Bundle Audit Committee (Open) 13 September 2018...Bundle Audit Committee (Open) 13 September 2018 1 PROCEDURAL MATTERS 1.1 13:00 - Welcome and Apologies For Absence 1.2 13:04 - Declarations

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


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


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


COMPLETED

19 14-Sep-17


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


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


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


External AuditCOMPLETED

19 14-Sep-17


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


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


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




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




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.




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




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.


STATUS SCHEDULE Appendix A



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






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







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)


Operational Service and Functional Management

Health Board Areas/Station review

follow up

Q3 March

Hospital handovers follow up

Q4 May

Escalation procedures


Clinical Contact Centre - Hear &

Treat


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






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


KEY PERFORMANCE INDICATORS Appendix B



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


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.




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



Audit and Assurance Services

Fleetwave II System Report Contents



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



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



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.




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.


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.




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.




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;




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.




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.




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


Action Plan


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


Action Plan


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.


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.


Completed

Will be completed by 6th September 2018


Action Plan


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.


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


Already actioned Completed


Action Plan


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.


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


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.


31st October 2018


Action Plan


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.


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


Action Plan


We recommend that the authorisation levels embedded into Fleetwave for approval of stock

orders should also be embedded for contract maintenance invoice approvals.


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


Action Plan


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.


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


Agreed

We will review tolerance levels in line with those used within Oracle.

Interim Deputy Director

of Finance

31st October 2018


Action Plan


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.


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


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


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


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


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*


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.


Action Plan


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.


Action Plan


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


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


2018/19


Private and Confidential



Annual Quality Statement Report Contents



CONTENTS Page

1. Introduction and Background 4

2. Scope and Objectives 4

3. Associated Risks 5


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


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 C

Management Action Plan Matters arising from Source Documents

Prioritisation of Recommendations Appendix D


Annual Quality Statement Report Contents



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:







party.

Annual Quality Statement Internal Audit Report




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.


2.1 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.




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 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.





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.



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.




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.


A thorough quality review of the AQS should also be undertaken by management before

it is published to ensure completeness and accuracy. High



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.


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





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



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.



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.



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.


Action Plan






Priority

Level

Explanation

Management

action

High


with key controls.

PLUS



Immediate*

Medium



PLUS


Within One

Month*

Low





Within

Three

Months*


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




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


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


evaluation was undertaken in relation to priority areas established after discussion and agreement with the Trust. Following interviews with relevant



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,




Action Plan




Responsibilities


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




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



Action Plan


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


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


2018/19




Continuous Professional Development Management Report Contents


CONTENTS Page







6. Summary of Audit Findings 7

7. Summary of Recommendations 10


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 C

Management Action Plan Assurance opinion and action plan risk rating


Continuous Professional Development Management Report Contents


Finance and Resources

Committee

ACKNOWLEDGEMENT


review.

Please note:





They are prepared for the sole use of Welsh Ambulance Services Trust and no responsibility is taken by the Audit


party.

Continuous Professional Development Management Internal Audit Report



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.


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;



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.




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


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.



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





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.


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


management attention with moderate impact

on residual risk exposure until resolved.




The findings from the review have highlighted three issues that are classified as weakness in the system control/design for Continuous

Professional Development Management


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


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:



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.



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



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.


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.


Number of

recommendations 2 3 0 5

Continuous Professional Development Management Welsh Ambulance Services NHS Trust

Action Plan


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.


Action Plan


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.


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


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


Action Plan


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.


Action Plan


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.


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


Action Plan



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


Development 1 January 2019


Action Plan


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.


Action Plan


consequences of not completing CPD hours and the compliance monitoring and

reporting process.


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


This recommendation is accepted and will be implemented in line with

recommendation 1 above.

Andrew Challenger, Interim

Head of Learning & Development 1 January 2019


Action Plan


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.


Action Plan



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


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


Action Plan


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.


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


Action Plan


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.


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.


Development 31 March 2020 (subject to funding)

CPD Management Welsh Ambulance Services NHS Trust







exposure.


















Priority

Level

Explanation

Management

action

High


with key controls.

PLUS



Immediate*

Medium



PLUS


Within One

Month*

Low





Within

Three

Months*



Confidentiality




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


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






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



an organisation’s objectives. The likelihood of achievement is affected by



circumstances.


improvements to the current internal control systems can be attained, recommendations have been made that if implemented, should ensure that






Responsibilities



and detection of irregularities and fraud. Internal audit work should not be seen as a substitute for management’s responsibilities for the design and


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.





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


2018/19




Volunteer Car Drivers’ Governance Arrangements Report Contents



CONTENTS Page







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



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



ACKNOWLEDGEMENT


review.

Please note:







party.

Volunteer Car Drivers’ Governance Arrangements Internal Audit Report




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.


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;




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.




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


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.




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





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


areas under review, are suitably designed and

applied effectively. More significant matters require management attention with moderate

impact on residual risk exposure until

resolved.




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.


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.


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.


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




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.




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




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.


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.


Number of

recommendations 3 2 0 5

Volunteer Car Drivers’ Governance Arrangements Welsh Ambulance Services NHS Trust


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.



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;



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.


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



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.


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


March 2019

Head of NEPTS Transformation

September 2019



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.



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.



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.




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




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





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.



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.


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



c) Review the recruitment process in place to ensure that there are minimal delays when recruiting volunteers.


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.


March 2019

NEPTS Volunteer Manager September 2019


March 2019



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.


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




The new Volunteer Manager, in partnership with the other NEPTS Managers will review and update the VCS Policy and progress through the policy process.




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.



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.


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




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.


September 2019


December 2019



September 2019

Volunteer Car Drivers’ Governance Arrangements








exposure.














Prioritisation of Recommendations In order to assist management in using our reports, we categorise our recommendations



Priority

Level

Explanation

Management

action

High


with key controls.

PLUS



Immediate*

Medium



PLUS


Within One

Month*

Low





Within

Three

Months*

Volunteer Drivers’ Governance Arrangements



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



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



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



personnel and a review of key documents, files and computer data, an

evaluation was made against applicable policies procedures and regulatory



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,








Responsibilities


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




work directed towards identification of fraud or other irregularities.






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


2018/19




Environmental Sustainability Reporting Contents



CONTENTS Page








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


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



Appendix C

Management Action Plan Matters arising from Source Documents

Prioritisation of Recommendations Appendix D


Environmental Sustainability Reporting Contents



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:







party.

Environmental Sustainability Reporting Internal Audit Report




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.


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;




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


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.





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.




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.




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


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.


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




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



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;



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.


Action Plan






Priority

Level

Explanation

Management

action

High


with key controls.

PLUS



Immediate*

Medium



PLUS


Within One

Month*

Low





Within

Three

Months*


Action Plan


Confidentiality




accept no responsibility to them in respect thereof. The report must not be




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





copies disclosed.

Audit





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



circumstances.


improvements to the current internal control systems can be attained,




Action Plan




Responsibilities



and detection of irregularities and fraud. Internal audit work should not be




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



Action Plan


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


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

[email protected].

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


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


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


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


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.


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.


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.


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

[email protected].

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


The person who delivered the work was Fflur Jones.

Contents


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


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


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


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


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.


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.


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


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


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.


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


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


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


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




Accepted (yes/no)


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




Accepted (yes/no)


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

Tudalen 2 o 20 - Ymwreiddio’r egwyddor datblygu cynaliadwy mewn ffyrdd o weithio – Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru

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

[email protected].

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


Fflur Jones oedd y sawl a gyflawnodd y gwaith.

Cynnwys


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


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


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


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


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.


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.


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


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


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.


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


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


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


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


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






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






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






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


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 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 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



16RT4PI0057 AJOURNMENT FEE Actual Payment 255.00





18RT4DP0102 VEHICLE HIRE Actual Payment 2,000.00

18RT4DP0102 POLICY EXCESS Actual Payment 150.00

18RT4DP0104 GENERAL DAMAGES SETTLEMENT Actual Payment 1,954.56


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



18RT4PI0029 ADJOURNMENT FEE Actual Payment 255.00

18RT4PI0033 TRANSCRIPTION COSTS Actual Payment 126.24

Totals 815,991.60

May-18



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-



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


16RT4PI0061 COURT FEE Actual Payment 100.00



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


18RT4PI0029 Claimant's Solicitor's Fees Actual Payment 180.00


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-




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


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


04RT4MN0003 EXPERT WITNESS Actual Payment 300.00



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


16RT4PI0057 CLAIMANT'S SOLICITOR'S FEES Actual Payment 250.00



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


18RT4PI0029 Conference Cancellation Fee Actual Payment 20.00





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



Totals 40,973.07

Jul-18


15RT4MN0003 WRP REFUND Actual Payment - 615.00






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 APPLICATION COSTS Actual Payment - 100.00


17RT4PI0043 Medical Report Actual Payment 990.00

18RT4DP0065 VEHICLE REPAIRS CN15BRF Actual Payment 372.00







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 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



EXECUTIVE Board Secretary

AUTHOR Corporate Governance Manager

CONTACT DETAILS Tel: 01633 626251 Email: [email protected]

CORPORATE OBJECTIVE All


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


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



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


QUALITY THEME All

HEALTH & CARE STANDARD All

REPORT PURPOSE To approve the policy.

CLOSED MATTER REASON


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?


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:


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




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




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




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.




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.




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.




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.




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;




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




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




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.




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




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.




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.




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.




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




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




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.

Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru Welsh Ambulance Services NHS Trust




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




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.