust taken to embed the sustainable development principle within its strategic and operational objectives and the way it works?
• What is the Trust doing to identify further opportunities to embed the sustainable development principle within the organisation going forward?
• What is the Trust doing to identify opportunities to work with partners and contribute more broadly to the delivery of the public service well-being duty?
46 We adopted a similar approach to our review as was taken for the Wales Audit Office Year One Commentary (below). We asked the Trust to respond to a ‘call for evidence’ which provided an opportunity for staff to tell us about the work they are doing. We also interviewed a number of Executive Directors, the Chief Ambulance Services Commissioner and reviewed key documents, such as the Integrated Medium Term Plan4.
Year One Commentary 47 The Auditor General for Wales (the Auditor General) is statutorily required to
examine public bodies prescribed by the Act to assess the extent to which they have acted in accordance with the sustainable development principle when;
a) setting their well-being objectives; and
b) taking steps to meet them. 48 In 2017-18, the Auditor General decided to undertake a preliminary piece of work,
in advance of commencing his formal examinations. This work is known as the Year One Commentary, which was published in May 2018.5
49 The Year One Commentary report provides the Auditor General’s commentary on how prescribed public bodies have responded to the Act in the first year. It gives some early feedback, without prescribing expectations for how prescribed public bodies should be undertaking their new responsibilities.
4 Integrated Medium Term Plan 2017-20 and 2018-21 iterations 5 ‘Reflecting on Year One’ Wales Audit Office
Appendix 2
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The Trust’s management response to recommendations
Exhibit 2: management response
The following table sets out the 2018 recommendations and the management response.
Ref Recommendation Intended outcome/ benefit
High priority (yes/no)
Accepted (yes/no)
Management response Completion date
Responsible officer
R1 The Trust should be mindful not to simply retrofit its work and planning to the sustainable development principle. It should take reasonable steps to ensure that the sustainable development principle is considered early and throughout its planning processes. The Trust could consider embedding prompts into its internal planning templates to help achieve this.
Ensuring the Trust maximises the benefits of using the sustainable development principle to drive changes in its internal and external planning practices.
Yes Yes The Trust will ensure that both the LDP and IMTP development processes include clear opportunities and prompts within its templates and guidance to ensure colleagues are considering the sustainable development principle within their short, medium and longer-term plans.
March 2019 Director of Planning and Performance
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Ref Recommendation Intended outcome/ benefit
High priority (yes/no)
Accepted (yes/no)
Management response Completion date
Responsible officer
R2 The Trust should articulate what success in working within the spirit of the Act would mean for the organisation. This could feature within some of the Trust’s key corporate documents, for example its Integrated Medium-Term Plan (IMTP) and long-term strategy, which could also support the broadening of understanding of the Act amongst staff.
The Trust has identified and articulated what it wants to achieve by working in the spirit of the Act and can therefore take steps to deliver that vision.
Yes Yes The Trust will ensure that its long-term strategy is clearly aligned to the key tenets of the WBFGA. The 2019-20 onwards IMTP will clearly articulate the Trust’s commitment to the Act, the ways in which any revised plans will reflect the principles of the Act and the tangible outcomes which the Trust anticipates seeing as a result of this approach. This will be echoed in the IMTP summary and any associated staff and stakeholder communication.
March 2019 Director of Partnerships and Engagement
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Ref Recommendation Intended outcome/ benefit
High priority (yes/no)
Accepted (yes/no)
Management response Completion date
Responsible officer
R3 Given capacity limitations, and its status as a non-prescribed body in the Act, the Trust should manage expectations amongst its partners about the extent to which it can meaningfully engage in discussions at the Public Service Board level. This should include clearly communicating the costs and benefits associated with such partnership working.
The Trust and its partners enabled to maximise the opportunities provided by its involvement at Public Service Boards.
Yes Yes The Executive Management Team will reconsider in autumn 2018 the capacity and other limitations of the organisation on its engagement with PSBs. As part of this appraisal process, the Trust will seek the views of a number of key partners (HBs, police, fire and rescue services, local authorities) to inform its position and to ensure that partners are both sighted on the commitment of the organisation to the WBFGA and recognise the need for advocacy on behalf of/consideration of the contribution of WAST to various PSB agenda/activities.
March 2019 Director of Partnerships and Engagement
Wales Audit Office 24 Cathedral Road Cardiff CF11 9LJ
Tel: 029 2032 0500 Fax: 029 2032 0600
Textphone: 029 2032 0660
E-mail: [email protected] Website: www.audit.wales
Swyddfa Archwilio Cymru 24 Heol y Gadeirlan Caerdydd CF11 9LJ
Ffôn: 029 2032 0500 Ffacs: 029 2032 0600
Ffôn testun: 029 2032 0660
E-bost: [email protected] Gwefan: www.archwilio.cymru
1 ITEM 2.2b 565A2018-19_Embedding the sustainable development principle into ways of working_final_Welsh.pdf
Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru Blwyddyn archwilio: 2017
Dyddiad cyhoeddi: Awst 2018
Cyfeirnod y ddogfen: 565A2018-19
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Paratowyd y ddogfen hon yn rhan o waith a gyflawnir yn unol â swyddogaethau statudol.
Os gwneir cais am wybodaeth y gallai’r ddogfen hon fod yn berthnasol iddi, tynnir sylw at y Cod Ymarfer a gyhoeddwyd o dan adran 45 o Ddeddf Rhyddid Gwybodaeth 2000.
Mae cod adran 45 yn nodi’r arfer a ddisgwylir gan awdurdodau cyhoeddus wrth ymdrin â cheisiadau, yn cynnwys ymgynghori â thrydydd partïon perthnasol. Mewn perthynas â’r ddogfen hon, mae
Archwilydd Cyffredinol Cymru a Swyddfa Archwilio Cymru yn drydydd partïon perthnasol. Dylid anfon unrhyw ymholiadau ynglŷn â datgelu neu ailddefnyddio’r ddogfen hon i Swyddfa Archwilio Cymru yn
We welcome correspondence and telephone calls in Welsh and English. Corresponding in Welsh will not lead to delay. Rydym yn croesawu gohebiaeth a galwadau ffôn yn Gymraeg a Saesneg. Ni fydd
gohebu yn Gymraeg yn arwain at oedi.
Fflur Jones oedd y sawl a gyflawnodd y gwaith.
Cynnwys
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Adroddiad cryno
Cyflwyniad 4
Crynodeb o’r canfyddiadau 5
Argymhellion 6
Adroddiad manwl
Mae’r Ymddiriedolaeth wedi croesawu’r cyfleoedd a gynigiwyd gan Ddeddf Llesiant Cenedlaethau’r Dyfodol, ond mae’n gwybod bod yn rhaid iddi wneud mwy i ymwreiddio’r egwyddor datblygu cynaliadwy yn ei ffyrdd o weithio 7
Er nad yw’n gorff rhagnodedig yn y Ddeddf, mae’r Ymddiriedolaeth yn cydnabod y manteision o integreiddio’r egwyddor datblygu cynaliadwy yn ei ffyrdd o weithio 7
Gall yr Ymddiriedolaeth ddangos enghreifftiau o waith cynllunio gwasanaethau cynaliadwy, ond nid yw’n cymhwyso’r egwyddor datblygu cynaliadwy yn systematig eto 9
Er gwaethaf capasiti cyfyngedig, mae’r Ymddiriedolaeth a’i chorff comisiynu yn datblygu eu dulliau fel bod yr Ymddiriedolaeth yn manteisio i’r eithaf ar gyfleoedd y Ddeddf 12
Atodiadau
Atodiad 1 – ein dull 14
Atodiad 1 – Sylwadau Blwyddyn Un 14
Atodiad 2 – ymateb rheolwyr yr Ymddiriedolaeth i’r argymhellion 16
Adroddiad cryno
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Cyflwyniad 1 Nod Deddf Llesiant Cenedlaethau’r Dyfodol (Cymru) 2015 (y Ddeddf) yw creu
Cymru yr ydym ni oll eisiau byw ynddi, nawr ac yn y dyfodol. Mae’r Ddeddf yn nodi sut y mae’n rhaid i 44 o gyrff cyhoeddus penodedig weithio, a gweithio gyda’i gilydd, i wella ymgymeriad â datblygu cynaliadwy, a ddiffinnir fel:
‘y broses o wella llesiant economaidd, cymdeithasol, amgylcheddol a diwylliannol Cymru drwy weithredu yn unol â’r egwyddor datblygu cynaliadwy, gan anelu at gyrraedd y nodau llesiant.’
Mae cyrff cyhoeddus sydd wedi eu cynnwys o dan y Ddeddf (cyrff rhagnodedig) yn cynnwys llywodraeth genedlaethol, llywodraeth leol, byrddau iechyd lleol, awdurdodau tân ac achub, parciau cenedlaethol a rhai cyrff noddedig. Mae’n rhaid iddynt bennu amcanion llesiant a chymryd pob cam rhesymol i’w bodloni wrth ymgymryd â datblygu cynaliadwy.
2 Mae’r Ddeddf yn diffinio’r egwyddor datblygu cynaliadwy fel; ‘gweithredu mewn modd sy’n ceisio sicrhau bod anghenion y presennol yn cael eu hateb heb gyfaddawdu â gallu cenedlaethau’r dyfodol i gyfarfod â’u hanghenion eu hunain’.
3 Er mwyn gweithredu yn y modd hwn, mae’n rhaid i gyrff cyhoeddus gymryd y ‘pum dull o weithio’ i ystyriaeth. Dyma nhw: • Edrych i’r tymor hir fel nad ydynt yn peryglu gallu cenedlaethau’r dyfodol i
ddiwallu eu hanghenion eu hunain; • Mabwysiadu dull integredig fel eu bod yn ystyried yr holl nodau llesiant wrth
benderfynu ar eu hamcanion llesiant; • Cynnwys amrywiaeth o’r boblogaeth yn y penderfyniadau sy’n effeithio
arnynt; • Gweithio ag eraill mewn ffordd gydweithredol i ddod o hyd i atebion
cynaliadwy a rennir; a • Deall yr achosion sydd wrth wraidd problemau i’w hatal rhag digwydd neu
waethygu.1 Yn y modd hwn, nod y Ddeddf yw gwella’r hyn y mae cyrff cyhoeddus yn ei wneud a’r ffordd y maent yn ei wneud fel y gallant wella llesiant Cymru ar y cyd.
4 Mae Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru (yr Ymddiriedolaeth) yn gweithredu fel gwasanaeth a gomisiynir. Comisiynir ei gwasanaethau gan saith Bwrdd Iechyd Cymru a Phrif Gomisiynydd y Gwasanaethau Ambiwlans. Mae’r rhain yn ffurfio’r Pwyllgor Gwasanaethau Ambiwlans Brys. Mae’r saith Bwrdd Iechyd yn gyrff rhagnodedig o dan y Ddeddf, ond nid yw’r Ymddiriedolaeth.
1 Llywodraeth Cymru, Rhannu Pwrpas: Rhannu Dyfodol Canllawiau Statudol ar Ddeddf Llesiant Cenedlaethau’r Dyfodol (Cymru) 2015, 2016
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5 Fodd bynnag, mae’r Ymddiriedolaeth wedi ymrwymo i weithio yn unol ag ysbryd y Ddeddf. Mae hyn yn cynnwys mabwysiadu’r egwyddor datblygu cynaliadwy i wella’r ffordd y mae’n gweithio, gan gynnwys sut y gall gyfrannu at lesiant gwasanaeth cyhoeddus a phoblogaeth ehangach.
6 Yn rhan o’i raglen o waith archwilio perfformiad lleol yn yr Ymddiriedolaeth, mae Archwilydd Cyffredinol Cymru wedi cynnal adolygiad o ddull yr Ymddiriedolaeth o ddefnyddio’r egwyddor datblygu cynaliadwy er mwyn helpu i siapio ei waith cynllunio busnes a darparu gwasanaethau. Mae’r adolygiad yn cynnig adborth i hysbysu dull yr Ymddiriedolaeth yn y dyfodol. Dylid ei ddarllen ochr yn ochr â ‘Sylwadau Blwyddyn Un’ ehangach yr Archwilydd Cyffredinol ar y cynnydd sy’n cael ei wneud gan y 44 corff rhagnodedig o ran gweithredu gofynion y Ddeddf.
7 Mae Atodiad 1 yn cynnig rhagor o wybodaeth am ein dull archwilio yn ogystal â manylion cryno am waith Sylwadau Blwyddyn Un ehangach yr Archwilydd Cyffredinol.
Crynodeb o’r canfyddiadau 8 Mae’r Ymddiriedolaeth wedi cydnabod y cyfleoedd a’r manteision a gynigir gan y
Ddeddf a’r egwyddor datblygu cynaliadwy er gwaethaf y ffaith nad yw’n ofynnol iddi gydymffurfio â nhw. Mae aelodau’r Tîm Gweithredol a’r Bwrdd ehangach wedi dweud bod yr egwyddor datblygu cynaliadwy yn cynnig cyfleoedd i’r sefydliad weithio mewn ffordd integredig gyda phartneriaid i wella gwasanaethau i bobl Cymru.
9 Mae’r Ymddiriedolaeth yn cydnabod ei bod ar gam cynnar o ran sefydlu ei ddull. Mae wedi archwilio yn ystod 2017 sut y gall gymhwyso’r egwyddor datblygu cynaliadwy. Mae wedi gwneud hyn wrth ddrafftio ei strategaeth amgylcheddol, ei rhaglen ystadau amlinellol strategol a sut y mae’n ymgysylltu ag agenda ehangach Byrddau Gwasanaethau Cyhoeddus.
10 Nid yw’r Ymddiriedolaeth wedi cymhwyso’r egwyddor datblygu cynaliadwy yn systematig ar draws y ffordd y mae’n cynllunio ac yn rhedeg ei gwasanaeth eto. Mae’r ffaith nad yw’r Ymddiriedolaeth yn gorff rhagnodedig yn y Ddeddf yn rhoi mwy o amser iddi ystyried ei dull. Fodd bynnag, o gofio ei hymrwymiad i ddefnyddio cyfleoedd a gynigir gan y Ddeddf, dylai’r Ymddiriedolaeth gynnal momentwm o ran bwrw ymlaen â’i chynlluniau. Mae’r Ymddiriedolaeth wedi sefydlu amcanion cydweithredol ar sail meysydd allweddol lle mae’r Ymddiriedolaeth yn dymuno gweithio mewn partneriaeth i gyflawni ei nodau. Mae’r Ymddiriedolaeth hefyd wedi ymrwymo i adolygu ei hamcanion corfforaethol yn 2018-19 i gymryd yr egwyddor datblygu cynaliadwy a’r cynllun strategol ar gyfer GIG Cymru i ystyriaeth.2
2 ‘Cymru Iachach: ein Cynllun Iechyd a Gofal Cymdeithasol’ a gyhoeddwyd ym mis Mehefin 2018
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11 Mae cyfyngiadau capasiti yn debygol o fod yn rhwystr posibl i’r Ymddiriedolaeth, o ran mabwysiadu’r egwyddor datblygu cynaliadwy yn fewnol ac o ran ei gallu i ymgysylltu’n ystyrlon â phartneriaid lluosog, er enghraifft y rheini yn y Byrddau Gwasanaethau Cyhoeddus. O gofio ei statws fel corff nad yw’r rhagnodedig, bydd angen i’r Ymddiriedolaeth fabwysiadu dull pragmatig sy’n cydbwyso materion capasiti ac adnoddau gyda’r manteision a allai ddeillio o fabwysiadu’r egwyddor datblygu cynaliadwy ac ymgysylltu cysylltiedig ag asiantaethau partner.
12 Dylai’r bwriadau comisiynu a gyflwynir i’r Ymddiriedolaeth gan y Pwyllgor Gwasanaethau Ambiwlans Brys helpu i siapio a hysbysu cynlluniau’r Ymddiriedolaeth. Mae’r Pwyllgor Gwasanaethau Ambiwlans Brys yn bwriadu cynnwys egwyddorion datblygu cynaliadwy yn ei fwriadau comisiynu o 2019-20 ac mae’r Ymddiriedolaeth wedi mynegi ei hymrwymiad i weithio yn unol â’r bwriadau hyn.
13 Caiff y canfyddiadau hyn eu harchwilio’n fwy manwl isod.
Argymhellion 14 Nid yw’n ofynnol i’r Ymddiriedolaeth gydymffurfio â Deddf Llesiant Cenedlaethau’r
Dyfodol. O ystyried ei bwriad datganedig i weithredu yn unol ag ysbryd y Ddeddf, gallai ei chael yn ddefnyddiol gweithredu’r argymhellion canlynol.
Arddangosyn 1: argymhellion
Argymhellion
A1 Dylai’r Ymddiriedolaeth fod yn ofalus i beidio ag ôl-weithredu ei gwaith a’i chynllunio i’r egwyddor datblygu cynaliadwy. Dylai gymryd camau rhesymol i sicrhau bod yr egwyddor datblygu cynaliadwy yn cael ei hystyried yn gynnar a thrwy gydol ei phrosesau cynllunio. Gallai’r Ymddiriedolaeth ystyried cynnwys cymhellion yn ei thempledi cynllunio mewnol er mwyn helpu i gyflawni hyn.
A2 Dylai’r Ymddiriedolaeth nodi’r hyn y byddai llwyddiant o ran gweithio yn unol ag ysbryd y Ddeddf yn ei olygu i’r sefydliad. Gellid cynnwys hyn yn rhai o ddogfennau corfforaethol allweddol yr Ymddiriedolaeth, er enghraifft ei Chynllun Tymor Canolig Integredig a’i strategaeth hirdymor, a allai hefyd gynorthwyo i ehangu dealltwriaeth o’r Ddeddf ymhlith y staff.
A3 O gofio cyfyngiadau capasiti a’i statws fel corff nad yw’n rhagnodedig yn y Ddeddf, dylai’r Ymddiriedolaeth reoli disgwyliadau ymhlith ei phartneriaid ynghylch i ba raddau y gall gymryd rhan ystyrlon mewn trafodaethau ar lefel Bwrdd Gwasanaethau Cyhoeddus. Dylai hyn gynnwys cyfathrebu’n eglur y costau a’r manteision sy’n gysylltiedig â gweithio partneriaeth o’r fath.
Adroddiad manwl
Tudalen 7 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Mae’r Ymddiriedolaeth wedi croesawu’r cyfleoedd a gynigiwyd gan Ddeddf Llesiant Cenedlaethau’r Dyfodol, ond mae’n gwybod bod yn rhaid iddi wneud mwy i ymwreiddio’r egwyddor datblygu cynaliadwy yn ei ffyrdd o weithio
Er nad yw’n gorff rhagnodedig yn y Ddeddf, mae’r Ymddiriedolaeth yn cydnabod y manteision o integreiddio’r egwyddor datblygu cynaliadwy yn ei ffyrdd o weithio 15 Gwnaed ymdrech gennym i ddeall safbwynt yr Ymddiriedolaeth o’r egwyddor
Datblygu Cynaliadwy a’r hyn y mae’n ei olygu i’r staff. Gofynnwyd gennym ‘Sut fyddech chi’n disgrifio’r egwyddor datblygu cynaliadwy a’r hyn y mae’n ei olygu i’ch sefydliad?’ ac i ddethol y categorïau canlynol yr oedd yn credu eu bod yn berthnasol: • Gwrthdyniad • Diangen • Cyfle • Rheidrwydd
16 Dangosodd yr Ymddiriedolaeth yn eglur yn ei hymateb ei bod o’r farn bod yr egwyddor yn cynnig ‘cyfle’ i helpu’r sefydliad ‘fynd i’r afael â rhai o’r heriau sylweddol y mae’n eu hwynebu’ a ‘darparu gwasanaethau mwy cynaliadwy a gwell canlyniadau i ddinasyddion’.
17 Mae’r Ymddiriedolaeth wedi mynegi safbwynt y gall cynllunio gwasanaethau yn unol â’r egwyddor datblygu cynaliadwy wella’r ddarpariaeth o wasanaethau. Mae’r Ymddiriedolaeth yn gorff llai sy’n gweithio fel rhan o system gwasanaethau cyhoeddus ehangach. Mae o’r farn bod yr egwyddor datblygu cynaliadwy yn ei helpu i symud y tu hwnt i’w ffyrdd traddodiadol o weithio tuag at ffordd fwy arloesol ac integredig o ddarparu gwasanaethau sydd o fudd i’r defnyddiwr.
18 Mae safbwyntiau’r Ymddiriedolaeth yn debyg i’r rheini a fynegwyd i ni gan lawer o’r cyrff rhagnodedig o dan y Ddeddf3 yn rhan o’n gwaith casglu tystiolaeth ar gyfer Sylwadau Blwyddyn Un yr Archwilydd Cyffredinol. Roedd disgrifiadau’r cyrff cyhoeddus o’r Ddeddf yn gadarnhaol ar y cyfan ac roedd y mwyafrif o’r farn bod gan y Ddeddf y potensial i wella ‘cynllunio strategol a gwneud penderfyniadau’ ac i ‘ysgogi newid cadarnhaol i ddiwylliant ac ymddygiad’.
3 Darparwyd yr ymateb hwn gan yr Ymddiriedolaeth yng nghyswllt y Ddeddf yn hytrach na’i hegwyddor datblygu cynaliadwy yn benodol.
Tudalen 8 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
19 Dywedodd cyrff iechyd eraill hefyd sut y gall y Ddeddf ychwanegu gwerth trwy annog golwg ehangach ar sut i wella iechyd y boblogaeth, gan gynnwys trwy fynd i’r afael ag anghydraddoldebau iechyd a chynyddu’r pwyslais ar waith ataliol. Roeddent o’r farn bod y Ddeddf yn bwysig i ysgogi ymateb cyfunol i’r heriau hyn. Yn yr un modd, nododd awdurdodau tân ac achub sut y mae’r Ddeddf yn cynnig cyfle i gryfhau cydweithrediad a chynyddu gwaith ataliol.
20 Aeth rhai cyrff cyhoeddus ymhellach gan ddweud eu bod o’r farn bod y Ddeddf yn ‘rheidrwydd’. Roedd cyrff iechyd, llywodraeth ganolog a chyrff noddedig ac awdurdodau tân ac achub yn fwy tebygol, yn gymesur, o’i disgrifio fel hyn. Roedd hyn yn tueddu i fod oherwydd eu bod yn teimlo y gallai’r Ddeddf helpu i ddarparu gwasanaethau mwy cynaliadwy a gwell canlyniadau i ddinasyddion.
21 Mae’r Ymddiriedolaeth yn dweud bod y newidiadau y mae’n bwriadu eu gwneud o ran yr egwyddor datblygu cynaliadwy yn ‘weddnewidiol’. Mae’n cydnabod ei fod ar gam cynnar o sefydlu ac ymwreiddio ei dull. Mae’r Ymddiriedolaeth wedi ymrwymo i ddefnyddio’r llwyfan a grëwyd gan y Ddeddf i wneud newidiadau sylweddol i’r ffordd y mae’n darparu gwasanaethau ac i’r ffordd y mae’n gweithio gyda phartneriaid.
22 Mae’r Ymddiriedolaeth yn gwybod nad yw’n ddichonol nac yn ddymunol parhau i ddarparu gwasanaethau yn yr un ffordd â nawr o ystyried y cyfyngiadau ariannol a'r galw cynyddol sy’n wynebu pob corff iechyd. Mae’r Ymddiriedolaeth wedi mynegi ymrwymiad i ymateb i anghenion newidiol cymdeithas mewn ffordd fwy prydlon, gyda phwyslais ar reoli galw, gwella iechyd, cynnal annibyniaeth a sicrhau bod gan ei staff y sgiliau gorau posibl i ddarparu gofal lefel uwch yn y gymuned.
Tudalen 9 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Gall yr Ymddiriedolaeth ddangos enghreifftiau o waith cynllunio gwasanaethau cynaliadwy, ond nid yw’n cymhwyso’r egwyddor datblygu cynaliadwy yn systematig eto 23 Yn ei Gynllun Tymor Canolig Integredig 2017-20, nododd yr Ymddiriedolaeth ei
huchelgais deublyg o fod yn ‘wasanaeth a arweinir yn glinigol ac sy’n weithredol effeithiol’. Nododd ymrwymiad hefyd i wella gwasanaethau yn unol â’i gweledigaeth o fod yn ‘wasanaeth ambiwlans blaenllaw sy’n darparu’r gofal gorau posibl.’ Ymrwymodd yr Ymddiriedolaeth yn y Cynllun Tymor Canolig Integredig i ymgysylltu â’r Ddeddf i ddatblygu ei hymatebion strategol i newidiadau rhagweledig i’r boblogaeth yn well.
24 Mae’r Ymddiriedolaeth wedi gwneud cynnydd yn erbyn y cynlluniau a amlinellwyd yn ei Chynllun Tymor Canolig Integredig. Er enghraifft, datblygodd yr Ymddiriedolaeth amcanion cydweithredol mewn sawl maes allweddol lle mae’n teimlo bod yn rhaid iddi weithio gyda phartneriaeth i gyflawni ei nodau, sef: • Ystadau • Hyfforddiant ac iechyd galwedigaethol • Y berthynas rhwng gwasanaethau tân ac ambiwlans
25 Mae’r Ymddiriedolaeth wedi ymrwymo i fynd ar drywydd yr amcanion hyn dros y tymor canolig i’r hirdymor ac mae’n gobeithio y bydd yn sicrhau canlyniadau gwell trwy ganolbwyntio ei gweithgarwch ar weithio mewn partneriaeth. Mae’r Ymddiriedolaeth hefyd wedi ymrwymo i fireinio ei hamcanion corfforaethol trwy gymhwyso’r egwyddor datblygu cynaliadwy a thrwy ystyried y cynllun strategol ar gyfer GIG Cymru.
26 Roedd yn ofynnol i gyrff cyhoeddus a ragnodwyd o dan y Ddeddf bennu eu hamcanion llesiant cyntaf yn 2017. Mae ein Sylwadau Blwyddyn Un yn amlygu dulliau amrywiol o bennu amcanion ymhlith y cyrff a ragnodwyd o dan y Ddeddf. Mae hefyd yn nodi sylw gan Gomisiynydd Cenedlaethau’r Dyfodol bod ‘cyrff cyhoeddus yn ymrwymo i amcanion llesiant sy’n lled debyg i’r amcanion corfforaethol y byddent wedi eu pennu cyn 2017’.
27 Mae ffyrdd eraill y mae’r Ymddiriedolaeth wedi mynd ati i wneud newidiadau wrth geisio cyflawni ei nod o weithio gan fabwysiadu’r egwyddor datblygu cynaliadwy yn cynnwys: • Polisi Datblygu Cynaliadwy’r Ymddiriedolaeth: Drafftiwyd yn 2017. Mae’r
polisi yn disgrifio datblygu cynaliadwy fel ‘un o’r egwyddorion sy’n llywio proses cynllunio strategol a gweithredol yr Ymddiriedolaeth’ ac yn cydnabod y manteision y gall eu cael i’w pholisïau a’i harferion; a
• Sesiynau Datblygu’r Bwrdd: Yn ystod 2017, cododd yr Ymddiriedolaeth ymwybyddiaeth o’r Ddeddf a’r egwyddor datblygu cynaliadwy ymhlith aelodau’r Bwrdd a’r Tîm Gweithredol trwy ddwy sesiwn Datblygu’r Bwrdd. Roedd Comisiynydd Cenedlaethau’r Dyfodol yn bresennol yn un sesiwn ac
Tudalen 10 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
ystyriodd yr aelodau y ffyrdd y gall yr Ymddiriedolaeth gyfrannu at fodloni saith nod llesiant Cymru.
28 Tynnodd yr Ymddiriedolaeth sylw hefyd at enghreifftiau o’i waith presennol sy’n cyd-fynd ag ysbryd yr egwyddor datblygu cynaliadwy a’r pum dull o weithio. Er nad yw’r egwyddor datblygu cynaliadwy wedi cael ei defnyddio’n bendant fel ysgogwr ar gyfer yr enghreifftiau hyn, maent yn dangos ystyriaeth o rai o’r pum dull o weithio gan gynnwys integreiddio ac atal. Roedd yr enghreifftiau yn cynnwys:
Datblygiad Gwasanaeth Perthnasedd i’r pum dull o weithio Optimeiddio’r ystâd trwy weithio’n agos gyda’r awdurdodau tân ac achub, fel yr Orsaf Tân ac Ambiwlans gyfunol yn Wrecsam.
Cydweithrediad, hirdymor
Achrediad llawn i System Rheoli Amgylcheddol safonol ISO14001:2004 ym mis Awst 2016, y bwriedir iddi wella effeithlonrwydd a lleihau gwastraff a defnydd o ynni a’i gost.
Hirdymor, atal
Cyrraedd y Safon Iechyd Corfforaethol Aur am ei hymrwymiad i wella iechyd a llesiant ei staff ym mis Ionawr 2018.
Hirdymor, atal
Lleihau galw’r rheini sy’n galw am y gwasanaeth yn aml trwy weithio gyda sefydliadau iechyd a goleuadau glas partner a’r unigolion eu hunain. Cydnabuwyd y gwaith hwn trwy Wobr GIG Cymru yn 2016.
Atal, cydweithredu, cyfranogiad
Cyflwyno’r cynllun parafeddygon cymunedol sy’n golygu bod parafeddygon yn gweithio’n agos gyda darparwyr gofal sylfaenol.
Atal, cydweithredu, integreiddio
Timau ymateb i gwympau. Atal, cydweithredu Rhoi clinigwyr mewn ystafelloedd galwadau’r heddlu i leihau’r galw am wasanaethau ambiwlans brys.
Cydweithredu, integreiddio, atal
29 Llywodraethir darpariaeth o wasanaethau’r Ymddiriedolaeth gan Comisiynu
Cydweithredol Cenedlaethol: Cytundeb Fframwaith Ansawdd a Chyflawni 2015-18 (y Fframwaith) ar gyfer gwasanaethau ambiwlans yng Nghymru. Cytundeb rhwng byrddau iechyd a’r Ymddiriedolaeth ar feysydd darparu gwasanaethau allweddol yw’r Fframwaith, ac mae’n nodi manylion yr hyn sy’n ofynnol gan yr Ymddiriedolaeth a sut y dylai’r Ymddiriedolaeth fodloni’r gofynion.
30 Mae’r Fframwaith wedi ei osod o fewn llwybr sy’n canolbwyntio ar y dinesydd ac yn disgrifio model pum cam ar gyfer darparu gwasanaethau ambiwlans brys yng Nghymru. Bwriedir i’r model hwn annog a galluogi cleifion i gael mynediad at wasanaethau trwy foddau eraill, mwy priodol cyn i’w hangen ddod yn un brys
Tudalen 11 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
a/neu’n fygythiad i’w bywydau, gan olygu bod angen ymateb gan y gwasanaeth ambiwlans brys.
31 Er nad yw’r egwyddor datblygu cynaliadwy a’r pum dull o weithio wedi eu nodi’n bendant fel ysgogwyr sy’n sail i’r Fframwaith a’r model pum cam, mae eu pwyslais ar ganlyniadau a phrofiad y claf yn hytrach na thargedau perfformiad yn cyd-fynd â’r egwyddor datblygu cynaliadwy a’r pum dull o weithio, yn enwedig cyfranogiad, integreiddio ac atal.
32 Er bod yr enghreifftiau hyn yn dangos sut y mae’r Ymddiriedolaeth yn ystyried cyfleoedd a goblygiadau ehangach yn ystod ei waith cynllunio gwasanaethau, dylai’r Ymddiriedolaeth fod yn ofalus i beidio ag ôl-weithredu ei waith i’r egwyddor datblygu cynaliadwy.
Tudalen 12 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Er gwaethaf capasiti cyfyngedig, mae’r Ymddiriedolaeth a’i chorff comisiynu yn datblygu eu dulliau fel bod yr Ymddiriedolaeth yn manteisio i’r eithaf ar gyfleoedd y Ddeddf
Mae’r Ymddiriedolaeth yn parhau i ddatblygu ei dull o ymwreiddio’r egwyddor datblygu cynaliadwy yn ei dulliau o weithio
33 Mae’r Ymddiriedolaeth yn gwybod bod ei hystyriaethau o ran cymhwyso’r egwyddor datblygu cynaliadwy i’r ffordd y mae’n gweithio ar gam cynnar. Mae capasiti yn ffactor arwyddocaol i’r Ymddiriedolaeth yn fewnol ac o ran ei gwaith partneriaeth. O gofio ei statws fel corff nad yw’n rhagnodedig, nid yw’r Ymddiriedolaeth wedi neilltuo’r un pwyslais a’r un lefel o adnoddau i wneud newidiadau i’w harferion sefydliadol ag aelodau rhagnodedig. Er bod hyn wedi effeithio ar y cyflymder y mae’r Ymddiriedolaeth wedi gwneud newidiadau, roedd y staff i ni siarad â nhw yn fodlon bod y dull hwn yn briodol ac yn gymesur.
34 Nid yw’r Ymddiriedolaeth wedi nodi eto sut y bydd llwyddiant o ran ymwreiddio’r egwyddor datblygu cynaliadwy yn edrych. Efallai y bydd yn canfod y byddai disgrifio’r hyn y byddai llwyddiant o ran gweithio yn unol ag ysbryd y Ddeddf yn ei olygu i’r sefydliad yn ymarfer defnyddiol wrth siapio ei dull.
35 Yn rhan o’n sylwadau blwyddyn un, cyfeiriodd llawer o gyrff rhagnodedig at newidiadau yr oeddent wedi eu gwneud i’w llywodraethiant er mwyn newid eu dulliau o weithio. Roedd llawer o’r rhain yn ymwneud â newidiadau llywodraethu fel diweddaru templedi penderfyniadau neu adroddiadau pwyllgor a thempledi cynllun busnes neu ddiweddaru dogfennau fel y Cyfansoddiad, y Cod Llywodraethu Corfforaethol neu’r Cod Ymddygiad.
36 Mae’r Ymddiriedolaeth wedi cydnabod y gallai ddefnyddio’r pum dull o weithio mewn ffordd fwy pendant wrth gynllunio gwasanaethau. Mae’r Ymddiriedolaeth yn ystyried opsiynau fel gwneud mwy o ddefnydd o dempledi cynllunio i ysgogi syniadau a chyflwyno hyfforddiant i’r staff. Byddai newidiadau o’r fath yn annog cyd-ddealltwriaeth o’r manteision a mwy o ystyriaeth o’r egwyddor datblygu cynaliadwy fel ysgogwr mwy gweledol ar gyfer prosesau cynllunio gwasanaethau a gwneud penderfyniadau ehangach.
37 Mae’r Ymddiriedolaeth wedi cymryd camau yn ystod 2018 i sicrhau bod ei chyfeiriad yn y dyfodol yn cyd-fynd â’r egwyddor datblygu cynaliadwy trwy gynnwys cynrychiolydd o Swyddfa’r Comisiynydd Llesiant Cenedlaethau’r Dyfodol ar y panel rhanddeiliaid wrth recriwtio ei Phrif Weithredwr newydd. Nod y panel oedd profi awydd, dull a phrofiad pob ymgeisydd o ran cydweithrediad a phartneriaeth. Gwnaed hyn gyda’r nod o sicrhau bod yr arweinyddiaeth o fewn yr Ymddiriedolaeth yn cydnabod ac yn croesawu’r cyfleoedd a gynigir gan yr egwyddor datblygu cynaliadwy.
38 Fel corff comisiynu’r Ymddiriedolaeth, mae’r Pwyllgor Gwasanaethau Ambiwlans Brys hefyd yn cydnabod y swyddogaeth sydd ganddo i’w chyflawni i sicrhau bod y
Tudalen 13 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
gwasanaethau y mae’n eu comisiynu gan yr Ymddiriedolaeth ar gyfer eu hardaloedd Bwrdd Iechyd priodol yn cyd-fynd â’r egwyddor datblygu cynaliadwy.
39 Bob blwyddyn, mae’r Pwyllgor Gwasanaethau Ambiwlans Brys yn cyflwyno bwriadau comisiynu i’r Ymddiriedolaeth y mae’n rhaid iddi eu halinio â’r camau yn ei Chynllun Tymor Canolig Integredig a’u cyflwyno i Lywodraeth Cymru. Mae Prif Gomisiynydd y Gwasanaethau Ambiwlans yn cynllunio i’r Pwyllgor Gwasanaethau Ambiwlans Brys ymwreiddio’r egwyddor datblygu cynaliadwy yn y gyfres nesaf o fwriadau comisiynu strategol ar gyfer 2019-20. Mae’r Ymddiriedolaeth wedi nodi ei hymrwymiad i weithio tuag at ofynion newydd yn y bwriadau comisiynu sy’n ymwneud â’r egwyddor datblygu cynaliadwy.
Mae’r Ymddiriedolaeth yn parhau i ystyried cyfleoedd i gymhwyso’r egwyddor datblygu cynaliadwy yn fwy eglur mewn gwaith partneriaeth
40 Ar adeg y gwaith maes, roedd yr Ymddiriedolaeth yn ystyried yr opsiynau a oedd ar gael iddi o ran gwaith partneriaeth yn unol ag ysbryd yr egwyddor datblygu cynaliadwy.
41 Ym mis Ionawr 2018, sefydlodd yr Ymddiriedolaeth Fforwm Cynllunio a Phartneriaethau Strategol mewnol sy’n cyfarfod bob chwe wythnos. Mae aelodau o’r fforwm hwn yn cynnwys y Cyfarwyddwr Meddygol, y Cyfarwyddwr Cynllunio a Pherfformiad a’r Cyfarwyddwr Ansawdd, Diogelwch a Phrofiad Cleifion. Mae’r fforwm yn cynnig llwyfan i aelodau staff allweddol drafod gwaith partneriaeth, gan gynnwys cyfleoedd i ymgysylltu â phartneriaid o dan y Ddeddf Gwasanaethau Cymdeithasol a Llesiant a Deddf Llesiant Cenedlaethau’r Dyfodol.
42 Yn fwy penodol, cytunodd Tîm Gweithredol yr Ymddiriedolaeth ddull y sefydliad o ymgysylltu â Byrddau Gwasanaethau Cyhoeddus ym mis Mawrth 2018, er mwyn cymryd rhan mewn trafodaethau strategol ar y ddarpariaeth o wasanaethau yn y dyfodol. Mae’r Ymddiriedolaeth yn teimlo’n gryf y gall gyfrannu at syniadau creadigol ar gyfer dylunio gwasanaethau a allai helpu i fodloni amcanion llesiant ledled Cymru. Fodd bynnag, mae capasiti’r Ymddiriedolaeth i ymgysylltu â phob un o’r Byrddau Gwasanaethau Cyhoeddus yn creu her sylweddol.
43 Mae’r Ymddiriedolaeth wedi ystyried sut orau y gallai ddefnyddio ei hadnoddau mewn ffordd sy’n cynnig gwerth i’r Ymddiriedolaeth ac i Fyrddau Gwasanaethau Cyhoeddus wrth gyflawni’r ddyletswydd llesiant. Mae wedi cytuno i dreialu cyfranogiad mewn pedwar Bwrdd Gwasanaethau Cyhoeddus yn ystod 2018, ar ôl iddi benderfynu pa bedwar Bwrdd Gwasanaethau Cyhoeddus sy’n cynnig y cyfle mwyaf i ychwanegu gwerth. Ei nod yw gwerthuso ei dull a’r fantais a’r effaith a geir yn ystod 2019-20.
Atodiad 1
Tudalen 14 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Ein dull 44 Gwnaed ymdrech gennym ar gyfer yr adolygiad hwn i ddeall safbwyntiau’r
Ymddiriedolaeth ar yr egwyddor datblygu cynaliadwy; yr hyn y mae staff allweddol yn ei gredu y mae gweithio yn unol ag ysbryd y Ddeddf yn ei olygu iddyn nhw; a sut y maent yn dechrau ymwreiddio’r egwyddor datblygu cynaliadwy.
45 Ystyriwyd y cwestiynau canlynol gennym yn benodol: • I ba raddau y mae’r Ymddiriedolaeth yn credu bod yr egwyddor datblygu
cynaliadwy o fudd i’r sefydliad? • Pa gamau allweddol y mae’r Ymddiriedolaeth wedi eu cymryd i ymwreiddio’r
egwyddor datblygu cynaliadwy yn ei hamcanion strategol a gweithredol a’r ffordd y mae’n gweithio?
• Beth mae’r Ymddiriedolaeth yn ei wneud i nodi cyfleoedd pellach i ymwreiddio’r egwyddor datblygu cynaliadwy yn y sefydliad ar gyfer y dyfodol?
• Beth mae’r Ymddiriedolaeth yn ei wneud i nodi cyfleoedd i weithio gyda phartneriaid ac i gyfrannu’n fwy eang at y ddarpariaeth o ddyletswydd llesiant gwasanaethau cyhoeddus?
46 Mabwysiadwyd dull tebyg gennym ni ar gyfer ein hadolygiad i’r un a fabwysiadwyd ar gyfer Sylwadau Blwyddyn Un Swyddfa Archwilio Cymru (isod). Gofynnwyd i’r Ymddiriedolaeth ymateb i ‘alwad am dystiolaeth’ a oedd yn cynnig cyfle i’r staff ddweud wrthym am y gwaith y maent yn ei wneud. Cyfwelwyd nifer o Gyfarwyddwyr Gweithredol a’r Prif Gomisiynydd y Gwasanaethau Ambiwlans gennym hefyd ac adolygwyd dogfennau allweddol, fel y Cynllun Tymor Canolig Integredig4.
Sylwadau Blwyddyn Un 47 Mae’n ofyniad statudol i Archwilydd Cyffredinol Cymru (yr Archwilydd Cyffredinol)
archwilio cyrff cyhoeddus a ragnodwyd gan y Ddeddf i asesu i ba raddau y maent wedi gweithredu yn unol â’r egwyddor datblygu cynaliadwy wrth:
a) bennu eu hamcanion llesiant; a b) cymryd camau i’w bodloni.
48 Yn 2017-18, penderfynodd yr Archwilydd Cyffredinol ymgymryd â darn rhagarweiniol o waith cyn cychwyn ei archwiliadau ffurfiol. Adnabyddir y gwaith hwn fel Sylwadau Blwyddyn Un, a gyhoeddwyd ym mis Mai 2018.5
4 Cynllun Tymor Canolig Integredig 2017-20 ac iteriadau 2018-21 5 ‘Myfyrio ar Flwyddyn Un’ Swyddfa Archwilio Cymru
Tudalen 15 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
49 Mae’r adroddiad Sylwadau Blwyddyn Un yn darparu sylwadau’r Archwilydd Cyffredinol ar sut y mae cyrff cyhoeddus rhagnodedig wedi ymateb i’r Ddeddf yn y flwyddyn gyntaf. Mae’n rhoi rhywfaint o adborth cynnar, heb ragnodi disgwyliadau o ran sut y dylai cyrff cyhoeddus rhagnodedig fod yn cyflawni eu cyfrifoldebau newydd.
Atodiad 2
Tudalen 16 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Ymateb rheolwyr yr Ymddiriedolaeth i’r argymhellion
Arddangosyn 2: ymateb y rheolwyr
Mae’r tabl canlynol yn nodi argymhellion 2018 ac ymateb y rheolwyr.
Cyf Argymhelliad Canlyniad/ mantais a fwriadwyd
Blaenoriaeth uchel (ydy/nac ydy)
Derbyniwyd (do/naddo)
Ymateb rheolwyr Dyddiad cwblhau
Swyddog cyfrifol
A1 Dylai’r Ymddiriedolaeth fod yn ofalus i beidio ag ôl-weithredu ei gwaith a’i chynllunio i’r egwyddor datblygu cynaliadwy. Dylai gymryd camau rhesymol i sicrhau bod yr egwyddor datblygu cynaliadwy yn cael ei hystyried yn gynnar a thrwy gydol ei phrosesau cynllunio. Gallai’r Ymddiriedolaeth ystyried cynnwys cymhellion yn ei thempledi cynllunio mewnol er mwyn helpu i gyflawni hyn.
Sicrhau bod yr Ymddiriedolaeth yn sicrhau’r manteision mwyaf posibl o ddefnyddio’r egwyddor datblygu cynaliadwy i ysgogi newidiadau i’w harferion cynllunio mewnol ac allanol.
Ydy Do Bydd yr Ymddiriedolaeth yn sicrhau bod prosesau datblygu’r CDLl a’r Cynllun Tymor Canolig Integredig yn cynnwys cyfleoedd a chymhellion eglur yn eu templedi a’u canllawiau i sicrhau bod cydweithwyr yn ystyried yr egwyddor datblygu cynaliadwy yn eu cynlluniau byrdymor, tymor canolog a thymor hwy.
Mawrth 2019 Y Cyfarwyddwr Cynllunio a Pherfformiad
Tudalen 17 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Cyf Argymhelliad Canlyniad/ mantais a fwriadwyd
Blaenoriaeth uchel (ydy/nac ydy)
Derbyniwyd (do/naddo)
Ymateb rheolwyr Dyddiad cwblhau
Swyddog cyfrifol
A2 Dylai’r Ymddiriedolaeth nodi’r hyn y byddai llwyddiant o ran gweithio yn unol ag ysbryd y Ddeddf yn ei olygu i’r sefydliad. Gellid cynnwys hyn yn rhai o ddogfennau corfforaethol allweddol yr Ymddiriedolaeth, er enghraifft ei Chynllun Tymor Canolig Integredig a’i strategaeth hirdymor, a allai hefyd gynorthwyo i ehangu dealltwriaeth o’r Ddeddf ymhlith y staff.
Mae’r Ymddiriedolaeth wedi nodi a datgan yr hyn y mae’n dymuno ei gyflawni trwy weithio yn unol ag ysbryd y Ddeddf a gall gymryd camau i wireddu’r weledigaeth honno felly.
Ydy Do Bydd yr Ymddiriedolaeth yn sicrhau bod ei strategaeth hirdymor yn cyd-fynd yn eglur â daliadau allweddol Deddf Llesiant Cenedlaethau’r Dyfodol. Bydd y Cynllun Tymor Canolig Integredig o 2019-20 ymlaen yn nodi’n eglur ymrwymiad yr Ymddiriedolaeth i’r Ddeddf, y ffyrdd y bydd unrhyw gynlluniau diwygiedig yn adlewyrchu egwyddorion y Ddeddf a’r canlyniadau gwirioneddol y mae’r Ymddiriedolaeth yn eu rhagweld o ganlyniad i’r dull hwn. Bydd hyn yn cael ei adlewyrchu yng nghrynodeb y Cynllun Tymor Canolig Integredig ac unrhyw gyfathrebu cysylltiedig gyda staff a rhanddeiliaid.
Mawrth 2019 Y Cyfarwyddwr Partneriaethau ac Ymgysylltu
Tudalen 18 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Cyf Argymhelliad Canlyniad/ mantais a fwriadwyd
Blaenoriaeth uchel (ydy/nac ydy)
Derbyniwyd (do/naddo)
Ymateb rheolwyr Dyddiad cwblhau
Swyddog cyfrifol
A3 O gofio cyfyngiadau capasiti a’i statws fel corff nad yw’n rhagnodedig yn y Ddeddf, dylai’r Ymddiriedolaeth reoli disgwyliadau ymhlith ei phartneriaid ynghylch i ba raddau y gall gymryd rhan ystyrlon mewn trafodaethau ar lefel Bwrdd Gwasanaethau Cyhoeddus. Dylai hyn gynnwys cyfathrebu’n eglur y costau a’r manteision sy’n gysylltiedig â gweithio partneriaeth o’r fath.
Galluogwyd yr Ymddiriedolaeth a’i phartneriaid i fanteisio i’r eithaf ar y cyfleoedd a gynigir gan ei chyfranogiad yn y Byrddau Gwasanaethau Cyhoeddus.
Ydy Do Bydd y Tîm Rheoli Gweithredol yn ailystyried yn ystod hydref 2018 cyfyngiadau capasiti ac eraill y sefydliad ar ei ymgysylltiad â Byrddau Gwasanaethau Cyhoeddus. Yn rhan o’r broses werthuso hon, bydd yr Ymddiriedolaeth yn gofyn am safbwyntiau nifer o bartneriaid allweddol (Byrddau Iechyd, gwasanaethau heddlu, tân ac achub, awdurdodau lleol) i hysbysu ei safbwynt ac i sicrhau bod partneriaid yn ymwybodol o ymrwymiad y sefydliad i Ddeddf Llesiant Cenedlaethau’r Dyfodol ac yn cydnabod yr angen am eiriolaeth ar ran/ystyriaeth o gyfraniad Ymddiriedolaeth Gwasanaethau Ambiwlans Cymru i wahanol
Mawrth 2019 Y Cyfarwyddwr Partneriaethau ac Ymgysylltu
Tudalen 19 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Cyf Argymhelliad Canlyniad/ mantais a fwriadwyd
Blaenoriaeth uchel (ydy/nac ydy)
Derbyniwyd (do/naddo)
Ymateb rheolwyr Dyddiad cwblhau
Swyddog cyfrifol
agendâu/gweithgareddau Byrddau Gwasanaethau Cyhoeddus.
Wales Audit Office 24 Cathedral Road Cardiff CF11 9LJ
Tel: 029 2032 0500 Fax: 029 2032 0600
Textphone: 029 2032 0660
E-mail: [email protected] Website: www.audit.wales
Swyddfa Archwilio Cymru 24 Heol y Gadeirlan Caerdydd CF11 9LJ
Ffôn: 029 2032 0500 Ffacs: 029 2032 0600
Ffôn testun: 029 2032 0660
E-bost: [email protected] Gwefan: www.archwilio.cymru
3.1 Losses and Special Payments Update (Interim Director of Finance and ICT)
1 ITEM 3.1 SBAR Losses and Special Payments Sept 2018.docx
Page 1 of 2
LOSSES AND SPECIAL PAYMENTS - PAYMENTS FOR THE PERIOD FROM 1st APRIL 2018 TO 31st JULY 2018
MEETING Audit Committee
DATE 13th September 2018
EXECUTIVE Director of Finance and ICT (INTERIM)
AUTHOR Financial Accountant
CONTACT DETAILS Chris Turley Tel: 01633 626201
Email: [email protected]
CORPORATE OBJECTIVE IMTP priority objective (s)
CORPORATE RISK (Ref if appropriate)
QUALITY THEME
HEALTH & CARE STANDARD
Health and Care Standard (s)
REPORT PURPOSE Note the contents as per SFI’s
CLOSED MATTER REASON N/A
REPORT APPROVAL ROUTE
WHERE WHEN WHY
Audit Committee 13th September 2018
Note as per SFI’s
AGENDA ITEM No 3.1
OPEN or CLOSED OPEN
No of ANNEXES ATTACHED 1
Page 2 of 2
SITUATION 1. In accordance with SFI’s all losses and special payments made are to be
reported to the Audit Committee on a regular basis. BACKGROUND 2. This report presents to the Committee details of Losses and Special Payments
made during the four months from 1st April 2018 to 31st July 2018 (ANNEX 1).
ASSESSMENT
3. Total Losses and Special Payments made during this period amounted to £0.913 million.
4. This relates to actual payments made, less reimbursements received from the
Welsh Risk Pool and does not relate to any adjustments made to the provision.
5. Payments were particularly large in April as a result of one high value case relating to a joint Health Board liability following a missed opportunity to admit a patient to hospital which contributed towards a long term spinal injury. An interim claim in respect of this case has been made to the Welsh Risk Pool and reimbursement is awaited.
RECOMMENDED: That the Losses and Special Payments Report for this period be received. REPORT CHECKLIST
Issues to be covered Paragraph Number (s) or “Not Applicable”
Equality Impact Assessment NA
Environmental/Sustainability NA
Estate NA
Health Improvement NA
Health and Safety NA
Financial Implications NA
Legal Implications NA
Patient Safety/Safeguarding NA
Risks NA
Reputational NA
Staff Side Consultation NA
1 ITEM 3.1a Annex 1 - Losses Special Payments 2018-19 M1-4 Final.pdf
Welsh Ambulance Services NHS TrustLosses and Special Payments
Summary of payments for the four months to 31st July 2018:£
April 2018 815,991.60
May 2018 27,614.62
June 2018 40,973.07
July 2018 28,357.29
912,936.58
Losses and Special Payments Breakdown:
Payment Type April May June July Aug Sept Oct Nov Dec Jan Feb Mar Total
£ £ £ £ £ £ £ £ £ £ £ £ £
Claimants Solicitor Costs 138,938.80 10,124.00 9,499.15 3,380.00 £161,941.95
Counsel fees 35,850.00 4,720.00 1,210.00 3,255.00 £45,035.00
CRU 1,274.00 1,889.00 637.00 £3,800.00
Damages 621,322.57 2,200.00 20,200.00 4,313.86 £648,036.43
Defence Costs 4,771.24 1,724.89 1,945.76 4,097.12 £12,539.01
Expert Witness 5,212.50 2,150.00 3,000.00 £10,362.50
Vehicle Repairs 8,622.49 16,508.66 5,968.16 10,613.31 £41,712.62
WRP Refund -9,551.93 -939.00 -£10,490.93
Court Refund £0.00
Total £815,991.60 £27,614.62 £40,973.07 £28,357.29 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £912,936.58
Welsh Ambulance Services NHS Trust
Losses and Special PaymentsKey
Total net cost by case MN Medical Negligence case
PI Personal Injury case
DP Damage to Property
£
18RT4PI0029 15,387.28 33 PI cases below £1,000
18RT4DP0029 7,005.79 18 DP cases below £1,000
18RT4MN0005 50.00
16RT4MN0009 250.00
04RT4MN0003 300.00
04RT4MN0003 300.00
18RT4MN0019 400.00
04RT4MN0003 450.00
04RT4MN0003 475.00
04RT4MN0003 550.00
15RT4MN0003 615.00
18RT4MN0020 660.00
16RT4MN0009 900.00
18RT4MN0023 1,300.00
18RT4MN0011 1,300.00
18RT4MN0021 1,300.00
04RT4MN0003 1,525.00
14RT4MN0003 3,000.00
16RT4MN0001 3,180.00
16RT4MN0009 3,700.00
14RT4MN0003 22,950.00
14RT4MN0003 23,223.80
14RT4MN0003 75,000.00
14RT4MN0003 591,291.08
15RT4PI0043 1,150.00
15RT4PI0032 1,155.38
15RT4PI0072 1,240.00
15RT4PI0043 1,250.00
17RT4PI0051 1,296.00
18RT4PI0052 1,344.00
19RT4PI0002 1,344.00
16RT4PI0057 1,705.00
18RT4PI0047 2,157.00
17RT4PI0043 2,200.00
15RT4PI0043 2,212.50
18RT4PI0003 2,419.00
18RT4PI0047 2,500.00
18RT4PI0003 2,900.00
14RT4PI0012 3,780.00
17RT4PI0051 4,000.00
18RT4PI0052 4,200.00
19RT4PI0002 4,200.00
15RT4PI0028 4,313.86
16RT4PI0060 4,347.00
15RT4PI0033 5,000.00
15RT4PI0047 5,000.00
16RT4PI0060 9,300.00
15RT4PI0072 10,000.00
15RT4PI0072 20,000.00
14RT4PI0012 32,000.00
19RT4DP0004 1,020.21
18RT4DP0103 1,054.44
19RT4DP0006 1,284.00
19RT4DP0001 1,425.32
19RT4DP0022 1,575.00
19RT4DP0015 1,811.71
18RT4DP0104 1,954.56
18RT4DP0110 1,961.92
18RT4DP0102 2,000.00
19RT4DP0023 2,243.88
19RT4DP0008 2,313.80
19RT4DP0012 2,350.00
18RT4DP0108 3,756.92
19RT4DP0012 6,320.00
18RT4DP0111 7,371.56
18RT4DP0065 70.00- REFUND OF DEFENCE COSTS
17RT4PI0050 1,012.50- REFUND OF DEFENCE COSTS
17RT4PI0026 60.00- REFUND OF DEFENCE COSTS
15RT4PI0022 9,551.93- WRP REFUND
15RT4PI0068 324.00- WRP REFUND
15RT4MN0003 615.00- WRP Refund
Total 912,936.58
Apr-18
Case Reference Details Type Amount (£)
04RT4MN0003 COUNSEL FEES Actual Payment 1,525.00
04RT4MN0003 COUNSEL FEES Actual Payment 475.00
14RT4DP0061 50% POLICY EXCESS Actual Payment 125.00
14RT4DP0061 GENERAL DAMAGES SETTLEMENT Actual Payment 805.50
14RT4MN0003 COUNSEL FEES Actual Payment 22,950.00
14RT4MN0003 EXPERT WITNESS Actual Payment 3,000.00
14RT4MN0003 GENERAL DAMAGES SETTLEMENT Actual Payment 591,291.08
14RT4MN0003 CLAIMANT'S SOLICITORS FEES Actual Payment 75,000.00
14RT4MN0003 CLAIMANT'S SOLICITORS FEES Actual Payment 23,223.80
14RT4PI0012 COST DRAFTSMAN'S FEES Actual Payment 3,780.00
14RT4PI0012 CLAIMANT'S SOLICITORS FEES Actual Payment 32,000.00
14RT4PI0012 COURT FEES Actual Payment 255.00
14RT4PI0012 COURT FEES Actual Payment 100.00
14RT4PI0044 CRU PAYMENT Actual Payment 627.00
15RT4PI0033 COUNSEL FEES Actual Payment 5,000.00
15RT4PI0043 COUNSEL FEES Actual Payment 1,150.00
15RT4PI0043 EXPERT WITNESS Actual Payment 2,212.50
15RT4PI0047 CLAIMANT'S SOLICITOR'S FEES Actual Payment 5,000.00
15RT4PI0072 COUNSEL FEES Actual Payment 550.00
15RT4PI0072 GENERAL DAMAGES SETTLEMENT Actual Payment 20,000.00
16RT4MN0009 COUNSEL FEES Actual Payment 3,700.00
16RT4PI0040 CRU PAYMENT Actual Payment 647.00
16RT4PI0057 AJOURNMENT FEE Actual Payment 255.00
17RT4PI0007 COUNSEL FEES Actual Payment 200.00
17RT4PI0026 COUNSEL FEES Actual Payment 300.00
17RT4PI0051 GENERAL DAMAGES SETTLEMENT Actual Payment 4,000.00
17RT4PI0051 CLAIMANT'S SOLICITORS FEES Actual Payment 1,296.00
18RT4DP0102 VEHICLE HIRE Actual Payment 2,000.00
18RT4DP0102 POLICY EXCESS Actual Payment 150.00
18RT4DP0104 GENERAL DAMAGES SETTLEMENT Actual Payment 1,954.56
18RT4DP0105 GENERAL DAMAGES SETTLEMENT Actual Payment 371.43
18RT4DP0107 VEHICLE REPAIRS Actual Payment 628.65
18RT4DP0108 VEHICLE REPAIRS Actual Payment 3,756.92
18RT4DP0110 VEHICLE DAMAGE AND COSTS Actual Payment 1,961.92
18RT4PI0003 GENERAL DAMAGES SETTLEMENT Actual Payment 2,900.00
18RT4PI0003 CLAIMANT'S SOLICITORS FEES Actual Payment 2,419.00
18RT4PI0029 ADJOURNMENT FEE Actual Payment 255.00
18RT4PI0033 TRANSCRIPTION COSTS Actual Payment 126.24
Totals 815,991.60
May-18
Case Reference Details Type Amount (£)
04RT4MN0003 COUNSEL FEES Actual Payment 450.00
09RT4PI0008 Professional Fees Actual Payment 620.00
14RT4PI0012 Counsel Fees Actual Payment 1,620.00
14RT4PI0012 Claimant's Solicitor's Fees Actual Payment 1,620.00-
15RT4MN0003 CRU PAYMENT Actual Payment 615.00
15RT4PI0022 WRP Refund Actual Payment 9,551.93-
15RT4PI0033 Professional Fees Actual Payment 908.04
15RT4PI0033 Professional Fees Actual Payment 944.35
15RT4PI0043 Counsel Fees Actual Payment 800.00
15RT4PI0068 CLAIMANTS SOLICITORS Actual Payment 324.00
15RT4PI0072 CRU Payment Actual Payment 637.00
15RT4PI0072 Claimant's Solicitor's Fees Actual Payment 10,000.00
15RT4PI0072 Claimant's Solicitor's Fees Actual Payment 1,240.00
16RT4MN0009 COUNSEL FEES Actual Payment 900.00
16RT4PI0061 COURT FEE Actual Payment 100.00
16RT4PI0068 Counsel Fees Actual Payment 300.00
17RT4PI0043 GENERAL DAMAGES SETTLEMENT Actual Payment 2,200.00
17RT4PI0050 Defendants Costs Refunded Actual Payment 1,012.50-
18RT4DP0053 Court Issuing Claim Fee Actual Payment 115.00
18RT4DP0065 Counsel Fees Actual Payment 350.00
18RT4DP0096 EXCESS Actual Payment 160.00
18RT4DP0103 REPAIRS TO THIRD PARTY VEHICLE Actual Payment 1,054.44
18RT4DP0106 VEHICLE REPAIR Actual Payment 673.02
18RT4DP0109 Witness Expenses Awarded Actual Payment 11.00
18RT4DP0109 Witness Expenses Awarded Actual Payment 11.00-
18RT4DP0110 REPAIRS TO THIRD PARTY VEHICLE Actual Payment 166.35
18RT4DP0111 REPAIR TO ROAD Actual Payment 7,371.56
18RT4MN0005 Transcription Fees Actual Payment 50.00
18RT4PI0008 Counsel Fees Actual Payment 300.00
18RT4PI0029 Claimant's Solicitor's Fees Actual Payment 180.00
18RT4PI0062 CRU PAYMENT Actual Payment 637.00
19RT4DP0001 VEHICLE REPAIR Actual Payment 1,425.32
19RT4DP0001 VEHICLE REPAIRS CN14KYJ 66% Actual Payment 1,084.64
19RT4DP0001 VEHICLE REPAIRS CN14KYJ 66% Actual Payment 1,084.64-
19RT4DP0003 REPAIRS TO THIRD PARTY VEHICLE Actual Payment 654.96
19RT4DP0004 REPAIRS TO THIRD PARTY VEHICLE Actual Payment 1,020.21
19RT4DP0006 REPAIRS TO THIRD PARTY VEHICLE Actual Payment 1,284.00
19RT4DP0007 VEHICLE REPAIR WN63ADO 50% Actual Payment 454.66
19RT4DP0007 VEHICLE REPAIR WN63ADO 50% Actual Payment 454.66-
19RT4DP0008 VEHICLE REPAIRS Actual Payment 2,313.80
19RT4DP0009 REPAIRS TO THIRD PARTY VEHICLE Actual Payment 385.00
19RT4DP0010 VEHICLE REPAIRS WX12CWY 66.6% Actual Payment 5,892.14
19RT4DP0010 VEHICLE REPAIRS WX12CWY 66.6% Actual Payment 5,892.14-
Totals 27,614.62
Jun-18
Case Reference Details Type Amount (£)
04RT4MN0003 EXPERT WITNESS Actual Payment 300.00
04RT4MN0003 EXPERT WITNESS Actual Payment 300.00
04RT4MN0003 COUNSEL FEES Actual Payment 550.00
15RT4PI0032 PROFESSIONAL FEES Actual Payment 1,155.38
15RT4PI0033 PROFESSIONAL FEES Actual Payment 760.38
15RT4PI0043 CLAIMANT'S SOLICITOR'S FEES Actual Payment 57.15
16RT4MN0009 EXPERT WITNESS Actual Payment 250.00
16RT4PI0057 CLAIMANT'S SOLICITOR'S FEES Actual Payment 250.00
16RT4PI0060 GENERAL DAMAGES SETTLEMENT Actual Payment 9,300.00
16RT4PI0060 CLAIMANT'S SOLICITOR'S FEES Actual Payment 4,347.00
17RT4PI0026 Trade Union LLP Payment Rec Actual Payment - 60.00
18RT4DP0065 PAYMENT INTO COURT Actual Payment - 70.00
18RT4DP0065 VEHICLE REPAIRS CN15BRF Actual Payment - 534.30
18RT4MN0020 Counsel Fees Actual Payment 660.00
18RT4MN0023 EXPERT WITNESS Actual Payment 1,300.00
18RT4PI0029 Conference Cancellation Fee Actual Payment 20.00
18RT4PI0047 GENERAL DAMAGES SETTLEMENT Actual Payment 2,500.00
18RT4PI0047 CLAIMANT'S SOLICITOR'S FEES Actual Payment 2,157.00
18RT4PI0052 GENERAL DAMAGES SETTLEMENT Actual Payment 4,200.00
18RT4PI0052 CLAIMANT'S SOLICITOR'S FEES Actual Payment 1,344.00
19RT4DP0011 Court Fee Actual Payment 70.00
19RT4DP0012 Vehicle Value TP Actual Payment 6,320.00
19RT4DP0013 VEHICLE REPAIRS TO CF13HCU Actual Payment 599.19
19RT4DP0013 VEHICLE REPAIRS TO CF13HCU Actual Payment - 599.19
19RT4DP0014 Vehicle Repairs to TP Actual Payment 252.46
19RT4DP0016 VEHICLE REPAIRS WX62JYR Actual Payment 1,252.50
19RT4DP0016 VEHICLE REPAIRS WX62JYR Actual Payment - 1,252.50
19RT4DP0018 VEHICLE REPAIRS CN13CPV Actual Payment 3,407.91
19RT4DP0018 VEHICLE REPAIRS CN13CPV Actual Payment - 3,407.91
19RT4PI0002 CLAIMANT'S SOLICITOR'S FEES Actual Payment 1,344.00
19RT4PI0002 GENERAL DAMAGES SETTLEMENT Actual Payment 4,200.00
Totals 40,973.07
Jul-18
Case Reference Details Type Amount (£)
15RT4MN0003 WRP REFUND Actual Payment - 615.00
15RT4PI0028 GENERAL DAMAGES SETTLEMENT Actual Payment 4,313.86
15RT4PI0031 CRU PAYMENT Actual Payment 637.00
15RT4PI0032 Professional Fees Actual Payment 790.00
15RT4PI0033 Professional Fees Actual Payment 771.50
15RT4PI0043 COUNSEL FEES Actual Payment 1,250.00
15RT4PI0047 LAW COSTS DRAFTSMEN Actual Payment 855.00
15RT4PI0068 WRP REFUND Actual Payment - 324.00
16RT4MN0001 CLAIMANT'S SOLICITOR'S FEES Actual Payment 3,180.00
16RT4PI0057 COUNSEL FEES Actual Payment 1,705.00
16RT4PI0057 APPLICATION COSTS Actual Payment - 100.00
17RT4PI0009 COUNSEL FEES Actual Payment 300.00
17RT4PI0043 Medical Report Actual Payment 990.00
18RT4DP0065 VEHICLE REPAIRS CN15BRF Actual Payment 372.00
18RT4DP0065 VEHICLE REPAIRS CN15BRF Actual Payment 80.00
18RT4DP0065 VEHICLE REPAIRS CN15BRF Actual Payment 75.00
18RT4DP0065 VEHICLE REPAIRS CN15BRF Actual Payment 7.30
18RT4MN0011 EXPERT WITNESS Actual Payment 1,300.00
18RT4MN0019 EXPERT WITNESS Actual Payment 400.00
18RT4MN0021 EXPERT WITNESS Actual Payment 1,300.00
18RT4PI0008 COURT FEE Actual Payment 790.62
19RT4DP0005 REPAIRS TO TP VEHICLE Actual Payment 669.86
19RT4DP0012 CAR HIRE AND RECOVERY Actual Payment 2,350.00
19RT4DP0015 DAMAGE TO PROPERTY Actual Payment 1,811.71
19RT4DP0016 GENERAL DAMAGES SETTLEMENT Actual Payment 447.27
19RT4DP0016 50% TP INSURANCE EXCESS Actual Payment 105.00
19RT4DP0019 EBERSPACHER UK LTD CE12CVW Actual Payment 188.93
19RT4DP0019 HK Motors CE12CVW Actual Payment 112.00
19RT4DP0019 Wilsons Accident Repair CE12CV Actual Payment 7,834.84
19RT4DP0019 Loss of Use @ 28 days CE12CVW Actual Payment 3,360.00
19RT4DP0019 CELTIC ASSESSORS CE12CVW Actual Payment 50.00
19RT4DP0019 CELTIC ASSESSORS CE12CVW Actual Payment 50.00
19RT4DP0019 Vehicle Repairs CE12CVW Actual Payment - 11,595.77
19RT4DP0022 DAMAGE TO TP VEHICLE Actual Payment 1,575.00
19RT4DP0022 HIRE CHARGES Actual Payment 876.29
19RT4DP0023 REPAIRS AND HIRE CHARGES Actual Payment 2,243.88
19RT4DP0024 VEHICLE REPAIRS CX57LCV Actual Payment 131.03
19RT4DP0024 VEHICLE REPAIRS CX57LCV Actual Payment - 131.03
19RT4PI0015 CLAIMANTS SOLICITORS FEES Actual Payment 200.00
Totals 28,357.29
3.3 Audit Recommendation Trackers (Corporate Governance Manager)
1 ITEM 3.3 Audit Recommendation Tracker Report September 2018.docx
1
AUDIT RECOMMENDATION TRACKERS
MEETING Audit Committee
DATE 13th September 2018
EXECUTIVE Board Secretary
AUTHOR Corporate Governance Manager
CONTACT DETAILS Tel: 01633 626251 Email: [email protected]
CORPORATE OBJECTIVE All
CORPORATE RISK (Ref if appropriate)
N/A
QUALITY THEME All
HEALTH & CARE STANDARD All
REPORT PURPOSE To inform Audit Committee of the progress made by the Trust in responding to recommendations from Internal Audit and Wales Audit Office.
CLOSED MATTER REASON Not Applicable
REPORT APPROVAL ROUTE
WHERE WHEN WHY
EMT 29th August 2018 To review progress made to date and assess completion dates.
Audit Committee 13th September 2018 To receive a progress report.
AGENDA ITEM No 3.3
OPEN or CLOSED Open
No of ANNEXES ATTACHED
0
2
SITUATION 1. The purpose of this paper is to provide the Audit Committee with a progress report
in respect of the work undertaken to address recommendations made as a result of internal and external audit reviews.
BACKGROUND 2. The audit recommendation trackers were implemented in August 2014 for the
purpose of tracking progress across the Trust to ensure that recommendations contained in internal and external audit review reports were actioned and in a timely manner.
3. In order to improve performance, as well as simplify the reporting process, a new Audit Tracker tool was developed in July 2018 which will closely monitor the status of Internal Audit recommendations and those issued by the Wales Audit Office.
4. This new design will provide Senior Managers with a workable tool that allows for closer scrutiny of audit recommendations.
ASSESSMENT 5. The tracker is stored in a shared drive and should be accessed by clicking on this
link - \\se-fp-c01\shared\Ambulance\Audit_Tracker
6. This document should be reviewed electronically in order to get the most out of the data being reported as it has been specifically developed to facilitate dynamic reporting arrangements dependent on the areas which are of most interest to users.
7. The new tracker is designed to provide a more detailed focus as to the reasons why recommendations are overdue or have not progressed within the agreed timeframes; this will highlight areas that may require additional support and ensures there are clear mechanisms in place to raise any issues. This is in contrast to the previous tracker which provided a more detailed narrative in relation to actions taken against each of the recommendations.
8. The Excel spreadsheet is separated into two tabs:
• Internal Audit Reviews
• External - Wales Audit Office Reviews Tab 1 - Internal Audit Reports
9. There are 88 current recommendations detailed in tab 1 on the tracker; however,
it should be noted that occasionally more than one responsible officer is allocated elements of a recommendation within the Internal Audit reports, these are shown separately across 101 lines on the tracker and are counted as separate recommendations for the purposes of this report.
3
10. 14 of the current recommendations relate to 2016/17 audit reports; 9 of which are reported as complete during this period with the remaining 5 being partially complete.
11. Of these 5 partially complete there are 3 that have a high priority rating and 2 are rated low priority.
12. There are 87 current recommendations detailed in the 2017/18 audit reports and of those 30 are not yet due for completion, 36 have been completed during this period and 21 are overdue.
13. Of these 21 overdue recommendations 3 have been rated high priority, 11 are of medium priority and 7 are low priority.
14. 12 of the overdue recommendations are partially complete and 4 have made no progress.
Tab 2 – External - Wales Audit Office Reports 15. This Annex describes 10 recommendations made following the 2016 and 2017
Structured Assessments.
16. 3 actions are completed this period, 4 are not yet due and 3 are overdue. Audit Tracker Discrepancies 17. At its May meeting, the Audit Committee expressed concern that a follow-up audit
report on the Payment of Rest Breaks (EMS) highlighted that previous audit recommendations had not been implemented, yet had been closed on the audit tracker as having been completed.
18. The Audit Committee requested further information on why this happened and assurances that this was not a routine occurrence.
19. The recommendations contained in the Payment of Rest Breaks report related to the checking, allocation of job numbers and the authorisation of claims for missed meal breaks. On discussion with the Operations Directorate, it was confirmed that the findings from the previous Internal Audit Report had been discussed at Directorate management meetings and that instructions were issued to managers and staff to comply with the recommendations. On that basis, the related actions on the audit tracker were closed as being completed.
20. However, the subsequent follow-up audit revealed that, whilst instructions were issued, compliance was limited across the Trust and this has led to the latest audit findings. It is recognised that management needs to improve checks to ensure implementation and compliance and recent changes to the process for reporting updates through the audit tracker have been designed to assist management and improve controls in this respect.
4
21. Over Q1 of 2018/19 management actions around improving the performance of the rest break policy and reducing the number of missed and interrupted breaks has been successful with an increase in EMS/CCC staff taking their break on time from circa 20% to circa 65%. Over the same period Trust expenditure on rest break allowances has reduced from circa £750k in the first five months of 17/18 to circa £80k in the opening five months of 18/19.
RECOMMENDED: That the Audit Committee review the progress made by the
Trust in addressing the Internal and External Audit Report recommendations.
EQUALITY IMPACT ASSESSMENT Not required.
3.5 Gifts and Hospitality Policy (Board Secretary)
1 ITEM 3.5 SBAR Gifts and Hospitality 130918.docx
1
Gifts and Hospitality Policy
MEETING Audit Committee
DATE 13th September 2018
EXECUTIVE Keith Cox, Board Secretary
AUTHOR Keith Cox, Board Secretary
CONTACT DETAILS [email protected]
CORPORATE OBJECTIVE To review and refresh the Gifts and Hospitality Policy
CORPORATE RISK (Ref if appropriate)
QUALITY THEME All
HEALTH & CARE STANDARD All
REPORT PURPOSE To approve the policy.
CLOSED MATTER REASON
REPORT APPROVAL ROUTE
WHERE WHEN WHY
Policy Group Meeting 19/03/18 To review initial draft
Policy Group Meeting 19/04/18 To review post consultation
Trade Union Partner Team Meeting 04/05/18 For WASPT Agenda
WASPT 21/05/18 Recommend for approval
EMT 20/06/18 Recommend for approval
Audit Committee 13/09/18 Approval and adoption
AGENDA ITEM No 3.5
OPEN or CLOSED Open
No of ANNEXES ATTACHED
1
2
SITUATION
1. The Gifts and Hospitality Policy was last revised in 2014 and was therefore due to be reviewed as a matter of routine. In addition, there was a requirement for some clarity around WAST seeking commercial sponsorship for events such as staff awards and also to reflect latest legislation, in particular requirements under the Bribery Act 2010. The aim of the refreshed policy is to provide guidance on these aspects as well as other matters relating to Gifts and Hospitality and to ensure all staff are treated in a fair and consistent way and within statutory legislation.
BACKGROUND
2. The policy was developed in partnership with Trade Union colleagues, the Counter Fraud and Communication Teams. The policy has also been compared to similar policies currently in use in Health Boards and Trusts within Wales The policy sets out the arrangements for when staff receives gifts and hospitality and provides guidance on commercial and other sponsorship.
ASSESSMENT
3. The policy has been updated in a number of areas. When comparing the existing Trust policy with similar policies in use within Health Boards and Trusts in Wales, it was noted that a number of those policies had set the upper value for gifts at £25, compared with the Trust which was set some time ago at £10. After consideration, it was considered that £25 was a more realistic figure and therefore the revised policy reflects this. No challenges, comments or observations were received on this amendment during the consultation.
4. The need to ensure that the policy reflects latest legislation under the Bribery Act 2010 was also highlighted and contributions from the Counter Fraud lead ensures that the revised policy is now up to date.
5. There was also a need to ensure that this policy provided some information and guidance on attracting sponsorship for events such as the staff awards. No such guidance currently exists and the Trust was therefore at risk of breaching commercial and government procurement principles, particularly those around fairness and equality of treatment. The Principles outlined in the policy have been influenced by HM Treasury and other public sector guidelines.
6. The attached Policy, Process and Guidance has been distributed to the teams mentioned above and has followed the approved Trust process for updating Trust policies. The draft policy has therefore been considered by the Policy Group and has undertaken full staff consultation. Feedback from all stakeholders has been included in the policy and related to completeness and formatting and did not change the content hence were not recorded on the consultation comments log. No comments have been excluded.
7. An Equality Impact Assessment has been undertaken and no issues have arisen. We
are also now content that the policy complies with legislation/regulations
3
RECOMMENDED: That the Audit Committee note the content of the attached Policy and approve for adoption across the Trust. APPENDICES
Appendix 1– EqIA
Appendix 2 - Policy Lead checklist
4
Appendix 1 – EqIA
Part A
Form 1: Preparation
1.
What are you equality impact assessing? What is the title of the document you are writing or the service review you are undertaking?
Gifts, Hospitality Interests; Commercial Sponsorship and Fundraising Policy
2.
Provide a brief description, including the aims and objectives of what you are assessing.
The aim of the policy is to ensure that arrangements are in place to support staff and Non-Executive Board members to act in a manner that upholds the Trust’s standards of behaviour and sets out specific arrangements for the declaration of interests, acceptance/refusal of offers of gifts, hospitality or sponsorship.
3.
Who is responsible for the document/work you are assessing – i.e. who has the authority to agree/approve any changes you identify are necessary?
Keith Cox, Corporate Secretary
4. Who is involved in undertaking this EQIA. Please list all names and Titles/Roles
Name
Title/Role
Keith Cox Corporate Secretary
Julie Boalch Corporate Governance Manager
Dylan Parry Trade Union Partner
5.
Is the Policy related to, or influenced by, other Policies/areas of work? Counter Fraud, Bribery & Corruption Policy Charitable Funds Policy
5
6.
Who are the key Stakeholders i.e who will be affected by your document or proposals?
All Trust employees and Non-Executive Board members
7.
What might help/hinder the success of whatever you are doing, for example communication, training etc?
N/A
Form 2: Considering the potential impact of your document, proposals etc in relation to equality and human rights
Characteristic/ actor to be considered
Potential Impact by Group. Is it:- Please detail any - Reports, Statistics, Websites, Links etc that
you have used to inform your assessment
and/or
- Any information gained during engagement
with staff or service users and/or
- Any other information that has informed
your assessment of potential impact
Positive (+) Negative (-) Neutral (N) No Impact/Not applicable (N/a)
Scale High Negative Medium Negative Low Negative Neutral Low Positive Medium Positive High Positive
Age
N/A High Positive
Disability
N/A High Positive
Gender Reassignment
N/A High Positive
Race / Ethnicity
N/A High Positive
Religion or Belief
N/A High Positive
Sex
N/A High Positive
Sexual Orientation
N/A High Positive
Pregnancy and Maternity (applies for employees)
N/A High Positive
6
Marriage and Civil Partnership (applies for employees)
N/A High Positive
Welsh Language
N/A High Positive
Human Rights
N/A High Positive
Guidance on completing Form 2: For each of the characteristics listed, and considering the aims and objectives you detailed in Q2 on
Form 1, you need to consider whether your document or proposal likely to affect people differently, and if so, will this be in a positive or
negative way? For example, you need to decide:
1 will it affect men and women differently?
2 will it affect disabled and non-disabled people differently?
3 will it affect people in different age groups differently? - and so on covering all the protected characteristics.
Use the table below to indicate the scale of any impact identified. The factors used to determine an overall assessment for each characteristic
should include consideration of scale and proportionality as well as potential impact.
Table A
High negative
Medium negative
Low negative
Neutral
Low positive
Medium positive
High positive
No impact/Not applicable
7
Form 3: Assessing Impact Against the General Equality Duty
As a public sector organisation, we are bound by the three elements of the “General Duty”. This means that we need to consider whether (if relevant) the policy or proposal will affect our ability to:- 1 Eliminate unlawful discrimination, harassment and victimisation;
2 Advance equality of opportunity; and
3 Foster good relations between different groups
1. Describe here (if relevant) how you are ensuring your policy
or proposal does not unlawfully discriminate, harass or victimise
N/A
2. Describe here how your policy or proposal could better
advance equality of opportunity (if relevant)
N/A
3. Describe here how your policy or proposal might be used to foster good relations between different groups (if relevant)
N/A
8
Part B:
Form 4 (i): Outcome Report
Organisation: Welsh Ambulance Services NHS Trust
1. What is being
assessed?
Gifts, Hospitality Interests; Commercial Sponsorship and Fundraising Policy
2. Brief Aims and
Objectives
The aim of the policy is to ensure that arrangements are in place to support staff and Non-Executive Board members to act in a manner that upholds the Trust’s standards of behaviour and sets out specific arrangements for the declaration of interests, acceptance/refusal of offers of gifts, hospitality or sponsorship.
3a. Could the impact of your
decision/policy be discriminatory under
equality legislation?
No
3b. Could any of the protected groups be
negatively affected?
No
3c. Is your decision or policy of high
significance – consider the scale and
potential impact across WAST including
costs/savings, the numbers of people
affected and any other factors?
No
Each characteristic recorded a positive impact.
Yes No
Record Reasons for Decision i.e. what did the assessment of scale on Form 2 indicate in terms of positive and negative impact for each characteristic?
Yes No N/A
Record Details:
9
Yes No
How is it being
monitored?
N/A
Who is responsible? Keith Cox, Corporate Secretary
What information is
being used?
N/A
When will the EqIA be reviewed? (Usually the same date the policy is reviewed)
3 years from date of approval
7. Where will your decision or policy be
forwarded for approval?
Finance and Resources Committee
8. Describe here what engagement you
have undertaken with stakeholders
including staff and service users to help
inform the assessment
Engaged with Policy Group members including representatives from Workforce & OD,
Trade Union representatives and Welsh Language Officer
Name
Title/Role
9. Name/role of person responsible for this Impact Assessment
Keith Cox Corporate Secretary
10. Name/role of person approving this Impact Assessment
10
Please Note: The Action Plan below forms an integral part of this Outcome Report
Form 4 (ii): Action Plan
This template details any actions that are planned following the completion of EqIA including those aimed at reducing or eliminating the
effects of potential or actual negative impact identified.
Proposed Actions
Who is responsible for this
action?
When will this be done by?
1. If the assessment indicates significant potential negative impact such that you cannot proceed, please give reasons and any alternative action(s) agreed:
2. What changes are you proposing to make (or have already made) to your document or proposal as a result of the EqIA?
3a. Where negative impact(s) on certain groups have been identified, what actions are you taking or are proposed to mitigate these impacts? Are these already in place?
3b. Where negative impact(s) on certain groups have been identified, and you are proceeding without mitigating them, describe here why you believe this is justified.
11
4. Provide details of any actions taken or planned to advance equality of opportunity as a result of this assessment.
Note: If your decision noted above is that you will need to move to a full impact assessment then you should refer to the full impact
assessment forms Part C
12
Appendix 2
Policy Lead Checklist – Gifts and Hospitality Policy
Yes/No/ Unsure
Comments
1. Trade Union Partners
Has the Staff Side Chair/Secretary been contacted?
Yes
Has the Staff Side Chair/Secretary acknowledged your request for a nominated Trade Union Lead?
Yes
2. Documentation
Has the Document Approval Form (DAF) been fully completed and submitted to Governance Team for processing?
Yes
Has the unique policy number been clearly stated on the policy?
Yes
Has the version number been included? Yes
Is it clearly stated which approved documents this version supersedes?
Yes
Has the classification of document been clearly stated?
Yes
Has the accompanying SBAR been completed to accompany the policy through the process?
Is it clearly stated who the Policy Lead is? Yes
Are the reasons for development/review of the policy clearly stated in the SBAR/DAF?
Yes
Has the policy been registered on the Trust’s central policy register database?
Yes
3. Layout
Has the correct policy template been utilised? Yes
Have the formatting guidelines been followed? Yes
Is there a contents page included? Yes
Have page numbers been included? Yes
Are the Appendices detailed at the end of the document?
Yes
4. Title
Is the title of the policy clear and unambiguous?
Yes
5. Introduction
Does the introduction clearly state what the policy about?
Yes
Is it clear why the policy is needed? Yes
Have the reasons, history and intent that lead to the creation of the policy been included?
Yes
13
Yes/No/ Unsure
Comments
6. Policy Statement
Is the commitment of WAST clearly stated? Yes
Does it include a statement of intent?
Does it include what is the desired outcome/motivating factors are?
Yes
7. Scope
Is the scope of the document clear? Yes
Is it clear to whom the policy applies? Yes
Is it clear which service area, professional groups or individuals are affected by the policy?
Yes
8. Aim
Is the aim clearly stated? Yes
Does it detail what the policy should achieve? Yes
9. Objectives
Does the policy clearly identify how the aim of the policy will be achieved?
Yes
10. Content
Are the key terms used in the policy? Yes
Is the language clear and concise? Yes
Are the intended outcomes described? Yes
Are the statements clear and unambiguous? Yes
11. Evidence Base
Is the type of evidence to support the document identified explicitly?
Yes
Are key references cited? Yes
Are the references cited in full? Yes
Are supporting documents referenced? Yes
12. Engagement
Has the policy been developed in partnership with relevant staff groups, services and departments?
Yes
13. Approval
Does the policy identify which committee/group will approve it?
Yes
14. Flow Chart Policy Process
Has the process contained in the Policy for the Development, Review and Approval of Policies been followed?
Yes
15. Approval Route
Has the policy been submitted to either the Employment Policy Sub Group or Policy Group for guidance and consideration?
Yes
14
Yes/No/ Unsure
Comments
16. Consultation
Has the policy been subject to a Trust wide consultation period – guided by the Policy Groups?
Yes
17. Dissemination and Implementation
Is there an outline/plan to identify how the document will be implemented and distributed?
Yes
Does the plan include the necessary training/support to ensure compliance?
18. Training
Have the training requirements been clearly identified?
N/A
Is there a clear timeline for training? N/A
Have training resources required been clearly specified?
N/A
Has a clear training plan been outlined in the document?
N/A
Have the appropriate representatives been engaged with and informed of training needs as a result of the policy being implemented?
N/A
19. Document Control
Does the document identify where it will be held and how a copy can be obtained?
Yes
20. Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPI’s to support the monitoring of compliance with and effectiveness of the document?
N/A
Is there a plan to review or audit compliance with the document?
N/A
Has an audit tool been built into the policy document?
N/A
21. Dates
Has the implementation date been included? Yes
Is the review date specified? Yes
Is the frequency of review identified? Yes
22. Overall Responsibility for the Document
Is it clear who is responsible for the document? Yes
Is it explicit who is responsible for managing and reviewing the policy?
Yes
Is it clear who will be responsible for co-ordinating the dissemination and implementation of the document?
Yes
Are the staff responsible for enforcing the policy clearly identified?
Yes
15
Yes/No/ Unsure
Comments
Is there a clear contact identified (the person to whom questions about the policy should be directed?
Yes
23. Legislation and Regulations
Does the document clearly state the relevant legislation or regulatory obligations considered in the development of the policy?
Yes
Does the policy detail the related organisational policies or other documents that it should be read in conjunction with?
Yes
24. Impact Assessments
Has an EqIA been carried out? Yes
Has the outcome been recorded in the Policy and the SBAR?
Yes
Have the Welsh Language standards been taken into account?
Currently part of EqIA process
Has an Environment assessment been carried out?
N/A
Has the policy been considered in relation to Counter Fraud?
Yes
25. Once Approved
Has the Governance Team been notified of approval and the policy returned to the Governance Team for uploading to the Trust central library and Policy and Procedures Intranet Page?
Yes
26. Policy Review
Is the person responsible for the review of the document aware of the review date?
Yes
1 ITEM 3.5a Gifts and Hospitality Policy 170418 final.pdf
Gifts, Hospitality Interests; Commercial Sponsorship And
Fundraising Policy
Policy Number: 035 Version No: 2.2 Supersedes: 2014/15 version
Date of Approval: Review Date: 3 years following approval
Approved by:
Date of EqIA: Date of Welsh Language Assessment:
Date of Counter Fraud Review:
Date of Environmental Impact Asses.
Type of Document:
Classification of Document:
12 December 2017
To be Incorporated following outcome of Welsh Language Standards Review
October 2017 N/A Policy Corporate
Brief Summary of Document:
The policy sets out specific arrangements for the appropriate declarations of interest and acceptance/refusal of offers of gifts, hospitality or sponsorship.
Scope: This policy is applicable to the whole Trust. It applies to all employees and all Non-Executive Board Members. The term employees includes all those who have an employment or honorary contract with the Trust.
To be read in conjunction with:
Counter Fraud, Bribery and Corruption Policy - 025 Charitable Funds Policy
Owning Committee Audit Committee
Policy Lead: Trade Union Lead:
Keith Cox Dylan Parry
Job Title: Board Secretary Trade Union Representative
Executive Director:
Keith Cox Job Title: Board Secretary
Agreed Implementation Date:
Welsh Ambulance Services NHS Trust
Insert Policy No: 035 Page 2 of 21 Version 2.0
Gifts, Hospitality, Interests; Commercial Sponsorship and Fundraising Policy
Version Control Sheet
Version Date Author Summary of Changes
2.0 31/10/17 Carl Window Updated counter fraud legislation references
2.0 09/11/17 Julie Boalch Transposed onto new template
2.0 13/02/18 Keith Cox Updated narrative
2.1 08/03/18 Julie Boalch Formatting
2.2 17/04/18 Keith Cox Comments post consultation
Keywords
Welsh Ambulance Services NHS Trust
Insert Policy No: 035 Page 3 of 21 Version 2.0
Gifts, Hospitality, Interests; Commercial Sponsorship and Fundraising Policy
Task and Finish Group Members
Where When
Name Job Title
Policy Approval Route
Where When Why
Policy Group Meeting 19/03/18 To review initial draft
Policy Group Meeting 19/04/18 To review post consultation
Trade Union Partner Team Meeting 04/05/18 For WASPT Agenda
WASPT 21/05/18 Recommend for approval
EMT 06/06/18 Recommend for approval
Audit Committee 13/09/18 Approval and adoption
Disclaimer If the review date of this document has passed please ensure that the version you are using is the most up to date either by contacting the document author or the Corporate Governance Manager
Welsh Ambulance Services NHS Trust
Insert Policy No: 035 Page 4 of 21 Version 2.0
Gifts, Hospitality, Interests; Commercial Sponsorship and Fundraising Policy
Contents 1. Introduction ....................................................................................................................... 5
2. Policy Statement ............................................................................................................... 6
3. Scope ............................................................................................................................... 6
4. Aim ................................................................................................................................... 6
5. Objectives ......................................................................................................................... 6
6. Definitions ......................................................................................................................... 6
7. Policy ................................................................................................................................ 7
8. Registers........................................................................................................................... 7
9. Gifts & Hospitality ............................................................................................................. 8
10. Declarations ...................................................................................................................... 9
11. Compliance And Legislation ............................................................................................. 9
12. The Bribery Act 2010 ........................................................................................................ 9
13. Commercial Sponsorship ................................................................................................ 10
14. Fundraising ..................................................................................................................... 11
15. Use Of The Trust Logo ................................................................................................... 12
16. Equality ........................................................................................................................... 12
17. Training and implementation........................................................................................... 12
18. Audit and monitoring ....................................................................................................... 12
19. Responsibilities ............................................................................................................... 12
20. Appendices ..................................................................................................................... 13
Appendix 1 - Procedure for the Declaration of Gifts and Hospitality ...................... 14
Appendix 2 - Procedure for the Declaration of Interests ........................................ 15
Appendix 3 – Declaration of Gifts and Hospitality .................................................. 17
Appendix 4 – Declaration of Interests .................................................................... 19
Welsh Ambulance Services NHS Trust
Insert Policy No: 035 Page 5 of 21 Version 2.0
Gifts, Hospitality, Interests; Commercial Sponsorship and Fundraising Policy
1. INTRODUCTION 1.1 The Welsh Government's Citizen-Centred Governance Principles apply to all public
bodies in Wales. These principles integrate all aspects of governance and embody the values and standards of behaviour expected at all levels of public services in Wales. “Public service values and associated behaviours are and must be at the heart of the NHS in Wales” The Board is strongly committed to the Trust being value-driven, rooted in Nolan principles and high standards of public life and behaviour, including openness, customer service standards, diversity and engaged leadership. The Board expects all employees and non-executive board members to practice high standards of corporate and personal conduct, based on the recognition that the needs of patients must come first. The “Seven Principles of Public Life”, or the “Nolan Principles” form the basis of the NHS Standards of Behaviour requirements for its employees and Independent Members. These are:-
Selflessness – Individuals should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or friends;
Integrity – Individuals should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties;
Objectivity – In carrying out public business, including making public appointments, awarding contracts, recommending individuals for rewards and benefits, choices should be made on merit;
Accountability – Individuals are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate for their position;
Openness – Individuals should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands it;
Honesty – Individuals have a duty to declare any private interests relating to their duties and to take steps to resolve any conflicts arising in a way that protects the public interest, and;
Leadership – Individuals should promote and support these principles by leadership and example.
These standards set parameters for business dealings which seek to ensure that such dealings are conducted in a spirit of openness, honesty and integrity. The receipt, or provision, of gifts or hospitality and the non-declaration of material interests is an area that has the potential for the acts of individuals to be called into question.
Welsh Ambulance Services NHS Trust
Insert Policy No: 035 Page 6 of 21 Version 2.0
Gifts, Hospitality, Interests; Commercial Sponsorship and Fundraising Policy
1.2 Guidance on Gifts, Hospitality, Interests and Commercial Sponsorship can be found in a number of Trust documents such as Standing Orders, the Scheme of Delegation and the Counter Fraud, Bribery & Corruption Policy. The purpose of this document is to consolidate this guidance and circulate the Trust’s policy on Gifts, Hospitality, Interests and Commercial Sponsorship in a single source of reference that details the actions to be taken in regard of Gifts, Hospitality, Interests and Commercial Sponsorship in order to protect the integrity of both individuals and the Trust.
1.3 The policy is supplemented by procedure notes for each subject area which are included as Appendices.
2. POLICY STATEMENT
The Trust is committed to ensuring that its Board members and staff practice the highest standard of conduct and behaviour. This policy sets out those expectations and provides supporting guidance so that all employees and Non-Executive members are informed and supported in delivering that aim.
3. SCOPE
This policy is applicable to the whole Trust. It applies to all employees and all Non-Executive Board Members. The term employees includes all those who have an employment or honorary contract with the Trust.
4. AIM
The aim of this policy is to ensure that arrangements are in place to support staff and Non-Executive Board members to act in a manner that upholds the Trust’s standards of behaviour as well as setting out specific arrangements for the appropriate declarations of interest and acceptance/refusal of offers of gifts, hospitality or sponsorship.
5. OBJECTIVES
This policy aims to clarify the respective responsibilities of individuals in the discharging of this policy, reflecting the Trust’s values and behaviours.
6. DEFINITIONS 6.1 Gifts
For the purpose of this policy, gifts are defined as any items of a material nature that have an intrinsic financial value in excess of £25 or a cumulative value in excess of £25 where several small gifts are received from the same or closely related source in a 12 month period.
6.2 Hospitality
For the purpose of this policy, hospitality is defined as the provision of food, drink, accommodation, entertainment, travel or attendance as a corporate guest at events.
Welsh Ambulance Services NHS Trust
Insert Policy No: 035 Page 7 of 21 Version 2.0
Gifts, Hospitality, Interests; Commercial Sponsorship and Fundraising Policy
6.3 Interests For the purpose of this policy, interests are defined as:
Directorships, including Non-Executive Directorships held in private companies or PLCs (with the exception of those of dormant companies);
Ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS;
Connections with organisations likely or possibly seeking to do business with the NHS;
A position of authority in a charity or voluntary organisation in the field of health and social care;
Any connection with a voluntary or other organisation contracting for NHS services;
Research funding / grants that may be received by an individual or their department;
Secondary Employment. 6.4 Commercial Sponsorship
For the purpose of this policy, commercial sponsorship is a commercial arrangement in which a sponsor, or a number of sponsors, provide a contribution in money or in kind to support an activity in return for certain specified benefits.
7. POLICY 7.1 In order to ensure compliance with the various Codes of Conduct, it is the policy of the
Trust that all employees must declare any offers of gifts, hospitality or commercial sponsorship whether the offers are accepted or not. In addition, it is the Trust’s policy that all employees must declare any relevant or material interests as detailed at Section 6.3.
8. REGISTERS 8.1 The Board Secretary will maintain the following central registers:
Board Members Register of Declaration of Interests;
Register of Gifts and Hospitality;
Use of the Trust’s seal (usually reserved for legal documents).
8.2 The content of Board Member’s Declarations of Interest together with the Register of Gifts and Hospitality will be subject to periodic reports to the Board and will be available for public inspection.
8.3 Line Managers will ensure that their registers of staff declarations of interest are available for inspection on request by members of the Executive Team, Internal or External Audit or the Counter Fraud Office if required.
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9. GIFTS & HOSPITALITY 9.1 Employees are required to declare any relevant and material interests and any offers of
gifts and hospitality together with any other interests as deemed appropriate by the Board Secretary. It is recommended that if in doubt, a declaration of interest should be made.
9.2 If offered gifts or hospitality, individuals should consider the following.
The circumstances in which the offer is made;
The nature and value of the gift or hospitality offered;
The appropriateness of accepting the gift or hospitality offered;
The ability or expectation to reciprocate the offer. 9.3 Casual gifts offered by contractors or others, for example at Christmas time, may not be
in any way connected with the performance of duties so as to constitute an offence under the Prevention of Corruption Acts. Such gifts should nevertheless be politely but firmly declined. Articles of low intrinsic value clearly issued for advertisements (such as calendars or diaries) need not be subject to this rule and may be accepted. In cases where small gifts of a non-cash nature with a value of no more than £25 are offered, such as a box of chocolates, they may be accepted by the employee receiving them but they should be reported to their line manager but do not need formal declaration as set out in this policy.
9.4 In cases of doubt, staff should either consult their line manager or politely decline acceptance. Under no circumstances should cash be accepted (even below the £25 threshold). In circumstances where the patient/relative, or any other person/organisation insists, you must make them aware that the gift can only be accepted as a charitable donation to the Trust’s Charitable Trust Fund. This must then be recorded as such. Further advice and guidance in relation to Charitable Funds can be obtained from the Corporate Accountant.
9.5 Modest hospitality, provided it is normal and reasonable in the circumstances, for example, lunches in the course of working visits, are acceptable, though it should be similar to the scale of hospitality which the NHS as an employer would be likely to offer. Staff should decline all other offers of gifts or hospitality and if in doubt should seek advice from their line manager or the Board Secretary.
9.6 In situations where individual staff receive a personal gift in excess of £25 from a member of the public as a result of their employment by the Trust through a will, gifts must be declared in the gifts and hospitality register and the Trust will expect the member of staff concerned to consider that, under this Policy, the gift be considered as a donation to the Trust’s Charitable Trust Fund for the benefit of all staff in the relevant district. The Head of Service in the relevant area will then be required to consult all of the staff involved for suggestions as to how the gift should be best used.
9.7 Individuals offering gifts or hospitality must be advised by the intended recipient of the requirement to declare such offers.
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9.8 Where there is uncertainty as to whether an interest or hospitality needs to be declared,
advice should be sought from the Board Secretary. 10. DECLARATIONS 10.1 Individuals must declare interests or offers of gifts or hospitality as detailed in the
procedure notes included as Appendices to this policy document. 11. COMPLIANCE AND LEGISLATION 11.1 All employees are required to comply with the policy on Gifts, Hospitality and Interests.
Failure to comply may result in a breach of Trust Standing Orders and consequently a breach of contractual terms and conditions, which could result in disciplinary action and, if appropriate, may be reported to the Trust’s Local Counter Fraud Specialist (LCFS) for investigation. Employees are reminded that compliance will ensure that the integrity of individuals is not open to question.
11.2 By virtue of the Bribery Act 2010 and related legislation, potentially, employees or the corporate body itself, may commit an offence should adequate provisions not be followed. It is an offence for employees corruptly to accept any gifts or consideration as an inducement or reward for:
Doing, or refraining from doing, anything in their official capacity; or
Showing favour or disfavour to any person in their official capacity.
11.3 Any money, gift or consideration received by an employee in public service from a person or organisation holding or seeking to obtain a contract will be deemed by the courts to have been received corruptly unless the employee proves to the contrary. Staff need to be aware that a breach of these provisions renders them liable to investigation by the Trust LCFS and which may lead to prosecution and subsequent loss of employment and superannuation rights in the NHS.
12. THE BRIBERY ACT 2010 12.1 The Bribery Act 2010 makes it a criminal offence to give, promise or offer a bribe, and
to request, agree to receive, or accept a bribe, either at home or abroad. It also introduced a corporate offence of failing to prevent bribery by the organisation not having adequate preventative procedures in place.
12.2 The linked guidance may support in ensuring both corporate and personal compliance of the act, “the quick start guide to Bribery https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/181764/bribery-act-2010-quick-start-guide.pdf
12.3. The risks of breaching the Bribery Act include the following:-
Criminal justice sanctions against directors, board members and other senior staff;
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Damage to the organisation’s reputation;
Conviction of bribery or corruption may lead to the organisation’s being precluded from future public procurement contracts;
Potential diversion and/or loss of resources;
Unforeseen and unbudgeted costs of investigations and/or defence of any legal action; and
Negative impact on patient/stakeholder perceptions.
12.4 The provisions within this Policy in terms of prohibiting the giving or acceptance of all gifts, hospitality and donations complies with the requirements of the Bribery Act and subsequent guidance.
12.5 Consideration should also be given to the Fraud Act 2006. The Fraud Act 2006 creates offences applicable to fraudulent activity namely:
Section 2 (fraud by false representation);
Section 3 (fraud by failing to disclose information); and
Section 4 (fraud by abuse of position). 12.6 The elements of the offences within the act require an element of dishonesty, which
results in the making a gain for themselves or another, or through causing a loss to another and exposing them to risk of a loss. The LCFS has responsibility for investigating alleged offences, and may work in conjunction with Local Police forces to secure appropriate sanctions. Reports of suspected fraud or corruption can be made direct to the LCFS, or through to the NHS Fraud and Corruption reporting line on 0800 028 40 60; or via the on-line reporting facility https://cfa.nhs.uk/reportfraud
13. COMMERCIAL SPONSORSHIP 13.1. Commercial sponsorship is a commercial arrangement in which a sponsor, or a number
of sponsors, provide a contribution in money or in kind to support an activity in return for certain specified benefits. The main areas where the Trust may benefit from sponsorship are:
One-off events (e.g. conferences, staff awards);
Campaigns;
Specific activities that the Trust would like to pursue which will benefit the community.
13.2 Sponsorship does not include:
The selling of advertising space;
Joint ventures;
Consultancies;
Grants;
Donations or bequests.
13.3 Sponsorship can be provided by the private sector, either a company or individual, or in some cases, the public and third sectors. Sponsorship can provide a useful source of funding for particular events or activities. However, sponsorship can present risks
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and in considering whether to accept sponsorship, the following principles should be adhered to:
Sponsorship should be sought in an open and even-handed manner with opportunities being offered as widely as possible;
Benefits should be for the Trust (not an individual) and should be proportionate;
Arrangements must not compromise the standing or image of the Trust;
Sponsorship should be for a specific activity or event and not a general endorsement of the Trust;
The sponsorship must not imply the Trust endorses particular products, services or companies and organisations;
Sponsorship should not be accepted from inappropriate sources, such as companies with dubious or doubtful backgrounds or who have poor financial or business practices;
Any arrangements which could bring adverse publicity to the event or the Trust. 13.4 Particular care should be taken when considering Sponsorship from companies or
organisation for which the Trust has, or could have, contractual business arrangements. The above principles should be adhered to and a renewal or an award of a contract should not be influenced by any sponsorship arrangements.
13.5 A sponsor would normally expect to receive a reciprocal benefit which may be beyond
a modest acknowledgement and companies may seek sponsorship for a number of legitimate business reasons. These include:
To raise the company’s image and profile;
To improve public/community relations;
To generate public exposure and media coverage;
To differentiate the company from its competitors;
To increase profit/market share.
13.6 Careful consideration should always be given to understanding what a sponsor might gain from the arrangement and these should be in-keeping with the principles listed above.
13.7 The Trust may also receive unsolicited proposals for sponsorship which is not in response to any action that the Trust has taken. The Trust should carefully consider such offers and ensure that the proposal meets the Trusts requirements, standards and principals. The Trust will need to ensure there are no conflicts of interest or that better value for money cannot be obtained by testing wider market interest.
13.8 All sponsorship arrangements should be approved by the appropriate Director. 14. FUNDRAISING 14.1. Individuals may from time to time receive requests to become involved in fundraising
activities, e.g. for first responder equipment. It is worth confirming that the Trust does not have insurance which would cover it for such activities and therefore individuals should not organise any such activities on behalf of the Trust. Employees participating
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in fundraising events arranged by others must do so in their own time. You should check that the organisers have carried out a suitable risk assessment and carry the requisite insurance.
15. USE OF THE TRUST LOGO 15.1. Likewise permission needs to be obtained from the Board Secretary or Head of
Communications on all occasions where you may be approached by an outside organisation seeking to use the Trust’s logo in connection with an event/function. Permission should also be sought by any member of staff wishing to use the logo in connection with any non-Trust related matter/event.
16. EQUALITY 16.1 This policy applies to all staff. An equality impact assessment has been undertaken and
no specific matters relating to equality have been identified. As the policy applies universally to all staff only a Part A equality impact assessment was undertaken.
17. TRAINING AND IMPLEMENTATION 17.1 All staff are required to comply with this policy. There are no particular training
requirements. 18. AUDIT AND MONITORING 18.1 The Board Secretary is responsible for ensuring this policy is complied with. Staff will
be regularly reminded of their responsibilities under the policy and senior staff declarations of interest are reviewed by the Audit Committee and published each year. Gifts, hospitality and sponsorship are also subject to annual internal and/or external audit inspection.
19. RESPONSIBILITIES 19.1 Chief Executive
The Chief Executive is the ‘Accountable Officer’ with overall responsibility for ensuring that the Trust operates efficiently, economically and with probity. The Chief Executive will ensure a policy framework is set and that arrangements are in place to support the delivery of that framework.
19.2 Executive Director of Finance and ICT
The Executive Director of Finance and ICT is responsible for ensuring appropriate monitoring arrangements are established to ensure that purchasing decisions are not being influenced by a sponsorship agreement. More information regarding procurement can be found at appendix 1.
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19.3 Board Secretary The Board Secretary has delegated responsibility for ensuring that the Trust is provided with competent advice and support regarding the contents and application of the Declarations of Interest, Gifts, Hospitality and Sponsorship policy.
19.4 Executive Directors and members of the Executive Team
Executive Directors and members of the Executive Team should ensure that:
Members of staff are aware of the requirements contained within this procedure and regular reminders are issued;
They lead by example and ensure that they personally declare any relevant interest or the offer of Gifts, Hospitality, Honoraria or Sponsorship;
They approve (or not) the acceptance of gifts, hospitality, honoraria and sponsorship that have been offered within their Directorate prior to the event;
Acceptance of any gifts, hospitality, honoraria or sponsorship complies with the standards of conduct outlined in this procedure;
They review the contents of the Registers of Declarations of Interest and Gifts, Hospitality, Honoraria and Sponsorship to assist with the verification of the accuracy of the information contained within it, when alerted to do so by the Board Secretary;
During periods of annual leave and prolonged absence, they delegate their responsibilities to their nominated deputy.
19.5 Line / Departmental Managers Line / Departmental Managers will:
Ensure that this policy is brought to the attention of members of staff for whom they are responsible, and that members of staff are aware of its implications for their work.
Ensure that members of staff are aware of the requirement to follow and comply with the procedure.
Support their members of staff in the application of the procedure, seeking advice from the Board Secretary or Corporate Governance Team as and when required.
19.6 All Staff All staff are required to comply with this policy. 20. APPENDICES
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Appendix 1 - Procedure for the Declaration of Gifts and Hospitality
PROCEDURE FOR THE DECLARATION OF GIFTS AND HOSPITALITY
Purpose
The purpose of this Procedure Note is to clarify the process for Trust employees when declaring the receipt of gifts and/or hospitality in compliance with the Trust’s policy on Gifts, Hospitality and Interest.
Form of Declaration
Declarations must be made in writing, and submitted on the proforma attached as Appendix 4 which includes the following information:
Nature of gift or hospitality offered;
Date offer made;
Details of the individual / organisation offering the gift or hospitality;
Initial action taken by the individual in receipt of the offer.
Submitting Declarations
Individuals are to submit any declarations to the relevant line manager as soon as is practicable.
Line Manager Responsibilities
In the first instance, Line Managers are to consider declarations received and assess whether the initial action taken by the individual is appropriate. Where Line Managers consider that it would be inappropriate to accept the offer made, they are to advise the individual accordingly recommending that the offer is declined.
On completion of the above action, Line Managers are to forward details of the declaration and their response to the Board Secretary.
Board Secretary Responsibilities
On receipt, the Board Secretary will review the content of declarations made and the advice subsequently provided by Line Managers to ensure that the recommended action is compliant with Trust policy. The Board Secretary will liaise directly with the relevant Line Manager in instances where this is not considered to be the case.
The Board Secretary will retain details of all declarations received in a central Register of Gifts and Hospitality which is presented annually to the Audit Committee.
The Board Secretary will be available to provide advice and clarification to Line Managers where required.
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Appendix 2 - Procedure for the Declaration of Interests
PROCEDURE FOR THE DECLARATION OF INTERESTS
Purpose
The purpose of this procedure note is to clarify the process for Trust employees when declaring relevant and material interests in compliance with the Trust’s policy on Gifts, Hospitality and Interests.
Form of Declaration
Declarations must be made in writing, and submitted on the proforma attached as Appendix 5 which includes the following information:
Name of individual making the declaration;
Position;
Nature of the interest(s) being declared;
Effective date of the interest.
Individuals must declare any financial or non-financial involvement that they or someone close to them are closely connected with – such as a spouse, partner or relative – has with an organisation linked, in any way, with the Trust.
This could, for example, relate to a contractor who is bidding for work from the Trust.
Individuals must also declare their membership of any organisation which might lead to conflict with their job – or at least give that impression to other people.
Submitting Declarations
Declarations must be submitted as soon as it practicable following acquisition of the interest. Individuals are to submit declarations of relevant and material interests to their line manager who should discuss any potential conflict of interest with the individual, raising any concerns with their respective Management Team. It is the line manager’s responsibility to securely file all received declarations and to maintain an electronic register of staff interests.
Periodic Declarations
The Code of Accountability for NHS Boards requires Board members to declare interest annually, or as and when they arise, and Standing Orders state that the Register of Interests shall be reviewed on an annual basis. The process for annual declarations by Board members and Board review of the Register of Interests will be co-ordinated by the Board Secretary.
In the interests of good practice, and in order to embed the declaration process throughout the organisation, the process of annual declarations and reviews will also be undertaken by relevant area Management Teams. This process will be coordinated by the Board Secretary.
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Board Secretary Responsibilities
The Board Secretary will agree timescales with area Management Teams for completion of the annual declaration by all staff within their area and will despatch forms for completion.
The Board Secretary will co-ordinate the annual declarations of interests by Board members and will record details of declarations in an electronic register of Interests file. The Board Secretary will ensure that all correspondence relating to the declarations is securely filed and that the Board members Register of interests is reviewed annually by the Board.
Registers
Line managers will ensure that their registers of staff declarations of interests are available for inspection on request by members of the Executive Team, Internal/External Audit or the Local Counter Fraud Officer.
The Board Secretary will ensure that the register of Board member declarations is available on request by members of the public.
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Appendix 3 – Declaration of Gifts and Hospitality
DECLARATION OF GIFTS AND HOSPITALITY
Name of individual making declaration
Department
Employee number
Nature of gift of hospitality received
Details of the individual/organisation offering the gift or hospitality
Value of the gift or hospitality
Date of offer
Initial action taken by individual
OFFER TENTATIVLY ACCEPTED OR DECLINED* *Please delete as appropriate
Signature
Date
This form is now to be submitted to your Line Manager as soon as possible.
LINE MANAGER
I have reviewed this declaration and consider that the initial action taken by the individual is appropriate*
I have reviewed this declaration and consider that the initial action taken by the individual in accepting the offer made is inappropriate and I have advised the individual accordingly that the offer be declined. *
*Please delete as appropriate
Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru Welsh Ambulance Services NHS Trust
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Line Manager Signature
Print Name Date
Signature
Print Name Date
Position
Employee number
Please now forward this form to the Board Secretary.
Board Secretary
I have reviewed this declaration and agree with the action taken by the Line Manager.*
I have reviewed this declaration and have advised the Line Manager that in this instance the action taken is not in accordance with Trust Policy.*
*Please delete as appropriate
The advice I have given is as follows:-
Signature
Board Secretary
Date
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Appendix 4 – Declaration of Interests
DECLARATION OF INTERESTS
Name of Individual making declaration
Department
Employee Number
Area of where conflicting exist may exist
Declaration Please list personal or specific interest to a contract or other employment whether paid or non-paid, voluntary or other non-paid work.
Financial Transactions/ salary or benefits in kind – (Please estimate if not yet known)
Effective date of the interest
SECONDARY EMPLOYMENT List public or private employment including consultancies and self-employment. Please also include employment or voluntary appointments at other NHS employers/organisations.
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DIRECTORSHIPS List public or private appointments, employment or consultancies, company directorships in private or limited companies.
INTEREST IN COMPANIES AND SECURITIES List substantial interest in ownership of private companies, business or consultancies that undertake or may be seeking to undertake business with the NHS.
PERSONAL OR DEPARTMENTAL SPONSORSHIP List a personal or departmental interest in any part of the pharmaceutical industry or sponsorship funding from a known NHS supplier or associated company/subsidiary, e.g. funding research, staff or equipment
POSITION IN CHARITY OR VOLUNTARY ORGANISATION Please list the position and interest, whether or not the charity is relevant to the NHS.
ANY OTHER INTEREST List any other connection with a voluntary, statutory, charitable or private body that could create a potential opportunity for conflicting interests. This may include land or buildings that you may
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seek to sell, rent or lease to the NHS.
I declare that the information I have given on this form is correct and complete and that I will not create a conflict of interest between my NHS employment and an external body/organisation or my personal business interests. I understand that if I knowingly provide false information or fail to disclose relevant information, this may result in disciplinary action and I may be liable to prosecution and/or civil proceedings. I consent to the disclosure of information on this form to review by the Trust’s Auditors and understand the form may be reviewed for the purpose of fraud prevention and detection by NHS Counter Fraud Specialists. I agree to submit further notices in order to bring up to date information given in this notice and will declare any interest I acquire after the date of this notice.
Signed
Print Date
OR I have no interests to declare and I confirm a nil declaration
Signed
Print Date
I confirm that I have reviewed the declaration and do not consider that what is disclosed presents a conflict of interest to the role/duties of the employee within the Trust.
Line Manager Signature
Print Date
The Line Manager is required to retain these declarations for inspection on request by
members of the Executive Team, Internal/External Audit or the Counter Fraud Officer.