Physical Verification of Fixed Assets - Health in · PDF fileAttachment 11i Physical Verification of Fixed Assets FINAL INTERNAL AUDIT REPORT 2015/16 Hywel Dda University Health Board

Attachment 11i

Physical Verification of Fixed Assets

FINAL INTERNAL AUDIT REPORT

2015/16

Hywel Dda University Health Board

Private and Confidential

NHS Wales Shared Services Partnership

Audit and Assurance Services

Assurance Rating

REASONABLE Assurance

Previous Rating: REASONABLE Assurance

Physical Verification of Fixed Assets Report

Contents


NHS Wales Audit & Assurance Services Page | 2

CONTENTS Page

1. Introduction and Background 3

2. Scope and Objectives 4

3. Associated Risks 4

Opinion and key findings

4. Overall Assurance Opinion 5

5. Assurance Summary 5

6. Summary of Audit Findings 7

Conclusion and Recommendations

7. Summary of Recommendations 13

Review reference: HDUHB 1515 Report status: Final

Fieldwork commencement: 1st February 2016 Fieldwork completion: 11th April 2016

Draft report issued: 20th April 2016

Management response received: 4th May 2016

Final report issued: 5th May 2016

Auditor: Ceri-Ann Corcoran, Arthur Burke.

Executive sign off Director of Finance, Planning & Performance Distribution Karen Miles; Eldeg Rosser; Peter Evans

Committee Audit & Risk Assurance Committee ACKNOWLEDGEMENT NHS Wales Audit and 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 and Assurance Services reports are prepared,

in accordance with the Service Strategy and Terms of Reference, approved by the Audit & Risk Assurance

Committee.

Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance

Services, and addressed to Independent Members or officers including those designated as Accountable Officer.

They are prepared for the sole use of the Hywel Dda University Health Board 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.

Appendix A Appendix B

Appendix C

Management Action Plan Complete Sample List of Assets Verified

Assurance opinion and action plan risk rating

Physical Verification of Fixed Assets Internal Audit Report



1. Introduction and Background

Internal Audit conducted a physical verification of fixed assets across

the three counties of Hywel Dda University Health Board (HDUHB).

Internal Audit has previously discussed the coverage of fixed assets with Wales Audit Office (WAO), and it was agreed that Internal Audit

would only physically verify fixed assets, with WAO reviewing all other

aspects. In addition to this, the Health Board has a three year cyclical verification programme in place, as agreed by the Audit & Risk

Assurance Committee. All Pembrokeshire county sites were covered during the financial year 2015/16.

To help contextualise the Health Board’s holdings; as at 31 December

2015 the net book value of the Health Board’s tangible assets stood at approximately £234.3 million. The table below shows how this is made

up:

The importance of notifying the Finance department, upon the disposal

or transfer of an asset, has been reiterated to Health Board staff on a quarterly basis, via global e-mails. The latest reminder via global e-

mail was sent out on 4 February 2016. Discussions with the Service Modernisation Team highlighted that whilst significant steps have been

taken to improve system compliance, the team remains reliant on departmental/ward managers keeping them informed of asset

movements.

The overall objective is to ensure that the fixed assets of the Health Board exist and are located in the locations stated on the asset list.

Category of Asset

Net Book Valuation

31/12/15

(£m)

%

Land, buildings, dwellings & assets

under construction 213.6 91.2

Plant & machinery 14.8 6.3

IM&T 4.0 1.7

Furniture & fittings 1.9 0.8

Transport 0.0 0.0

Total 234.3 100




2. Scope and Objectives

120 fixed assets were randomly selected from the Asset Register for physical verification, the sample covering the four main hospitals of the

Health Board. Full details can be seen in Appendix B of this report, with only the exceptions being noted in the main body of the report.

3. Associated Risks

Failure to accurately record and identify assets could lead to capital assets recorded in the financial accounts to be mis-stated.




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 Fixed

Assets system 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.

5. Assurance Summary

The summary of assurance given against the individual areas tested is

outlined in the table below:

RATING INDICATOR DEFINITION

Reason

ab

le

Assu

ran

ce

The Board can take reasonable assurance

that arrangements to secure governance, risk management and internal control, within those

areas under review, are suitably designed and applied effectively. Some matters require

management attention in control design or compliance with low to moderate impact on

residual risk exposure until resolved.

ASSURANCE SUMMARY

Audit Scope

1 Follow up of Previous Audit Report (HDUHB1422)

2 BGH Physical Verification

3 GGH Physical Verification




* The above ratings are not necessarily given equal weighting when generating the audit opinion.

Design of Systems/Controls (D)

No findings were identified that are classified as a weakness in the system

/ control design for the management of Fixed Assets. These would be identified in the Management Action Plan as (D).

Operation of System/Controls (O)

All the findings from the review are classified as a weakness in the operation of the designed system / control for the management of Fixed

Assets. These are identified in the Management Action Plan as (O).

4 PPH Physical Verification

5 WGH Physical Verification




6. Summary of Audit Findings

The key findings by the individual locations tested are reported in the section below:

Follow up

The following areas of good practice were noted:

The Asset Register has been significantly updated to show all

departments/wards and progress has been made in updating asset details such as serial number/make/model. One County

is reviewed annually on a cyclical basis by Finance, this has helped to improve the accuracy of the Asset Register.

Quarterly global email messages are sent out to remind

departments/wards of their responsibilities to inform Finance of any disposals made.

Stronger communications have been developed with EBME and IT. They have their own registers and Finance have

access to these. It is not considered necessary to include the Finance register numbers in the EBME database.

The anomalies in last year’s report have been investigated and the Asset Register amended accordingly.

Physical Verification

A total of 40 assets of the 120 sampled, could not be physically

verified at the location listed. It should be noted that 7 of the 40 exceptions (as highlighted in the following tables) were either

verified at different locations to that recorded in the Asset Register,

or have subsequently been confirmed by the department as still being in use. Details of each exception are listed in the tables

below:




Location: Bronglais General Hospital

Department Asset No. Asset Description Net Book

Value (NBV) Findings

Management Response

HOTEL SERVICES

3065

Franking Machine

£0.00

This franking machine has been disposed of, a new one has been purchased.

Finance were not informed that this asset had been disposed of. Asset has now been removed from the register.

ENDOSCOPY 5384 Colonoscope (Variable)

£0.00 Dept has had a new colonoscope - this one went back to Fuji.

As above.

RADIOLOGY

5795

Ultrasound Scanner

£0.00

Model 'Aplio 80 XV' is not present, but 'Aplio 80 XG' is. The Dept. Coordinator – Radiology stated that they disposed of one scanner in 2013 and bought a new one. So it is assumed that the XV model was the one disposed of and it was replaced by the XG.

As above.

BIOCHEMISTRY

7623

Osmometer

£0.00

The dept has a new osmometer (serial no. 05111224A) it was swapped for this one.

As above.

THEATRE

8382

Orthopaedic Drills

£2,559.34

Audit were informed that there are 5 or 6 drills in the department but that none of them have asset numbers on them.

We are awaiting a response from the department asking for verification that the drills are still held.

DSU

8884

Patient Monitoring System

£3,377.19

No 'Intelivue MP50' monitors on the ward, only model 'MP30's.

We are awaiting a response from the department for clarification on this asset.

DSU

008986-11

Minor Surgery Lamp

£619.19

Not found within Day Clinic Unit but was told it was in use in main Theatre department.

This appears to have been verified.

A & E

009225-06


£2,440.56

Not found.

We are awaiting a response from the department as to the circumstances of this asset.




Location: Withybush General Hospital

Department Asset No. Asset

Description

Net Book Value (NBV)

Findings Management

Response

DENTAL CLINIC 4356 Dental Cart £0.00

Dental Clinic has gone. It was later confirmed by e-mail that the asset is now in Surgery 1, Purple Corridor.


ECG 5180 Digital Pathfinder £0.00

1 (32481) of 2 verified. 9813 has gone back to the company, no longer used.


ENDOSCOPY 008008-01 Drying Cabinet £8,389.67 Not found.


HOTEL SERVICES 5388

Combination Oven £1,748.11

Two ovens listed - only the oven with serial number 743658 was found. 727869 has been disposed of.


HOTEL SERVICES 6216 Trolley Heated £0.00

All the trollies were newer than year 2000 when this trolley was purchased.


PHARMACY 4227

Cytotoxic Dispensing Safety Ca £0.00

The asset matching the age of that on register has been disposed of and new ones have been purchased as per conversation with Pharmacy staff. As above.

SCBU 5567 Infant Ventilator £0.00

SCBU no longer exists as a ward and asset could not be found. Site Works Supervisor stated that asset has been moved to Bay 3 next to SCBU.

The asset has been confirmed as obsolete by the department therefore we have removed it from the asset register.

THEATRE 4132 Camera System £0.00 Not found, shown around by ODP.

The department has confirmed that the asset is in use.

THEATRE 4796 Phrenic Nerve Stimulator £0.00

One of four found, asset number of 4656. Shown around by ODP.


WARD 10 5705 Patients Hoist £0.00 Asset was disposed of within the last month, ward has been using one from

Finance were not informed that




Manual Handling whilst awaiting a new hoist. Confirmed with Staff Nurse.

this asset had been disposed of. Asset has now been removed from the register.

Location: Glangwili General Hospital

Department Asset No.

Asset Description

Net Book Value (NBV)

Findings Management Response

CILGERRAN 004733-03 Pulse Oximeter £0.00

Spoke to Medical Devices Trainer and EBME Department Manager who confirmed it had been disposed of.


CILGERRAN 005259-01

SpO2 Pulse Oximeter £0.00

Spoke to Medical Devices Trainer and EBME Department Manager who confirmed it had been disposed of.


DINEFWR 9300 Equipment - Dinefwr £5,507.44

Insufficient detail in the name of asset on Asset Register and no other identification marks to assist. Asset not found on Ward.

We have provided details to the department of what this equipment is and are awaiting a response for verification.

ENDOSCOPY 007928-02

A6 Colour Printer £86.19

In process of transferring this item to Theatre so is not currently on the ward, but is in the hospital still.

The department has confirmed that this asset is now located in Theatre.

ENDOSCOPY 9118 Patient Trollley System £4,244.03

Several on ward, none of which match asset number.

Asset numbers relate to their reference number on the fixed asset register and are not attached to assets. We have emailed the department to confirm this particular asset is still present.

HDU 005061 Volumetric Pump £0.00 Not found.

This asset has been confirmed by the department as still in use.

ICU 5091 Volumetric Pump £0.00 Senior Sister couldn't find item.


ICU 7409 Syringe Pump £0.00 Senior Sister couldn't find item.


LABOUR 004819- Radiant £0.00 Confirmed with EBME Department Finance were not




WARD 03 Heaters Manager that asset is a heated blanket but it was beyond economic repair.

informed by the department. Asset has now been removed from the register.

PICTON 4583 Light Source Camera Stack £0.00

Found the camera stack in Aberglasney Suite.


PUMP LIBRARY

004983-15

Volumetric Pump £0.00 Not found.


THEATRE 4074 Syringe Pump £0.00 EBME confirmed that asset was disposed of and replaced.


Location: Prince Philip Hospital

Department Asset No.

Asset Description Net Book

Value (NBV) Findings

Management Response

BLOCK 6 COM 6975 Repose Pressure Equipment £0.00

Not found.

Asset has now been removed from the register.

CLINICDECISI 009392-17

Patient Monitoring System £4,242.48

Not found.

We are awaiting a response from the department as to whether this asset is still in use.

DAYCARE UNIT 4787

Phaco Instrument Pack £0.00

Moved to Amman Valley Hospital according to Day Surgical Unit Sister.


EBME 4050 Syringe Pump x 3 £0.00

Not found.


ENDOSCOPY 5111 Trolley Stack £0.00

Two trolley stacks found, neither have correct identifying numbers.


HISTOLOGY 5597 Microscope £0.00

Not found, may have been sent to GGH.


ITU 004925-12 Syringe Pump £0.00

Not found.


ORTHOPAEDIC THEATRE 004534

Intellivue MP70 Anaesthetics £0.00

Not found.


PUMP LIBRARY

003994-01 Syringe Pump £0.00

Not found, Pump Library doesn't exist.

We are awaiting a response from




the department as to whether this asset is still in use.

THEATRE 005199 Force Triad Energy Sys £0.00

Two are in the department but neither have serial numbers on them.





7. Summary of Recommendations

The audit findings and recommendations are detailed in Appendix A together with the management action plan and implementation timetable.

A summary of these recommendations by priority is outlined below:

Priority H M L Total

Number of

recommendations 0 1 0 1

Physical Verification of Fixed Assets Hywel Dda University Health Board

Action Plan

NHS Wales Audit & Assurance Services Appendix A

Finding 1: Physical Verification (O)

Risk

Anomalies were found in 40 out of the 120 assets physically verified, as described in the tables above.

The assets of the Health Board could be mis-stated.

Recommendation 1 Priority level

The anomalies listed in the tables above should be investigated and, if required, the

asset register adjusted appropriately, to reflect an accurate position.

Management Response 1 Responsible Officer/ Deadline

The recommendation is noted and has been actioned.

It is worth noting that the Service Modernisation Team (Finance) can only amend the capital asset register once they have been made aware of any changes, it is the

responsibility of the ward/department managers to inform them of any changes. Global email reminders are sent regularly and a 3 year cyclical verification process is

undertaken.

Head of Service Modernisation.

May 2016.



Action Plan

NHS Wales Audit & Assurance Services Appendix

Complete Sample List of Assets Verified Across the Health Board

Bronglais General Hospital

Sam

ple

Re

f

Department Asset No. Asset Description Asset

Physically Verified?

Comments

1 A & E 008846-06 Syringe Pump

2 A & E 009225-06


3 A & E 008293-02 Patient Monitor

4 A & E 008825 Disinfection Dishwashers

5 BIOCHEMISTRY 007623 Osmometer

The dept has a new osmometer (serial no. 05111224A) it was swapped for this one.

6 BIOCHEMISTRY 008009-01-05 Pharmacy Fridge

The dept would be better described as Blood Sciences.

7 CLINICAL DECISION 008881-05


8 CMU 005577 Patient Monitor

9 DSU 008829 Shoe washer and basket

Only one unit in DSU, no asset number on it but the model of washer is correct.

10 DSU 008884


No 'Intelivue MP50' monitors on the ward, only model 'MP30's.

11 DSU 008986-11 Minor Surgery Lamp

Not found within Day Clinic Unit but was told it was in use in main Theatre department.

12 ENDOSCOPY 005384 Colonoscope (Variable)

Dept has had a new colonoscope - this one went back to Fuji.

13 ESTATES 007196-01 Gas Fired Chiller Unit

14 GWENLLIAN 005941 Monitor & Defib

15 HOTEL SERVICES 003065 Franking Machine

This franking machine been disposed of , a new one has been purchased.

16 HOTEL SERVICES 003134

Temperature monitoring System

Spoke to head chef, this system has never been set up properly and used.

17 ICU 005660-09 Infusion Pump

18 ITU 008294-05 Patient Monitor

19 MATERNITY 009214 Fetal Monitor - Mounted

20 OPD 005518 Flexible Laryngoscope

21

RADIOLOGY 005795 Ultrasound Scanner

Model 'Aplio 80 XV' is not present, but 'Aplio 80 XG' is. Dept. Coordinator - Radiology) confirmed they disposed of one scanner in 2013 and bought a new one. So it is assumed that the XV model was the one disposed of and it was replaced by the XG.

22 THEATRE 008037-13 Patient Monitor

Unable to verify exactly as no serial number in register. One (of four)



Action Plan


however was verified.

23 THEATRE 008382 Orthopaedic drills

Informed that there are 5 or 6 drills in the department but that none of them have asset numbers on them.

24 THEATRE 006007 Ultrasound Scanner

25 YSTWYTH 005892 Patient Monitor

Withybush General Hospital

Sam

ple

Ref



Comments

1 A & E 007871

Patient Monitor – Resus Bay 4

2 A & E 007903 Defibrillator/Monitor

3 ACDU 009427 ECG Pagewriter

4 CATERING 9538 WGH Repl Combi Oven

5 DAY THEATRE 008672 HD Camera System

The EBME number was noted to be '48853' as the item was examined.

6 DENTAL CLINIC 004356 Dental Cart Department no longer exists.

7 ECG 005180 Digital Pathfinder

1 (32481) of 2 verified. 9813 has gone back to the company, no longer used.

8 ENDOSCOPY 008008-01 Drying Cabinet Not found.

9 ENDOSCOPY 008908 Evis Broncoscope

10 ESTATES 008045-01

Snow Clearance Ride on Machine

11

HAEMATOLOGY 002704 Haematology Coagulometers

The make is 'Sysmex' not 'Sysme' as on the Asset Register. Both machines were verified.

12 HOTEL SERVICES 005388 Combination Oven

Two ovens listed - only the oven with serial number 743658 was found. 727869 has been disposed of.

13 HOTEL SERVICES 006216 Trolley Heated

All the trollies were newer than year 2000 (date of the asset on the register).



Action Plan


14

ITU 004495 Haemofiltration Unit

Two units on the ward, one with the EBME number of 43349 and one without an EBME number or other identifying number matching asset list.

15 PHARMACY 004227

Cytotoxic Dispensing Safety Ca

The asset matching the age of that on register has been disposed of and new ones have been purchased.

16 RADIOLOGY 009143 Transducer

Several Transducers on ward, unable to identify specific one due to lack of information on Asset Register.

17

SCBU 005567 Infant Ventilator

SCBU no longer exists as a ward and asset could not be found. Site Works Supervisor stated that asset has been moved to Bay 3 next to SCBU.

18 THEATRE 004132 Camera System Not found.

19 THEATRE 004652

Anaesthetic Room Anaesthetic Machine

Asset not found in Theatre, was located in Day Surgery.

20 THEATRE 4796 Phrenic Nerve Stimulator

One of four found, asset number of 4656.

21

WARD 10 005705 Patients Hoist

Asset was disposed of within the last month, ward has been using one from Manual Handling whilst awaiting a new hoist.

22 WARD 11 5945 Hi Lo Bath Only Hi Lo Bath on the ward.

23 WARD 11 007302 Stroke Monitor

24 WARD 11 007716 Cardiac Monitor

25 X RAY 004966 Ultrasound Machine

Glangwili General Hospital

Sam

ple

Ref



Comments

1 A & E 005128 Ultrasound Scanner

2 A & E 005858-12 Patient Monitor



Action Plan


3 A & E 008702-09 Strecher Trolley

Spoke to Sister, couldn't find trolley with asset number on but found "App I.D" numbers on all but one. They included 9582, 9586, 9930, 9596, 9923 and a final one without an app I.D.

4 ANAESTHETICS 005374-03 Anaesthetic Machine

Email from Senior OPD confirming asset is located in Theatre 3. Perhaps re-name the Anaesthetics department on Asset Register to theatre. Asset Register to be amended to reflect this.

5 BIOCHEMISTRY 002958 A/C Biochem & Histology

6 CARDIOLOGY 008331 Echo Workstation

7 CARDIOLOGY 008887 Wireless Pagewriter

8 CCU 004304-01 Defibrillator

9 CERI 004343-03 Dinamap

10 CILGERRAN 004733-03 Pulse Oximeter EBME Department Manager confirmed it

had been disposed of.

11 CILGERRAN 005259-01 SpO2 Pulse Oximeter EBME Department Manager confirmed it

had been disposed of.

12 CILGERRAN 009262-07 Volumetric Pump

EBME Department Manager confirmed they are in use in the hospital but not in Cilgerran.

13 CILGERRAN 009271-01 Patient Monitor

14 CILGERRAN 009363-10 Volumetric Pump

EBME Department Manager confirmed they are in use in the hospital but not in Cilgerran.

15 COLPOSCOPY 004518 Hysteroscope

Only one on the ward (EBME No. COLP/029) - Serial no. of 0721658 provided by EBME.

16 CRITICAL C U 8098 Patient Monitors

17 CRITICAL C U 008123 Ventilator

18 CSSD 008747 Washer Disinfector (C)

Confirmed in washroom.

19 DAY THEATRE 005173-11 Defibrillator



Action Plan


Sam

ple

Ref



Comments

20 DINEFWR 9300 Equipment – Dinefwr

Asset not found. Insufficient detail in the name of asset on Asset Register and no other identification marks to assist.

21 ENDOSCOPY 004430 400 Series Video Colon

22 ENDOSCOPY 004895-02 Colonoscope (A094)

23 ENDOSCOPY 007754-02 Double Scope Cupboard Two cupboards present but neither had

identifying asset numbers on them.

24 ENDOSCOPY 007928-02 A6 Colour Printer

In the process of transferring this item to Theatre so is not currently on the ward, but is in the hospital still.

25 ENDOSCOPY 009118 Patient Trolley System Several on ward, none of which match

the asset number.

26 HDU 005061 Volumetric Pump

Not found.

27 HDU 007409-25 Syringe Pump

28 HISTOLOGY 007460-01 Consultant Microscope

29 HISTOLOGY 008035 Microscope and Equipment

30 HOTEL SERVICES 003085 Fagor Steam Operated Boil Pans

31 HSDU 009554 Storascope

HSDU is now called CSSD, one piece of machinery was said to loosely match the asset description but awaiting email confirmation of whether it is correct or not.

32 ICU 003995-07 Syringe Pump

33 ICU 005091 Volumetric Pump

Not found.

34 ICU 007409 Syringe Pump

Not found.

35 LABOUR WARD 004819-03 Radiant Heaters

Confirmed with EBME department manager that asset is a heated blanket but it was beyond economic repair.

36 LABOUR WARD 008044-06 Volumetric Infusion Pump



Action Plan


37 LAUNDRY 003184 Washer/Extractor

38 LAUNDRY 008666 Flat Work Feeder

39 PICTON 004583 Light Source Camera Stack

Found the camera stack in Aberglasney suite – this item belongs in Aberglasney suite not Picton therefore Asset Register is inaccurate.

40 PUMP LIBRARY 004983-15 Volumetric Pump

Not found.

41 SCBU 008450-03 Syringe Pump

42 THEATRE 004074 Syringe Pump EBME stated asset was disposed of and

replaced.

43 THEATRE 005431 CM-Rec Patient Monitor Senior ODP confirmed asset is located in

Recovery.

44 X RAY 005730 Rad Speed - Room 2

45 X RAY 005848 Ultimax System & Vitera Workstation – Rom1



Action Plan


Prince Philip Hospital

Sam

ple

Ref



Comments

1 BCU 008072 Ultrasound Scanner

2 BLOCK 6 COM 006975

Repose Pressure Equipment

3 CARDIOLOGY

005733-01 ECG Machine with Trolley

4 CATERING

003091-01-02 Walk in Coldroom 3

5 CLINICAL DECISIONS UNIT

009392-17 Patient Monitoring System

6 DAY THEATRE

004687-02-02 Patient Monitor

7 DAYCARE UNIT 004787 Phaco Instrument Pack

Moved to Amman Valley according to Day Surgical Unit Sister.

8 EBME 004050 Syringe Pump x 3

9 ENDOSCOPY 005111 Trolley Stack

Two trolley stacks found, neither have correct identifying numbers

10 HISTOLOGY 005597 Microscope Not found, may have been sent to GGH.

11 HSDU

007758-03 Compressor

Two pumps present, unsure if correct ones as Asset Register has little information on them.

12 HSDU

008010-07 Pass Through Hatch

13 ITU

004925-12 Syringe Pump

14 ITU

005703-05-03 Patient Monitor & Server

15 ITU 009309 Bariatric Chair

16 OPD

004875-02

Slit Lamp & Motorised Table

17 PHARMACY 002747 Pharmacy Robotics

18 ORTHOPAEDIC THEATRE 004534

Intellivue MP70 Anaesthetics Monitor

19 PUMP LIBRARY

003994-01 Syringe Pump

20 THEATRE 004337

Diathermy Trolley with Suction

21 THEATRE 005199 Force Triad Energy System

There are two are in the department but neither have serial numbers on them.

22 THEATRE 008477

Operating table & attachments

23 THEATRE - DSU

008944-08

Telescopes for Laryngos, Equip x 2

24 WARD 6 004143 Cardiac Monitor

25 WARD 9

007467-03 Patient Monitor



Action Plan


2015/16 Audit Assurance Ratings

Substantial Assurance - The Board can take substantial assurance that

arrangements to secure governance, risk management and internal control, within those

areas under review, are suitably designed and applied effectively. Few matters require

attention and are compliance or advisory in nature with low impact on residual risk

exposure.

Reasonable Assurance - The Board can take reasonable assurance that

arrangements to secure governance, risk management and internal control, within those

areas under review, are suitably designed and applied effectively. Some matters require

management attention in control design or compliance with low to moderate impact on

residual risk exposure until resolved.

Limited Assurance - The Board can take limited assurance that arrangements

to secure governance, risk management and internal control, within those areas under

review, are suitably designed and applied effectively. More significant matters require

management attention with moderate impact on residual risk exposure until resolved.

No Assurance - The Board has no assurance that arrangements to secure

governance, risk management and internal control, within those areas under review, are

suitably designed and applied effectively. Action is required to address the whole control

framework in this area with high impact on residual risk exposure until resolved.

Prioritisation of Recommendations

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

according to their level of priority as follows:

* Unless a more appropriate timescale is identified/agreed at the assignment.

Priority

Level

Explanation

Management

action

High

Poor key control design OR widespread non-compliance

with key controls.

PLUS

Significant risk to achievement of a system objective OR

evidence present of material loss, error or misstatement.

Immediate*

Medium

Minor weakness in control design OR limited non-

compliance with established controls.

PLUS

Some risk to achievement of a system objective.

Within One

Month*

Low

Potential to enhance system design to improve efficiency or

effectiveness of controls.

These are generally issues of good practice for

management consideration.

Within

Three

Months*



Action Plan

NHS Wales Audit & Assurance Services

Office details: St Brides St David’s Park Carmarthen Carmarthenshire SA31 3HB

Contact details: 01267 239781

Documents

Physical Verification of Fixed Assets - Health in · PDF fileAttachment 11i Physical Verification of Fixed Assets FINAL INTERNAL AUDIT REPORT 2015/16 Hywel Dda University Health Board