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Minutes of the Audit and Governance Committee Meeting held on 19 September 2013 in the Shibden Meeting Room, F Mill, Dean Clough, Halifax

Present:

John Mallalieu Dr Majid Azeb Jackie Bird Dr Peter Davies Kate Smyth

Lay Member (Chair) GP Member Registered Nurse GP Member Lay Member

Also present:

Sarah Antemes Sam Byrnes Julie Lawreniuk Michelle Marsden Martin Pursey Judith Salter Janet Smart Penny Woodhead Jane Brownlie

Head of Commissioning – Continuing Care/Funded Nursing Care (for item 34/13) Associate WSYBCSU (for item 33/13) Chief Finance Officer Internal Audit Manager Head of Contracting and Procurement (for items 40, 41 & 43/13) Corporate and Governance Manager (for items 35, 36, 37 & 39/13) Senior Associate WSYBCSU (for item 32/13) Head of Quality (for item 38/13) Governance Lead

26/13

DECLARATIONS OF INTEREST Majid Azeb and Peter Davies declared an interest in items 35/13 (Local Dispute Resolution Procedure, 40/13 (List of Tenders) and 41/13 (Contracts Register).

27/13 MINUTES OF THE PREVIOUS MEETING HELD ON 8 AUGUST 2013 The minutes of the previous meeting held on 8 August 2013 were accepted as a correct record.

28/13 STRATEGIC REVIEW (OUTSTANDING MATTER ARISING FROM MINUTES OF 30 MAY 2013) Reference was made to an outstanding action from the minutes of the meeting held on 30 May 2013 regarding the requirement for information on the total cost of the contract for support to the Strategic Review and the authorisation procedures and financial limits applied. The Head of Contracting and Procurement advised that the total cost of the contract was £951,000 split over NHS Calderdale and NHS Kirklees. It was reported that on 6 November 2012 the NHS Calderdale, Kirklees and Wakefield District Cluster Board had approved a contract with PA Consulting, which had a ceiling of £600,000. It was reported that subsequently some diagnostic work was undertaken and there was a re-scoping of what was required and this led to a contract

Agenda Item 14a

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extension of £153,000 at the end of 2012. In response to questions from the Chair, it was confirmed that the value of the extension was such that Cluster Board approval had not been required, the cost had been split 50/50 with NHS Kirklees and the Head of Contracting and Procurement confirmed that the correct procurement processes (as specified within Standing Orders/Standing Financial Instructions) had been applied. The extension had been granted on the basis of there being clear benefit to an extension as opposed to starting the contracting process again. In preparation for the end of the contract there had then been discussions on the handover of work from PA Consulting to the Commissioning Support Unit and this had led to a further contract extension of £98,000 since the CSU had not been in a position to take over the work until June 2013. It was noted that the first contract extension had been approved by the PCT but the second extension had been approved under the CCG’s Standing Financial Instructions. In response to a question from a GP Member, the Head of Contracting and Procurement explained that in order to extend a contract it was necessary to waive the usual competitive tendering requirements and Standing Financial Instructions outlined the specific circumstances in which this could occur. He commented that the waiver enabled a proportionate response to the situation, as the alternative of going back out to the market to re-tender would not have been practical in view of the timescales. The Chair commented that his understand was that this waiver had occurred at the very end of a lengthy piece of work and where the Commissioning Support Unit had not been in a position to take over the work immediately. A GP Member referred to the cost of the entire contract and asked about whether Value for Money had been obtained. The Head of Contracting and Procurement referred to the fact that initially there had been a competitive tendering exercise, five of the ten companies that had originally expressed an interest had submitted tenders and they had ranged from £600,000 to £1,100,000, with the tender from PA Consulting being the lowest. It had therefore been known, at the time the original tender had been awarded, that the figure quoted was tight. The Head of Contracting and Procurement added that it was quite common for a consultancy brief to be clear at the outset, but to subsequently change and thus affect the ultimate cost. He added that there was a governance process within the review and for example there had been regular reports to the former Clinical Commissioning Executive and subsequently the CCG Governing Body. The Registered Nurse asked whether the waivers of Standing Orders to enable contract extensions were audited. The Head of Contracting and Procurement advised that historically, waivers rarely occurred (although there were two to be considered later in this meeting). The Chief Finance Officer suggested that the number of waivers be reviewed at the end of the financial year and that it then be decided whether an Internal Audit review should be undertaken. DECISIONS 1. That the oral report be noted.

2. That the number of waivers be reviewed and the end of the financial year

and that it then be decided whether an Internal Audit review should be undertaken.

ACTION ACTION

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29/13 INTERNAL AUDIT AND COUNTER FRAUD UPDATE REPORT

The Internal Audit Manager presented this report which provided an update on recent activity by Internal Audit and Counter Fraud. It was noted that although the 2013/14 work plans for Internal Audit and Counter Fraud had been referred to at previous meetings they had not been formally approved. Copies of the work plans were therefore appended to this report for consideration and approval. Summaries of two Internal Audit reports finalised since the previous meeting were appended to the report. The first of these reports concerned complaints and it was noted that an audit opinion of significant assurance had been given. It was reported that the investigation had included a gap analysis of the CCG’s position against NHS England’s “Guide to good handling of complaints for CCGs”, the Local Authority Social Services and NHS Complaints (England) Regulations 2009 and recommendations in the Francis Report regarding effective complaint handling. The Internal Audit Manager advised that although some gaps had been found between the CCG’s Complaints Framework policy and the guidance, the way in which complaints were being handled in practice was consistent with the requirements in the guidance and it was not considered necessary to bring forward the review of the CCG’s Complaints Framework policy. With regard to the Internal Audit work regarding the Francis report, it was explained that in order to avoid duplication, the approach taken had been to review the work already undertaken. In response to a question from the Chair the Internal Audit Manager confirmed that the CCG’s Action Plan on the Francis report was sufficiently robust to be audited against. It was noted that a further report would be submitted to a subsequent meeting. The second finalised Internal Audit report related to the Assurance Framework and the Internal Audit Manager advised that a formal audit opinion had not been issued on this investigation, that overall the Assurance Framework had been found to be satisfactory. Some gaps in assurance had been identified however, so two recommendations for improvement had been made, both of which had been accepted. With regard to Counter Fraud, it was reported that the main focus had been on fraud awareness and training. It was noted that one training session had already taken place and more were scheduled. A GP Member commented upon the importance of capturing feedback on the training. The Internal Audit Manager commented that, although the Counter Fraud annual work plan was being recommended for approval, it was intended that this would be reviewed when NHS Protect issued its formal standards for proactive work to be undertaken at commissioning organisations. DECISIONS 1. That the report be noted.

ACTION

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2. That the Internal Audit Annual Work Plan for 2013/14 be approved and progress on its implementation be noted.

3. That the Counter Fraud Work Plan for 2013/14 be approved and progress on its implementation be noted.

30/13 EXTERNAL AUDIT TECHNICAL UPDATE

The Chief Finance Officer presented this update on behalf of the KPMG Manager for Calderdale CCG, who was not able to attend this meeting. It was noted that a KPMG Audit Manager would be expected to attend future meetings and that provision of information concerning External Audit would not ordinarily be presented by the Chief Finance Officer. The Chief Finance Officer asked whether the Committee would like to continue to receive these updates in the future. It was agreed that External Audit Technical Updates should continue to be included on the Committee Agendas, that there should not be detailed presentations on them, but that Committee members be offered the opportunity to ask questions on their content. DECISIONS 1. That the update be noted.

2. That external audit technical updates be submitted to subsequent

meetings.

31/13 SUMMARY OF CCG ACCOUNTS REQUIREMENTS The Chief Finance Officer presented this paper from HFMA which summarised the statutory requirements for CCG accounts, the guidance available, the expected format of accounts and key accounting issues for CCGs in 2013/14. Reference was made to the fact that the former Clinical Commissioning Executive had shadowed the PCT’s annual accounts process and the Chief Finance Officer advised that the statutory requirements were similar to those of the former PCT. However, she referred to a new financial ledger that had been implemented from April 2013 and advised that although this was held by the CCG, NHS England had access and could obtain reports from it remotely. The Chief Finance Officer reported that the CCG’s opening balance sheet had not yet been finalised, but that she hoped it would be available to be presented to the next meeting. In response to a question from a GP Member, she advised that although the CCG’s budgets were agreed, the opening balance sheet could not simply be based on the former PCT’s closing balance sheet because several other bodies, in addition to the CCG had taken responsibilities from the PCT, such as NHS England and the Local Authority. The Chair referred to previous discussions he had had about the possibility of a training session on the new format of the accounts (possibly in January 2014).

ACTION

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DECISIONS 1. That the report be noted.

2. That, if available, the CCG opening balance sheet be presented to

the next meeting.

3. That further consideration be given to a training session being held on the new format of the accounts, possibly in January 2014.

ACTION ACTION

32/13 HIGH LEVEL RISK REGISTER POSITION STATEMENT The Commissioning Support Unit Senior Associate for Risk and Governance presented this report which summarised the process for detailed review of the CCG’s risks and included at its appendix the high level risks captured on the CCG’s risk register as at 22 August 2013. A GP Member asked about the sequence of the end of the risk log cycles and the consideration of reports at this Committee and the Governing Body. Concern was expressed at the time lag involved. The Corporate and Governance Manager advised that she had previously looked at this, but would give further consideration as to whether the cycles could be better aligned. The Registered Nurse referred to the start date of some of the risks, with one dating back to 2007. It was confirmed that some of the risks had been passed from the PCT to the CCG and that although those risks themselves remained the same, the register included updated information on the action being taken to address them. It was also explained that the Quality Committee and the Finance and Performance Committee carried out the review of the individual risks and so they received more detailed information than this committee, which concentrated more of an overview and monitored the processes. A GP Member asked about the rationale for the scoring on risk 290 regarding Health Care Associated Infections. The Chair asked that the next risk register report include a short explanation of the rationale behind the scoring of risks as high level. The Corporate and Governance Manager advised that the third paragraph of section 3.5.1 regarding the risk on NHS 111 and West Yorkshire Urgent Care was included in error and needed to be deleted/omitted from the report to the Governing Body as the discussion had been at Quality Committee and not Finance and Performance Committee (the same paragraph was correctly included in section 3.5.2). DECISIONS 1. That the High Level Risk Log and position statement be received.

2. That, subject to the deletion of the third paragraph of Section 3.5.1,

the review of the risks undertaken by the Finance and Performance

ACTION

ACTION

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Committee and the Quality Committee be noted.

3. That, subject to the deletion of the third paragraph of Section 3.5.1, the High Level Risk Log and position statement be recommended to the Governing Body as a true reflection of the risk position as at 22 August 2013

ACTION

33/13 INFORMATION GOVERNANCE TOOLKIT: IMPROVEMENT ACTION PLAN AND PROGRESS REPORT The Commissioning Support Unit Associate Information Governance Specialist presented this report which referred to the requirement for the CCG to submit an annual information governance assessment, by completing the Information Governance Toolkit performance assessment tool. It was reported that, by 31 March 2014, the CCG was required to achieve level 2 performance against 28 specific requirements within the toolkit. An assessment of the CCG’s current position against each of the requirements had been undertaken and an Improvement Plan drawn up to identify specific actions needed to enable the CCG to achieve the minimum level 2 score by 31 March 2014 (and level 3 where level 2 had previously been achieved). The assessment and improvement plan was appended to the report and the Committee was being asked to approve this plan. Reference was made to a number of key actions scheduled for September and October 2013 and it was reported that some progress had already made in implementing the Improvement Plan. In response to a question from a GP Member it was confirmed that the Toolkit applied to the work of the CCG as an organisation, rather than activity within member GP practices. The Registered Nurse asked about arrangements for assurance of progress in implementing the Improvement Plan and it was reported that the Senior Management Team was monitoring progress and it was intended to bring an update report to the remaining Audit and Governance Committee meetings in 2013/14. The Chair suggested that the progress reports include a RAG rating. DECISIONS 1. That NHS Calderdale CCGʼs baseline position and forecast year end

Information Governance Toolkit scores be noted.

2. That the Information Governance Toolkit Assessment and Improvement Plan 2013/14 be approved.

3. That the Information Asset Risk Management Plan and Work

Package be approved.

4. That the progress made to date and the next steps, as identified within the report, be noted.

ACTION

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5. That further update reports, including a RAG rating on progress

towards to required Information Governance Toolkit scores be submitted to the next three meetings.

ACTION

34/13 PERSONAL HEALTH BUDGETS UPDATE REPORT The Head of Commissioning – Continuing Care/Funded Nursing Care presented this report which referred to the government commitment that by April 2014, people eligible for NHS Continuing Healthcare would have the right to ask for a personal health budget, including a direct payment for healthcare. The report outlined the steps being taken to ensure that appropriate systems and processes were in place to enable the introduction of Personal Health Budgets and identified key areas of risk, both for the individual and for the CCG. It was noted that the Senior Management Team had approved a governance structure, that included the establishment of a Project Board (which included a lay member and a clinical member) to oversee the work streams and would report in to Quality Committee and Finance and Performance Committee when specific issues arose. The proposal for the Audit and Governance Committee to take on the role of overviewing the process was noted. The Chair commented upon the risks associated with the implementation of this new form of commissioning and commented that he believed it would be appropriate for the committee to take on this role. It was suggested that the Chief Finance Officer and the Head of Commissioning – Continuing Care/Funded Nursing Care discuss further the process for reporting back to this Committee. DECISIONS 1. That the report be noted.

2. That the Audit and Governance Committeeʼs role in oversight of the

initial implementation of Personal Health Budgets be noted.

ACTION

35/13 LOCAL DISPUTE RESOLUTION PROCEDURE It was noted that Dr Majid Azeb and Dr Peter Davies had declared an interest in this item. The Corporate and Governance Manager presented this report which referred to the commitment within the CCG’s Constitution to develop and agree a clear process for handling and resolving disputes between the CCG and any of its 26 member practices. A proposed Local Dispute Resolution Procedure was appended to the report and it was noted that this had been based on the procedure that previously existed between the Primary Care Trust and primary care contractors and the document “BMA commissioning: Model dispute resolution procedure”.

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A GP Member referred to the Panel membership outlined at point 4.1 of the procedure, which described the Administrator as non-voting and asked about the status of the other panel members listed. It was reported that all the other members would be voting members with the possible exception of the two co-opted members described at point 4.4 whose voting status would be determined by the Panel Chair in advance of the meeting. A GP Member asked about feedback on the frequency of use of the procedure. The Corporate and Governance Manager advised that an integrated governance report was intended to be presented from November 2013 and she suggested that information on the use of this procedure could be included within that report. The Chair asked about Stage 3 of the procedure, where a dispute had not been able to be resolved locally and it therefore had to be forwarded to NHS England’s West Yorkshire Area Team. It was understood that NHS England had not yet developed a procedure for Stage 3, but it was agreed that further information would be circulated once it became available. DECISIONS 1. That further information be circulated on NHS Englandʼs procedure

for Stage 3 once it became available.

2. That, subject to decision 1. above, the Local Dispute Resolution Procedure be approved.

ACTION

36/13 GOVERNING BODY ASSURANCE FRAMEWORK The Corporate and Governance Manager presented this report which referred to the purpose of the Assurance Framework being to identify the principal risks to the CCG delivering its strategic objectives and action to be taken to mitigate against those risks. It was noted that the Governing Body had previously authorised the Audit and Governance Committee to review the Assurance Framework on a six monthly basis, with the first review being due in September 2013. Internal Audit had therefore undertaken a review of the Assurance Framework and a copy of the audit findings was appended to this report. It was noted that two recommendations had been made following findings that assurances were not sufficiently specific and a lack of evidence of action plans being in place to address the identified gaps in assurance. The Registered Nurse commented upon the significant proportion of corporate risks and asked about the relationship with the corporate risk register. It was commented that this tied in with the fact that the Assurance Framework was based on the CCG’s strategic objectives. However, reference was also made to point 3.5 of the report which referred to further work being carried out to test the Assurance Framework against the CCG corporate risk register, the health and wellbeing priorities and any associated risks and comments/recommendations from the Senior Management Team.

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The Internal Audit Manager commented that copies of the Good Practice Briefing – Assurance for Boards were available for committee members on request. It was noted that an updated version of the Assurance Framework was planned to be presented to the next meeting. DECISIONS

1. That receipt of the Internal Audit report on the Assurance Framework (also received under item 29/13) be noted.

2. That authority be granted to proceed to the next steps outlined in the report.

37/13 UPDATE ON REVIEW OF REGISTER OF INTERESTS

The Corporate and Governance Manager advised that legislation required the CCG to maintain registers of interests in respect of members of the CCG, members of its Governing Body, members of its committees and sub-committees and its employees. It was confirmed that there was already a register of interests of Governing Body members (which would shortly be updated) and a letter had been drafted for clinical and lay associates. Consideration was being given to whether the employees register should be restricted to those employees who were in a position to influence CCG decisions. It was also reported that further consideration was being given as to which individuals within member practices were included in the definition of members of the CCG and work would then begin on compiling that register. DECISION That the oral update be noted.

38/13 PROCESSES FOR THE MANAGEMENT OF SERIOUS INCIDENTS – ASSURANCE STATEMENT AND PERFORMANCE REPORT, QUARTER 1 The Head of Quality presented this report which had been considered by the Quality Committee on 25 July 2013. This report was being presented to demonstrate the application of governance systems in respect of Serious Incidents and thus assist the Audit and Governance Committee in performing its function of monitoring governance processes. Reference was made to the policy and procedure for the performance and management of Serious Incidents attached at Appendix B and it was confirmed that this policy was consistent with the new NHS England framework. The Head of Quality advised that Internal Audit was to review the CCG’s Serious Incident processes and she believed this would be valuable, particularly in view of issues with providers concerning timeliness of reporting. In terms of monitoring the Head of Quality advised that there were monthly formal meetings with CHFT and SWYPFT regarding Serious Incidents and weekly meetings between staff. The Chair asked about

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possible sanctions and contractual levers where reporting was being delayed. It was reported that the contracts with providers referred to the requirement of complying with the policy and failure to do so would lead to issues being escalated through the Quality Surveillance Group. The Head of Quality reported that she was assured that the providers were managing their incidents, but there were some issues on the classification of the incidents and she added that the definition of a “serious incident” was not very specific. The Chair expressed concern that delayed reporting damaged the CCG’s ability to see the wider picture of what was happening across Calderdale. A GP member referred to learning from the Francis report and he commented that, as with complaints, it was important that the occurrence of serious incidents was given appropriate attention. The Head of Quality advised that she was satisfied that when serious incidents occurred the situation was being managed well and commented upon improved transparency at CHFT, with its Quality Committee minutes now being publicly available, so that it was possible to trace how a particular incident had been handled. DECISION That the report be noted.

39/13 OPERATIONAL AMENDMENTS TO THE CONSTITUTION - UPDATE The Corporate and Governance Manager presented this progress report regarding proposed amendments to the CCG’s Constitution accepted by the CCG membership and the Governing Body in June/July 2013. It was confirmed that the proposed amendments to be submitted to NHS England for approval and an informal response had been received. Reference was made to four areas in which variations were being suggested by NHS England and it was reported that none of these suggestions constituted a material change to the document. Three of the suggestions had been accepted, but further discussions had taken place in respect of the fourth suggestion that the description of the Director of Public Health and the Director of Adult Health and Social Services be changed from “non-voting member” to “advisor”. It was agreed that the outcome of the discussions on the use of the description “non-voting member” or “advisor” be reported to the next meeting. DECISIONS

1. That the report be noted.

2. That the outcome of the discussions on the use of the description “ non-voting member” or “ advisor” be reported to the next meeting.

ACTION

ACTION

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40/13 LIST OF TENDERS It was noted that Dr Majid Azeb and Dr Peter Davies had declared an interest in this item. The Head of Contracting and Procurement presented this report which provided an outline of tenders under way, the progress made on each tender process and key dates against outstanding actions on these tender processes. Particular reference was made to the procurements taking place under the Any Qualified Provider framework. It was noted that a procurement process had begun for a multi-disciplinary team to support Calderdale care homes for older people. In response to a question from a GP Member it was confirmed that there was a QIPP scheme for care homes in 2013/14, but that it had always been anticipated that it would only have a part year effect. DECISION That the report be received and the activity and progress on procurements be noted.

41/13 CONTRACTS REGISTER UPDATE It was noted that Dr Majid Azeb and Dr Peter Davies had declared an interest in this item. The Head of Contracting and Procurement presented this report which provided an update on the work on-going to maintain and update it. A copy of the Contracts Register as at 12 September 2013 was appended to the report. The Chair commented upon significant progress having been made with many contracts, but in discussion it was confirmed that contracts were marked as “completed” when the CCG/CSU had completed its work on the contract rather than meaning that signed contracts had been returned. A GP member pointed out that the description of service in contracts 799, 780, 784 and 865 – 868 should read Non Obstetric Ultrasound and not Non Obstructive Ultrasound. DECISION That the report be noted.

42/13 WAIVERS OF STANDING ORDERS The Head of Contracting and Procurement reported orally on a recent decision to waive formal tendering procedures and invite a single source tender for the provision of walk-in centres as Park Ward and Todmorden on a fixed term contract for a maximum period of one year.

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It was explained that in 2008/9 each PCT had been required to commission at least one GP health centre in its area to be open from 8a.m. to 8p.m., 7 days a week and combining an “open access”/walk-in element for unregistered patients. Accordingly a contract had been awarded to Care UK Ltd, which incorporated both GP services for registered patients and walk-in services for Park Ward and Todmorden. It was reported that the contract was due to end on 4 October 2013. It was pointed out that, upon the abolition of PCTs in March 2013, responsibility for commissioning Primary Medical Services had passed to NHS England and the responsibility for the commissioning of primary care services for non-registered patients and urgent care had passed to CCGs. It was reported that NHS England was in the process of contracting with a new provider (Locala CIC) to provide primary care services for patients registered at the Park and Todmorden health centres. However a timeline had been agreed for the new contract to commence in November/December and the contract with the existing provider of registered and walk-in services was being extended until that time. With regard to future walk-in service provision, the CCG had commissioned West and South Yorkshire and Bassetlaw Commissioning Support Unit to help establish a longer term model for unscheduled care and potentially including walk-in service provision. Public engagement and dialogue with the Health and Wellbeing Board, the Local Authority Scrutiny Committee and elected members had indicated that it would not be appropriate to completely close the existing walk-in provision prior to a new model of provision being available to take its place. The CCG had therefore committed to maintain a walk-in service on weekends and Bank Holidays until the new model was introduced (expected to be in the summer of 2014. It was therefore intended to commission an interim service to cover weekends and Bank Holidays until the new model was introduced. The waiver of Standing Orders/Standing Financial Instructions was to enable a single source tender to be invited from the organisation with which NHS England was in the process of contracting with for the provision of primary medical services at Park and Todmorden wards. It was reported that, with regard to the rationale for compliance with Standing Financial Instruction requirements, the following issues had been considered; � The fact that NHS Calderdale had market tested for these services over

successive years and its experience had been that the capability and availability to deliver to timescale had been limited.

� There was a clear rationale to deliver a solution through which there was a clear link between the GP contract and the Walk - In service in terms of economies of scale and flexibility for providers.

� The changes in commissioning responsibility consequent to the establishment of the Health Act in April 2013 which split the responsibilities for commissioning GP services and Urgent Care Services had had an impact upon commissioning processes.

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The Head of Contracting and Procurement referred to the provisions within Standing Financial Instructions and specifically Section 16.11 which set out the circumstances where formal tendering procedures could be waived by the Chair and one other Governing Body Member. He advised that the following Standing Financial Instructions were applicable in this case: “(a) the timescale genuinely precludes competitive tendering. Failure to

plan the work properly would not be regarded as a justification for waiving the requirement to tender;

(b) there is a clear benefit to be gained from maintaining continuity with an earlier project. However, in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive tendering;”

The Head of Commissioning and Procurement advised that the decision to waive Standing Orders/Standing Financial Instructions had already been taken by the Deputy Chair and another member of the Governing Body but that Standing Orders/Standing Financial Instructions also required all such waivers to be reported to the Audit and Governance Committee. In discussion, reference was made to the absence of a written report on this item and it was agreed that a written report be presented to the next meeting on the rationale and the process for the waiving of competitive tendering requirements. DECISIONS 1. That the Head of Commissioning and Procurementʼs oral report be

noted. 2. That in future all reports regarding the waiver of Standing

Orders/Standing Financial Instructions, other that nil returns, be submitted to the Committee in advance of the meeting and in writing.

3. That a report be presented to the next meeting on the rationale and

process for the waiving of competitive tendering requirements.

43/13 LOSSES AND COMPENSATIONS It was noted that there had been no losses or compensations since the previous meeting.

44/13 GIFTS AND HOSPITALITY It was noted that there had been no gifts or hospitality reported since the previous meeting.

45/13 ITEMS FOR THE GOVERNING BODY OR OTHER COMMITTEES High Level Risk Register Position Statement – for referral to the Governing Body

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Local Dispute Resolution Policy and Personal Health Budgets - to be referred to in Chief Officer’s report to the Governing Body

CHAIR

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Audit and Governance Committee action sheet 19 September 2013

Report name Action no. @

Action required Lead Current status*

Comments (include, expected completion

date, areas of concern etc)

Strategic Review

28/13 Number of waivers to be reviewed at end of financial year and a decision to be taken as to whether to be the subject of an Internal Audit review

Julie Lawreniuk

Not yet due

Summary of CCG Accounts Requirements

31/13 1. CCG Opening Balance Sheet to be presented to next meeting (if available)

2. Consideration to be given to a training session on the new format of the accounts, possibly in January 2013

Julie Lawreniuk

Underway

On Agenda for meeting on 21.11.13

High Level Risk Register Position Statement

32/13 1. Next Risk Register report to include a short explanation of the rationale behind the scoring of risks as high level

2. Third paragraph of section 3.5.1 to be deleted prior to presentation of report to the Governing Body

3. Subject to 2. above, position statement to be recommended to the Governing Body as a true reflection of the risk position as at 22 August 2013

Janet Smart Janet Smart Janet Smart

Complete Complete Complete

Information Governance Toolkit

33/13 Further progress reports (including a RAG rating on progress) to be presented to the next three meetings.

Sam Byrnes Underway

Personal Health Budgets Update Report

34/13 Chief Finance Officer and Head of Commissioning – Continuing Care/Funded Nursing Care to discuss further the arrangements for reporting back to this committee

Julie Lawreniuk/ Sarah Antemes

Underway

Local Dispute Resolution Procedure

35/13 Information on NHS Englandʼs Stage 3 of the procedure to be circulated when available

Judith Salter Not yet available

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Operational Amendments to the Constitution

39/13 Outcome of discussions on the reference in the Constitution to the description “ non-voting member” or “ advisor” to be reported to the next meeting.

Judith Salter Item Agenda for meeting on 21.11.13

Waivers of Standing Orders

42/13 Report to be presented to the next meeting on the rationale and process for the waiving of competitive tendering requirements

Martin Pursey Item on Agenda for meeting on 21.11.13