FINAL REPORT
NHS FIFE
INTERNAL AUDIT SERVICE
DEPARTMENTAL REVIEW - VHK LAUNDRY
REPORT NO. B40a/14
Issued To:
J Wilson, Chief Executive
C Bowring, Director of Finance
J Leiper, Director of Estates, Facilities and Capital Services
J Rotheram, Facilities Manager, Estates and Facilities
A Greer, Laundry Services Manager (VHK)
H Knox, Director of Acute Services
M Porter, Acting General Manager Kirkcaldy & Levenmouth CHP
S Manion, General Manager, Dunfermline & West Fife CHP
V Irons, General Manager, Glenrothes & North East Fife CHP
A McCreadie, Asst. Director of Finance (Management Accounting)
Follow-Up Co-ordinator
Audit Committee
External Audit
Date Issued: 11 September 2013
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Departmental Review-VHK Laundry - Report No. B40a/14
INTRODUCTION & SCOPE
1. The Internal Audit strategic planning process is based on a risk assessment of a
number of systems identified as being pertinent to the overall control environment
of the Board. The Annual Internal Audit Plan is derived from this process and
traditionally we evaluate and test each system independently of the others.
Recognising that systems do not operate in isolation we carry out a review of a
number of systems within a sample of departments to be agreed with
management.
2. The scope of this review is to evaluate and report on controls established within
the Laundry Service at Victoria Hospital to manage the risks relating to the
Laundry Service with a focus on the undernoted areas:

Risk Management

Staff Performance Management

Business Continuity

Management of Sickness Absence

Payroll information

Infection Control

Policies and Procedures
(Departmental)

Fire and Health & Safety

Security Management & Stock
Control

Service Contracts
OBJECTIVES
3. Our audit work was designed to evaluate whether appropriate systems were in
place and operating effectively to mitigate risks to the achievement of the
objectives identified below.
4. The relevant service objective of the review was to provide assurance that
systems of internal control are embedded in the operations of the Board and form
part of its culture.
RISKS
5. The following risks could prevent the achievement of the above objectives and
were identified as within scope for this audit.
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Departmental Review-VHK Laundry - Report No. B40a/14
 Written procedures may not be available to address identified risks
 Information and communication processes may not exist to support decision
making
 Arrangements may not exist to monitor the continuing effectiveness and
efficiency of operation and controls
 Resources deployed may not deliver the agreed service
AUDIT OPINION AND FINDINGS
6. The audit opinion is Category B – Broadly Satisfactory – There is an adequate
and effective system of risk management, control and governance to address
risks to the achievement of objectives, although minor weaknesses are present. A
description of all audit opinion categories is given in the final section of this report.
7. Overall financial management and other controls were found to operate to a
satisfactory standard at the location considered. The individual audit opinions for
each area considered were as follows:
Systems
Audit Opinion
VHK Laundry
Risk Management
B
Business Continuity
A
Payroll Information
A
Policies and Procedures (Departmental)
B
Security Management & Stock Management
A
Staff Performance Management
C
Management of Sickness Absence
A
Infection Control
A
Fire and Health & Safety
A
Service Contracts
B
8. The laundry provides a service to approximately 17 hospitals. The key driver to
the effective and efficient operation of the service is the necessity to ensure that
at all times a suitably qualified staff skill mix is available and that equipment
operates to the required standard. Overall the areas reviewed are considered to
be contributing positively to the achievement of those requirements.
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9. Local management data is used to monitor the performance, efficiency and
productivity of the laundry service. This is supplemented by quarterly national
benchmarking reports, which provide a comparison with laundry services in other
NHS Boards. The national data shows that NHS Fife’s laundry service compares
favourably with the laundry service provided in other Board areas. Recently there
has been an investment in 10 new driers to provide cost and operational
efficiencies. Procedures are in place to enable clients to advise if they are not
satisfied with the quality of service provided. These procedures are intended to
identify emerging service quality issues so that action(s) to remedy the problem
can be taken as necessary.
10. The NHS Fife Health & Safety Management Assistant system is used as the
basis for addressing the risks associated with laundry activities. Mechanisms,
such as hourly rotation of duties, are also in place to achieve a safe and healthy
environment for staff and to prevent repetitive strain injuries. Although staff have
access to NHS Fife policies and procedures, the hard copies of the policies and
procedures made available to staff have not been kept up to date.
11. As previously recommended in our previous audit (B35/13 - Service Contract
Income) a review of the laundry service Service Level Agreement between NHS
Fife and Forth Valley is now in the process of being finalised to ensure that the
contract adequately reflects all of the costs incurred in delivering the service to
NHS Forth Valley. This contract accounts for just under 50% of all laundry activity
in NHS Fife.
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12. A small number of instances were noted where controls could be improved,
including:
 A review of the laundry training records indicates that staff training has fallen
behind schedule, including mandatory training on fire safety, manual handling
and infection control. Laundry management have confirmed that they are
aware of this situation and that a review of staff training is pending.
 Personal development plans are not in place for the majority of laundry staff
with low take up of the eKSF system evident.
 The majority of the hard copies of policies and procedures kept in the folder in
the communal work area for laundry staff are out of date. In addition the
process for staff to evidence that they have read and understood pertinent
policies and procedures has not routinely been followed.
 Currently there are two laundry policies, GP/L3 - Safe Handling of Laundry and
GP/P7 - Care of Patients Personal Laundry, which are beyond their review
dates and require review and re-issue via the appropriate approval process.
 Examination of the Datix Register demonstrates that there are several risks
relating to laundry services. One of these risks is recorded as a high risk but
has a 3 year review date. This period between risk review is considered too
long for a high level risk.
ACTION
13. An action plan has been agreed with management to address the identified
weaknesses. A follow-up of implementation of the agreed actions will be
undertaken in accordance with the audit reporting protocol.
ACKNOWLEDGEMENT
14. We would like to thank all members of staff for the help and co-operation received
during the course of the audit.
David Archibald BAcc CPFA
Regional Audit Manager
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Internal Audit Service
Departmental Review-VHK Laundry
Report No. B40a/14
DEFINITION OF ASSURANCE CATEGORIES AND RECOMMENDATION PRIORITIES
Categories of Assurance:
A
Good
There is an adequate and effective system of risk management,
control and governance to address risks to the achievement of
objectives.
B
Broadly Satisfactory
There is an adequate and effective system of risk management,
control and governance to address risks to the achievement of
objectives, although minor weaknesses are present.
C
Adequate
Business objectives are likely to be achieved. However,
improvements are required to enhance the adequacy/ effectiveness
of risk management, control and governance.
D
Inadequate
There is increased risk that objectives may not be achieved.
Improvements are required to enhance the adequacy and/or
effectiveness of risk management, control and governance.
E
Unsatisfactory
There is considerable risk that the system will fail to meet its
objectives. Significant improvements are required to improve the
adequacy and effectiveness of risk management, control and
governance and to place reliance on the system for corporate
governance assurance.
F
Unacceptable
The system has failed or there is a real and substantial risk that the
system will fail to meet its objectives. Immediate action is required
to improve the adequacy and effectiveness of risk management,
control and governance.
The priorities relating to Internal Audit recommendations are defined as follows:
Priority 1 recommendations relate to critical issues, which will feature in our evaluation of
the Governance Statement. These are significant matters relating to factors critical to the
success of the organisation. The weakness may also give rise to material loss or error or
seriously impact on the reputation of the organisation and require urgent attention by a
Director.
Priority 2 recommendations relate to important issues that require the attention of senior
management and may also give rise to material financial loss or error.
Priority 1 and 2 recommendations are highlighted to the Audit Committee and included
in the main body of the report within the Audit Opinion and Findings
Priority 3 recommendations are usually matters that can be corrected through line
management action or improvements to the efficiency and effectiveness of controls.
Priority 4 recommendations are recommendations that improve the efficiency and
effectiveness of controls operated mainly at supervisory level. The weaknesses highlighted
do not affect the ability of the controls to meet their objectives in any significant way.
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