Agenda and supporting papers - Plymouth Hospitals NHS Trust
Agenda and supporting papers - Plymouth Hospitals NHS Trust
Agenda and supporting papers - Plymouth Hospitals NHS Trust
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Item 18<br />
SUMMARY REPORT<br />
<strong>Trust</strong> Board 5 July 2013<br />
Subject<br />
Prepared by<br />
Approved by<br />
Presented by<br />
Audit Committee Chair’s Report<br />
Board Secretary<br />
Margaret Schwarz, NED Chair<br />
Margaret Schwarz, NED Chair<br />
Purpose<br />
This paper provides a summary of assurances received <strong>and</strong> issues or<br />
concerns that the Audit Committee feels should be brought to the attention<br />
of the <strong>Trust</strong> Board, or to other Board Committees, resulting from the Audit<br />
Committee meeting on 31 May 2013.<br />
Corporate Objectives<br />
Decision<br />
Approval<br />
Information<br />
Assurance<br />
Quality Care Inspired People Healthy Organisation Innovate & Collaborate<br />
•<br />
Executive Summary<br />
The Committee received internal management, Internal Audit <strong>and</strong> External Audit reports.<br />
CQC Outcome Review<br />
In accordance with its forward work plan, at each meeting the Committee tests the<br />
adequacy of assurance <strong>and</strong> the process for testing compliance of a CQC outcome. The<br />
Committee assessed Outcome 21 Records, an issue of longst<strong>and</strong>ing concern. The review<br />
had been scheduled as a result of known focus by the Care Quality Commission. The<br />
Director of Planning & Site Services reported on evidence of compliance, gaps in assurance<br />
or areas where evidence of compliance could be strengthened <strong>and</strong> the actions in place to<br />
address these issues. Three issues identified by a CQC inspection in 2012 remain a<br />
concern:<br />
• Security of case notes on wards.<br />
• Updating case notes in a timely manner.<br />
• Treatment Escalation Plans not being completed consistently in respect of DNAR.<br />
The Committee received limited assurance that the planned actions would achieve<br />
compliance <strong>and</strong> no assurance on the timescale for achieving compliance. Health<br />
records was again raised as a concern in verbal feedback from the CQC following a recent<br />
inspection <strong>and</strong> the Committee noted that their written report of their findings was imminent.<br />
The Safety & Quality Committee would continue to oversee this issue.<br />
Bevan Brittan Risk update<br />
This covered key points from the Francis Report, focusing on the requirement for <strong>NHS</strong> trusts<br />
to consider the Report’s recommendations <strong>and</strong> to decide how, <strong>and</strong> to what extent, to apply<br />
them to their respective organisations. Key advice for the Board was to avoid complacency<br />
through over-reliance on positive feedback from patient surveys. More generally, in terms<br />
of the Board’s responsibility to ensure the provision of safe patient care, the advice was for<br />
the Board to be mindful of the pressure in the wider health system <strong>and</strong> to ensure that its<br />
decisions were based on reliable data.<br />
Annual Reports<br />
The Committee reviewed three annual reports for the year 2012/13; Counter Fraud, Internal<br />
•<br />
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