Audit Committee Assurance Report - May 2024

Meeting: Public Meeting

Date: 8 May 2024

Report Title: Audit Committee Assurance Report

Agenda Item: PUB24/05/7.1

Committee Date: 21 February 2024

Meeting Chair: George Lynn – Non-Executive Director and Committee Chair

Meeting Quorate: YES

Purpose: Assurance

Recommendation: The Board is asked to receive assurance from the business discussed at the meeting and to review the matters for escalation and referral.

Link to Strategic Objective:

• Be an exceptional place to work, volunteer and learn
• Provide outstanding quality of care and performance
• Be excellent collaborators and innovators as system partners
• Be an environmentally and financially sustainable organisation

Summary of Items Considered at the Meeting

Board Assurance Framework and Risk Management

Consideration: Overview of strategic and corporate risk management of the organisation.

Resolution/Outcome: Noted that despite no changes in risk scoring, relevant assurance committees are undertaking reviews to feed into Executive Board reviews in March 2024. Committee proposed risk appetite and tolerance assessments were tabled in the meeting.

Assurance: Reasonable

Group Assurance Report

Consideration: Report on levels of assurance provided in areas reported to CRG at its last meeting.

Resolution/Outcome: Noted that five groups reported reasonable/moderate assurance, one limited and another substantial. There were no areas for escalation identified by CRG.

Assurance: Reasonable

Freedom of Information

Consideration: Annual Report on FOI volumes, compliance, ICO interaction.

Resolution/Outcome: Noted the increase in FOI requests, not helped by current unavailability of website (and information).

• Compliance of responses fluctuates (Av 61% on time)
• Open FOIs - all time high
• Informatic data (response times, call times), Financial and HR
• Three ICO late reporting complaints since April 2023
• One ICO Decision Notice

Assurance: Limited

Information Governance updates

Consideration: Update on the Trust’s current position with respect to:

• Digital Security Protection Tool compliance
• Information Governance breaches
• Subject Access Requests and FOI’s

Resolution/Outcome: Noted:

• DSPT internal audit Feb 2024
• IG breaches continue at c.14 (key areas email misdirection and accessing NICE recordings
• 2025 DSPT to be merged with Cyber Assurance – significant increase in reporting

Assurance: Reasonable

Risk Management Strategy and Policy

Consideration: Draft revised Risk Management Policy

Resolution/Outcome: Noted a significant proposed re-write of the Risk Management Policy and appendices. Approved for consideration by Executive Committees and Board.

Assurance: Reasonable

Financial Management - Contract Renewals

Consideration: Oversight of current renewals in progress and issues/risks associated with contract renewals.

Resolution/Outcome: Noted progress across supplier categories. Two areas were highlighted as potential approval and timing issues:

• Occupational Health – the decision not to renew and bring much of the provision in-house will entail new contracts for OH related services (to be specified).
• Vehicle MOT, repairs and maintenance – not yet clearly specified but contract ends September 2024.

Assurance: Reasonable

Annual Accounts timetable

Consideration: Report on 2023-24 Accounts timetable

Resolution/Outcome: Key deadlines identified and the timetable of actions established to enable the Trust to meet these deadlines.

Assurance: Substantial

Losses and special payments

Consideration: Report on compliance with HM Treasury 2023 "managing public money"

Resolution/Outcome: Noted nine ex-gratia payments (November 2023 to January 2024) totalling £66k. In addition, a further 11 PILON payments totalling £88.2k (of which £57.1k relates to MARS settlements). It was reported that YTD MARS payments amount to £905.9k in 2023/24.

Assurance: Reasonable

Tenders and waivers

Consideration: Report on Tenders and Waivers (November 2023 – January 2024).

Resolution/Outcome: Noted that the Trust had appeared by Q3 to be on-track to meet financial waivers target. However, based on January 2024 numbers, it is expected that targets will be closely missed. Noted historic trajectory towards targets, but queried what needs to happen to meet targets within EEAST?

Assurance: Reasonable

Procurement Act 2023 introduction

Consideration: Review of impact on Trust of compliance with new procurement process and reporting requirements.

Resolution/Outcome: Noted that the Act represents an opportunity to be more innovative in procurement processes, be more flexible, be more transparent and to embrace SME’s and the voluntary sector, whilst further supporting sustainability, Net Zero and other social value goals. It will however increase the admin burden on procurement and also, increase the risk of challenge through the courts.

Assurance: Reasonable

Counter Fraud reporting and 24/25 planning

Consideration: Update on Counter Fraud team since November 2023, and plan for 2023/24.

Resolution/Outcome: Noted continuing progress in managing fraud across EEAST. Noted that the Team’s work is communicated across the organisation. We approved the draft work plan for 2024/25.

Assurance: Reasonable

Internal audit reports

Consideration: Update on emerging IA work against 2023/24 plan. Including:

• Business Continuity and Disaster Recovery (limited assurance)
• Grievance Reporting and Management (substantial assurance)
• Violence in the workplace (reasonable assurance)
• Planned and Preventative Estate Maintenance – Sustainability (reasonable assurance)
• Clinical Audit (substantial assurance) and Private Ambulance Service (reasonable assurance)

Resolution/Outcome: Noted progress to date, in particular two items:

• Clinical Audit – substantial assurance. Members thanked the internal audit team for their support in addressing past issues.
• Business Continuity and DR - limited assurance arose because of 11 important action points identified by tiaa. Agreed to escalate to ELT and Board for discussion,

Assurance: Reasonable

External audit update report

Consideration: External Audit Plan presented for 2024 Audit Plan.

Resolution/Outcome: Approved EY 2024 Audit Plan.

Assurance: Reasonable

Matters for escalation or referral

Risk Management Strategy and Policy Document

Referred to: Other committees and Executive Directors Reason: To note Approval of Draft Risk Management Strategy and Policy Document

Reservation of Powers to Trust Board and Scheme of Delegated Standing Financial Instructions

Referred to: Trust Board Reason: Recommended that Reservation of Powers to Trust Board and Scheme of Delegated Standing Financial Instructions be Approved for 2024/25.

DSPT- FOI and SARS

Referred to: ELT and Trust Board Reason: Recommended that Board and ELT consider planning for increasing FOI and SARS activity and expected enhanced DSPT reporting. EEAST team are struggling against an increasing volume of information requests, with internal directed responses not being acted on promptly, leading in turn to ICO complaints, notices and potential fines. This is a situation which will only get worse without specific interventions in staff training, internal processes, and inevitably funding.

Internal Audit – Business Continuity and DR (limited assurance)

Referred to: ELT and Trust Board Reason: Recommended that ELT and Board consider the commentary and actions relating to tiaa’s report on Business Continuity and DR.

Noting additionally that the Compliance and Risk Group’s report to Audit Committee considered that the Business Continuity Management level of assurance in this area is “Reasonable”.