NOTICE IS HEREBY GIVEN THAT A MEETING OF

THE BRO MORGANNWG NHS TRUST WILL BE HELD AT 1.00PM IN THE BOARDROOM, PRINCESS OF WALES HOSPITAL

ON THURSDAY 7TH FEBRUARY 2008

Lunch will be available from 12.30pm – Meeting will commence at 1:00pm

AGENDA Attached

Marked 1. Welcome & Introductions

Verbal

2. Apologies for Absence

Verbal

3. To Receive/matters arising from: 3.1 Minutes of the Board Meeting held on 6th December 2007 3.2 Minutes of the Special Board Meetings held on 23rd November 2007 3.3 Minutes of Healthcare Governance Committee held on 3rd December 2007 3.4 Minutes of the Financial Audit Committee held on 11th December 2007

3.13.2(i)(ii)

3.33.4

4. Report of the Chairman 4.1 Schedule of Activities 4.2 Update – Sierra Leone

4.1verbal

5. Presentation: • Mental Health Act Commission Annual Report for 2007

- Michael Green (Area Commissioner)

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6. Report of the Chief Executive 6.1 Merger of Swansea and Bro Morgannwg NHS Trusts 6.2 Performance Report November 2007 6.3 WHC (2007) 086 - NHS Wales Annual Operating Framework 2008/09 6.4 Referral To Treatment Times – Clinic Outcomes Recording 6.5 Capital Schemes 6.6 Appointment of Contractors/Consultants 6.7 Partnership Working – Update 6.8 Information Management & Technology Policies 6.9 HIW Review of Learning Disabilities Services for Young People and Adults 6.10 All Wales Patient Safety Campaign : ‘Save 1000 Lives’ 6.11 Healthcare Standards & Governance – All Wales Board Workshop 6.12 Positive News Stories 6.13 Suicide Prevention Group – Update

6.2(i)(ii)(iii)

6.76.8

6.116.12

7. Report of the Director of Finance 7.1 Financial Position to 31st December 2007 7.2 Public Sector Payment Policy 7.3 Charitable Funds 7.4 Welsh Health Supplies 7.5 Annual Audit Letter 7.6 WHC (2008)002 - Strengthening Welsh Language provision within NHS Services in Wales

7.57.6(i)(ii)

8. Report of the Deputy Chief Executive

8.1 Acute Services Board (ASB) – Update 8.2 Policies 8.3 Agenda for Change Update 8.4 Corporate Health Standard Award 8.5 Cycle Solutions Bike Scheme Proposal 8.6 Compliments and Formal Complaints 8.7 Risk Management Annual Report 2006/7 8.8 Records Management Update

8.2(i)(ii)(iii)

8.4(i)(ii)

8.68.78.8

9. Healthcare Governance Report 9.1 Healthcare Standards Self-Assessment 2007/8

10. Report of the Nurse Director 10.1 Dignity In Care Programme For Wales Briefing Report

10.1

11. Report of the Medical Director 11.1 Consultant Contract – All Wales Annual Report 2006/07 11.2 Consultant Appointments 11.3 Data Protection and Confidentiality Policy

11.1(i)(ii)(iii)

11.211.3

12. Any Other Business

13.

Dates of Meetings:- • 3rd April 2008, Boardroom, Neath Port Talbot Hospital (Provisional)

Appendix 3.1

MINUTES OF THE MEETING OF THE BRO MORGANNWG NHS TRUST

HELD AT NEATH PORT TALBOT HOSPITAL ON 6th DECEMBER 2007

PRESENT Mr W Griffiths Chairman Mr P M Williams Chief Executive Mr B Ferguson Medical Director Mr P G Stauber Director of Planning Ms D J Morgan Director of Improvement and Information Mr E Williams Director of Finance Mrs V Franklin Director of Nursing Ms C Doyle Non Executive Director Professor N Palastanga Non Executive Director Mr E Griffiths Non Executive Director Mr C Henrywood Non Executive Director Mr D Davies Non Executive Director Mr M Williams Associate Board Member (Acting Chair of Swansea NHS Trust) (from 2007.73.2) Mrs M Lee Non Executive Director Miss S Lloyd Jones Deputy Chief Executive IN ATTENDANCE Mrs D Gunning Chair, Bridgend Community Health Council (CHC) Mrs S Holley Transcriber for Mrs Gunning Mrs S Miller Staff Side Representative Mr D Sage Staff Side Representative Miss C Lewis Deputy Nurse Director (shadowing the Nurse Director) Mr G Harrop Chief Officer, Vale of Glamorgan CHC Mrs W Penrhyn-Jones Head of Administration APOLOGIES Mr C Johnson Non Executive Director Ms C Doyle Non Executive Director Professor N Palastanga Non Executive Director 2007.66 WELCOME & INTRODUCTIONS The Chairman welcomed Mrs Gunning, Mrs Holley and Miss Lewis to the meeting. Mr

Griffiths also welcomed Staff Side Representatives to the meeting.

2007.67 TO RECEIVE: 2007.68 MINUTES OF THE TRUST BOARD MEETING HELD ON 4th

OCTOBER 2007 The minutes were received and approved as an accurate record.

2007.69 MINUTES OF THE HEALTHCARE GOVERNANCE COMMITTEE

HELD ON 1st OCTOBER 2007 The minutes were received.

2007.70 MINUTES OF THE MENTAL HEALTH AND LEARNING

DISABILITIES SERVICES SUB-COMMITTEE HELD ON 28th NOVEMBER 2007

The minutes were received. Mr D Davies drew the Board’s attention to the reference within the minutes to the new Mental Health Act, which would place considerable further responsibility upon the Trust particularly around the Manager’s Hearings function. Those involved in this work would require re-training which was being scheduled. Mr Davies also referenced item 15C-Uncontested Renewals. Such hearings under the Mental Health

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Act did not specify a need for full attendance by all lead professionals. It was noted that whilst the report would still need to be provided in such cases, the attendance of the patient and a nurse would meet the requirements of the Act and this revision to current processes had therefore been approved by the sub Committee for implementation. Mr Davies advised that where a patient was not seeking discharge but was content for just themselves and a nurse to be present, Hearings would go ahead on this basis. The change in process was applauded by Non Executives however it was highlighted that the success of this new system would be entirely dependent on the timeliness on the circulation of papers. Mr Davies concurred and stated that Mrs L Rogan had recently been appointed as the Trust’s new Mental Health Act Administrator and that had given an undertaking to review the process of circulation of papers to ensure that these were received by all concerned at least one week before the hearing. Mrs M Lee indicated that she had some general issues with regard to Manager’s Hearings and that she intended to speak with Mr Davies outside the meeting to resolve these.

2007.71 MATTERS ARISING NOT OTHERWISE ON THE AGENDA There were no other matters to report.

2007.72 REPORT OF THE CHAIRMAN 2007.72.1 PENNIES FROM HEAVEN AND SIERRA LEONE INITIATIVE The report set out the background to the Pennies from Heaven scheme, a charitable process

whereby employees could chose to indicate they wished to donate the spare pennies from their monthly pay to a charity nominated by the Trust. The Department of Health was facilitating the introduction of the scheme into the NHS and the ESR system had been configured to allow NHS organisations to take up the scheme. The report summarised Scheme’s key elements. The report also outlined the initiative being developed by the Trust as part of the Welsh Assembly Government’s project to encourage the Welsh NHS to develop a nurtured long-standing relationships with sub Sahara Africa. Bro Morgannwg’s initiative would focus on links with Sierra Leone, beginning with opportunities for supporting the Children’s Hospital in Free Town. An account would be established as part of the Trust endowment fund to receive contributions and pay for approved costs arising out of the project. The Chairman also reported that the Joint Staff Consultative Committee had supported the Pennies From Heaven initiative and the link with Sierra Leone. The Board supported the introduction of the Pennies From Heaven project and agreed that the benefiting charity should be the Trust Sierra Leone project fund.

2007.72.2 SCHEDULE OF ACTIVITIES The Board noted the schedule of activities undertaken by the Chairman since the previous

meeting of the Board. The Chairman referenced the recent Research and Development day which he and the Chief Executive had both attended. The Chairman said that he had been overwhelmed by the number for research projects that had been put forward for the day. Mr Henrywood suggested that a summary be publicised on the Trust’s website. The Board noted the positive Research and Development Day.

2007.73 REPORT OF THE CHIEF EXECUTIVE 2007.73.1 PERFORMANCE REPORT NOVEMBER 2007 Performance reported from April 2007 onwards, against the Assembly targets, continued to

reflect local reporting standards agreed with the Regional Office. The report also identified the indicators which needed to the achieved under part A and Part B of the Incentive and

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Sanctions Framework for NHS Wales. (WHC (2009) 069 had been issued at the end of September 2007 and received by the Board at its subsequent meeting in October 2007. The only part A target that the Trust had not met during a month was the 95% A&E 4 hour target. For the purposes of the Incentives and Sanctions Framework, Trust performance against this target was due to be measured on the position achieved during the month of March 2008. On the basis of current performance and assuming the A&E target was met at the year end, the Trust would achieve a score of 20 out of a possible 22, placing it in Band 1, making it eligible for incentives. The Inpatient/Day Case waiting list continued to improve during October. The only Speciality outside profile was Ophthalmology and the Trust was working with Swansea NHS colleagues to provide additional ad hoc capacity where possible. The draft November 2007 position showed a further modest improvement. With regard to Diagnostic and Therapy waiting times, all areas were within profile apart from Nerve Conduction Studies (NCS), which was just outside profile. Performance in terms of the 4 hour target within A&E stood at 92.63% against a target of 95%. The report set out details of issues which were having an impact on the performance of the A&E department of the Princess of Wales Hospital. Such pressures were being reflected nationally with a downturn in performance across Wales for the past two months and robust action plans had been put into place to improve the Trust’s performance by the year end. Compliance of 100% had been achieved in respect of Cancer waiting times for both the 62 day and 31 day pathway targets. Issues remained with regard to the delivery of targets where treatment was being delivered outside the Trust and the draft November 2007 picture showed two such breaches. These issues were being worked through on a patient by patient basis. In terms of Chronic Disease Management and Multiple Admissions, the Trust was recording an admission rate of 16% for the rolling 12 month period to September against a target of 14.6% - a 2% improvement in year. This demonstrated that initiatives introduced to avoid unnecessary hospital admission and to support patients living in the community with chronic conditions were having an impact. The Trust continued to perform well against the average Length of Stay target for chronic conditions. The volume of non-Mental Health Delayed Transfer of Care patients remained consistent with previous months and over the local target. Reducing the numbers remained a significant challenge for the LHB and the Trust and multi-agency meetings were continuing to explore the relevant issues. From December, a Choice of Accommodation Policy was due to be implemented following approval by the Bridgend Local Authority. In respect of average Length of Stay targets, Elective General Surgery, Gynaecology and Trauma & Orthopaedics were relevant to the Incentives and Sanctions framework. Each was consistently meeting the required targets. Performance in terms of Basket Procedures had been achieved in respect of the Hernia and Arthroscopy cases with the Laparoscopy target being only missed by one patient. The Bunions target was also being met for the first time. Elective Cases Treated as Day Cases were showing improvement within General Surgery during October, which in turn had improved the Trust’s overall performance. Some 73% of Elective Operations had been undertaken on a Day Case basis against a target of 75%. Performance against the number of Elective Operations Carried Out on the Day of Admission showed that all specialities were meeting targets. The Outpatient Improvement Group continued to drive progress against the New to Follow Up and DNA targets in respect of outpatient appointments. The report also detailed the Trust’s Long Term Agreement position in respect of principle Commissioners as at the end of October 2007.

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Non Executives asked why Sickness/Absence performance relating to the September and October 2007 period had been omitted from the report. The Deputy Chief Executive explained that an All Wales Task and Finish Group was currently looking at the relevant issues across the Principality as this was connected with the ESR system. Whilst information for the organisation as a whole was not currently available, information regarding the management of sickness was being maintained at local level in order that this important issue could continue to be appropriately managed. The Board noted the monthly performance report.

2007.73.2 LIKELIHOOD OF DELIVERY ASSESSMENT (LODA) As part of the Delivery and Support Unit’s (DSU) structure and process to deliver the 2009

Access targets, Integrated Implementation and Delivery Plans (known as LODA) had been issued to the NHS in Wales in April 2007. The aggregate of weighted scores provided the Trust with an overall total of 54.5% placing it fifth in Wales. The LODA covering letter along with the full analysis was appended to the report for information. The LODA process was due to be formally undertaken on a monthly basis with the expectation that performance would improve on an incremental basis through each iteration. The Director of Planning was working through these issues with the respective Directorates. An action plan had been submitted to the DSU on 3rd December 2007. The Board noted the progress with the LODA process.

2007.73.3 CAPITAL SCHEMES With regard to the modernisation of Mental Health services, planning approval had been

granted as of 8th October 2007 for the new Day Centre to be constructed on land on the bottom of Quarella Road, Bridgend. The enabling works contract at Glanrhyd Hospital. Completion was expected in April 2008 which would result in the decentralisation of all services on the site and the vacation of current plant areas. Plans for the Rehabilitation Unit proposed for the rear of the current Trust Headquarters site had been agreed and detailed work was due to begin. Mr D Davies sought confirmation of the timescale for this project which the Director of Planning advised would be approximately 15 weeks. Work to expand Ultrasound at the Princess of Wales Hospital had been completed and it was anticipated this would be within budget despite additional works being undertaken. A delay in the receipt of planning permission for the Intermediate Care Services Project had resulted in the contractor’s costs needing to be recalculated. The contract was subsequently been awarded to CJ Construction (Wales Ltd). The design of the main building was considerably above the budgeted cost due to cost indices having increased since the original Business Case had been prepared. A substantial planning contingency had however been included. Plans for the extension to the Postgraduate Centre at the Princess of Wales Hospital had been signed off and a detailed programme was awaited from the design team. With regard to the replacement of engineering services at Princess of Wales Hospital, pre-contract meetings had been held for all four schemes.

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Work on the refurbishment of the old Caswell Clinic at Glanrhyd Hospital to provide temporary accommodation for the Child and Adolescent Mental Health Service was progressing and staff from the Harvey Jones Unit had undertaken a number of site visits. Patients were due to be admitted to the new Unit in the New Year. The Outline Business Case for the new Child and Adolescent Mental Health Unit was being finalised and a full report was due to be presented to the Trust’s Capital Investment Committee in December. The new MRI scanner for Neath Port Talbot Hospital was due for delivery by the end March 2008. The PFI Consortium had appointed Finnlayson to undertake the enabling works and installation of the equipment. A problem with the foul drainage system within Ward 7 at Princess of Wales Hospital had resulted in an incident in October 2007, which had caused extensive damage to a screening room and Fluoroscopy Screening equipment. As a result, Bridgend locality patients had been redirected to Neath Port Talbot Hospital as a temporary measure. The Trust would be making a claim for the costs of rectifying the damage via the Welsh Risk Pool. In the meantime, the replacement of the equipment would be covered from the capital budget. The Board noted the progress on the various ongoing Capital projects.

2007.73.4 APPOINTMENT OF CONTRACTORS/CONSULTANTS With regard to the proposed Chemotherapy Outreach Facility and the multidisciplinary

team accommodation, a single quotation action was authorised. Lawray Ltd had recommended undertaking a feasibility study of the proposed site at the Princess of Wales Hospital to determine the most appropriate location for the Unit. A fee bid which totalled £6,372.45 was subsequently opened in accordance with Standing Orders. To complete the study before the Winter period, it had been necessary to confirm the appointment immediately and in accordance with Standing Order 30.3, these appointments were approved by the Chairman on behalf on the Board. The Board ratified the appointment of Lawray Ltd. The report detailed the background to the appointment of Quantity Surveyors in relation to the installation for the MRI scanner at NPTH. Due to the nature of the work it was estimated that fees for this project would be below £3000 and therefore in accordance with clause 22.5 of the Contract’s C, Schedule 4 of Standing Orders, one company had been invited to submit a bid. The bid received from Parry and Dawkin of Swansea amounted to £2,950 for all stages. So that the Quantity Surveyor could be involved in discussions with the Consortium and develop a working knowledge of the scheme, it was necessary to confirm the appointment without delay. Therefore, in accordance with Standing Order 30.3, the Chairman approved the appointment of Parry and Dawkin as Quantity Surveyors for the project. The Board ratified the appointment of Parry and Dawkin. The Third Party Development Scheme to provide a Primary Care Centre in Cowbridge was proceeding and once complete, all activity would transfer from the current Health Centre to the new accommodation and the Board would be asked to declare the property surplus to requirements so that it can be offered for sale on the open market. White Young Green had already been engaged to act for the Trust in making representations concerning the property and had amassed a knowledge regarding the site. Approval was therefore given for single quotation action in their appointment as Planning Consultants for the disposal process. They had produced a comprehensive planning report with the recommendation that the Trust appoint a Property Agent to advise on marketing. Copies of the bids submitted as part of the fee bid process were appended to the report. Welsh Health Estates recommended the appointment of Watts and Morgan as Property Agents for the scheme.

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The Board approved the appointment of Watts and Morgan. Following the approval of the Business Justification Case for the Engineering Services Project at the Princess of Wales Hospital. NIFES Consulting Ltd had been appointed as Services Engineers who had be working with the Trust to develop specifications for each of the four individual schemes which included emergency generators, the CHP Unit, replacement of boilers and replacement of lifts. The report set out details of the tender process in respect of each of the schemes. In respect of emergency generators, Banks Wood & Partners confirmed that the tender submitted by Lorne Stewart Plc was a comparative bid and it was therefore recommended that the tender be accepted and the contract awarded in the sum of £156,956.00 plus VAT. In respect of the CHP Unit. Banks Wood & Partners had recommended that the tender from Ener-G Combined Power Ltd in the sum of £305,973.00 plus VAT be awarded. In respect of the replacement of boilers, Banks Wood & partners recommended that the tender be awarded to F.P Hurley & Sons Ltd in the sum of £253,303.00 plus VAT. In respect of the replacement of lifts it had been recommended that the tender from Ace Elevators Ltd be accepted and the contract be awarded in the sum of £559,757.00 plus VAT. Whilst the award of contracts in excess of £250,000 was reserved for the Trust Board, in order to obtain an early start on all of the above schemes and so that it could be possible to achieve expenditure levels for the current financial year, the Chairman approved the award of the contract as permitted by Standing Order 30.3. The report noted that due to the uncertain condition of this panel, it had been recommended that a contingency sum of £50,000 be added to the tender submitted by Ace Elevators Ltd to ensure that funding was available should the panel require replacement. The Director of Planning acknowledged the report currently suggested that this element of the contract had only been omitted by Ace Elevators Ltd, whereas his recollection was that this item had been omitted by each of the companies submitting tenders. Mr Stauber would clarify this. The Board ratified the appointment of Lorne Stewart, Ener-G Combined Power Ltd and F.P Hurley & Sons Ltd. The Board also ratified the appointment of Ace Elevators Ltd subject to confirmation that the contingency sum in respect of the existing lift control panel had been omitted from each of the tenders submitted. The report referenced the programme initiated in January 2003 by the Welsh Assembly Government to install Automated Pharmacy Dispensing Systems at selected hospitals. It was already The system was already established at the Princess of Wales Hospital and it was proposed that Neath Port Talbot Hospital be included within the programme with a system being installed by the end of April 2008. The Consortium had the right to undertake any works required to the Neath Port Talbot Hospital and negotiations had begun regarding the enabling works required to prepare for the installation of the Pharmacy Robot System. Details of the enabling costs were set out in the report which would be funded by the Assembly. The overall estimated expenditure including works and equipment was £351,644.00. In order to confirm the Trust was prepared to award the contract and therefore obtain Business Case approval, the Chairman had approved the award of the contract as authorised by Standing Order 30.3. The Board ratified the appointment of ARX as equipment suppliers and the PFI Consortium to undertake installation works. Neath Port Talbot Hospital was also due to have a MRI scanner installed. The Consortium had appointed Track Consulting to project manage the works and bids had been inbited invited for the necessary work as outlined within the report. The Consortium proposed to appoint Finnlayson to undertake the works. In order to coordinate the installation works

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with the delivery of equipment, the Chairman had approved the costs provided by the Consortium as authorised by Standing Order 30.3. The Board ratified the appointment of Finnlayson. The scheme to award the contract for the development of the first phase of the new car park at Cimla Hospital had been awarded to CJ Construction Ltd. Due to a delay in the award of the planning approval for the scheme, it had been necessary for the contractor to reassess their tender and CJ Construction Ltd indicated their bid needed to be increased by £9,000 due to a rise in material costs. The revised tender bid remained below the second lowest bid level and approval was therefore obtained for the acceptance of the revised bid and the award of the contract to CJ Construction Ltd. The Board ratified the appointment of CJ Construction Ltd A project was being progressed at the Princess of Wales Hospital to increase the provision of single cubicles and upgrade Wards 5 and 6 at the Princess of Wales Hospital. The pre-tender estimate for this work was £950,000 exclusive of VAT. The report provided details of the tenders received. The project quantity surveyor confirmed that the lowest tender of Edmunds Webster Ltd should be recommended for acceptance. The Board ratified the appointment of Edmunds Webster Ltd.

2007.73.5 DISPOSAL OF PROPERTY Following the commissioning of the new Dulais Valley Primary Care Centre, the Health

Centre in Seven Sisters had been vacated and declared surplus to requirements. An offer of £55,000had since been accepted on the property The Board noted the completion of the sale of the former Seven Sisters Health Centre.

2007.73.6 DELEGATED LIMIT ACCREDITATION PROCESS The Trust had undertaken the accreditation process required to increase its delegated

capital limit. Appended to the report was the final report following accreditation which confirmed that an unconditional recommendation would be made to Welsh Assembly Government for Bro Morgannwg NHS Trust to have their delegated capital increased to £8 million. The Board noted the successful outcome of the accreditation review.

2007.73.7 ESTATES PERFORMANCE Appended to the report were extracts from the Estate Condition and Performance Report

for the NHS Estate in Wales 2006/07, which have been produced by Welsh Health Estates. An appendix provided detail regarding the Trust’s Estate against the five facets, which were dictated as mandatory by the NHS Estates. A further appendix set out how the Trust compared with other Trusts throughout Wales. The Board noted the performance of the Trust’s Estate.

2007.73.8 S31 HEALTH ACT FLEXIBILITIES The Board had previously agreed that the Trust’s legal advisors, Morgan Cole, should

review the draft Standard Template Agreements (STA) and that their advice be incorporated into the STAs following which the Board would be asked to formally adopt the STA. The advice received was that the templates were good in general and provided

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working documents setting out the main objectives and obligations clearly and concisely. It was also pointed out that the STAs were general templates and would therefore need to be adapted for the requirements of specific projects. The narrative received from Morgan Cole also provided general advice on the Partnership Agreements and a number of key points were summarised within the report in terms of the nature of the agreement, responsibility and accountability for service provision, complaints, insurance and indemnity, annual budget and agreement and TUPE. Whilst the Trust was currently awaiting written confirmation from the Welsh Risk Pool that it was content with the insurance section of the template, the Trust’s external Auditors had already confirmed they had no areas of specific concern. The revised STA’s were appended to the report for the Board’s approval. The report set out the proposed way in which any further amendments would be made to the standard template models to provide clarity and transparency on each Agreement. Legal advice would be taken on individual Agreements dependant on the degree of amendment required. The Chief Executive advised that the Trust would be seeking to apply the process in respect of the new Mental Health facility from the 1st April 2008. Mr Henrywood suggested there was a need for further clarity around the meaning being applied to the word ‘term’ within the STA so that there was no doubt regarding what the Trust wished to indicate by this word. The Chief Executive undertook to ensure that any such anomalies were resolved before the first completed Agreement was presented to the Board. The Board approved the two Standard Template Agreements and endorsed the arrangements for managing specific schemes under the Health Act Flexibilities.

2007.73.9 PARTNERSHIP WORKING: LOCAL SERVICE BOARDS, HEALTH SOCIAL CARE AND WELL BEING STRATEGY CONSULTATION

The report provided an update on progress in terms of the establishment of Local Service Boards(LSB). Each LSB was engaged in rationalising the range of partnership groups. The Trust’s Merger Workstream dealing with for partnership issues was currently identifying and taking into account the varied demands and expectations of partnership working between and within each Borough and client group from Swansea to the Vale of Glamorgan. Trust officers were also becoming involved in the work to develop shared organisational objectives and performance indicators that would form the basis of the proposed Local Service Agreements that were required to be developed for implementation from April 2008. The report referenced the draft Health, Social Care and Well Being Strategies produced by the Neath Port Talbot, Bridgend and Vale of Glamorgan boroughs, which had been issued for consultation. Appended to the report were short, public documents which had been issued widely within Neath Port Talbot and Bridgend. Each Borough partnership had interpreted the Welsh Assembly guidance on the extent and depth of the consultation in a slightly different manner and therefore the consultation periods varied. The report summarised key themes within the strategies. The Trust’s Partnership Development Manager was coordinating the receipt of consultation comments and a copy of the Trust’s response to the consultations would be submitted to the next meeting for information. Mr Henrywood expressed disappointment with the lack of emphasis within the documents to the responsibilities of the public in respect of their own good health. The Board noted the update regarding the work of the Local Service Boards and the consultations that were ongoing.

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2007.73.10 BRIDGEND CITIZENSHIP AWARDS The dedication and commitment of four Bro Morgannwg Health Service Staff were

identified within the report had been rewarded with the presentation of much deserved citizen awards from Councillor Mari Jones, Mayor of Bridgend at a ceremony held in November 2007. The Board noted the receipt of the above rewards and the Chairman undertook to write to the individual members of staff congratulating them on behalf of the Board.

2007.73.11 SUMMARY OF WELSH HEALTH CIRCULARS Appended to the report was a summary of the Welsh Health Circular that was issued

during the previous 6 month period. The Board noted the publication of the Circular.

2007.73.12 IM&T CARE MANAGEMENT STRATEGY – UPDATE ON PROGRESS The above Strategy and Implementation plan had been approved by the Trust Board in

November 2006 and set out a wide ranging programme of developments. An exercise had recently been completed to prioritise the remaining work to ensure that key schemes could be completed before the end of the financial year. Appended to the report was an update on significant progress made to date setting out the next steps for each of the schemes. The report also drew the Board’s attention to a number of other ongoing pieces of work in respect of Structured Electronic Correspondence, the Community & Therapies Modernisation Project in terms of the PIMS plus system and also web-based results reporting for the Neath Port Talbot locality. The Board noted progress on these key projects

2007.74 REPORT OF THE DIRECTOR OF FINANCE 2007.74.1 FINANCIAL POSITION TO 31st OCTOBER 2007 The report showed an overall balanced position for the Trust after taking into account Cost

Improvement Programme targets. Most Directorates were continuing to deliver breakeven or near breakeven positions despite some challenging savings targets in 2007/8. LTA negotiations with Commissioners, in terms of the agreement of Financial and Activity Quantums for 2007/8 was being progressed to completion with all Commissioners so that potential income risks identified earlier in the year had almost been resolved. The Director of Finance reported that he had received notice of the closed month 8 position that morning, which again showed the Trust’s financial position remained in balance. The Board noted the balanced financial position.

2007.74.2 PUBLIC SECTOR PAYMENT POLICY The cumulative target related compliance figure to 31st October 2007 was 97.28% with an

in-month level of compliance during October 2007 of 95.76%. The Board noted PSPP performance.

2007.74.3 CHARITABLE FUNDS The total value of all funds held at 31st October 2007 was £1,255,875.02 compared with

£1,261,317.92 at the end of September 2007. During September and October, income of

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£47,468.31 was received with expenditure totalling £62,137.56. The report also detailed significant donations/requests during the month of October 2007 and the main items of expenditure by Directorate. The Board noted the charitable funds activity during October 2007.

2007.74.4 WELSH HEALTH SUPPLIES (WHS) The report detailed key issues faced by WHS during the period September to October

2007. A table summarised performance over the period September – October 2007 amounted to £8,151,670 which remained in line with the target set for the year. The work of the former Supplies Consortium had now been incorporated into WHS. The Annual Report produced by WHS for 2006/7 had recently been published. The Board noted the ongoing developments within WHS.

2007.75 REPORT OF THE DEPUTY CHIEF EXECUTIVE 2007.75.1 ACUTE SERVICES BOARD (ASB) – UPDATE The report provided a summary of the projects that were ongoing under the supervision of

the Acute Services Board. As part of the Ward Modernisation Project a number of successes identified as part of the initial project were being applied to all Wards at the Princess of Wales and Neath Port Talbot Hospitals. The second phase of the project would focus on the skills and competencies required to effectively and efficiently run a ward, resulting in building up a staffing profile for acute wards to assist future workforce planning. Work around the Stroke Care Pathway was progressing with the Directorate of Medical Specialities. The report referenced the results of the electronic Transfer of Care project which sought to improve the discharge process in addition to enhancing the flow of patient medication information from Wards to Pharmacy and also aiding communication between secondary and primary care. The report also provided an update with regard to the development of a Respiratory PDSA. The Board noted progress on the various projects being managed by the Acute Services Board.

2007.75.2 WORKFORCE REPORT The report presented a summary of information in relation to staffing profile, Starters,

Leavers, Turnover & Stability, the organisation Sickness Absence, Vacancies by Directorate and Employee Relations issues. The Trust’s average sickness absence figure to the end of August 2007 stood at 5.56%, which represented a decrease on the previously reported level. The Deputy Chief Executive reported that the Trust was continually encouraging Directorates to proactively manage sickness absence issues working in partnership with staff side colleagues. The Chairman sought information regarding those departments or Directorates which were not maintaining adequate performance in terms of sickness absence. Miss Lloyd Jones was able to report that the Directorate of Medical Specialities had made great strides in terms of their previous position and undertook to provide further details. The Board noted the report.

2007.75.3 POLICIES AND STRATEGY FOR RATIFICATION The report confirmed that the policies being presented for approval had already been

ratified by the Joint Staff Consultative Committee and as well as the Management Executive. The purpose of the Health at Work Strategy was to provide direction to the

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Trust for the promotion of Health and Well being of staff at work. The physical Activity Policy underpinned the Health at Work Strategy with the aim of developing a culture that encouraged employees to realise their health potential. The Board approved the Health at Work strategy and the Physical Activity policy.

2007.75.4 EQUALITY & DIVERSITY An annual progress report regarding its Race Equality scheme action plan was under

development and in accordance with Welsh Assembly Government requirements, the Trust and the LHBs had developed a Mental Health Race Equality Action Plan. The Trust was required to engage with the communities it served and in order to achieve this had begun collecting patient equality data, by conducting two pilot studies in the Princess of Wales and Neath and Port Talbot Hospitals. Results had been presented to the Trust’s Patient Equality Monitoring Group and the Equality Improvement Steering Group. The results had also been sent to the All Wales Patient Equality Monitoring Group. The Trust had held the required three month statutory consultation period for the development of its Gender Equality Scheme, which it was anticipated would be published via the Trust’s Internet and Intranet sites early in the New Year. A structured programme of Equality and Diversity awareness raising was being developed across all levels within the Trust with the initial focus on medical staff. A wide range of information had been produced and disseminated to members of staff all of which would be made available on the Trust’s Intranet site. A new training package was being developed in relation to the use of Equality Impact Assessments. The Board noted the update.

2007.75.5 SKILLS DEVELOPMENT COORDINATOR FOR HEALTH CARE SUPPORT WORKERS

The Trust was to host the post of Skills Development Coordinator to develop education & learning opportunities for healthcare support workers employed within the healthcare community of Bro Morgannwg and the Bridgend, Neath Port Talbot and Vale LHBs. The fixed term post was being funded by NLIAH and would be managed by the Trust’s Learning and Organisational Development Department. The post would allow Trust and LHB managers to identify education and training needs for healthcare support workers, to develop recognised in-house training programmes, to work with local education providers to deliver accredited training programmes and also to provide support and mentoring to those undertaking the training. The Board noted and supported the creation of this post.

2007.75.6 BRING RESPECT TO WORK The Welsh Assembly Government had published a document entitled Bringing Respect to

Work which was appended to the report. This had been developed in association with the NHS, Healthcare Unions and the NHS Centre for Equality and Human Rights. It sought to bring an end to bullying, harassment and to ensure staff within NHS Wales were respected. The report summarised the document’s main principals. Whilst the Trust had already undertaken a significant amount of work in this area, the Deputy Chief Executive also highlighted that the latest NHS Wales Staff Survey was about to be released to Trusts and that this would help inform the organisation of the views and experiences of staff in relation to this particular issue. Bringing respect to work also included a model Dignity at Work Policy which was felt to be very similar to the Trust’s existing policy. Following further assessment, recommendations would be made with regard to any action required.

12

The Board noted the publication of bringing Respect to Work. 2007.75.7 COMPLIMENTS & FORMAL COMPLAINTS Appended to the report was a summary in relation to compliments and formal complaints

received for the period 1st April 2007 to the 30th September 2007, by Directorate. Overall the performance against the 20 day response target was 80% for the period with the acknowledgement target being maintained at 100%. The Board noted the report regarding compliments and formal complaints.

2007.75.8 NHS COMPLAINTS IN WALES 2006/07 Appended to the report was a copy of the Welsh Assembly Government’s report on NHS

Complaints in Wales. The report reminded the Board that detailed information regarding complaints received by the Trust during the year 2006/7 had been contained within the Complaints Annual Report which had been approved by the Board at the October 2007 meeting. The Board noted the report.

2007.75.9 RECORDS MANAGEMENT STRATEGY The strategy aimed to provide an overarching view of what was needed to take the Trust

forward, enabling it look smarter and through the use of consistent standards and processes achieve a records management system that was fit for the 21st Century. The revised edition had been approved by the Trust’s Records Management Group as well as the Management Executive. The Board approved the Records Management Strategy.

2007.75.10 NHS REDRESS (WALES) – PUTTING THINGS RIGHT PROJECT - MILESTONE REPORT

Appended to the report were details of progress made by the above project. Survey responses had been received and analysed and working groups had been established in the areas of legal advice, investigations and advocacy and assistance. The Board noted the position.

2007.75.11 TRADE UNION REPRESENTATIVES ON TRUST BOARDS The Welsh Assembly Government had recently published a document entitled Working in

Partnerships with Trust Boards - A Handbook for Trade Union Representatives at Trust Boards. The handbook stated that there should be a minimum of two Trade Union Representatives and a maximum of three who should attend Trust Board Meetings. The JSCC had formally requested that an additional Trade Union representative be invited to this Board meeting and Phillipa Rees, RCN, had been elected on this basis. In preparation for the proposed merger and in recognition of the importance of partnership working, it was recommended that the Trust Board invited an additional Trade Union Representative to attend its meetings. The Board approved the recommendation that three Trade Union Representatives be invited to attend Board meetings.

2007.76 HEALTHCARE GOVERNANCE REPORT 2007.76.1 PUBLIC SERVICES OMBUDSMAN FOR WALES – REPORT OF COMPLAINT

INVESTIGATION (TRUST CASE REFERENCE 181/8/2601) This case involved an elderly patient admitted to Tonna Hospital in 2005. Whilst the Trust

13

had attempted to satisfy relatives under local resolution, they had remained dissatisfied and referred the matter to the Ombudsman for investigation. The Ombudsman subsequently made a range of recommendations to address the issues identified. The report was due to be considered in detail by the Trust’s Healthcare Governance Committee and a further written apology had been sent to the complainant providing an update on actions taken to date and those that were planned. The implementation of actions set out within the plan were due to be monitored by the Trust’s Operational Risk Management Group. The Chairman commented that he was satisfied that the matter had now been thoroughly examined and that appropriate action was being taken. It was noted that there would be an increase in the level of audit of health record documentation and that this would be maintained until the Trust was satisfied that standards were at a satisfactory level. The Board noted the report and the way in which this matter was being actioned.

2007.76.2 NATIONAL PUBLIC HEALTH SERVICE (NPHS) FOR WALES STAPHYLOCOCCUS AUREUS BACTERAEMIA SURVEILLANCE REPORT. BRO MORGANNWG NHS TRUST 25th REPORT 01/07/06-30/06/07 (PUBLISHED NOVEMBER 2007)

The NPHS had published their most recent report identifying quarterly trend data for the period 1st July 2006 to 30th July 2007, which was appended to the report. MRSA Bacteraemia rates per 100,000 bed days stood at 8 which equated with the All Wales Acute Trust average. Staphylococcus Aureus Bacteraemia rates per 100,000 bed days identified the Trust as having a figure of 22 compared with an All Wales mean score of 26. The report therefore continued to identify the Trust as scoring below the overall Welsh average. The Chairman commented that it was important that the Trust continued its efforts to drive down infection rates further in line with the philosophy of the Trust’s Zero-tolerance Infection Control group. Reference was made by a Non Executive Director to the height of the gel holders within the Trust Hospitals and suggested that these were not currently accessible to wheelchair users. The Nurse Director advised that risk assessments had been undertaken which had resulted in the containers being placed at a height that was not going to pose a risk to children. The Board received the Infection Control report.

2007.76.3 HEALTHCARE INSPECTORATE WALES (HIW) – REVIEW OF LEARNING DISABILITY SERVICES

HIW had visited a range of services within the Bro Morgannwg area, which included the private and independent sector services, during June 2007. This was part of a three regions review under an All Wales report which was accepted to be issued by the end of the year. A further update would be submitted to the Board on this issue once HIW had finalised the publication. The Board noted the position.

2007.76.4 HEALTHCARE STANDARDS (HCS) SELF-ASSESSMENT 2006/07 The HCS Self-Assessment had focused on 32 healthcare standards, which divided into a

number of criteria, which required assessment at Corporate, Operational and User Experience levels. The report set out the main points contained within HIW’s findings. The Trust has had an opportunity to respond to the content of the draft report which had been published on 30th November 2007. Whilst Regional Office had specified that

14

although the Board had provided advanced authority in October 2007 to allow for the Chief Executive and Executive Directors to agree the final Health Care Standards Improvement Plan, the Board was formally expected to review and approve this Improvement Plan, which was tabled for this purpose. The Board approved the Healthcare Standards Improvement Plan.

2007.77 REPORT OF THE NURSE DIRECTOR 2007.77.1 COMMUNICATION STRATEGY TO PROMOTE COMPLIANCE WITH

INFECTION PREVENTION AND CONTROL PRACTICES BY SERVICE USERS AND VISITORS

The Communication Strategy which was appended to the report was aimed at those people visiting the Hospital and their role in supporting staff in minimising the spread of infection. This had been developed with close involvement of the public and stakeholder through workshops held with the Trust’s Public Involvement Development Group and the Disability Equality Forum. The Board approved the Communication Strategy.

2007.77.2 A STRATEGY FOR PATIENT AND PUBLIC CONNECTIONS The strategy appended to the report was focused on building on the work achieved to date

by developing links between patient and public involvement, improving the patient experience and providing patient support. It aimed to focus on the engagement of the citizen, partnership working and the links to improving the fundamental delivery of care. Mrs Miller commented that whilst she supported the new strategy she felt that there should be additional staff representation from those that readily engaged with the public on a day to day basis. The Nurse Director acknowledged this point and agreed to further discuss it with the Trust’s Head of Patient Experience to establish the level of the staff whom were currently involved. A typographical error was also noted in relation to the spelling of Mr Henrywood’s name on page 16 of the document. The Board supported the strategy for patient and public connections.

2007.77.3 NUTRITION AND CATERING ANNUAL REPORT The Trust’s Nutrition Steering Group was chaired by the Nurse Director who had

responsibility for coordinating nutritional care, developing strategy and monitoring performance against nutritional standards. A copy of the Nutritional and Catering Annual Report was appended. Mr E Griffiths commented that with regard to point 4.2 on page 4, he felt that the Annual Report should be amended to take account of the fact that the issues examined as part of the Audit of Hospital Fridges had been resolved. The Nurse Director acknowledged this and agreed to incorporate this point. The Board noted progress to date.

15

2007.78 ANY OTHER BUSINESS Mr E Griffiths sought reassurance in respect of the Trust’s security processes around the

secure management of patient identifiable information. The Director of Improvement and Information Management was able to provide the necessary reassurances to Mr Griffiths and the Board that the Trust had robust processes in place in terms of information security. The Chairman took the opportunity to wish everyone a very Merry Christmas and Happy New Year. There was no further business and the meeting was closed.

2007.79 DATE AND TIME OF NEXT MEETING 7th February 2008, Boardroom, Princess of Wales Hospital. ………………………. WIN GRIFFITHS CHAIRMAN

Appendix 3.2(i)

MINUTES OF THE MEETING OF THE BOARDS OF BRO MORGANNWG AND SWANSEA NHS TRUSTS

HELD ON FRIDAY 23 NOVEMBER 2007 AT 9.30 am AT THE LECTURE THEATRE,

NEATH PORT TALBOT HOSPITAL

PRESENT: Bro Morgannwg NHS Trust Win Griffiths, Chairman

Paul Williams, Chief Executive Sheelagh Lloyd Jones, Deputy Chief Executive Eifion Williams, Director of Finance Vicki Franklin, Director of Nursing Bruce Ferguson, Medical Director Paul Stauber, Director of Planning Debbie Morgan, Director of Information & Improvement David Davies, Non-Executive Director Charles Henrywood, Non-Executive Director Eifion Griffiths, Non-Executive Director Mary Lee, Non-Executive Director Ceri Doyle, Non-Executive Director David Sage, Staff Side representative Sandra Miller, Staff Side representative Swansea NHS Trust Michael Williams, Acting Chairman (in the Chair)

Calum Campbell, Acting Chief Executive John Calvert, Medical Director Liz Rix, Director of Nursing David Roberts, Director of Finance Geraint Evans, Director of Human Resources Steve Combe, Director of Governance Rob Royce, Director of Planning, Estates & Facilities Janet Williams, Acting Director of Operations Ed Davies, Acting Director of I M & T Chantal Patel, Non-Executive Director Robert Francis-Davies, Non-Executive Director Rob Davies, Non-Executive Director Ken Morgan, Non-Executive Director Gillian Stephens, Non-Executive Director

Professor Julian Hopkin, Head of School of Medicine, University of Wales, Swansea

Pat Dwan, Staff Side Representative Walter Thomas, Staff Side Representative IN ATTENDANCE: Mr G Harrop, Vale of Glamorgan CHC Mrs B Bowness, Project Manager Mrs W Penrhyn Jones, Head of Administration, Bro

Morgannwg

1

Appendix 3.2(i)

01/07 CHAIRMAN’S INTRODUCTION

Mr Michael Williams welcomed everyone to the meeting. He advised Directors that the reason for the meeting was to consider a report on the outcome of consultation on the proposed merger of the Bro Morgannwg and Swansea NHS Trusts. He thanked the Executive Teams of both Trusts and the Project Managers for their work throughout the consultation process.

02/07 APOLOGIES FOR ABSENCE

Apologies for absence were received from Professor M Jones, Mr C Johnson, Professor N Palastanga, Dr P Mangat.

03/07 OUTCOME OF CONSULTATION ON THE PROPOSED MERGER OF BRO MORGANNWG & SWANSEA NHS TRUSTS

A report setting out the outcome of consultation in respect of the proposed merger between Bro Morgannwg and Swansea NHS Trusts, together with proposals for action was received.

In introducing the report Mr Paul Williams highlighted the following issues:

- The consultation arrangements which had been discussed with Community Health Councils at an early stage. As a result the Community Health Councils had confirmed that an 8 week consultation was sufficient.

- No objections to the proposed merger had been received. As a result there had not been the need to consider any extension to the consultation period.

- The process of consultation, which had been as wide ranging and inclusive as possible, with 24 consultation meetings being held.

- The arrangements to consult with staff, which allowed all staff the opportunity to comment on the merger proposals, including open meetings, and engaging staff through bulletins and a joint intranet site.

- The positive responses received from the 28 respondents as set out in the report.

- The open and inclusive process that had been followed, which had been welcomed by many of those consulted.

- The number of positive comments received, together with

2

Appendix 3.2(i)

constructive issues to be taken forward, which were summarised in Appendix 1 of the report.

- Many of the issues raised had been anticipated in “Aiming Higher” and would need to be taken forward both up to, and beyond, the establishment of the new Trust. None of these issues were considered to be so fundamental as to mean the merger proposals should not proceed.

- The comments received from staff interests, which had shown enthusiasm for the proposals to gain University title and had raised issues related to service change, HR issues, representation on the Trust Board and its Committees, and the need to ensure appointment processes were open and transparent.

- The fact that service changes were outside the scope of consultation and any formal proposals for major service change would be the subject of separate policies and processes.

- The comments received from the Medical Staff Committees and other professional groups as set out in the report.

- The comments received from Community Health Councils, which were supportive and welcomed the proposals regarding University Trust title. The comments stressed the need to ensure effective partnership working and the early engagement of CHCs in any service-related issues. Concerns had been raised regarding the proposed timescales for establishing the Trust. Whilst accepting the challenging timescale, it was considered that both Trusts had sufficiently experienced and skilled staff to ensure that these timescales were met.

- The comments received from Local Health Boards, which were supportive.

- The comments received from the three Local Authorities which had responded, which were supportive. The responses had highlighted issues regarding future partnership working arrangements. There had been no formal response from the Vale of Glamorgan County Borough Council, although he had attended a meeting of the Scrutiny Committee of the Council, where support for the proposals had been expressed.

- The positive response from voluntary organisations, where a conference had been held where over 40 separate voluntary organisations had been represented.

- The comments from other interested parties, as set out in the report.

- The dialogue during consultation regarding values, where two

3

Appendix 3.2(i)

further suggestions had been made. These would be incorporated into a further draft set of values to be developed by the Human Resources Work Stream which would ensure that the agreed values were embedded in the new organisation.

- The proposed name for the new Trust, where the Project Board had considered this matter in detail and proposed the name of “Swansea Bro Morgannwg University NHS Trust”.

- The Equality Impact Assessment undertaken, where no issues had been raised to date. This would be the subject of continuous review.

- The proposal to be granted University Trust title, which would provide major benefits as set out in the report. Swansea NHS Trust was currently designated as a University Trust through the Association of UK Hospitals, although it had not been granted the title “University Trust”. It was proposed that a full case for achieving University Trust title be developed and sent to the Minister, based on the benefits set out in Appendix 3 of the report. Discussions had already been held with Swansea University at a senior level and the University Council was due to consider this matter at a meeting on 26 November 2007.

- The proposal that, subject to Board’s approval, a letter be sent to the Minister seeking the establishment of the new Trust from 1 April 2008, as set out in the draft letter at Appendix 4 of the report.

- The proposal that the Project Board would continue to oversee the merger of the two Trusts and the establishment of the new Trust based on the agreed Terms of Reference and the need for the Boards to consider future working arrangements.

In discussing the report the following issues were raised:

- Mr Win Griffiths expressed his thanks to Mr Paul Williams and both Executive Teams for the thorough and professional approach taken through the consultation process. He expressed the view that the merged Trust would bring significant benefits to patients, staff and the wider community and expressed his confidence that both Trusts had the talent, experience and expertise to achieve a successful merger. He stressed the importance of ensuring full Staff Side involvement in the future.

- Dr Walter Thomas indicated that staff had had full opportunity to contribute to the consultation process. He expressed his concern that, in some quarters, the merger was perceived as a takeover which, he felt, was unhelpful and unfair. Mr Calum Campbell indicated that people should judge both Trusts on their record and that it was important that the proposed values of the new organisation would be adhered to as a strong foundation for the

4

Appendix 3.2(i)

new Trust. Mr Paul Williams confirmed that it was critical that everyone involved in the merger process continued to highlight the fact that both existing Trusts had successful track records and that the new Trust would work in an open and fair way.

- Mr Robert Francis-Davies stressed the need for openness and transparency in any future appointment process and the opportunities to provide high quality health care to the population that the merger proposals brought.

- Mrs Gill Stephens enquired as to why it was proposed to deal with the University title separately from the proposed establishment of the Trust.

- Mr Paul Williams stated that, as the arrangements for the granting of University title required further clarification, it was thought essential that this be separated from the establishment of the Trust so that there were no unnecessary delays in obtaining approval to merge.

- Professor Julian Hopkin indicated that University title would mean the new Trust would have a strong commitment to research and training and it would be important to have reciprocal representation on the University Council and Trust Board.

- Mr Charles Henrywood expressed the view that the Welsh translation of the name of the new Trust should be Prifysgol and not Athrofa as set out in the report.

- It was agreed that the Welsh translation should read “Ymddiriedolaeth Prifysgol GIG Abertawe Bro Morgannwg”.

The meeting was adjourned to allow separate meetings of the Bro Morgannwg and Swansea Trust Boards to consider the proposals formally.

The meeting was then re-convened. Mr Win Griffiths, as Chairman of Bro Morgannwg NHS Trust, confirmed that the Bro Morgannwg Trust Board had discussed the proposals set out in the report in detail and had unanimously resolved to support the recommendations set out in the report, subject to a further resolution that the Welsh translation of the proposed name of the new Trust be “Ymddiriedolaeth Prifysgol GIG Abertawe Bro Morgannwg”.

Mr Michael Williams, Acting Chairman of Swansea NHS Trust, confirmed that the Swansea NHS Trust Board had considered the proposals in detail. The Board deliberations included issues regarding the size of the new Trust; the need for the organisation to be seen as a cohesive whole and emphasis on improving services to

5

Appendix 3.2(i)

patients and staff.

The Swansea Trust Board had unanimously resolved to support the recommendations in the report, subject to an amendment to the recommendation regarding the issues raised during consultation and the commitment to address these. This would mean the resolution would be amended to read “On the basis of the positive support for the proposed merger and the commitment to address the issues raised during consultation, the Minister be asked to approve the establishment of the new Trust with effect from 1 April 2008”.

As both Boards had unanimously agreed to the resolutions, the meeting was closed.

6

SPECIAL MEETING OF THE BRO MORGANNWG NHS TRUST HELD IN THE EDUCATION CENTRE,

NEATH PORT TALBOT HOSPITAL Appendix 3.2(ii) ON 23rd NOVEMBER 2007

PRESENT Mr W Griffiths Chairman Mr PM Williams Chief Executive Miss S Lloyd Jones Deputy Chief Executive Ms DJ Morgan Director of Information & Improvement Mr P G Stauber Director of Planning Ms V Franklin Nurse Director Dr B Ferguson Medical Director Mrs M Lee Non Executive Director Mr C Henrywood Non Executive Director Mr E Griffiths Non Executive Director Ms C Doyle Non Executive Director Mr D Davies Non Executive Director IN ATTENDANCE Mr G Harrop Chief Officer, Vale Community Health Council (CHC) Mrs S Miller Staff Side Representative Mr D Sage Staff Side Representative Mrs B Bowness Joint Project Manager Mrs W Penrhyn-Jones Head of Administration APOLOGIES Mr C Johnson Non Executive Director Professor N Palastanga Non Executive Director Mrs D Gunning Chair, Bridgend CHC Mr K Dee Chief Officer, Bridgend CHC

Actions 2007.63 WELCOME Mr Griffiths welcomed everyone to the meeting. The Board noted with regret

Mr Johnson’s recent illness and best wishes were tendered for his speedy recovery.

2007.64 OUTCOME OF CONSULTATION ON THE PROPOSED MERGER OF BRO MORGANNWG & SWANSEA NHS TRUSTS

The Chairman invited those present to offer comments on the outcome of the consultation and the proposals for action. Non Executive Directors pledged their support for the proposed merger whilst acknowledging that there was considerable work ahead to successfully bring the two organisations together. Clinical engagement was highlighted as being key to the new Trust being capable of delivering services fit for the 21st Century. With regard to the management structure the Chief Executive advised that he anticipated the proposed interim management arrangements for very senior

1

Actions managers would be developed during December 2007 (in order that, should the Minister give her approval), work could begin as a matter of urgency to allow the new organisation to be in place by 1st April 2008. Mr Sage underlined the importance of the continued involvement of staff side representatives in work stream meetings. The Chief Executive acknowledged this as important and confirmed that this would continue. The Medical Director commented that he felt the proposed new organisation would result in more sustainable, safe clinical services and that there was great potential to unlock in terms of the engagement of all clinicians. Mr W Griffiths said that the merger presented an opportunity for both organisations to learn from one another and create a successful new Trust which had the potential to boost opportunities and support and improve services by pooling staff experience and expertise and in so doing, provide high quality services for patients. Mr E Williams stated that the work involved in bringing together the two organisations could not be underestimated. Whilst there were technical matters to be resolved as part of the merger process, both Trusts were however forecasting a break-even position. There were also issues within the health community that would require careful management. The Director of Finance felt confident that the merger presented opportunities to help any new organisation steer through the challenging financial agenda that currently existed throughout the NHS in Wales. Following discussion, the only other point raised related to the Welsh language translation of ‘University’ within the proposed title for the new organisation. Resolved: The Trust Board

- Noted the extensive consultation that had taken place on the proposals to merge.

- Noted the positive formal responses received in respect of the consultation on the proposed merger from accredited staff organisations, CHCs and other key stakeholders.

- Agreed that, on the basis of the positive support for the proposed merger, the Minister be asked to approve the establishment of the new Trust with effect from 1st April 2008.

- Agreed that the letter to the Minister seeking her approval to proceed to merger should include a request that a submission be made setting out the case for University Trust title.

- Re-affirmed that the Project Board continue to oversee the merger of the two Trusts and the establishment of the new

2

Actions Trust

- Agreed that the name of the new organisation should be Ymddiriedilaeth GIG Prifysgol Abertawe Bro Morgannwg” – “Swansea Bro Morgannwg University NHS Trust

-

2007.65 ANY OTHER BUSINESS There was no further business and the meeting as closed.

……………………. WIN GRIFFITHS CHAIRMAN

3

Appendix 3.3

MINUTES OF THE HEALTHCARE GOVERNANCE COMMITTEE OPEN SESSION

HELD ON MONDAY 3RD DECEMBER 2007 AT 9.30 IN

THE BOARDROOM, GLANRHYD HOSPITAL

Present Professor N Palastanga Non Executive Director (Chair) Dr B Ferguson Medical Director Ms D Morgan Director of Information & Improvement Dr B Kirsop Medical Director, Bridgend LHB Mrs M Watkins Neath Port Talbot CHC Representative Mrs V Franklin Nurse Director Mr D Edwards Information Governance Manager Ms K Nicholson Assistant Head of Governance Support Unit Mrs G Davies Bridgend CHC In Attendance Ms Christine Hopkins Point of Care Testing Co-ordinator Ms Christine Mansell Pathology General Manager Dr Gareth Tudor Clinical Director, Radiology & Endoscopy Mr Ian McLelland Directorate Manager, Radiology & Endoscopy Mrs A Jones Administrative Assistant Apologies Miss S Lloyd Jones Deputy Chief Executive Mr D Davies Non Executive Director Mrs Mary Lee Non Executive Director Mr G Westlake Finance Mr C Johnson Non Executive Director Mrs K Davies Head of Physiotherapy Services Dr J Williams Deputy Medical Director Mrs C Lewis Acting Deputy Nurse Director Mrs A Charnock Clinical Governance Facilitator Mr P Jones Head of Patient Experience Mrs D Davies Head of Governance Support Unit Mr C Henrywood Non Executive Director Mrs L Jones Multiprofessional Training & Education Representative Mrs A Biffin General Manager, Medical Director’s Department

Action PART ‘A’ - DIRECTORATE PRESENTATIONS

1 Pathology Directorate

Ms Christine Hopkins and Ms Christine Mansell delivered a presentation detailing the Pathology Directorates’ Clinical Governance structure and processes as well as highlighting key achievements and challenges. Mr Nigel Palastanga commended the Directorate for their work resulting in the reduction of complaints. Dr Gareth Tudor and Mr Ian McLelland delivered a presentation detailing the Clinical Governance structure for the Directorate of Radiology & Endoscopy.

Appendix 3.3

Mr Nigel Palastanga thanked both directorates for their comprehensive presentations.

PART `B` - OPEN SESSION

2 MINUTES OF THE HEALTHCARE GOVERNANCE MEETING HELD ON 14TH MAY 2007 The minutes were received and accepted as an accurate record.

3 MATTERS ARISING NOT OTHERWISE ON THE AGENDA None

4 REPORT OF THE DEPUTY CHIEF EXECUTIVE Report from the Operational Risk Management Group Reports from the meetings held on 26 June 2007and 9 October 2007 were presented.

Healthcare Standards Self Assessment Update Ms Kate Nicholson detailed key points from the Healthcare Inspectorate Wales report received in early November 2007.

NHS Redress Mrs Dawn Davies will provide an update at the next meeting.

DD

5 INFECTION CONTROL ZERO TOLERANCE BOARD Mrs Victoria Franklin advised the committee on the 9 workstreams that report to the board. There has been a considerable amount of work done around hand-washing and there are plans for large posters and leaflets to be distributed throughout the Trust.

6 HEATHCARE INSPECTORATE WALES (HIW) OF LEARNING DISABILITIES Mrs Victoria Franklin informed the committee that no immediate feedback has been received following the review of June 2007. Mrs Franklin agreed to update the committee when this information is available.

7 STRATEGY FOR PATIENT & PUBLIC CONNECTIONS Mrs Victoria Franklin presented the draft strategy to the committee. Mrs Franklin advised that the new strategy is focussed on building on the work achieved to date and it’s strategic aim is to provide high quality care that reflects the needs of the patient and the local population served by the Trust.

8 FOR INFORMATION

8(i) Children & Young Peoples Strategy Mrs Victoria Franklin informed the committee that the Trust held a children’s Conference on 9th November 2007. Mrs Franklin advised that this strategy will be the first in the UK. It was planned to be presented at

Appendix 3.3

Trust Board for approval, however, following consultation with various children it was agreed that the strategy would be re-written in a way that children can understand. Work is currently being undertaken to find groups that can re-write the strategy.

8(ii) Children’s Strategy Group Mrs Victoria Franklin presented the minutes of the meeting held on 14th September 2007. It was noted that point 12.3 regarding the Doctor’s retirement would be kept on the agenda until the post has been filled.

8(ii) Public Involvement Development Group The minutes of the meeting held on 25th September 2007 were presented to the committee.

8(iii) Disability Equality Forum The minutes of the meeting held on 14th August 2007 were presented to the committee.

8(iv) Healthcare Governance Performance Report Dr Bruce Ferguson presented the report to the committee. Dr Ferguson highlighted high figures for Indicator 5 – Stroke readmissions within 28 days of discharge, but advised the committee that this was due to patient’s being readmitted with issues outside of their stroke-care. Dr Bridget Craddock queried figures for misadventures. Ms Debbie Morgan advised that it is the responsibility of the clinicians to clearly state this information for Clinical Coding colleagues to input it accurately.

8(v) Top Ten Bacteraemia Report Dr Bruce Ferguson presented the report to the committee for the period July 2006 – June 2007. Dr Ferguson advised that this information is also monitored by Infection Control Committee.

8(vi) Healthcare Inspectorate Wales Annual Report on the Local Supervisory Authority for Midwives in Wales Mrs Victoria Franklin informed the committee of the 1st Annual report. The Trust received a very positive report and all standards set by the NMC are being met.

8(vii) Welsh Health Circulars – WHC(2007) 068 / 079 Dr Bruce Ferguson presented the Welsh Health Circulars to the committee for information.

8(viii) Status of New Interventional Procedures Dr Bruce Ferguson presented the Status of New Interventional Procedures approved by the Clinical Effectiveness Steering Group.

5(ix) Clinical Audit Plan 2007 - 2008 Dr Bruce Ferguson advised the committee that further work will be completed on the plan and then it will be produced as the Clinical audit Report.

Appendix 3.3

8(x) Abdominal Aortic Aneurysm Screening Programme Newsletter

Dr Bruce Ferguson advised the committee of the Annual Research Day held by the Trust. They received 49 research posters and these were shortlisted to 18. Each shortlisted department gave a presentation. The Abdominal Aortic Aneurysm Screening Programme was awarded the best presentation.

9 ANY OTHER BUSINESS None.

10 DATE OF NEXT MEETING The next meeting will take place on Monday 4th February at 9:45am in the Boardroom, Neath Port Talbot Hospital.

Appendix 3.4

1

MEETING OF THE FINANCIAL AUDIT COMMITTEE HELD ON TUESDAY 11TH DECEMBER 2007

AT 8.30AM IN THE BOARDROOM GLANRHYD HOSPITAL

PRESENT Mrs M Lee Non Executive Director (Chair) Mr C Henrywood Non Executive Director (Vice Chair) Mr E Griffiths Non Executive Director IN ATTENDANCE Mr E Williams Director of Finance Mrs K Jones Associate Director of Finance Mr T Roberts Local Counter Fraud Specialist Mrs A Ryan Audit Manager, Grant Thornton UK LLP Mr G Davies Senior Partner, Grant Thornton UK LLP Ms AM Harkin Engagement Partner, Wales Audit Office Ms G Gillet Principle Auditor, Wales Audit Office Ms H Cottrell Performance Specialist, Wales Audit Office Mr H Richards Senior Audit Manager, Capital & PFI Audit Services (for minute 12.07.11) Mr D Butler Capital & PFI Audit Services (for minute 12.07.11) Ms H Dover Director of Community & Therapy Services (for minute 12.07.05(a)) Ms F Reynolds Head of Nursing, Community & Therapy Services (for minute 12.07.05(a)) Ms A Fisher Financial Resources Manager (for minute 12.07.05(a)) Mr P Spivey Deputy Director of Human Resources (for minute 12.07.05(b)) Ms H Fletcher Assistant General Manager, Neath Port Talbot Hospital (for minute 12.07.05(c) & 12.07.05(d)) Ms S Strong Assistant Manager, Women & Childrens Services (for minute 12.07.05(c)) Ms S James Head of Administration, Learning Disability Services (for minute 12.07.05(c)) Mr C Mustard Assistant Director of IT (for minute 12.07.05(c)) Ms L Cox Site/Support Services Manager, Glanrhyd (for minute 12.07.05(d)) Mrs E M Jeffery Deputy Head of Administration APOLOGIES Mr M Coe Audit Manager, Wales Audit Office Actions A ITEMS FOR DISCUSSION 12.07.01 WELCOME AND INTRODUCTIONS Mrs Lee welcomed Ms Gillet and Ms Cottrell and members to the

meeting.

12.07.02 TO RECEIVE: 12.07.02.1 MINUTES OF THE FINANCIAL AUDIT COMMITTEE HELD

ON 2ND OCTOBER 2007

The minutes were accepted as an accurate record with the following amendment:- 10.07.02.3 MINUTES OF THE HEALTHCARE GOVERNANCE SUB COMMITTEE(OPEN) HELD ON 9TH JULY 2007 The last sentence should read “It was stated that due to there being representation across several Committees by Non Executive Directors this provided the Financial Audit Committee with continuity”.

Appendix 3.4

2

Actions 12.07.02.2 MINUTES OF THE CAPITAL INVESTMENT COMMITTEE

HELD ON 17TH SEPTEMBER 2007

The minutes were received. Mr E Griffiths confirmed that the appointment of a Capital Development Manager would take place under the new framework.

12.07.02.3 MINUTES OF THE INFORMING HEALTHCARE GOVERNANCE SUB COMMITTEE HELD ON 17TH OCTOBER 2007

The minutes were received.

12.07.02.4 MINUTES OF THE HEALTHCARE GOVERNANCE SUB COMMITTEE (OPEN) HELD ON 1ST OCTOBER 2007

The minutes were received.

12.07.02.5 MINUTES OF THE HEALTHCARE GOVERNANCE SUB COMMITTEE (CLOSED) HELD ON 1ST OCTOBER 2007

The minutes were received.

12.07.03 MATTERS ARISING NOT OTHERWISE ON THE AGENDA 10.07.02.3 MINUTES OF THE HEALTHCARE GOVERNANCE SUB

COMMITTEE (0PEN) HELD ON 9TH JULY 2007

Mr G Davies informed members that a meeting with Dr B Ferguson to discuss a work programme for the Healthcare Governance Committee had not taken place and had been deferred. It was felt that due to the pending merger and the fact that there were currently two different internal audit systems used in the two Trusts, this item would need further discussion.

10.07.03 MATTERS ARISING NOT OTHERWISE ON THE AGENDA – 08.07.21 – STANDING ORDER REVIEW 2007/08

It was confirmed that the question of changing the name of the Financial Audit Committee, would be discussed as part of one of the merger workstreams.

10.07.9(b) WARD STAFFING – FOLLOW UP REVIEW ACUTE HOSPITAL PORTFOLIO PHASE 5

Mr Henrywood reported that he had not yet had the opportunity to meet with Professor Palastanga.

10.07.19 CASWELL CLINIC PROGRESS REPORT It was noted that Morgan Cole had written to the Company, but a

response had not yet been received.

Appendix 3.4

3

Actions 10.07.20 SELF ASSESSMENT CHECKLIST 2007/08 Mrs K Jones confirmed that work was underway to produce an

assurance map, identifying the relevant Committees and processes involved and it was anticipated that this would be available for the next Audit Committee.

KJ

12.07.04 COUNTER FRAUD WORK The attached report detailed activity during the period October 2007 to

December 2007 and progress against the action plan. Included in the report were policy and procedure reviews, development of anti-fraud culture and detecting and preventing fraud. Details of current and concluded investigations were also included. Mr C Henrywood questioned whether or not the Trust was entitled to claim back any monies if Fraud had been committed. The question was noted and Mr E Williams agreed to investigate whether or not this was included or should be added to the policy, as this may act as a further deterrent against fraud. With regard to Item 5.2 it was felt that the new E-Rostering system would help prevent any long or back to back shift patterns occurring and that it was Trust policy that any employee undertaking a secondary employment should discuss this with their Manager. The Committee noted the report.

EW

12.07.05 TO RECEIVE REPORTS FROM GRANT THORNTON UK LLP REPORTS FOR DISCUSSION

12.07.05(a) COMMUNITY & THERAPY DIRECTORATE Mrs Lee welcomed Mrs H Dover, Director, Ms F Reynolds, Head of

Nursing, and Ms A Fisher, Financial Resources Manager, to the meeting. The report outlined that the systems of control were found to be mostly satisfactory throughout the Directorate with the exception of Maesgwyn Community Hospital, where the controls were found to be marginally satisfactory, with two key findings and three minor findings arising from the audit work. Mrs H Dover confirmed that Maesgwyn had made a considerable improvement, and the main issue had been the change in culture and working practices and that this was work in progress. Mrs Dover was confident that continued improvements would be made and that all recommendations in the action plan would be carried out.

Appendix 3.4

4

Actions Spot checks had been implemented and workshops had been held reminding key members of staff of the new processes. An internal audit was recently carried out by the Directorate using the Grant Thornton compliance checklist and any issues picked up were rectified with immediate effect. 1:1 meetings with ward managers and lead nurses were being held and monthly meetings held with Community Managers, ensuring that progress regarding the action plans were monitored. It was also noted that best practice was being shared between Community Hospitals using Cimla as the template. It was noted that there was limited administrative support within the Directorate and this was an issue that was currently being investigated. The Committee noted the report.

12.07.05(b) PAYROLL DIRECTORATE Mrs Lee welcomed Mr P Spivey, Deputy Director of Human Resources

to the meeting. The report outlined that the systems of control were found to be marginally satisfactory in respect of the payroll processes, with five key findings and seven minor findings arising from the audit work. The systems of control in respect of the Payroll Department’s own compliance with key financial controls was good, with one minor finding. Mr P Spivey informed members that Mr C Addams was currently on a phased return to work and therefore unable to attend. Mr P Spivey reported that over the last 18 months there had been a significant amount of changes within the Payroll Department, in particular the introduction of the Electronic Staff Record (ESR) and Agenda for Change and work was ongoing to ensure that robust systems were in place within the Department. It was noted that with regards to the authorised signatory list, systems needed to be in place to ensure that these lists were kept up to date. It was reported that it was also the responsibility of the Directorate to ensure that Payroll were kept informed of any changes. Changes were made within the Department whereby duties were reallocated to three members of staff, ensuring sufficient cover in light of any absences. Staff training was also undertaken and it was felt that guidelines should be developed to ensure that managers carry out the processes effectively. Regular meetings were held and systems constantly reviewed.

Appendix 3.4

5

Actions An interim Payroll manager with extensive knowledge of the ESR system had been appointed for three months to provide advice on new processes and the ESR system. Work was also underway to interface the electronic rostering system with ESR to enable a move away from paycards. Mr G Davies reported that a follow up audit would be undertaken at the end of January 2008. The Committee noted the report.

12.07.05(c) MOBILE PHONES Mrs Lee welcomed Ms S Strong, Assistant Manager, Women &

Childrens Services, Ms S James, Head of Administration, Learning Disability Services, Ms H Fletcher, Assistant General Manager, Neath Port Talbot Hospital, and Mr C Mustard, Assistant Director of IT to the

eeting. m The report outlined that the systems of control were found to be marginally satisfactory in respect of Women and Children’s Services, Planning, Learning Disabilities, and Information and Technology Directorates, with ten key findings and three minor findings arising from the audit work. The systems of control in respect of the Community & Therapies and Mental Health Directorates were found to be mostly satisfactory. Mr E Williams reported that Mr P Williams, Chief Executive had indicated that immediate action needed to be taken on these findings. Mr C Mustard informed members that all actions had been completed and that all mobile phone bills were reviewed for personal calls and these calls were subsequently paid by the member of staff. Ms S Strong reported that in Women & Children’s Services they had a database with details of all individuals who had a mobile phone and all bills again were reviewed for personal calls and subsequently paid. Ms H Fletcher confirmed that Directorates had details of what phones were in use, costs incurred and any trends identified and that work had recently been undertaken to reduce costs. Mr G Davies stated that it may be possible for the mobile phone company to itemise personal calls on each bill to assist with this process. If each member of staff using a Trust mobile gave a list of their personal numbers, the Company could extract these from the bill and itemise them separately. Ms H Fletcher agreed to explore this option.

Appendix 3.4

6

Actions It was noted that Accounts Payable were investigating the possibility of electronic invoicing for mobile phones in the future. The Committee noted the report.

12.07.05(d) TAXI USAGE Mrs Lee welcomed Ms H Fletcher, Assistant General Manager, Neath

Port Talbot Hospital, and Ms L Cox, Site/Support Services Manager, Glanrhyd to the meeting. The report outlined that the systems of control were found to be marginally satisfactory, with four key findings and two minor findings arising from the audit work. Ms L Cox reported that taxis were used for the transportation of notes and samples to and from A&E at Princess of Wales Hospital between the hours of 6pm and 7am. All notes were in sealed envelopes and security tagged. It was felt that this exposed the Trust to the risk of loss of sensitive information and reputational risk. Ms Cox informed members that a detailed costing exercise had been undertaken, to see how much it would cost to employ extra staff to cover out of hours instead of using taxis. Unfortunately, the exercise proved that two members of staff would be required to cover these shifts seven days a week and that this was in fact more costly than using taxis. It was felt that the risk of losing sensitive information and the reputational risk to the Trust outweighed the cost implications. The Committee noted their concerns and reservations over the use of taxis for transportation of sensitive information and samples and that this should be brought to the attention of the Chair of the Operational Risk Management Group. Ms L Cox stated that discussions were underway with Swansea regarding their transport arrangements and whether Bro Morgannwg NHS Trust could use a similar system in the future. It was noted in the report that due to the closure of Groeswen Hospital a high number of out of hours journeys were being undertaken for both hospitals. The report outlined that the reason for the use of a taxi was not found to be adequately detailed in the majority of cases. It was felt that the requisition slip should state full details of the reason for the journey including why the taxi has had to be used. Ms Cox and Ms Fletcher agreed to reinforce this to the relevant staff members.

KJ

LC/HF

Appendix 3.4

7

Actions Ms Fletcher reported that at Neath Port Talbot Hospital, Doctors were asked to pay directly for the taxi and claim these back on their expenses and agreed to liaise with Personnel and investigate whether this could be implemented across both sites. Mr E Williams asked that Ms H Fletcher explore alternative arrangements with regard to the key findings in the report and report back to the Committee. The Committee noted the report.

HF

HF

12.07.05(e) PROGRESS REPORT Mr G Davies confirmed that with regard to the 2006/07 programme of

work, 53 final reports had been agreed and one report remained in draft. With regard to the Internal Audit Plan for 2007/08, it was noted that 17 final reports had been agreed to date and five draft reports had been issued as detailed in the report. Mr G Davies reported that the Internal Audit Manager had attended a meeting of the e-rostering project group and it was envisaged that further meetings would be attended and audit time input into the e-rostering project to provide pro-active advice as the project developed. Mr G Davies informed the Committee that concerns were raised regarding the WRMS/Healthcare Standards Audit, due to the fact that no guidance had been received from the Welsh Assembly Government and informed the Committee that the signing off of this audit may be affected. The Wales Audit Office noted this information. The Committee noted the progress report.

12.07.06 INTERNAL AUDIT REGISTER 2007/2008 Attached were summary extracts of 2007/2008 Internal Audit Registers,

as at 3rd December 2007. For 2007/2008, fieldwork had been completed in 22 areas, with all draft and final reports being received on time and 94% of management responses had been received by the due dates. The Committee noted the report.

Appendix 3.4

8

Actions 12.07.07 INTERNAL AUDIT ACTION PLANS

The report detailed the current status of the Action Plans agreed with Internal Audit for 2007/2008 to date. The current status of the 2007/2008 action plans was detailed, with 23 of the findings reported having been brought forward from 2006/07, of which 14 (60%) were outstanding. Of the 54 ongoing, 100% have not yet reached their implementation date. The conclusion indicated that the vast majority of findings had now been implemented and good progress had been made with the remaining audit report findings. The Committee noted the report.

12.07.08 TO RECEIVE REPORTS FROM WALES AUDIT OFFICE 12.07.08(a) FINANCIAL AUDIT COMMITTEE UPDATE The report contained a record of progress in concluding the agreed

programme of work for 2005/2006 and 2006/2007 and tracked completion of performance reviews coming to a close from previous years plans. An update on the 2006/2007 programme was provided as summarised in the report. Ms A M Harkin reported that all audits within the Accounts and the Financial aspect of Corporate Governance Programme had been completed with the exception of the Audit of Efficiency Gains, which would be available for the next meeting. It was noted that all reports on the Performance Management Review Programme for 2005/06 had been completed and good progress was being made in the 2006/07 Programme. The Committee asked that a “Concluded” column be added to the summary report and it was agreed that this would be implemented for the next meeting. The Committee noted the report.

AMH

12.07.08(b) AUDIT OF FINANCIAL STATEMENTS 2006/07 The Audit of Financial Statements 2006/07 was appended for

information. The report outlined that the Trust had effective high level internal financial accounting controls, which provided a sound basis for the preparation of the Financial Statements. Good quality draft accounts were submitted which were supported by comprehensive working papers.

Appendix 3.4

9

Actions The effective closedown process resulted in minimal amendments being made to the accounts and an unqualified opinion was given by the Auditor General for Wales on 27th June 2007. Recommendations for further areas of improvement were outlined in the report. Ms A M Harkin reported that the use of the Team-mate audit software had proved invaluable in completing the statements and thanked finance colleagues for all their efforts. The Committee noted the report.

12.07.08(c) ANNUAL AUDIT LETTER 2006/07 The Annual Audit Letter 2006/2007 summarised the conclusions from

the 2006/2007 audit and reported on the significant issues that arose from this audit. It outlined that the Trust’s resources in all material respects, were properly used and accounted for and the Trust had proper arrangements to help it deliver efficient, economical, and effective services. Ms A M Harkin stated that this was a very positive report and congratulated Mr E Williams and his team on the efforts made throughout the year. On behalf of the Trust, Mr E Williams thanked the Wales Audit Office team for their continued support and joint working. The Committee noted the report.

12.07.08(d) MANAGEMENT OF HELP DESK Ms H Cottrell confirmed that all recommendations had been completed

resulting in a marked improvement in the service provision. There was now a set of operating standards against which performance could be monitored. The Committee noted the report.

12.07.08(e) AHP5 A&E FOLLOW UP Ms H Cottrell summarised the above report. In 2005, the Wales Audit

Office undertook the Acute Hospital Portfolio Phase 5 (AHP 5) review of accident and emergency services in the Trust. The report and agreed action plan from this review was published in March 2006. The Action plan centred on improving the patient experience, efficiency of the service and capacity to meet demand.

Appendix 3.4

10

Actions This follow up review sought to answer the question: Has the Trust made progress in addressing the issues identified in the Acute Hospitals Portfolio Review of Accident and Emergency? The report concluded that the Trust’s Accident and Emergency Services had improved since the 2005 review with good performance recorded for waiting time targets and the development of new services and facilities. Whilst improvements had been made in improving attendance, there was still scope to reduce sickness absences further. Whilst a separate Action Plan would not be developed, two recommendations were outlined in the report as continuing to be a priority. It was queried whether this review was being carried out on an All Wales perspective and Ms H Cottrell agreed to investigate. The Committee noted the report.

HC

12.07.08(f) MAKING THE CONNECTIONS Attached for information was the slide show presentation entitled

“Making the Connections – Feedback on Key Findings. Ms H Cottrell summarised the presentation which included the overall objectives for the review, the purpose of the presentation, what the conclusions were based upon, audit judgements/maturity matrix, key findings, working together as the Welsh public service, patient and public engagement, preparing the workforce, use of resources, good practice and next steps. The Committee noted the report.

12.07.09 EXTERNAL AUDIT REGISTER 2006/07 Attached was a summary extract for the 2006/2007 External Audit

Register, as at 3rd December 2007. It was noted that the target dates set to monitor the outlined areas, mirrored those of the Internal Audit, with the exception of completion of draft reports, where an extra week had been agreed to reflect the complexity of some of the reports. The report outlined that the majority of Trust Management responses and final reports from Wales Audit Office had been received on time and would continue to be monitored and reported to the Committee. The Committee noted the report.

Appendix 3.4

11

Actions 12.07.10 EXTERNAL AUDIT ACTION PLANS The report detailed the current status of the Action Plans agreed with

External Audit for 2004/2005 and 2005/2006. The table indicated that 119 (75%) had been completed and of the 39 ongoing 77% had not yet reached the implementation date. The Committee noted the report.

12.07.11 TO RECEIVE REPORTS FROM CAPITAL AND PFI AUDIT SERVICES

12.07.11(a) AUDIT PLAN PROGRESS REPORT The report provided colleagues with a progress statement of the Capital

and PFI Audit Services audit plans as at 23rd November 2007. The report had been developed to monitor the delivery of the strategic audit plan; the status and progress of individual assignments; receipt of draft and final audit reports; the ratings applied and a summary of recommendations made at individual audits. The report outlined that the 2007/08 audit plan was being progressed and all fieldwork for 2006/07 had been completed. The audit of the intermediate care services development at Cimla Hospital was to be finalised with the draft report meeting scheduled for 5th December 2007. Direction from the Trust regarding the progression of the Caswell Clinic final account (2005/06 audit plan) was also anticipated and Mr E Williams agreed to investigate progress on this matter. The Committee noted the report.

EW

12.07.11(b) NEATH/PORT TALBOT OPERATIONAL PFI REVIEW The audit was undertaken to evaluate processes and procedures put into

place by the Trust to monitor the operational PFI arrangements at Neath Port Talbot Hospital. The review was undertaken to determine the adequacy of, and operational compliance with, the established systems for the management and control of capital projects at the Trust, taking account of the Capital Investment Manual and other supporting regulatory and procedural requirements, as appropriate. The audit findings and recommendations were outlined in the report and a significant level of assurance was determined. Mr E Williams agreed to investigate with Mr P Stauber whether proceeds from the sale of Neath and Port Talbot Hospital sites had been reflected in the unitary payment included at the project agreement.

EW

Appendix 3.4

12

Actions It was also agreed that any verbal assurances should be backed up by documentary evidence so that an audit trail can be provided. Mr H Richards noted that Item 2.2.1 No 4, Performance Management should indicate that it had obtained significant assurance and not full assurance as stated in the table in the report. Mr E Williams reported that monies had been set aside for accruals and any changes in the PFI have been accounted for in the invoice. The Committee noted the report.

12.07.11(c) 10.07.16(c) CAPITAL SYSTEMS 2006/07 Mr H Richards confirmed that the contract was awarded following

verbal feedback but that formal written confirmation was received at a later date. The Committee noted the report.

12.07.12 CAPITAL & PFI REGISTER 2007/2008 Attached was a summary extract of the 2007/2008 Capital & PFI Audit

Register as at 30th November 2007. It was noted that the target dates set to monitor the outlined areas, mirror those of external audit. The Committee noted the report.

12.07.13 CAPITAL & PFI ACTION PLANS The report detailed the current status of the Action Plans agreed with

Capital & PFI for 2006/2007 & 2007/08. The table indicated that 43 (44%) had been completed and of the 55 ongoing 64% had not yet eached their implementation date. r

The Committee noted the report.

12.07.14 TO RECEIVE SINGLE TENDER ACTION APPROVALS – 1ST SEPTEMBER – 30TH NOVEMBER 2007.

PROBES FOR TOSHIBA ULTRASOUND MACHINE A single tender action had been received from the Radiology

Department, Neath Port Talbot Hospital, to place an order for probes for an ultrasound machine. The linear and endo cavity probes were required for the Toshiba Aplio ultrasound machine and competitive tenders could not be sought, as Toshiba Medical Systems were the original manufacturer of the ultrasound machine and the sole supplier of the probes, therefore a single tender action was required. The Committee noted the report.

Appendix 3.4

13

Actions PROBE FOR B&K ULTRASOUND MACHINE A single tender action had been received from the Radiology

Department, Neath Port Talbot Hospital, to place an order for a probe for an ultrasound machine. The bi plane trans rectal probe was used to undertake trus biopsies with the B&K Falcon XEL Endo-Anal Scanner and competitive tenders could not be sought, as B&K Medical were the original manufacturer of the ultrasound scanner machine and the sole supplier of the probes, therefore a single tender action was required. The Committee noted the report.

TENDER FOR MEDIATION SKILLS A single tender action had been received from Louise Joseph, Assistant

Director, Learning & OD to place an order with Conflict Management Plus to run a 4 day accredited programme for a Certificate in Mediation Skills for the Trust. The Trust needs to increase the number of trained mediators across the organisation and Conflict Management had previously facilitated a 4 day programme for Senior Managers. Conflict Management were the only known supplier to the Trust able to facilitate such a course and the Training Department would like to use the same company for quality assurance and consistency purposes and therefore a single tender action was required. The Committee noted the report.

MAINTENANCE OF MASS SPECTROPHOTOMETER A single tender action had been received from the Contracts Manager at

the South & West Wales Trust Supplies Partnership, to place an order with Thermo Limited to renew the maintenance on the Mass Spectrophotometer in Clinical Biochemistry at the Princess of Wales Hospital. This instrument was vital to the Drugs of Abuse screening programme and Thermo were the only contractor capable of maintaining this kit and therefore a single tender action was required. The Committee asked that assurance be sought that Thermo Limited were the only contractor capable of maintaining this kit and Mr E Griffiths agreed to take this query to the Capital Investment Committee. Mr E Williams reported that future maintenance contracts would be reviewed to ascertain whether whole life service costs and sustainability costs could be included. The Committee noted the report.

EG

Appendix 3.4

14

Actions REPLACEMENT X-RAY TUBE A single tender action had been received from the Directorate Manager,

Radiology, to place an order for a replacement x-ray tube for use with their x-ray machine in Room 2, Neath Port Talbot Hospital. The tube has failed due to excessive use and a replacement was required. Competitive tenders could not be sought as GE Healthcare was the sole manufacturer and supplier of the replacement tube on a service exchange basis and therefore a single tender action was required. Mr C Henrywood questioned why plain film radiography was being used and whether or not new machines had digital films. Mr E Williams agreed to investigate. The Committee noted the report.

EW

MAINTENANCE OF DR9000 DIRECTVIEW SYSTEM A single tender action had been received from the Contracts Manager at

the South & West Wales Trust Supplies Partnership, to place an order with Carestream Healthcare (Kodak) to renew the maintenance on the Directview System located in the Radiology Department at the Princess of Wales Hospital. Carestream Healthcare (Kodak) was the original supplier of this equipment and sole supplier for maintenance support and therefore a single tender action was required. The Committee noted the report.

MAINTENANCE OF LEICA EQUIPMENT A single tender action had been received from the Contracts Manager,

Welsh Health Supplies Local Contracting on behalf of the Trust Procurement Partnership, to place orders for the maintenance of Leica equipment in Princess of Wales Hospital. In order to guarantee functionality of their equipment, there was no alternative contractors who could provide cover for this complex equipment and Leica were the original suppliers and sole suppliers for maintenance support and therefore a single tender action was required. T

he Committee noted the report.

X-RAY ROOM 3, PRINCESS OF WALES HOSPITAL A single tender action was received regarding the damage caused within

the x-ray department at the Princess of Wales Hospital. It was noted that the suppliers of the equipment would need to be commissioned to review their installation and due to the interfaces between the room finishes and the equipment it was considered that the original contractor should be called to repair the damage. Therefore a single tender action was required in respect of the appointment of Seimens and KITTO Construction Ltd.

Appendix 3.4

15

Actions Mr E Williams stated that attempts were being made to recover some of the costs from the Welsh Risk Pool. The Committee noted the report.

12.07.15 CUMULATIVE SINGLE TENDER ACTIONS 2007/08 The report outlined all single tender actions for 2007/08 up to the period

ending 30th November 2007. The Committee noted the report.

12.07.16 HOSPITALITY REGISTER 1ST AUGUST– 31st AUGUST 2007 The report outlined any Hospitality/Events/Gifts registered for the

period 1st April to 30th November 2007. The Committee asked that a more detailed description be provided and attempts made to ascertain a value for entries. Mrs E Jeffery agreed to implement this when possible. The Committee noted the report.

EMJ

12.07.17 FINAL ACCOUNTS FOR FUNDS HELD ON TRUST 2006/07 Attached for information was the eighth Annual Report and Accounts of

the Bro Morgannwg NHS Trust Charitable Fund, which had been compiled in accordance with the requirements of the Charities Act 1993 (Part VI) and the Charities (Accounts and Reports) Regulations 2005. The report included an overview of the Charity’s History, objects of the Charity, review of fund information, finance and performance, and governance and management arrangements. The Committee noted the report.

12.07.18 ANNUAL ACCOUNTS 2007/08 UPDATE The report provided an update on the Trust’s preparation for the

2007/08 Annual Accounts earlier closure process, which this year required the Trust to prepare Draft Accounts by 8th May 2008, 7 days earlier than 2006/07. The report outlined accounting reviews being undertaken by the Trust prior to the impending merger with Swansea and advised that International Financial Reporting Standards (IFRS), whilst being applicable for the financial year 2008/09 would require that the opening balance sheet for financial year 2007/08 was restated for IFRS.

Appendix 3.4

16

Actions The report also outlined the significant items included in the 2006/07 Balance Sheet and the likely position at year end 31st March 2008 and detailed the actions being taken by the Trust to manage these issues. The Committee agreed the proposals outlined in the report.

B ITEMS FOR NOTING/INFORMATION 12.07.19 LOSSES & SPECIAL PAYMENTS The report detailed the total losses and special payments recorded by the

Trust for the quarter ending 31st October 2007. The Committee noted the report.

12.07.20 TO RECEIVE REPORTS FROM GRANT THORNTON UK LLP REPORTS FOR NOTING/INFORMATION 2007/08 f) LEASE CARS (MOSTLY SATISFACTORY) There were three key findings arising from the audit work and three

minor findings. The overall conclusion was that the adequacy and controls of application and internal controls were mostly satisfactory. The Committee noted the report.

g) PLANNING AND ESTATES (MOSTLY SATISFACTORY) There was one key finding arising from the audit work and five minor

findings. The overall conclusion was that the adequacy and application of internal control was mostly satisfactory. The Committee noted the report.

h) BUDGETARY CONTROL AND FINANCIAL MANAGEMENT (GOOD)

There were no key findings arising from the audit work and two minor findings. The overall conclusion was that the adequacy and application of internal controls was good. The Committee noted the report.

i) OPHTHALMIC SERVICES FOLLOW UP (MOSTLY SATISFACTORY)

There was one key finding arising from the audit work and no minor findings. The overall conclusion was that the adequacy and application of internal controls was mostly satisfactory. The Committee noted the report.

Appendix 3.4

17

Actions j) NLIAH EXPENSES REVIEW (MOSTLY SATISFACTORY) There was one key finding arising from the audit work and three minor

findings. The overall conclusion was that the adequacy and application of internal controls were mostly satisfactory. Mr G Davies reported that extensive work had been undertaken within this audit and was very pleased with the result. The Committee noted the report.

k) INFORMING HEALTHCARE – SEPTEMBER 2007 (MOSTLY SATISFACTORY)

There were four key findings arising from the audit work and five minor findings. The overall conclusion was that the adequacy and application of internal controls were mostly satisfactory. The Committee noted the report.

l) WELSH HEALTH SUPPLIES – CONTRACTOR MONITORING (MOSTLY SATISFACTORY)

There were two key findings arising from the audit work and five minor findings. The overall conclusion was that the adequacy and application of internal controls were mostly satisfactory. The Committee noted the report.

m) NON-PAY EXPENDITURE (MOSTLY SATISFACTORY) There were no key findings arising from the audit work and five minor

findings. The overall conclusion was that the adequacy and application of internal controls were mostly satisfactory. The Committee noted the report.

n) PRINCESS OF WALES RESTAURANTS FOLLOW UP (MOSTLY SATISFACTORY)

There were two key findings arising from the audit work and six minor findings. The overall conclusion was that the adequacy and application of internal controls were mostly satisfactory. The Committee noted the report.

Appendix 3.4

18

Actions o) HEALTHCARE AT HOME REVIEW Attached for information was a letter from Grant Thornton, informing

the Trust that an ad hoc review audit of the processes surrounding the Healthcare at Home initiative had been completed. The overall opinion was that the system was satisfactory, although some minor issues had been identified during testing and these were outlined in the letter. The Committee noted the report.

12.07.21 ANY OTHER BUSINESS An informal discussion was held regarding internal audit arrangements

in the proposed trust. It was noted that at present there were two very different structures with Bro Morgannwg NHS Trust using Grant Thornton UK LLP and Swansea NHS Trust having their own internal audit department. It was felt at this stage that no one option was preferred but that work would have to be undertaken together to establish one way of working. It was noted that the current arrangements would stay in place for the 1st year. It was agreed that for the interim Grant Thornton would continue to service the Hosted Agencies to ensure continuity. Mr E Williams stated that a paper would be submitted to the Project Board and an update would be provided at the next meeting. The Committee noted the report.

EW

12.07.22 DATE AND TIME OF NEXT MEETING The date of the next meeting was 12th February 2007 in the Boardroom,

Neath Port Talbot Hospital at 8.30am.

Appendix 4.1

CHAIRMAN’S ACTIVITIES December 6th Administration

Trust Board Wales Quality Awards 7th Administration Bridgend Mayor’s function 10th Administration Bridgend Partnership Board Collaborative State Launch, Senydd Mental Health Managers/Voluntary/Charity Organisations

Meeting between Swansea and Bro Morgannwg Trust Chairmen and Chief Executives

11th Administration Volunteers Christmas Lunch

Carol Service, Princess of Wales Hospital 12th Swansea Performance Management Committee University meeting – Singleton Hospital 13th Chief Executive’s Modernisation & Innovation Awards Prospective Consultant Anaesthetists 14th Joint Trust Project Board Y Bwthyn Volunteers Lunch Prospective Consultant Anaesthetist 17th Meeting between Cardiff Trust and Bro Morgannwg Trust Chairs and

CEOs on service provision 18th Prospective Consultant Anaesthetist Vale of Glamorgan Local Service Board Prospective Consultant Anaesthetist Clinical Excellence Awards 19th Dr. Andrew Miller – Sierra Leone Prospective Consultant Anaesthetist Patient Experience Volunteers lunch 20th Consultant Anaesthetist Appointment Panel 21st Estates Staff – Neath Port Talbot Hospital Tonna Hospital – Ward Rounds Neath Port Talbot Hospital – Ward Rounds Glanrhyd Hospital – Ward Rounds 24th Maesteg Hospital – Ward Rounds Maesgwyn Hospital – Ward Rounds 25th Princess of Wales Hospital – Ward Rounds

JANUARY 15th Interview for Funding for Sierra Leone – WAG Trust Board Workshop 16th All Wales Chairs meeting All Wales Chairs meeting with Minister 17th Sierra Leone High Commission 18th Administration

Official opening of Heronsbridge School Bridgend LSB Welsh Confederation – Future of Resource Sub Committee Glamorgan Gazette 21st Administration Neath Port Talbot LSB 22nd Administration Sierra Leone meeting 23rd Interview Panel for Medical and Nurse Directors “B” Tech Presentations 24th Administration 28th Administration Trust Project Merger Board 29th – 31st Sierra Leone

: Meeting of the : Trust Board : 7th February 2008 : AGENDUM NO 6

REPORT OF THE CHIEF EXECUTIVE 1. MERGER OF SWANSEA AND BRO MORGANNWG NHS

TRUSTS Following the Special Board meeting held on 23rd November 2007, a letter was sent to the Minister for Health and Social Services seeking her approval to merge the Swansea and Bro Morgannwg NHS Trusts. Subsequently further correspondence was sent to the Minister setting out the case for University title. The Board will be aware that the Minister subsequently gave her approval to abolish the Swansea and Bro Morgannwg NHS Trusts and to establish a new Trust with effect from 1st April 2008. Appointment of Chairman The Minister has announced that Mr Win Griffiths, Chairman of Bro Morgannwg Trust will be the Chairman of the new Trust. It is anticipated that Non Executive Director posts will be advertised shortly. Trust Name and Title The Minister has announced that the new Trust to be formed on 1st April 2008 will be called the Abertawe Bro Morgannwg University NHS Trust. The name includes confirmation that the Trust will have University title. University status has already been conferred on the new Trust by Swansea University. Interim Management Arrangements The following is a list of all the interim appointments made to date:

Interim Position Name

Chief Executive

Paul Williams

Assistant Chief Executive Div Director – West

Calum Campbell

Deputy Divisional Director – West

Rob Royce

Assistant Chief Executive Div Director – East

Sheelagh Lloyd Jones

Deputy Divisional Director – East

Janet Williams

Director of Finance Eifion Williams

Deputy Director of Finance

David Roberts

Medical Director

Bruce Ferguson

Deputy Medical Director

John Calvert

Director of Nursing

Liz Rix

Deputy Director of Nursing

Vicki Franklin

Director of I M & T and Performance Improvement

Debbie Morgan

Associate Director of IT

Ed Davies

Director of Planning

Paul Stauber

Director of Human Resources

Geraint Evans

Director of Corporate Affairs/Company Secretary

Steve Combe

The next stage of the process is to consider the Clinical Directorate structure and discussions have commenced with clinicians and managers on this important issue through a workshop held on 16 January 2008 and a joint meeting of the Medical Staff Advisory Committees held on 22nd January 2008. The feedback from this workshop is currently being collated and a further event is planned for March 2008. Realising the Benefits of Merger The Project Board considered a paper setting out some of the early benefits already being seen as a result of the merger process and the plans in place to ensure that the benefits set out in “Aiming Higher” are realised. Building a Shared Culture for the New Trust. As we move closer to the establishment of the Abertawe Bro Morgannwg University NHS Trust, it is critical that we start to build a shared culture which will underpin the values of the new organisation. To understand our starting point, a cultural survey of both organisations will take place at the end of February 2008. A survey will be sent to every member of staff attached to their February payslip. The purpose of the survey is to ask for views and opinions on communication, management, leadership & clinical engagement in the existing organisation and to explore values and aspirations for the new organisation. The Board is asked to note the report update regarding progress with the merger. 2. PERFORMANCE REPORT – NOVEMBER 2007 Introduction The January 2008 performance report is attached as Appendix 6.2(i) and provides latest performance against the Annual Operating Framework Targets, Core Measures and Long Term Agreements.

Performance reported from April 2007 onwards against the national targets continues to reflect local reporting standards agreed with the Regional Office. These arrangements ensure that some indicators (i.e. where only small numbers are recorded in month) are not reported and that clinical exceptions and outlying performance is also taken into account. Performance reporting in this final quarter of the year will focus on the key indicators which must be achieved under Part A and Part B of the “Incentive and Sanctions Framework for NHS Wales” as noted in WHC (2009) 069 which was issued at the end of September. Incentives and Sanctions Appendix 6.2(ii) reports the scores for the Incentives and Sanctions Framework based on December’s performance. In respect of Part A, the 95% 4-hour A&E wait target was achieved for the second month in succession, and the Trust was only one of two in Wales to maintain this compliance. There was also significant reduction in the number of patients waiting over 8 hours with only 7 patients breaching this target. However, under the terms of the Incentives and Sanctions Framework both the 4 hour and the 8 hour target have to be met in March 2008 to proceed to scoring against Part B of the Framework. In addition one patient breached the Part A Cancer target in December, which would mean that a point would have been lost had this performance been counted as part of the Incentives and Sanctions assessment and the Trust would not have been eligible to progress to the Part B assessment under the Framework. A detailed audit of the reason for the breach has been carried out, with the result that the case involved complex clinical investigation and treatment and also that the final treatment was carried out in the Swansea NHS Trust. For the Part B of the Framework the Trust would have lost a point for each of the following targets which were not met in December – Cancer waiting times, Multiple Admissions, Day case Laparoscopy and Cancelled Operations. The score for December performance according to the Incentives and Sanctions Framework is 17 (although technically the 7 out of 8 score for Part A would mean part B could not be scored). A score of 17 means that the Trust would be eligible for a £0.5m incentive subject to fulfilling the necessary criteria. Further details of the Trust’s performance and actions being taken to improve performance against these targets are shown below. 1. Annual Operating Framework 1.1 Measure 1: Inpatient/Day Case Waiting Times (Part A) The Trust remains within profile for all specialties with the exception of Ophthalmology which is reporting one day case patient waiting longer than 22 weeks. This patient requires a specialist corneal graft which requires specialist input and the patient will be treated in late January on the next available specialist list.

1.2 Measure 2: Outpatient Waiting Times (Part A) The Trust remains within profile for all specialities for Outpatient performance with the exception of General Medicine. The General Medicine Outpatient position is reporting 40 patients waiting over 22 weeks against a profile of 30. All of the 40 patients are respiratory medicine patients waiting across the Trust and planned additional clinics have been put in place at both Princess of Wales Hospital and Neath Port Talbot Hospital for the period January to March 2008. These planned extra clinics will bring the General Medicine position to within profile for January and will deliver the 22 weeks target for the specialty. 1.3 Measure 3&4: Diagnostic & Therapies Waiting Times (Part A) The Trust has no patients waiting over 24 weeks for therapy services at the end of December for non Learning Disability services. However, there are minor pressures on Learning Disability OT and SALT and plans are in place to commence treatment for these patients. The Trust does not record Learning Disability patients against waiting times profiles as these are excluded from the LDP process, but recognises the need for waiting times improvement in Learning Disabilities services, which is underway. With regard to diagnostics, all services are within profile with the exception of endoscopy. These profiles have been maintained despite the loss of X-Ray room 3 at Princess of Wales Hospital for the reporting month of December. Endoscopy is reporting 39 patients waiting over 14 weeks against a profile of 19. These scopes are cytoscopies and additional cystoscopy sessions are planned to return this performance to profile. 1.4 Measure 5: A&E Waiting Times (Part A) Performance for the 4-hour target in December was 96.8% against a target of 95%. The 100% 8-hour target was not met in December with only 7 breaches. The senior manager role of pulling patients through the department between the hours of 5pm and 8pm on weekdays has helped to improve performance and will continue as will the daily scrutiny of performance and delivery of robust action plans which have been put in place to maintain performance. 1.5 Measure 9: Cancer Waiting Times (Part A) For the month of December the Trust has again achieved 100% compliance with the 31 day cancer target, treating a total of 47 patients within target time. However, there was 1 breach patient against the 62 day target out of the 13 patients treated in December. This patient was a complex head and neck cancer patient who had a complex diagnostic pathway before commencing chemotherapy at Swansea NHS Trust. The patient was treated on day 63. This performance is 92% in month and hence scores a zero in Part A of the Incentives and Sanctions Framework against the 95% target. The 95% level is not helpful to the Trust as the Trust seldom treats over 20 patients a month on 62 day pathways and hence a single breach will not achieve target levels. The Trust continues to work on a zero breach culture for all patients regardless of complexity of diagnostic pathways. Indications from the cancer patient tracking system are that there will be no breaches reported in January for the Trust.

1.6 Measure 10: Chronic Disease Management Multiple Admissions/ Average Length of Stay (Part B) Although performance has remained stable (at around 16% against a target of 14.6%) throughout the year, the performance measure does not accurately reflect the actions put in place to prevent hospital stays for Chronic Conditions patients which has led to reduced admission rate overall for these patients. Detailed analysis of the multiple admission patients has shown that only 25% of patients (22 patients overall) were admitted more than 3 times in the rolling 12 month period measured by this target. Each of these 22 patients has been reviewed and actions have been taken to ensure they are adequately supported in the community by either District Nurses, specialist nurses within the COPD outreach teams or the new Case Managers. The Community and Therapies Directorate and the Medical Specialities Directorate are working closely on reducing further the admission rate for patients with Chronic Conditions and have developed a detailed action plan which will continue to be reviewed monthly through the Trusts performance management arrangements. The second part of the readmissions target, which relates to the average length of stay for chronic condition patients, continues to be achieved with an average length of stay of 5.3 days against the 5.7 days target. 2. Core Measures 2.1 Average Length of Stay (Part B) Only three specialties, Elective General Surgery, Gynaecology and T&O, are included as Part B targets in the Incentives and Sanctions Framework. All three length of stay targets continue to be achieved. 2.2 Basket of Daycase Procedures (Part B) Of the three procedures included in the Incentives and Sanctions Framework, the Trust consistently meets the hernia target. The arthroscopy target was achieved for November but laparoscopy performance continues to be below target at 83%. This under-performance was due to only one patient not having their operation carried out on a daycase basis during the month of November 2007. The Directorate of Women & Children’s Services are implementing changes to the operating theatre lists in January 2008 to ensure all Laparoscopy procedures are carried out utilising morning lists in future which will improve performance and ensure the target is met. Performance will be measured on the basis of April 2008 outturn for the purposes of the Incentives and Sanctions framework. 2.3 Cancelled Operations at short notice (Part B) The target is for no more than 4.7% of operations to be cancelled on the day or day before operation. Performance throughout the year has remained well within this threshold and averages 4.1% to date against this target. During December however the rate rose to 5.8%, as a result of reduced theatre time available due to the Christmas period and higher than usual rates of patient-related cancellations due to acute illness. It is expected that the rate for January will fall back in line with year-to-date performance and remain within target for the remainder of the year. Performance during April 2008 will be used to score against the Incentives and Sanctions framework.

3. Long Term Agreement Performance Appendix 6.2(iii) shows the LTA position for the Trust's principal commissioners as at the end of November 2007. For Bridgend LHB the Trust is 15% over performing against Outpatients, 38% over performing against Day Cases with the Inpatient position is 7% behind target. The Inpatient underperformance is a result of the impact the new Emergency Department way of working and discussions are ongoing as to how to best reflect this from an LTA perspective. A similar position exists for Neath Port Talbot LHB where outpatients and day cases are over performing by 8% and 16% respectively, although inpatient performance is marginally behind at 2%. With regard to the former Bro Taf area LHB's a similar pattern is emerging in 2007/08 to 2006/07 with Rhondda Cynon Taf contracts generally underperforming and the Vale LHB performance taking up this capacity with Outpatients over performing by 29%, Day Cases by 31% and Inpatients marginally behind at 7%. Gwent based LHBs continue to underperform on Outpatients and Day Cases although there over performance on Inpatients of 46% (32 patients in total). The Gwent contracts are potentially at risk for 2008/09 as these LHBs seek to commission services more locally. Former Dyfed Powys based LHBs are showing over performance on Outpatients and Day Cases with Inpatients balanced. The Board is asked to note the monthly Performance Report. 3. WHC (2007) 086 – NHS WALES ANNUAL OPERATING

FRAMEWORK 2008/09 The publication of WHC (2007) 086 – NHS Wales Annual Operating Framework (AOF) 2008/09 sets out the Welsh Assembly Government requirements for delivery in 2008/09.

The process for 2008/09 has been extended to include not only the traditional Ministerial Priorities (old SaFF targets) but also Efficiency and Productivity Improvement, Service Improvement, Organisational Improvement, LDP Planning and Financial Delivery elements. The process is therefore considerably more complex and integrated than previous year’s submissions.

This report describes and highlights the key components within this year’s AOF. The full document will be available at the meeting, should Board members wish to have sight of the full document. The key components are as follows: -

• Principles of the AOF and timescales • The targets themselves • The process to complete the AOF process

Principles of the AOF • AOF is to be produced by each organisation (not a health community based composite). • AOF should be financially balanced to include LDP impacts and impacts of delivering other targets. • The AOF response format is set out through published WAG proformas which are detailed and numerous (covered later) • Where Trusts are planned to merge the AOF should be planned and developed, where possible, on the basis of the new organisation. Timescales • First draft to Regional Office 31st January 2008 • Final AOF Submitted 29th February 2008 • Approved AOF signed off by Regional Office 31st March 2008 • LTAs in place 30th April 2008

Targets The AOF targets have been grouped into 4 main categories as outlined below. The Trust’s submission (under WAG requirements) needs to include an individual pro-forma summary on each of these target areas. Directorates will have key role to play in identifying the solutions which will lead to the delivery of these targets. The targets are broken down under the following headings. a) Improving Services These targets are based on the implementation of broad service change plans. Included in this section are such targets as delivering the Mental Health NSF, introduction of screening programmes, delivering Cancer Standards, Management of Chronic Conditions, Healthcare Standards etc. Each of the 24 target areas represents a significant service improvement programme. Key for Bro Morgannwg NHS Trust and the new Trust will be how Chronic Conditions Management, Cancer Service Delivery, Cardiac Service Delivery and Mental Health NSF are delivered. The Trust will need to demonstrate clear progress in delivering the significant number of individual targets within each of these areas. The implications of delivering all of the requirements of the service improvements are as yet not quantified but as stated earlier in this report, directorate involvement in developing modern and innovative solutions will be key.

b) Improving Organisations The 6 targets in this section reflect the identified development areas for organisations to improve and are based around organisational change, these are:- • Commissioning – all organisations to deliver commissioning requirements to be

outlined by the Welsh Assembly Government. • Information – all organisations to undertake comprehensive and complete impact

assessment for new or revised information requirements. • Demand Management – LHB’s to achieve agreed levels of demand through the LDP

and LTA processes.

• Modernisation Assessments – each health community to update its Design for Improvement Plans.

• Reducing Violence – Trust to address the specific actions within the Memorandum of Understanding as per Welsh Assembly Government and Criminal Prosecution Service Document.

• Violence and Aggression Training Passport – all Trust’s must demonstrate full compliance with the Violence Passport by 31st December 2008.

It is unlikely that there will be significant resource requirements for these targets but these will require structured change management to deliver.

c) Annual National Targets - Ministerial Priorities These are the traditional SaFF targets of which there are 20 in all for 2008/09. The Board will be aware that the Trust was asked to feedback on draft targets in late 2007 and this section now reflects the final targets following the conclusion of this consultation proves. As previously stated, the full detail of these targets has been previously circulated. Listed below are the key targets from a Trust perspective which will require robust plans from the directorates to outline how the targets will be delivered in 2008/09.

• Target 1 – All acute, diagnostic and therapy waiting times are included here, including the first time Referral to Treatment measurement has featured at Ministerial level. These targets link directly to the LDP process. • Target 2 – These are the 4 hour and 8 hour A&E targets. These are fully understood but will need to be sustained in 2008/09. • Target 3 – The 31 day and 62 day Cancer targets remain unchanged. • Target 4 – Ambulance response times. • Target 5 – Cardiac RTT target of 32 weeks from referral to treatment. Bro Morgannwg NHS Trust is well on the way to delivering its part of this target provided that HCW threats to remove funding for some angiography capacity can be managed. Opportunities in the new Trust to address patient pathways to support this delivery. • Target 6 – Sexual Health services. All patients to have access to core sexual health within 2 working days. Delivery of this target will have a resource requirement. • Target 8 – Reduction in EMA rate and EMA length of stay. Bro Morgannwg NHS Trust has been successful in managing the length of stay component but the EMA rate still requires address. This target has featured in 2007/08 and is a development of the 2007/08 target. These targets will need consideration alongside the improving services targets above in terms of Chronic Condition management. • Target 9 – Stroke Services. Each patient suspected of having a stroke must be

admitted to a dedicated and co-located stroke unit staffed by a multi disciplinary dedicated stroke team. The Trust is currently developing its plan to comply with the requirement of co-location of stroke beds by May 2008. It is not anticipated that a significant lead time is required to facilitate the bed changes.

• Target 12 – Call to Needle. Trust has work streams in place to work towards this target. • Target 14 – Mental Health Assertive Outreach model. In accordance with the Mental Health NSF organisations must supply an assertive outreach service. The precise requirements are currently being assessed by Mental Health colleagues but this is likely to identify a resource requirement. • Target 15 – Mental Health liaison service for older people with mental health problems in general hospital settings to be established. • Target 16 – achieve all milestones within the approved Local Mental Health Action

Plans. The Trust has approved action plans for each locality. Workstreams are in place with partner organisations to assess the service model for assertive outreach. The current assessment is that this is not a resource neutral development and the detail of this requirement is currently being worked through as part of the AOF process.

• Targets 17 & 18 – DTOC (excluding MH) reduce numbers of DToCs and numbers of

days DToC is target 17. Target 18 is same parameters but for Mental Health only. The Trust Management Executive has received a report from the Director of Community and Therapy Services regarding the next steps for DToCs and a process review and escalation policy are currently being considered to improve performance in this challenging area.

• Target 19 – Ambulance handover of patients within 15 minutes from patient arrival

to transfer to A&E clinical care. This data is not currently captured routinely by the Trust or by the Ambulance Trust, but the Welsh Assembly Government has issued supplementary guidance stating that this target is to be measured by the Ambulance Trust systems already present in A&E departments. The timing for this measure commences at the same point as the current 4 hour wait target and therefore achievement of this target will not impact down stream flows of patients into the main hospital as this is a patient management process already present within this Trust.

• Target 20 – Healthcare associated infections and the reduction of these rates. The

AOF document requires all the Trust’s to achieve local infection reduction targets in agreement with the Welsh Healthcare Associated Infection Programme (WHAIP) Team. Bro Morgannwg NHS Trust is currently well below the average infection rates for Wales and the Chief Executive’s zero tolerance approach to infection control will assist the Trust in continuing to improve performance in this area.

d) Efficiency and productivity The usual suite of efficiency and productivity targets has been produced again for 2008/09. The Trust will continue to work with the Regional Office to establish a full understanding of the local issues which may affect delivery. These targets are not new to the Trust and represent a continuation and refinement of the work already underway to deliver the 2007/08 levels. These targets will continue to be integrated into directorate Designed for Improvement plans and will require the continuation of current internal performance management systems to ensure delivery.

Process to Complete the AOF In accordance with the timetable identified, the first draft AOF was submitted to Regional Office on 31st January 2008. This involved the submission of the proformas template document (one for each target) along with details of the Trust’s Local Delivery Plan (LDP) and a comprehensive review of current Trust performance against the 2008/09 targets. A copy of the submission will be available at the Board meeting. For the draft submission deadline of 31st January 2008, Bro Morgannwg NHS Trust was not required to consider any impacts of the merger within the AOF. However as part of finalising the document by 29th February 2008 both Trusts will need to work collaboratively in order to produce a single health community wide AOF in partnership with the three principal Local Health Boards. The details of how this process will work are currently being discussed with the Regional Office. The Board is asked to note the content and structure of the AOF document and to note that the first draft was submitted to Regional Office, in accordance with the agreed timescale.

4. REFERAL TO TREATMENT TIMES – CLINIC OUTCOMES

RECORDING The Board will be aware that the Welsh Assembly Government has set a waiting times target that no patient shall wait longer than 26 weeks from referral to initiation of treatment. This target is to be achieved by December 2009 and sustained thereafter.

The AOF targets referred to in Section 1 now include a specific measureable target for the delivery of Referral to Treatment (RTT) waiting times. The Trust is currently reporting RTT data to the Delivery and Support Unit (DSU) on a monthly basis but this data does not yet capture all patient treatment events and directorate support is required to make this data capture complete in terms of patient coverage. Clinic Outcomes In order for RTT times to be measured accurately the Trust is required to capture decisions made along the patient treatment pathway. Traditionally waiting times have stopped at either the first outpatient appointment, when a patient presents for a theatre procedure or when they elect to leave the waiting list themselves. However, the new RTT measurement is based on when treatment is actually initiated rather than when a patient presents at hospital for either outpatients, inpatients or day case attendance. The key part of the RTT measurement is to capture when treatment is initiated. These treatment initiations are not currently captured within the NHS in Wales and hence a new system of data capture is required to do this. The DSU requires that all Trusts introduce a system of clinic outcomes data capture. The process is focussed on the recording of what happens to the patient when they attend for either a new or follow up appointment. Systems are already in place to record when theatre based surgical events take place but these represent only a small proportion of the patients who have treatment initiated and for obvious reasons this excludes medical specialties. Therefore, the inclusion of all patient treatment events for all specialties will be through the completion of an outcome form for each patient attendance in the outpatient setting.

These forms will need to be completed by the clinician who is making the decision regarding the next stage of the patient’s care. This can be Medical, Nursing or PAMs staff. Roll Out The Trust has secured funding from the Delivery and Support Unit to establish a small team who will work with clinicians, outpatient staff and information department colleagues to implement clinic outcomes recording. The IT development required to carry this out has already been completed enabling the roll out of clinic outcomes recording. A Clinic Outcomes Implementation Manager has been appointed who will be leading the planning required to ensure that clinic outcomes forms are rolled out across the Trust to improve the robustness of data recording for this new measure. All Trusts in Wales are required to improve their RTT data quality and to this end all Trusts are implementing variations upon the clinic outcomes theme to capture key patient pathway events. Discussions on how the new merged organisation will manage its RTT processes and reporting (particularly where clinical pathways span the two current Trusts) are currently being held through the information workstreams. It is envisaged the new Trust will be submitting a single RTT report for performance management purposes to external bodies but will retain the flexibility of locality based reporting for local arrangements. The Board is requested to note the requirement to implement clinic outcome recording to ensure that the RTT process is robust. 5. CAPITAL SCHEMES • Modernisation of Mental Health services Tenders for the new Day Centre to be constructed on land at the bottom of Quarella Road were invited on the 18th January 2008 and are to be returned to the Trust on the 22nd February 2008. Provided that tenders are within the approved pre tender estimate it is anticipated that work will begin on site at the beginning of April 2008, with completion by January 2009.

The Heads of Terms for the lease of the land have been agreed with Bridgend County Borough Council and lease documentation is currently being prepared. In the event that this documentation is not completed by the time the contract is awarded the Council have confirmed that they will grant the Trust a licence to start the works. The enabling works contract at Glanrhyd Hospital was proceeding very well until Mid December 2007 when asbestos was discovered in one of the plant rooms. Following an examination by specialist contractors more contaminated material was discovered in other areas and a specialist contractor was appointed to remove the material and undertake environmental cleaning in all areas affected. Although the main contractors, Lorne Stewart plc, have been very proactive in re-organising their programme and re-sequencing works there has been a delay of approximately 4 – 5 weeks on the overall scheme and completion is now not expected to be achieved until May 2008 although every effort will be made to recoup the time lost. Tender documentation is being prepared for the demolition package on the site and tenders will be invited for this scheme in February 2008 so that the contract can be let and start immediately following the completion of the enabling works scheme.

Following the review of the schedules of accommodation, the plans for the proposed Continuing Care Unit on the Glanrhyd Hospital site have been amended and are to be discussed with the Users on the 29th January 2008. Any amendments agreed will be incorporated within the plans and detailed design will begin immediately. During this process regular meetings will be held with the Planning Department of Bridgend County Borough Council to ensure that they are kept informed of the process and proposals and are able to input comments through design therefore avoiding any undue delay in the planning application stage. It is anticipated that construction of the unit will begin in October 2008 however the completion date will depend on the scope of the phasing of the contract that will be required due to the need to retain the block fronting the courtyard until some of the new accommodation is commissioned. The plans for the Rehabilitation Unit have now been signed off by the Steering Group following meetings with the staff of each of the three Units involved in the development. A meeting is now being arranged by the Project Architects with the local Planning Department to explain and detail the proposals for the scheme and at the same time detailed design will commence. A number of ground surveys have been undertaken at the Trust Headquarters site to determine the ground conditions and a small exercise is presently being completed to clear up the last query from the Environmental Agency on the flood consequence survey. This concerns the emergency evacuation of the upper Quarella Road area in the event of a major flood. The scheme will only require the rear portion of the Trust Headquarters site and the Trust will consider the use of the residual site over the coming months. It is anticipated that a start on site on this scheme will be achieved in September 2008 with completion in August 2009. A search for land continues in the south west Ogwr, to find a suitable site for the final component of the project. The Trust was recently unsuccessful in a bid of a site in the area. Welsh Health Estates continued their search for suitable sites and are continuing to monitor the market and maintain contact with local and national agents and local authorities. Unfortunately, until a site is identified there is very little further progress that can be made on this particular scheme.

• Cimla Hospital Work on the first phase of the car park at Cimla Hospital is proceeding but it has been badly affected by the atrocious weather conditions experienced since Christmas. The contract is presently some seventeen working days behind programme and completion is now anticipated for 21st February 2008. The design of the extension to the main hospital has now been completed and it is intended that tenders will be invited on 1st February for return on 29th February 2008. Providing the lowest tender is within the pre-tender estimate the contract will be awarded at the beginning of March for a start on site in early April 2008.

• Princess of Wales Hospital - Multi Professional Education Centre The Design Team is now in the detailed design stage of the project. A full brief has been provided and a meeting has been arranged for the 6th February with a specialised company and the IT Department to review the audio visual requirements of the scheme. Initial meetings have been held with the planning department of Bridgend County Borough Council and a planning application will be submitted in the near future. It is anticipated that tenders will be invited in June 2008, with a start on site at the end of the summer 2008. The contract period is expected to be in the region of 15 -18 months but this will depend upon the contractors proposals for building the building. • Glanrhyd Hospital - Child and Adolescent Mental Health Unit – Temporary

Solution Work on the refurbishment of the old Caswell Clinic at Glanrhyd Hospital was completed in accordance with programme and was handed over to the Trust on the 21st December 2007. The unit was commissioned over the Christmas period and patients from the Harvey Jones Unit were re-admitted to the new accommodation immediately following the New Year. Patients and staff have expressed their appreciation of the scheme and the accommodation that has been provided. • Princess of Wales Hospital - Child and Adolescent Mental Health Unit The Outline Business case for the permanent Unit to be constructed on the Princess of Wales Hospital site was submitted to the Welsh Assembly Government on 24th December 2008. The approval period expires on 29th January 2008 at which time the Trust will have to decide whether to proceed any further with the design of the project at its own risk. There is a certain amount of work that has been undertaken by the Supply Chain Partnership during the approval period which mainly focuses on the environmental issues around the site which have to be undertaken in the correct season if they are to avoid delaying the overall programme. • Neath Port Talbot Hospital - MRI Scanner The installation work for the MRI scanner is proceeding at Neath port Talbot Hospital and is expected to be completed in April 2008. An order for the MRI Scanner has been placed with Toshiba and the contractors for the enabling works are liaising with the company on delivery and installation dates. • Princess of Wales Hospital - Replacement of Engineering Services As reported at the last meeting of the Board the contracts for all four schemes included in the project have been let and orders placed by the individual companies for the plant. Work on the replacement of the first lift commenced in November 2007 and the overall completion is programmed for 30th September 2008. Work on the installation of the CHP engine, Standby Generators and Steam Generators commenced on site on 21st January 2008. The contracts for the first two schemes are due to complete on 26th and 27th of March respectively while the installation of the Steam Generators is programmed to complete by 6th June 2008.

• Neath Port Talbot Hospital - Wireless LAN Work is proceeding well on the installation of a Wireless LAN system at Neath Port Talbot Hospital. The ground and first floors are nearing completion and, once these are complete activity will move to the second floor. It is anticipated that the work will be completed well before the end of the financial year. • Princess of Wales Hospital - Gamma Camera Work is proceeding well on the pre-installation work for the new Gamma Camera within the X-Ray Department of the Princess of Wales Hospital. The old equipment was removed from site at the beginning of January and the refurbishment of the room is proceeding in accordance with programme. The equipment has been ordered from GE and they have confirmed a delivery date to site of 18th February 2008. It is anticipated that the installation and commissioning including RPA checks will be complete by the 8th March 2008 when the equipment will be available for use. The completion of this scheme will complete the refurbishment of the department that began with the development of the Ultrasound Suite. • Neath Port Talbot Hospital - Pharmacy Robot The strip out of the Pharmacy Department at Neath Port Talbot Hospital has commenced in order to create space for the delivery and installation of the new Pharmacy Robot. It is anticipated that the robot will be installed and commissioned into use by the end of the financial year. • End of Year Capital Bids On 8th January 2008 the Trust received a letter from the Welsh Assembly Government inviting bids against surplus capital from the all Wales Capital programme. A number of conditions were imposed on bids which had to be submitted by the 18th January for schemes under £250,000 and by the 25th January for schemes above this value. The Trust’s submission totalled £3.1m. A Welsh Assembly Government response is anticipated shortly and the Board will be updated at the meeting. The Board is asked to note the report. 6. APPOINTMENT OF CONTRACTORS/CONSULTANTS In accordance with Clause 22.4 of the Contracts Code, Schedule 4 of Standing Orders the appointment of consultants is an action reserved for the Trust Board as is the award of contracts of a value in excess of £250,000. Since the last meeting there have been a number of occasions where urgent action was required in such areas so that work could proceed without undue delay. As authorised by Standing Order 30.3 such action was approved by the Chairman on behalf of the Board in the following cases:-

• CAMHS Approval of Five Week Approval Period The Outline Business Case for the new CAMHS Unit at the Princess of Wales Hospital was submitted to the Welsh Assembly Government on the 24th December 2007.

In accordance with the Designed for Life : Building for Wales Framework Agreement the appointment of the Supply Chain Partner, Trust Project Manager and Trust Cost Advisor was only confirmed for the period leading up to the submission of the OBC and this period expired on the 23rd November 2007. The Framework arrangements allow for the appointments to be extended for a further 5 weeks which was the time originally established as the “Approval Period” set aside for the Welsh Assembly Government to evaluate and approve the Business Case before work could commence on the preparation of the OBC.

The OBC resource schedules submitted by all three organisations identified separately the resources that would be required for this period as follows:-

• HBG Ltd (SCP) £81,787.61 • Gleeds Management Services Ltd (TPM) £10,340.00 • Davis Langdon (TCA) £3,000.00

These costs would be recoverable from the Welsh Assembly Government and would only be expended on production of fee invoices with supporting timesheets. The acceptance of the additional fee costs would constitute an extension of an existing contract which, in accordance with Standing Order 44.5, required the approval of the Chief Executive and notification to the Trust Board. Following the approval of the Chief Executive the Design Team were instructed that work during this period should focus on the development of the plans and specifications for the new multi storey car park and the access road into the Hospital site as it will be vital for the Trust to achieve an early start on this aspect of the project if the programme for overall completion and commissioning by the end of 2010 is to be achieved. The Board is asked to ratify the extension of the commission of the Supply Chain Partnership, Trust Project Manager and Trust Cost Advisor.

• Appointment of Quantity Surveyor, Gamma Camera In accordance with Standing Order 39.4 approval for the use of single quotation action in the appointment of a Quantity Surveyor for the above mentioned scheme was obtained due to the specialised nature of the contract. Parry and Dawkin were invited to submit a fee bid for the position on the 27th November for return by the 5th December 2007. This company have undertaken a number of similar schemes for the Trust in the past and their performance has always been satisfactory. A fee bid was received and opened in accordance with standing orders. The proposed fee from Parry and Dawkin is a lump sum bid of £3,500 against a pre tender estimate for the works cost of £105,000. This bid compared favourably with the previous appointment of the company for the Replacement of Room 6 at a fee of £2,950 against a works cost of £53,984 equating to a reduction in percentage terms from 5.45% to 3.33%.

In order to achieve a start on the enabling works straight after Christmas it was necessary for the QS to be appointed immediately to evaluate the tender from the contractors for the installation works. Therefore in accordance with Standing Order 30.3 the Chairman approved the appointment of Parry and Dawkin as Quantity Surveyors on the scheme.

The Board is asked to ratify the appointment of Parry and Dawkin as Quantity Surveyors for the Gamma Camera Installation Works

• Appointment of Management Consultants and Quantity Surveyors to look at the

feasibility of an Orthopaedic Elective Centre In October 2007 it was agreed that the Trust would undertake a Feasibility Study into the implications of creating an Elective Orthopaedic Centre at Neath Port Talbot Hospital. In order to assist the Trust it was necessary to appoint Management Consultants and Quantity Surveyors.

• Management Consultants The Programme Management Unit of the Welsh Assembly Government has established a Framework Agreement for the appointment of Management Consultants and included in the list of companies involved in the Agreement is Tribal Consulting. This company provided support to the Trust in the preparation of the Benefits Analysis and Risk Register to support the Full Business Case for the Modernisation of Mental Health Services Project and also recently completed the Strategic Outline Case for the Next Steps – Closer to Home Project.

Tribal worked well with Trust staff in the development of these documents. They met the demanding timescales set by the Trust and provided finished documents of a high standard which were submitted to the Welsh Assembly Government without amendment. The company were therefore invited to submit a fee bid for the preparation of a SOC for this project and this was received on the 19th October 2009. The proposed fee bid was in the sum of £19,965 and promised delivery of the completed document within the stated timescales if approval to proceed was given immediately. The Chairman therefore approved the appointment of Tribal Consulting as authorised by Standing Order 30.3. The Board is asked to ratify the appointment of Tribal Consulting as Management Consultants for the scheme.

• Quantity Surveyors Lee Wakemans were invited to fee bid for this work and their tender was received and opened on Wednesday 21st November 2007. One of the partners had spoken to Tribal Consulting to ascertain the scope of the work involved in the commission and based on these discussions they submitted an offer of £7,450 for the work. As a comparison the Trust invited fee bids for quantity surveying services on the preparation of a Business Justification Case for the Intermediate Care Services Project in March 2006 and bids ranged from £4,450 to £13,528. It was anticipated that quite complex work would be required to assess the options requiring a greater involvement from the Quantity Surveyor and therefore it was considered that the bid from Lee Wakemans was reasonable.

In order that the company could begin work with Tribal Consulting the Chairman approved their appointment as Quantity Surveyors for the preparation of the Orthopaedic SOC as authorised by Standing Order 30.3. The Board is asked to ratify the appointment of Lee Wakemans as Quantity Surveyors on the scheme. 7. PARTNERSHIP WORKING – UPDATE Health Social Care and Wellbeing strategy development and consultation The Board is aware, from December meeting, of the consultation process being conducted across the three local boroughs. Attached for information at Appendix 6.7 is a copy of the formal comments submitted subsequently on behalf of the Trust to the Neath Port Talbot and Bridgend policy coordinators. The Trust’s response to the Vale of Glamorgan document welcomed the simplicity of its style but sought greater clarity from the final strategy on the practical implications of some of the high-level commitments, particularly with regard to anticipated population changes. The Trust’s input into the Bridgend and Neath Port Talbot strategies continues. The revised Neath Port Talbot document nears completion and work is underway to develop a communication strategy to embed it in the wider community. The Bridgend document will be updated following the closure of formal consultation next week, particularly to capture messages received during the public event at Bridgend Recreation Centre on 25th January. Local Service Boards (LSB) The Bridgend LSB has designated Superintendent Tim Jones as the first Chair of a new Delivery Board through which all the borough’s partnerships will be performance-managed. Programme briefs are being developed for each partnership, setting out project leads and partnership objectives expressed in outcomes, key milestones and measures. The Neath Port Talbot LSB has agreed a work programme that confirms its focus on the Delivering Integrated Services Project and commissions further work on the health and social implications of economic inactivity, travel and transport. Delayed Transfers of Care were discussed within the context of their comprising a symbol of the failure to progress an integrated service agenda and a number of recommended actions are being pursued to ensure targets are met, including the potential appointment of a shared DToC manager. The Joint Trust Merger project’s partnership workstream has incorporated the principles and key messages discussed in last month’s Trust Workshop within the proposed new approach to partnership being developed with Swansea colleagues. This seeks to ensure that the new Trust’s partnership objectives, as identified in the HSC&Wb strategies and other joint plans, are both appropriate, and achieved. Once agreed by the joint Project Board, the proposed approach to partnership management within the new Trust will be shared with colleagues in the Local Service Boards. The Board is asked to note progress. Further updates will be provided in due course.

8. INFORMATION MANAGEMENT & TECHNOLOGY POLICIES The policies listed below and attached as Appendix 6.8 were reapproved for a further 12 months at the January 2008 meeting of the Management Executive. Work is already progressing well in terms of developing new versions of these policies, which will take full account of the scope of the new organisation and these will be presented to the Trust Board in due course. • Internet Access Policy • Email Policy • IT Security Policy The Board is asked to ratify the re-approval of the above listed policies. 9. HIW REVIEW OF LEARNING DISABILITIES SERVICES FOR

YOUNG PEOPLE AND ADULTS Introduction In 2006 the Healthcare Commission in England reported "significant failings" in learning disability services provided by Cornwall Partnership NHS Trust and in 2007 found outmoded institutionalised care which had led to the neglect of people with learning disabilities at Sutton and Merton Primary Care Trust. Healthcare Inspectorate Wales therefore decided that it was in the national interest of people with learning disabilities, their families and carers, for a review to be undertaken in Wales to answer the following question: How well does the NHS in Wales commission and provide specialist learning disability services for young people and adults? There were three “regional” areas visited, with reports produced for each area, these being:

South East North Mid and West

There was also an All Wales report; these reports were all published in December 2007. Report Findings Overall there were no significant failings found, however the review identified:

• Flaws and gaps in systems for transition planning.

• It determined that commissioning at a local and national level was poorly understood and managed, and that there is a clear need to develop national and regional structures and processes that support the commissioning and delivery of coordinated services for people with learning disabilities across Wales.

• In answer to the question asked by the review they found that although pockets of noteworthy practice were identified, services for young people and adults with learning disabilities in Wales are stagnating. The noteworthy practice identified in the South East region was:

o Positive Behavioural Support training -- Bro Morgannwg NHS Trust o Periodic Service Review -- Bro Morgannwg NHS Trust

Recommendations There were 26 recommendations in all, none of which related uniquely to NHS Trusts other than in Gwent. The recommendations within each of the Regional reports were consistent and also the same as those in the All Wales report. There is only one regional specific recommendation for the South East which is: "Service user involvement in the commissioning and provision of services must be increased". The areas to be noted are:

• It was felt that the criteria for eligibility for specialist learning disability services was restrictive. However should this criteria, for example IQ 70 and below, be widened then there could be a significant dilution in services for people with a learning disability.

• The report identified a significant conflict between Health (LHB's) and Social

Services in respect of funding issues.

• An issue that has been raised in other quarters, particularly by the Disability Rights Commission, was that of service users within continuing care NHS settings not being registered with a GP. This is an issue that is fully supported, however a solution is still to be found in respect of the legal position; HIW were unable to give any advice on this issue.

• The review stated that Bro Morgannwg NHS Trust does not have access to advocacy

services for service users in the continuing care units. In discussions prior to the publication of the reports it was agreed that this was not strictly true as advocacy services are commissioned in Cardiff, although this was not subsequently reported. The report also failed to identify the responsibilities of Commissioners on this issue, and also did not acknowledge that this is not a provider responsibility in order for such services to be independent.

• Comments were made as to the lack of evidence of skill mix evaluation, even though

there has been significant work done in this respect and is an issue addressed within the strategic document: “Closer to Home”.

Next Steps The report identifies three areas:

• The Welsh Assembly Government, Health Commission Wales, Local Health Boards, and NHS Trusts all need to consider and act upon the recommendations.

• HIW will work with the Welsh Assembly Government and DHSS policy leads to

discuss the development of an implementation plan to ensure all actions recommended are taken forward in a timely manner.

• As part of this process individual NHS organisations will be required to feed all

actions they are to take forward into their Healthcare Standards Improvement Plan. All providers and Commissioners will also need to address the recommendations in the development of action plans.

The review was welcomed and fully supported. Although there were no surprises within any of the reports with most areas identified already been actioned, a formal action plan, in line with the next steps, will now be developed. Given that the recommendations and findings have implications for Commissioners this action plan will be developed in partnership. The Board is asked to note the above. 10. ALL WALES PATIENT SAFETY CAMPAIGN : ‘SAVE 1000

LIVES’ The Healthcare Quality Improvement Plan: Designed to Deliver 2006 (QuIP) describes a collaborative program to improve patient safety and increase healthcare quality across Wales. It sets out 14 actions which will be taken forward, and supported by, a number of agencies and partners including the Clinical Support and Development Unit, Welsh Centre for Health, National Public Health Service for Wales, National Patient Safety Agency and the National Leadership Innovation Agency. The 1000 Lives Campaign brings together a number of the actions in the QuIP. It presents an opportunity to energise involvement of frontline staff, as well as Board members, in the quality and safety agenda across Wales and will build on the excellent work already underway in Wales, and accelerate these efforts around patient safety. The Campaign will launch on Monday 21st April 2008 to co-inside with the 60th Anniversary of the NHS, and will last for 2 years. The aims of the Campaign are to: • Avoid 50,000 episodes of harm including 1,000 deaths in Welsh Healthcare • Raise the profile of patient safety and healthcares proactive response with a larger

public audience • Build a re-usable national Infrastructure for Change in Wales Six evidence based interventions have been agreed as the planks of the Campaign in Wales. These are: • Improving Leadership for Quality • Improving Medicines Management • Reducing Surgical Complications • Reducing Healthcare Associated Infections (HCAI)

• Improving General Medical and Surgical Ward Care • Improving Critical Care The new Trust has enrolled in the Save 1000 Lives Campaign which will commence with two learning events for Executive Directors and other key staff on 18th/19th March and 21st/22nd April. This is an important initiative for Wales and for the new Trust as it provides the opportunity to engage with frontline staff in improving quality and safety and ensuring evidence based, more reliable care processes are delivered across the new Trust. The Board is asked to note the new Trust enrolment in the ‘Save 1000 Lives Campaign’. 11. HEALTHCARE STANDARDS & GOVERNANCE – ALL WALES

BOARD WORKSHOP Attached as Appendix 6.11 is a letter form the Welsh Assembly Government regarding an All Wales Workshop. The purpose of the workshop scheduled for 6th March 2008 will be to discuss the Boards’ role and responsibilities in relation to Governance and the Healthcare Standards for Wales. It is aimed at Chief Executives, Chairs, Medical Directors, and Nurse Directors and any other Executive or Non Executive Board members who have responsibility for Healthcare Standards and Governance. The Board will note that 6th March 2008 coincides with the next planned Trust Board Workshop. Bearing in mind that the All Wales event will involve a significant number of Board members, it is suggested that this event takes precedence. The Board is asked to note the arrangements for the All Wales Board Workshop regarding Healthcare Standards & Governance. 12. POSITIVE NEWS STORIES In recent weeks the Trust has enjoyed a number of positive news stories. The most prominent stories are attached as Appendix 6.12 in the form of media releases. The Board is asked to note the report. 13. SUICIDE PREVENTION GROUP - UPDATE The increasing number of apparent suicides of young people in the Bridgend locality has attracted considerable media interest in the past few weeks. It was brought to the attention of the Bridgend Local Service Board(LSB)’s meeting on 18th January 2008 as an emerging issue that needed to be tackled on a community basis, rather than as a police or health issue. A joint media statement was co-ordinated and issued subsequently 23rd January 2008 by the CBC on behalf of the LSB to reassure the local population that the issue had already been identified as a major issue for the Borough and was being addressed through a number of measures including a Suicide Prevention Strategy that was being developed by a multi-agency group led by the Trust.

It was in this context that Tegwyn Williams, Consultant Forensic Psychiatrist joined Hilary Anthony, Director of Education and Chair of the Local Safeguarding Children Board (LSCB) and Tony Garthwaite, Executive Director of Strategic Change acted as a panel which responded to questions from the media on Friday 25th January 2008. Also on this day, LHB, CBC and Police colleagues met to discuss the emerging situation and agreed that an extraordinary meeting of the LSCB would be held on 1st February 2008 to review the final draft of the Suicide Prevention Strategy and consider any other appropriate actions. The meeting would be attended by Trust representatives, as well as the other agencies who form part of its membership and the LSB. This will also include the Voluntary Sector. The document seeks to educate and reinforce to the local community the various advice, counselling and treatment networks that exist through the agencies involved in creating the Strategy. As it is known from wider research that only a quarter of those who take their own lives are likely to make contact with the NHS, the Strategy also seeks to de-stigmatize the experience of accessing mental health services so that people feel comfortable enough to seek help when they need it. The Board is asked to note the position and will be kept informed of progress with this Strategy’s implementation.

Bro Morgannwg Performance Summary

Indicator Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 TargetYear to date

performance

Incentives and

sanctionsComments

Timeliness

1

22 week Maximum Wait for Inpatients

and Day cases449 482 370 314 318 206 151 169 174 0 174 Part A

The Trust remains within profile for all specialties with the exception

of 1 Ophthalmology day case over a profile of zero. This patient is

waiting for a specialist corneal graft and has been appointed in

January.

2

22 week Maximum Wait for Outpatients 2264 1735 1305 863 1031 782 517 342 246 0 246 Part A

The Trust remains within profile for all specialties with the exception

of General Medicine (40 patients against a profile of 30). All of the

40 patients are within Respiratory Medicine. Additional clinics are in

place for the rest of the financial year to increase Respiratory

Medicine capacity.

3

14 week diagnostic and Therapy

Waits (High Impact Change no 2)309 367 342 205 197 163 128 118 116 0 116 Part A

The Trust is within all profile for all diagnostic areas with the

exception of endoscopy (39 against a profile of 19).Additional

planned clinics are in place to recover this position.

4

24 weeks Specified Therapy Services

(High Impact Change 2)37 39 28 24 23 22 13 0 0 0 0 Part A

All therapy services are within profile and on a bottom line basis. All

therapy services are below the 24 week target for December. Note:

this excludes Learning Disability patients

5

95% of Patients to spend less than four

hours in A&E96.23% 97.10% 94.13% 96.30% 95.22% 93.63% 92.63% 96.04% 96.81% 95% 96.81% Part A 4983 Attendances in December compared with 5338 in November.

5a

All patients to spend less than 8 hours

in A&E POW Only15 11 36 22 14 19 45 35 7 0 7 Part A

Significant improvement. Working on assumption that will need to

be at 0 for March, plans are in place to try to achieve this.

7

Cardiac Referral To Treatment times (

22 weeks op and 13 weeks dc)0 0 0 0 0 0 0 0 0 0

0

Part B

9

Cancer 2 month referral to treatment

wait75% 67% 77% 77% 87% 92% 100% 92% 92%

98% Part A,

100% Part BPart A

Overall performance 92% - This is due to one breach in the Head

and Neck site.

Breast 83% 100% 100% 100% 100% 100% 100% 100% 100%98% Part A,

100% Part BPart A+B 3 of 3 on target

Gynaecological NIL NIL 100% NIL NIL 100% NIL NIL NIL98% Part A,

100% Part BPart A+B Nil return

Head & Neck 100% NIL NIL NIL 100% NIL 100% NIL 50%98% Part A,

100% Part BPart A+B 1 of 2 on target

Lower GI 50% 100% 33% 100% 75% 100% 100% 100% 100%98% Part A,

100% Part BPart A+B 1 of 1 on target

Lung 0% 25% 86% 67% 100% 100% 100% 75% NIL98% Part A,

100% Part BPart A+B Nil return

Skin 100% 100% 100% 100% 100% 100% 100% 100% 100%98% Part A,

100% Part BPart A+B 2 of 2 on target

Upper GI 100% NIL NIL 100% 100% 100% 100% NIL 100%98% Part A,

100% Part BPart A+B 4 of 4 on target

Urological 100% 33% 33% 25% 0% 50% 100% NIL 100%98% Part A,

100% Part BPart A+B 1 of 1 on target

Other 100% 0% 100% 100% 100% 100% 100% 100% NIL98% Part A,

100% Part BPart A+B Nil return

Annual Operating Framework - Rolling 12 month position

2007/08 Targets

November 2007 Performance Report. 1 of 9

Appendix 6.2(i)

Bro Morgannwg Performance Summary

Indicator Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 TargetYear to date

performance

Incentives and

sanctions

9bCancer 1 month Diagnosis to treatment wait 99% 92% 93% 95% 94% 97% 100% 99% 100%

98% Part A, 100%

Part BPart A+B Overall performance 100%

Breast 100% 91% 87%100% 100%

100% 100% 100% 100%98% Part A, 100%

Part BPart A+B 12 of 12 on target

Gynaecological 100% 100% 100%50% 75%

100% 100% 100% 100%98% Part A, 100%

Part BPart A+B 1 of 1 on target

Head & Neck NIL 100% 100% 100% 100% NIL 100% 75% 100%98% Part A, 100%

Part BPart A+B 4 of 4 on target

Lower GI 100% 100% 94%93% 86%

100% 100% 100% 100%98% Part A, 100%

Part BPart A+B 7 of 7 on target

Lung 90% 91% 100%71% 100%

67% 100% 100% 100%98% Part A, 100%

Part BPart A+B 6 of 6 on target

Skin 100% 89% 100%100% 100%

100% 100% 100% 100%98% Part A, 100%

Part BPart A+B 2 of 2 on target

Upper GI 90% 100% 66% 100% 100% 100% 100% 100% 100%98% Part A, 100%

Part BPart A+B 1 of 1 on target

Urological 95% 82% 91% 93% 100% 100% 100% 100% 100%98% Part A, 100%

Part BPart A+B 11 of 11 on target

Other 100% 100% 100% 100% 100% 100% 100% 100% 100%98% Part A, 100%

Part BPart A+B 3 of 3 on target

#

Average Length of Stay for Chronic

conditions of 5.7 days5.50 5.60 5.60 5.50 5.30 5.30 5.30 5.30 5.7 5.3 Part B

The reporting of this indicator relates to the HRGs of three specific

chronic conditions - Diabetes/CHD/COPD. Allocation of the HRG

forms part of the Clinical Coding process which is undertaken within

6 weeks of discharge.

10b

Multiple Admission Rate of 14.6%. Chronic

Conditions16.10% 16.10% 15.90% 15.70% 16.20% 16.00% 15.90% 16.40% 14.6% 16.40% Part B

#

Completion of Stage 1 (2006-08) of the

implementation plan of the NSF for older

people

Good progress continues to be made with the implementation plan

as identified via the SAAT. Multi Agency Working Groups in

Bridgend and Neath Port Talbot continue to make progress against

key actions within the plan. Target assessed as green in line with

#

To reduce number of delayed transfers of

care (excluding mental health)26 35 30 47 39 45 43 47 43 25 43

The Trust continues to work with Local Health Boards and Multi

Agency colleagues to address the ongoing discharge planning

arrangements for these patients. Paper is being submitted to MEB

To reduce number of days from delayed

transfers of care (excluding mental health)2,280 2308 2413 3125 3083 3511 3798 3815 3387 1340 3387 ""

#

To reduce number of delayed transfers of

care in mental health10 7 7 14 15 16 13 10 10 12 10 ""

15a

To reduce number of days delayed for

delayed transfers of care in Mental Health1,146 1124 901 934 1217 1539 1438 1334 1374 576 1374 ""

#70% call to Needle times 70% Call to Needle time audits are reported on a quarterly basis.

#

Health Community will establish a specialist

cessation service for smokers undergoing

elective surgery

The Surgical Directorate are implementing Pre-assessment which

will incorporate smoking cessation.

#

Implement each of the 2007/08 ,milestones

in the cancer network action plans

The SWWCN has agreed action plans for the implementation of

these milestones and additional resources are being made

available to support this

#

Implement each of the 2007/08 milestones

in the local mental health action plans

In Bridgend the status is amber. All key actions for the second

quarter have been achieved except KA18. Currently awaiting

commissioning guidance and KA22. LHB and Trust are discussing

capacity issues that are acting as a barrier to implementation. NPT

#

All health communities will establish a

baseline for people on enhanced care

programme approach CPA who have or are

at high risk of disengaging with services.

Preliminary audit undertaken using local questionnaire. Results

being collated. Welsh Assembly Government questionnaire to be

circulated in January 2008. Electronic CPA form will help to identify

patients on enhanced CPA which will be subject to monthly census.

#

Infection control: Locally agreed Reduction

targets with regional offices and WHAIPT.

The Trust continues to be well below the Welsh average for core

indicators. The Trust is developing a zero tolerance approach to

infection control as ongoing action to sustain this good

performance.

Patient Experience

Effectiveness

50%

Safety

Efficiency

November 2007 Performance Report. 2 of 9

Appendix 6.2(i)

Bro Morgannwg Performance Summary

Indicator Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 TargetYear to date

performance

Incentives and

sanctionsComments

1Average length of Stay

Elective ENT

1.0 0.9 1.2 1.0 1.1 1.3 1.0 1.0 1.0 1.2 1.5

As agreed with the Regional Office one record for December with

length of stay 39 days has been excluded. Untrimmed Average

Length of Stay is 1.5 days.

Emergency ENT3.5 2.7 3.3 3.5 1.4 3.3 1.6 2.9 2.2 2.5 2.2

Elective General Medicine (Acute Sites

only)

5.1 5.2 5.8 7.2 5.4 5.2 5.0 4.8 6.7 6.0 13.4

As agreed with the Regional Office, measurement is for

acute sites only. As agreed with the Regional Office two

records for December with lengths of stay 88, 38 days

have been excluded. Untrimmed Average Length of Stay is

13.4 days.

Emergency General Medicine (Acute Sites

only)4.9 4.6 5.0 4.8 4.1 4.2 4.5 4.3 4.0 5.0 4.0

As agreed with the Regional Office, measurement is for acute sites

only.

Elective General Surgery3.8 4.4 3.3 4.4 3.4 3.8 3.4 3.1 3.7 3.8 3.7 Part B

Emergency General Surgery4.4 4.0 3.8 3.4 4.2 4.7 4.4 4.3 4.1 4.4 4.1

Elective Gynaecology1.6 1.7 1.7 2.5 2.3 2.3 2.2 2.3 1.9 2.7 1.9 Part B

Emergency Gynaecology2.5 1.3 1.8 1.5 1.5 1.5 1.7 1.9 1.7 1.5 1.7

The increase this month appears to be caused two patients with a

length of stay of 10 and 12 days

Elective Ophthalmology

1.5 2.4 2.4 0.9 1.1 3.0 1.7 1.1 2.3 1.0 2.3As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 8 cases undertaken in December

Emergency Ophthalmology

3.3 5.0 3.4 2.5 2.3 2.3 11.5 1.0 2.2 1.0As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 1 cases undertaken in December

Elective T&O

4.8 5.4 4.2 5.8 3.9 4.5 4.7 4.7 4.2 5.0 4.2 Part B

The reporting of this indicator is a month in arrears due to revised

processes for monitoring and reporting length of stay for Care of

Elderly patients on Orthopaedic wards. There are 6 patients that

were excluded in December Data that have a cobmined length of

stay of 186 days

Emergency T&O

8.8 8.4 8.3 8.3 8.2 6.1 8.8 5.9 6.5

The reporting of this indicator is a month in arrears due to revised

processes for monitoring and reporting length of stay for Care of

Elderly patients on Orthopaedic wards. There are 3 patients that

were excluded in December Data that have a cobmined length of

stay of 162 days

Elective Urology3.0 2.5 2.3 2.5 2.2 1.8 2.2 2.1 2.2 2.8 2.2

Emergency Urology 3.7 2.8 4.1 3.3 2.0 4.7 4.8 5.4 3.6

Directorate are undertaking an audit of long stay patients from April

07 to date.

3

Basket of Procedures - High Impact

Change no 1

These indicators are reported a month in arrears in order to reflect

more complete clinically coded data.

Inguinal Hernia Repair 78% 83% 77% 79% 76% 70% 87% 81% 67% 81% Part B

Varicose Vein Procedures 50% 53% 82% 57% 30% 50% 57% 80% 80% 80%As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 7 cases undertaken in November

Varicose Veins with L86 100% 53% 95% 67% 30% 74% 56% 88% 80% 88%

Arthroscopy 75% 70% 82% 83% 86% 82% 80% 86% 82% 86% Part B

Bunions 45% 38% 57% 33% 25% 71% 56% 63% 67% 63%As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 8 cases undertaken in November

Cataracts 98% 99% 98% 99% 99% 99% 99% 99% 100% 99%

Hysteroscopy with/wo D&C 91% 92% 93% 90% 93% 100% 87% 100% 92% 100%

Laparoscopy, D&T 85% 86% 74% 79% 84% 83% 84% 83% 86% 83% Part B This target would have been achieved had one more patient been

treated as a day case.

Core Measures - Efficiency and Productivity Measures - Rolling 12 month position

Efficiency and Productivity Measures Core Measures

November 2007 Performance Report. 3 of 9

Appendix 6.2(i)

Bro Morgannwg Performance Summary

Indicator Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 TargetYear to date

performance

Incentives and

sanctionsComments

Haemorrhoidectomy - - - 17% 33% 0% 0% 100% 57% 100%As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 1 cases undertaken in November

Excision of Breast Lump 100% 50% 100% 75% 71% 50% 100% 100% 88% 100%As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 6 cases undertaken in November

Circumcision 89% 77% 50% 83% 86% 92% 62% 88% 93% 88%

TURBTS 20% 44% 43% 28% 46% 46% 41% 27% 43% 27%

Removal Of Metalware 71% 85% 71% 69% 73% 71% 89% 86% 71% 86% As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 7 cases undertaken in November

Duputyrens contracture 100% 50% 33% 25% 75% 33% 71% 100% 83% 100% As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 1 cases undertaken in November

Myringotomy 100% 99% 98% 99% 90% 100% 100% 100% 100% 100%

Sub Mucous Resection 14% 0% 13% 25% 0% 18% 38% 67% 36% 67% As agreed with the Regional Office, exclusions occur if activity

remains under 10 cases. 3 cases undertaken in November

4

Elective Cases Treated as Day cases

(High Impact Change no 1) (Cleansed)

General Surgery. 53% 51% 49% 48% 48% 45% 52% 43% 59% 50%

Urology 77% 80% 76% 71% 78% 81% 78% 74% 82% 77%

Trauma and Orthopaedics 46% 43% 44% 43% 40% 44% 47% 45% 34% 43%

ENT 71% 75% 74% 74% 75% 69% 74% 66% 62% 71%

Ophthalmology 97% 98% 97% 96% 97% 97% 96% 96% 97% 97%

Oral Surgery 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Gynaecology 75% 75% 75% 76% 80% 78% 79% 76% 78% 77%

All Surgical Specialties - Inc non cleansed

OPDC 70% 71% 68% 67% 70% 69% 70% 67% 68%75% 69%

5

Elective Operations carried out on day

of Admission (High Impact Change 9)

General Surgery. 29% 22% 29% 39% 31% 35% 47% 45% 47% 44% 36%

Urology 44% 50% 54% 34% 55% 56% 44% 47% 50% 48% 48%

Trauma and Orthopaedics 35% 34% 45% 36% 48% 50% 44% 43% 41% 41% 42%

ENT 96% 96% 98% 100% 98% 99% 97% 99% 92% 93% 98%

Ophthalmology 80% 86% 100% 89% 83% 67% 82% 75% 50% 88% 81%

Gynaecology 97% 87% 90% 80% 87% 93% 87% 89% 80% 56% 88%

6

Elective Admissions with no Procedure

(High impact change 9)

Day case (cleansed) 4.51% 3.78% 3.29% 3.28% 3.13% 3.38% 3.04% 2.41% 3.70% 3.14%

Inpatient 3.46% 2.69% 3.16% 3.16% 2.92% 2.45% 2.33% 2.27% 2.70% 2.53%

ENT did not hit their target this month. It should be noted out of a

total of 13 patients only 1 patient did not have their operation

carried out on the day of admission

Whilst still not hitting the target work is ongoing to address

Work within the Pre assessment project is addressing these

performance issues and further improvements expected in early

2008.

November 2007 Performance Report. 4 of 9

Appendix 6.2(i)

Bro Morgannwg Performance Summary

Indicator Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 TargetYear to date

performance

Incentives and

sanctions

7Short Stay emergency Admissions

General Surgery 40% 39% 44% 43% 41% 37% 45% 37% 41% 24.9% 40.7%

Trauma and Orthopaedics 33% 28% 38% 44% 32% 32% 19% 27% 39% 25.2% 31.9%

General Medicine 38% 37% 38% 38% 41% 40% 35% 36% 36% 28.5% 37.6%

8

Long Stay Admissions (High impact

change 7)22.02% 20.79% 16.87% 14.79% 14.58% 16.57% 17.17% 21.56% 16.61% 9.5% 17.9%

The decrease in December is due to the decrease in the number of

discharges in month. Decreasing from 36 dischaged in Novmeber

to 27 in December.

#New : FU Ratios (High Impact change no

5)

General Surgery1.30 1.11 1.17 1.19 1.13 1.09 1.05 1.16 1.03 1.2 1.12

Urology2.1 2.1 1.7 1.6 1.6 1.9 1.9 1.85 1.15 2.1 1.176

T&O1.8 2.0 1.9 1.9 1.8 1.8 2.0 2.2 2.0 1.9 1.96

ENT1.6 1.4 1.5 1.5 1.6 1.3 1.3 1.3 1.3 1.3 1.42

Ophthalmology3.1 2.9 2.9 2.1 2.8 2.9 2.4 2.4 2.2 2.3 2.58

Oral Surgery1.5 1.7 1.6 1.1 1.3 1.5 1.7 1.4 1.4 0.9 1.4

Orthodontics13.0 2.8 3.9 5.2 5.1 4.7 5.5 3.7 3.9 4.4 4.38

General Medicine3.0 3.1 3.0 2.9 3.1 2.7 3.0 3.6 3.7 2.6 3.23

Haematology7.8 6.8 5.3 5.5 3.3 3.7 3.6 5.3 4.0 12.1 4.49

Dermatology2.2 2.1 1.7 2.1 1.7 2.2 1.8 2.1 2.1 1.4 2.02

Rheumatology2.2 2.3 2.1 2.2 2.1 2.5 2.4 2.5 2.6 3.1 2.47

Paediatrics3.2 2.9 2.9 2.3 2.5 3.1 2.4 2.7 3.2 2.1 2.93

Gynaecology1.3 1.2 1.2 1.2 1.2 1.1 1.1 1.2 1.1 1.3 1.19

# DNA Rates

New DNA Rate6.2% 7.2% 6.6% 7.6% 7.7% 8.2% 8.4% 7.6% 8.7% 5% 7.58%

FU DNA Rate8.3% 8.2% 8.7% 8.7% 8.6% 8.3% 8.5% 7.7% 8.4% 7% 8.37%

FU MH DNA RATE9.5% 9.4% 12.2% 8.3% 11.9% 12.0% 12.0% 10.9% 9.6% 12% 10.90%

NEW MH DNA RATE13.8% 17.3% 12.3% 13.9% 14.3% 6.8% 7.8% 13.2% 13.0% 10% 12.30%

Performance improvement continues to be targeted through the

Outpatient Steering Group. With the Outpatients department

working closely with the Clinical champions to target areas for

improved performance.

NLIAH project commencing.

November 2007 Performance Report. 5 of 9

Appendix 6.2(i)

Bro Morgannwg Performance Summary

Indicator Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 TargetYear to date

performance

Incentives and

sanctions.Comments

# Clinic Cancellation Rates 0.7% 0.7% 0.8% 0.8% 0.9% 0.3% 0.5% 0.8% 1.7% 4.30% 0.75%

#

Cancelled operations (High impact

change 9)5.5% 2.8% 3.9% 3.5% 3.9% 4.1% 4.0% 3.4% 5.8% 4.70% 5.80%

Part B

The number of operation undertaken in December compared to

November has decreased by 26% due to the Christmas period.

Decreased from 1257 to 926 in December. There were 54

cancellations within the month, 22 of which were patient

cancellations due to acute illness and DNA.

General Surgery5.0% 2.4% 3.1% 4.4% 1.0% 2.0% 3.6% 4.7% 4.6% 4.70% 3.45%

Urology3.0% 8.0% 9.3% 2.1% 3.9% 4.1% 5.4% 4.5% 2.4% 4.70% 4.78%

T&O8.0% 2.3% 2.8% 3.3% 8.5% 5.7% 3.9% 4.2% 7.6% 4.70% 5.23%

ENT4.0% 0.0% 2.1% 7.8% 0.0% 3.8% 4.1% 0.9% 3.7% 4.70% 2.89%

Ophthalmology5.0% 0.0% 2.7% 1.2% 0.0% 4.0% 3.9% 0.0% 8.7% 4.70% 2.54%

Oral Surgery0.0% 0.0% 8.3% 15.4% 20.0% 15.4% 15.8% 40.0% 14.3% 4.70% 14.16%

Anaesthetics0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.70% 0.00%

Gynaecology3.1% 6.1% 6.2% 2.8% 4.4% 4.4% 3.8% 2.0% 4.5% 4.70% 3.90%

#

Theatre Utilisation Late starts early

finishes (High impact change 9)

Late Starts % POW Main7.0% 8.0% 16.0% 11.0% 20.0% 15.0% 8.0% 13.0% 8.0% 10.00%

Early finishes % POW Main21.0% 23.0% 20.0% 26.0% 28.0% 22.0% 14.0% 8.0% 34.0% 10.00%

Late Starts % NPT Main12.0% 15.0% 8.0% 18.0% 12.0% 13.0% 12.0% 8.0% 11.0% 10.00%

Early finishes % NPT Main40.0% 31.0% 33.0% 39.0% 26.0% 41.0% 23.0% 18.0% 34.0% 10.00%

#

A&E follow up rates (High Impact

change no 5)

POW A&E 4.99% 5.20% 4.85% 4.08% 3.91% 4.26% 4.50% 3.86% 3.64% 5.80% 4.38%

NPT LAC 3.63% 4.87% 5.17% 3.33% 5.49% 4.45% 4.76% 4.81% 5.22% 7.40% 4.85%

workforce measures

# Sickness Rates 5.39% 5.59% 5.74% 5.74% 5.11% 5.32% 5.41% 4.20%

# Agency Spend 1.30% 1.30% 1.40% 1.40% 1.40% 1.30% 1.30% 1.30% 0.80%

A review for the month is being undertaken to identify adjustments.

NLIAH is undertaking a Process mapping exercise.

November 2007 Performance Report. 6 of 9

Appendix 6.2(i)

Bro Morgannwg Performance Summary

1LTA performance Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Monthly target Annual Target YTD Var %

1a

Bridgend LHB 1449 1591 1503 1622 1580 1633 1620 2111 1556 18669 7%

Bridgend LHB var -107 35 -53 66 24 77 64 555

Neath Port Talbot LHB 935 923 1028 1025 997 1001 1043 1521 947 11361 16%

Neath Port Talbot LHB var -12 -24 81 78 50 54 96 574

Vale LHB 216 225 214 220 216 225 186 341 207 2484 15%

Vale LHB var 9 18 7 13 9 18 -21 134

Swansea LHB 20 19 25 19 32 23 32 48 23 276 25%

Swansea LHB var -3 -4 2 -4 9 0 9 25

1b

Bridgend LHB 2,509 2912 2992 3071 2882 2843 3293 1509 2512 30144 13%

Bridgend LHB var -3 400 480 559 370 331 781 -1003

Neath Port Talbot LHB 2,042 2196 2345 2460 2217 2273 2600 948 2165 25980 -2%

Neath Port Talbot LHB var -123 31 180 295 52 108 435 -1217

Vale LHB 357 428 463 460 426 315 476 215 312 3746 34%

Vale LHB var 45 116 151 148 114 3 164 -97

Swansea LHB 37 57 66 73 79 80 97 25 89 1068 -37%

Swansea LHB var -52 -32 -23 -16 -10 -9 8 -64

1c

Bridgend LHB 1883 2,206 2,041 2,102 1,962 2,082 2,161 3041 1503 18036 32%

Bridgend LHB var 380 703 538 599 459 579 658 -1006

Neath Port Talbot LHB 1274 1393 1322 1436 1304 1276 1453 2528 1207 14484 32%

Neath Port Talbot LHB var 67 186 115 229 97 69 246 1321

Vale LHB 290 311 290 270 282 401 263 497 198 2376 86%

Vale LHB Var 92 113 92 72 84 203 65 299

Swansea LHB 37 57 66 52 57 37 56 80 52 624 8%

Swansea LHB var -15 5 14 0 5 -15 4 28

Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07

2 Referrals

Accident and Emergency 820 661 657 663 678 745 777 656 547

Consultant 1078 1266 1152 1243 968 850 1397 1434 1182

Dental 141 176 132 184 174 174 252 269 174

GP/Practice 4673 5472 5229 5707 5321 5051 5684 5240 4381

Other Referral 556 635 643 826 669 564 732 701 524

SELF 67 96 84 195 233 201 213 244 149

All Referrals 7335 8306 7897 8818 8043 7585 9055 8544 6959

1

Risk Adjusted Mortality - expected/index

rate 100 Trust 79 vs peer 79

2

Risk adjusted LOS - expected/index rate

100 Trust 85 vs peer 80

3Readmissions within 28 days of Discharge

5% vs 5.8%

Benchmarking

Inpatients Variance

Trust 84 vs peer 76

Trust 83 vs peer 77

3.9% vs 4.2%

Bench Marks

Local Indicators

QTR 4 2006/07 QTR 2 2007/08QTR 1 2007/08

Outpatient variance

Day cases variance

November 2007 Performance Report. 7 of 9

Appendix 6.2(i)

Access Summary

Additional DSU Specific Targets

22 week IP/DC Waits against profile.

0

100

200

300

400

500

600

700

800

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Days Stay

22 Week Maximum wait for Inpatients &DaycasesTarget

22 week Outpatient waits against Profile.

0

500

1000

1500

2000

2500

3000

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Days Stay

22 Week Maximum wait for Outpatients

Target

24 Week diagnostic waits

0

100

200

300

400

500

600

700

800

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Days Stay

14 week Diagnostic & Therapy wait TargetA&E 4 hour Wait.

80.00%

82.00%

84.00%

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Days Stay

95% less than four hour Waits Target

Cancer 1 month wait

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Days Stay

Cancer 1 month Diagnosis to Treatment times.Cancer 2 month wait

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Days Stay

Cancer 2 month Diagnosis to Treatment times.

Appendix 6.2(i)

Emergency Summary

DTOC Non Mental Health.

0

5

10

15

20

25

30

35

40

45

50

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

No of patients

To reduce number of delayed transfers of care(excluding mental health)Target

DTOC Non Mental Health Days.

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Days Stay

To reduce number of days from delayed transfersof care (excluding mental health)Target

DTOC Mental Health Days.

0

200

400

600

800

1000

1200

1400

1600

1800

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Days Stay

To reduce number of days delayed for delayedtransfers of care in Mental HealthTarget

DTOC Mental Health.

0

2

4

6

8

10

12

14

16

18

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

No of Patients

To reduce number of delayed transfers of care inmental healthTarget

LOS for Chronic conditions

-

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Days Stay

Average Length of Stay for Chronic conditions of5.7 daysTarget

Multiple Admission Rates Chronic Diseases

14.00%

14.50%

15.00%

15.50%

16.00%

16.50%

17.00%

17.50%

18.00%

18.50%

Apr-

06

May-

06

Jun-

06

Jul-06 Aug-

06

Sep-

06

Oct-

06

Nov-

06

Dec-

06

Jan-

07

Feb-

07

Mar-

07

Apr-

07

May-

07

Jun-

07

Jul-07 Aug-

07

Sep-

07

Oct-

07

Nov-

07

Month

% multiple Admissions

Multiple Admissions

Appendix 6.2(i)

Appendix 6.2(ii)

Bro Morgannwg NHS Trust

Incentives and Sanctions Framework

Self Assessed Score (December 2007 Performance)

SaFF Target No. Target Score CommentsScore Based on December 2007

1 To reduce the maximum waiting time for inpatient or daycasetreatment to 22 weeks.

1 Trust is currently within agreed profiles and this is projected tocontinue.

1

2 To reduce the maximum waiting time for first outpatientappointment to 22 weeks.

1 Trust is currently within agreed profiles and this is projected tocontinue.

1

3 To reduce the maximum waiting time for access to specifieddiagnostic services to 14 weeks.

1 Trust is currently within agreed profiles and this is projected tocontinue.

1

4 To reduce the maximum waiting time for access to specified therapyservices to 24 weeks.

1 Trust is currently within agreed profiles and this is projected tocontinue.

1

5 95% of all new patients (including paediatrics) to spend less than 4hours in a major A&E department from arrival until admission,transfer or discharge. No one should wait longer than 8 hours foradmission transfer or discharge*.

1 4 hour target for December is 96.81%. Against the 8 hour target 7patients did achieve the target in the entire month. Whilst this is not100% the Trust would contest that it should be scored as such giventhat A&E attendences each month are around 5,500.

1

9(i) Patients referred by their GP with urgent suspected cancer andsubsequently diagnosed as such by a Cancer Specialist will startdefinitive treatment within 2 months of receipt of referral.

1 For December the Trust achieved 92% on this target (1 patient breached)

0

9(ii) Patients not referred as urgent suspected cancer but subsequentlydiagnosed with cancer will start definitive treatment within 1 monthof diagnosis, regardless of the referral route. ** Tolerance levels of98% and 95%

1 For December the Trust achieved 100% on this target 1

The achievement of financial balance (i.e. breakeven or surplusonly).

1 Current forecast is for achievement of break even. 1

Sub Total 8 7

On this basis the Trust would not proceed to part B given the 92% cancer score but B has been marked for illusration purposes only.

SaFF Target No. Target Score CommentsScore Based on December 2007

7 All patients referred by a GP or other medical practitioner to secondary or tertiary cardiology will receive definitive treatment within 52 weeks of receipt of the original referral by the receiving Trust.

1 Trust is currently delivering this target and re-modelled pathway facilities this.

1

9(i) Patients referred by their GP with urgent suspected cancer and subsequently diagnosed as such by a Cancer Specialist will start definitive treatment within 2 months of receipt of referral.

1 For December the Trust achieved 92% on this target (1 patient breached)

0

9(ii) Patients not referred as urgent suspected cancer but subsequentlydiagnosed with cancer will start definitive treatment within 1 monthof diagnosis, regardless of the referral route. *** Achievement of100% performance in 31 and 62 day access.

1 For December the Trust achieved 100% on this target 1

10 To improve the management of chronic conditions for patients, thehealth community will achieve:(i) an average length of stray of no greater than 5.7 days for emergency medical admissions.

1 December 5.3% 1

(ii) a multiple admission rate of or no greater than 14.6%. 1 December 16.4% 020 The health community will implement all milestones for 200708

contained within the approved Local Mental Health Action Plans.1 In Bridgend .. status is amber .. all key actions for the second

quarter have been achieved except KA18 .. awaiting commissioningguidance and KA22 .. LHB and Trust discussing capacity issuesacting as barrier to implementation.

1

NPT .. status is amber with 3 work streams now in place andgateway worker and psychological therapy service reorganisation tocomplete in January 2008.

Implementation of the Quality Improvement Plan requirements for2007/08.

1 Measurement basis for this target remains unclear. Trust isprogressing well on implementing QuIP and would contest that thisi 1

1

Average length of stay for elective procedures:• General Surgery 1 3.7 for December 1• Trauma and orthopaedics 1 4.2 for December 1• Gynaecology 1 1.9 for December 1Daycases procedures• Arthroscopy 1 86% for December 1• Laparoscopy 1 83% for December 0• Hernia 1 81% for December 1

14 Cancelled operations 1 5.8% for December. However this refects the time of year given thatypicla cancellation level is averaging around 3.9%

0

Sub Total 14 10

TOTAL 22 17

3

Part B: Targets and scores for 2007/08

1

Part A: Targets and scores for 2007/08

Appendix 6.2(iii)

Bro Morgannwg NHS Trust

Month 08 - 2007/08 LTA performance by LHB

Target Actual Variance % Var Target Actual Variance % Var Target Actual Variance % Var

Bridgend 22,609 26,092 3,483 15% 14,002 12,987 (1,015) -7% 13,528 18,668 5,140 38%NPT 19,487 21,100 1,613 8% 8,520 8,392 (128) -2% 10,869 12,622 1,753 16%Swansea 1,072 699 (373) -35% 208 215 7 3% 464 471 7 2%IMH Total 43,168 47,891 4,723 11% 22,730 21,594 (1,136) -5% 24,861 31,761 6,900 28%

Cardiff 173 119 (54) -31% 131 84 (47) -36% 134 156 22 16%Merthyr 42 29 (13) -31% 20 20 0 0% 37 13 (24) -65%RCT 877 726 (151) -17% 530 460 (70) -13% 1,050 1,112 62 6%Vale 3,037 3,913 876 29% 1,949 1,804 (145) -7% 2,048 2,686 638 31%Bro Taf Total 4,129 4,787 658 16% 2,630 2,368 (262) -10% 3,269 3,967 698 21%

Carms 89 249 160 180% 55 56 1 2% 92 157 65 71%Ceredigion 2 22 20 1000% 2 3 1 50% 2 8 6 300%Pembrokeshire 23 37 14 61% 14 16 2 14% 23 29 6 26%Powys 318 448 130 41% 194 191 (3) -2% 326 347 21 6%Dyfed Powys Total 432 756 324 75% 265 266 1 0% 443 541 98 22%

Blaneau Gwent 9 5 (4) -44% 6 9 3 50% 9 8 (1) -11%Caerphilly 46 49 3 7% 31 51 20 65% 45 18 (27) -60%Monmouthshire 11 8 (3) -27% 7 12 5 71% 9 1 (8) -89%Newport 19 10 (9) -47% 12 14 2 17% 17 14 (3) -18%Torfaen 20 11 (9) -45% 13 15 2 15% 19 3 (16) -84%

Gwent Total 105 83 (22) -21% 69 101 32 46% 99 44 (55) -56%

Angiographies 880 823 (57) -6%

Note - Gwent targets not yet disaggregated and hence are only measured against target on a total basis

OP IP DC

01/02/2008 11:41 LTA by LHB Month 08

Appendix 6.7 21st December 2008 Karen Stephens* Partnership and Strategy manager Neath Port Talbot County Borough Council and Local Health Board Dear Ms Stephens Health Social Care and Well-being Strategy 2008-11, Consultation on Draft Strategy Your request for formal comments on the draft HSC&WB strategy for Neath Port Talbot Borough refers. Although Trust staff will continue to work with you and colleagues within the Partnership Board to shape the final document and associated action plan over the next few months, the following reflects the overall consensus within the Trust on the consultation document that was published last month. The Trust welcomes the focus on the work to be done to identify potential health needs at an early stage and improve health and well being across the range of sectors with which our partners in the Local Service Board, as well as Health and Social Care are involved, particularly the emphasis on mental health and well being, services for people with a learning disability, and for the older person and the disabled, chiefly the ambitious work that is being taken forward through the Delivering Integrated Services project. We look forward to working with colleagues to ensure that the final strategy: • Fully reflects the ambitious joint working required to move forward the health

improvement agenda, particularly with regard to mental health and well being, physical activity, diet and exercise and tobacco control

• Engages the citizen in planning and service delivery and modernisation initiatives; a key challenge for us all

• Is very clear about priorities, outcomes and milestones that it is intended we reach together over the next three years, and the measures we will use to know whether we are making progress.

• Highlights the challenges all key partners face as major employers in the area to deliver the messages within our own workplaces. The Trust has recently approved Health Living and Physical Activity policies and looks forward to working with partners to share similar messages and take them forward together within the community for example in the ongoing work to achieve Corporate Health Standard goals.

I hope you find these comments helpful, and wish you and colleagues well in developing a robust strategy and action plan that the whole Partnership can look forward to delivering together over the next 3 years. Yours sincerely Lindsay Davies, Partnership Development Manager for Bro Morgannwg NHS Trust * an identical letter was sent to Deborah Smith, Health Social Care and Well being Coordinator at Bridgend Borough Council.

Appendix 6.8

Information M Page 1 of 5 anagement Directorate Status: DraftDate: 01/02/0

INTERNET ACCESS POLICY

Originator: IT Security Manager Date Approved: August 2004 Approved by: Trust Board Date for Review: January 2008

– Edition 2 8

Appendix 6.8

In e Page 2 of 5 formation Management DirectoratSDate: 0 /

tatus: Draft – Edition 2 1/02 08

Background In the use of the Internet and web technology as an information resource haInTr Purpose Th this policy is to provide guidance to individual users on accessing information vi to outline the user’s responsibilities and to inform managers and users of the pr DInternet: The Internet is also known as the ‘world wide web’ and consists of an international ne rs and systems permanently linked through high speed connections. Every coanbyth InTh ork es y the same way. HofN Wthvian ent standard package is Microsoft Internet Explorer (Version 5 or above), wha CThprIn sites only contain work related inf rmation. Thtoem U ed that the principles of using the Internet are similar to those of reviewing and rea publications and that if in doubt, the same principles should be applied. ThisIT

1. F

• Access to the Internet is controlled by the use of sophisticated scanning software, this works bysire

the last few years s expanded dramatically. It is acknowledged that having access to information and using the

ternet as a tool for achieving this, is a necessary part of daily working life for many staff in the ust.

e purpose of a the Internet, ocedure to be followed for gaining and authorising Internet access.

efinitions

twork of computenceivable type of information is available on the web. It is public, global and wide open to yone who has an Internet connection. For example, home PC users can access the Internet linking via their telephone line to an Internet Service Provider (ISP), who provides access to e web much like a cable company links your television to the TV networks.

tranet: An Intranet is restricted to people who are connected to a private company network. e Trust has its own internal Intranet. Other than that, the Internet and the Intranet wsentiall

OWIS: The all-Wales NHS Intranet site. HOWIS is a web site, which is published for the use the NHS in Wales only and provides links to other Organisations and Services within the HS domain.

eb browser: The web browser is the special software, which is used to obtain information off e Internet and the Intranet. The web browser uses hyperlinks to automatically retrieve and ew online documents called web pages. Web browsers are commercial software programs

the Trust’s currdhich is usually loaded on all PCs used within the Trust. If you are unsure whether your PC s this facility please contact the IT Service Desk.

ontext of this policy e Trust encourages the use of web technology to access information to support working

actice whether it is for clinical, managerial or educational purposes. Access to the Trust’s tranet site and HOWIS remains unrestricted as these o

ere is, however, a need for clear guidelines for Internet users, as the Internet is easily open inappropriate use and can lead to lost productivity, disciplinary action and prosecution if the

ployee breaks the law.

sers are remindding written

e following conditions apply to all Trust employees who have access to Internet facilities. It important that all points are understood. If you need further clarification, please contact the Security Manager

iltering

analysing each Internet site a user requests against a set of rules. If access to a particular te falls within the personal threshold (20 mins per day ) or the site is considered to be ‘work lated’ then access is allowed, if not, then access is denied. A record is kept of each users

Appendix 6.8

Informati n Mo anagement Directorate Page 3 of 5 Status: DraftDate: 01/02/0

acau

• If staff feel that they need access to a site that is being blocked then they should contact the IT

ein

2. Cond

p by the Trust’s IT Department after the appropriate no

Se • Ab nary

Pr • t

M minded that, as a Trust resource, the Internet is in many ways similar to the

• U

in

3.

• Access to Internet based E-mail providers such as Hotmail, Freeserve, Tiscali etc is prohibited . However, all staff who are eligible to have an account for

ctors.net service as e-mails are scanned for viruses at by the provider of this service.

• N

thinf

•

– Edition 2 8

cess and denied access requests by the software and certain denied access sites tomatically send an alarm e-mail to the IT Security Manager.

S curity manager who can unblock the site on a temporary, permanent basis, for that dividual, a group of individuals or for all staff in the Trust.

itions & Restrictions

• Access to the Internet can only be set umination form has been approved by the user’s line manager. The user must also read this

policy and agree to abide by its Terms and Conditions. e guideline in Procedure for authorising Internet access section below.

use or inappropriate use of Internet facilities will be dealt with under the Trust’s Discipliocedure.

I is each user’s responsibility to ensure that their Internet facilities are used appropriately. anagers are re

telephone systems and should be managed accordingly.

se of the Trust’s Internet facilities are constantly monitored in order to detect any appropriate use.

Inappropriate use

du to the risk of Virus infectionDoctors.net can access the Do

e

ever access, copy or store material that is offensive, obscene, vulgar, racist, sexist, reatening or libellous. If a user accidentally encounters an inappropriate site, they must orm the IT Security Manager immediately.

Access to any non-work related sites are restricted to a maximum of 20 mins per day, and must not interfere with work performance, this time limit is enforced by the Internet Filtering

ftware. Access to pornographic, offensive and Internet mail sites are still however totally stricted.

Sore

•

Seston

• Never partake in on-line discussion forums that are not relevant to your job.

4. Tr

• Tr ust’s IT Training &

m

• Tr ining on the use of the clinical knowledge databases available via HOWIS such as Medline an Cinahl, can be arranged by contacting the Post Graduate Libraries sited at the Princess of

rt Talbot Hospitals.

5.

Never download or install program files from the Internet without contacting either the IT rvice Desk or the IT Security Manager first, as this could damage or interfere with the

andard desktop programs on your PC. (This does not apply to programs, which are offered the Trust’s Intranet site such as Adobe Acrobat Reader.)

aining

aining on the use of web browser software is carried out by the TrI plementation Team as part of the E-benefits training programme.

ad

Wales and Neath Po

Communication of the Internet policy

Appendix 6.8

Information M gemen Page 4 of 5 ana t Directorate Status: Draft ition 2 Date: 01/02/0

•

• Copies of this policy are available to all staff via the Policies tab on the Trust’s Intranet site.

6. Procedure for authorising Internet access

Users/Managers are requested to complete the ‘Request form’ which can be found as part of h

–8 Ed

This policy will be brought to the attention of all new staff during induction, web browser training and when staff are connected to the Internet.

•t e E-forms system on the Trust Intranet home page (http://nww.bromor-t wales.nhs.uk/eforms/r. ). On completion of this form an e-mail will automatically be sent to the

levant manager for approval, who will accept or decline the request for Internet access.

cess to the Internet is restricted to valid network users, if Internet access is required and the

re • Ac

person is not a valid network user then the IT Service Desk will create a new user and the p

• O

laithiso

7. Se

• All users are responsible for ensuring that there is no unauthorised access to their PC or their

• r

he 8. r

Alth me threshold has been exceeded or whether the requested Internet site is iltering software records every attempted breach in eliberately attempted to access inappropriate maatof Thsu 1.

and PC address

2. dence will be attached to an e-mail and sent to the relevant Directorate Manager. The attachment will be password protected and the Directorate Manager willpas

3. It wwhiof tsho

4. Th The Directo r must report the outcome of the investigation via the Trust incident re ng pNB e ITinappropria

a proving manager will be contacted by e-mail as soon as this account has been set up.

nce Internet access has granted the user will be asked to accept the terms and conditions d out in this policy. If the user does not accept them then the user will be unable to log on. If

happens then the user must either contact the IT Service Desk or the IT Security Manager t cancel their internet access request.

curity

Internet facility.

Users should keep personal passwords secure and confidential and take all reasonable p ecautions in order to avoid inappropriate use of the Internet by others, for which they will be

ld responsible

P ocedure for enforcing the policy

l Internet use is monitored and managed by filtering software which checks to see whether e individual access ticlassified as being work related or not. The f the access rules. If a user is found to have d

terial, or has attempted to access sites that breech this policy then this will be brought to the tention of the relevant Directorate Manager /Clinical Director and, depending on the severity the breach, the Trust’s disciplinary procedure may be invoked.

e IT Security Manager will use the following procedure if a breach of this policy is spected:

Collate evidence of the breach from the Internet access logs including addresses of the Internet sites that an attempt to access has been made, the nameof the person suspected of the breach, a full audit of the time spent on each internet site and a description of the suspected breach.

The evi

be instructed to contact the IT Security Manager by telephone to obtain the sword. ill then be the responsibility of the Directorate Manager to investigate the breach, ch will include an interview with the suspected user, and depending on the severity he case, this may result in the Trust’s disciplinary procedure being invoked. Advice uld be sought from the Personnel Department on the appropriate action.

e IT Security Manager will complete a Trust incident form.

rate Manageporti rocess.

: Th Security Manager is also bound by this policy and will not access any of the te Internet sites.

Appendix 6.8

Information Management Directorate Page 5 of 5 Status: Draft – Edition 2 Date: 01/02/08

9. C ts

ontact Location & Number Advice

ontac

C

IT anager Bridgend 5 4060 Chri omor

All IT secu Security M WHTN – 0185s.Phillips@br -tr.wales.nhs.uk

rity issues

IT Service Desk Bridithelp adin

s

gend WHTN - 01855 3636 option 2 Advice downlodesk@bromor-tr.wales.nhs.uk problem

on virus software; g files; reporting

with Internet access IT Training & I lementation Team

BridNeath WHTN – 01881 2442 Advice onmp

gend WHTN – 01855 4062 IT training

P rid WHTNNeath WHTN – 01881 2369

g trof the web based

knowledge dost Grad Library B gend – 01855 2114 Bookin

use aining sessions on the

atabases

10. Policy review

This policy will be reviewed on an annual basis and approved by the Management Executive.

Appendix 6.8

Information Management Directorate Page 1 of 7

E-MAIL POLICY

Originator: Information Management Date Approved: August 2004 Approved by: Trust Board Date for Review: January 2008

Status: Version 3.1 Date: January 2008

Appendix 6.8

Information Management Directorate Page 2 of 7 Status: Version 3.1 Date: January 2008

Bro Morgannwg NHS Trust Policy on the use of the Trust’s e-mail facilities

Purpose The purpose of this policy is to provide a framework for the use of e-mail within the Trust, guidance to individual users on the use of e-mail facilities, to outline the user’s responsibilities and to inform staff that e-mails entering and leaving the Trust are automatically scanned to ensure compliance with this policy. Introduction The use of electronic methods of communication wherever possible is a key principal of working within Bro Morgannwg NHS Trust. E-mail is being used more and more to replace the traditional paper-based approach to communication. As with any system in widespread and routine use, e-mail can provide many benefits when used correctly but can also lead to frustration and annoyance if used inappropriately. The key benefits of using e-mail appropriately are: • improved and faster communication between users • improved access to information • improved sharing of information • a reduction in the time spent copying and distributing information • improved working practices However, inappropriate use of e-mail can lead to: • ineffective use of time and resources • wasted time • theft due to infringement of copyright laws • the spread of PC viruses • disciplinary action The Trust uses the Microsoft Outlook e-mail application. This package is the Trust’s desktop standard for all e-mail and diary scheduling facilities. No other e-mail packages are therefore supported by the Trust’s IT Department. Users are reminded that the principles of using e-mail are similar to those of written communication on Trust headed notepaper, and that if in doubt, the same principles should be applied. Managers are reminded that e-mail is a Trust resource, in many ways similar to the telephone system and should be managed as such. The following conditions apply to all Trust employees who have access to e-mail facilities: 1. Scanning Software

• All e-mail entering or leaving the Trust passes through scanning software, this software scans the

content for inappropriate material. Any mails found with inappropriate content will either be quarantined for further investigation, or automatically deleted.

• All quarantined e-mails will be investigated by the IT Security Manager who will take one of the

following actions:

• Release the mail if the content is not deemed to breech this policy. • Delete any offending incoming mails • Contact the member of staff to issue a warning about the content depending on the content of

mail. • Contact the Directorate Manager to report the incident, the evidence will be attached to an e-

mail and sent to the relevant Directorate Manager. The attachment will be password protected and the Directorate Manager will be instructed to contact the IT Security Manager by telephone to obtain the password. It will then be the responsibility of the Directorate Manager

Appendix 6.8

Information Management Directorate Page 3 of 7 Status: Version 3.1 Date: January 2008

to investigate the breach, which will include an interview with the suspected user, and depending on the severity of the case, this may result in the Trust’s disciplinary procedure being invoked. Advice should be sought from the Personnel Department on the appropriate action. The IT Security Manager will complete a Trust incident form. In such instances the evidence will be retained and may be used in a disciplinary or legal procedure as appropriate.

2. Conditions & Restrictions

• The distribution of documents containing ‘person identifiable information’ via external e-mail (i.e. any address outside Bro Morgannwg Trust) is strictly forbidden unless the documents are encrypted. Access to person identifiable information is restricted and release of such information must be in accordance with the Caldicott principles, Data Protection Act and the general duty of confidentiality. Therefore, if you must send person identifiable data internally (i.e. within the Trust) only include data items which are essential (see the good practice guidelines at the end of this policy). Contact the IT Security Manager for further advice.

• The distribution of chain letters via e-mail is forbidden. If you receive such a chain e-mail delete it and

inform the IT Security Manager that a chain e-mail may be circulating within the Trust.

• Never send blanket e-mail (i.e. e-mail to all users in the address book) without first contacting the IT Security Manager. This practice wastes the time of the majority of e-mail users and slows down the Trust’s communication network. There may be other methods of distributing the information such as the Trust Intranet that are more appropriate.

• Attachments greater than 10mb will not be delivered, as this will cause disruption to the network.

Please contact the IT Help Desk for further advice. • Users have a responsibility to draft all e-mails carefully, and to ensure that mails do not contain any

information which could be interpreted as discriminatory or harassing, or which could offend.

• E-mail users have a responsibility to ensure that copyright and licensing laws are not breached when composing or forwarding e-mails and e-mail attachments.

• Limited personal use of the e-mail system is permitted if it does not interfere with work performance and if it adheres to the Trust’s e-mail standards and conditions.

• Departmental managers are required to inform the IT Department when staff leave the Trust’s

employment. This is achieved automatically via the E-Termination form system, Departing staff are expected to empty their accounts, inboxes etc before leaving the Trust and to share or forward any information that is still required. The users account will be hidden for 1 calendar month after their last working day and will be deleted after this time unless the manager contacts the IT Security Manager.

• Staff who take up a post within another department within the Trust must also empty their accounts,

inboxes etc before leaving, as this position may be unrelated to the previous role. Their account will be again hidden for 1 month and then deleted unless the manage contacts the IT Security Manager.

• Managers are also required to inform the IT Department of staff who are expected to be absent from

the Trust for a significant period of time e.g. on maternity leave or long term sick leave as these accounts can be disabled until the user returns to work.

• When a patient contacts the Trust via e-mail the subsequent correspondence to patients should be

limited to information relating to basic information e.g. appointment rescheduling and general good practice guidelines, but all clinical information and person identifiable information should not be transferred via e-mail. If this type of information is requested then perhaps a reply using the following words may be considered.

"Thank you for your e-mail, however due to patient confidentiality Bro Morgannwg NHS Trust does not send clinical information via e-mail. Please contact me directly to discuss the issues further.

Appendix 6.8

Information Management Directorate Page 4 of 7 Status: Version 3.1 Date: January 2008

3. Meeting Room Bookings

• All meeting rooms within the Trust must be set up as a resource within the Outlook address book and

also must be booked via e-mail. Contact the IT Trainers for further help and guidance in setting up or on the use of this facility.

4. Security

• All users will be warned by the Trust’s IT Department either via an e-mail or on the Trusts intranet site if there is a known virus circulating. Users should not open any e-mail or e-mail attachments, which are from unknown sources and should contact the IT Service Desk for advice.

• All users are responsible for ensuring that there is no unauthorised access to their PC or their e-mail

account.

• Users should keep personal passwords secure and confidential and take all reasonable precautions in order to avoid inappropriate use of their account by others, for which they will be held responsible.

5. Inappropriate use

• Creation or exchange of messages or attachments that contain material that could be considered as

offensive, obscene, racist, sexist, threatening, libellous, containing bad language or jokes is strictly prohibited. Reported abuse of e-mail facilities will be dealt with under the Trust’s Disciplinary Procedure.

6. Training

• Training on the use of e-mail facilities is provided by the Trust’s IT Training & Implementation Team.

The trainers will advise on how the Outlook e-mail system can be used to manage mails, calendars, contact lists and files and how it can be tailored to support departmental office working practices.

7. E-mail disclaimer

• The following disclaimer will be automatically included at the end of all external e-mails sent via the

Trust’s e-mail system. ‘Cymraeg:- Mae'r neges hon yn gyfrinachol nad chi yw'r derbynnydd y bwriedid y neges ar ei gyfer, byddwch mor garedig â rhoi gwybod i'r anfonydd yn ddi-oed. Dylid ystyried un rhywd datganiadau neu sylwadau a wneir uchod yn rhai personol,ac nid o angen rhaid yn rhai o eiddo Ymddiriedolaeth GIG Bro Morgannwg, nac unrhyw ran gyfansoddol ohoni na chorff cysylltiedig. Cofiwch fod yn ymwybodol ei bod yn bosibl y bydd disgwyl i Ymddiriedolaeth GIG Bro Morgannwg roi cyhoeddusrwydd i gynnwys unrhyw ebost neu ohebiaeth a dderbynnir, yn unol ag amodau'r Ddeddf Rhyddid Gwybodaeth 2000. I gael mwy o wybodaeth am Ryddid Gwybodaeth, cofiwch gyfeirio at wefan Ymddiriedolaeth GIG Bro Morgannwg ar www.bromor-tr.wales.nhs.uk English:- This message is confidential. If you are not the intended recipient of the message then please notify the sender immediately. Any of the statements or comments made above should be regarded as personal and not necessarily those of Bro Morgannwg NHS Trust, any constituent part or connected body. Please be aware that, under the terms of the Freedom of Information Act 2000, Bro Morgannwg NHS Trust may be required to make public the content of any emails or correspondence received. For further information on Freedom of Information, please refer to the Bro Morgannwg NHS Trust website at www.bromor-tr.wales.nhs.uk.’

Appendix 6.8

Information Management Directorate Page 5 of 7 Status: Version 3.1 Date: January 2008

The inclusion of the disclaimer is seen as a precautionary measure to guard against the Trust becoming liable for litigation from any individual or organisation.

8. Communication of the e-mail policy

• This policy will be brought to the attention of all new staff during induction, e-mail training and before setting up the user’s e-mail account.

• Copies of this policy will be available to all staff via the Policies Tab on the Trust’s Intranet site.

9. Methods of monitoring the policy

• E-mail account usage will be monitored. Any user found not accessing their account for 1 month will

become subject to a review. The IT Department will contact the user’s line manager in order to investigate the reason for non-use. Infrequent use of an account may result in the account being disabled. Dormant accounts are a security risk and therefore need to be monitored on a regular basis.

• Mailbox sizes will be monitored. Large mailboxes slow down the Trust’s network systems. Mailboxes

can be controlled by good housekeeping such as deleting or filing mails (see How to use E-mail correctly section (appendix 1)). The IT Trainers will contact users and provide advice and training on how to manage their mailbox.

10. Contacts

Contact Number, Location & E-mail Address Advice

IT Security Manager

Bridgend WHTN – 01855 4060 Chris.Phillips@bromor-tr.wales.nhs.uk

All IT security issues

IT Service Desk

Bridgend WHTN - 01855 3636 option 2 ithelpdesk@bromor-tr.wales.nhs.uk

Advice on e-mail viruses; reporting problems with e-mail

IT Training & Implementation Team

Bridgend WHTN – 01855 3636 option 1

Booking training sessions; advice on using e-mail functions

11. How to apply for an E-mail account

• E-mail accounts must be applied for using the E-forms system that can be found on the home page of the Trust intranet site (http://nww.bromor-tr.wales.nhs.uk/eforms/).

• This system will e-mail the appropriate manager who will need to approve or decline the application.

• Approved applications will be automatically e-mailed to the IT Helpdesk for set up.

12. Policy review

This policy will be reviewed on an annual basis and submitted to the Management Executive and Trust Board for approval.

Appendix 6.8

Information Management Directorate Page 6 of 7 Status: Version 3.1 Date: January 2008

Appendix 1 How to use E-mail correctly

• Always attend training courses and seminars to learn how to get the most from using e-mail. • Always send documents via e-mail if the intended recipients have e-mail accounts. There is no need to

attach a memo to an e-mail as the text can be typed into the mail itself.

• Always use the e-mail system to keep an electronic diary, send appointments and organise meetings. The full benefits of electronic working can only be realised when it is used throughout the organisation.

• Always send an appointment and not a mail containing appointment details, so the recipient can deal with the appointment quickly and it can be entered in the recipients electronic diary seamlessly.

• Always use e-mail if your message is relatively short, informal or internal. Use a letter as an attachment to an e-mail if the letter is formal and would normally have been printed on headed notepaper.

Remember: Electronic communication is the preferred method for written correspondence. The exception to this rule being medical and legal documents, which require signatures.

• Always practice ‘good housekeeping’ on e-mail accounts. Deal with incoming e-mail on a daily basis

by: • Filing – using a structured filing system within Outlook or your personal or shared files • Forwarding – to another user if it is more relevant for them to deal with • Flagging - using the flag facility to automatically ‘bring forward’ the mail at a predetermined time

as a reminder • Finishing - deleting mail from the inbox once it has been dealt with. For further information contact the IT Training Team.

• Please remember that e-mails are records and are therefore subject to the Trust records access, retention and destruction regulations please refer to the Records Management Strategy for further details.

• Always be selective when copying other users into a mail. Only copy them if there is something for

them to do or be aware of. • Always complete the ‘Subject’ header of the mail so that the recipient knows what the mail is about.

• Always use the automatic spell checking facility prior to sending a mail.

• Always check the content of your e-mails before sending. Check that the e-mail is succinct and easy to

understand and is clear about what you wish to communicate. Read it back from the recipient’s point of view.

• Always incorporate your designation and contact details especially when sending external mail.

• Always make use of the automatic Out of Office reply facility when on leave or away from the office, so that people are aware that you can not respond immediately. Incorporate details of an alternative contact person if applicable.

• Always recycle paper especially if documents are only for internal use. Recycled paper can be used in laser printers (i.e. paper that has already been used on one side and is still in good condition). For further advice contact the IT Service Desk.

• Always access your e-mail account regularly and at least once a week in order to deal with your mail.

Appendix 6.8

Information Management Directorate Page 7 of 7 Status: Version 3.1 Date: January 2008

• Never use e-mail in circumstances when other forms of communication would be more appropriate, e.g. telephone call.

• Never sign your e-mail with ‘xxx’ or any combination of x’s, the scanning software will immediately

isolate all mails with this in the content.

Good practice guidelines for users sending or receiving

patient identifiable information via the internal e-mail system

Caldicott requirements: Before including any patient identifiable information in an e-mail – Ask yourself the following questions:

Is the purpose for using the data justifiable? Is it absolutely necessary to use person identifiable information? If so, are all the data items absolutely necessary? Am I sending the mail to people who are known and trusted?

If the answer to all of the questions is ‘Yes’ then you may proceed with sending the information ~ If the answer to any of the questions is ‘No’, then revise your e-mail accordingly.

Information security:

All senders and recipients of patient identifiable information should: Ensure their PCs are password protected (via power-on and screen saver passwords) Not leave patient identifiable information on screen where others may view it Delete patient identifiable information when it is no longer of use.

Appendix 6.8

IT SECURITY POLICY

Originator: Information Management Date Approved: August 2004 Approved by: Trust Board Date for Review: January 2008

Information Management Directorate Page 1 of 13 Date : January 2008 Status: Draft Version 2.0

Appendix 6.8

INDEX

Page

1. The basic elements of IT Security 3

2. The management of IT Security 4

3. Responsibilities and good practice guidelines 5

4. Controlling Access to Systems 7

5. Systems Management 7

6. Communication of the IT security policy 8

7. Procedure for enforcing the policy 8

8. Contacts 8

9. Policy review 8

10 point guide to Information & IT Security Appendix 1

Information Management Directorate Page 2 of 13 Date : January 2008 Status: Draft Version 2.0

Appendix 6.8

Bro Morgannwg NHS Trust Information Technology (IT) security policy Introduction The security of the IT systems and information in use in Bro Morgannwg NHS Trust is extremely important for a number of reasons. Firstly, a wide range of data is held on systems, some of which is person based and therefore highly confidential. Secondly, the law holds both the Trust and its employees legally responsible for elements of IT Security. Finally the Welsh Assembly Government (WAG) stipulates that the Trust must comply with agreed standards for IT Security (ISO27001) Information security affects ALL members of staff, even non-computer users. All staff have a duty to safeguard the confidentiality of the data with which they come into contact. Failure to comply may result in disciplinary action against employees. Equally, all staff need to be able to rely on the integrity and availability of information to be effective in their work. The Caldicott Principles must be applied at all times in the management of patient identifiable data. The six Caldicott principles are:

1. Justify the Purpose [s]

Every proposed use or transfer of patient-identifiable information within or from an organisation should be clearly defined and scrutinised, with continuing uses regularly reviewed by the appropriate guardian.

2. NEVER use patient identifiable information unless it is absolutely necessary Patient-identifiable information should not be used unless there is no alternative.

3. Use the minimum necessary patient-identifiable information Where use of patient-identifiable information is considered to be essential, each individual item of information should be justified with the aim of reducing identifiability.

4. Access to patient-identifiable information should be on a strict need to know basis Only those individuals who need access to patient-identifiable information should have access to it, and they should only have access to the information items that they need to see.

5. Everyone should be aware of their responsibilities Action should be taken to ensure that those handling patient-identifiable information – both clinical and non-clinical staff-are aware of their responsibilities and obligations to respect confidentiality.

6. Understand and comply with the law Every use of patient-identifiable information must be lawful. Someone in each organisation should be responsible for ensuring that the organisation complies with legal requirements

1. The basic elements of IT Security Confidentiality The Trust stores a vast amount of data relating to individuals. This ranges from computerised records of patient registrations, hospital contacts and treatments through to paper based records with payroll details, personal files and patient case notes. The Trust has a legal responsibility, which is shared by its staff to ensure that this data is not accessible to anyone without appropriate authorisation. Integrity The Trust has a duty to ensure that the data it holds is accurate, and remains accurate throughout the time it is held. This means that precautions must be taken to ensure that the data is not changed, through accidental misuse, deliberate abuse or even through the failure of a computer system to store it properly. Availability Data is only useful if the people who need it have access to it. As a result, the Trust must ensure that the people who depend on particular items of information, gain timely access.

Information Management Directorate Page 3 of 13 Date : January 2008 Status: Draft Version 2.0

Appendix 6.8

2. The management of IT Security The following table outlines the main individuals and groups who have responsibility for the management of IT security within the Trust. Chief Executive The National Assembly holds the Chief Executive responsible for IT Security

Information Governance Manager

The Trust is registered under the Data Protection Act (1998). The Data Protection Officer within the Trust is the Information Governance Manager

IT Security Manager The IT Security Manager is the primary contact for all IT Security issues within the Trust.

System Manager Many key systems within the Trust have a Systems Manager. Where this is a member of the Trust, he or she is responsible for: • Operational security on a day-to-day basis, and in conjunction with the IT

Security Officer and the Data Owner

Data owner For each key system, there is also a nominated data owner. The Data Owner is responsible for: • Determining the uses of data within the system • Determining those who may access the data • Ensuring that staff using the system are aware of their IT security

responsibilities, including this policy and those set out within the system’s System Security Policy (SSP) and Standard Operating Procedures (SOP)

• The Data Owners must assure themselves that the System Manager is securely managing the system, whether this a member of the Trust, or by an external body.

Directorate Manager Directorates must ensure that there is an identified Data Owner for each

system they are responsible for.

All staff All members of staff are responsible for ensuring that they: • Are aware of their responsibilities as described in the Trust’s Information

Technology Security policy. • Are aware of those responsibilities summarised in the Trust’s “10 Point

Guide to IT Security” which can be found at Appendix 1. • Any specific security issues identified during training on an IT system

within the Trust.

Information Management Directorate Page 4 of 13 Date : January 2008 Status: Draft Version 2.0

Appendix 6.8

3. Responsibilities and good practice guidelines The following guidelines apply to all Trust employees who have access to information technology. A copy of the Trust’s ’10 point guide to IT security’, which summarises the main points of this policy, can be found as an Appendix to this document. Viruses

• NEVER download any software from the Internet or from any other source which has not been approved by the Trust’s IT Department.

• All Computers in the Trust have virus software installed on them. This software is automatically updated on a regular basis. Contact the IT Department for more information on virus checking software.

The IT Department will ensure that all networked PCs and servers have an approved virus checker loaded on

set up, however, new viruses are constantly emerging and it is important that users do not interrupt automatic updating of this software as it is this process that keeps the software up-to-date. User accounts and Passwords

• NEVER share your personal passwords with other users. • NEVER ask colleagues for their passwords, e.g. prior to them taking annual leave, shared access to

colleagues network areas MUST be authorised by a manager using the E-Forms system. • Always change your passwords when prompted. Passwords must have a minimum of 6 characters but for

added security 8 or more characters is preferred, these should contain Alpha and Numeric characters. Good example:

Choose a line or two from a poem, song or phrase and use just the first letters and then add in a number. -We All Live In A Yellow Submarine and add 4, so the password would be WALIAYS4

Unsuitable example : Name of your spouse, parent, colleague, friend or pet Telephone number or Car registration

• DO NOT write down or e-mail your password • Users should set up screen saver password; this should have an interval of no more than 5 mins. All new

PC’s will have this feature enabled automatically. Physical Security

• NEVER download person identifiable information or other sensitive information onto removable media such as floppy disks, CDROMS, tapes, removable hard disks, or Notebooks etc unless absolutely necessary. Seek authorisation and advice from the IT Security Manager if this is necessary.

• NEVER leave portable computer equipment in view when not being used. Lock them in a drawer/cupboard if they are not being used for a period of time. (i.e. overnight).

• The disposal of any equipment or media containing sensitive information should be carried out by a member of the IT Department, and with the knowledge of the System’s Data Owner.

• NEVER attach any external device (such as a modem, memory stick) to a networked PC without the prior consent of the IT Department.

• DO store computer equipment in secure offices wherever possible.

The IT Department will ensure all equipment is security marked on set up. Users are requested to inform the IT Department when any new equipment is purchased so that it can be security marked. Software licenses

• NEVER use illegal software. All software used in the Trust must be legal. Copying and dispersal of software should only be performed within the terms of the licence agreement for that software. Evaluation software must be deleted once the evaluation period is over.

• NEVER download or use Public Domain Software.

Information Management Directorate Page 5 of 13 Date : January 2008 Status: Draft Version 2.0

Appendix 6.8

All hard copy licenses must be held securely, either within the relevant directorate, or centrally within the IT Department. Incident Reporting

• Always report any incidents which could compromise the availability, integrity or confidentiality of a system. The incident should be reported on a standard Trust Incident form. The IT Security Manager should be informed immediately.

The Trust must report relevant IT security incidents to the IT Manager for Health Solutions Wales who co-

ordinates, on behalf of the Welsh Assembly Government, all-Wales initiatives on IT Security. Information Security

• NEVER leave items containing personal information lying around where unauthorised people might see them; put them away if you are leaving your desk for any length of time.

• NEVER divulge any information to anyone who does not have the authority to know it. When sending a fax containing patient identifiable information, phone first to make sure that the recipient is present to receive it.

• NEVER leave printouts containing patient identifiable information on the printer. When you no longer need identifiable data, destroy it - shred any paper records, and delete identifiable data from computer systems.

• NEVER unnecessarily use personal details when discussing work matters. • NEVER take removable media e.g. floppy disks, CDs, USB memory sticks etc containing patient identifiable

or sensitive information off site, without the prior knowledge of the relevant Data Owner. Such media should be appropriately labelled, but not so as to betray its contents. Appropriate measures should be taken to ensure the media is kept secure and out of view when not in use. Where practical, sensitive information that is taken off site should be encrypted. Contact the IT Security Manager for further advice.

• NEVER store any important documents on a PC’s hard disk (C: drive). Information stored on a hard disk will be lost if the disk is found to be unrecoverable in the event of failure or if the PC is stolen.

• ALWAYS ensure that important documents (such as patient letters) are stored on the Trust's network. This ensures that the information is backed up daily in a secure environment, and if a PC breaks down any other authorised networked PC within the Trust can gain access.

• ALWAYS treat personal data held on computer systems and in paper format with discretion. The data is subject to the requirements of the Data Protection Act.

• ALWAYS refer members of the public requesting access to data held about them to the Health Records Manager.

Storage of data

• ALWAYS save all work to the designated Network drives, this will allow the information to be backed up on a regular basis and will ensure that this information cannot be accessed by any unauthorised source.

• NEVER save any work to local drives, floppies, CD ROM’s or portable memory devices. 4. Controlling Access to Systems E-mail and Internet access

• Identified managers within each Directorate/Department approve new E-mail or Internet accounts via the E-forms system. This can be found on the Home page of the Trust’s Intranet Site.

• Further guidance on the use of the E-forms system can also be found on the e-forms page.

System Security • All systems are controlled via user names and passwords. Where applicable, user passwords will be

automatically changed at least quarterly. • New user requests must come from the Directorate/Departmental Manager. Identified managers within

each Directorate/Department approve user access to departmental systems and change user access via the E-forms system, which can be found on the home page of the Trust Intranet site.

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Appendix 6.8

• Managers are reminded to inform IT when staff either leave the Trust or transfer to another Department/Directorate as their access rights may need to be amended.

• Similarly, Data Owners should inform relevant System Managers when staff who have held an account on an information system leave the Trust, so that their account can be revoked.

• A password system will be used to manage access to systems via a Modem link for system support or data download by external companies. The Modem will be switched off on completion of the task and a record will be maintained of each use, the passwords will be subsequently changed.

• The System Security Policy (SSP) and a Standard Operating Procedure (SOP) for each system will contain a more detailed section on access control methods particular to that system.

Security Logs

• The server security log records security events relating to successful and unsuccessful log in attempts onto the Trust’s network. These events are monitored daily and any possible breaches to security are investigated.

5. Systems Management In general, the security of all business critical systems is managed through a System Security Policy (SSP) and a Standard Operating Procedure (SOP) and is the responsibility of the relevant System Manager in conjunction with the relevant Data Owner to develop and implement these procedures. The SSP will:

• Detail the level of security required for a particular identified and defined computer system with the aim of ensuring that the system is adequately protected in the light of the perceived risks to that system

• Outline any risks associated with the system, and any countermeasures that can be undertaken to minimise the risk

• Incorporate security controls to maintain the accuracy, validity, completeness and currency of the data input, held and processed

• Outline any validation checks applied, to ensure that processing errors or deliberate acts that may corrupt correctly entered data are minimised

• Document security and back-up procedures • Document the disaster recovery procedures for business critical systems.

The SOP contains details of the subjects listed below: Document Name Description / Notes Configuration Change Used to record any changes to a systems hardware or software configuration. Configuration Change Log A Log of the BMSM001 Configuration Change forms. Backup Configuration Description of Components involved in the backup process Configuration Notes General doc that can be used to contain additional information for any of the BMSM forms as required. User Access Form Record of when a user was added & retired from a system Host File Update Form Record of Hosts file updated – who added the entry etc Hardware Configuration Notes of hardware set up. Includes any site customisations Software Configuration Notes of software set up. Maintenance Support Details of support contact details for hardware and software Software Patch Record of a particular system before and after a patch is applied Operating Procedures This document is to be used as reference to find out which procedures are to be carried out on a system and the frequency of them. Printer Setup Record of printer set up – giving technical and contact details System Recovery Document describing recovery procedures and where to find relevant documentation Procedure Log Log of Operating Procedures. This is where all Procedures carried out on a system are to be logged. Support Log Log of all support calls made to external companies, and any major calls to System Administration due to system errors Software Patch Log Log of software patches applied. Engineer Log Log of dial in or on-site engineers. Includes dates and times of access and reasons why work was carried out. System Availability Log Log of system downtime, reasons and responsibilities Roles and Responsibilities A description of the Roles and Responsibilities of internal and external personnel involved with the system. Printer Setup Log List of system printers.

User Audit and Validation Create and regularly maintain a list of authorised users of this system and its applications.

System Communications Contact methods and notification details prior to or during disruption of service.

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Appendix 6.8

6. Communication of the IT security policy • All staff are made aware of their duty to uphold the confidentiality of Trust data in their day to day work via

their departmental induction process. • This policy will be brought to the attention of all new staff during the multi-disciplinary staff induction day. A

summary of the policy is provided in the Trust’s Induction Handbook. At induction, the following legislation regarding the confidentiality of data, is brought to the attention of new staff:

Access to Records Act 1990 Data Protection Act 1998 Caldicott Report The Computer Misuse act 1990 The Copyright, Design and Patents Act 1988 The EC Directive on Legal Protection of Databases 1996 Electronics Communication Act 2000 Freedom of Information Act 2000 Human Rights Act The Health and Social Care Reform Act 2001 Trust’s IT Security Policy ISO27001 Information Security Standard

• Copies of this policy will be available to all staff via the Policies Tab on the Trust’s Intranet site 7. Procedure for enforcing the policy

• Any breaches of IT security will be brought to the attention of the relevant Head of Department/Clinical Director and, depending on the severity of the breach, the Trust’s disciplinary procedure may be invoked.

8. Contacts

• If you require further information on any aspects of Information Security, then please contact the following staff for advice:

IT Security Manager (for advice on all IT security issues) Chris Phillips, Telephone: Bridgend WHTN – 01855 3650 E-mail: chris.phillips@bromor-tr.wales.nhs.uk Data Protection Co-ordinator (for advice on compliance with the Data Protection Act) Dorian Edwards, Information Governance Manager Telephone: Bridgend WHTN – 01852 3942 E-mail: dorian.edwards@bromor-tr.wales.nhs.uk

9. Policy review

This policy will be reviewed on an annual basis and submitted to the Management Executive and Trust Board for approval.

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Appendix 6.8

Appendix 1

10 point guide to Information & IT Security

1 The basic elements of information security Information security affects ALL members of staff, even non-computer users. All staff have a duty to safeguard the confidentiality of the data with which they come into contact. Failure to comply may result in disciplinary action against employees. Equally, all staff need to be able to rely on the integrity and availability of information to be effective in their work.

• Confidentiality

The Trust has a legal responsibility, which is shared by its staff to ensure that any data relating to individuals is not accessible to anyone without appropriate authorisation. This applies to paper based data as well as electronic data.

• Integrity The Trust has a duty to ensure that the data it holds is accurate, and remains accurate throughout the time it is held. This means that precautions must be taken to ensure that the data is not changed, through accidental misuse, deliberate abuse or even through the failure of a computer system to store it properly.

• Availability Data is only useful if the people who need it have access to it. As a result, the Trust must ensure that the people who depend on particular items of information, gain timely access.

2 Apply the Caldicott Principles when dealing with Patient Identifiable Information

The Caldicott Principles must be applied at all times in the management of patient identifiable data. The six Caldicott principles are:

1. Justify the Purpose [s] - Every proposed

use or transfer of patient-identifiable information within or from an organisation should be clearly defined and scrutinised, with continuing uses regularly reviewed by the appropriate guardian within the Trust who is the Medical Director.

2. NEVER use patient identifiable information unless it is absolutely necessary - Patient-identifiable information should not be used unless there is no alternative.

3. Use the minimum necessary patient-identifiable information - where the use of patient-identifiable information is considered to be essential, each individual item of information should be justified with the aim of reducing identifiability.

4. Access to patient-identifiable information should be on a strict need to know basis - Only those individuals who need access to patient-identifiable information should have access to it, and they should only have access to the information items that they need to see.

5. Everyone should be aware of their responsibilities - Action should

be taken to ensure that those handling patient-identifiable information – both clinical and non-clinical staff - are aware of their responsibilities and obligations to respect confidentiality.

6. Understand and comply with the law - Every use of patient-

identifiable information must be lawful. Someone in each organisation should be responsible for ensuring that the organisation complies with legal requirements

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Appendix 6.8

3 DOS & DON’TS RELATING TO INFORMATION SECURITY

• NEVER download patient identifiable information or other sensitive information onto removable media such as floppy disks, CDROMS, tapes, removable hard disks etc unless absolutely necessary. Seek authorisation and advice from the relevant Data Owner

• DO ensure if you are sending or receiving patient identifiable information via e-mail that your PC is password protected (via power-on and screen saver passwords).

• NEVER take removable media e.g. floppy disks, CDs

etc containing patient identifiable or sensitive information off site, without the prior knowledge of the relevant Data Owner as above. Such media should be appropriately labelled, but not so as to betray its contents. Appropriate measures should be taken to ensure the media is kept secure and out of view when not in use. Where practical, sensitive information that is taken off site should be encrypted. Contact the IT Department for further advice.

• DO password protect sensitive files. Contact the IT Department for further information or visit the IT Training web site for instructions.

• DO ensure that important documents (such as

patient letters) are stored on the Trust's network. This ensures that the information is backed up daily in a secure environment, and if a PC breaks down any other authorised networked PC within the Trust can gain access.

• DO treat personal data held on computer

systems and in paper format with discretion. The data is subject to the requirements of the Data Protection Act 1998.

• DO refer members of the public requesting

access to data held about them to the Health Records Manager. Access to data is managed in accordance with the Data Protection Act 1998.

• NEVER leave items containing personal information lying around where unauthorised people might see them; or leave patient identifiable information on screen where others may view it

• NEVER divulge any information to anyone who does not have the authority to know it. When sending a fax containing patient identifiable information, phone first to make sure that the recipient is present to receive it.

• NEVER assume the data is correct just because it is "on the system".

• NEVER leave printouts containing patient identifiable information on the printer. When you no longer need identifiable data, destroy it - shred any paper records, and delete identifiable data from computer systems.

• NEVER unnecessarily use personal details when discussing work matters.

• NEVER store any important documents on a PC’s hard disk (C: drive). Information stored on a hard disk will be lost if the disk is found to be unrecoverable in the event of failure.

4 Passwords

• NEVER share your personal passwords with other users. If you need access to another user’s work information then this must be set up via shared facilities across the communications network. Contact the IT Help Desk for more information.

• NEVER write down your passwords.

• DO change your passwords when prompted.

Passwords must have a minimum of 6 characters.

• DO log out after completing your work,

especially if other authorised users access the PC.

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Appendix 6.8

5 Hardware

• NEVER leave portable computers in view. Lock them in a drawer/cupboard if they are not being used for a period of time. (i.e. overnight).

• NEVER attach any external device (such as

a modem) to a networked PC without the prior consent of the IT Service Desk or relevant System Manager.

• DO ensure all equipment is security marked with

the Trust’s name and registered on the IT Department inventory.

• DO store computer equipment in secure offices

wherever possible.

6 Software

• NEVER use illegal software. All software used in the Trust must be legal. This includes ‘shareware’. Copying and dispersal of software should only be performed within the terms of the licence agreement for that software. Evaluation software must be deleted once the evaluation period is over.

• NEVER dispose of any equipment or media

containing sensitive information. This should be carried out by a member of the IT Department, and with the knowledge of the systems Data Owner.

• NEVER down load any software from the

Internet or from any other source, which has not been approved by the Trust’s IT Department.

• DO ensure that the virus checking software on

your PC is kept up-to-date. The latest version of anti virus software is updated automatically.

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Appendix 6.8

7 Security of e-mail • Access to e-mail can only be set up by the

Trust’s IT Department after the appropriate e-form has been authorised by the appropriate manager. The user must also read the Trust’s E-mail policy and agree to abide by the policy’s terms and conditions.

• NEVER send patient identifiable information

via external e-mail (i.e. Internet mail). Access to patient identifiable information is restricted and release of such information must be in accordance with the Caldicott principles, Data Protection Act and the general duty of confidentiality. Therefore, if you must send patient identifiable data internally (i.e. within the Trust, NHS Wales or NHSNet) only include data items that are essential (see the Caldicott Principles). Contact the IT Security Manager for further advice.

• NEVER send blanket e-mail (i.e. e-mail to all

users in the address book) without first contacting the Head of IT Security. This practice wastes the time of the majority of e-mail users and slows down the Trust’s communication network. Most users will only have a discrete circle of contacts that need to be informed of operational issues.

• NEVER attach large files to an e-mail, as this will

cause disruption to the network. Files over 10MB (10240 kilobytes) should not be sent. Please contact the IT Security Manager for further advice

8 Internet Security • Access to the Internet can only be set up by

the Trust’s IT Department after an e-form has been authorised by the appropriate manager. The user must also read the Trust’s Internet policy and agree to abide by the policy’s terms and conditions.

• NEVER access, copy or store material that is

offensive, obscene, vulgar, racist, sexist, threatening or libellous. If a user accidentally encounters an inappropriate site, they must inform the IT Security Manager immediately.

• NEVER download large files (over 2MB or

2048 kilobytes) from the Internet during normal office hours (or 10MB outside of these hours) as this will have a detrimental effect on the communications network internally and externally. Please contact the IT Service Desk for further advice

• NEVER download files from the Internet

unless you have specifically requested this through the IT Security Manager.. Please contact the IT Security Manager if you are unsure or need advice.

• NEVER download or install program files from

the Internet as this could damage or interfere with the standard desktop programs on your PC. Please contact the IT Service Desk for further advice. (This does not apply to programs that are offered on the Trust’s Intranet site such as Adobe Acrobat Reader.)

• DO keep your personal passwords secure and confidential and take all reasonable precautions in order to avoid inappropriate use of the Internet by others, for which users will be held responsible.

NB: Access to the Trust’s Intranet site, HOWIS and other web sites available via NHSnet remains unrestricted.

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Appendix 6.8

9 IT System security

• In general, the security of all business critical systems is managed through a System Security Policy (SSP) and a Standard Operating Procedure (SOP) and is the responsibility of the relevant IT System Manager in conjunction with the relevant Data Owner to develop and implement these procedures.

• Access to Trust systems can be set up via

the Trust’s IT Department after an e-form has been authorised by the appropriate manager. The user must also read the Trust’s IT Security Policy and abide by the policy’s terms and conditions.

• Users’ of Trust systems such as PIMS, PIMS+,

Review etc should be made aware of their responsibilities, at their departmental inductions.

• Users of business critical systems should always

receive training before being allowed access.

10 Incident Reporting DO report any incidents, which could compromise the availability, integrity or confidentiality of a system. The

incident should be reported on a standard Trust Incident form. The IT Security Manager should be informed immediately.

Contacts Contact Number & Location Advice

Caldicott Guardian (Medical Director)

Bridgend WHTN – 01852 2968 Bruce.ferguson@bromor-tr.wales.nhs.uk

Caldicott principles

IT Security Manager

Bridgend WHTN – 01855 3650 Chris.Phillips@bromor-tr.wales.nhs.uk

All IT security issues Advice on encryption methods; advice on computer security issues

IT Service Desk Bridgend WHTN - 01855 3636 option 2 ithelpdesk@bromor-tr.wales.nhs.uk

Advice on viruses; reporting problems with IT systems

IT Training & Implementation Team

Bridgend WHTN – 01855 4062 Neath WHTN – 01881 2442 Training on IT applications

Data Protection Co-ordinator (Information Governance Manager)

Bridgend WHTN – 01852 3942 Dorian.edwards@bromor-tr.wales.nhs.uk

Compliance with the Data Protection Act

Information Management Directorate Page 13 of 13 Date : January 2008 Status: Draft Version 2.0

Parc Cathays ▪ Cathays Park

Caerdydd ▪ Cardiff CF10 3NQ

Ffôn * Tel

Appendix 6.11

To: Chief Executives, Chairs, Medical Directors and Nurse Directors 23 January 2008

Dear Colleague HEALTHCARE STANDARDS & GOVERNANCE - ALL WALES BOARD WORKSHOP Now that we are moving into the second year of the Healthcare Standards assessment process, we are holding a workshop for all NHS Trust Boards. The purpose of this workshop will be to discuss the Boards’ role and responsibilities in relation to Governance and the Healthcare Standards for Wales. It is therefore aimed at Chief Executives, Chairs, Medical Directors and Nurse Directors of Boards and any other executive or non-executive members of the Board who have responsibility for Healthcare Standards and governance. We would like to consider the following issues: • How do the Healthcare Standards support good governance? • How can Boards use the Healthcare Standards to help prioritise and manage

services? • How do we get the balance right in terms of internal assurance and external

review? • Where does performance management fit? • What support and development needs exist? The workshop will take place on 6th March 2008 at the All Nations Centre, Cardiff. Please confirm your attendance by returning the enclosed form either by post to Kiera Lewis, or electronically to kiera.lewis@wales.gsi.gov.uk before Friday, 15th February 2008. We would also ask you to confirm the attendance of other Board

Ffacs * Fax

GTN:

members and their specific remits within the organisation. The agenda and final details of the workshop will be sent to you closer to the event. If you have any queries about the workshops, please contact Wendy Morgan on 029 2082 3209 or by email to wendy.morgan@wales.gsi.gov.uk . Yours sincerely

WENDY CHATHAM Director, Quality, Standards & Safety Improvement Directorate

ALL WALES BOARD WORKSHOP 2008

REPLY FORM

I would like to attend the workshop on the 6th March 2008 at the All Nations Centre, Cardiff.

Name…………………………………………………………………………………. Job Title………………………………………………………………………………. Organisation………………………………………………………………………….. Full address (inc postcode)…………………………..…………………………….. ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………. Telephone number……………………………………………………….………….. E-mail………………………………………………………………………………….. Vegetarian/special dietary needs ……………………………………………..…… Disabilities special needs……………………………………………………………. Please return the completed form by 15th February 2008 to: Miss Kiera Lewis Quality, Standards & Safety Improvement Division Welsh Assembly Government 4th Floor Cathays Park Cardiff CF10 3NQ or by email to kiera.lewis@wales.gsi.gov.uk

A Consultant Physician, who has worked tirelessly to promote patient choice and has championedthe cause of elderly people within the health and social agenda, has been awarded an OBEOBE in theNew Year's Honours ListNew Year's Honours List.

Dr Ed WilkinsDr Ed Wilkins (pictured) held the post of Clinical Director of the MedicalSpecialties Directorate (formerly known as the Integrated MedicineDirectorate) from 1996 to the end of January 2007. During this time, hestrove relentlessly in pursuit of the highest standards of care for theelderly across Bro Morgannwg NHS Trust and, for a time and at greatpersonal expense, undertook a locum Consultant Physician post at theformer Neath General Hospital to support the introduction of concepts hehad implemented at the Princess of Wales Hospital, particularly in regardto rehabilitation services for the elderly. In recognition of his work withthe elderly, Dr Wilkins became a member of the group set up to developThe Older People's Strategy for Wales to advise the Welsh AssemblyGovernment.

Dr Wilkins is highly respected by colleagues and patients and provides an enviable example forjunior medical staff and new Consultants alike. He also has many links with voluntaryorganisations, in particular the Cymru Wales council of the British Geriatrics Society and AgeConcern Cymru.

Constantly looking to develop new, innovative, working practices, Dr Wilkins established MedicalAssessment and Pre Discharge facilities, as well as leading a whole systems review of the interfacebetween Primary and Secondary Care in the Trust. Out of this work, and in response to the needto find new ways of dealing with an increasing emergency patient workload, he was alsoinstrumental in establishing a Rapid Assessment Unit at the Princess of Wales Hospital whichsucceeded in significantly reducing the number of patients who needed to be admitted to hospitalfor treatment.

At the National level he has worked closely with the Welsh Assembly Government in ensuring thatthe Medical Profession advises and supports the Government in its role of developing Health policyand strategy. He has contributed significantly to the development of Medical Professional Advisorystructures within Wales and these are unique within the UK. He is currently the Chair of the WelshMedical Committee and Chair of the Mid and West Wales Regional Advisory Committee.

Congratulating Dr Wilkins, Paul WilliamsPaul Williams, Bro Morgannwg's Chief Executive, commented: "I wasabsolutely delighted to hear that you had received this Honour. Your total commitment to theService is worthy of recognition."

Dr WilkinsDr Wilkins responded: "It has been a great privilege and honour to receive this award. It hasbeen an even greater privilege to have worked within this Trust and its Executive, Medical, Nursingand other Professional colleagues. I have met some remarkable people during my career but nonemore than the Carers whose spirit and selfless devotion has been a constant reminder of all that'sgood about human nature. My final and special thanks must be to my wife whose support has beenthe fundamental ingredient in all my achievements."

For more information, please contact:For more information, please contact:Wendy Penrhyn-JonesWendy Penrhyn-JonesHead of AdministrationHead of Administration

01656 75275201656 752752

DEDICATED DOCTOR AWARDED OBE

Friday 11 January 2008

Appendix 6.12

A nurse who has been instrumental in providing unique

wound care treatment to the people of Bridgend, Neath

Port Talbot and the western Vale of Glamorgan has been

awarded an MBEMBE in the New Year's Honours ListNew Year's Honours List.

Mary JonesMary Jones, known affectionately as "MaggotyMaggotyMaryMary" to her friends and colleagues, joined the SurgicalMaterials Testing Laboratory (SMTL) in 1995 as aresearch nurse in wound care, performing clinical trialson surgical dressings. However, she rapidly becameinvolved in the maggot therapy project, which was in itsinfancy, and performed some of the first MDT (MaggotDebridement Therapy) treatments in the UK since there-emergence of MDT.

Mary went on to become a skilled practitioner and proponent of MDT, training nurses in this uniquetherapy all over the UK. She is also a popular speaker at conferences and has presented atnumerous nursing and medical meetings in the UK and Internationally. Mary is now working forZoobiotic, a commercial organisation formed through partnership between the NHS and industry.

Working with Dr Steve Thomas and other members of the team from SMTL, Mary has beeninstrumental in promoting MDT amongst healthcare professionals and patients. Her caring attitudeand excellent personal communication skills instill confidence in patients and staff who are exposedto MDT for the first time, sometimes under distressing circumstances.

A delighted MaryMary (pictured) said: "I'm thrilled to have been awarded an MBE in the New Year'sHonours List, especially as I was nominated by my peers."

Congratulating Mary on her Honour, Paul WilliamsPaul Williams, Bro Morgannwg's Chief Executive, said: "Iwas so delighted to see that you have been recognised for your services to health care in Wales inthe New Year's Honours. Your dedication to pioneering wound care and commitment to nursing isan inspiration."

For more information, please contact:For more information, please contact:Eve JefferyEve Jeffery

Deputy Head of AdministrationDeputy Head of Administration01656 75275201656 752752

Notes to EditorNotes to Editor:Bro Morgannwg NHS Trust manages the Surgical Materials Testing Laboratory which providestesting and technical services on medical devices and dressings for the NHS in Wales as well ascommercial testing for medical device companies worldwide.

ZooBiotic is a private limited wound care company based in Bridgend. It has been in existence sinceApril 2005 and was a spin out from the Bro Morgannwg NHS Trust. It specialises in thedevelopment, manufacture and use of larval therapy for chronic, infected and necrotic wounds inboth humans and animals.

MBE FOR "MAGGOTY MARY"

Monday 7 January 2008

Appendix 6.12

The Glan-y-Môr Community Midwifery TeamGlan-y-Môr Community Midwifery Team, who serve the women of Porthcawl and itssurrounding areas, have earned Bro Morgannwg NHS Trust midwives their fifth prestigious RoyalRoyalCollege of Midwives (RCM)College of Midwives (RCM) prize prize in as many years. This year, the accolade was awarded inparticular for achieving a home birth rate of 24% and improving breastfeeding rates.

The Team won first prize in the "Promoting EffectivePromoting EffectiveMidwifery in Community SettingsMidwifery in Community Settings" category for theirsubmission, First point of contact - rhetoric orFirst point of contact - rhetoric orreality: the Five Year Planreality: the Five Year Plan. Five years ago, sixmidwives formed a case-loading team, working in thecommunity, to establish the midwife as the first point ofcontact, raising the home birth rate, improving breastfeedingrates and 'getting to know the community as a professionalfriend.' Through careful planning, negotiation, working withother professionals and user groups and by winning thehearts and minds of local women, their families and the widercommunity, this goal has now been realised. All womenserved by the Glan-y-Môr Team now receive ante natal carefrom midwives from a single base.

The RCM Award judges loved the enthusiasm, commitmentand passion shown by the Glan-y-Môr midwives. Their focuson promoting normality by increasing home births anddecreasing the intervention rate was described as 'admirableand clearly effective.'

A delighted Angela HopkinAngela Hopkin, Team Co-ordinator, receivedthe Award on behalf of the Team from Ann Keen, MP,Parliamentary Under Secretary for Health Services, at anaward ceremony in London last week. She was accompaniedby Cathy DowlingCathy Dowling, Bro Morgannwg's Head of Midwifery who commented: "We are delighted toonce again receive such high level recognition for our maternity services from within our ownprofession. To have been shortlisted from so many entries (of such high standard and from acrossthe UK) in different categories in five consecutive years is an achievement in itself but to have wonfirst prize three times is recognition of how hard our midwives are working to ensure highstandards of midwifery care to mothers, babies and their families."

Trust Chairman, Win GriffithsWin Griffiths, added: "Yet again our midwifery staff have done us proud. It isdifficult to over emphasise the culture of quality and improvement that is embedded in thedepartment and I congratulate our midwives in their continuing success in receiving awards fromthe Royal College of Midwives."

For more information, please contact:For more information, please contact:Cathy DowlingCathy Dowling

Head of MidwiferyHead of MidwiferyWomen & Children's ServicesWomen & Children's Services

01656 75230701656 752307

Notes to EditorNotes to Editor:During the last four years, the RCM has awarded Bro Morgannwg's midwives first prize in the"Retention and RecruitmentRetention and Recruitment" and "Evidence in PracticeEvidence in Practice" categories and runner up prizesin the "Working TogetherWorking Together" and "Excellence in Midwifery Management or LeadershipExcellence in Midwifery Management or Leadership"categories.

The Glan-y-Môr Team are no strangers to winning awards: they won a prestigious TrustTrustModernisation AwardModernisation Award in 2004 for their project "Increasing Normal Births and ReducingIntervention."

INCREASED HOME BIRTH RATE IS A WINNER!

Monday 28 January 2008

The Glan-y-Môr team,pictured from left to right,are: Helen Spry, AngelaHopkin, Beverly Poulton(back row) and PennyInskip and Julie James(front row). Inset is a

photograph of Penny Smithwho was unable to attend

last week’s awardceremony in London.

Appendix 6.12

The Princess of Wales Hospital'sPrincess of Wales Hospital's excellent record of providing quality care for the people andcommunities it serves has been recognised by the awarding of prestigious Charter Mark statusCharter Mark statusfor the fourth timefourth time in a row.

Charter Mark - the way in which the UK Government recognises excellence - is only awarded afterintensive independent scrutiny. The Hospital's performance was measured against 63 stringentcriteria, receiving full compliancefull compliance with Charter Mark standards in 59 areas59 areas and beingcommended in five areasfive areas of 'Best PracticeBest Practice':

Being ranked by CHKS as a Top 40 best hospital.The innovative and structured volunteer programme, funded by a Big Lottery award.The improvements to the Emergency Department and Clinical Decision Unit.The further development of PIMS+ (Patient Information Management System) and medical

record integration.The excellent work being done in Breast Care in relation to nipple reconstruction and tattooing.

Charter Mark assessor Mike SmithMike Smith reported: "It is clear from the visit that the service iscontinuing to change and develop, but reassuring that the various change initiatives are beingproperly managed and linked to consultation with representatives of stakeholders."

Gaenor ShawGaenor Shaw, the Hospital's General Manager, stated: "This really shows how staff have beenworking hard to reach levels of excellence in providing high standards to service for the mostimportant person in healthcare - the patient. I am very proud of the staff who work here and theservices provided, but we cannot afford to get complacent about things and are always ready toimprove things further."

Paul WilliamsPaul Williams, Bro Morgannwg's Chief Executive, commented: "The fact that a high level ofservice has been acknowledged by an external agency is very pleasing, and confirms otherinternal audits to ensure that services remain at the highest level. All staff are to be congratulatedfor their role in making the hospital a successful one."

For more information, please contact:For more information, please contact:Jo WilliamsJo Williams

Assistant General ManagerAssistant General ManagerPrincess of Wales HospitalPrincess of Wales Hospital

01656 75230301656 752303

HOSPITAL EARNS ITS 4TH SUCCESSIVE CHARTER MARK!

Thursday 31 January 2008

: Meeting of the : Trust Board : 7th February 2008

: AGENDUM NO 7

REPORT OF THE DIRECTOR OF FINANCE

1. FINANCIAL POSITION TO 31st DECEMBER 2007 The financial report for Month 9 shows an overall balanced position for the Trust after taking into account the Trust’s CIP targets. It is pleasing to note once again that most Directorates are continuing to deliver break-even or near break-even positions despite a very challenging savings target in 2007/2008. There are, however, some Directorates which are overspent on in delivering their service targets, although month 9 has seen reductions in the in-month overspends across all Directorates. Executive Directors are continuing to work with these Directorates to help resolve the key issues, including the full year achievement of the CIP savings targets. In terms of LTA negotiations with Commissioners, agreement of the LTA financial and activity quantums in 2007/2008 is largely complete, so that the potential income risks identified earlier in 2007/2008 have almost all been resolved. The Trust is planning to achieve a break even position at the year end, and is on course to achieve this position. The Board is asked to note the balanced position in Month 9. 2. PUBLIC SECTOR PAYMENT POLICY The cumulative target related compliance figure (number of invoices paid) to 31st December 2007 is 97.11%, with the in-month level of compliance during December 2007 being 95.9% (November current month was 97.1%). Every effort continues to be made to ensure a high level of compliance is maintained. The Board is asked to note the continuation of the achievement of the PSPP target compliance to the end of December 2007. 3. CHARITABLE FUNDS The value of all funds held at 31st December 2007 totalled £1,239,766 compared with £1,306,019 at 1st April 2007. Donations and bequests totaling £246,419 have been received since the 1st April 2007, and the table below shows a summary of income received since the last report to the Trust Board in October

Donation /Bequest from: Fund Amount Social Services

Tonna EMI Fund

£ 1,512

Cardiff University Port Talbot Patients 1,000Coity Village Association Y Bwthyn Newydd 1,720Huggard Charitable Trust Cardiology Study Fund 5,000Alison Harrington Y Rhosyn Palliative Care 1,000Karen Hendry Neath General Fund 1,560Huggard Charitable Trust Ophthalmology Fund 1,000Balance of other donations during the period Various 26,874Total for period November – December 2007 39,666

Expenditure totaling £312,672 have been incurred since the 1st April 2007, and an expenditure summary for November and December is shown in the table below.

Supplier Expenditure Type Fund Amount De Soutter Medical Ltd

Extractor System

League of Friends Neath

£ 2,483

Powersport Int. Ltd Chair Y Bwthyn Newydd 1,904Huntleigh Diagnostics Ltd

Foetal Dopplex League of Friends Port Talbot 1,857

Powersport Int. Ltd Comfy Recliner Y Bwthyn Newydd 5,339Mackworth Products Ltd

Bed Screens Tonna EMI Fund 1,590

Institute of Psychosexual, Children’s Clinic

2 members of staff attended - Medical Training Course

Family Planning Fund 1,500

Millbrook Medical Echocardiography Course PoWH Cardiology Fund 1,100Village Hotel & Leisure Club

Accommodation and food for 150 delegates for Masterclass in Palliative Care

Y Bwthyn Newydd 6,300

Future Inns Cardiff Bay

Hire events Room GP Tutors Accounts 1,396

Hi-Tide Inn Room Hire NPTH Surgery General Fund 1,042Royal Welsh College of Music & Drama

Communication Workshop

GP Tutors Accounts 1,645

Nottingham Breast Cancer

2 members of staff from Breast Care Unit Registration and accommodation at 3-day breast care seminar

PoWH Breast Cancer Fund 1,004

Various Suppliers Balance of Expenditure items

Various 20,484

Total for period November – December 2007 47,644

The total Charitable Fund balance of £1,239,766 as at 31st December 2007 is analysed by Directorate below:

Directorate Summary Fund Balances

£ Surgery 109,483 Medical Specialties 466,684 Anaesthetics 38,308 Women & Child Health 67,398 Pathology 4,768 Radiology 32,330 Community 93,806 Medical Education 122,435 Mental Health 68,091 Learning Disabilities 31,628 Forensic 3,790 Medical Director & Nursing 14,898 Personnel & Operations 163,823 Neath General Manager 21,910 POW General Manager 414 Total 1239,766

The Board is asked to note the Charitable Funds activity to the period ending 31st December 2007. 4. WELSH HEALTH SUPPLIES The following updates colleagues on the key issues faced by WHS in the period November – December 2007. (a) MATERIALS MANAGEMENT STORES SERVICE

In the reporting period the stores service has had to deal with the of the upgrade of the Oracle system which involved having two working days without the system and the normal Christmas and New Year deliveries. As a consequence of this it had been a particularly busy time for the stores and some customers did have problems with a few stock lines which is reflected in the stores efficiency table shown below. The majority of the problems were resolved and in general customers experienced very little service disruption either through the upgrade process or indeed through the bank holiday period. Another contributory factor on the stores service has been delays with the recruitment process which, whilst they were eventually overcome, nevertheless did contribute to some of the operational difficulties. Discussions have also taken place with Oracle to clarify our requirements for a revised warehouse management system. This information has been shared with all of the bidders currently looking to take on the service once the Mckesson contract comes to an end.

Discussions are also ongoing with NHS Supply Chain (DHL) regarding the cross docking trial and it is expected that this will commence in February. Discussions have also taken place with Swansea NHS Trust with a view to WHS commencing a ‘ delivery to ward service’ and this is due to commence towards the end of January 2008. The following performance report covers the period November – December 2007 and as previously noted some service difficulties were encountered. Target Sept Oct Sept Oct Bridgend Denbigh A Provisions 95% 99.7% 97.6% 96.3% 96.7% B Staff Uniforms 97.5% 98.0% 95.4% 99.3% 95.7% C Patients Clothing 97.5% 99.5% 97.8% 95.4% 90.9% E Dressings 99% 97.5% 91.6% 96.6% 95.8% F Medical & Surgical 99% 99.4% 98.8% 95.5% 96.0% G Patient Appliances 99% 99.4% 99.2% 98.3% 96.2% K Lab Disposables 99% 99.0% 99.6% 96.1% 98.2% M Cleaning Materials 97.5% 99.6% 97.0% 97.1% 93.2% P Electrical 95% 99.8% 99.9% 98.5% 98.9% U Hardware & Crockery 97.5% 99.9% 100.0% 95.3% 97.6% V Bedding & Linen 95% 98.8% 98.9% 94.6% 91.8%

(b) CONTRACTING

The Contracting Programme has generally been delivered to timescale however because of some staff shortages, there have been a number of contracts which have been delayed by up to two weeks. The recruitment process is still ongoing and actions are being taken to prioritise work whilst we await the arrival of the new starters. The savings figure for the period to end of December amounts to £10,277,636 and remains in line with the target which has been set for the year.

£4,038,508

£21,375

£2,838,003£3,379,750

£319,789£591,959

£146,797

£0

£1,000,000

£2,000,000

£3,000,000

£4,000,000

£5,000,000

Pharmacy Facilities Medical Projects IHC CapitalEquipping

ContractingLocal Team

Contract Savings made against Original TargetsApril 2007 - December 2007

Total - £10,277,636

Target Actual to Date

A review of the SLA WHS has with IHC was undertaken during the reporting period and a very positive meeting took place at which the contribution WHS and the procurement team are making to the overall programme was recognised. As reported previously difficulties continue to be experienced in the availability of contracts from NHS Supply Chain (DHL) (formerly PASA) and a planned meeting to pursue this with the Business Services Authority is scheduled to take place in order to finally resolve these matters.

(c) WELSH PUBLIC SECTOR COOPERATION AND COLLABORATION As part of the work with Value Wales and other Welsh Public Sector organisations, agreement has now been reached on the sourcing plan for the Welsh Public Sector. Along side this, agreement has also been reached on a standard process to be applied to the negotiation of contracts that are undertaken under a collaborative basis. This work was marked by a ‘Signing Ceremony’ held on Monday 19th November 2007.

(d) FORMER SOUTH & WEST WALES SUPPLIES CONSORTIUM The main focus for WHS in this area continues to be the local contracting and equipping service. Work on revising the capital equipping plan is currently ongoing and discussions are continuing with Trusts on the additional resources required to deal with the projected activity through 2008/09 this will form part of the discussion with members of the partnership over the next few months. The work on the local contracting team has been focused around the non pay expenditure and in trying to identify areas of opportunity which will benefit Trusts within the Partnership rather than the limited value work that was previously being undertaken and which is now being past back to Trusts to deal with. The task and finish group is continuing to review this activity and this is also being done in parallel with the work that four of the Trusts have been undertaking with a view of bringing their departments together when the formal Trust merger takes place.

The Board is asked to note the ongoing developments within Welsh Health Supplies. 5. ANNUAL AUDIT LETTER 2006/2007 The Annual Audit Letter from District Audit is attached as Appendix 7.5. The Trust Board is invited to receive the letter which confirms that the 2006/2007 accounts are materially correct and that the Auditors have given an unqualified opinion on the Trust’s Statement of Accounts. The Wales Audit Office has drawn the attention of the Trust Board to the following key messages contained within the Annual Audit Letter:

The Trust’s accounts for 2006/2007 were properly prepared and materially accurate The Trust met its key financial targets for 2006/2007 The Trust has appropriate financial management arrangements; and Examination of the Trust’s significant financial systems did not identify any material

weaknesses in internal control.

The Trust has proper arrangements to help it deliver efficient, economical and effective services and the key statements were as follows:

The Trust had proper arrangements in 2006/207 to help it achieve economy, effectiveness and in its use of resources

The Trust is performing well against the Welsh Risk Pool Standards; and There are no matters arising from my work in this area for 2006/2007 that I wish to

draw to your attention. Trust Performance The Trust continues to perform very well in comparison with other Trusts in Wales and England during 2006/2007. It has remained one of the top 40 hospitals in Wales and England by CHKS, which is an independent research company. It also met all of the waiting times targets set by the Welsh Assembly Government for inpatients and day cases and outpatients and is making significant progress towards making further improvements. In addition to meeting key service targets, the Trust again met its three statutory financial targets. It remains one of the few Trusts in Wales to deliver on the key requirements for both service and finance without receiving additional support. Throughout the financial year, the Trust was forecasting that it would remain within its budget. This was achieved, despite significant cost pressures, due to a cost improvement programme that was delivered in the year, and that actually exceeded the planned £4m of improvements by £0.3m.

The Trust’s good performance in meetings its financial targets each year looks set to continue. Forecasts as at August 2007 indicate that the Trust will again achieve a breakeven position at the year end, will not exceed its EFL and is currently paying 97.7% of non-NHS invoices within 30 days. A number of financial risks have been identified but the Trust has already identified a number of required actions to ensure that these risks are monitored and managed carefully throughout the remainder of the 2007/2008 financial year.

Financial Management Arrangements The Trust’s financial management arrangements are effective, with continued high level of awareness of key budgetary and detailed cost pressures within Directorates. Systems of Internal Financial Control The Trust’s significant financial systems can be relied upon to produce materially correct outputs. With the introduction of the new payroll system, a number of significant control issues were identified with the implementation of the new system and it was found that the payroll expenditure reported in the Trust’s accounts was materially correct and these control issues were appropriately referred to in the Trust’s Statement of Internal Control for 2006/2007.

Performance against the Welsh Risk Pool’s Management Standards The risk management standards effectively define the governance framework required by NHS bodies to manage their overall business. Compliance is deemed to be the achievement of a score of not less than 75% overall and 75% in the core standards assessed by the Welsh Risk Pool. The Trust exceeded this 75% threshold for each of the core standards, are summarised below:

Welsh Risk Pool Management Standard 2006/2007 2005/2006 2004/2005

Risk Management Policy and Strategy 100% 98% 98% Risk assessment and treatment / risk profile 100% 94% 99% Incident and hazard reporting 100% 100% 100% Governance 100% 100% 100% Financial Management 100% 100% 100%

Programme of Performance Work During 2006/2007 a risk based programme of audit work was undertaking. A selection of the key findings from this work is summarised below:

Study Audit Finding / Status AHP Phase 6 - Admissions

There is evidence of efficient management of the emergency admissions pathway, there is scope to improve the management of elective admissions through strengthened pre-admission processes, further focus on chronological appointing and continued reduction of the suspended patient waiting list.

AHP – Medicine Management

Whilst many medicine management arrangements are well developed at the Trust, the development of a new strategy provides an opportunity to use pharmacy resources more effectively in order to achieve continued improvements in clinical effectiveness and patient safety.

Sickness Absence Findings will be presented locally although there will also be a national report presented to the National Assembly’s Audit Committee in 2008.

Making the Connections The Trust is making good progress in implementing the Making the Connections Agenda, with examples of well developed joint working and public / patient engagement and a co-ordinated approach to workforce planning.

Chronic Disease Management

The Trust, Bridgend LHB and Neath Port Talbot LHB deliver a wide range of services for patients with chronic conditions across community settings. The Health community is actively seeking to evaluate all services for chronic conditions and ensure that there is equity of access and provision for all residents in the community. There is evidence of:

Developing shared vision for equitable and coherent services through the DIS – Delivering Integrated Services project.

The Health Community is undertaking a review to provide opportunities for service redesign.

Planning and commissioning structures are well developed across the Health Community with good foundations for joint working and there is clear evidence of progress and implementation plans are being developed.

The Board is asked to note the content of the Annual Audit Letter and the key messages for the Board. 6. WHC (2008) 002 STRENGTHENING WELSH LANGUAGE

PROVISION WITHIN NHS SERVICES IN WALES The above circular was issued on 18th January 2008 (Appendix 7.6(i)) which sets out the various actions the Welsh Assembly Government require Trusts and LHBs to take to ensure that the provision of services in Welsh, particularly in relation to the priority groups (Children and Young People, Older People, People with Learning Disabilities and those using Mental Health Services). The circular also requires Trusts to appoint, by 30th April 2008, a full time Welsh Language Officer who will be primarily responsible for strengthening Welsh Language Services within their organisations. The circular goes on to advise that the Minister has re-established the Welsh Language Task Group which will provide national leadership and strategic direction. Every Trust is required to have a Welsh Language Champion who drives the strategic agenda forward within the organisation. Within Bro Morgannwg, this is myself with the Head of Administration acting as the Trust’s Welsh Language Contact Point with responsibility for leading operational activity. Ann Lloyd, Chief Executive NHS Wales will be monitoring progress and feedback to the Minister and Deputy Minister for Health and Social Services which will be considered at the Chairs and Chief Executives Annual Review meetings. This report also gives me the opportunity to update the Board as to the progress that has been made in respect of the Trust’s Welsh Language Scheme. Attached as Appendix 7.6(ii) is a summary of progress during the period April 2006 to December 2007. The Board is asked to note the continuing efforts to recruit a full time Welsh Language Officer by 30th April 2008.

Annual Audit Letter 2006/2007 Bro Morgannwg NHS Trust

November 2007

Author: Ann-Marie Harkin Ref: 915A2007

Appendix 7.5

Page 2 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Contents Summary 4

Detailed Letter

The Trust’s resources in all material respects, were properly used and accounted for

The Trusts 2006/2007 accounts were properly prepared and materially accurate

6

The Trust met its key financial targets for 2006/2007 8

The Trust has appropriate financial management arrangements 9

My examination of the Trust’s significant financial systems did not identify any material weaknesses in internal control

9

The Trust has proper arrangement to help it deliver efficient, economical and effective services

The Trust had proper arrangements in 2006/2007 to help it achieve economy, efficiency and effectiveness in its use of resources

9

The Trust is achieving the required performance against the Welsh Risk Pool’s Standards

10

While performance audit work supports my conclusion about the arrangements to secure efficient, economical and effective services, my findings have drawn attention to areas where the Trust can make further improvements in its services

11

Appendices

Conclusion on Bro Morgannwg NHS Trust’s arrangements for 2006/2007 for securing economy, efficiency and effectiveness in its use of resources

21

My criteria for assessing Bro Morgannwg NHS Trust’s arrangements during 2006/2007 for securing economy, efficiency and effectiveness in its use of resources

22

Reports delivered during the 2006/2007 audit 23

Audit fee 24

Appendix 7.5

Page 3 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Status of this report This document has been prepared for the internal use of Bro Morgannwg NHS Trust as part of work performed in accordance with statutory functions, the Code of Audit and Inspection Practice and the ‘Statement of Responsibilities’ issued by the Auditor General for Wales. No responsibility is taken by the Wales Audit Office (the Auditor General and his staff) in relation to any member, director, officer or other employee in their individual capacity, or to any third party. 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, where applicable, his appointed auditor) is a relevant third party. Any enquiries regarding disclosure or re-use of this document should be sent to the Wales Audit Office at infoofficer@wao.gov.uk.

Appendix 7.5

Page 4 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Summary 1. This Annual Audit Letter to members of Bro Morgannwg NHS Trust (the Trust)

summarises the conclusions from my 2006/2007 audit. The work reported on in the Letter has been performed on my behalf by the Wales Audit Office. The work planned for the year was set out in the agreed Audit Strategy. The Letter reports for Trust members the significant issues arising from my audit, together with my comments on other current issues.

2. More detail on the specific aspects of my audit can be found in the separate reports I have issued during the year. These reports are discussed and agreed with officers and presented to the Audit Committee. The reports I have issued are shown in Appendix 3.

3. A number of references are made within this Letter to guidance and documentation I have issued, including the Code of Audit and Inspection Practice (the Code). This was relevant to the whole of the audit year and refers to the Statement of Responsibilities of Auditors and Inspectors and of Audited and Inspected Bodies summarising the key responsibilities of auditors. My audit has been conducted in accordance with the principles set out in that Statement. What I say about the results of my audit should be viewed in the context of that more formal background.

4. I adopt a risk-based approach to planning the audit, and my audit work has focused on your significant financial and operational risks that are relevant to my audit responsibilities. The audit work is structured around the key elements of my responsibilities as set out in the Code.

5. From my financial audit work I have concluded that the Trust’s resources have, in all material respects, been properly used and accounted for in 2006/2007: • the Trust’s accounts for 2006/2007 were properly prepared and materially

accurate; • the Trust met its key financial targets for 2006/2007; • the Trust has appropriate financial management arrangements; and • my examination of the Trust’s significant financial systems did not identify

any material weaknesses in internal control. 6. The Trust has proper arrangements to help it deliver efficient, economical and

effective services: • the Trust had proper arrangements in 2006/2007 to help it achieve

economy, efficiency and effectiveness in its use of resources; • the Trust is performing well against the Welsh Risk Pool’s Standards; and • while performance audit work supports my conclusion about the

arrangements to secure efficient, economical and effective services, my findings have drawn attention to areas where the Trust can further improve its services.

Appendix 7.5

Page 5 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

7. This Letter has been agreed with the Trust’s Executives. The Letter will be presented to the Audit Committee on 11 December 2007. It will then be presented to the subsequent Trust meeting in December 2007 and a copy provided to every Director of the Trust Board.

8. I aim to deliver a high standard of audit which makes a positive and practical contribution and supports the Trust’s own agenda. I am grateful to you and your staff for your assistance during the audit. Ann-Marie Harkin Engagement Partner For and on behalf of the Auditor General for Wales December 2007

Appendix 7.5

Detailed Letter

Page 6 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

The Trust’s resources, in all material respects, were properly used and accounted for

9. The Financial Statements are an essential means by which the Trust accounts for its stewardship of the resources at its disposal and its financial performance in the use of those resources.

10. As the Trust’s external auditor, I am required to audit the financial statements and to issue an auditor’s report which includes an opinion on whether the financial statements present a true and fair view. Our financial audit work covers the following key areas: • financial statements (or accounts); • financial health; • financial management; and • financial systems.

The Trust’s 2006/2007 accounts were properly prepared and materially accurate 11. The earlier deadline dates set for the Whole of Government Accounts initiative

have been met by the Trust. The Trust’s draft accounts were prepared in accordance with the requirements of the Welsh Assembly Government (Assembly Government) NHS Trust Manual for Accounts 2006/2007 and were submitted for audit by the due date of 15 May 2007.

12. During the year the Trust purchased and implemented a new TeamMate software package to enhance the accounts production and audit process. Trust officers worked with auditors to ensure that audit requirements were identified and that the relevant working papers were incorporated into TeamMate. As in previous years the quality of the Trust’s supporting working papers was excellent and this together with the use of TeamMate by both the Trust and ourselves helped to ensure a smooth audit process. The application of this package in future years should reap significant benefits not just for the year end accounts in helping to meet continually challenging accounts completion targets, but also in applying it to other financial and information processes within the Trust.

13. I am required by Internal Standard on Auditing (ISA) 260 to report issues arising from my work to ‘those charged with governance’ (the Financial Audit Committee) before I issue my audit opinion on the accounts.

14. My Engagement Partner, Ann-Marie Harkin, reported these issues to the Financial Audit Committee meeting the requirements of ISA 260. The key issues are set out in Exhibit 1.

Appendix 7.5

Detailed Letter

Page 7 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Exhibit 1: ISA 260 reporting requirements Reporting requirement Auditor’s response Expected modifications to the auditor’s report.

No modifications to the auditor’s report.

Unadjusted mis-statements. There were no unadjusted misstatements.

Material weaknesses in the accounting and internal control systems identified during the audit.

No matters arose.

Views about the qualitative aspects of the entity’s accounting practices and financial reporting.

No matters arose.

Matters specifically required by other auditing standards to be communicated to those charged with governance.

No matters arose.

Any other relevant matters relating to the audit.

No matters arose.

15. I have concluded that the accounts give a true and fair view of the state of affairs

of the Trust as at 31 March 2007 and of its surplus for the year then ended. In addition, I am sufficiently satisfied that the expenditure and income have been applied to the purposes intended by the National Assembly for Wales (National Assembly) and the financial transactions conform to the authorities that govern them.

16. On 25 June 2007 I issued my opinion on the Trust’s accounts. The Trust’s summarised accounts are contained in the Trust’s Annual Report which was presented to its Annual General Meeting on 4 September 2007.

17. The audited accounts were submitted to the Assembly Government after approval by the Trust Board at its meeting on 25 June 2007. This met the prescribed 27 June 2007 deadline.

18. I am also required to lay a copy of the audited accounts before the National Assembly and I did this on 4 July 2007.

Appendix 7.5

Detailed Letter

Page 8 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

The Trust met its key financial targets for 2006/2007 19. Overall, the Trust successfully managed its spending plans for the financial year

2006/2007, with expenditure of £328.537 million in line with the budget and available finances from NHS and other sources. A summary of performance against financial targets is shown in Exhibit 2.

Exhibit 2: Performance against financial targets 2006/2007 Target Target

met Achieved

1. In year Break Even Requirement The Trust must achieve ‘operational financial balance’ each year. 2. ‘Taking one year with another’ Break Even Requirement The Trust must achieve ongoing ‘operational financial balance’.

Yes Yes

The Trust’s expenditure was within its available resources, making a small surplus of £68,000.

External Financing Limit (EFL) The Trust is required to remain within the EFL limit set by the Assembly Government.

Yes

The Trust achieved its external financing requirement of £6,308,000.

Public Sector Payment Policy The Trust is required to pay 95% of non-NHS trade creditors within 30 days of receipt of goods or a valid invoice.

Yes

The Trust paid 95.7% of non-NHS invoices within 30 days.

20. Throughout the financial year the Trust was forecasting that it would remain within

its budget. This was achieved, despite significant cost pressures, due to a cost improvement programme that was delivered in the year, and that actually exceeded the planned £4.0 million of improvements by £0.3 million.

21. The Trust’s good performance in meeting its financial targets each year looks set to continue. Forecasts as at August 2007 indicate that the Trust will again achieve a breakeven position at the year end, will not exceed its EFL and is currently paying 97.7 per cent of non-NHS invoices within 30 days. A number of financial risks have been identified but the Trust has already identified a number of required actions to ensure that these risks are monitored and managed carefully throughout the remainder of the 2007/2008 financial year.

Appendix 7.5

Detailed Letter

Page 9 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

The Trust has appropriate financial management arrangements 22. We have reviewed the Trust’s arrangement for financial management such

as budgetary control. The Trust’s financial management arrangements are effective, with continued high level of awareness of key budgetary and detailed cost pressures within directorates.

My examination of the Trust’s significant financial systems did not identify any material weaknesses in internal control

23. Our review of the Trust’s financial systems has involved documenting the significant financial systems and where necessary testing the operation of internal controls. We have also reviewed the Trust’s Statement on Internal Control and considered the findings arising from the work of Internal Audit in 2006/2007.

24. We have concluded that the Trust’s significant financial systems can be relied upon to produce materially correct outputs.

25. During 2006-2007, in common with other health bodies in Wales, the Trust implemented a new payroll system. A number of significant control issues were identified with the implementation of the new system which required us to undertake additional analytical techniques in order to ensure that the payroll expenditure reported in the Trust’s accounts was materially correct. I am satisfied that this was the case. The Trust’s Accountable Officer has also appropriately referred to these control issues in the Trust’s Statement on Internal Control for 2006/2007.

The Trust has proper arrangement to help it deliver efficient, economical and effective services

The Trust had proper arrangements in 2006/2007 to help it achieve economy, efficiency and effectiveness in its use of resources 26. In examining the Trust’s accounts each year, I am required under Section 61(3) of

the Public Audit (Wales) Act 2004 to satisfy myself that it has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. This requirement is also reflected in my Code. My formal conclusion on the Trust’s arrangements for 2006/2007 is set out in Appendix 1.

Appendix 7.5

Detailed Letter

Page 10 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

27. The focus of my work for the purposes of the annual conclusion is on the evidenced existence of these arrangements themselves. I am not commenting on the effectiveness of the arrangements during the year, and management should not seek to take assurance from the findings of my work in this regard. My separate Value for Money audit work does consider where the arrangements or their operation could be improved. The results of such work carried out during 2006-2007 are set out in paragraph 37 below. This latter work informs my conclusion on the existence of arrangements that the Trust had in place during the year to properly support the achievement of its responsibility to secure economy, efficiency and effectiveness in its use of resources, but is not essential to it.

28. The Accountable Officer is responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in the Trust’s use of resources. For the purposes of my work, I have evaluated the Trust’s systems against a number of questions. This approach is set out in detail in Appendix 2. For each question, I consider whether there are gaps in the arrangements expected to be in place, and the significance of those gaps.

29. In considering significance, I look at the potential impact expected arrangements are absent. For example, an absence of budgetary control arrangements is likely to have a significant impact on an organisation’s ability to secure value for money in its use of resources. Where I find significant gaps in the arrangements, then I may raise issues and make recommendations for improving them.

30. There are no matters arising from my work in this area for 2006/2007 that I wish to draw to your attention.

The Trust is achieving the required performance against the Welsh Risk Pool’s Standards 31. The Trust’s arrangements meet the required risk management standards of the

Welsh Risk Pool. These standards cover a wide range of areas including: • risk management policy and strategy; • risk assessment and treatment/risk profile; • incident and hazard reporting; • governance; and • financial management.

32. These risk management standards effectively define the governance framework required by NHS bodies to manage their overall business. Compliance is deemed to be the achievement of a score of not less than 75 per cent overall and 75 per cent in the core standards assessed by the Welsh Risk Pool. The Trust exceeded this 75 per cent threshold for each of the core standards, as summarised below in Exhibit 4:

Appendix 7.5

Detailed Letter

Page 11 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Exhibit 4: Performance against the Welsh Risk Pool’s Core Risk Management Standards

Welsh Risk Pool Management Standard 2006/2007 2005/2006 2004/2005 Risk management policy and strategy 100% 98% 98%Risk assessment and treatment / Risk Profile 100% 94% 99%Incident and hazard reporting 100% 100% 100%Governance 100% 100% 100%Financial Management 100% 100% 100%

While performance audit work supports my conclusion about the arrangements to secure efficient, economical and effective services, my findings have drawn attention to areas where the Trust can make further improvements in its services 33. As in previous years, I have undertaken a risk based programme of audit work

aimed at improving performance in services. Exhibit 5 sets out the performance audit work undertaken since my last Audit Letter.

Exhibit 5: Programme of performance work: Bro Morgannwg NHS Trust Study Audit findings/status AHP Phase 6 The Acute Hospital Portfolio (AHP) Phase 6 compared arrangements at the Trust to those in other trusts in Wales, England, Northern Ireland, and the Isle of Man. These audits sought to determine whether services at the Trust were delivered efficiently and effectively. A suite of five topics were included, with Imaging, Endoscopy and Pathology included in the Annual Audit Letter for 2005/2006. Findings for Medicines Management and Admissions are summarised below.

AHP- Admissions Effective management of emergency and elective inpatient admissions is a fundamental responsibility of both managers and clinicians alike. The ability of the NHS in Wales to improve patient experience and meet modernisation targets is dependent on the adoption of good practice to support effective and efficient patient pathways. The AHP Phase 6 review compared the performance of the Trust’s admissions management to those in other trusts in Wales, England, Northern Ireland, and the Isle of Man. The review sought to determine whether the Trust effectively manages inpatient admissions through assessing whether there was an efficient emergency pathway; an efficient elective pathway; and the capacity to meet demand. The Report was agreed with the Trust in January 2007.

I concluded that while there is evidence of efficient management of the emergency admissions pathway, there is scope to improve the management of elective admissions through strengthened preadmission processes, further focus on chronological appointing and continued reduction of the suspended patient waiting list.

Appendix 7.5

Detailed Letter

Page 12 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status AHP- Medicines Management Medicines form an important component of the care provided to patients in hospitals and NHS trusts need well developed medicines management processes to help them deliver high quality, value for money and patient focused care. Effective management of patients’ medicines can reduce length of stay and the level of re-admissions. Medicines Management is broader than just the pharmacy department, and should be a trust wide focus. This review sought to determine whether the Trust effectively manages its medicines management services. The AHP Phase 6 compared Medicines Management arrangements at the Trust to those in other trusts in Wales, England, Northern Ireland, and the Isle of Man. This review sought to determine whether the Trust effectively manages its medicines management services, through assessing whether: • current medicines management practices

promote clinical effectiveness; • there are arrangements in place to support a

strong safety culture; • there is a clear patient focus in terms of

information, advice and support; and; • appropriate management arrangements are in

place to support effective medicines management.

The report was agreed with the Trust in May 2007.

I concluded that whilst many medicine management arrangements are well developed at the Trust, the development of a new strategy provides an opportunity to use pharmacy resources more effectively in order to achieve continued improvements in clinical effectiveness and patient safety.

Sickness Absence In May 2007 the Wales Audit Office launched its new Good Practice Exchange website across the Welsh public sector http://www.wao.gov.uk/goodpracticeexchange.asp. This website contains a range of information outlining good practice in the management of sickness absence. Linked to our rollout of this good practice project and to follow up on action taken across the NHS Wales following the previous Auditor General’s 2004 report, The Management of Sickness Absence by NHS Trusts in Wales, I have examined the current arrangements for the management of sickness absence in order to answer the following question. • Has the Trust made good progress in improving

its sickness absence management arrangements since the previous Auditor General’s report in 2004?

I shall be agreeing and reporting on my findings locally, although there will also be a national report which will be presented to the National Assembly’s Audit Committee in early 2008. It is in this national report that we shall be making specific recommendations for further action across all of the NHS trusts and Local Health Boards (LHBs) in Wales. We are also hopeful that, through this work, we will identify additional good practice case studies for inclusion as part of the Good Practice Exchange.

Appendix 7.5

Detailed Letter

Page 13 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status Making the Connections The principles and objectives set out in Making the Connections are embedded within Designed for Life, the Assembly Government’s 10 year vision for creating world class health and social care services in Wales. Making the Connections challenges NHS bodies, along with other public services to be responsive to the needs of individuals and communities and to ensure that their services are delivered efficiently and with a commitment to equality. I have therefore undertaken a major review across the public sector in Wales to assess the extent to which public services are meeting the challenges of the Making the Connections agenda. Audit work has been undertaken across the NHS, as well as in local government and central government, to review of progress in four key thematic areas: • working together as the Welsh public

service; • making the best use of resources; • putting the patient/service user at the

centre (public and patient involvement); and

• preparing and developing the workforce.

The Trust is making good progress in implementing the Making the Connections agenda, with examples of well developed joint working and public / patient engagement, and a co-ordinated approach to workforce planning

Appendix 7.5

Detailed Letter

Page 14 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status Chronic Disease Management In Wales, the elderly population is projected to grow by 11 per cent up to 2020. It is estimated that 75 per cent of those aged 75 years and over have at least one chronic condition and that approximately 78 per cent of all health spend is connected to chronic conditions. Designed for Life (Assembly Government May 2005), is clear that improving the management of chronic conditions is a key part of achieving more sustainable, effective and efficient service Within this context, the Chronic Conditions Management Review undertaken in all NHS Trusts and LHBs, examined whether chronic conditions are managed effectively, given the current configuration of services, by: • analysing the impact of chronic

conditions on the service; • assessing current service

provision for people with chronic conditions; and

• reviewing the arrangements and the potential to reshape services for people with chronic conditions in the health and social care community.

The underpinning review data was released to NHS Wales in August 2007 and a national report is due to be published in 2008.

I concluded that the Trust, Bridgend LHB and Neath Port Talbot LHB (the Health Community) deliver a wide range of services for patients with chronic conditions across community settings. The impact of chronic conditions in the catchment area is considerable and there are currently inequities in service provision. These inequities are acknowledged by the Health Community, which has well developed partnership arrangements. The Health Community is actively seeking to evaluate all services for chronic conditions and ensure that there is equity of access and provision for all residents in the community. In reaching this conclusion, we found that: • There is evidence of a developing

shared vision for equitable and coherent services across the Health Community. ‘Delivering Integrated Services’ has been established to provide a shared strategic focus for service developments, including those relating to chronic conditions. Concerns remain about funding arrangements and the balance of shared responsibilities.

• A wide range of services is in place to support patients with chronic conditions although currently provision is variable across the catchment area. An evaluation of chronic condition services is being undertaken by the Health Community to provide opportunities for service redesign.

• Planning and commissioning structures are well developed across the Health Community with good foundations for joint working. The vision for equitable and integrated community services is understood, there is clear evidence of progress and implementation plans are being developed.

Appendix 7.5

Detailed Letter

Page 15 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status Review of accuracy of waiting list information in NHS trusts The length of time people wait for planned NHS treatment is a key concern for most patients and the need to secure shorter waiting times has become a key strategic goal for the Assembly Government. Ambitious new targets have been announced which state that, by the end of March 2007, patients will wait a maximum of eight months for inpatient/day-case admission and no more than eight months for an outpatient appointment. By the end of December 2009, the maximum wait for a patients referral to treatment to include both inpatient and outpatient treatment will be 26 weeks. In June 2006, I reported the results of my follow-up to a detailed all-Wales report on waiting times, published in January 2005, by my predecessor as Auditor General. I concluded that the NHS in Wales had made considerable progress in reducing long waiting times and in addressing their causes, but that further action was needed manage known risks that might impede delivery of the ambitious 2009 target. My report highlighted the risk that such a determined focus on a target can sometimes lead to inappropriate activity or even manipulation of data. In recognition of that risk, the Assembly Government requested the Wales Audit Office to undertake, in the early part of 2007, a spot check review of the quality of waiting list information in NHS trusts in Wales to provide independent assurance that the reported figures are accurate and based on good quality data. In this Trust, the review focused on waiting lists in T&O and Ears, Nose and Throat (ENT).

I have concluded that while most aspects of waiting list management in the Trust are robust and consistent with good practice, proactive management of suspensions is an area for improvement. We therefore concluded that overall, arrangements are acceptable. In reaching this conclusion, I found: • there are robust arrangements in place

to manage waiting lists and to support accurate submission of central returns;

• arrangements for managing suspensions are acceptable and the Trust is working to reduce suspension levels in T&O and sustain a reduction in suspension length; and

• there is robust application of the Guide to Good Practice and waiting list data is consistent and accurate.

Appendix 7.5

Detailed Letter

Page 16 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status Day Surgery Follow-up Review In 2005, the Wales Audit Office undertook the AHP Phase 5 review of Day Surgery in the Trust. The report and agreed Action Plan from this review were published in December 2005. The Action Plan centred on improving performance, utilising existing facilities more effectively and sharing good practice. In following up on progress made, this review sought to answer the question: • Has the Trust made progress on

addressing the issues identified in the AHP Review of Day Surgery?

At the time of the follow-up review, the Trust had commenced an extensive review of day surgery location, provision and delivery, taking forward the recommendations on capacity and case mix made in the AHP Phase 5 Report.

I concluded that considerable progress has been made in analysing and understanding day surgery performance. The Trust should continue to drive improvement, building on existing achievements and ensuring inclusion of service developments and associated good practice in any longer term theatre strategic plans: • good quality patient experience is

recognised as a priority and the Trust is working with key stakeholders to enhance service delivery and promote good practice;

• the AHP Phase 5 recommendations on service efficiency are being progressed with dedicated managerial support and ongoing service review and development; and

• day surgery capacity is being reviewed by the Trust however staff sickness remains an issue.

Accident and Emergency Follow-up Review In 2005, the Wales Audit Office undertook the AHP Phase 5 review of Accident and Emergency services at Bro Morgannwg Trust. The report and agreed action plan from this review were published in March 2006.The Action Plan centred on improving the patient experience, efficiency of the service and capacity to meet demand.

Accident and Emergency services at the Trust have improved since our AHP Review in 2005 with good performance recorded for waiting time targets and the development of new services and facilities. Whilst improvements have been made in improving attendance, there is still scope to reduce sickness absence further: • The patient experience in Accident and

Emergency continues to improve. Waiting time targets are being achieved, the facilities for emergency medicine have improved following review. Well developed systems enable regular clinical audits to support clinical service delivery.

• Accident and Emergency services have been subject to considerable review and reconfiguration. There is evidence that sickness absence and turnover rates are beginning to improve as a result of action planning but close monitoring is required to ensure objectives are delivered.

• The capacity of the Accident and Emergency Department and the Local Accident Centre continue to be reviewed in partnership with LHBs. Demand management initiatives and service changes are being planned and introduced as a result of this collaborative work.

Appendix 7.5

Detailed Letter

Page 17 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status Ward Staffing Follow-up Review In 2005, the Wales Audit Office undertook the AHP Phase 5 review of Ward Staffing in the Trust. The report and agreed Action Plan from this review were published in December 2005. The Action Plan centred on improving the patient experience, utilising staffing skills facilities and understanding and managing nursing staff costs. This follow up review sought to answer the question: • Has the Trust made progress on

addressing the issues identified in the AHP Review of Ward Staffing?

At the time of the follow-up review, the Trust has progressed work in a number of the areas highlighted in the Action Plan. Some elements of this work have been linked to the implementation of Agenda for Change and the Trust has used this process to support the review of nursing staff grades and roles. The Trust has made progress in areas including management development and training, skill mix review, rostering and in the management of bank staff. All recommendations in the action plan are currently being addressed although in some areas it is too early to assess the results.

My review concluded that the Trust has made considerable progress in reviewing and understanding ward staffing issues. This understanding is supporting service change and development. The Trust should continue to drive improvement in the patient experience and monitor, review and implement plans to improve the efficient use of staff and staff resources. In reaching this conclusion I found: • considerable progress has been made

in improving the patient experience and this is evidenced through improved staff training and the monitoring of pressure sores;

• the Trust is increasing nursing service efficiency through ongoing service review and system development;

• ward staffing costs are reviewed routinely and outcomes are being systematically implemented; and

• overall nursing capacity is being reviewed including the contribution made by specialist nurses and healthcare assistants to enable more appropriate deployment of staff.

Appendix 7.5

Detailed Letter

Page 18 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status Performance Management Follow-up Review In May 2005 the Assembly Government published ‘Designed for Life – Creating World Class Health and Social Care for Wales in the 21st century’. It is a strategy for the future of health and social care in Wales. The Trust has identified performance as a key corporate risk and has developed a performance management strategy to meet the targets set. This requires the Trust to rely on good internal and external partnerships and to move towards a whole system approach to performance management. Many of the challenges in achieving its objective involve more than just improvements in service delivery but also in achieving significant change in attitudes both within the Trust and in partnership working and ensuring that the Trust is responsive to changes in capacity and demand. Within this context and following on from my review of the Trust’s performance management arrangements in 2005, I examined whether the Trust has achieved significant, sustainable and consistent improvement in performance and has addressed the recommendations included in my 2005 review.

I concluded that the Trust has achieved significant and sustainable improvement in performance management although, as outlined above, delivery of A&E waiting times remains a critical issue for the Trust. Attention is therefore needed to demonstrate consistent improvement and to further develop its whole system approach to performance management with partner organisations. In reaching this conclusion I also found that: • the Trust is engaging NHS Wales to

develop the Performance Management Framework (PMF) and is sharing good practice as part of a learning organisation strategy;

• the performance management reporting process has been refined to provide the Trust Board with both strategic and locality specific information;

• the Trust is working with partner organisations to develop the PMF and is moving towards a whole system approach to performance management; and

• performance has improved over previous years and the Trust continues to focus on the delivery of core SaFF targets.

Appendix 7.5

Detailed Letter

Page 19 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status AHP 7: Maternity Services Review Nationally about one in 10 requests to the Healthcare Commission for investigation are related to maternity services. The Commission have chosen to include maternity services in the AHP after reviews at a number of individual NHS Trusts in England identified concerns over the quality of maternity care. In Wales, Healthcare Inspectorate Wales (HIW) have recently completed an all Wales review on the clinical governance arrangements for maternity services to provide assurance that similar quality of care concerns are not present in Welsh maternity units. The AHP work currently in progress will compliment HIW’s clinical governance findings, providing detailed benchmarked performance analyses on both quality of care and use of resources in relation to maternity services. This constitutes a comprehensive mechanism to assist Trusts in developing and improving the safety and value for money of their maternity services.

Fieldwork completed. Healthcare Commission national data sets available. Feedback of the draft findings and draft reporting is planned for December 2007. My conclusions from this review will be included in next years Annual Audit Letter.

Theatres review In 2003, the Wales Audit Office undertook the AHP Phase 3 review of Operating Theatres at the Trust. This review identified that at the time, elective theatre utilisation was low and there were high cancellation rates. This review will examine current theatre performance and aim to ask ‘Does the Trust provide value for money theatre services?’

Fieldwork commenced in November 2007 and feedback of the draft findings is planned for December 2007 with draft reporting January 2008. My findings from this review will be reported in next year’s annual audit letter.

Additional Performance audit The focus of this work is currently being agreed with the Trust. This may include work to support Trust merger or other tailored audit to support service improvement.

Appendix 7.5

Detailed Letter

Page 20 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Study Audit findings/status The European Working Time Directive The European Working Time Directive (EWTD), in the context of Welsh health and social care services, relates primarily to the way in which on-call work should be classified and the way in which compensatory rest is taken. Under EWTD, all of the on-call period will count as working time if staff are resident on site, regardless of whether they are working or not. This has significant implications for employers of NHS and social care staff, including care home workers. Since 1 August 2004, EWTD has also applied to junior doctors in the NHS. Currently, their working hours should not exceed an average of 56 hours per week with the aim of reducing their working hours by August 2009 to not exceed an average of 48 hours per week (the current limit for other workers – although employees can choose to opt out and work longer hours should they wish). As at the end of 2006, an assessment by the Assembly Government across NHS trusts in Wales indicated that only 33 per cent of junior doctor posts across Wales were yet compliant with this 2009 target. I shall be examining: • the progress that the Trust is

making in working towards these 2009 targets for junior doctors, reflecting on previous recommendations made by the Assembly Government; and

• the extent to which the Trust can demonstrate that it is managing compliance with all of the basic rights and protections provided for under EWTD, regardless of staff group.

My findings will be reported in next year’s Annual Audit Letter.

34. All work in progress will be reported in the usual way to the Audit Committee and

the results summarised in next year’s Annual Audit Letter.

Appendix 7.5

Appendices

Appendix 1

Page 21 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Conclusion on Bro Morgannwg NHS Trust’s arrangements for the year ended 31 March 2007 for securing economy, efficiency and effectiveness in its use of resources

Accountable Officer’s Responsibilities The Accountable Officer is responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in the Trust’s use of resources, and to ensure proper stewardship and governance. The Accountable Officer is also responsible for regularly reviewing the adequacy and effectiveness of these arrangements.

Auditor’s Responsibilities I have a responsibility under Section 61(3) of the Public Audit Wales Act 2004 to conclude from my audit of the Trust’s annual accounts and other relevant information whether I am satisfied that it has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. For the purposes of my work in this area, I have assessed ‘proper arrangements’ as principally comprising an organisation’s corporate performance management and financial management arrangements, significant elements of which are defined in paragraph 48 of my Code of Audit and Inspection Practice. I report if significant matters have come to my attention which prevents me from concluding that the Trust has made such proper arrangements. In carrying out my work, I have not considered whether the arrangements in place represent all those that could be in place. I am also not required to consider, nor have I considered as part of this aspect of my work, the effectiveness of the arrangements in place in securing value for money during the year under review.

Conclusion The following conclusion has been based on, and limited to, work carried out as part of my audit of the 2006/2007 accounts, together with any other information that I have considered to be relevant to my examination, to establish, in all significant respects, what arrangements the Trust had in place during the year to support the achievement of its responsibility to secure economy, efficiency and effectiveness in its use of resources. Based on the Trust’s statement of internal control, and as a result of the work carried out, as described above, as part of my audit of the 2006/2007 accounts, and all other information that I have considered to be relevant, I am satisfied overall as to the existence of the arrangements that the Trust had in place during the year to support the achievement of its responsibility for securing economy, efficiency and effectiveness in its use of resources. I have also raised various issues with the Trust, and made recommendations to improve its arrangements. These matters are further discussed and explained in my Annual Audit Letter to the Trust.

Jeremy Colman Auditor General for Wales December 2007

Wales Audit Office 2-4 Park Grove Cardiff CF10 3PA

Appendix 7.5

Appendices

Appendix 2

Page 22 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Criteria for assessing Bro Morgannwg NHS Trust’s arrangements during 2006/2007 for securing economy, efficiency and effectiveness in its use of resources Corporate Performance Management and Financial Management Arrangements

Questions on Arrangements

Establishing objectives, determining policy and making decisions

Has the Trust put in place arrangements for setting, reviewing and implementing its strategic and operational objectives?

Meeting needs of users and taxpayers

Has the Trust put in place channels of communication with patients and their representatives, and other stakeholders including partners, and are there monitoring arrangements to ensure that key messages about services are taken into account?

Compliance with established policies

Has the Trust put in place arrangements to maintain a sound system of internal control, including those for ensuring compliance with laws and regulations, and internal policies and procedures?

Managing operational and financial risks

Has the Trust put in place arrangements to manage its significant business risks?

Managing financial and other resources

Has the Trust put in place arrangements to evaluate and improve the value for money it achieves in its use of resources? Has the Trust put in place a medium-term financial strategy, budgets and a capital programme that are soundly based and designed to deliver its strategic priorities? Has the Trust put in place arrangements to ensure that its spending matches its available resources? Has the Trust put in place arrangements for managing and monitoring performance against budgets, taking corrective action where appropriate, and reporting the results to senior management and the Trust? Has the Trust put in place arrangements for the management of its asset base?

Monitoring and reviewing performance

Has the Trust put in place arrangements for monitoring and scrutiny of performance, to identify potential variances against strategic objectives, standards and targets, for taking action where necessary and reporting to the Trust?

Has the Trust put in place arrangements to monitor the quality of its published performance information, and to report the results to trust members?

Proper standards of conduct etc

Has the Trust put in place arrangements that are designed to promote and ensure probity and propriety in the conduct of its business?

Appendix 7.5

Appendices

Appendix 3

Page 23 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Reports delivered during the 2006/2007 audit Report Date Audit Strategy December 2006

Acute Hospitals Portfolio 6: Admissions Management March 2007

Acute Hospitals Portfolio 6: Medicines Management May 2007

Financial Accounts Audit and Report to those Charged with Governance

June 2007

AGW’s Audit Report on the 2006/2007 Accounts June 2007

Acute Hospitals Portfolio 5: Day Surgery follow up August 2007

Securing Improvement 2: Chronic Disease Management

August 2007

Review of accuracy of waiting list information in NHS Trusts

August 2007

Acute Hospitals Portfolio 5: Ward staffing follow up September 2007

Making the Connections December 2007

Acute Hospitals Portfolio 5: Accident & Emergency follow up

December 2007

Annual Audit Letter December 2007

Appendix 7.5

Appendices

Appendix 4

Page 24 of 26 Bro Morgannwg NHS Trust - Annual Audit Letter 2006/2007

Audit fee The Audit Strategy for 2006/2007 set out the proposed audit fee of £174,377 (plus VAT). The table below sets out my latest estimate of the actual fee for 2006/2007, on the basis that some work remains in progress.

Analysis of proposed and actual audit fee 2006/2007 Code area Planned fee

2006/2007 (£)

Estimated actual fee 2006/2007

(£) Financial Accounts 52,157 52,157

Performance 122,220 122,220

Total 174,377 174,377

Appendix 7.5

Appendix 7.5

Wales Audit Office 2-4 Park Grove Cardiff CF10 3PA Tel: 029 2026 0260 Fax: 029 2026 0026 Textphone: 029 2026 2646 E-mail: info@wao.gov.uk Website: www.wao.gov.uk

Appendix 7.5

WHC (2008) 002

WELSH HEALTH CIRCULAR

Parc Cathays Caerdydd CF10 3NQ Cathays Park

Cardiff CF10 3NQ

Issue Date: 18th January 2008

Status: Action

Title: Strengthening Welsh Language provision within NHS services in Wales

For Action by: NHS Trusts and Local Health Boards

Action required: See paragraphs 10, 11, 13, 14 and 15

For Information to: See attached list

Sender: Ann Lloyd, Chief Executive NHS Wales, Department for Health and Social Services, Welsh Assembly Government

Welsh Assembly Government contact(s) : Ann Davies, NHS Welsh Language Unit Tel: 029 20825797 Fax: 029 2082 5257 Richard Timothy, NHS Welsh Language Unit Tel: 029 20825712 Fax: 029 2082 5257 Corporate Management, Department for Health and Social Services, Welsh Assembly Government

Enclosure(s): Annex 1 – Job Description, Annex 2 – North Wales LHBs’ Model and Job Description and Annex 3 – Terms of Reference and Membership for the All Wales Task Group for the Welsh Language in Healthcare Services

Tel: GTN:

Llinell union/Direct line: Ffacs/Fax:

Minicom: 029 20823280 http://howis.wales.nhs.uk/whcirculars.cfm

Appendix 7.6(i)

2 Summary 1. The purpose of this circular is to inform NHS organisations of the following

requirements regarding Welsh language provision within the health service:

1) Every NHS Trust should appoint a full time Welsh Language Officer

to promote the development of bilingual health care within their organisations.

2) LHBs in the Mid and West and South East Regions should pool

funds in order to develop regional Welsh Language Units, based on the model operating in the North Wales region.

2. These arrangements should be in place by 30 April 2008. Background 3. The Welsh Consumer Council report “Welsh in the Health Service” (June

2000) emphasised the lack of services available through the medium of Welsh and highlighted the lack of sensitivity towards the care needs of Welsh speaking patients. The report concluded that there was a shortage of Welsh speaking staff in the NHS in Wales and that insufficient consideration was given to language choice as a factor in healthcare.

4. In response, the then Health Minister established a Task Group to tackle

the issues raised in the report. Welsh Health Circular (2002) 020 required every NHS organisation to nominate a Welsh Language Champion (ideally a board member) and a Contact Point to lead the operational work.

5. The Department established a Welsh Language Unit to provide leadership

and support to the service on this issue. 6. During the last five years progress has been made in strengthening

provision, but the pace of the development varies considerably. 7. In 1998 The Council of Europe ratified the European Charter for Regional

and Minority Languages. They established a Committee of Experts (ComEx) to present a report every three years.

8. The ComEx report released in July 2006 noted:

“The Committee of Experts acknowledges the positive steps being taken. However, since the undertaking requires the authorities to ensure that Welsh is used in health and social care services, the Committee of Experts must conclude that the undertaking is not fulfilled at present.”

9. Following consideration of the report, the Committee of Ministers

Recommendations were published in March 2007. One recommendation

Appendix 7.6(i)

3related to health and social service in Wales: “take further measures to ensure that health and social care facilities offer services in Welsh”.

Action 10. Action should be taken by every NHS organisation to ensure that it

strengthens the provision of services in Welsh, particularly to the following priority groups:

• children and young people • older people • people with learning disabilities • users of mental health services

11. The following action is required:

• NHS Trusts are required to appoint a full time Welsh Language Officer, to be responsible for leading work to strengthen Welsh Language services in their organisations. The Welsh Language Officers are to be in place by 30 April 2008. Attached please find in Annex 1 a model job description, which Trusts might wish to use.

• LHBs in Mid and West Wales and the South East are required to pool funds in order to establish regional Welsh Language Units based on the model already in place in North Wales. Attached please find in Annex 2 the details of the North Wales Language Unit model.

12. The Minister has re-established the Welsh Language Task Group, which

will provide national leadership and strategic direction to the task of strengthening Welsh Language provision within the service. The Task Group is chaired by Gwenda Thomas, Deputy Minister for Social Services. Attached please find in Annex 3 the terms of reference and membership details of the group. The focus of the Task Group’s work will be implementing Welsh Language Schemes, so as to improve the patient’s experience.

13. Every NHS organisation should have nominated a Welsh Language

Champion (ideally a board member) who is able to drive the strategic agenda forward. The Welsh Language Champions Network has been revised and now meets on a regional basis, which should ensure regular attendance from all organisations.

14. All organisations should have nominated a Welsh Language Contact Point,

who is responsible for leading operational activity. Organisations should ensure regular attendance at the All Wales Welsh Language Contacts Network meetings.

15. We have recently commissioned a review of the Welsh Language in

Healthcare Awards. During January and February we will be undertaking research in this area. I would be grateful if you ensure that your organisation participates in this review.

Appendix 7.6(i)

4 16. Last month, a WHC was issued on the Annual Operating Framework for

2008/9. Paragraphs 3.64, 3.65 and 3.66 refer to the provision of Welsh language services.

17. The NHS Welsh Language Unit will continue to provide leadership, advice

and support to the service to develop this work. Please do not hesitate to contact them if you require advice or support.

18. I will monitor progress and provide feedback to the Minister and Deputy

Minister for Health and Social Services. Progress in this area will be considered at Chairs and Chief Executives Annual Review Meetings.

Ann Lloyd Chief Executive, NHS Wales

Appendix 7.6(i)

5

Distribution List

Chief Executives NHS Trusts Chief Executives Local Health Boards HR Directors Business Services Centres Director Welsh NHS Confederation Chief Officer Board of Community Health Councils in Wales Director Welsh Local Government Association Dean of the Faculty of Health Studies University of Wales, Bangor Chief Executive Equality and Human Rights Commission Disability Rights Commission Equal Opportunities Commission Chief Executive NLIAH Director British Dental Association (Wales) Dean Cardiff University School of Dentistry Postgraduate Dean Cardiff University School of Dentistry Postgraduate Dean Cardiff University School of Medicine Director information services Cardiff University School of Medicine Secretary British Medical Association (Wales) Regional Head of Health UNISON Director Royal College of Nursing (Wales) Wales Secretary British Orthoptic Society Chair Optometry Wales Secretary Optometry Wales Wales Secretary AMICUS MSF Regional Secretary The GMB Regional Secretary Transport & General Workers Union Chief Executive Community Pharmacy Wales Policy Officer Royal College of General Practitioners General Secretary Wales TUC Assistant Director Chartered Society of Physiotherapists Director Capital Audit Team Director Denbighshire Voluntary Services Council Secretary College of Occupational Therapists Officer for Wales Society of Radiographers IR Officer Society of Chiropodists and Podiatrists Regional Secretary Union of Construction Allied Trades and Technicians Board Secretary for Wales Royal College of Midwives Officer for Wales AMICUS Electrical & Engineering Staff Association Regional Secretary AMICUS Amalgamated Electrical and Engineering Union Welsh Executive Royal Pharmaceutical Society of Great Britain Health & Social Care Policy Officer Wales Council for Voluntary Action National Member for Wales AMICUS - Guild of Health Care Pharmacists Business manager Institute of Health Care Management Welsh Division Deputy Chief Executive Association of Optometrists Director General Audit Commission (Wales) Director Business Service Centres Patch Managers Business Service Centres across Wales (6 copies each) Secretariat Statutory Health Advisory Committees Academy of Royal Colleges Wales Regional Directors DHSS Wales Regional Offices Chief Executive Health Commission Wales (Specialist Services) Library and Knowledge Management Service

National Public Health Service

Chief Executive Welsh Language Board / Bwrdd yr Iaith Gymraeg Librarian Health Promotion Library Information Systems Librarian Healthcare Inspectorate Wales

Appendix 7.6(i)

Annex 1 - Job Description

JOB DESCRIPTION

DETAILS OF POST Title of post: Welsh Language Officer PURPOSE OF POST To provide strategic direction, leadership and specialist advice to all departments across the Trust in order strengthen the provision of bilingual services to patients. Ensure that the Trust delivers its statutory legal requirements related to the Welsh Language Act 1993. To lead the implementation of the Trust’s Welsh Language Scheme in order to improve bilingual services to patients To evaluate and report progress to the Trust’s Board and as appropriate to the Welsh Language Board and the Department for Health and Social Services (DHSS), Welsh Assembly Government. DUTIES AND RESPONSIBILITIES Provide Corporate Leadership 1. Provide leadership and advice on Welsh language matters to all

departments within the Trust 2. Promote and monitor the development and implementation of the Trust’s

Welsh Language Scheme, and take action to ensure that staff comply with the scheme.

3. Ensure that priority is given to strengthening bilingual services to the

following groups: o children and young people, o users of mental health services, o older people, o people with learning disabilities.

4. Develop initiatives to implement the Trust’s Welsh Language Scheme in

accordance with the Welsh Language Act 1993. 5. Develop clear links with the Equality and Diversity programmes within

the Trust to ensure that the Welsh language dimension is addressed in the context of equality and appropriateness.

Appendix 7.6(i)

Annex 1 - Job Description 6. Work closely with the Trust’s Welsh Language Champion and provide

advice to Executive Board as appropriate. 7. Create, maintain and enhance productive working relationships, both

internally and externally (e.g. Welsh Language Board, Department of Health and Social Services).

Training 8. Work with the HR Department to develop and implement Welsh

language training programmes as part of the Trust’s organisational development programme, so as to increase the workforce’s Welsh language awareness, capacity and skills. This is to be included in induction and ongoing professional training programmes for all staff.

9. Work with the HR Department to develop a Bilingual Skills Strategy for

the Trust. Operational Processes and Mechanisms 10. Co-ordinate and produce annual/compliance reports on the

implementation of the Welsh Language Scheme for the Welsh Language Board.

11. Report to the DHSS Welsh Assembly Government on Welsh language

elements included in the Annual Operating Framework. 12. Maintain and develop a database of Welsh speaking staff within the

Trust who are willing to conduct media interviews or take part in public events, or are willing to act as Welsh language champions within their department.

13. Promote opportunities to strengthen bilingual services in partnership

with other NHS organisations and partners. 14. Act as the Trust’s Welsh Language Contact Point and work in

partnership with the Department’s Welsh Language Unit as appropriate.

15. Ensure all staff and consultants who prepare policies are aware of the

requirements of the Trust’s Welsh Language Scheme and assess the linguistic effect of new policies and initiatives to ensure they comply with the Scheme.

Appendix 7.6(i)

Annex 2 – North Wales LHBs’ Model and Job Description

NORTH WALES LHBs’ WELSH LANGUAGE UNIT’S ROLE AND RESPONSIBILITIES

SECRETARIAL/ADMINISTRATIVE SUPPORT

WELSH LANGUAGE OFFICER

Translation Service to 6 Local Health Boards in North Wales – Board Papers; Letters; Reports; Information Leaflets; Websites (Wordfast translation memory)

Contingency arrangements when the Welsh Language Officer is out of

the office, for example at meetings or on holiday

Simultaneous translation – buying the service when necessary

Networks and Administration:

North Wales NHS Bilingual Forum Welsh Language Monitoring Group

North Wales Bilingual Forum Contact Point Group LHB Champions Group Gwynedd LHB Bilingual Committee Terminology Group

Advice/Guidance to 6 Local Health Boards in North Wales on the

Welsh Language Scheme – a leaflet on the implementation of the Welsh Language Scheme ‘Cofiwch/Peidiwch ag Anghofio’

Welsh Training/Resource Library – Lunch Club, Lonc a Chlonc, Welsh

Support on e-mail

Language Awareness – running induction/language awareness courses using the Iechyd Da Pack from the Welsh Language Unit, Welsh Assembly Government

Raising awareness/promoting bilingualism within the LHBs – a

database of signs, promoting bilingualism booklet

Contact with the Media – interviews in Welsh with Radio Cymru. Leaflet ‘Advice on Interviews with the Media/Public Presentations through the medium of Welsh’

Appendix 7.6(i)

Annex 2 – North Wales LHBs’ Model and Job Description

NORTH WALES LOCAL HEALTH BOARDS

Job Description

Job Title: Welsh Language Officer Grade: Senior Manager Band B Hours of work: 37 hours per week Department: Finance Directorate Accountable to: Director of Finance Responsible to: Director of Finance Purpose of the job: To ensure effective implementation of the Welsh Language Schemes across 6 Local Health Boards (LHBs) in North Wales in accordance with the Welsh Language Act 1993 in co-operation with Welsh Language Scheme Co-ordinators and provide a comprehensive translation service to the 6 LHBs, BSC and NPHS in North Wales. Key Responsibilities: 1. Welsh Language Schemes 2. Translation Service 3. Training and Development 4. Communication 5. Manage People Key Result Areas: 1. Welsh Language Scheme 1.1 Provide advice and direction to the 6 Local Health Boards and their

relevant committees on the implementation of their Welsh Language Schemes.

1.2 Provide professional advice and information to the 6 LHBs on the

implications of relevant legislation as appropriate. 1.3 Plan actions required to meet legislative requirements as appropriate. 1.4 Monitor the response of the 6 LHBs to their own policy as required. 1.5 Provide advice and guidance to other parties as appropriate/on request

(voluntary organisations, primary care professionals, surgeries)

Appendix 7.6(i)

Annex 2 – North Wales LHBs’ Model and Job Description 1.6 Provide professional advice and support to LHBs’ Board level Welsh

Language Champions in their role. 1.7 Responsible for managing and providing professional advice to LHBs

on development of LHBs’ Annual Reports on implementation of Welsh Language Schemes.

2. Translation Service 2.1 Provide professional and specialist advice on development of medical

terminology. 2.2 Research, prepare and supply information to relevant parties (e.g.

translated documents) 2.3 Provide a comprehensive translation service for the 6 LHBs, BSC and

NPHS in North Wales within necessary timescales. 2.4 Translate complex clinical and technical material and ensure accuracy. 2.5 Responsible for proof-reading and editing translated material within

tight timescales. 2.6 Responsible for providing advice in response to enquiries from staff

regarding translation of material. 2.7 Responsible for ensuring high quality of work translated elsewhere. 3. Training and Development 3.1 Responsible for training and development of team and self to enhance

performance. 3.2 Provide information and advice on Welsh language training as

required. 3.3 Responsible for delivering Welsh Language Awareness Training via

Induction Sessions and produce monitoring reports for submission to Welsh Assembly Government.

4. Communication 4.1 Provide professional advice and information for action towards meeting

organisational objectives. 4.2 Create, maintain and enhance productive working relationships, both

internally and externally (e.g. Welsh Language Board, Welsh Assembly

Appendix 7.6(i)

Annex 2 – North Wales LHBs’ Model and Job Description

Government, Translators’ Guild, partner agencies at Board and senior management level)

4.3 Represent the 6 LHBs and any Welsh Language based Committee at

relevant meetings (including all Wales Welsh Language Task Group) in advisory role.

4.4 Lead Welsh Terminology Group in developing a glossary of medical

terms. 4.5 Responsible for managing meetings to facilitate implementation of

Welsh Language Schemes (i.e. Welsh Language Monitoring Group, North Wales Bilingualism Forum for the NHS) and providing advice on all aspects of communication and bilingualism within the NHS.

4.6 Press/media – represent LHBs at press conferences, interviews with

the Welsh media on issues pertaining to the Welsh language within the NHS.

4.7 Develop initiatives to raise awareness of obligations to comply with

Welsh Language Schemes within the NHS in accordance with the Welsh Language Act 1993.

4.8 Responsible for producing a comprehensive response to public

consultation documents on behalf of the LHBs. 5. Manage People 5.1 Allocate work to staff within the job holder’s responsibility and provide

feedback as appropriate 5.2 Ensure that staff are kept sufficiently informed about organisational

policies and progress on a regular basis. 5.3 Responsible for the management of administrative/secretarial function

within Welsh Unit. 5.4 Responsible for the recruitment and training of

administrative/secretarial and translator post within the Welsh Unit.

Appendix 7.6(i)

Annex 3– Terms of Reference and Membership for the All Wales Task Group for the Welsh Language in Healthcare Services

All Wales Task Group for the Welsh Language in Healthcare Services (2007)

Terms of Reference

1. Advise the NHS Welsh Language Unit on priorities in implementing Welsh language provision within the service

2. To help identify best practice, advise on dissemination and track

implementation

3. To advise the Unit on improving the provision of Welsh language services in health and social services.

4. To act as “mystery shoppers” to test the provision of Welsh language

services in health and social care

5. To provide feedback to the Unit on language provision issues within the service

Membership Gwenda Thomas Deputy Minister for Health and Social Services - Chair of the Taskgroup Rhiannon Davies - Welsh Language Contact Point, Gwent Healthcare NHS Trust Siân Howys - Child Protection Department, Ceredigion Social Services Alexis Jones - Speech & Language Therapist, Bro Morgannwg NHS Trust Carol Jones - Chief Officer Carmarthenshire CHC Dr Elin Walker Jones - Clinical Psychologist, Conwy & Denbighshire NHS Trust Gareth Jones - Policy Officer Mind Cymru Sharon Jones - Welsh Language Contact Point, North Wales LHBs Euros Owen - Co-ordinator Strategy for Older People, Swansea City Council Gwerfyl Roberts - Lecturer School of Nursing & Midwifery, University of Wales, Bangor Andrew White - Health and Voluntary Sector Unit, Welsh Language Board Melanie Williams - Trainer Expert Patient Programme, Gwynedd LHB Frequency of meetings The Task Group to meet twice a year.

Appendix 7.6(i)

Appendix 7.6(ii)

Bro Morgannwg NHS Trust Progress Report to December 2007– Welsh Language Issues

1. KEY THEMES

1.2 Forward Planning

The Trust’s Welsh Language Scheme was approved by the Welsh Language Board in July 2007. The Scheme contains an action plan to enable forward planning and monitoring targets. When drawing up new policies/procedures language requirements are considered through the Equality Impact Assessment Toolkit. Whilst good progress has been made in rolling out the Trust’s Welsh Language Scheme, the organisation’s Head of Corporate Administration who is responsible for the management of Welsh Language issues on a day to day basis, is of the view that there is justification for the appointment of a part-time (Welsh Speaking) Welsh Language Officer and put this case to the Trust’s Welsh Language Steering Group and the Director of Finance, who is also the Trust’s Welsh Language Champion. Both fully supported such an appointment being pursued. The Trust’s vision for this post is that a dedicated member of staff will drive forward the implementation of its Welsh Language Scheme at a faster pace than is achievable within existing resources. This person would be able to provide expert advice to staff on Welsh language issues as well as enthusing them about the language and its particular importance to first language Welsh speakers in the priority groups (elderly, very young, those clients with Learning Disabilities and Mental Health needs). Despite funding for this appointment being set aside by the Trust, to date, despite two trawls and interviews it has not yet been possible to recruit a suitable candidate. Following the merger of the Trust with Swansea NHS Trust, further efforts will be made to recruit to this important post.

1.2 Awareness

Directorate/Departmental representatives from the Trust’s Welsh Language Group have responsibility for promoting Welsh language issues at local level. New staff joining the Trust, receive language awareness training as part of the multi-disciplinary induction process. The intranet is a helpful tool in circulating information to staff as is the Trust’s fully bilingual newsletter which has been produced in this format for the last two years. The Autumn 2007 edition was dedicated to increasing awareness of Welsh Language issues.

1.3 Leadership and Practical Support

The Trust is fortunate to have a first language Welsh speaker as its Welsh Language Champion and the Trust’s Vice Chairman as the Chair of its Welsh Language Steering Group. Undoubtedly the appointment of a dedicated Welsh Language Officer would further improve the leadership and practical support for this key issue. The Trust’ made a submission to the Assembly’s ‘Welsh Language in Healthcare Awards’ in the Spring of 2007 and was rewarded with first prize for the use of a bilingual speech and language therapy assessment tool. The Department concerned earned themselves a £1000 to invest in further promotion of the Welsh Language. The Trust had previously won the award for the design and commitment to 100% bilingualism in respect of its Internet Site. From May 2007, the Trust launched ‘Buddy Sessions’. These provide an informal learning environment over a lunchtime session during which Welsh language learners can practice what they have learnt with bilingual staff. This boosts confidence and maintains skills.

The Trust makes good use of the ‘free’ Welsh Language translation and checking service provided through HOWIS for notices and posters. The Trust uses a variety of accredited translators for documents such as the Annual Report. There are times when it can be difficult to get a lengthy document translated quickly due a supply and demand issues in terms of the number of skilled translators. The Trust would therefore support the need for a central resource dedicated to the NHS for this service.

The Trust manages a Welsh Language Resources page on its Intranet site to provide local advice to staff, a list of common terms and ‘phrases of the week’ to encourage learners. This page also reminds staff how to access other Welsh Language resources and contains a list of common terms for temporary and permanent signage as well as greeting phrases. The Trust has excellent working relationships with the Welsh Language Board and the Assembly’s Welsh Language Unit. The latter sought contributions from Bro Morgannwg evidencing examples of good practice for the production of a DVD summarising good practice in Welsh Language provision in the NHS in Wales.

The Trust has agreed Terms of Reference for its Welsh Language Group, responsible for effective implementation of the Welsh Language Scheme across the organisation.

1.4 Bilingual Skills

For the past two years the Trust has contracted with Neath Port Talbot College to host Welsh Language lessons for staff. The first cohort included the Chair and vice Chair of the Trust who agreed to ‘lead from the top’ by attending and completing the course themselves. The Head of Corporate Administration has also since completed the second cohort that began in April 2007. From October 2007 a third cohort of staff from a variety of occupations across the Trust commenced their foundation lessons bringing the total number of staff to attend classes to 120. Another 40 staff are also due to commence their ‘second level’ language classes from January 2008. Certificates celebrating staff success have been presented to staff completing the Trust hosted Welsh Language courses. These events have been led by the Chief Executive and the Director of Finance to show the commitment to the Welsh language from the very top of the organisation. Staff have been very keen to take up the ‘free’ Welsh Language lessons hosted by the Trust and bilingual speakers have been keen to support the Buddy events. Whilst staff are becoming more and more aware of the resources the Trust has put in place to support them to comply with the Welsh Language Scheme and are keen to make use of these tools, there is room for improvement and a dedicated Welsh Language Officer would improve compliance further. Demand has outstripped supply and therefore, in order to encourage other staff who were unable to join Trust hosted language classes, a policy is being put in place to provide reimbursement (up to a defined level) to those staff completing an accredited Welsh course arranged outside the Trust. Despite the willingness of staff to take on new language skills, the Trust is at a disadvantage compared with North Wales which has many more Welsh speakers. It is therefore going to take a very long time to catch up in terms of this skills deficit and this inevitably means that the demands upon already on resources. The Trust is keen to undertake a linguistic skills strategy as set out in its revised Scheme and is awaiting the recommended model from the Welsh Language Board.

1.5 Complaints

The Trust receives very few complaints about Welsh Language issues and would always seek to resolve these promptly and learn any lessons from the issues raised. During 2006/07, there were no formal written complaints.

1.6 Internal Monitoring

The Trust’s Welsh Language Group holds responsibility for ensuring consistent and appropriate implementation of the Welsh Language Scheme across the organisation. The Trust’s Head of Administration and her deputy also conduct this informally, providing advice and assistance as necessary.

1.7 External Monitoring

This is based on comments and advice received from the Welsh Language Board, the Welsh Assembly Government’s Welsh Language Unit, any other surveys that may be carried out (such as those for accreditation for instance), as well as any suggestions or complaints received from other sources.

The Trust has mechanisms in place to enable it to respond appropriately to any suggestions or criticisms that are levelled in connection with the Welsh Language. Demand for public documents through the medium of Welsh is still very low but the Trust is proud to have a well stocked data base of Patient Information leaflets that are 100% bilingual. Whilst the Trust always provides simultaneous Welsh Language Translation facilities at its Annual Public Meetings – this has not to date been required by either members of the public or staff who have attended. The Trust occasionally receives requests for interviews from Welsh Language media however it is not always possible to accede to such requests due to the short notice provided. However, the Trust does ensure that all of its media releases are issued bilingually. During the current preparations pending the merger of this organisation with Swansea NHS Trust, Bro Morgannwg demonstrated commitment to Welsh language issues by publishing all of joint staff Communication Bulletins and its Consultation Document bilingually both on the Intranet and Internet sites.

1.8 Service from Others

The Trust has a procedure in place to ensure tenders issued for the Trust Facilities Management contracts include a specific reference to the requirements of the Trust’s Welsh Language Scheme. The Trust's Terms & Conditions for the Supply of Goods, Services and the Maintenance of Equipment also contains a standard clause relating to the Trust’s Welsh Language Scheme.

1.9 Corporate Reporting

Through the Trust’s Welsh Language Group, reports flow to the Trust’s Management Executive and Trust Board regarding Welsh Language issues in general and also about implementation of the Scheme. The Trust’s Head of Corporate Administration is also ensuring that Welsh Language issues are firmly on the agenda of the new Trust that will result from the merger of Bro Morgannwg with Swansea NHS Trust.

: Meeting of the : Trust Board : 7th February 2008 : AGENDUM NO 8

REPORT OF THE DEPUTY CHIEF EXECUTIVE 1. ACUTE SERVICES BOARD (ASB) – UPDATE 1.1. Project Pharmacy The Chief Pharmacist gave a brief review of the areas where work had been undertaken recently. This included:

• Transfer of care document and the medication module of this. A planned roll out of this was requested as a matter of urgency;

• Impact of the Patient Own medication (POMs) project - a Plan Do Study Act (PDSA) looking at improving delays of patients attending the Discharge Lounge was required early in February 2008.

• Training for doctors – it was highlighted that this should be led by the Chief Pharmacist and involve others as necessary

• Potential for transferring resources to areas of greatest need – this will be looked at by the Chief Pharmacist

1.2. Health Records and Outpatient Modernisation project The Clinical Champion along with the project manager identified a number of areas where progress had already been clearly demonstrated:

• Prioritisation of referrals • Pooling of lists • NLIAH input into improving DNA rate • New booking process introduced, and SMS Reminder service expanded • Automation of filling and sealing of approximately 30,000 outpatient letter • Installation of contact management system (end January 2008) • Identification and introduction of clinical champions • Short term increase in resource to aid the validation of follow up

Prioritisation of referrals within 5 days of receipt SPECIALTY Performance April 07 Performance December 07General Surgery 93.5% 95.6% Urology 91.1% 96.4% Orthopaedics 75% 91.3% ENT 96.9% 97.2% Ophthalmology 84.3% 92% Max Fax 89.1% 93.4% General medicine 73.7% 94% Chest medicine 88.8% 96% Cardiology Inc in gen med 98.2% Dermatology 95.2% 94.7% Neurology 74.2% 98% Rheumatology 75.5% 93.9% Paediatrics 93.9% 93.9% Gynaecology 76.7% 94.8% Chemical pathology 55.6% 100% Heamatology 87.9% 95.3%

1.3. Discharge project - Update An update of the initial results behind Nurse Facilitated Discharge over weekends was presented, which showed a 52% increase in discharges over the average for the last year. This will be rolled out to all wards across the two acute hospitals. In addition other PDSAs being undertaken over the next three months were highlighted – such as improved use of Discharge Lounge. Further work undertaken through surveys looked at issues relating to delays in longer stay patients. 1.4 Managing emergency/elective pressures Key Directorates have agreed actions to maximise capacity over the winter, to aid in ensuring that all targets are met during this period and in particular during March 2008, the Accident and Emergency targets. The initiatives will be undertaken as part of an escalation exercise, and will be controlled and managed by the Emergency/Elective Pressures Group. The following have been included over and above the usual escalation arrangements:

• Community hospitals – abolish cut off times for transfer of patients , consider Saturday and Sunday transfers, look at direct admission from Emergency Department/Local Accident Centre for certain patients, and when “appropriate” patients have not been identified, other patients to be considered

• Rehabilitation (Princess of Wales Hospital) – to be far more pro-active in identifying patients for these wards.

• All acute wards in Neath Port Talbot Hospital and Princess of Wales Hospital to identify three potential patients for outlying every shift

• Utilising 4 rooms in Short Stay Unit for acute patients, and use of ambulatory care out of hours

• Increase staffing in key areas • Flexibility through bed managers of ensuring that patients in mid-areas between

Hospitals are directed to hospital with capacity. • No delays when full diverts required, and when necessary treat and transfer patients • Surgical/ringfenced areas to use spare capacity for “outliers” • Review infection control procedures

The Board is asked to note the progress made by the ASB. 2. POLICIES • Alcohol, Drug and Substance Misuse Policy The previous alcohol policies have been updated. The revised policy, attached as Appendix 8.2(i), includes Alcohol, Drug and Substance Misuse. The policy has been discussed and agreed through the Trust Employee Health and Well-Being Group (Corporate Health Standard) and at the JSCC. The Management Executive approved the policy in January 2008. The over-riding policy remains that Employees must not consume or be under the influence of alcohol, illegal drugs or substances during working hours – including breaks, when on-call or stand by. The policy has been updated to reflect the principles of support and treatment as well as dealing with any problems fairly and appropriately which the necessary recourse to the Trust Disciplinary Policy in matters of misconduct. The Trust wishes to encourage employees who suspect they may have an alcohol, drug or substance misuse problem to come forward to their manager or Occupational health Department for a confidential discussion, where help and support can be provided. Where Managers observe deterioration in work performance, erratic timekeeping and/or behavioural problems such observations provide a manager with legitimate grounds to enter into private and open discussions with the employee. The manager should, however, seek the advice of the Occupational Health or Human Resources Department at the time. Arrangements are being made to deliver a training session on the updated policy via the Directorate Development Programme. The Board is asked to ratify the policy. • Freedom of Information Policy & Freedom of Information Operational Procedures The above policy and procedures are attached as Appendix 8.2(ii) are now due for re-approval. They have been reviewed and need no changes. In view of the impending proposed Trust merger, it is recommended that these documents be rolled-over for 12 months. The Board is asked to agree that the above policy and procedures be rolled-over for 12 months for review.

• Governance Support Unit Policies The following policies and procedures are due for re-approval by the Board in February 2008 and are attached as Appendix 8.2(iii). They have been reviewed and need no changes. It is proposed that the current documents are extended for a further period of 12 months, whilst policies and procedures fit for the new organisation are developed for consultation.

• Risk Management Policy and Strategy • Adverse Incident Policy • Adverse Incident Procedure • Adverse Incident Guidance

The Board is asked to agree that the above policy and procedures be rolled-over for 12 months for review. 3. AGENDA FOR CHANGE UPDATE The Trust has made a commitment that all staff will be assimilated and paid their arrears under Agenda for Change by 31st March 2008. To date there are only 117 staff to be assimilated. The outstanding staff are those from Hosted Agencies, staff awaiting the outcome of a review of their banding, and those requiring a Job Analysis Questionnaire. These remaining staff will be assimilated by 31st March 2008. Excellent progress has been made on the payment of arrears in the last month. As a result of the earlier payday only 408 staff were paid their arrears in January. Work is ongoing to ensure that the remaining staff will receive their arrears by 31st March 2008. The Trust Board is asked to note this update 4. CORPORATE HEALTH STANDARD AWARD The Corporate Health Standard, run by the Welsh Assembly Government, is the quality mark for workplace health promotion in Wales. It is presented in Bronze, Silver, Gold and Platinum categories to public and private sector-organisations implementing practices to promote the health and well-being of their employees. Attached, as Appendix 8.4(i), is a summary of the key components of the Standard. Like other workplace quality initiatives, it is a progressive programme and organisations are reassessed every three years. The work to achieve the Standard is consistent with the Business Excellence Model, which drives quality and organisational development in many organisations. The Trust currently holds the Silver Award. All Local Health Boards and NHS Trusts have targets set out in Designed for Life to achieve Gold or Platinum Corporate Health Standard Awards by 2008. A similar requirement has been placed on County Borough Councils. A Mock Assessment for the Trust was held on Thursday 22nd November 2007 and a full assessment will take place on 28th and 29th February, 2008.

The Health and Well Being Working group currently meet on a monthly basis to discuss the action plan, attached as Appendix 8.4(ii) how to achieve the target and health and well-being issues. The group has been made aware of the work being taken forward by Trust staff in developing and implementing Health Social Care and Wellbeing Strategies for 2008-11 in every county. The Corporate Health Standard Platinum category requires that employers demonstrate business excellence and sustainable development in their environment, economic and social goals. The Trust must have obtained the Gold Standard prior to consideration of Platinum. The work undertaken by the Health and Social Care Strategy will underpin the Trust as a major player within the community. Recently the HR department updated the Trust Intranet and introduced a dedicated section - Employee Health & Wellbeing. This can be accessed via the HR & Operations Directorate or via the Hot Topics button on the front page of the Intranet. The Board is asked to note the commitment to workplace health and well being of Trust employees and the attached Action Plan. 5. CYCLE SOLUTIONS BIKE SCHEME PROPOSAL The Corporate Health Standard is the quality mark for workplace health promotion in Wales. The Trust currently holds the Silver Award and is aiming to achieve Gold in the assessment in February 2008. Evidence is required for the Gold award to demonstrate how the Trust provides support and encouragement to employees in regard to physical activity, for example, evidence of cycle pools, bike purchase schemes or similar initiatives. The purpose of this paper is to provide information and make recommendation that the Trust adopts a Cycle Solutions Scheme for employees. Benefits A bike scheme would enhance the Trust’s existing employee benefits scheme, through ‘Salary Sacrifice’, with savings to the individual of up to 41% on retail prices of bicycles, NIC savings and Income Tax Savings. The Trust will need to co-ordinate the scheme and make deductions from Payroll; however, the Trust will expect a saving of approximately 9.2% on NIC/Income Tax. Other schemes of this nature include the Childcare Voucher Scheme. The scheme would also aid the Trust to support improving staff health, fitness and morale, reducing parking & congestion problems, and improve the Trust’s environmental image. A provider, ‘Wheelies Direct’ have presented to the Trust and currently provide a scheme to Swansea NHS Trust. This company who hold the UK’s widest selection of bicycles and safety equipment, offer any adult bike (& safety equipment) up to £1000, and are reputed to offer first class sales and customer care advice. Swansea NHS Trust introduced the Bike Scheme in Summer 2007, with an initial take up of 68 bikes, and is planning another intake for the scheme during Summer 2008.

How the Scheme works/considerations for Employees Similar to lease car scheme, employee enters into a contract with the Trust for a period of

12 or 18 months (Trust decides timescale), monthly salary sacrifice with the opportunity to purchase the bike with a one off final payment, or return the bike.

Any adult bike (& safety equipment) up to £1000 The scheme is based on ‘salary sacrifice’ which could have an effect on retirement or ill

health pension, death in service lump sum, initial widow/er’s pension if taken in the last three years of service. The NHS pensions agency can provide estimates of the effects for staff thinking of taking up the scheme.

Employee is required to have their own insurance. Warrantee is provided for the duration of the lease. A requirement to sign a terms & conditions contract. A commitment that the bike would be used for 50% of work travelling. Maximum of two bikes may be leased through the scheme. A 7 day cooling off period for applicants joining the scheme.

Implications for the Trust Some upgrading of facilities would be required on various sites, ie, additional bike racks

and additional shower facilities for staff. The Environmental Energy Dept is currently in process of submitting a bid for a grant from the Sports Council for Wales to assist, and indications are we could obtain a grant for approximately £24,000, and the Trust would be obliged to contribute up to 20% of any grant awarded.

The scheme would be offered to monthly paid staff only as it would present risk to manage it for weekly payroll, as leavers may be unable to make full payment from final salary.

Trust will offer 1 or 2 intake dates per year. There could be a shortfall in very few cases of employees terminating without making

final payment – and this would fall back to the Trust, however, this could be outweighed by the Trust saving an overall 9.2% saving on NIC/Income Tax.

As it is a salary sacrifice scheme and the Trust would enter an agreement with a leasing company, Procurement Department has confirmed that there is no requirement to conduct the scheme via Procurement.

Administration The Environmental Energy Department will be responsible for the full administration of the scheme, with support from Human Resources. Cycle Solutions will provide marketing materials, administration and hire agreements. Payroll Responsibility Payroll will be required to make deductions from pay to cover the lease/scheme. Payroll will inform the Scheme Provider when staff leaves the Trust. The Provider will give information on the deduction required for their final salary payment. In some instances employees may have terminated before being able to reclaim any outstanding monies. In these instances the Trust would be responsible for the outstanding dept with the Leasing Company, and would endeavour to recover monies from the employee via the Trust’s debtor process.

The Provider has confirmed that although there may be a shortfall in very few cases, this would be offset by the Trust saving an overall 9.2% on NIC/Income Tax. It will be down to the employee’s manager to ensure a termination is completed in a timely manner to enable recovery on monies from final salary. Swansea NHS Trust confirmed that on one occasion they have had to reclaim monies, the Leasing Company did not require employees to pay a further payment at the end, as it was felt unrealistic for the Trust to try and trace an ex-employee. Publicity The HR Directorate will co-ordinate the publicity of the scheme via the Trust Website, Trust Newsletter, E-mail Directorates. Staff Side will promote via the UNISON website. Cycle Solutions will provide the relevant posters, leaflets and FAQ leaflet for circulation. Conclusions o The introduction of the Bike Scheme will satisfy the criteria for evidence for the Gold

Award under the Corporate Health Standard. o A bike scheme will enhance the Trust’s exiting employee benefits scheme o Employees can make savings of up to 41% on retail prices of bicycles o The Trust can save against NIC and Income Tax. o The scheme will aid Trust to support improving staff health, fitness and morale o Scheme will assist in a reduction in parking and congestion problems within the Trust o Improve the Trust’s environmental image o The Trust would take financial responsibility for the scheme with a Leasing Company. Recommendations a) It is recommended that the Board note the introduction of a Cycle Scheme as outlined

above for employees. b) It is recommended that the Trust establish a multi-disciplinary project group with

appropriate representation from Estates, HR, Finance, Staff Side to implement the scheme.

c) It is recommended that the Trust offer two intake dates per year. 6. COMPLIMENTS AND FORMAL COMPLAINTS Appendix 8.6 provides information on Compliments and Formal Complaints for the period 1/4/07 to 30/11/07, by Directorate. Performance against the 2-day acknowledgement target was maintained at 100% and performance against the 20-day response target was 76%, for the period. The Board is asked to note this information.

7. RISK MANAGEMENT ANNUAL REPORT 2006/7 The Risk Management Annual Report for 2006/07 is attached at Appendix 8.7. The report is intended to provide an update for the Board on the risk management system including activities and progress in the year to ensure the robust, proactive management of risks and the learning of lessons from the risks that occur. Directorates and Management Executive were given the opportunity to provide comments in the early stages of the report’s production. The final version was approved by the Operational Risk Management Group. The Board is asked to note the report. 8. RECORDS MANAGEMENT UPDATE This report provides the Board with an update regarding progress made in terms of a variety of records management issues across the Trust during the past year. The Trust’s Records Management Group met on four occasions and a copy of its revised Terms of Reference are attached at Appendix 8.8. During the past 12 months the group has received reports on a series of issues including, the Health Records Accreditation Project Freedom of Information Requests, Key Performance Indicators in respect of records issues, Health Records Audit Programme, Records Storage, Clinical Coding, the Caldicott Audit and the positive Corporate Governance Review. Further detail on some of these issues is set out below. In addition, the Group reviewed and approved the Trust’s revised Records Management Strategy which the Trust Board approved in December 2007. The Group are currently in the process of drawing together an action plan arising from the Strategy which will take account of Welsh Risk Management Standards and Health Care Standards criteria as well as issues of importance that have arisen around records management issues that require action. Training for staff on the Data Protection Act, Records Management and the Freedom of Information Act is continuing to be carried out on a monthly basis and also on demand for specific staff groups. Training is also now available for staff to access electronically via the Intranet. During the year, some 260 staff took part in this training. Work is currently underway with the Trust’s Review of Mandatory/Statutory Training Group so that this training can become more targeted to specific staff groups. All Directorates, whether clinical or non clinical have designated staff with specific responsibility for records management issues. Health Records Documentation Audits are being carried out by the Health Records and Clinical Audit Departments in line with Welsh Risk Management Standards and the CHKS Patient Records and Information Records Management Programme (PRIMAP). The audit looks at the structure of the records and the quality of the record keeping by clinical staff. Details of the various audits are listed in the Trust’s Audit Programme. PRIMAP provides a framework for quality assurance and quality improvement for patient records and information management service enabling the Trust to examine itself against and benchmark with other Trusts. Work is progressing well in preparation for the next PRIMAP Audit later this year.

The Caldicott Audit is part of the Healthcare Confidentiality Programme in Wales. Trusts audit their performance across a wide range of confidentiality and security measures. This will highlight areas where improvement is needed and provide a benchmark for evaluating progress. The Audit undertaken in January 2008 showed the Trust has continued to achieve a good standard and overall there was evidence that staff were actively applying the Trust’s policies in terms of the security of records as well as demonstrating day to day records management practices. However, the Trust is not complacent and will continue to a planned programme of audits to continue to ‘test’ the use of Trust’s Data Protection and Confidentiality Policy. A number of policies have been reviewed and reapproved during the year to maintain the strict processes in place around the management of health records. The Trust is working with colleagues in Swansea NHS Trust to streamline existing records management related policies in order that these can be redeveloped for the new organisation. The Board is asked to note the annual update.

ALCOHOL, DRUG AND SUBSTANCE MISUSE POLICY This document can be made available in alternative formats or other languages, on request, as is reasonably practicable to do so.

Originator: Human Resources Dept Date Approved: 23rd January 2008 Approved by: Management Executive Date for Review: 23rd January 2011 Policy ID: 528 .

Appendix 8.2(i)

CONTENTS

1. INTRODUCTION 2 2. DEFINITION 2 3. AIMS AND OBJECTIVES 2 4. PRINCIPLES AND VALUES 3 5. IMPLEMENTATION 4

5.1 IDENTIFYING THE PROBLEM 5.2 MANAGER RESPONSIBILITIES 5.3 IMMEDIATE ACTION/RESPONSE 5.4 EMPLOYEE RESPONSIBILITIES

6. TRUST POLICY OF SUPPORT 6 7. DISCIPLINARY PROCEDURE 7 8. EDUCATION AND TRAINING 8 9. REVIEW AND MONITORING 8 APPENDIX 1 - The Law on Drugs 9 APPENDIX 2 - Problems at Work 10 APPENDIX 2 - Sources of help and support 12

1

Appendix 8.2(i)

Bro Morgannwg NHS Trust

Alcohol, Drug and Substance Misuse Policy 1. Introduction The Trust has a duty to protect and maintain the health, safety and welfare of its employees, and to enable those employees to achieve acceptable standards of work performance and behaviour. The Trust recognises that alcohol and drug related problems are primarily matters of health and social concern and therefore will provide support for those employees requiring help and treatment. The Trust will promote the highest standards of awareness of all our staff in all matters and issues relating to alcohol/drugs/substance misuse. The Trust will also seek to minimise the risks, dangers and complaints concerning the standards of health, conduct and capability of our staff and their contribution to the standards of health care for patients. The Management of Health and Safety at Work Regulations, 1999, state that employers could become liable to prosecution should they knowingly allow an employee to continue working if they are affected by alcohol or drugs, thus placing other employees and colleagues at risk. The Trust is also obliged to comply with the Misuse of Drugs Act 1971 and notify police if an employee is found to be in possession of drugs or to be supplying illegal substances.(See Appendix 1) 2. Definition Alcohol and drug related problems are defined as any drinking or illegal drug taking, either intermittent or continual and either in work or in social time, which interferes with a person’s health and or work capability/conduct. 3. Aims and Objectives The objectives of the policy are:-

• To create an open approach in which alcohol and drug related problems can be admitted and dealt with in a fair manner.

• To offer help and support to employees who either suspect or

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know they have an alcohol or drug related problem.

• To provide practical advice and guidance for employees about the prevention and management of alcohol, drug-related and substance misuse problems.

• To raise awareness of the risks and lifestyle factors associated

with drinking and drug taking, promoting a culture which discourages excessive alcohol consumption and any form of drug taking.

• To enable managers to deal effectively with the early

identification of employees whose conduct and/or job performance is affected by misuse of substances.

• To maintain a safe working environment. • To reduce associated sickness absence levels. • To enlist the assistance and co-operation of all staff and other

supportive organisations in seeking to secure these aims. 4. Principles and Values The Policy is based on the following:-

• Employees (including volunteers and contractors) must not consume or be under the influence of alcohol or illegal drugs /substances during working hours. (including breaks, when on-call or stand by)

• It is difficult to predict the time it takes for an individual to

eliminate alcohol and or illegal substances from the body, the effects may still be apparent some time afterwards and impair the person’s ability to carry out their work safely or effectively.

• It is not acceptable for individuals to report for work with a

hangover or suffering from the after effects of consuming alcohol or illegal substances.

• Employees must be made aware that to use, possess, consume,

store or sell drugs on Trust premises, will be considered as gross misconduct. The Trust’s Disciplinary and Dismissal Policy will be invoked which would lead to disciplinary action being taken, which may include dismissal.

• Health Advice relating to alcohol consumption and substance misuse will be provided by the Trust Occupational Health

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Department. Appropriate treatment and or referral on to specialist help will be provided to individuals who have alcohol and or substance misuse problems.

• Employees may be referred to Occupational Health by either a

self referral or management referral. • Any individual seeking support regarding their alcohol or drug

problem will be guaranteed strict confidentiality from Occupational Health and the Human Resources Department.

Prescribed Medication:

• It is acknowledged that some prescription medications may impair a person’s ability to perform certain tasks / work duties safely. Individuals should seek advice from their GP or the Occupational Health Department when starting this type of medication.

5. Implementation 5.1 Identifying the Problem Employees who believe or suspect that they may have an alcohol, drug or substance misuse problem, are encouraged to come forward to their manager, or Occupational Health Department via a self referral, for a confidential discussion. Subsequently, the employee will be afforded help and support in obtaining the appropriate medical treatment, counselling and/or rehabilitation, even if the problem is not yet affecting performance. If counselling or treatment cannot be arranged outside of work time, they will be granted leave to undergo treatment which will be regarded as sick leave in line with their terms and conditions of employment. They will however, have to satisfy the Trust that they are keeping their appointments and co-operating with an appropriate treatment programme. It is recognised that it may take an employee a period of time to overcome such problems. During treatment and upon the advice of Occupational Health, consideration will be given to modification of the individual’s role or hours of work for a limited period of time.

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If further problems arise, or if there is evidence of a relapse following completion of the treatment, the Manager should discuss the case which will be considered on its merits with Human Resources and

Appendix 8.2(i)

Occupational Health. Failure to seek help repeatedly or failure to co-operate with treatment may result in disciplinary action. 5.2 Manager Responsibilities Managers who suspect that an employee may have an alcohol or substance misuse problem should take appropriate action to discuss the matter with the employee. Managers must be aware of the possible symptoms in the workplace of substance misuse, while understanding these symptoms may have another cause. Initial discussion regarding symptoms should take place between the individual and the manager dependent on local circumstances and practice. Managers may draw conclusions about an employee’s substance Misuse problems as a result of observations of deteriorating work performance, erratic timekeeping and/or behavioural problems. (See Appendix 2) Such observations provide a manager with legitimate grounds to enter into private, frank and open discussions with the employee about the problem. Occupational Health support and advice should be offered. If there is no improvement over an agreed period of time, the line manager and HR representative will inform the individual of the observed facts, the possible disciplinary consequences and the potential that he/she had a problem of substance misuse. The individual will be given the opportunity to be referred for further help to avoid these consequences. A referral to Occupational Health will be made and where appropriate, the Occupational Health Department will make arrangements to refer the individual to a trained counsellor. In all cases of fitness to return to work or otherwise during or after any period of substance misuse, the decision will be made by the line manager in consultation with a member of Occupational Health Department and Human Resources staff, and after taking account of all relevant information. Managers must ensure that a copy of the Alcohol and Drug and Substance Misuse Policy is available in their Directorate. Managers are to ensure that information on specialist agencies that may be able to help an individual with an Alcohol, Drug or substance misuse related problem is available to employees as appropriate. This may include Occupational Health, Counselling and Advisory services. (See Appendix 3) Managers are to ensure that employees are aware of this policy and the Trust’s Staff Charter through Departmental Induction procedures.

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Appendix 8.2(i)

If an individual presents for work and is considered to be under the influence of alcohol, drugs or other substance misuse the immediate line manager has a responsibility to make the situation safe by relieving the individual of their duties. The individual should be asked to attend a meeting with the immediate line manager before returning to duty where the issue will be raised under the principles outlined within this policy. 5.4 Employee Responsibilities Employees are to ensure that they work in accordance with the Health and Safety legislation. They are to take reasonable care for themselves and others who may be affected their actions or omissions at work as stated in the Health and Safety at Work Act 1974. Employees have an obligation to work safely within the boundaries of this policy. If a colleague notices obvious signs of substance misuse in another employee, this should be reported to the immediate line manager who will similarly arrange to interview the employee concerned without revealing the identity of the person who provided the information. Employees are to co-operate fully with professional help and support once a problem has been identified. 6. The Trust’s Policy of Support includes: Whilst the Trust will endeavour to support the individual, it is important to reiterate that drug, alcohol and substance misuse has no place in the working environment, and that any action taken is underpinned by the Trust’s Disciplinary Policy. However, support will be provided by: • Referral to Occupational Health. • Referral to appropriate treatment agencies with individual’s

consent and in conjunction with the individual’s GP. • Appropriate time off for such treatment. • Appropriate modification to duties and/or hours during any period

of treatment (with the employee’s consent) and where possible without affecting patient care.

• Recognition of any periods of treatment as periods of sickness absence under the Trust’s Sickness Policy, although definitions for the management of short term absence will not apply in the first instance.

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Appendix 8.2(i)

• Payment of normal salary under the terms of the Trust’s Sickness Policy.

• Suspension of disciplinary procedure during periods of treatment

and rehabilitation. • The right of the employee to be accompanied by his/her friend or

representative of their staff side at all stages of the procedure. 7. The Disciplinary Procedure in relation to the Policy Any member of the Trust found to be supplying, producing, cultivating, using or keeping illegal drugs on Trust premises may be dealt with through the Trust Disciplinary Procedure and referred to the Police for criminal proceedings. Where the individual seeks, or is willing to accept help to overcome a problem associated with substance misuse, the Trust will suspend disciplinary proceedings until the outcome of any treatment. However, in the following circumstances, the individual will be dealt

with under the Trust’s Disciplinary Policy, including dismissal:

• Where the individual refuses to accept there is a substance misuse problem but job performance, attendance or behavioural problems indicate that a problem exists.

• Where the individual accepts that there is a substance misuse

problem but refuses to accept or seek help.

• Where the individual embarks on a programme of medical treatment and rehabilitation but fails to complete it.

• Where an individual who has undertaken a course of treatment

shows evidence of recurrence of the problem, the Trust, at its discretion, may provide further support and treatment depending upon the prognosis.

• In cases where excessive alcohol consumption or

drug/substance abuse leading to behaviour contrary to accepted standards of conduct and safety. Due consideration will be given to all relevant factors and circumstances, including any underlying problems of alcohol/substance abuse.

• Employees will not be subject to disciplinary action on the grounds that they have declined to accept offers of help or withdrawn from help offered, provided work performance is satisfactory.

• Employees, who may have a drink, drugs or substance misuse

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problem, cannot be excused from complying with the accepted standards of conduct and safety of the workforce. Any individual who behaves contrary to these standards will be dealt with under the Disciplinary Procedure.

• In cases of alcohol/drug/substance misuse, the normal

response will be the use of this Policy. It is only in exceptional circumstances that the Disciplinary Procedure will be used in isolation.

• Employment may be terminated in cases of

alcohol/drug/substance misuse where the subsequent action taken leads to the loss of qualifications required doing the job e.g. professional registration, driving licence.

8. Education and Training The Trust will provide appropriate education and information to all employees about alcohol, drug or substance misuse including promotion of any National initiatives via the Occupational Health Department. These include:

• Recommended safe limit for alcohol consumption for men and women.

• The effects of overindulgence in alcohol on health.

• The effects of drug taking on health.

• The prevention and recognition of drug-related problems.

• The effects of substance misuse on health.

• Sources of support in relation to alcohol, drug-related and

substance misuse problems. (See Appendix 3)

• Explain an employee’s duty in relation to a colleague who has a problem with substance misuse and the effects it can cause.

9. Monitoring and Review The policy will be reviewed three years after its implementation or sooner if required.

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Appendix 8.2(i)

APPENDIX 1 THE LAW ON DRUGS It is an offence under the Misuse of Drugs Act 1971: (i) to supply or offer to supply a controlled drug to another in

contravention of the Act; (ii)to be in possession of, or to possess with intent to supply to

another, a controlled drug in contravention of the Act, it is a defence to the offence of possession that, knowing or suspecting it to be a controlled drug, the accused took possession of it for the purpose of preventing another from committing or continuing to commit an offence and that as soon as possible after taking possession of it he took all such steps as were reasonably open to him to destroy the drug or to deliver it into the custody of a person lawfully entitled to take custody of it

(iii)for the occupier or someone concerned in the management of

premises knowingly to permit or suffer on those premises the smoking of cannabis, or the production, attempted production, supplying, attempting to supply or offering to supply of controlled drugs to take on those premises.

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Appendix 8.2(i)

APPENDIX 2 PROBLEMS AT WORK CAUSED BY ALCOHOL / DRUG /

SUBSTANCE MISUSE Given the wide variety of jobs within the Trust, some of the following will be relatively more important than others, dependent on the task undertaken. However, any substance misuse can cause severe problems, not only for the individual and his/her family, but also for fellow employees and patients. Those problems can occur not just in the more obvious area of Health & Safety but also due to unsatisfactory work performance and poor relationships at work. Problems can appear in some or all of these ways: It should be noted that the following performance problems are not always symptomatic of substance misuse related problems but could signify stress, mental or physical illness or the presence of problems external to the workplace. Work Performance

• Poor decision making • Absences from post - more than normally required • Overlong breaks • Decrease in concentration - jobs take longer, require greater

effort • Difficulty in recalling instructions and details • Decline in quality and quantity of work • Increase in errors of judgement • Increased tiredness • Loss of interest in work • General unreliability and unpredictability • Improbable excuses for poor performance • Accident prone

Accidents Evidence suggests that the problem drinker is between 3 to 4 times more likely to have or cause accident at work than someone without a problem of this nature. In some cases for instance operating machinery, even ‘sensible limits’ of drink can be too much. As such problems can be caused by:

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Appendix 8.2(i)

• High accident rates in work • Accidents off the job i.e. at home or travelling to/from work. • Accidents can also be caused as a result of misuse of drugs or

other substances covered within the remit of this policy. Poor Relationships with Fellow Employees

• Over reaction to real or imagined criticism • Unreasonable resentments • Irritability • Complaints from fellow workers • Borrowing money from colleagues • Avoidance of Supervisor and/or fellow workers • All of these can subsequently lead to grievances and disputes in

the workplace. Individual Behaviour

• Reporting to work smelling of drink • Increasingly unkempt appearance • Decline in personal hygiene

Non Attendance Non attendance manifests itself in a number of ways:

• Unusually high sickness levels, often accompanied by imprecise reason on medical certificates.

• Multiple instances of unauthorised weekends or days off. • Late applications for half or one days annual leave. • Excessive lateness at start of duty and after lunch breaks • Leaving early • Unauthorised breaks • Frequent short term absence from duty (with or without

explanation)

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Appendix 8.2(i)

APPENDIX 3

SOURCES OF HELP and SUPPORT

INTERNAL

Bro Morgannwg NHS Trust’s Occupational Health Department. Individuals’ may self refer by contacting 01656 752158(POW) or on 01639 683197 (NPTH)

The following organisations are just some that are available

throughout the country. There are many, many more.

WELSH ORGANISATIONS

ALCOHOLICS ANONYMOUS New Trinity United Reform Church Cowbridge Road East Cardiff Tel: 02920 373939

NATIONAL HELPLINE: 0845 7697555

24 HOUR SERVICE

www.alcoholics-anonymous.org.uk

THE SAMARITANS UK Line 0845 7909090 www.samaritans.org.uk Cardiff East & Glamorgan 75 Cowbridge Road East Cardiff Tel: 02920 344022 2 Green Street Bridgend Tel: 01656 662333

Turning Point Cymru 57-59 St Mary Street Cardiff, CF10 1FF Tel: 02920 227327 Advice, counselling and support centres for users, families and friends.

Cardiff Community Addictions Unit ADFER UNIT West 1 Ward Whitchurch Hospital Cardiff, CF4 7XB Tel: 02920 693191 Treatment for people with drug, alcohol and solvent problems and help in rehabilitation.

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Appendix 8.2(i)

Cardiff MIND Neath MIND Re-Solv 166 Newport Rd Ty Croeso The Society for the Prevention of Cardiff 32 Victoria Gdns Solvent and Volatile Substance CF24 1DL Neath, SA11 3BH Abuse (VSA) 20A Berriew Street Tel: 02920 402040/ 01639 643510 admin@cardiffmind.orgneathmind@btconnect.com Help and information. Co-ordination of tranquilliser withdrawal self-help groups

Welshpool Powys, SY21 7SQ Tel: 01938 556750 www.re-solv.orgPromotes education on solvent abuse, sponsors teaching and information programmes, produces guidance material and good practice for prevention.

FREEPHONE HELPLINE 01785 810762

NATIONAL DRUG HELPLINE 0800 776600

Free confidential advice and information on drugs 24 hours a day

Drugscope 40 Bermondsey Street London SE1 3UP Tel: 0207 940 7500 Provide information on wide range of drug related topics.

Narcotics Anonymous WCSWA SC PO Box 2643 Bristol, BS% SBN Tel: 0117 924 0084 NAHelpline@ukna.org

NATIONAL HELPLINE: 0845 3733366

24 HOUR SERVICE First point of contact for people

needing support and advice about the nature

of drug addiction.

BAC(British Association for

Counselling)

Youth Access 1-2 Taylor’s Yard

15 St John’s Business Park 67 Alderbrook Road Lutterworth London Leicestershire SW12 8AD LE17 4HB Tel: 0208 772 9900 www.bacp.co.uk admin@youthaccess.org.uk

Information on counselling and advisory services throughout the country.

Information and referral to counselling agencies throughout the Country.

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Appendix 8.2(i)

Originator: Corporate Administration Date Approved: 23rd January 2008 Approved by: Management Executive Date for Review: 23 rd anuary 2009 JPolicy ID: 226

FREEDOM OF INFORMATION ACT 2000 POLICY This document can be made available in alternative formats or other languages, on request, as is reasonably practicable to do so.

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Appendix 8.2(ii)

CONTENTS

1. BACKGROUND................................................................................................. 2 2. PURPOSE......................................................................................................... 2 3. SCOPE.............................................................................................................. 2 4. ROLES AND RESPONSIBILITIES.................................................................... 3 5. PUBLICATION SCHEME .................................................................................. 4 6. GENERAL RIGHTS OF ACCESS TO RECORDED INFORMATION ................ 4 7. PROCESSING A REQUEST............................................................................. 5 8. EXEMPTIONS................................................................................................... 6 9. CHARGES AND FEES...................................................................................... 6 10. TIME LIMITS FOR COMPLIANCE WITH REQUESTS...................................... 7 11. TRANSFERRING REQUESTS FOR INFORMATION....................................... 7 12. CONSULTATION WITH THIRD PARTIES ........................................................ 7 13. PUBLIC SECTOR CONTRACTS ...................................................................... 7 14. ACCEPTING INFORMATION IN CONFIDENCE FROM THIRD PARTIES....... 8 15. COMPLAINTS................................................................................................... 8 16. RECORDS MANAGEMENT.............................................................................. 8 17. TRAINING ......................................................................................................... 8 18. LEGAL ADVICE ................................................................................................ 8 19. WELSH LANGUAGE ACT................................................................................. 8 20. AUDIT AND REVIEW ........................................................................................ 8 21. REFERENCES AND RELATED POLICIES....................................................... 9

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Appendix 8.2(ii)

1. BACKGROUND 1.1 The Freedom of Information Act (FOIA) is part of the Government’s

commitment to greater openness in the public sector. The underlying principle is that all information held by a public authority should be freely available unless an exemption applies. The FOIA seeks to balance three rights:

• The right to information • The right to confidentiality • The right to effective public administration.

1.2 The Act embodies much of what is already good practice in the NHS as set

out in the NHS Code of Openness. It supplements & complements the Data Protection Act (DPA), which gives individuals access to personal information held about them. The FOIA, which comes fully into force from 1st January 2005, gives access to all other information and is fully retrospective.

2. PURPOSE 2.1 This document is a statement of what Bro Morgannwg NHS Trust will do to

ensure compliance with the Freedom of Information Act 2000 and the statutory Codes of Practice issued by the Department of Constitutional Affairs1. It is not a statement of how compliance will be achieved; this is a matter for operational procedures. The Trust will take into account guidance notes which are issued from time to time (by the Department of Constitutional Affairs, the Information Commissioner and the National Archives Office) and will update its policy and operational procedure at timely intervals or following publication of significant national guidance.

2.2 It explains the principles which underpin the Trust’s commitment to openness

and transparency in the decisions made about the provision of health care to the local community

2.3 It sets out a commitment to full implementation procedures to ensure

compliance with the Codes of Practice issued under Sections 45 and 46 of the Act2 .

2.4 It emphasises the importance of good record keeping which ultimately is the

responsibility of all staff using or creating records. 2.5 It identifies the need for ongoing, effective training, which meets the needs of

staff at all levels within the organisation. 2.6 It acknowledges the need for Trust staff to pro-actively provide advice and

assistance to anyone wishing to access information3

3. SCOPE 3.1 This Policy applies to all Trust employees (including honorary contract

holders, agency staff, students, work placements and volunteers) and to Non-Executive Directors.

1 under sections 45 and 46 of the FOIA 2 Code of practice on the Discharge of Public Authorities` Functions under Part 1 of the Freedom of Information Act and the Code of Practice on the Management of Records issued under sections 45 and 46 of the FOIA 2000 respectively by the Department of Constitutional Affairs 3 Section 16 of FOIA

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Appendix 8.2(ii)

3.2 This policy is applicable to all the activities arising out of the daily workings of the Trust or the bodies which it hosts including activities undertaken in conjunction with other stakeholders such as other NHS organisations, the local authority, the police, voluntary organisations, commercial suppliers and the Welsh Assembly Government. Systems for handling information requests received by or about host organisations will be detailed in the Trust's FOI Operational Procedure. FOI requests received by hosted organisations (about themselves or other public bodies on which they hold information) will be classed as 'routine' and will be handled by those organisations. Complex FOI requests may need to be handled in conjunction with the Trust's FOI Co-ordinator.

3.3 Requests for certain classes of information may fall under the Environmental

Information Regulations (EIR) which come into force 1st January 2005 or the Data Protection Act (DPA), the provisions of which have been extended by the FOIA.

3.4 The Trust accepts that patients and staff have a right to privacy and

confidentiality which are dealt with under the provisions of the DPA 1998. The FOIA clearly explains that it runs in parallel with the DPA which only provides access to applicants wishing to have sight of their personal data. This Policy does not change the common law duty of confidence or statutory provisions (including the Human Rights Act 1998 and the DPA) that prevent disclosure of personally identifiable information.

4. ROLES AND RESPONSIBILITIES 4.1 The Chief Executive is ultimately responsible for the Trust complying with

FOIA/EIR/DPA. On a day-to-day basis, responsibility will be delegated to the Deputy Chief Executive who will ensure there are effective arrangements in place to enable compliance. This officer will also assume Board responsibility for FOI issues and will be known as the 'FOI Champion'.

4.2 The Head of Administration will be responsible for the implementation of the

policy and operational procedure. This post holder will also be responsible for submitting reports to the Management Executive and the Trust Board setting out trends in volume of requests, compliance with timescale targets and complaints etc. The Head of Administration will oversee the operation of the Trust’s procedure for accessing information and will work in tandem with the Caldicott Guardian and Information Governance Manager to achieve this.

4.3 The FOI Request Coordinator will operate the procedure on a day to day

basis taking advice from the Head of Administration where necessary. 4.4 Executive Directors will assist the FOI Co-ordinator in the process of

examining information gathered in response to a request for information to determine if the Trust is able to proceed to disclosure.

4.5 The operational procedure will set out levels of authority in relation to

decisions around disclosure of information. 4.6 The operational procedure will set out the responsibilities of Executives and

Non Executive Directors in “Internal Review” which provides a system for reviewing decisions made in relation to releasing information.

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Appendix 8.2(ii)

4.7 Directorate Leads for FOI/Records Management will be responsible for relaying formal requests to the FOI Request Co-ordinator and presenting relevant information to the FOI Request Co-ordinator who will arrange for a decision as to disclosure to be made.

4.8 Clinical Directors, Managers and Supervisors are responsible for ensuring

that this policy, and any associated procedures governing the actions of Directorate staff are communicated and fully understood within their area.

4.9 New staff will receive information about the FOIA/EIR as part of Corporate

Induction processes and local induction. 4.10 Timescales procedure for releasing information will be set out in the

operational procedure. In general, however, any request for information which staff receive that is outside their scope or remit will be relayed to the FOI Request Co-ordinator within one working day of its receipt.

4.11 Any request for information conveyed to the Trust by e-mail will not be

deemed to have been received if the addressee had an out of office message in place.

5. PUBLICATION SCHEME 5.1 The Trust adopted a model Publication Scheme which has been approved by

the Information Commissioner and this was launched in October 2003. The Publication Scheme can be accessed through the Trust’s website (www.bromor-tr.wales.nhs.uk). All new employees of the Trust will be made aware of the Scheme as part of induction and it will be featured in the Trust Newsletter and on the Trust Intranet/Internet site.

5.2 The Trust will seek to publish as much information about its activities so that

members of the public do not necessarily have to make a formal request for access to information under the Freedom of Information Act.

5.3 The Trust’s Publication Scheme is a living document and its content will be

monitored by the Head of Administration who will be responsible for updating corporate information. Directorate FOI/Records Management Leads will make monthly reports to the Head of Administration providing new or additional information for publication.

5.4 Where a piece of disclosable information has been requested on three or

more occasions during of period of six months, this will result in the information being added to the publication scheme.

6. GENERAL RIGHTS OF ACCESS TO RECORDED INFORMATION 6.1 Section 1 of the Act gives a general right of access from 1st January 2005 to

recorded information held by the Trust, subject to certain conditions or exemptions contained in the Act. Information could be held in any form, e.g. e-mail, paper, audio/video tape, photograph, diary entries, minutes/agenda papers, briefings, etc.

6.2 Anyone making a formal request for information is entitled:

- to be informed in writing whether the Trust holds the information of the description specified in the request (this is referred to as the “duty to confirm or deny”); and

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Appendix 8.2(ii)

- if the Trust holds the information, to have this made available to them.

6.3 However, a certain level of information has always been given to the public

and the provisions of the FOIA are not meant to interfere with this. Staff wherever they are in the organisation will therefore carry on dealing with these day to day matters. Where the subject matter is outside the normal scope of the member of staff or may have implications under other legislation such as the DPA, staff will need to relay requests to the FOI Request Co-ordinator who will be equipped to manage such requests.

6.4 Whilst there is no requirement for the applicant to specify that the request is

being made in accordance with the provisions of the Act, the provisions of the Act will apply to all formal requests. The request must be written with via a letter or sent by email and give a name and address (which need not necessarily be their own) and a description of the information requested. For information falling into the remit of EIR, the request need not be written.

6.5 The Act is fully retrospective and will apply to all information held by the Trust

at the time the request is made. Systems already exist within the Trust for archiving and destroying information. The Trust’s Records Management Strategy references guidance received under WHC 2000 (71) setting out retention and destruction guidance which Directorates operate alongside local guidelines. It could be that on occasion the information being sought by an applicant has legitimately been destroyed in accordance with these guidelines.

6.6 It is not appropriate to ask the applicant for the reason or purpose behind their

request, although the Trust can request further detail about the information required to help refine vague or broad requests.

6.7 The Trust will produce guidance to help any applicant who may wish to make

a request for information. Copies of the leaflet will be available from the FOI Request Co-ordinator or from the Trust’s Internet/Intranet website. The Trust will also produce a leaflet to provide an aide memoire for staff reminding them of their responsibilities should someone pass a request for information to them.

6.8 The importance of effective record management (paper and electronic) is

acknowledged as vital not only for the day to day business efficiency of the Trust but also in terms of the Trust’s obligations under FOI, EIR and Data Protection. Staff must take responsibility for the records they use and create. Advice on the storage, transportation and filing of records is contained in the Health Records Policy and the Records Management Strategy.

7. PROCESSING A REQUEST 7.1 A procedure for the management of formal requests for information will be

approved by the Management Executive and published on the Trust’s Intranet Policies web page.

7.2 Directorate/Department FOI/ Records Management Leads will need to be

clear about the records their area holds (electronic and paper, archived and current) in order that they can promptly advise the FOI Request Co-ordinator if they hold anything relevant when requests are received.

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Appendix 8.2(ii)

7.3 The FOIA, DPA and the EIR provide timescales for responses. For FOI and EIR these are 20 working days and for DPA the timescale is 40 calendar days. Within these times the request must be acknowledged, a decision needs to be made as to whether the information requested is “held” and if so if all of it is fully disclosable, or partly disclosable, or none of the information can be released. It may be necessary to consult a third party if the information in question is about them or their organisation/company although the Trust is not obliged to take their views into account in every circumstance. Each part of their process has administrative consequences which need to be carefully thought out and the decision making process recorded in case the applicant wishes to question it later. These timescales are likely to be challenging and the importance of keeping the applicant informed to avoid unnecessary breakdowns in communication is acknowledged.

8. EXEMPTIONS 8.1 There are two categories of exemption, absolute and non-absolute. An

absolute exemption means that the Trust is exempt from disclosure. A non-absolute exemption requires the Trust to also apply the public interest test to establish whether the application of the exemption is outweighed by the public interest in disclosing the information. These are complex and the sustainability of certain of these provisions will ultimately be a decision for the Information Commissioner.

8.2 In determining whether an exemption may apply, if the request includes other

information which the Trust is confident it can release, then this will be disclosed without unnecessary delay.

8.3 The FOI Request Co-ordinator will develop expertise in this area which

should over time reduce the necessity for seeking legal advice unless the circumstances are complex.

8.4 On occasion it may be necessary to delete or redact certain information for

legitimate reasons. The FOI Request Co-ordinator will apply the necessary means to ensure that whether such instances involve paper or electronic information – the applicant will not be able to override the redaction process. A copy of the original document will be retained for reference should the matter become the subject of an internal review or and Information Commissioner’s complaint investigation.

8.5 If the Trust chooses to refuse a request for information under any of the

exemptions, the applicant will be informed of the reasons for this decision within twenty working days. As set out in section 17(7) of the Act the applicant will also be informed of routes for making a complaint, i.e. Internal Review and the Information Commissioner.

9. CHARGES AND FEES 9.1 Generally, the Trust will not charge for information that it has chosen to

publish under its Publication Scheme. Charges may be levied for hard copies, multiple copies or copying onto media such as CD-ROM. The Publication Scheme and the procedures that support this Policy will provide further guidance on charging.

9.2 The Trust will follow the statutory Fees Regulations for general rights of

access made under the Act.

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Appendix 8.2(ii)

9.3 In all cases where the Trust chooses to charge for information or levy a fee arising from an information request under general rights of access, a fees notice will be issued to the applicant as required by Section 9 of the Act. Applicants will be required to pay any fees within a period of three months beginning with the day on which the fees notice is given to them.

10. TIME LIMITS FOR COMPLIANCE WITH REQUESTS 10.1 The Trust has systems and procedures to ensure that the organisation

complies with the duty to confirm or deny and to provide the information requested wherever possible within twenty working days of a request or within a reasonable period of time where the public interest test has to be considered.

11. TRANSFERRING REQUESTS FOR INFORMATION 11.1 A request can only be transferred to another public body where the Trust

receives a request for information which it does not hold, within the meaning of section 3(2) of the Act, but which is held by that other public authority. If the Trust receives a request and holds some but not all of the information requested, a transfer may be made only in respect of Trust information which it does not hold (but which is held by another public authority).

11.2 All transfers of requests will take place as soon as is practicable and the

applicant will be informed once this has been done. Where the Trust is unable either to advise the applicant which other public authority holds, or may hold, the requested information or to facilitate the transfer of the request to another authority (or considers it inappropriate to do so) it will consider what advice, if any, it can provide to the applicant to enable him or her to pursue his or her request.

12. CONSULTATION WITH THIRD PARTIES 12.1 The Trust recognises that in some cases the decision as to the disclosure

may affect the legal rights of a third party, for example where information is subject to the common law duty of confidence or where it constitutes “personal data” within the meaning of the Data Protection Act 1998 (“the DPA”). Unless an exemption under the Act applies, the Trust will be obliged to disclose that information in response to a request. Wherever possible the Trust will attempt to advise the party who provided the disclosable information that this has been requested.

13. PUBLIC SECTOR CONTRACTS 13.1 The Trust’s procurement processes will be compliant with any applicable EC

procurement regulations and also with the Act. This Policy should be read in conjunction with the Trust’s procurement policy. Partnership agencies and commercial suppliers of goods and services should be made aware of the Trust’s obligations under the Act and under the Section 45 Code. In deciding whether any information may be exempt from disclosure because it may involve a breach of confidentiality imposed by a third party or it may breach a “trade secret” or it may prejudice the commercial interest of any party, the Trust will take into account current guidance issued by the Information Commissioner or the Department of Constitutional Affairs.

7

Appendix 8.2(ii)

14. ACCEPTING INFORMATION IN CONFIDENCE FROM THIRD PARTIES 14.1 The Trust will only accept information from third parties “in confidence” if it is

necessary to obtain that information in connection with the exercise of any of the authority’s functions and it would not be otherwise provided.

14.2 The Trust will not agree to hold information received from third parties “in

confidence” which is not confidential in nature. Again, acceptance of any confidentiality provisions must be for good reasons, capable of being justified to the Information Commissioner.

14.3 Internally generated Trust documents/correspondence cannot be classed as

“in confidence” for the purposes of FOIA. Provisions under the Data Protection Act are unaffected. However, information held in relation to a patient’s individual case/treatment of personally identifiable information held in relation to a member of staff’s employment are not subject to the FOI. Prior to the release of any documents/correspondence they will be reviewed and redaction undertaken as necessary in line with FOIA principles.

15. COMPLAINTS 15.1 A procedure for dealing with complaints will be contained in the operational

procedure. This will set out the process referred to as Internal Review. 15.2 The procedure will also refer applicants to their right under section 50 of the

Act to apply to the Information Commissioner if they remain dissatisfied with the conduct of the Trust following attempts at Internal review of their complaint.

16. RECORDS MANAGEMENT 16.1 The Trust has a separate policy with supporting systems and procedures that

will ensure compliance with Lord Chancellor’s Code of Practice on the Management of Records under section 46 of the Freedom of Information Act 2000 and the Welsh Health Circular (2000)71. This is the Records Management Strategy.

17. TRAINING 17.1 The Trust will establish a training plan which will:

• Provide greater awareness of the FOIA, Environmental Information Regulations and Data Protection Act awareness;

• Meet the needs of staff throughout the organisation; • Ensure the competence of individuals at appropriate levels.

18. LEGAL ADVICE 18.1 Occasions will arise when there is a need for legal advice, and this will be co-

ordinated through the Head of Administration. 19. WELSH LANGUAGE ACT 19.1 This policy acknowledges the need to comply with the Trusts Welsh

Language Scheme. 20. AUDIT AND REVIEW 20.1 Performance under this policy will be measured by regular auditing.

8

Appendix 8.2(ii)

20.2 This policy will be reviewed bi-annually and amendments made to meet the Trust’s objectives to achieve FOIA compliance.

21. REFERENCES AND RELATED POLICIES

• Data Protection Act 1998 • Freedom of Information Act 2000 • Lord Chancellor’s Code of Practice on the Discharge of Public Authorities’

Functions under Part I of the Freedom of Information Act 2000, issued under section 45 of the Act, November 2002

• Lord Chancellor’s Code of Practice on the Management of Records under section 46 of the Freedom of Information Act 2000, November 2002.

• Department of Constitutional Affairs web site • Information Commission web site • National Archives web site • Bro Morgannwg NHS Trust Records Management Strategy • Bro Morgannwg NHS Trust Complaints Procedure • Bro Morgannwg NHS Trust FOI Operational Procedures • Bro Morgannwg NHS Trust Procurement Policy • Bro Morgannwg NHS Trust Standing Orders • Welsh Risk Management Standards 6, 7 and 8

9

Appendix 8.2(ii)

Originator: Corporate Administration Date Approved: 23rd January 2008 Approved by: Management Executive Date for Review: 23rd January 2009 Policy ID: 227

OPERATIONAL PROCEDURES FREEDOM OF INFORMATION ACT 2000 This document can be made available in alternative formats or other languages, on request, as is reasonably practicable to do so.

Appendix 8.2(ii)

CONTENTS 1. INTRODUCTION 1.1 Freedom of Information Act 2000 1.2 Department of Constitutional Affairs 1.3 Duty to Provide Advice and Assistance 1.4 Aims and Scope of the Operational Procedure 1.5 Publication Scheme/general right of access 1.6 Responsibilities 1.7 Guidance Leaflets 1.8 Normal business - dealing with "non-formal requests for information 2. CATEGORISING AN ENQUIRY 3. DEALING WITH THE INITIAL APPLICATION FOR INFORMATION 3.1 Publication Scheme Applications 3.2 General Right of Access Applications 4. PROCESSING REQUESTS FOR INFORMATION 4.1 Stage One - Receipt of a Request 4.2 Stage Two - Accessing Information 4.3 Stage Three - Providing Information 5. REFUSAL OF REQUESTS 6. PROVISION OF ADVICE AND ASSISTANCE TO APPLICANTS 6.1 FOI Co-ordinator 6.2 Provision of insufficient information 6.3 Applicant is unprepared or unable to pay a charge or fee or fees exceed appropriate limit 6.4 Vexatious or repeated requests 6.5 Requests which appear to be part of an organised campaign 7. TRANSFERRING A REQUEST FOR INFORMATION 8. CONSULTATION WITH THIRD PARTIES 8.1 Where a request affects legal rights of a third party 8.2 Consultation in non-legal circumstances 8.3 Consultation with a number of third parties 8.4 Where there is no response or a refusal to consent by the third party 9. CHARGES AND FEES 9.1 Publication Scheme Charges 9.2 Fees under general right of access 9.3 Fees, Charges and Timescales 10. COMPLAINTS AND FEEDBACK 11. ACCESSING AND MAINTAINING THE PUBLICATION SCHEME 12. TRAINING AND AWARENESS RAISING 13. LEGAL ADVICE 14. REVIEW 15. REFERENCES

Appendix 8.2(ii)

1. INTRODUCTION 1.1 Freedom of Information Act 2000 (FOIA) 1.1.1 This Operational Procedure puts into practical effect the Freedom of Information Policy of Bro

Morgannwg NHS Trust and should be read in conjunction with it. 1.2 Department of Constitutional Affairs Code of Practice 1.2.1 This document is based upon the Code of Practice issued by the Department of Constitutional

Affairs pursuant to section 45(5) of the Act1. It is designed to support implementation of the Act and ensure compliance with Code of Practice.

1.2.2 Failure to comply with the Code of Practice may result in making a best practice

recommendation by the Information Commissioner, Under Section 47 of the Act the Information Commissioner has a duty to promote the observance of the Code by public authorities. Evidence of compliance with the Code by the Trust will be regarded as evidence of good practice.

1.3 Duty to Provide Advice and Assistance 1.3.1 Section 16 of the Act places a duty on public authorities to provide advice and assistance to

applicants. The procedures in this manual will facilitate compliance with this duty which, again, is enforceable by the Information Commissioner. In the discharge of this duty the Trust will take account of other Acts of Parliament that may be relevant to the provision of advice and assistance to those requesting information, e.g. the Human Rights Act 1998, the Data Protection Act 1998, the Disability Discrimination Act 1995 and the Race Relations Act 1976 (as amended by the Race Relations (Amendment) Act 2000).

1.3.2 All staff will be responsible for the discharge of this duty in respect of this Trust. 1.4 Aims and Scope of the Operational Procedure 1.4.1 In common with the Code of Practice, the aim of this procedure is to facilitate the disclosure of

information under the Act by setting out good administrative practice that the Trust will follow when handling requests for information, including, where appropriate, the transfer of a request to a different authority;

1.4.2 Board Directors and staff (including agency/casual staff) must be aware of, and adhere to,

these procedures, which apply to all individuals engaged in the discharge of the duties of this Trust.

1.4.3 This procedure will be reviewed in line with the Trust's Policy on Policies. 1.5 Publication Scheme/general right of access 1.5.1 Requests for information under the Act will arise from two different rights:

• the right of access to the material published on the Trust’s Publication Scheme; or • the general right of access to recorded information held by public authorities.

1.5.2 The Trust has adopted a model Publication Scheme for NHS Trusts and is a proactive tool for

the dissemination of information relating to the business of the Trust and should be as comprehensive as possible. The Scheme is accessible through the Trust’s web site at www.bromor-tr.wales.nhs.uk. The FOI Co-ordinator will review the Publication Scheme for content and accuracy on a six-monthly basis. The Information Commissioner will formally review the Publication Scheme every three to four years.

1 Lord Chancellor’s Code of Practice On The Discharge of Public Authorities’ Functions Under Part I of the Freedom of Information Act 2000, Issued under Section 45 of the Act, November 2002

3

Appendix 8.2(ii)

1.6 Responsibilities 1.6.1 The Deputy Chief Executive is responsible to the Board for the operation of FOIA within the

Trust. The postholder will also act as the contact point for complaints about the operation of FOIA within the Trust.

1.6.2 The Head of Administration is responsible for ensuring FOIA requests trust-wide are

responded to within the agreed timescale. The postholder will make the decisions on fees, exemptions, vexatious requests and seeking legal advice. The postholder will have authority to process routine responses to requests for information and will work with the Executive Team to reach agreement on how the Trust will respond to complex/contentious requests.

1.6.3 The FOI Co-ordinator will be responsible for managing the FOIA administrative process and

working in conjunction with Directorates Leads and the Head of Administration/Executive Directors in responding to FOIA requests.

1.6.4 The FOIA Directorate Leads are responsible for ensuring that FOIA requests are dealt with in

their Directorates in a timely, reliable and efficient manner and for liasing with the FOIR Co-ordinator regarding completing requests. Directorate Leads are responsible for responding to the FOI Co-ordinator within five working days in terms of providing information being requested by an applicant.

1.7 Guidance Leaflet 1.1.1 Attached at Appendices 1 & 2 are copies of the Guidance Leaflets aimed at members of the

public and staff. Staff will need to make the respective leaflet available to the public. 1.8 Normal Business - Dealing With "Non-formal" Requests For Information 1.8.1 Whilst any request in writing for access to information is a request made under the Act, in

practice, information is made available on a daily basis by the Trust to stakeholders through staff as part of the routine day to day business of providing healthcare services. It would be impractical and overly bureaucratic to attempt to record this activity for FOIA purposes.

1.8.2 It is therefore not appropriate to use these procedures and refer issues to the FOIA

Directorate Lead/FOI Co-ordinator where, for example:

• information that is part of the Trust’s normal business process. This would also include information contained in leaflets and other reference material that has already been approved for use by the Trust. This would also include the Publication Scheme, Trust Board papers, Annual Reports, the Delivery Plan and service information leaflets;

• information about current care and treatment of an individual using established practices – for example, sharing care plans with the service user as part of normal clinical interactions;

• information that is already reasonably accessible to the applicant by other means; • where a request does not include a name and address for correspondence/e-mail

contact; • a request is made orally (unless it is a request under Environmental Information

Regulations (see 2).

4

Appendix 8.2(ii)

2. CATEGORISING AN ENQUIRY

There be many types of requests and it is important to establish what type of information is being asked for by using the table below: Request Format Legislation Deadline Information about the applicant (or someone authorised to act on their behalf

Must be written

Data Protection Act

40 calendar days

Information about someone else (a ‘third party’) or any other written information.

Must be written

Freedom of Information

20 working days

Information about the environment or human interaction with the environment (land, landscape, soil, water, air, atmosphere, flora and fauna etc)

Can be oral or written

Environmental Information Regulations

20 working days

General advice e.g. opening hours, how to get to the office, anything which can be answered immediately from memory e.g. local knowledge, etc.

Any None None

3. DEALING WITH THE INITIAL APPLICATION FOR INFORMATION

3.1 Publication Scheme Applications 3.1.1 The Publication Scheme directs all applicants who require assistance in obtaining information

from the Trust to the Head of Administration. As the Publication Scheme also lists the contact details of other key people within the Trust, these individuals may also receive enquiries via the Publication Scheme. The Trust also has an e-mail inquiries facility, which could receive requests for information. This is managed by staff within the Head of Administration's Department.

3.1.2 In the event that a request arising from the Publication Scheme is directed to an individual

other than the FOI Co-ordinator, that individual must:

• take the name and contact details of the applicant; • ascertain what information the applicant wants and inform them that their request will be

referred to the FOI Co-ordinator within one working day; • provide the applicant with the contact details of the FOI Co-ordinator and inform them that

their enquiry will be responded to as soon as possible and within a maximum of twenty working days;

• pass the applicant’s name, contact details and a detailed account of what information

they require to the FOI Co-ordinator. 3.2 General Right of Access Applications 3.2.1 Applications made under the general right of access to recorded information will relate to all

recorded information not listed in the Publication Scheme. These requests may be retrospective in that they may seek information held by the organisation that is no longer being actively used or that has been archived.

3.2.2 Unless part of normal day to day business processes, all written requests for information to

the Trust must, from 1st January 2005, be treated as if they are a FOIA request.

5

Appendix 8.2(ii)

3.2.3 All applications must be received in writing (which includes a request transmitted electronically) and include a postal or email address. Where a member of staff receives a request that is not part of routine business activity this must be passed to their FOIA Directorate Lead/FOI Co-ordinator within one working day. If the application has been made in the form of a letter the original documentation should also be sent to the FOIA Divisional/Directorate Lead/FOI Co-ordinator in addition to the facsimile or electronic copy.

3.2.4 Once the FOIA Directorate Lead/FOI Co-ordinator has received the applicant’s request the

procedures for processing requests for information will be activated and the request logged. 4. PROCESSING REQUESTS FOR INFORMATION 4.1 Stage One - Receipt of a Request 4.1.1 On receipt of a request the FOIA Directorate Lead/Head of Administration will be responsible

for ensuring that a system is used for the recording of requests and this is kept up to date.

• Initial Date Received by the Trust • Name and Contact Details of Initial Recipient • Date Received • Name of applicant • Contact Details • Access route – Publication Scheme or general right of access • Information Requested

A summary of all the information that the Trust will record, for the purposes of monitoring compliance with the Act, can be found in Appendix 3.

4.1.2 The FOIA Co-ordinator will write to the applicant (email contact will be appropriate if the

applicant has made contact by email) within two working days of receipt of the applicant’s request to inform the applicant that their request has been received and is being considered (Appendix 4). A record will be kept of this contact.

4.1.3 If the request relates to information contained within the Trust’s Publication Scheme this will

be dealt with by the FOI Co-ordinator. If the request comes under the general right of access, the FOI Co-ordinator will determine whether the information being requests is already available via the Trust's Publication Scheme, and if not, whether exemptions apply (see 5.1). If neither of these apply, the FOIA Directorate Leads/ FOI Co-ordinator will seek access to the information from the relevant Directorate(s).

4.2 Stage Two - Accessing the Information 4.2.1 Upon receipt of an information request from the FOIA Directorate Lead, the FOI Co-ordinator

will contact relevant Directorates and required them to respond within five working days to confirm whether they hold the information and, if so, to provide it. If it is not possible to meet this deadline, the FOIA Co-ordinator must be informed so that contact can be made with the applicant (Appendix 5).

4.2.3 The FOIA Co-ordinator will then review the information within five working days. This review

will take into account any exemptions that may be available and/or fees that may be payable before providing the information to the applicant. It is important that the relevant information is identified if this is contained within a document or folder so that the FOI Co-ordinator does not incur any unnecessary time in pinpointing the relevant detail.

4.2.4 If any exemptions are applicable (after consultation with the Head of Administration), the

Procedure for the Refusal of Requests will be activated (see 5). If fees are payable (after consultation with the Head of Administration) the applicant will be issued with a Fees Notice as described in 9.2.

6

Appendix 8.2(ii)

4.3 Stage Three - Providing Information 4.3.1 If no fees or charges are either payable or outstanding, or if no exemptions are applicable, the

FOI Co-ordinator will write to the applicant as soon as possible to provide the requested information.

4.3.2 Information will be provided to applicants by any one or more of the following means, namely:

(a) as a copy of the information in permanent form or another form acceptable to the applicant.

(b) through the provision of a reasonable opportunity to inspect a record containing the information.

(c) through the provision of a digest or summary of the information in permanent form or in another form acceptable to the applicant.

4.3.3 Should it not be practicable to comply with the preference requested by the applicant, the FOI

Co-ordinator will notify the applicant of the reasons for this. The information will then be provided by such means as deemed reasonable.

5. REFUSAL OF REQUESTS 5.1 A request for information may be refused in whole or in part. A request for information may

be refused if:

(a) the information is exempt from disclosure under Part II of the Act. (b) a fees notice or charge has not been paid within three months beginning on the day

on which the fees notice was given to the applicant/the applicant was notified of the charge (see 9.3).

(c) the cost of compliance exceeds the appropriate limit, as set out in statutory Fees Regulations.

(d) the request is demonstrably vexatious or repeated. 5.2 If the FOI Co-ordinator in consultation with the Head of Administration chooses to refuse a

request for information for any of the reasons set out at paragraph 5.1 above, the applicant will be informed of the reasons for this decision within twenty working days. In line with section 17(7) of the Act, the applicant will also be informed of the Trust’s Internal Review process and of the statutory right to complain to the Information Commissioner (see 10.5).

5.3 Section 17 of the Act requires written notice to be given to the applicant when the Trust

refuses to disclose requested information and any such notice will be signed by the Head of Administration/an Executive Director. There are four different types of notice (Appendix 6).

5.6.1 The FOI Co-ordinator will keep records of all notices issued to refuse requests for information

and will maintain a file recording the decision making process. This file will be subject to periodic review to maintain consistency in decision-making.

6. PROVISION OF ADVICE AND ASSISTANCE TO APPLICANTS 6.1 FOI Co-ordinator 6.1.1 The FOI Co-ordinator will act as the key contact point for staff within the Trust and can be

contacted at Trust Headquarters, Direct Line 01656 752939/752940. 6.1.2 The FOI Co-ordinator will provide advice and assistance to potential and actual applicants for

information under the Act. 6.1.3 A record will be kept of all instances, including those described below, where the FOI Co-

ordinator has provided advice and assistance to potential/actual applicants. 6.1.4 The FOI Co-ordinator will also act as a source of advice and support for Trust staff in regard

to the Act.

7

Appendix 8.2(ii)

6.1.5 Where a potential applicant is unable to frame a request in writing, the FOI Co-ordinator will take reasonable steps to ensure that appropriate assistance is given to enable the individual to make a request for information.

6.1.6 Appropriate assistance might include:

• advising the applicant that another person or agency (such as Community Health Councils, Citizens Advice Bureau or other provider of information, advice or advocacy) may be able to assist them with the application, or make the application on their behalf;

• in exceptional circumstances, offering to take a note of the application over the telephone and then send the note to the applicant for confirmation (in which case the written note of the telephone request, once verified by the applicant and returned, would constitute a written request for information and the statutory time limit for reply would begin when the written confirmation was received).

6.1.7 This list is not exhaustive, and the FOI Co-ordinator will discuss with the applicant the options

available to them thus ensuring flexibility and offering the advice and assistance most appropriate to the circumstances of the individual potential applicant.

6.2 Provision of insufficient information 6.2.1 Where the applicant has not described the information sought in a way that enables the Trust

to identify or locate it, or the request is ambiguous, the FOI Co-ordinator will contact the applicant to seek clarification (Appendix 7).

6.2.2 The purpose of this contact will be to clarify the nature of the information sought, not to

determine the aims or motivation of the applicant. 6.2.3 Appropriate assistance in this instance might include:

• providing a general response to the request setting out options for further information which could be provided on request.

• providing an outline of the different kinds of information which might meet the terms of the request;

• providing access to detailed catalogues and indexes, where these are available, to help the applicant ascertain the nature and extent of the information held by the authority;

• providing, wherever possible, identifiers such as a file reference number, or a description of a particular record so that an applicant can decide if the information is appropriate for their needs;

6.2.4 The FOI Co-ordinator will offer advice and assistance appropriate to the circumstances. The

Trust recognises that applicants cannot reasonably be expected to possess identifiers such as a file reference number, or a description of a particular record, unless this information is made available by the authority for the use of applicants.

6.2.5 Successfully identified information for which the Trust does not wish to claim an exemption

will be disclosed. If it is still not possible to identify the nature of some or all of the information being sought by the applicant, the FOI Co-ordinator will explain to the applicant why the FOI Co-ordinator cannot process that part of the request any further and will make them aware of the Trust's Internal Review process (see 10.1) and of the applicant's rights under section 50 of the Act.

6.2.6 The twenty working day time limit is not activated until the applicant has provided sufficient

information for the Trust to supply the applicant with the information sought.

8

Appendix 8.2(ii)

6.3 Applicant is unprepared or unable to pay a fee or fees exceed appropriate limit 6.3.1 In some circumstances an applicant may indicate that they are not prepared or are unable to

pay the fee set out the fees notice. In such cases the FOI Co-ordinator, after consultation with the Head of Administration will contact the applicant and explore ways in which the fee or charge may be reduced. For example by:

• providing information electronically instead of in hard copy; or • inviting the applicant to view the information and take notes or to select the information

the applicant feels to be most relevant.

6.3.2 Under section 12(1) and regulations made under section 12(4) of the Act, the Trust is not obliged to comply with a request for information where the cost of complying would exceed the "appropriate limit" (i.e. cost threshold). In such circumstances, the Trust has three options: (a) to refuse the request on the basis that it exceeds the cost threshold; (b) to charge, under section 13 of the Act, for the provision of the information; (c) to seek a means by which information could be provided within the cost ceiling.

6.3.3 In the event of a request exceeding the cost ceiling and the applicant still wishes to pursue the original request, the FOI Co-ordinator will ask the applicant whether or not he or she would be willing to pay the full fee for the information requested.

6.3.4 If the applicant is willing to pay the full fee for the information requested a Fees Notice will be

issued. If the applicant is unwilling to pay the full fee the Procedure for Refusal of a Request will be initiated ( see 5). The applicant will also be informed of their rights to appeal under the Trust’s Internal Review process and section 50 of the Act (see 10.1).

6.4 Vexatious or repeated requests 6.4.1 The Corporate Services Manager will liaise with the Head of Administration on any requests

considered repeated or vexatious. Decisions regarding these will be taken by the Head of Administration. The applicants will be advised in writing of the decision in conjunction with the FOI Champion.

6.4.2 In such circumstances, the FOI Co-ordinator should be able to demonstrate that the

applicant’s request is vexatious or repeated based upon the monitoring data that has been collected. Each request must be considered individually and on its merits.

6.5 Requests which appear to be part of an organised campaign 6.5.1 The Trust may receive a number of related requests that, under section 12(1) and regulations

under section 12(4), take the cumulative cost of compliance over the “appropriate limit” as prescribed in Fees Regulations (Appendix 10).

6.5.2 In such circumstances the FOI Co-ordinator will consider whether the information could be

disclosed in another, more cost effective, manner i.e. published on the website. 7. TRANSFERRING A REQUEST FOR INFORMATION 7.1 If the Trust receives a request for information which it does not hold, within the meaning of

section 3(2) of the Act, but which is held by another public authority, the FOI Co-ordinator, after consultation with the Head of Administration, will oversee the process for considering whether to transfer the request to the other public authority.

9

Appendix 8.2(ii)

7.2 The definition of "holding" of information includes situations where a copy of a record produced or supplied by another person or body (but does not extend to holding a record on behalf of another person or body as provided for in section 3(2)(a) of the Act). Provided the Trust “holds” information that is requested, it will be under an obligation, irrespective of whether the information was produced by the Trust, to confirm or deny and to subsequently provide the information.

7.3 The Trust will deal will all initial requests for information in accordance with the procedure

described in 4. Where the Trust does not hold all or part of the information requested, the applicant will be advised of this either in writing or in writing as well as verbally.

The initial options that will be offered to applicants whose information requests cannot be fulfilled in full or in part by the Trust will be as follows:

• contacting the applicant and informing him or her that the information requested may be

held by another public body; • suggesting that the applicant re-applies to the body that the Trust believes to hold the

information; • providing him or her with contact details for that body.

7.4 Before transferring a request for information, the FOI Co-ordinator will consider:

• whether a transfer is appropriate; and if so • whether the applicant is likely to have any grounds to object to the transfer;

7.5 Where a request or part of a request is transferred between public bodies, the receiving body

must comply with its obligations under Part I of the Act in the same way as it would for a request that is received direct from an applicant. The time for complying with such a request will be measured from the day that the receiving authority receives the request.

7.6 All transfers of requests should take place as soon as is practicable, and the applicant should

be informed as soon as possible once this has been done. The target time for such transfers by the Trust to another public authority will be twenty working days.

7.7 A record will be kept of all activity associated with the transfer of requests for information to

other public bodies. 8. CONSULTATION WITH THIRD PARTIES 8.1 Where a request affects legal rights of a third party 8.1.1 In some cases the disclosure of information pursuant to a request may affect the legal rights

of a third party. This may arise where information is subject to the common law duty of confidence or where it constitutes "personal data" within the meaning of the Data Protection Act 1998 ("the DPA"). Unless an exemption provided for in the Act applies in relation to any particular information, the Trust is obliged to disclose that information in response to a request.

8.1.2 In some cases disclosure of information cannot be made without the consent of a third party.

For example, where information has been obtained from a third party, disclosure of that information without consent would in some circumstances constitute an actionable breach of confidence, such that the exemption at section 41 of the Act would apply. In such cases the FOI Co-ordinator will consult the third party with a view to seeking the consent of the third party to the disclosure, unless such a consultation is not practicable, for example because the third party cannot be located or because the costs of consulting them would be disproportionate.

10

Appendix 8.2(ii)

8.1.3 Where information constitutes "personal data" within the meaning of the DPA, the FOI Co-ordinator will have regard to section 40 of the Act which makes detailed provision for cases in which a request relates to such information and deals with the interplay between the Act and the DPA in such cases.

8.1.4 A record will be kept by the FOI Co-ordinator of all contacts with third parties regarding

consultation and decision making relating to the disclosure of information that may affect the third parties’ legal rights.

8.2 Consultation in non-legal circumstances 8.2.1 Where the interests of a third party that may be affected by a disclosure do not give rise to

legal rights, consultation may still be appropriate. The FOI Co-ordinator will lead any consultation where:

• the views of the third party may assist the decision of whether an exemption under the

Act applies to the information requested; or • the views of the third party may assist a decision.

8.2.2 The FOI Co-ordinator, in consultation with the Head of Administration, may consider that consultation is not appropriate where the cost of consulting with third parties would be disproportionate.

8.2.3 Consultation will be unnecessary where:

• There is no intention to disclose the information relying on some other legitimate ground under the terms of the Act;

• the views of the third party can have no effect on the decision of the authority, for example, where there is other legislation preventing or requiring the disclosure of this information.

8.2.4 A record will be kept by the FOI Co-ordinator of all contacts with third parties regarding

consultation and decision making relating to the disclosure of information. 8.3 Consultation with a number of third parties 8.3.1 Where the interests of a number of third parties may be affected by the disclosure and those

parties have a representative organisation, which can express views on their behalf, the Head of Administration may consider it sufficiently appropriate to consult that representative organisation only. For example, a consultation may take place with the Staffside Representatives regarding the views of the Trust’s workforce.

8.3.2 If there is no representative organisation, the FOI Co-ordinator may consider that it would be

sufficient to consult a representative sample of the third parties in question. 8.3.3 A record will be kept by the FOI Co-ordinator of all contacts with representative organisations

or representative samples of third parties regarding consultations and decision making in relation to the disclosure of information.

8.4 Where there is no response or a refusal to consent by the third party 8.4.1 The fact that a third party has not responded to consultation does not relieve the Trust of its

duty to disclose information under the Act, or its duty to reply within the time specified in the Act.

8.4.2 In all cases, it is for the Trust not the third party to determine whether or not information

should be disclosed under the Act. A refusal to consent to disclosure by a third party does not, in itself, mean information should be withheld.

11

Appendix 8.2(ii)

8.4.3 A record will be kept by the FOI Co-ordinator of all responses to consultations and the decision making processes that arise from them.

9. CHARGES AND FEES 9.1 Publication Scheme Charges 9.1.1 Information that is available from the Trust’s web site will be free of charge, although any

charges for Internet Service provider and personal printing costs must be met by the individual applicant. For those without Internet access, a single print-out of the information as on the web site will be available by postal or personal application to the Corporate Services Manager.

9.1.2 Most information will be available free of charge, although the Trust may seek an appropriate

fee where information needs to be duplicated. 9.1.3 Requests for multiple printouts, or for archived copies of documents that are no longer

accessible or available on the web, may attract a charge for the retrieval, photocopy, postage and so on. In such circumstances, the Corporate Services Manager will inform the applicant in writing of the cost and the charges that will have to be paid in advance.

9.1.4 Leaflets and brochures already produced by the Trust will be available free of charge for a

single copy. 9.1.5 Any “glossy” or other bound paper documents, or information contained on CD ROM, video or

other media may be subject to a charge as determined by the costs to the Trust of producing the information. A price will be given on application to the applicant.

9.1.6 Any information that can be transmitted by e-mail-will be provided free of charge, unless

otherwise stated. 9.1.7 The charges will be reviewed regularly by the Head of Administration in conjunction with the

Finance Department. 9.2 Fees under general right of access 9.2.1 The Trust will levy a fee in accordance with Fees Regulations (Appendix 10) made under the

Act in respect of requests made under the general right of access. 9.2.2 The Fees Regulations do not apply:

• to material made available under the Trust’s Publication Scheme under section 19 (see 9.1);

• to information which is reasonably accessible to the applicant by other means within the meaning of the exemption provided for at section 21; or

• where provision is made by or under any enactment as to the fee that may be charged by the Trust for disclosure of the information as provided in sections 9(5) and 13(3) of the Act".

9.2.3 The Trust will issue Fees Notices by the ‘Recorded Signed for’ service to ensure that the

Trust has a record of the date upon which the applicant is given the notice. 9.2.4 A record will be kept of the date of despatch to the applicant of the Fees Notice and of the

date that payment is received.

12

Appendix 8.2(ii)

9.3 Fees, Charges and Time scales 9.3.1 If a Fees Notice is issued to an applicant (Appendices 8 & 9), the ‘clock stops’ and then once

an applicant has paid the necessary fees, the ‘clock’ starts again from the point within the twenty working days that it ‘stopped’. The applicant may then, subject to any exemptions, be provided with the information requested.

9.3.2 Applicants will have three months beginning on the day on which they were given the Fees

Notice to pay the fee/charge in question. 10. COMPLAINTS AND FEEDBACK 10.1 The Trust will have a process in place whereby dissatisfied applicants can ask for a decision

to be reconsidered - this will be know as the Internal Review process. Any parties involved in conducting the original decision-making process around an FOI request, will not be eligible to be involved in the Internal Review process but they will need to speak with those that are.

10.2 Comments and feedback collated by the FOI Co-ordinator about the discharge of the duties of

the Trust in relation to the FOIA will all be forwarded to the Head of Administration for reporting purposes.

10.3 All complaints, verbal or written (including those transmitted by electronic means), must be

made known to the Trust’s FOIA Champion. 10.4 Any complaints will be dealt with as a specific FOIA complaint in accordance with the

following Internal Review Process:

- Complaints regarding decisions made by the Head of Administration/ Executive Team will be considered by the FOI Champion;

- Complaints regarding decision made by the Executive Team will be considered by the Chief Executive;

- Complaints regarding decisions made by the Chief Executive/Deputy Chief Executive will be considered by the Trust's Chairman/ designated FOI Non Executive Director;

- All complaints will be acknowledged within two working days, and will be investigated and responded to within twenty working days. If there is an extenuating circumstance that means a reply within this timescale is not possible the applicant will be informed.

10.5 All complainants will be informed of their right to complain directly to the Information

Commissioner (Appendix 9), and will be given the Information Commissioner’s contact details. Complainants who remain dissatisfied with the Trust at the end of the Internal Review process will be reminded of their right to take their complaint to the Information Commissioner.

11. ACCESSING AND MAINTAINING THE PUBLICATION SCHEME 11.1 The Head of Administration, with the assistance of the FOI Co-ordinator and FOIA Directorate

Leads, will review the Publication Scheme on a regular basis. 11.2 The Information Commissioner will review the model Publication Scheme that the Trust has

chosen to adopt in terms of the classes of information utilised and structure in 2007. 11.3 The Publication Scheme will be featured prominently on the Trust’s web site. 11.4 Hard copies of the Publication Scheme will be available from the Publication Scheme

Co-ordinator/FOI Co-ordinator.

13

Appendix 8.2(ii)

14

12. TRAINING AND AWARENESS RAISING 12.1 Staff awareness training on the implications of the Freedom of Information Act 2000, the

Trust’s Freedom of Information Act 2000 Policy and this Operational Manual will be the responsibility of the FOIA Directorate Leads. Directorate Leads will have been invited to attend sessions arranged by the FOI Project Lead/FOI Co-ordinator, which would have been provided in preparation for 1st January 2005.

12.2 Information on the Act will also be provided to Trust staff on induction to the Trust. The

Trust’s Policy on the Act will be cascaded through the organisation’s policy distribution system. Regular updates will also be provided through the Trust’s internal communications systems.

12.3 Further advice and information on the FOI Act will be available on the Trust’s Intranet and

Internet sites and directly from the Head of Administration/FOI Co-ordinator. 13. LEGAL ADVICE 13.1 The Head of Administration will be the conduit through which legal advice on FOIA is sought

and given. 13.2 A record will be kept by the FOI Co-ordinator of the advice sought from and given by the

Trust’s solicitors. 14. REPORTING ARRANGEMENTS 14.1 Information regarding number/type of requests will be reported on a quarterly basis to the

Management Executive. Reports to the Trust Board will be as and when required, but at least on an annual basis.

15. REVIEW 15.1 This document will be reviewed and updated as necessary, but at least on a yearly basis. 16. REFERENCES

• Freedom of Information Act 2000 • Lord Chancellor’s Code of Practice on the Discharge of Public Authorities’ Functions

under Part I of the Freedom of Information Act 2000, issued under Section 45 of the Act. • Bro Morgannwg NHS Trust Freedom of Information Act Policy • Bro Morgannwg NHS Trust Records Management Strategy • Bro Morgannwg NHS Trust Complaints Procedure • Bro Morgannwg NHS Trust FOI Operational Procedures • Bro Morgannwg NHS Trust Procurement Policy • Bro Morgannwg NHS Trust Standing Orders • Welsh Risk Management Standards 6, 7 and 8

Appendix 8.2(ii)

KEY RIGHTS AND OBLIGATIONS UNDER THE FOI ACT 2000

The Applicant • has the right to request information • has the right to be informed in writing if this

information is available The Trust • has a duty to provide reasonable advice and assistance to

anyone making a request • must aim to respond within 20 working days and keep

the applicant informed if this cannot be met • does not have to release information if there is a

provision in the Act conferring an absolute exemption • must consider releasing information in the public

interest if applicable • where practicable, should supply the information

requested, in the format requested • is not obliged to comply with a request if the costs

involved exceed the upper fees limit • if refusing a request, must tell the applicant why and

state which exemption is being relied on • must maintain an up-to-date Publication Scheme and

publish information in accordance with this Scheme

RESPECTING AN INDIVIDUAL’S RIGHT TO CONFIDENTIALITY

The Freedom of Information Act does not change the rights of individuals, whether they are patients or members of staff, to expect that the personal information that the Trust holds about them is protected. Maintaining the legal right of confidentiality of all personal information continues to be an important commitment for the Trust.

OUR COMMITMENT TO YOU

• To be as open as we can be in relation to the work we do

• To do our best to provide you with any information you are seeking

• To work within the required timescales • To refer any complaints about release of

information for Internal Review by someone who is independent of the original decision.

• If you remain dissatisfied, you can refer any concerns you may have to the Information Commissioner at :

Information Commissioner’s Office – Wales

2 Alexandra Gate Fford Pengam

Cardiff CF24 2SA

Tel: 029 2089 4929

e-mail: wales@ico.gsi.gov.uk

Appendix 1

THE FREEDOM OF INFORMATION (FOI) ACT 2000

THE ACT

The Freedom of Information Act 2000 gives public right of access to a variety of records and information held by public bodies. This comes into force on 1st January 2005 and can relate to any information subject to certain exemptions.

THE PUBLICATION SCHEME

Implementation of the Act began in October 2003 when all public bodies were required to make their “Publication Schemes” available. Bro Morgannwg’s Publication Scheme contains general information about the Trust and specifies the information that is readily available to the public. The Bro Morgannwg NHS Trust Publication Scheme is available on the Trust web site at: http://www.bromor–tr.wales.nhs.uk or a paper copy is available from the Freedom of Information Co-ordinator, Bro Morgannwg NHS Trust, 71 Quarella Road, Bridgend, CF31 1YE, Tel 01656 752940/2939, e-mail inquiries@bromor-tr.wales.nhs.uk

Appendix 8.2(ii)

Appendix 2

16

THE FREEDOM OF INFORMATION (FOI) ACT 2000 THE ACT

The Freedom of Information Act 2000 gives public right of access to a variety of records and information held by public bodies. This comes into force on 1st January 2005 and can relate to any information subject to certain exemptions.

THE PUBLICATION SCHEME

Implementation of the Act began in October 2003 when all public bodies were required to make their “Publication Schemes” available. Bro Morgannwg’s Publication Scheme contains general information about the Trust and specifies the information that is readily available. The Bro Morgannwg NHS Trust Publication Scheme is available on the Trust web site at: http://www.bromor–tr.wales.nhs.uk or a paper copy is available from the Freedom of Information Co-ordinator/ Head of Administration, Bro Morgannwg NHS Trust, 71 Quarella Road, Bridgend, CF31 1YE, Tel 01656 752940/2939 or via inquiries@bromor-tr.wales.nhs.uk

KEY RIGHTS AND OBLIGATIONS UNDER THE FOI ACT 2000

The Applicant • has the right to request information • has the right to be informed in writing if this

information is available The Trust • has a duty to provide reasonable advice and assistance to

anyone making a request • must aim to respond within 20 working days and keep

the applicant informed if this cannot be met • does not have to release information if there is a

provision in the Act conferring an absolute exemption • must consider releasing information in the public

interest if applicable • where practicable, should supply the information

requested, in the format requested • is not obliged to comply with a request if the costs

involved exceed the upper fees limit • if refusing a request, must tell the applicant why and

state which exemption is being relied on • must maintain an up-to-date Publication Scheme and

publish information in accordance with this Scheme

RESPECTING AN INDIVIDUAL’S RIGHT TO CONFIDENTIALITY

The Freedom of Information Act does not change the rights of individuals, whether they are patients or members of staff, to expect that the personal information that the Trust holds about them is protected. Maintaining the legal right of confidentiality of all personal information continues to be an important commitment for the Trust.

WHAT DOES FREEDOM OF INFORMATION MEAN FOR TRUST STAFF? As part of its daily business, the Trust deals with a variety of informal requests for information. The changes in legislation around Freedom of Information are not meant to interfere with the flow of information: they merely provide a framework for the public to make formal requests for information should they wish to do so. Formal information requests need to be in writing (e-mail or by letter) and a name and address needs to be supplied for the Trust to reply. Requests do not have to be addressed to the FOI Co-ordinator and may simply be sent to a member of staff by e-mail or handed to them. It is very important that these formal requests are relayed to the Freedom of Information Co-ordinator within one working day. Also coming into force from 1st January 2005 are Environmental Information Regulations (EIR). These cover issues such as infection rates, how we manage the disposal of waste, energy issues, maintenance issues etc. Information requested under the EIR need not be in writing and can be made over the telephone or in person. If staff are unclear about whether a request for information is a formal request, they should seek advice from their manager (or their Directorate FOI Lead). Advice can also be sought from the Trust’s FOI Co-ordinator. Remember, for the Trust to be able to respond to requests for information effectively, records systems need to be well maintained. Staff are responsible for the records they use or create. For further information on the Trust’s policies on FOI, EIR, the Data Protection Act and Records Management, click on the 'Policies' tab on the Intranet.

Appendix 8.2(ii)

APPENDIX 3 - RECORD KEEPING TO MONITOR FOI COMPLIANCE The Trust will record the following information for the purposes of compliance with FOI. Initial Application/Upon Receipt of a Request Where request is received by FOI Lead/ FOI Co-ordinator • Initial date received. • Name and contact details of initial recipient of request. • Date received by FOI Lead/FOI Co-ordinator. • Name of applicant and contact details. • Access route – Publication Scheme or general right of access. • Summary of information requested. • Letter/e-mail acknowledging receipt of request to applicant. Accessing Information Internal Contacts • Name and contact details of person(s) holding information. • Date information requested from person(s) holding information. • Extensions granted due to difficulties in locating or retrieving information. Contacts with applicant • Information given on progress of request to applicant. • Advice and assistance given to applicant. • Date of issue, receipt and payment by applicant of any Fees Notices/notification of charges. • Decision making processes leading to application of exemptions or the refusal of requests. • Exemption notices and notifications of a refusal of a request issued to applicants. Contacts with other individuals/organisations • Activity associated with transfers of requests to other public authorities. • Activity associated with consultation and decision making with third parties on the disclosure of

information. Providing the Information • Date upon which the information was provided to the applicant. • Form in which the information was requested. • Format in which the information was provided. • Any reasons for a difference between the format in which the information was provided and the

form in which it was requested.

Appendix 8.2(ii)

APPENDIX 4

Ref: Date: Dear Information Request Thank you for your letter of «Date2». Please find enclosed our leaflet giving guidance on our procedure for managing requests for information which is covered by the Freedom of Information Act 2000. We are processing your request and will write to you shortly. In the meantime if you have any queries then please contact us at the above address. Yours sincerely Wendy Penrhyn-Jones Head of Administration

18

Appendix 8.2(ii)

APPENDIX 5

Ref: Date: Dear Request under Freedom of Information Act 2000 Further to our letter of «Blah» I am writing to let you know we are still in the process of collating the information you requested. Unfortunately, due to the nature of your request we are unlikely to be able to respond within the required twenty (20) working days. The reason for the delay is as follows …………………………………….. We can, however, provide you with the following information at this stage: ………………………….. Please accept our apologies for this delay. If you need any further assistance please do not hesitate to contact us at the above address. Yours sincerely Wendy Penrhyn-Jones Head of Administration

19

Appendix 8.2(ii)

APPENDIX 6

(a) Notice 1 to be issued when any Part II provision is relied upon to claim either that the duty to confirm or deny is excluded or that the information is exempt.

(b) Notice 2 to be issued when the Trust is relying on one of the Part II provisions which

does not confer absolute exemption, but has not yet decided where the balance of public interest lies.

(c) Notice 3 is a statement of reasons for claiming that the public interest in maintaining

the exclusion of the duty to confirm or deny, or in maintaining an exemption, outweighs the public interest in disclosing whether the authority holds particular information, or in disclosing information as the case may be.

(d) Notice 4 is issued when the Trust claims that the section 12 or section 14 exemptions

applies (that is, that the cost of compliance would exceed the appropriate limit, or that the request is vexatious or repeated).

5.4.1 Notice 1 must state that the Trust is relying on a claim that a provision of Part II relating to the

duty to confirm or deny is relevant to the request, or that the information sought is exempt information, specify the exemption relied upon, and state why the exemption applies if that would not otherwise be apparent. A statement as to why the exemption applies need not be made if, or to the extent that, it would involve disclosure of information which would itself be exempt information.

5.4.2 Notice 2 must include all the information that has to be included in the first type of notice and

indicate that no decision as to the balance of public interest has yet been made. It must also contain an estimate of the date by which a decision is expected.

5.4.3 As to the “public interest” test notices, Section 17(3) of the Act comes into play once a

decision has been made as to the balance of public interest which is adverse to the applicant. The reasons for that decision may be included in the first form of notice. Alternatively, when the authority has initially given a notice of the second type, it may state the reasons in a separate and subsequent notice (Notice 3) given within such time as is reasonable in the circumstances. A statement as to why the balance is in favour of maintaining the exclusion need not be made if, or to the extent that, it would involve disclosure of information which would itself be exempt information.

5.4.4 Notice 4, which would state that section 12 or section 14 of the Act is relied upon must be

given within the time for complying with section 1(1) of the Act.

20

Appendix 8.2(ii)

APPENDIX 7

Ref: Date: Dear Request under Freedom of Information Act 2000 Thank you for your request which we received on «Date2». Please find enclosed our leaflet giving guidance on our procedure for managing requests for information which is covered under the Freedom of Information Act 2000. To help us process your request for information we would be grateful if you could provide us with more specific details as to the information you are seeking. It would be helpful if you could telephone me in order to discuss your needs in more detail on 01656 752939/752940. I look forward to hearing from you. Yours sincerely Wendy Penrhyn-Jones Head of Administration

21

Appendix 8.2(ii)

APPENDIX 8 Ref: Date: Dear Request under Freedom of Information Act 2000 Thank you for your request for information regarding «Blah» which we received on «Date2». Under the terms of the Freedom of Information Act 2000 the Trust will make a charge for supplying the information you requested to cover the estimated costs in retrieving and providing the information. The fee for providing this information is £«Fee». Please confirm in writing enclosing the appropriate payment if you wish to pursue your request. Once your payment has been processed the information will be supplied to you. If you need any further assistance please do not hesitate to contact us at the above address. Yours sincerely Wendy Penrhyn-Jones Head of Administration

22

Appendix 8.2(ii)

APPENDIX 9 Ref: Date:

Dear Request under Freedom of Information Act 2000 Thank you for your request of «Date2» seeking information on:

Under the terms of the Freedom of Information Act 2000 we are able to supply you with the following:-

The Trust will make a charge for supplying the information you requested to cover the estimated costs in retrieving and providing the information. The fee for providing this information is £«Fee». If you are not satisfied with the decision to withhold certain information, you have a right to complain and request an Internal Review. You should forward your complaint to Miss Sheelagh Lloyd Jones, FOI Champion. Should you wish to take your complaint further, if you are still unhappy with the decision after review, you may wish to contact: The Information Commissioner’s – Wales 2 Alexandra Gate Fford Pengam Cardiff CF24 2SA In the meantime if you have any queries then please contact us at the above address. Yours sincerely Wendy Penrhyn Jones Head of Administration

23

Appendix 8.2(ii)

APPENDIX 10

S T A T U T O R Y I N S T R U M E N T S

2004 No. 3244

FREEDOM OF INFORMATION

DATA PROTECTION

The Freedom of Information and Data Protection (Appropriate Limit and Fees) Regulations 2004

Made December 2004 Laid before Parliament December 2004 Coming into force 1st January 2005

The Secretary of State, in exercise of the powers conferred upon him by sections 9(3) and (4), 12(3), (4) and (5), and 13(1) and (2) of the Freedom of Information Act 2000(a), and by sections 9A(5) and 67(2) of the Data Protection Act 1998(b), and having consulted the Information Commissioner in accordance with section 67(3) of the Data Protection Act 1998, hereby makes the following Regulations: Citation and commencement 1. These Regulations may be cited as the Freedom of Information and Data Protection (Appropriate Limit and Fees) Regulations 2004 and come into force on 1st January 2005. Interpretation 2. In these Regulations— “the 2000 Act” means the Freedom of Information Act 2000; “the 1998 Act” means the Data Protection Act 1998; and “the appropriate limit” is to be construed in accordance with the provision made in regulation 3. The appropriate limit 3.—(1) This regulation has effect to prescribe the appropriate limit referred to in section 9A(3) and (4) of the 1998 Act and the appropriate limit referred to in section 12(1) and (2) of the 2000 Act. (2) In the case of a public authority which is listed in Part I of Schedule 1 to the 2000 Act, the appropriate limit is £600. (3) In the case of any other public authority, the appropriate limit is £450. Estimating the cost of complying with a request – general 4.—(1) This regulation has effect in any case in which a public authority proposes to estimate whether the cost of complying with a relevant request would exceed the appropriate limit.

(a) 2000 c.36 (b) 1998 c.29. Section 9A of the Data Protection Act 1998 was inserted by section 69(2) of the Freedom of Information Act 2000.

24

Appendix 8.2(ii)

(2) A relevant request is any request to the extent that it is a request– (a) (a) for unstructured personal data within the meaning of section 9A(1) of the 1998 Act , and to

which section 7(1) of that Act would, apart from the appropriate limit, to any extent apply, or (b) information to which section 1(1) of the 2000 Act would, apart from the appropriate limit, to

any extent apply. (3) In a case in which this regulation has effect, a public authority may, for the purpose of its estimate, take account only of the costs it reasonably expects to incur in relation to the request in–

(a) determining whether it holds the information, (b) locating the information, or a document which may contain the information, (c) retrieving the information, or a document which may contain the information, and (d) extracting the information from a document containing it.

(4) To the extent to which any of the costs which a public authority takes into account are attributable to the time which persons undertaking any of the activities mentioned in paragraph (3) on behalf of the authority are expected to spend on those activities, those costs are to be estimated at a rate of £25 per person per hour. Estimating the cost of complying with a request – aggregation of related requests 5.—(1) In circumstances in which this regulation applies, where two or more requests for information to which section 1(1) of the 2000 Act would, apart from the appropriate limit, to any extent apply, are made to a public authority—

(a) by one person, or (b) by different persons who appear to the public authority to be acting in concert or in pursuance

of a campaign, the estimated cost of complying with any of the requests is to be taken to be the total costs which may be taken into account by the authority, under regulation 4, of complying with all of them.

(2) This regulation applies in circumstances in which–

(a) the two or more requests referred to in paragraph (1) relate, to any extent, to the same or similar information, and

(b) those requests are received by the public authority within any period of sixty consecutive working days.

(3) In this regulation, “working day” means any day other than a Saturday, a Sunday, Christmas Day, Good Friday or a day which is a bank holiday under the Banking and Financial Dealings Act 1971 (b) in any part of the United Kingdom. Maximum fee for complying with section 1(1) of the 2000 Act 6.—(1) Any fee to be charged under section 9 of the 2000 Act by a public authority to whom a request for information is made is not to exceed the maximum determined by the public authority in accordance with this regulation. (2) Subject to paragraph (4), the maximum fee is a sum equivalent to the total costs the public authority reasonably expects to incur in relation to the request in–

(a) informing the person making the request whether it holds the information, and (b) communicating the information to the person making the request.

(a) Section 9A(6) of the Data Protection Act 1998 provides that any estimate of the appropriate limit

for the purposes of that section must be made in accordance with regulations made under section 12(5) of the Freedom of Information Act 2000.

(b) 1971 c.80.

25

Appendix 8.2(ii)

(3) Costs which may be taken into account by a public authority for the purposes of this regulation include, but are not limited to, the costs of–

(a) complying with any obligation under section 11(1) of the 2000 Act as to the means or form of communicating the information,

(b) reproducing any document containing the information, and (c) postage and other forms of transmitting the information.

(4) But a public authority may not take into account for the purposes of this regulation any costs which are attributable to the time which persons undertaking activities mentioned in paragraph (2) on behalf of the authority are expected to spend on those activities. Maximum fee for communication of information under section 13 of the 2000 Act 7.—(1) Any fee to be charged under section 13 of the 2000 Act by a public authority to whom a request for information is made is not to exceed the maximum determined by a public authority in accordance with this regulation. (2) The maximum fee is a sum equivalent to the total of—

(a) the costs which the public authority may take into account under regulation 4 in relation to that request, and

(b) the costs it reasonably expects to incur in relation to the request in—

(i) informing the person making the request whether it holds the information, and (ii) communicating the information to the person making the request.

(3) But a public authority is to disregard, for the purposes of paragraph(2)(a), any costs which it may take into account under regulation 4 solely by virtue of the provision made by regulation 5. (4) Costs which may be taken into account by a public authority for the purposes of paragraph (2)(b) include, but are not limited to, the costs of–

(a) giving effect to any preference expressed by the person making the request as to the means or form of communicating the information,

(b) reproducing any document containing the information, and (c) postage and other forms of transmitting the information.

(5) For the purposes of this regulation, the provision for the estimation of costs made by regulation 4(4) is to be taken to apply to the costs mentioned in paragraph (2)(b) as it does to the costs mentioned in regulation 4(3). Signatory text

Name Parliamentary Under Secretary of State

Date Department for Constitutional Affairs

EXPLANATORY NOTE

(This note is not part of the Order) These Regulations prescribe “the appropriate amount” for the purposes of section 9A of the Data Protection Act 1998 and section 12 of the Freedom of Information Act 2000. If a public authority estimates that the cost of complying with a request for the information to which either of those provisions applies would exceed the appropriate amount, then the obligations which would otherwise be imposed by section 7 of the 1998 Act and section 1 of the 2000 Act in respect of such requests for information do not apply. Regulation 3 prescribes an appropriate limit of £600 in the case of the public bodies listed in Part I of Schedule 1 to the 2000 Act (including government departments). An appropriate limit of £450 is prescribed in relation to all other public authorities.

26

Appendix 8.2(ii)

Regulation 4 makes provision as to the costs to be estimated, and as to the manner in which they are to be estimated, for the purpose of estimating whether the cost of complying with a request would exceed the appropriate limit. The costs which may be taken into account are limited to those which the public authority reasonably expects to incur in undertaking certain specified activities in response to the request. Regulation 5 makes supplementary provision as to the estimation of costs in cases to which the 2000 Act applies. It provides that in relation to multiple requests which are related in specified ways by reference to those making the requests, the information to which the requests relate, and the timing of the requests, the estimated costs of complying with any single request is to be taken to be the aggregate estimated costs of complying with them all. Regulation 6 makes provision as to the maximum fee that a public authority may specify in a fees notice under section 9 of the 2000 Act as a charge for complying with its duty under section 1(1) of the Act. The maximum is to be calculated by reference to specified limited aspects of the costs of informing the requester whether it holds the information and, if so, of communicating it to the requester. Section 13 of the 2000 Act makes new provision for public authorities to be able to charge for the communication of information whose communication is not required because of the effect of the appropriate limit and is not otherwise required by law. Regulation 7 makes provision as to the maximum fee that a public authority may charge for the communication of information in the exercise of that power. The maximum is to be calculated by reference to the total costs which may be taken into account in estimating whether the cost of complying with the request would exceed the appropriate limit (excluding any costs “aggregated” from other requests), together with the full costs of informing the requester whether the information is held, and, if so, of communicating it to the requester.

27

Appendix 8.2(ii)

Originator: Governance Support Unit Date Approved: 23rd January 2008 Approved by: Management Executive Date for Review: 23 rd anuary 2009 JPolicy ID: 457

RISK MANAGEMENT POLICY AND STRATEGY 2007/08 This document can be made available in alternative formats or other languages, on request, as is reasonably practicable to do so.

Appendix 8.2(iii)

CONTENTS

Page

1 Introduction

3

2 Policy Statements

3

3 Aims

4

4 Strategy

4

5 Key Risk Areas 5

6 Risk Management Structure - Roles and Responsibilities

6

7 The Risk Management Process

10

8 Risk Funding and Insurance

15

9 Risk Management Documentation

15

10 Risk Management Training

16

11 Adverse Incident Reporting

16

12 Claims and Complaints Management

16

13 Trust Annual Risk Management Plan

16

APPENDIX A – Risk Register format APPENDIX B – Risk Assessment Form APPENDIX C - Risk Management Structure Chart APPENDIX D – WRMS Self Assessment Strategy

2

Appendix 8.2(iii)

1 INTRODUCTION 1.1 Good governance requires that boards of NHS organisations satisfy themselves

that systems are in place to ensure that risks that threaten the achievement of objectives and the safety and quality of services to patients are assessed and managed efficiently, effectively and economically. This requires processes/systems to monitor and review the quality of all activities, ensuring that lessons are learnt when things go wrong and these feed/determine improvements in practice and that staff meet prevailing professional standards and comply with legislative responsibilities. Risk Management is one of the systems supporting the achievement of these requirements.

1.2 The Trust has adopted an integrated approach to Risk Management that deals with risks of all types - clinical, non-clinical, financial and organisational.

1.3 Risk can be defined as 'the possibility of incurring misfortune, injury or loss'. All organisational activities carry risk and the risks associated with a large healthcare Trust are complex and extensive. Risks may be associated with people (patients, staff, students, visitors, contractors), buildings and estate, equipment and consumables, systems and management.

1.4 Risk Management is a proactive approach that aims to identify, assess and prioritise risks for action, so as to minimise the negative consequences of risks.

1.5 This combined policy and strategy confirms the commitment of Bro Morgannwg NHS Trust to meet its responsibilities in effectively managing risks, recognising the contribution this makes to the delivery of high quality care for patients, a safer environment of care for patients and visitors, safer systems of work and a safer work environment for staff, students and contractors and the effective operation of the organisation.

1.6 In the course of 2007/8, the Welsh Risk Management Standards will be amalgamated with the Healthcare Standards for Wales and a revised process of assessment will become applicable. The Trust will, therefore, review this Policy and Strategy when information on future requirements becomes available.

2 POLICY STATEMENTS

2.1 Bro Morgannwg NHS Trust is committed to providing the highest standards of care and safety to all people in contact with its services.

2.2 The Trust recognises its responsibility to protect: • its patients, staff, students, visitors and contractors from harm, • its capital, financial resources and estate, and • its reputation and the confidence of the public in the services it delivers.

2.3 Accordingly, the Trust has adopted the following definition of risk:

'Anything that poses a threat to the achievement of our objectives or delivery of safe and quality services to the population we serve or the safety and well-being of the staff we employ. This includes anything that could damage the reputation of the Trust and undermine the public's confidence in our services'.

2.4 The Trust has adopted an integrated and systematic approach to Risk Management, in recognition of the fact that all activities of the Trust carry risks.

3

Appendix 8.2(iii)

2.5 The Trust Board understands that successful Risk Management is achieved through the development of a blame-free culture that nurtures the identification and management of risks in an open and honest manner and errors or adverse incidents are handled sensitively, with appropriate support for patients and staff and the opportunities to learn are maximised. The Adverse Incident Reporting System is not part of the disciplinary process.

2.6 All Trust staff have a responsibility for managing risk and the Trust encourages and supports staff to take ownership of that responsibility through education and communication. This enables all staff to make a contribution to continued improvement in the quality of care.

3 AIMS

3.1 The aims of this Risk Management Policy and Strategy are:

1. to ensure the management of risk is consistent with, and supports the achievement of, the Trust's strategic objectives

2. provide safe and high quality services to patients and a safe environment

for patients, staff and others through the effective identification of hazards and efficient management of risks.

3. to raise awareness of and to identify and manage risk issues through

education, training and effective and open, two-way communication

4. to minimise the financial and other negative consequences of losses and claims

5. to learn from adverse incidents, complaints and claims and thereby

reduce risk for the future

6. to ensure that opportunities are maximised through the sound control of any risks presented by new developments and activities

7. to meet statutory, legal, financial and professional obligations

8. to improve and maintain compliance with the ongoing requirements of

the Welsh Risk Management Standards

4 STRATEGY

4.1 The Trust's Strategy for managing its risks is:

to ensure an integrated approach to Risk Management, irrespective of the type of risk, through the structures and processes detailed in this document

to aim to manage all risks to an acceptable level taking due account of the need to prioritise actions to reflect financial and other resource constraints

to ensure the Risk Management processes and all contributing processes (adverse incident reporting, complaints and claims management etc) are subject to regular review to ensure a fit and cohesion with strategic and organisational objectives

4

Appendix 8.2(iii)

to ensure the core Welsh Risk Management Standards (Risk Management Policy & Strategy, Risk Profile and Incident & Hazard Reporting) and the overall Risk Management process is implemented consistently and systematically across the Trust

to recognise that the Welsh Risk Management Standards are not all-inclusive but serve to assist the Trust to establish a comprehensive risk profile

to ensure ownership of risks and responsibility for Risk Management at appropriate levels of the organisation

to ensure that risk issues and priorities are considered at every level of business and financial planning throughout the organisation

to ensure that communications relating to risks and Risk Management are relevant, timely and appropriately targeted, in accordance with the Trust Communications Policy and Strategy

to ensure that risk issues are adequately considered as part of the individual performance review process and reflected in performance and development objectives

to ensure that the Risk Management awareness and training needs of staff are assessed and met

to support staff to understand and adhere to the policies and procedures designed to minimise risk

to adopt and monitor performance against Critical Success Factors/Indicators for Risk Management and ensure that the Indicators themselves are regularly reviewed

to achieve maximum compliance with the Welsh Risk Management Standards through ongoing self-assessment, audit, action planning and monitoring of implementation

to ensure Risk Management plans are approved annually by the Trust Board and action plans for the Welsh Risk Management Standards are communicated to the Welsh Assembly Government in accordance with prescribed timescales

5 KEY RISK AREAS

5.1 Key risk areas and issues for all Trust's in Wales are reflected in the Welsh Risk

Management Standards developed by the Welsh Assembly and the Welsh Risk Pool. For 2007/8, there are 40 standards, listed below.

5.2 Compliance with the Welsh Risk Management Standards is at the core of this Risk Management Policy and Strategy. Appendix D outlines the WRMS self- assessment strategy for the Trust.

5

Appendix 8.2(iii)

WELSH RISK MANAGEMENT STANDARDS 2006/7

1 Risk Management Policy and Strategy 2 Risk Profile 3 Incident and Hazard Reporting 4 Complaints 5 Claims Management 6 Policies and Procedures 7 Records Management 8 Communications 9 Consent to Treatment 10 Clinical Effectiveness and Risk Management 11 Supervision of Staff 12 Assessing Competence 13 Occupational Health and Safety 14 Infection Control 15 Maternity 16 Operating Department Services 17 Accident and Emergency 18 Mental health 19 Community 20 Ambulance - Not applicable to the Bro Morgannwg NHS Trust 21 Learning Disabilities 22 Buildings, Land, Plant and Non-Medical Equipment 23 Nutrition & Catering 24 Contractors and Contractor Control 25 Emergency Preparedness 26 Environmental Management 27 Fire Safety 28 Human Resources 29 Information Management and Technology 30 Medical Equipment and Devices 31 Medicines Management 33 Security Management 34 Transport 35 Waste Management 36 Decontamination of Re-Usable Medical Devices and Equipment 37 Governance 38 Financial Management 39 Safeguarding the Welfare of Children 40 Cleanliness

6 RISK MANAGEMENT STRUCTURE –

Roles and Responsibilities

6.1 The Chief Executive and Deputy Chief Executive

6.1.1 The Chief Executive has overall responsibility to the Trust Board for the policy, strategy and operation of Risk Management within the Trust.

6.1.2 The Deputy Chief Executive has delegated responsibility for co-ordinating all operational Risk Management and Controls Assurance activities on behalf of the Chief Executive.

6

Appendix 8.2(iii)

6.2 Clinical Governance and the Clinical Governance Committee

6.2.1 The Medical Director and Nurse Director have responsibility for Clinical Governance issues, including ensuring that clinical risks are managed within the overall risk management system and there are links with clinical audit.

6.2.2 The Healthcare Governance Committee provides an assurance to the Trust Board that lessons are learned from the examination of risks, incidents, complaints and claims these are translated into improved clinical practice.

6.3 The Director of Finance and the Audit Committee

6.3.1 The Director of Finance has responsibility for the probity of financial systems and financial management within the Trust.

6.3.2 The Audit Committee provides an assurance to the Trust Board that internal Risk Management controls, systems and processes are effective and that lessons are being learnt and translated into positive service improvements.

6.3.3 Internal Audit reports and the integrated action plans developed in conjunction with the Trust are reviewed and endorsed by the Audit Committee.

6.4 The Management Executive

The Management Executive is concerned with all aspects of operational management and performance of the Trust. The Operational Risk Management Group (ORMG) formally reports to the Management Executive with onward reporting of items requiring Trust Board notification or action and provides information on its activities to the Healthcare Governance Committee.

6.5 The Operational Risk Management Group

6.5.1 The purpose of the Operational Risk Management Group is to oversee the Risk Management agenda, ensuring compliance with all relevant and associated Trust strategies and policies. The group meets every three weeks and takes a pro-active role in promoting the management of an open culture based upon sharing lessons and learning from risks, complaints and claims. The functions of the group are: General:

• To oversee the annual review of the Risk Management Policy and Strategy and the review of affiliated policies, as necessary.

• To consider the implications of developments that affect the Risk Management agenda, including legal developments, and the response needed.

• To review the Directorate and Corporate Risk Registers in accordance with an agreed programme.

• To receive and consider KPI’s, Performance Reports and commission investigations/actions as appropriate to improve poor performance.

• To oversee activities to achieve and sustain full compliance with all the Welsh Risk Management Standards

• To receive NPSA alerts and notices and agree the process for action and monitoring implementation

• To receive and approve the Annual Risk Management Report. • To receive and consider reports from other risk groups within the Trust

and internal and external audit reports on risk issues, when appropriate.

7

Appendix 8.2(iii)

Incidents, Complaints, Claims and Inquests:

• To receive reports of all incidents reported, examine individual serious incidents and commission appropriate investigations.

• To receive reports of all formal complaints and agree the management of selected complaints.

• To receive and advise upon the management of all Independent Review Secretariat and Ombudsman requests and responses to reports.

• To receive reports of all new claims and inquests and agree the management of selected cases, considering the use of suitable alternative dispute resolution methods, when appropriate.

• To approve claims admissions and settlements, where appropriate • To approve action plans. • To commission appropriate work in response to the analysis and review of

trends and clusters. • To consider external reporting requirements on individual cases or

clusters.

Learning and Sharing Lessons:

To identify and ensure Trust-wide sharing and learning resulting from incidents, complaints, claims and inquests.

To ensure action plans developed in response to incidents, complaints, claims and inquests are linked into the educational, audit and effectiveness and Health and Safety agendas.

To review the outcomes of Clinical Audit activity, from a risk management perspective, commissioning actions as necessary

To approve and monitor the delivery of the Risk Management training and education programme.

To review lessons learnt by other organisations, relevant external guidance and requirements, determining implications for the Trust and commissioning actions/ implementation as necessary

6.5.2 The Operational Risk Management Group ensures communication with other

Trust committees and groups, where necessary, that have operational responsibilities across a range of risk areas to ensure that no risk activity is omitted from consideration or scrutiny. These committees and groups each have stated Terms of Reference and Membership.

6.6 The Governance Support Unit (GSU)

6.6.1 The role of the GSU is to communicate and co-ordinate the process of risk management throughout the Trust on behalf of the Deputy Chief Executive and Risk Management Steering Group. Specifically this involves the following responsibilities:

• the co-ordination of activities to progress compliance with the Welsh Risk Management Standards and Corporate Governance Milestones

• undertaking formal self-assessments against the Welsh Risk Management Standards

• supporting the development of Directorate-based Risk/Governance Groups to identify and manage risks at a local level

• educating and stimulating Trust staff to take an active role in risk management

• supporting and promoting the learning of lessons and development of robust Risk Management actions

• co-ordinating development of the Trust and Directorate Risk Registers based on the Trust’s agreed objectives.

8

Appendix 8.2(iii)

• ensuring full and prompt reporting of all adverse events and near misses and ensuring that all necessary action is taken. This involves ensuring that immediate needs are met, the appropriate Trust staff and statutory authorities are informed as appropriate, and feeding data and analyses back into the organisation

• managing claims efficiently, effectively, economically and in accordance with the legal timescales, so as to minimise the financial and other negative consequences e.g. distress to the claimant, negative publicity etc,

• managing complaints in accordance with the NHS Complaints procedure for Wales, ensuring equity for both complainants and staff,

• acting as a central source of information on risk and legal issues, disseminating this information as necessary

• ensuring effective liaison with other organisations, maximising the opportunities for shared learning and development

• ensuring effective liaison with other organisations with whom there is a shared responsibility for risk management, such as the Welsh Risk Pool.

6.6.2 In discharging its responsibilities, the GSU works closely with other departments

and functions (notably, the Clinical Governance Co-ordination team, the Patient Experience team, the Health and Safety Department, the Estates and Facilities functions, Personnel and Training teams and the Finance Directorate).

6.7 Directorate Risk/Governance Groups

6.7.1 Directorate Risk/Governance Groups exist within each Clinical Directorate. Membership is comprised of staff able to consider a broad range of risks, i.e. clinical, health and safety, organisational etc.

6.7.2 The role of the groups includes ensuring that:

• risks within the directorate are identified, assessed, prioritised for both action and resources and managed in accordance with overall Trust policies, utilising the Directorate Risk Register

• the importance of managing risk is communicated to all staff within the directorate

• data from incidents, claims and complaints is reviewed to identify any trends or areas for further analysis and action

• actions to learn lessons and reduce future risk levels are adequately planned, their implementation is monitored and their effectiveness assessed on an ongoing basis.

6.8 All Trust Staff

6.8.1 All staff of the Trust are expected to demonstrate a basic awareness of risk and

be able to assist in the identification of real or potential risks and to act to prevent or minimise such risks, either directly or through bringing them to the attention of the appropriate manager. All staff are expected to report adverse events and near misses.

6.8.2 A Risk Assessment Guide has been developed to assist staff in the identification of risk through the assessment process.

6.8.3 All staff should anticipate that risk management responsibilities will form part of individual performance review at which time specific risk management performance and development objectives will be agreed and set, as appropriate.

9

Appendix 8.2(iii)

6.9 Welsh Risk Pool (WRP)

6.9.1 The Welsh Risk Pool acts as the Trust's principal insurer against loss or damage. It operates as a mutual insurance pool for, Trusts and other public healthcare organisations in Wales, with membership dependent upon a minimum level of compliance with the Welsh Risk Management Standards.

6.9.2 The WRP is responsible for auditing the compliance of its members and ensuring members do not present a disproportionate risk to the pool, to the detriment of other members. It is also responsible for utilising the resources of the pool in accordance with its agreed procedures.

7 THE RISK MANAGEMENT PROCESS

7.1 The Trust has based its Risk Management process on AS/NZS 4360:1999, the international standard model of Risk Management, as advocated under circular WHC(2000)13. The process has the following stages.

7.2 Establish the Context

7.2.1 Risk Management activity in the Trust takes place within the context of the environment in which the Trust operates and achievement of the Trust's strategic and organisational objectives (encompassing the Trust's defined Critical Success Factors).

7.2.2

Risk Management occurs at three levels in the Trust - at an individual patient or staff member level, at a service level, as some risks are particular to certain services, and at a Trust-wide level. This Risk Management policy and strategy is not intended to be applicable to the specific risks presented by or to an individual, although there are some similarities in procedures, but the broader service and Trust-wide risks.

7.3 Risk Identification

7.3.1 This step is intended to identify the risks that the Trust needs to manage, specifically, what can happen, how and why.

7.3.2 The Trust identifies risks through proactive and reactive means. Proactively, the Trust considers scenarios and makes judgments based on experience of the issues and also uses the learning points of others.

7.3.3 The Trust reacts to data, information and situations presented by adverse incidents, claims, complaints, audits, service and risk reviews, both internally and externally, in order to foster greater understanding of hazards, risks and the suitability and effectiveness of various controls and barriers.

7.4 Risk Assessment (consisting of risk analysis, risk rating and risk priority)

7.4.1 The envisaged or actual Consequences and Likelihood are analysed in the context of any risk controls that have already been put into place.

7.4.2 It is acknowledged that, in practice, both Steps 1 and 2 are subjective and will depend on the knowledge and expertise of the person(s) involved in the risk assessment process. To mitigate this, risk assessment is most appropriately conducted as a group/multi-disciplinary activity.

10

Appendix 8.2(iii)

STEP 1: Taking into account any risk controls already in place, what would be the most likely outcome if the risk/incident were to occur/reoccur? (CONSEQUENCES)

Those considering this matter need to think about any incidents that have occurred and the circumstances surrounding them. Were any 'lucky outcome'? Could the outcome realistically have been much worse? If an incident happens again, how might people realistically be affected? What potential implications would there be in terms of resources, cost, relations with the public etc? Table 1 helps to map the answers to these questions.

Each of the columns must be considered and a decision made on the most realistic scenario if the risk/incident should occur/reoccur. For example: • Would a person die or would the most realistic outcome be that the person would

suffer an injury or some impairment of health that they would recover from in any given time?

• How might people be affected/harmed by the incident? • Is it likely that the Trust might be the subject of a local press 'campaign' but unlikely

that the national press would report the matter? The MOST SERIOUS of the realistic consequences identified is considered against the descriptors in Table 1 and the relevant CONSEQUENCES level chosen.

TABLE 1: QUALITATIVE MEASURES OF CONSEQUENCE

Descriptor Actual or potential unintended

impact on individual(s) - patient, family member, visitor,

contractor, staff member

Number of persons

affected or potentially affected at one time

Actual or potential impact on the Trust

1 NEGLIGIBLE

No harm, harm prevented or very minor harm. Example(s): Cut or bruise. First-aid treatment only required. Some extra observation required.

N/A No damage or very minor damage. Very minimal impact. No service disruption. Direct financial loss/cost to the Trust or litigation risk up to £10,000. Example(s): Wastepaper basket fire

2

MINOR

Avoidable short-term, non-permanent harm or impairment of health - full recovery in up to 1 month. Example(s): - Minor healthcare associated

infection. - Temporary avoidable increase in

pain experience.

1 to 2 Short-term damage, remedial within 1 month. Increased length of hospital stay or increased level of care - between 1 and 7 days. Single failure to meet internal quality standards. Damage or direct financial loss to the Trust or litigation risk up to £100,000. Staff sickness < 3 days. Low risk of complaint.

11

Appendix 8.2(iii)

3

MODERATE

Avoidable semi-permanent injury or impairment of health or damage - recovery in up to 1 year. Additional interventions required or treatment needed to be cancelled. Necessary to transfer to another centre for treatment/care. Example(s): - Temporary loss of mobility - Temporary loss of vision - Healthcare associated infection

taking up to 1 year to resolve e.g. MRSA

- Further/new surgical intervention required

3 to 15 Example(s): Control and Restraint situation. Violent incident in A&E.

Damage remedial in up to 1 year. Increased length of hospital stay or increased level of care - between 8 and 15 days Temporary restrictions on service(s) / service disruption. Repeated failures to meet internal quality standards. Staff sickness > 3 days. Local adverse publicity / moderate loss of confidence in the organisation. Direct financial loss/cost to the Trust or litigation risk up to £250,000. MHRA Reportable. Mental Health Act Commission Assessment. Complaint anticipated. HSE Improvement Notice issued.

4

MAJOR

Irrecoverable injury or impairment of health, having a lifelong adverse effect on lifestyle, quality of life, physical and mental well-being. Example(s)/including: - Procedures involving wrong

patient or wrong body part. - Loss of major body part(s). - Retained instrument/material

after surgery. - Healthcare associated infection,

which may result in major permanent harm e.g. Hepatitis C.

- Haemolytic transfusion reaction.

- Radiation dose much greater or less than intended, whilst undergoing a medical exposure.

- Mis-diagnosis with poor prognosis of return to health

- Infant abduction or discharge to the wrong family.

- Rape (but only where it is determined that rape has occurred or there is sufficient evidence to make the allegation serious).

16 to 50 Example(s): - loss of

specimens - hostage

situation

Increased length of stay or care over 15 days. Adverse national publicity. Loss of confidence in the Trust. Ability of Trust to provide a service adversely affected / temporary service closure. Direct financial loss/cost to the Trust or litigation risk up to £1m. Prohibition Notice / Executive Officer fined. Failure to meet national and professional standards of quality. Example(s): Trust-wide PAS/PIMs failure

5

CRITICAL

Avoidable loss of life or unnecessary shortening of life expectancy. Example(s)/including: - unexpected death of a patient

whilst under the direct care of a health care professional

- healthcare associated infection resulting in or with potential to result in death e.g. hospital acquired legionellosis

- suicide or homicide committed

Many (over 50). Example(s): - screening

errors and failure to recall

- vaccination errors

Significant adverse national / international publicity. Severe loss of confidence in the Trust. Extended service closure. Direct financial loss/cost to Trust or litigation risk over £1M. Criminal prosecution. CHAI visit. Example(s): - Major loss of healthcare facilities

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Appendix 8.2(iii)

by a patient being treated for a mental health condition

due to fire - Loss/destruction of medical records department and all patient records stored within

STEP 2: Taking into account any risk controls already in place, what are the chances of the risk/incident happening, or happening again, in the Trust? (LIKELIHOOD) The likelihood is selected from Table 2 below.

TABLE 2: QUALITATIVE MEASURES OF LIKELIHOOD

Level and Descriptor

Description Example

In the region of 10 Yearly 1

RARE

Would only occur/reoccur in very exceptional circumstances; considered a very remote probability that it could happen/happen again.

2 UNLIKELY

Not expected to occur/reoccur but there is some possibility

In the region of 5 yearly

3 POSSIBLE

May occur/reoccur at some time / occasionally

Once every 1-4 years No more than 2 or 3 times per year

4 PROBABLE

Will probably occur/reoccur but will not be a persistent issue

5 EXPECTED

Will occur/reoccur and likely to be frequent

Daily/weekly/ monthly

STEP 3: What is the overall risk score for the incident? The answers obtained in Steps 1 and 2 are plotted on Table 3 - the Risk Matrix.

TABLE 3: QUALITATIVE RISK ASSESSMENT MATRIX

LEVEL OF RISK = CONSEQUENCES X LIKELIHOOD LIKELIHOOD

CONSEQUENCES 1 Rare

2 Unlikely

3 Possible

4 Probable

5

Expected 1

Negligible 1 2 3 4 5

2 Minor

2 4 6 8 10

3 Moderate

3 6 9 12 15

4 Major

4 8 12 16 20

5 Critical

5 10 15 20 25

13

Appendix 8.2(iii)

7.4.2 The risk score determines the overall risk ranking and priority of the risk for

action (risk treatments) and the level of operational review – see Table 4. Healthcare, by its very nature, is complex and carries inherent risk. The Trust’s risk management systems and processes are not designed to eliminate all risk, which is unrealistic, but to manage risk to a reasonably practicable level. Account has to be taken of the resource constraints that the Trust faces and risks have to be prioritised for action and resources. These issues will receive consideration at each stage of operational review.

TABLE 4:

1 - 4 LOW (Green)

No additional action is required over and above existing management measures.

5 -8 MODERATE

(Yellow)

Efforts should be made to reduce the risk although the costs of reduction must be carefully considered. Actions should be determined and initiated such that a degree of risk reduction will be achieved within 12 months even though full completion of all actions may take longer in some instances.

9 – 12 SIGNIFICANT

(Amber)

This level of risk must be closely managed by Directorates and will be subject to periodic Operational Risk Management Group consideration/review. Actions should be determined and initiated such that a degree of risk reduction will be achieved within 6 months even though full completion of all actions may take longer in some instances.

15 - 25 HIGH (Red)

Board level notification/attention of this level of risk is required, via the Operational Risk Management Group. Urgent attention to the risk and close monitoring are required.

7.5 Risk Treatment

7.5.1 The range of options for minmising the Consequences and/or Likelihood of the

risk are identified and an option is selected for implementation (on the basis of an assessment of benefits and resource implications i.e. effectiveness and the best value for money).

7.5.2 Once an option has been accepted, detailed action plans are developed to support and direct implementation.

7.6 Monitoring and Review

7.6.1 Risks are rarely static and are maintained under review. The level and frequency of review is associated with the risk ranking and priority of the risk. Analysis of incidents, claims and complaints assists in assessing the effectiveness of risk controls. Also the strategic and organisational context may be adjusted to reflect changing circumstances. The Risk Management cycle must, therefore, be regularly repeated, on a minimum annual basis.

14

Appendix 8.2(iii)

7.7 Communication

7.7.1 The Trust understands that effective internal and external communication is essential to ensuring that those responsible for implementing risk management and those that have a vested interest understand the basis on which decisions are made and why particular actions are required. This is embodied in the Trust Communication Strategy.

8 RISK FUNDING AND INSURANCE

8.1 The resource implications of risk treatments and the priorities to be addressed will be incorporated into Department/Directorate and Trust business planning processes. The Risk Register will be a key-supporting tool for overall financial planning within the context of the Service and Financial Framework and capital utilisation.

8.2 The Trust carries the financial implications of all losses and claims up to the level of the Excess applicable under Welsh Risk Pool procedures. The Welsh Risk Pool acts as the Trust's insurer for all losses above this Excess except those that are specifically insured through the commercial insurance sector, such as Loss of Profit from schemes that generate an income for the Trust (e.g. the supply of maggots).

9 RISK MANAGEMENT DOCUMENTATION

9.1 Risk Management Policy and Strategy

9.1.1 This document is the Risk Management Policy and Strategy and it will be subjected to annual review.

9.2 Risk Register

9.2.1 The Trust's Risk Register is comprised of the Directorate Risk Registers and the Corporate Risk Register, in which Trust and Directorate –wide risks are recorded.

9.2.2 The Risk Register is the repository of information about risks, including source, nature, existing controls, Consequences and Likelihood ratings, priority, treatment options and risk reduction potential and a summary of elements of the action plan for the agreed treatments. An example of the format is attached as Appendix A.

9.3 Risk Assessment Forms

9.3.1 The Risk Rating Form that may be used for risks that are to be entered in the Risk Registers is attached as Appendix B but the use of comments boxes attached to cells within the Registers may also be used to record the necessary information.

9.4 Risk Action Plans

9.4.1 As a minimum, action plans should document:

the treatments (actions) to be implemented who has responsibility for implementation of the actions/plan what resources are being utilised the timetable for implementation

15

Appendix 8.2(iii)

16

the mechanisms and frequency for the review of progress and completion of

the actions/plan.

10 RISK MANAGEMENT TRAINING

10.1 The Trust raises awareness of risk management and educates and trains staff to undertake risk management through a large variety of means, including but not limited to: > Risk Management Training Programme

Basic awareness at Trust Multi-Disciplinary Induction Directorate and Department specifics at local induction Post Graduate programmes for medical staff On the job supervision, coaching and training of all staff Violence and Aggression training programmes Manual Handling training programmes Ad Hoc coaching and training by the Governance Support Unit team , the Health and Safety team, the Estates teams, the Control of Infection team etc.

11 ADVERSE INCIDENT REPORTING

11.1 The Trust's Adverse Incident Reporting System is covered within the Adverse

Incident Policy, Procedure and Guidance documents.

11.2 The Trust records all reported incidents in the Datix System and analyses the data to aid risk identification, analysis, the learning of lessons and evaluation of the effectiveness of risk treatments at all levels in the organisation.

12 CLAIMS AND COMPLAINTS

12.1 The co-ordination of complaints handling is undertaken by the Governance Support Unit in the Human Resources & Operations Directorate in accordance with the Trust's Complaints Handling Policy and Procedure.

12.2 The management of claims for clinical negligence and personal injury is undertaken by the Governance Support Unit in accordance with the Trust's Claims Management Procedure.

12.2 Risks identified in the course of both are managed in accordance with this policy and strategy and analysis of claims and complaints assists the Trust to gauge the effectiveness of risk management actions implemented.

13 TRUST ANNUAL RISK MANAGEMENT PLAN

13.1 This is reviewed annually and published as part of the Risk Management Annual Report.

Appendix 8.2(iii)

17

APPENDIX A

Appendix 8.2(iii)

18

Appendix 8.2(iii)

I

APPENDIX B

Appendix 8.2(iii)

I

TRUST BOARD

Chief Executive Management Executive

Deputy Chief Executive

Operational Risk Management Group

Healthcare Governance Committee

Directorate Risk/Governance Groups, H&S

Committee/Infection Control Committee

Governance Support Unit

H&S Dept, Estates Dept, Personnel, Finance, Clinical Governance Co-

di ti T

Audit Committee

Internal Audit

All Managers

All Staff

Operational Management Independent Assurance

RISK MANAGEMENT STRUCTURE APPENDIX C

WRMS Task Leads

Appendix 8.2(iii)

APPENDIX D

Bro Morgannwg NHS Trust

Welsh Risk Management Standards

Self-Assessment Strategy The Trust is required to undertake a self-assessment against the complete set of standards as part of a continuous review process. The self-assessments will be subject to validation and verification by internal and external auditors, within the normal audit programme. This self-assessment will be undertaken for all Welsh Risk Management Standards. The assessment period to which evidence applies is 1st April to 31st March each year, with the assessment taking place at an agreed time between March and July. The results of this self-assessment and the associated action plans will be submitted to the Welsh Assembly Government by August each year. The self-assessment scores and action plans have to be approved by the Board prior to submission to the Welsh Assembly Government. The Role of the Board in Risk Management

The overall objective of the Welsh Risk Management Standards is to improve the effectiveness of risk reduction and risk control in Welsh Trusts. The Welsh Risk Management Standards are a toolkit to inform the Board about the significant risks within the organisation. They exist to assist the Board in identifying risks, which help determine unacceptable levels of risk, and to then decide on where best to direct limited resources to eliminate or reduce those risks. The Board is responsible for the organisation’s system of internal control, including risk management. It needs to have appropriate policies on risk management and internal control and seek regular assurance on whether the system is in place and functioning properly. As Accountable Officer, the Chief Executive has overall responsibility for the delivery of the Welsh Risk Management Standards requirements. It is the responsibility of the Chief Executive, on behalf of the Board, to sign the Statement on Internal Control within the annual financial statements. All Board members must therefore be assured of the appropriateness, completeness and accuracy of the information that supplements the statement.

2

Appendix 8.2(iii)

WELSH RISK MANAGEMENT STANDARDS The Standards are presented in checklist format to enable a logical progression through self-assessment. The first page of each Standard contains a description of the Standard and a rationale, which explains the broad purpose behind it’s inclusion, and model guidance references to provide further advice about how the Trust is expected to approach the Standards. The detail of each Standard is contained within each of the “Areas for Assessment”, providing the key information for self assessment and Welsh Risk Pool Assessment, and examples of evidence that must be presented to demonstrate compliance with the Standards.

SELF ASSESSMENT • Self assessment is a process that enables the Trust to measure and therefore

improve it’s performance. It involves getting the right people and functions together to openly and honestly examine the workings of the Trust against the Welsh Risk Management Standards. Objective evidence must be produced to verify compliance with the Standards. This will also be required for any subsequent independent verification activity.

• Accreditation with other healthcare quality schemes (e.g. Health Quality

Services, ISO9002, Investors in People etc) will not affect the assessment process, and no automatic compliance with the Welsh Risk Management Standards will be assumed.

• Scores will be generated for each Standard as benchmarks for performance

improvement. Strengths and weaknesses will be identified and from the weaknesses, opportunities for improvement can be determined and an action plan produced. These action plans will be submitted to the Board for agreement and subsequently to the Assembly.

• The Trust has developed this strategy for conducting self-assessments against all Standards. A sound strategy is essential to ensure that the self-assessment will be conducted efficiently and effectively.

Management of the Standards 1. The Trust’s Corporate Risk Manager (Corporate Lead) will take responsibility

for the co-ordination of the Welsh Risk Management Standards in preparation for the annual assessment. The Corporate and Task leads will liaise frequently to review progress against the standards.

2. The Task lead will have responsibility for developing the evidence file for each

standard and will ensure that all evidence is fully referenced to each section of the areas for assessment. Any revision to the standards issued from the Welsh Risk Pool or the Welsh Assembly Government will be incorporated by the task lead into the relevant standard.

3

Appendix 8.2(iii)

3. The Task leads will be responsible for gathering all evidence to support the standards and for the continuos updating of files throughout the audit year, and will complete the evidence file prior to the self assessment. The task leads will also provide quarterly action plans indicating progress against any area for assessment that does not have full compliance. The action plans will be monitored by the Operational Risk Management Group. A final action plan will be required from task leads by the Operational Risk Management Group on completion of the self- assessment and Welsh Risk Pool assessment, which will be approved by the Board and submitted to the Welsh Assembly Government.

4. The strategy recognises that the core Standards (Risk Management Policy

and Strategy, Risk Profile, Adverse Incident and Hazard Reporting, Governance and Financial Management) and the overall risk management process need to be implemented consistently and systematically across the organisation.

5. Recognition that the Standards are not all-inclusive and serve to assist

organisations to establish a comprehensive risk profile/register 6. Information on the results of compliance against individual Standards and

their associated action plans will be centrally brought together no later than June and communicated by the Board to the Welsh Assembly Government at the beginning of August each year.

Scoring Guidelines • The scoring of responses to the areas for assessment contained within the

Standards is important if a robust indication of overall compliance is to be obtained for benchmarking purposes, and for demonstrating improvement over time. At the same time, it is important to recognise that it is the action planning and implementation processes resulting from self-assessment against the Standards that dictate the success of the assurance agenda, and not debating scores.

• The table below gives guidance on assigning scores against “Yes”, “No”, and “Partial” responses. Particular attention should be given to scoring against “Partial” responses as these call for a degree of judgement by the assessors.

4

Appendix 8.2(iii)

Response Score Rationale Table

Response

Score Rationale

No • No compliance anywhere in the organisation with any of the requirements set by the criterion.

0%

• A low degree of organisation-wide compliance with the requirements set by the criterion.

Partial 1-29%

• Demonstrate evidence that a start has been made towards compliance in some or all parts of the organisation.

• Percentage of compliance based on professional judgement by competent persons as part of the self-assessment process.

Scoring Methodology • Where there is limited or no specific guidance for areas for assessment, this

will be added on an ongoing basis. • Examples of the type of evidence required to demonstrate compliance with

areas of assessment are given in Italics in each area for assessment. Where the Standard refers to the evidence itself (e.g. “there is a risk register….”), the example line reads “as above”.

• The assessors (whether external or internal) will indicate their assessment of compliance with each of the various “Areas for Assessment”, by using a “Yes”, “No” or “Partial” compliance mark. Where more than one element of evidence has been reviewed, each of these elements will contribute to the assessment mark for each area of assessment. A “Not Applicable” mark may also be given, and no score should be given against such assessments.

• Full compliance can only be achieved if the organisation meets the compliance assessment in full for the whole year or where applicable over a 6-month period.

• Partial compliance must be given in the following circumstances: *Where the organisation meets the compliance assessment in full, but not for the whole period of assessment; or

*Where only part of the test has been met.

Partial 30-69% • A moderate degree of organisation-wide compliance with the requirements set by the criterion.

• Demonstrable evidence that work is ongoing across most parts of the organisation to achieve compliance, though some directorates or departments may be in the very early stages of compliance.

• Percentage of compliance based on professional judgement by competent persons as part of the self-assessment process.

Partial 70-99% • Substantive organisation-wide compliance with all requirements set by the criterion.

• Demonstrate evidence that most parts of the organisation are meeting most of the requirements set by the criterion.

• Only minor non-compliance’s requiring, in the main, minor action(s).

• Percentage of compliance based on professional judgement by competent persons as part of the self-assessment process.

5

Appendix 8.2(iii)

• The allocation of scores for each of the “Areas for Assessment” will then be made by the assessor, based on the assessments of compliance and the associated comments.

WEIGHTING OF “AREAS FOR ASSESSMENT” • Within each Standard, there are a number of “Areas for Assessment”. Each of

these will be allocated a weighting score. • The prescribed weightings are based on the relative importance of the

Standard’s issues to reduce and control risks, together with the relative difficulty of achieving the issue concerned, as shown in the following table.

Difficulty

Importance

1 2 3 A 4 10 20 B 10 25 50 C 20 50 100

Difficulty

A The creation or development of a new policy, appointment of staff

(e.g. Policies on consent, incident reporting, communications, appointment of Risk Manager, etc).

B The operational implementation of a procedure, system or process.

(e.g. introduction of incident reporting process, training programmes on records management, undertaking risk assessments, complaints/claims process managed effectively, etc).

C Actual improvements being made, risk reduced, changing

the values, beliefs and/or culture of the organisation

(e.g. demonstration that issues identifies through incidents/complaints/claims have brought about change, consent policy operating effectively, open and clear communication channels evidenced by minutes and interviews, etc.)

6

Appendix 8.2(iii)

Importance 1 Is moderately important to the management of risks within

an organisation. Absence of compliance with this area would create some difficulties in effectively managing risks.

(e.g. specific policies, i.e. communication, effective clinical audit process, records destruction/management policy)

2 Is highly important to the management of risk within an

organisation. Absence of compliance with this area would create substantial difficulties in effectively managing risk.

(e.g. appointment of a risk manager, formalised risk assessment process, incident reporting process and review, a senior manager responsible for records management, Risk Management Committee)

3 Essential/fundamental to reducing and/or effective

management of risk within the organisation. Absence of this area would expose the organisation to major risk and would prohibit the organisation from managing risks.

(e.g. a set of policies/procedures – specific ones carry more risk than others i.e. consent, records management – records management strategy, risk management strategy/policy)

Weighting of Welsh Risk Management Standards The Welsh Risk Pool has applied various weightings for each of the Standards. These weightings have been allocated to reflect the relative importance in achieving effective risk reduction and risk control impacting upon potential litigation against the Trust. The prescribed weightings are as follows:

Welsh Risk Management Standards Weightings 2006-07

Standard No.

Standard Weighting

1 Risk Management Policy and Strategy 100 2 Risk Profile 100 3 Incident and Hazard Reporting 100 4 Complaints 50 5 Claims Management 50 6 Policies and Procedures 25 7 Records Management 50 8 Communications 100 9 Consent to Treatment 100 10 Clinical Audit 20 11 Supervision of Staff 100 12 Assessing Competence 100

7

Appendix 8.2(iii)

13 Occupational Health and Safety (formerly Health and Safety)

50

14 Infection Control 100 15 Maternity 300 16 Operating Department Services

(formerly Operating Theatres) 50

17 Accident & Emergency 50 18 Mental Health 25 19 Community 25 20 Ambulance 50 21 Learning Disabilities 25 22 Buildings, Land, Plant and other Non-Medical Equipment 10 23 Nutrition & Catering

(formerly Catering and Food Hygiene) 25

24 Contractors and Contractor Control 25 25 Emergency Preparedness 10 26 Environmental Management 10 27 Fire Safety 50 28 Human Resources 25 29 Information Management and Technology 25 30 Medical Equipment and Devices 100 31 Medicines Management 100 32 Professional and Product Liability (Suspended) - 33 Security Management 25 34 Transport 4 35 Waste Management 50 36 Decontamination of Re-usable Medical Devices and Equipment 50 37 Governance 100 38 Finance 100 39 Safeguarding the Welfare of Children 50 40 Cleanliness 50

FURTHER GUIDANCE: • WHC (2000) 13: Corporate Governance in the NHS in Wales: Controls

assurance statements 1999-2000: Risk Management and Organisational Control

• WHC (2000) 57: Corporate Governance in NHS: Controls Assurance Statements for 1999-2000 and the introduction of Welsh Risk Management Standards

• The foreword to the Welsh Risk Management Standards (November 2000) • Management of Risk: A Strategic Overview (The “Orange Book”), HM Treasury

(January 2001) The Welsh Risk Management Standards for Trusts are on the WRP website at http://howis.wales.nhs.uk

8

Appendix 8.2(iii)

Originator: Governance Support Unit Date Approved: 23rd January 2008 Approved by: Management Executive Date for Review: 23rd January 2009 Policy ID: 269

ADVERSE INCIDENT POLICY APPLICABLE TO MANAGING, REPORTING, INVESTIGATING, ANALYSING AND LEARNING FROM ADVERSE INCIDENTS RELATED DOCUMENTS: ADVERSE INCIDENT PROCEDURE ADVERSE INCIDENT GUIDANCE This document can be made available in alternative formats or other languages, on request, as is reasonably practicable to do so.

Appendix 8.2(iii)

TABLE OF CONTENTS

Page 1 Introduction

3

2 Policy Objectives

3

3 Scope and Definitions

4

4 Operational Arrangements

6

5 Ensuring a Leaning and Supportive Culture

7

6 Ensuring an Open Culture

8

7 Confidentiality

8

8 Training

9

2

Appendix 8.2(iii)

1. INTRODUCTION 1.1 The Trust's Risk Management system is based on a proactive approach to preventing,

reducing and controlling risks in order to protect patients, the public, our staff and the Trust from unintended harm, damage and losses. This includes a commitment to apply the lessons that are learned from Adverse Incidents.

1.2 This document is the Trust's Policy and Procedure for managing, reporting, analysing and learning from Adverse Incidents and hazards that arise in the course of the Trust conducting its business. It exists to ensure that all Adverse Incidents and hazards are managed and analysed consistently, effectively and within a supportive environment and that lessons are learnt in order to reduce risk for the future.

1.3 Adverse Incident management and reporting assists the Trust to: • act speedily, effectively, efficiently and sympathetically with the Incident itself and with

any complaint or legal claim that may follow the occurrence • identify problems and risks and better understand how they arise • assess the effectiveness of measures put in place to try and control risks • develop future actions aimed at reducing the occurrence or severity of a risk

1.4 A cornerstone of this policy and procedure is the need to establish the underlying cause(s) of Adverse Incidents through appropriate and structured investigative techniques, including root cause analysis. Unless the causes of Adverse Incidents are properly understood, lessons cannot be identified and learned and suitable improvements cannot be made to secure a reduction in the future level of risk.

2. POLICY OBJECTIVES

The Trust will ensure that:

1. The reporting of Adverse Incidents and hazards makes a positive contribution to

continuous improvement, that the purpose of Incident reporting is non-punitive and there is adequate support available.

2. Those involved in an Adverse Incident receive an adequate explanation of what

happened, an apology where this is appropriate and are assured that action to try and prevent a similar occurrence is being or will be taken.

3. There are clear definitions of what constitutes a reportable Adverse Incident and hazard

and mechanisms to make staff aware of the definitions and understand how to apply them in practice.

4. All Adverse Incidents and hazards are reported to the designated person, or persons,

and managed in accordance with this procedure. 5. All serious Incidents and hazards are reported immediately to the designated person, or

persons, and information on these Incidents is ‘fast-tracked’ to relevant external stakeholders in accordance with this procedure.

3

Appendix 8.2(iii)

6. All reported Incidents are graded according to their actual impact on and their potential future risk to patients, staff, other persons and the Trust and are reviewed to establish the precise stakeholder reporting requirements.

7. Adverse Incidents are subject to an appropriate level of investigation and causal

analysis and, where relevant, an improvement strategy is prepared. 8. Category Red Adverse Incidents or those otherwise defined within the Serious

Incidents Reporting Policy and Procedure are reported in accordance with the defined requirements

9. For all category Red Incidents, a full root cause analysis is undertaken and reported to

any appropriate agencies within 45 working days of occurrence of the Incident. 10. There is co-operation with the Mid and West Wales Regional Office of NHS Wales to

establish the need for any independent investigation or inquiry, and also co-operation with other stakeholders who might be required to undertake investigations and/or inquiries into the circumstances surrounding a particular Adverse Incident.

11. Aggregate reviews of Incident data/information are carried out on an ongoing basis and

the significant results communicated to identified stakeholders. 12. Lessons are learned from individual Adverse Incidents and from aggregate reviews at

every level in the organisation including, Ward, Unit, Department, Directorate and Trust-wide. Improvement strategies aimed at learning lessons, changing practice and reducing future risk are developed, implemented and monitored by the organisation.

13. In accordance with the Trust Risk Management Policy and Strategy, lessons are

learned from wider experiences, including the experiences of other Trusts, feedback from the Welsh Risk Pool, feedback from the National Patient Safety Agency, legal developments/case law, other agencies/bodies, and benchmarking. These will also generate improvement strategies aimed at learning lessons, changing practice and reducing future risk.

14. Adherence with and the effectiveness of this policy and procedure are monitored by the

Trust through audit, application of performance indicators and assessment against the Welsh Risk Management Standards.

3. SCOPE and DEFINITIONS 3.1 This policy and procedure applies to a broad range of circumstances and occurrences that

meet the definitions of a reportable Adverse Incident or hazard as defined below.

3.2 ADVERSE INCIDENT =

Any unintended or unexpected occurrence, which could have or did lead to harm, damage or loss.

3.3 This definition encompasses all the following. Any relevant or necessary sub-classification of

Adverse Incidents will be undertaken by the Governance Support Unit upon receipt of the Adverse Incident report.

4

Appendix 8.2(iii)

• Near Miss - any unintended or unexpected occurrence that could have led to harm, loss or damage but which ran to completion and fortunately no harm, loss or damage actually occurred or where there was some intervention, which actually prevented the occurrence and there was, therefore, no harm, loss or damage

• Errors - that could have or did lead to harm, loss or damage • Accident - any unintentional occurrence of harm or physical damage nor arising out of

the conduct of an operation, examination or other clinical treatment • Ill Health or Disease - known or suspected work or environment-related ill health or

disease e.g. infection, dermatitis, hearing-loss • Hazard or Trigger - anything with the potential to cause harm, damage or loss that is

not dealt with through maintenance requisition forms e.g. faulty medical equipment, failures to follow protocols etc., where no specific person has been identified as having been harmed or could have been harmed

3.4 HARM is considered to be any injury (physical or psychological), disease, suffering,

disability, impairment of normal function or death.

3.5 DAMAGE is considered to be an impairment of the normal function of an item of physical property

3.6 LOSS is considered to be a monetary loss or reduction in monetary value or the deprivation of use/presence of an item of physical property.

3.7 Specific guidance and examples of reportable Adverse Incidents are contained within the Adverse Incident Guidance.

3.8 Not everything that happens is a reportable Adverse Incident. For example, patients are admitted to hospital and despite every care, they may suffer a cardiac arrest due to their overall clinical condition. This is clearly an unwanted outcome but not preventable or unexpected. Such an occurrence is not a reportable Adverse Incident unless there has been some untoward contributory factor, for example, it might have been possible to resuscitate the patient following the arrest, but staff were unable to do so because the defibrillator was defective.

3.9 An Adverse Incident Report should not be completed where staff wish to register a point of view or highlight that a situation is less than ideal unless there is a clear hazard present. There are other, more appropriate, means of raising and dealing with such situations. The Trust also has other policies that may be the more appropriate avenue for raising a concern or issue e.g. the Staff Concerns Policy, Individual Grievance Policy and Harassment at Work Policy. In the event that a member of staff is unsure whether an occurrence meets the definition of a reportable Incident, this should be discussed with the line manager, with escalation through the department, directorate, professional leads etc., as necessary.

3.10 Definitions in use by other agencies, that may place obligations on the Trust, have been taken into account, as far as possible. (For example, the requirements for reporting serious Incidents to the Regional Office and the definitions contained within those requirements).

5

Appendix 8.2(iii)

3.11 The occurrence or circumstance must arise in the course of one or more of the following:

during Trust care, whether on or off Trust premises in the discharge of duties for which a member of staff is employed by the Trust in connection with a member of staff acting in accordance with their employment elsewhere than on Trust premises whilst a person is legitimately ion Trust premises whilst a person is not legitimately on Trust premises (as the Occupiers Liability Act imposes certain duties in respect of trespassers)

4. OPERATIONAL ARRANGEMENTS 4.1 ALL staff, whether directly involved in an Adverse Incident or not, should ensure that all

Adverse Incidents, no matter how minor they might appear, are reported using the Adverse Incident Report Form. This ensures that the Trust has the opportunity to learn from Adverse Incidents and improve matters for the future.

4.2 Any person in the Trust who deals with volunteers and external contractors should ensure that such persons are made aware of pertinent aspects of this Policy and Procedure.

4.3 Staff should always attempt to satisfactorily resolve issues that are brought to their attention by patients and other persons. However, patients and other persons are equally entitled to submit an Adverse Incident Report to the Trust if they wish to do so. Staff should ensure that a report form is made available in response to such a request. In the future it will also be possible for patients and third parties to report an Incident directly to the National Patient Safety Agency (NPSA) through that agency's on-line reporting facilities. Any Incidents reported directly to the NPSA will be routed back to the Trust for investigation and action under this Policy and its supporting Procedure.

4.4 Every manager in the Trust should work to create and sustain an environment whereby staff feel able to express any concerns they may have and know that these will be taken seriously and dealt with confidentially.

4.5 Directorate Management Teams should ensure that local arrangements for the implementation of this policy and procedure are developed and these are communicated to staff.

4.6 Directorate Governance Groups should: • promote a culture of openness within the Directorate to encourage and ensure that all

Adverse Incidents are reported and investigated appropriately; • consider Incident investigations/reports, identify learning points and agree/develop risk

management action plans; • ensure there is a process within the Directorate to monitor that actions are completed

and signed off; • ensure there are adequate mechanisms for feedback and the sharing of learning from

Adverse Incidents across the Directorate including links into education programmes; • review aggregated Incident analyses considering trends, areas for further investigation

or data analysis etc and use this information to develop or update risk assessments and treatment plans;

• ensure that issues raised by and lessons from Adverse Incident reporting are integrated with the other elements of Clinical Governance.

6

Appendix 8.2(iii)

4.7 There are many sources of advice to Directorates depending on the nature of any particular

Incident or process involved, including professional leads, Personnel teams, Occupational Health Department, the Infection Control Team, EBME etc. The GOVERNANCE SUPPORT UNIT and the Health and Safety Department are also tasked with providing advice to Directorates. Where called upon to do so by the Executive team, the GOVERNANCE SUPPORT UNIT and the Health and Safety Department will directly participate in the investigation of individual Adverse Incidents and the development of appropriate actions to reduce risk for the future.

4.8 The Chief Executive/Deputy Chief Executive will decide how media interests are to be managed. All media releases and interviews must be authorised by the Chief Executive/Deputy Chief Executive in consultation with Executive Director colleagues.

5. ENSURING A LEARNING AND SUPPORTIVE CULTURE

5.1 Healthcare is delivered in a complex, high technology environment, requiring many different

human judgements, interventions and decisions. Throughout the NHS, pressures occur when there is an imbalance in capacity and demand. Against such a background, the Trust recognises that honest mistakes will occur and things will sometimes go wrong. When they do, the Trust sets out to ascertain what happened and why in order to learn from the experience and use that learning to reduce risk for the future. Adverse Incident reporting should, therefore, be seen as a positive learning opportunity and not a demoralising focus on mistakes or blame.

5.2 Whilst a mistake often contributes to the occurrence or outcome of an Adverse Incident, it will usually have occurred as a result of one or a number of underlying causes that lie in organisational systems and blame cannot, and will not, be attributed to individual members of staff. The Trust is committed to reducing risk through investigating and analysing Adverse Incidents to identify the fundamental and underlying causes and taking actions to address those issues. Identifying and addressing our systems problems is, therefore, the key to reducing future risk.

5.3 The Trust, therefore, promotes a culture of 'just blame' where a reported Adverse Incident is only likely to lead to instigation of the Trust Disciplinary Policy when the investigation reveals that the actions/conduct of an individual or individuals:

• involved a deliberate intent to harm • was a flagrant disregard for the safety of patients or others (e.g. treating patients

whilst under the influence of alcohol) • forseeably placed the safety of patients, staff or others at risk • was a deliberately repeated breach of policy or procedures • was a criminal act (e.g. theft, assault) • was a malicious act (including malicious reporting of untrue allegations against a

colleague) • evidences repeated non-reporting of errors or violations • evidences repeated failure to engage in learning lessons

5.4 The Trust will utilise the 'Incident Decision Tree' tool, developed by the National Patient

Safety Agency, to ensure appropriate and consistent decisions are made in this respect. Further information on the Incident Decision Tree will be incorporated into relevant Trust policies and procedures.

7

Appendix 8.2(iii)

5.5 Making an Adverse Incident Report does not constitute an admission of liability. The information is used to enable the Trust to gather all the facts for investigation, analysis, learning and future risk reduction.

5.6 The Trust understands that being involved in a situation that has resulted in harm to a patient, a member of staff or any other person can be traumatic. Managers and professional leads will support staff in such situations. Specialised assistance is also available thought the Occupational Health Department.

6. ENSURING AN OPEN CULTURE 6.1 The Trust is committed to being open with patients, or their relatives and carers, if they have

been affected by an Adverse Incident.

6.2 It is now widely recognised and supported by research that an open approach and the provision of timely and appropriate information is important to reassure patients. It has also been shown that patients are more tolerant of Adverse Incidents and mistakes when they are disclosed promptly, fully and compassionately. Those affected by Adverse occurrences naturally and increasingly ask for explanations of what led to the Adverse occurrence. Often, closely linked to this wish for information is the fact they will feel some consolation if lessons have been learned for the future and others will not suffer as they have. Sections A and F of the Adverse Incident Procedure detail the procedures for such communications.

6.3 It is natural and desirable for those involved in treatment or any other circumstances that produce an Adverse outcome, to sympathise with those affected and to express sorrow or regret at the outcome. Such expressions do not normally constitute an admission of liability. Advice and assistance can be sought from Professional Leads including the Medical Director and Executive Director of Nursing and also from the Head of the Governance Support Unit where there is any concern in this respect.

7 . CONFIDENTIALITY 7.1 At all times, a completed or partially completed Adverse Incident Report form is a confidential

document and must be handled and stored accordingly by all concerned. Investigations will be respectful and confidential.

7.2 Staff need to be aware that the information recorded on an Adverse Incident Report form is transferred in full to the electronic record within the Datix System. This, therefore, includes the elements of personal information provided on the form: • Name • Designation • Payroll Number Should more information be provided on the form, this will also be captured in the Datix record.

7.3 Staff also need to be aware that in the interests of good governance and risk management, such information may be used for analysis, for example, anonymised analyses of sickness absence related to Adverse Incidents. In addition, the Trust has a responsibility to undertake specific analyses that may be linked to the practice and behaviour of individuals. Such analyses will be produced by the Governance Support Unit and shared on a 'need to know' basis only. All such analyses are confidential and must be handled and stored accordingly by all concerned.

8

Appendix 8.2(iii)

8. TRAINING 8.1 The Trust will continue to actively promote awareness and understanding of this policy and

procedure, to all members of staff, which includes all employees, bank staff, agency staff and locum staff, through:

Multi-Disciplinary staff Induction Directorate and Department Induction Professional Induction Ongoing training needs identified as part of individual ongoing performance review and delivered through the Risk Management Education Programme Risk Management newsletters, Incident alerts, poster campaigns etc

8.2 All persons who will be required to facilitate a Root Cause Analysis will receive training to do

so and their performance and any further training needs will be considered as part of their Individual Performance Review.

8.3 Where an investigation into an Adverse Incident reveals a training issue, the line manager will consider not only what actions must be taken in respect of the individual but also whether there is a need for wider re-enforcement. Where this need is considered to extend beyond the local remit or there are implications for Trust-wide training, action will be taken to highlight this to all relevant individuals and groups.

9

Appendix 8.2(iii)

ADVERSE INCIDENT PROCEDURE APPLICABLE TO MANAGING, REPORTING, INVESTIGATING, ANALYSING AND LEARNING FROM ADVERSE INCIDENTS RELATED DOCUMENTS: ADVERSE INCIDENT POLICY ADVERSE INCIDENT GUIDANCE This document can be made available in alternative formats or other languages, on request, as is reasonably practicable to do so.

Originator: Governance Support Unit rdDate Approved: 23 January 2008

Approved by: Management Executive rdDate for Review: 23 January 2009

Policy ID: 430

Appendix 8.2(iii)

2

TABLE OF CONTENTS

1 Appendix 1 - Schematic of the Process

4

SECTION A: THE IMMEDIATE MANAGEMENT OF ADVERSE INCIDENTS 1 Notification To/Contact With The Senior Person On Duty

5

2 Responding To The Immediate Needs Of The Persons Involved

5

3 Re-Establishing A Safe Environment

5

4 Preservation Of Evidence

5

5 Communicating with Persons Affected and Supporting Staff

6

SECTION B: REPORTING AND GRADING ADVERSE INCIDENTS 1 General Points

7

2 Completing and Processing the Adverse Incident Report

7

3 Grading Adverse Incidents

10

SECTION C: SERIOUS/RED INCIDENTS - INITIAL MANAGEMENT, INTERNAL REPORTING and EXTERNAL REPORTING

1 Incidents Occurring During Normal Working Hours

15

2 Incidents Occurring Outside Normal Working Hours

19

3 Contact Information

20

4 Follow-Up Action

20

SECTION D: INVESTIGATING AND ANALYSING ADVERSE INCIDENTS 1 General Points

21

2 Level and Nature of Investigation and Analysis

22

3 Co-operating With Independent Investigations And/Or Inquiries Required By Relevant Stakeholders

24

SECTION E: GENERATING RECOMMENDATIONS AND ACTION PLANS

24

SECTION F: FEEDBACK TO PATIENTS/RELATIVES/CARERS, STAFF AND TEAMS AND SHARING THE LEARNING

Appendix 8.2(iii)

3

1 Patients, Relatives and Carers

25

2 Staff and Teams Involved

25

3 Sharing the Learning

26

SECTION G: MONITORING AND REVIEWING THE EFFECTIVENESS OF ACTIONS TAKEN

26

SECTION H: EXTERNAL REPORTING REQUIREMENTS

26

SECTION I: OTHER MECHANISMS FOR DETECTING ADVERSE INCIDENTS

29

APPENDICES

2 IR1 - Adverse Incident Report form

3 IR2 - Witness Report

4 IR3 - Investigation Report form

5 IR4 - Medical Device form

6

IR5 – Drug Form

7 Serious Incidents - Management Reporting Within Normal Working Hours (Flowchart)

8 Serious Incidents - Management Reporting Outside Normal Working Hours (Flowchart)

9 Form for notifying the Regional Office of a Serious Adverse Patient Incident

Appendix 8.2(iii)

4

INCIDENT REPORTING PROCESS ADVERSE EVENT

OR NEAR MISS

IMMEDIATE ACTION 1. Make person(s) / area safe. 2. Obtain medical aid if required. 3. Inform manager on duty ASAP 4. Complete incident form IR1 and grade

incident within 24 hours

GREEN INCIDENT No injury or damage caused. No

investigation unless deemed necessary by Directorate Risk

Co-ordinator or GSU

AMBER INCIDENT Semi-permanent injury (i.e. will

recover, but may take some time e.g. up to one year or more.

Investigation necessary

RED INCIDENT Avoidable death / Major resource

implication / Avoidable shortening of life expectancy / Major life-long injury

e.g. loss of limb / Life-long loss of service. Investigation necessary

Investigation to be completed as advised by commissioning executive team / or as determined

FOLLOW SUI POLICY

Incident form IR1 to be completed and handed to Line Manager within 3 working

days of incident date

Directorate Risk Co-ordinator to receive form within 7 days of incident date and

forward to GSU within 10 days of incident date

Report to any external agencies as

necessary eg. MDA/MHRA, NPSA, HSE (RIDDOR), Police, etc

Investigation to be completed and IR1 & IR3 form to be received at GSU within 10 working days of incident date

Investigation to be completed and IR3 form to be received at GSU within 20 working days of incident date

WHAT WAS THE GRADE?

IR1 form to be received at GSU within 10 days of incident date

Hand to Directorate Risk Coordinator within 7 days of incident date and forward

to GSU within 10 days of incident date

YELLOW INCIDENT Minor injury / damage i.e. no lasting

effects, will be resolved in a time period of no more than 1 month. No major

resource implications. Investigation necessary

Hand to Directorate Risk Coordinator within 7 days

of incident date

Hand IR1 to Line Manager within 3 working days of incident date

Directorate Manager or deputy to complete IR3 after conducting an investigation using an approved method of root cause analysis.

Report to any external agencies as necessary eg. MDA/MHRA, NPSA,

HSE (RIDDOR), Police, etc

Hand IR1 to Line Manager within 3 working days of incident date

Hand IR1 to Line Manager within 3 working days of incident date

Hand to Directorate Risk Coordinator within 7 days

of incident date

Directorate Manager or deputy to complete IR3 after conducting an investigation using an approved method of root cause analysis.

Report to any external agencies as necessary eg. MDA/MHRA, NPSA,

HSE (RIDDOR), Police, etc

Appendix 8.2(iii)

5

Section A THE IMMEDIATE MANAGEMENT OF ADVERSE INCIDENTS (See Section C for Serious/Red Incidents)

1. Notification To/Contact With The Senior Person On Duty 1.1 Each Department and Directorates should define their requirements and ensure these are

communicated to staff.

2. Responding To The Immediate Needs Of The Persons Involved 2.1 Where any person has sustained an injury, examination and treatment must be offered. This

might include referral to A&E/LAC. Refusal of that offer must be noted on the Adverse Incident Report Form IR1.

2.2 If the Incident in any way relates to the use of medical equipment, disconnect the equipment from the patient.

2.3 If the Incident involves a patient, the Consultant or lead professional in charge of the patient's care must be informed.

3. Re-Establishing A Safe Environment 3.1 Take appropriate action to contain the situation, as agreed with the contact person/senior

person on duty. Notify or seek advice from specialist advisors/departments, as necessary (e.g. Infection Control, Pharmacy etc).

4. Preservation Of Evidence 4.1 It is important that there is a common sense approach and that there is discussion within the

department/directorate in any given situation.

4.2 Where it is suspected that drugs may be defective/contaminated/out of date etc, they must be taken out of use and contact made with Pharmacy for advice.

4.3 If the Incident involves any faulty or damaged medical equipment, it must be removed from use, appropriately labelled and retained for inspection by EBME. All accessories and disposables/consumables must be retained intact. Settings must not be adjusted. The equipment must be clearly labelled as defective and it must be stored in a place and manner such that it cannot be accidentally or intentionally brought back into use in the intervening period until all investigations are complete and formal approval has been given for the re-introduction of the item. The supplier or manufacturer of an item should not be contacted at this particular time.

4.4 If the Incident involves any faulty or damaged non-medical equipment, it must be removed from use, appropriately labelled and retained for inspection by Estates or IT. It must be stored in a manner such that it cannot be accidentally or intentionally brought back into use in the intervening period until all investigations are complete and formal approval has been given for the re-introduction of the item.

4.5 Once investigations are complete, should any equipment be identified as requiring service or repair a works requisition must be submitted as a matter of urgency or any other necessary action taken but it is vitally important that a photograph of the equipment be taken prior to repair taking place.

4.6 Advice can be sought from the Governance Support Unit or Health and Safety Department if it is considered that a photograph of the environment/facility is necessary/helpful.

Appendix 8.2(iii)

6

5. Communicating with Persons Affected and Supporting Staff

5.1 The National Patient Safety Agency currently has no evidence to suggest that Incidents that

resulted in no harm or where harm was prevented by intervention (sometimes referred to as 'Near Misses') should be disclosed to patients. Therefore, this section relates to the occurrence of an Adverse Incident that has resulted in actual harm.

5.2 Where an Adverse Incident has resulted in minor harm, the patient, or relatives/carers, should be informed by the member of staff who has been providing his/her care, by way of a discussion.

5.3 For more significant levels of harm, a higher-level response is needed from the senior clinician who is responsible for the patient's care. In such instances the patient, their relatives or their carer, as appropriate, should be provided with:

• a clear and factual explanation of what happened • acknowledgement of the distress that has been caused and a sincere statement of

regret for that distress • sympathetic support • clear information on what will happen from then onwards • a view on the likely health outcome and what can be done to repair or redress the harm

done. If the patient requires further therapeutic management or rehabilitation, the patient should be clearly informed of the ongoing clinical management plan

• reassurance that steps will be taken to learn from what has happened and try to prevent a repeat occurrence

• confirmation that further information will be available once the investigation is complete and lessons learnt and actions to be taken to prevent recurrence have been identified.

5.4 Advice and assistance can be sought from Executive Directors, Directorate Management

Teams, Professional Leads and the Head of the Governance Support Unit on any aspect.

5.5 A record of the Adverse Incident must be written in the patient's clinical notes. This is in addition to completion of the Adverse Incident Report Form. The Adverse Incident Report Form is a tool for managing risk and does not form part of the patient record. It must not be filed in the patient's clinical notes after it has been returned to the directorate by the Governance Support Unit.

5.6 The discharge letter sent to the patient's General Practitioner or appropriate Community Care service should contain summary details of:

• the nature of the Incident and the continuing care and treatment • the current condition of the patient • key investigations • recent results • prognosis

5.7 Staff involved in Adverse Incidents may require assistance and support. What is appropriate is

likely to depend on the nature of what has happened and the outcome. Some areas may be covered by particular policies, such as the Inoculation Policy. The Line Manager of the reporter will need to consider the involvement of and advice from appropriate persons and departments including the Directorate Management Team, Professional Leads, Executive Directors, Personnel, Occupational Health Department etc.

Section B REPORTING AND GRADING ADVERSE INCIDENTS

Appendix 8.2(iii)

7

1. General Points

1.1 This section covers the internal reporting of Incidents only. External reporting procedures are detailed in Section H. The management and reporting of Serious/Red Incidents is covered in Section C.

1.2 Directorates should customise these framework procedures into practical working arrangements and communicate these to all their staff.

1.3 Detailed explanations of the type of information to be recorded in each area or under each question within the report form and why that information is required are contained within the Adverse Incident Guidance. This document also provides general information on Adverse Incident Report forms. Every area/question had been included in the form for a valid and valuable purpose and it is, therefore, important that every area is completed/every question answered.

2. Completing and Processing The Adverse Incident Report Form 2.1 The Adverse Incident Report form IR1 (see Appendix 2) is designed to capture the initial facts

of:

• WHAT happened and • WHERE, • WHO was involved, • any ACTIONS taken at the time • the result of the INCIDENT GRADING, • any RISK REDUCTION MEASURES that have been or can be taken and any other

facts immediately apparent or available. This is the only form required for GREEN Incidents.

2.2 For any Incidents where an investigation is conducted, a separate form is used to capture information about the INVESTIGATION, LEARNING POINTS identified as a result of the investigation and the RISK REDUCTION MEASURES that have been implemented or are planned. This is covered in Sections D and E.

2.3 Completion of an Adverse Incident Report form IR1 or a Witness Report IR2 does not constitute an admission of liability of any kind.

Staff involved in the Incident: 2.4 • Complete the Adverse Incident Report form IR1 within 24 hours of the Incident. In

addition, if the Incident involves a Medical Device complete form IR4 which should be downloaded from the Governance Support Unit web site and attached to form IR1.

• Grade the Incident in accordance with the guidance later in this section.

• If there are witnesses, Witness Reports should be completed. This is critically

important in the case of Significant (Amber) or Serious (Red) Incidents. A Witness Report IR2 is a supplementary form but an integral part of the Adverse Incident Report, when completed. Witnesses should be reminded that no allegations are being made against them and that the purpose of providing a report is simply to obtain factual information that could be of assistance in establishing the facts leading up to the Incident.

A Witness Report or a formal statement may also be requested later, as part of an investigation.

Some staff may request that their union or professional body sees their Witness Report

Appendix 8.2(iii)

8

prior to submission, and should a subsequent interview be necessary, may wish to be accompanied by their staff representative.

• For all Adverse Incidents involving Child Protection issues or failures, the reporter should ensure that the information recorded on the IR1 includes how the incident came to his/her attention, whether a Child Protection referral was required, if YES - who made it and if NO, why. Please refer to Child Protection Guidelines for clarification. A copy of the IR1 form must be sent to the Named Trust Child Protection Health Professionals.

• Sign and date the form and send it to your line manager immediately to ensure that the line manager receives the report within 3 working days of the Incident date.

• Examples of Child Protection Incidents could be as follows:

• Failure to recognise child abuse • Failure to follow Child Protection Procedures • Failure to make an appropriate referral to a statutory agency • Failure to follow up a referral in writing (if this failure leads to a lack of action by social

services) • Failure to provide information to a child protection Section 47 enquiry or a Child Protection

Case Conference • Failure to pass on child protection concerns and/or make referral on a tertiary transfer of a

child • Failure to share information to safeguard the welfare of a child • Failure to act on an allegation of, or incident of abuse by a health professional • Health attempting to investigate child protection issues alone • ‘Hiding’[ behind confidentiality • Professional difference of opinion (see Resolution of Professional Differences Policy)

Line Manager/Ward Manager/Department Manager/Consultant (as appropriate): 2.5 Within 2 working days of receiving the Incident report, the line manager of the person who

has reported the incident must take the following action:

• Check that the Incident as described constitutes a reportable Incident under the definitions of the Adverse Incident Policy. If it does not, ensure that all staff involved are assisted to understand why this is and what alternative course of action may be appropriate.

• Where a patient is directly affected, inform the Consultant or lead professional in

charge about the Incident, if this has not already been done. Ensure the Consultant's/lead professional’s comments are recorded, if this is thought to be appropriate.

• Check the details of the Incident and that all relevant internal contacts have been made

(e.g. with the Infection Control Team).

• Check the grading that has been applied. Change the grading, if appropriate, but document why.

• If a risk assessment has previously been conducted for the particular occurrence or

task undertaken, ensure that a copy is attached to the report form.

• For all Adverse Incidents involving Child Protection issues or failures, send a copy of the IR1 forms to the Named Trust Child Protection Health Professionals (see also Child Protection Strategy/Policy).

Appendix 8.2(iii)

9

• Where applicable, make an appropriate RIDDOR report - see Section 5 of the Adverse Incident Guidance – recording the RIDDOR report number on the Incident form. For these RIDDOR Incidents only, send a copy of the IR1 to Occupational Health Department. RIDDOR reports can be done online via www.RIDDOR.gov.uk

• For all Adverse Incidents involving a medical device, send a copy of the IR1 and IR4

forms to EBME, together with the equipment and accessories involved.

• For all Adverse Incidents involving a drug error, send a copy of the IR1 and IR5 forms to the Chief Pharmacist, Princess of Wales.

• Check all other relevant external reporting requirements and liaise appropriately (see

Section H).

• Sign and date the IR1

• Forward the IR1 to the nominated Directorate Risk Co-ordinator.

Directorate Risk Co-ordinator (or suitable deputy in the event of absence): 2.6 • Undertake a check on the Incident as described and the grading applied and raise any

concerns or issues with the Line Manager/Ward Manager/Department Manager/Consultant

• Report as defined within agreed Directorate procedures, but these should include the

submission of a suitable report being made to the Directorate Governance/Risk Group.

• The Directorate Risk Co-ordinator or designated person should ensure that the IR1 is sent to the Governance Support Unit within 7 working days of the Incident date.

3. Grading Adverse Incidents 3.1 All reported Adverse Incidents must be graded according to:

1. the actual outcome/consequences of the Incident 2. the potential future risk of harm/loss/damage

3.2 Grading Incidents according to the actual consequences and the potential future risk

establishes the level of investigation and causal analysis that must be carried out and the reporting requirements.

3.3 The person completing the Incident Report Form should grade the Adverse Incident in the first instance, using the Grading Matrix and Tables in Section 5.

3.4 The immediate assessment of the Incident grade should be undertaken quickly, and it is not necessary for the person completing the Incident report form to be in possession of all the facts at the time of grading the Incident. There is always scope for re-grading the Incident as the facts and issues emerge. An Incident grading can also be re-examined at the time when the risk reduction options are determined. This will also assist in prioritising the actions planned.

3.5 In line with the requirements of Welsh Risk Management Standard 1, the grading system adopted for Adverse Incidents has been closely linked to the process and matrices used by the Trust for prioritising risks within the Risk Register (see Risk Management Policy and Strategy).

STEP 1:

Appendix 8.2(iii)

What was the actual or apparent outcome/impact of the Adverse Incident that has occurred? (CONSEQUENCES)

This judgement is based on the actual outcome of the Incident, which is mapped against Table 1 in order to determine the relevant descriptor. When considering harm to persons, it is necessary to consider psychological harm as well as physical harm. In this Step, the actual outcome of the Incident is colour coded, based on the relevant descriptors:

10

MODERATE SEVERE MAJOR NEGLIGIBLE MINOR

AMBER INCIDENT

RED INCIDENT RED INCIDENTGREEN YELLOW INCIDENT INCIDENT

Any Adverse Incident that has resulted in SEVERE or MAJOR harm/loss/damage is considered a RED (SERIOUS) Adverse Incident and must be immediately considered for a full Root Cause Analysis investigation. Completion of steps 2 and 3 are unnecessary for such Incidents.

For Adverse Incidents resulting in NEGLIGIBLE, MINOR or MODERATE levels of harm/loss/damage, Steps 2, 3 and 4 must be completed in order to determine the level of investigation required.

Appendix 8.2(iii)

11

TABLE 1: Definitions for outcome/impact (CONSEQUENCES)

Descriptor Actual or potential unintended impact on individual(s)

- patient, family member, visitor, contractor, staff member

Number of persons affected

or potentially affected at one

time

Actual or potential impact on the Trust

NEGLIGIBLE

Green

No harm, harm prevented or very minor harm. Example(s): Cut or bruise. First-aid treatment only required. Some extra observation required.

N/A No damage or very minor damage. No direct financial loss or financial loss up to £1,000. Very minimal impact. No service disruption. Example(s): Wastepaper basket fire

MINOR

Yellow

Avoidable short-term, non-permanent harm or impairment of health - full recovery in up to 1 month. Example(s): - Minor healthcare associated

infection. - Temporary avoidable

increase in pain experience.

1 to 2 Short-term damage, remedial within 1 month. Increased length of hospital stay or increased level of care - between 1 and 7 days. Single failure to meet internal quality standards. Damage or direct financial loss up to £10,000. Staff sickness < 3 days. Minor service disruption.

MODERATE

Amber

Avoidable semi-permanent injury or impairment of health or damage - recovery in up to 1 year. Additional interventions required or treatment needed to be cancelled. Extra stay in hospital, readmission or return to surgery required. Necessary to transfer to another centre for treatment/care. Example(s): - Temporary loss of mobility - Temporary loss of vision - Healthcare associated

infection taking up to 1 year to resolve e.g. MRSA

- Further/new surgical intervention required

3 to 15 Example(s): Control and Restraint situation. Violent Incident in A&E.

Damage remedial in up to 1 year. Direct financial loss/cost up to £100,000. Increased length of hospital stay or increased level of care - between 8 and 15 days Temporary restrictions on service(s) / service disruption. Repeated failures to meet internal quality standards. Staff sickness > 3 days. Local adverse publicity / moderate loss of confidence in the organisation. MHIRA Reportable. Mental Health Act Commission Assessment. HSE Improvement Notice issued.

SEVERE

Red

Irrecoverable injury or impairment of health, having a lifelong adverse effect on lifestyle, quality of life, physical and mental well-being. Example(s)/including: - Procedures involving wrong

patient or wrong body part. - Loss of major body part(s). - Retained instrument/material

16 to 50 Example(s): - loss of

specimens - hostage

situation

Adverse national publicity. Loss of confidence in the Trust. Ability of Trust to provide a service adversely affected / temporary service closure - considerable resources needed to remedy situation - up to £1M. Increased length of stay or care over 15 days. Prohibition Notice / Executive Officer fined.

Appendix 8.2(iii)

12

after surgery. - Healthcare associated

infection, which may result in major permanent harm e.g. Hepatitis C.

- Haemolytic transfusion reaction.

- Radiation dose much greater or less than intended, whilst undergoing a medical exposure.

- Mis-diagnosis with poor prognosis of return to health

- Infant abduction or discharge to the wrong family.

- Rape (but only where it is determined that rape has occurred or there is sufficient evidence to make the allegation serious).

Failure to meet national and professional standards of quality. Example(s): Trust-wide PAS/PIMs failure

MAJOR

Red

Avoidable loss of life or unnecessary shortening of life expectancy. Example(s)/including: - unexpected death of a

patient whilst under the direct care of a health care professional

- healthcare associated infection resulting in or with potential to result in death e.g. hospital acquired legionellosis

- suicide or homicide committed by a patient being treated for a mental health condition

Many (over 50). Example(s): - screening

errors and failure to recall

- vaccination errors

Significant adverse national / international publicity. Severe loss of confidence in the Trust. Extended service closure. Criminal prosecution. CHAI visit. Direct financial cost over £1M. Example(s): - Major loss of healthcare facilities due to fire - Loss/destruction of medical records department and all patient records stored within

Appendix 8.2(iii)

13

STEP 2: What are the chances of this Adverse Incident happening again in the Trust? (LIKELIHOOD)

The likelihood that such an Incident would reoccur within the Trust is selected from Table 2 below. As previously stated, it is acknowledged that, in practice, both Steps 2 and 3 are subjective and will depend on the knowledge and expertise of the person(s) involved in the grading process. It is also acknowledged that any particular Adverse Incidents may well fall outside the immediate experience of those immediately involved.

TABLE 2: Definitions for chance of reoccurrence (LIKELIHOOD)

Descriptor Description RARE Would only reoccur in very exceptional circumstances; considered a very remote

probability that it could happen again.

UNLIKELY Not expected to reoccur but there is some possibility

POSSIBLE May reoccur at some time / occasionally

PROBABLE Will probably reoccur but will not be a persistent issue

EXPECTED Will reoccur and likely to be frequent

Appendix 8.2(iii)

14

STEP 3:

What would be the most likely outcome if the Incident were to reoccur?

The most likely consequence of the Incident if it does happen again, is selected from Table 1. Those considering this matter need to think about the Incident that has just occurred and the circumstances surrounding it. Was the outcome a 'lucky outcome' today? Could the outcome realistically have been much worse? If the Incident happens again, how might people realistically be affected? What potential implications would there be in terms of resources, cost, relations with the public etc? Table 1 helps to map the answers to these questions.

Each of the columns must be considered and a decision made on the most realistic scenario if the Incident should reoccur. IMPORTANT for Steps 3 and 4: When Incidents are future risk assessed, the status quo must be maintained in terms of circumstances. I.e. the same type of patient, in the same place at the same time. For example if the actual Incident involved a patient under close observations trying to hang him/herself in the shower room, the risk assessment must replicate these circumstances. The assessor must not be tempted to think about all patients potentially trying to commit suicide anywhere in the hospital. Such situations have to be separately risk assessed. Also, the Incident risk assessment cannot take account of any additional risk control actions over and above those already in place. For example: Would a person die or would the most realistic outcome be that the person would suffer an

injury or some impairment of health that they would recover from in any given time? How might people be affected/harmed by the Incident? Is it likely that the Trust might be the subject of a local press 'campaign' but unlikely that the

national press would report the matter? The MOST SERIOUS consequence identified determines the future consequence rating of the Incident.

STEP 4: What is the overall risk score for a potential future Incident?

The answers obtained in Steps 2 and 3 are plotted on Table 3 - the Risk Matrix.

Table 3: Risk Matrix

Likelihood

Rare Unlikely Possible Probable Expected Negligible Green Green Green Green Yellow Minor Green Green Yellow Yellow Amber Moderate Green Yellow Amber Amber Red Major Green Yellow Amber Red Red

Co

nse

qu

en

ce

Critical Yellow Amber Red Red Red

Appendix 8.2(iii)

15

The resulting colour code determines the level of investigation required and the management accountability for this. IMPORTANT: If the colour code represents a lesser risk that the colour code obtained at Step 1, then the colour code result under Step 1 should be used to determine the level of investigation. If, however, the colour obtained at Step 4 is represents a higher level of risk that that obtained in Step 1, the colour code result of Step 4 should be used to determine the level of investigation.

SECTION C SERIOUS/RED INCIDENTS - INITIAL MANAGEMENT, INTERNAL REPORTING and EXTERNAL REPORTING Appendices 7 and 8 flowchart the management reporting arrangements for serious incidents within and outside normal working hours. These should be laminated and displayed in relevant areas, including clinical areas if practicable. 1. Incidents Occurring During Normal Working Hours (Monday To Friday, 08.30 To 17.30) Step 1 - Immediate Action The immediate handling of the Adverse Incident will be the responsibility of the most senior

person at the scene. That person needs to: • Ensure the immediate safety and care of people involved i.e. patients, visitors, staff.

• If warranted, make contact with the emergency services. • Preserve all evidence for the subsequent investigation, ensuring it is kept secure (this

may be a police investigation as well as an internal investigation). • If necessary, secure the area, to ensure everything is untouched. Lock doors and put

up signs clearly stating that no-one is permitted to enter the area. • Explain the reason for the closure to patients, relatives, visitors and staff in the vicinity,

without breaching confidentiality. • Inform the appropriate person of the situation (see Step 2 - Reporting). • Complete the Trust Adverse Incident Report form IR1, documenting the sequence of

events. If there are witnesses, ensure they complete a Witness Report IR2. These documents must be received by the Head of the Governance Support Unit within 24 hours.

Step 2 - Internal Reporting and Further Actions

• The senior person at the scene should inform the Clinical Director/Director, Directorate Manager, Head of Nursing or Head of Profession, by telephone, of the situation and actions taken so far.

• The relevant member of the Directorate team should identify any further action required

and by whom and instigate that action. If the Incident concerns one or more Directorates, contact must be made with each and a lead Directorate agreed.

• The relevant member of the Directorate team should contact an Executive Director to

relay a synopsis of the Incident and the Executive Director should brief the Deputy Chief Executive/Chief Executive.

Appendix 8.2(iii)

16

• If the Incident involves a patient, the relevant member of the Directorate team must ensure the responsible Consultant or the most senior member of the Care Team is informed and that he/she speaks with the relevant parties, which may include the patient, next of kin, their carer, their GP etc. as soon as possible. Contact must be maintained and information conveyed on further developments in a timely manner.

• If a member/members of staff are involved, the relevant member of the Directorate

team must make arrangements to ensure the relevant next of kin is kept fully apprised of the situation.

• The relevant member of the Directorate team must ensure the relevant General

Manager is kept fully apprised of the situation and developments. • The Directorate Management Team must ensure that the Trust Adverse Incident Report

Form IR1 is completed and supplied to the Governance Support Unit within 24 hours. • The Directorate Management Team must ensure that witness reports are obtained as a

matter of urgency and supplied to the Governance Support Unit as soon as they are available.

• Any communications undertaken by e-mail must comply with the Trust's E-Mail Policy

and Caldicott Principles. • The Chief Executive/Deputy Chief Executive will decide whether the incident requires

instigation of the Trust Major Incident Procedure and make contact with the appropriate General Manager.

• The Chief Executive/Deputy Chief Executive will assign a lead Executive to oversee the

investigation and analysis of the Incident and the formulation of recommendations.

• The Chief Executive/Deputy Chief Executive will make suitable arrangements for the Chairman/Deputy Chairman to be informed of the Incident and will arrange a meeting of the Board members, should this be necessary, in order that they can be briefed.

• The Chief Executive/Deputy Chief Executive will decide whether the Incident has the

potential to generate a significant number of calls from the public/media and whether a designated helpline is to be established. Also, whether any immediate legal advice is required.

• The lead Executive assigned to the Incident and the Directorate Management Team will

organise appropriate support for any staff that were involved in the Incident or witnessed the Incident. This will include supporting staff that may need to be interviewed by the police and/or other authorities.

Step 3 - External Reporting POLICE The Chief Executive/Deputy Chief Executive will decide whether the Police should be notified

of the incident.

HEALTH AND SAFETY EXECUTIVE The Directorate Management Team will be responsible for making contact with the Trust

Health and Safety Manager regarding any necessity to make contact with the Health and safety Executive and relaying the outcome to the lead Executive.

MID AND WEST WALES REGIONAL OFFICE, NHS WALES

Appendix 8.2(iii)

17

A Welsh Health Circular will be issued in due course supplementing these arrangements but in the interim, this section clarifies the role of the Regional Office in terms of receiving information, taking action, resolving situations and consolidation.

A proactive approach must be taken in order to promote the 'no surprises' culture.

Any RED incident will require reporting to the Regional Office. However, the Trust is also required to report occurrences that have the potential to be of public concern that may not always be graded as RED. Currently, the incidents that must be reported to the Regional Office include:

• An event that has resulted in an unanticipated death or major permanent loss of function (sensory, motor, physiological, or intellectual impairment not present on admission requiring continued treatment or life-style change) not related to the natural course of the patient's illness/underlying condition/pregnancy/childbirth.

• Suicide or homicide committed by an NHS patient being treated for a mental health

disorder.

• Abscondment of detained patients assessed as high risk of self-harm or harm to others and non-return within 24 hours.

• Procedures involving the wrong patient or body part.

• Retained instruments or other material after surgery requiring re-operation.

• Haemolytic transfusion reaction.

• Serious medication related error.

• Child abduction or discharge home with the wrong family.

• Known or suspected case of healthcare associated infection that may result in major

permanent harm e.g. Hepatitis C.

• Rape/sexual assault (but only on determination that the rape/assault has actually occurred or the organisation believes there is sufficient evidence to make the allegation a serious one.

• Any serious acts of violence or aggression.

• Incidents occurring through apparent self-neglect on the part of a patient (mental

health)

• Any adverse incident that has the potential to stop or significantly impact on normal service delivery.

• Home oxygen service.

Note: This list is not exhaustive and an element of judgement will be inevitable in determining what should be reported.

If the Directorate Management Team is unclear on whether the incident is sufficiently serious to be reported to the Regional Office, referral should be made to the Medical Director/Executive Director of Nursing or other Executive Director.

Once the decision has been made that the incident needs to be reported to the Regional Office, a Notification form (see Appendix 9) must be completed by the Executive Director and faxed/e-mailed/hand-delivered to the Head of the Governance Support Unit at THQ within 24

Appendix 8.2(iii)

18

hours. Incidents involving Forensic Psychiatry should be reported to Health Commission Wales at this time. This should be done by a nominated person within the Forensic Psychiatry Directorate, to alleviate duplication.

The Head of the Governance Support Unit will make telephone contact with the Regional Office within the first 24 hours and will also fax a copy of the Notification form to the Regional Office once it has been seen by the lead Executive Director. The name of the person spoken to and the data and time that the verbal report was made will be recorded. The facts of the incident, immediate action taken, any media involvement and who is 'fronting' the response will be relayed to the Regional Office.

If a senior member of the Regional Office Team is not immediately available, they are required to return the Trust's call within one hour.

Contact information is detailed contained in Point 3.

2. Serious Incidents Occurring Outside Normal Working Hours Step 1 - Immediate Action The immediate handling of the Adverse Incident will be the responsibility of the most senior

person at the scene. That person needs to:

• Ensure the immediate safety and care of people involved i.e. patients, visitors, staff. • If warranted, make contact with the emergency services. • Preserve all evidence for the subsequent investigation, ensuring it is kept secure (this

may be a police investigation as well as an internal investigation). • If necessary, secure the area, to ensure everything is untouched. Lock doors and put

up signs clearly stating that no-one is permitted to enter the area. • Explain the reason for the closure to patients, relatives, visitors and staff in the vicinity,

without breaching confidentiality. • Inform the appropriate person of the situation (see Step 2 - Reporting). • Complete the Trust Adverse Incident Report form IR1, documenting the sequence of

events. If there are witnesses, ensure they complete a Witness Report IR2. These documents must be received by the Head of the Governance Support Unit within 24 hours.

Step 2 - Immediate Internal and External Reporting • the senior person taking responsibility at the scene must notify the On-Call Manager of

the Incident and the action being taken

• the On-Call Manager must notify the Executive Director On-Call of the Incident and discuss the action already being taken and to be taken.

• The On-Call Manager and Executive Director On-Call will organise contact with the

senior staff in the relevant Ward/Department to ensure that appropriate action is taken prior to commencement of the next working day

• If the incident is sufficiently serious, the Executive Director On-Call should contact the

Chief Executive/Deputy Chief Executive and a decision will be made on whether contact with the designated On-call Professional at the Welsh Assembly Government is necessary (see Contact Information below). If contact is made with the On-call Professional at the Welsh Assembly Government, the Regional Office must still be contacted at 09.00 hrs on the next working day

• The Regional Office must be notified of the incident at 09.00 hrs on the next working

day.

Appendix 8.2(iii)

19

The Executive Director On-Call will contact the relevant Directorate management Team the next working day, following which, the steps outlined under the 'Normal Working Hours' procedure should be followed.

3. Contact Information During Normal Working Hours (M-F, 09.00 to 17.00 hrs):

Governance Support Unit at THQ: Tel: 01656 753931 or 01656 754183

Fax: 01656 753998

Mid and West Wales Regional Office Tel: 01267 225 250 Fax: 01267 225 260

Outside Normal Working Hours: Welsh Assembly Government Professional On-call Tel: 07626 360 2169 or

07866 746 964

4. Follow-Up Action

Once verbal contact has been made with the Regional Office and the Notification form faxed through, Regional Office staff are designated with responsibility for forwarding details on to the Welsh Assembly Government.

Once the Trust's investigation into the incident and analysis is complete the Head of the Governance Support Unit will submit an appropriate report to the Regional Office. The Trust's Action Plan will also be forwarded to the Regional Office as soon as it is available.

The Regional Office will take responsibility for relaying this information to the Welsh Assembly Government.

Implementation of the Trust's Action Plan will be monitored by the Regional Office / Welsh Assembly Government on an ongoing basis as part of the Performance Management Arrangements.

SECTION D INVESTIGATING AND ANALYSING ADVERSE INCIDENTS 1. General Points

1.1 Further guidance relating to investigation and analysing Adverse Incidents is contained within

the Adverse Incident Guidance.

1.2 The purpose of investigating and analysing Adverse Incidents is to identify lessons and make recommendations for reducing risk for the future.

1.3 The investigation and analysis needs to answer the following questions: • What happened? • How it happened? • Why it happened?

Appendix 8.2(iii)

20

Integral to this is the need to examine the appropriateness of individual actions and decisions that were taken, given the particular context (whether clinical or non-clinical) and consideration of the alternatives that might have prevented the Incident. Actions can then be developed, planned and implemented that should reduce future reoccurrence and/or reduce the outcome/consequences of any future reoccurrence.

1.4 The Trust acknowledges that Adverse Incidents in the healthcare setting rarely have a single cause and to focus on what may appear to be the most immediate, obvious or simple cause, rather then all the underlying contributory causes / root causes, has a negative impact on our ability to understand how and why Incidents occur and put in place effective actions to avoid them in the future1.

1.5 Investigations of Green or Yellow Incidents should be reported using Investigation Report Form IR3, which should be forwarded to the Governance Support Unit.

1.6 Incidents of every grade will be subjected to aggregated analyses. Such analyses can highlight clusters, patterns or trends not noticeable from individual Incident analysis, which must trigger a risk assessment. Complaints and Claims records are also contained in the Datix System, enabling the examination of correlations between Incidents, complaints and claims. This also provides valuable information for learning and improving operational processes. Commonly reoccurring Incidents or issues identified in this way may justify a root cause analysis-type investigation. This will be a matter for consideration and commission by relevant teams, departments, directorates and groups across the Trust.

1.7 Results of an investigation must be used to identify learning points and generate recommendations for improvement. See Section E.

1.8 On completion of any investigation, there should be feedback to all staff involved and the wider team on the outcome of the investigation, learning points and actions to be taken. See Section F.

1.9 Risks highlighted through Incident reporting/investigation/analysis should be recorded in Risk Registers and regularly reviewed, monitored and re-assessed through that process.

2. Level and nature of investigation and analysis 2.1 The Incident risk grading determines the level and type of investigation and causal analysis.

GREEN

INCIDENTS Green Incidents represent a low risk. Accordingly, there is no requirement to investigate individual Green Incidents unless either Directorate Risk Co-ordinators or Corporate Departments or Groups determine that this is necessary. Instead the focus will be on aggregated analyses of such Incidents. Where discretion to investigate an individual Green Incident is exercised, this should not be a lengthy matter; possibly no longer than 1 hour. It should involve the investigator talking to those involved to establish the basic facts of what, how and why the Incident happened and with such Incidents the causal factors should be quickly and easily identified. The investigation should be completed within 10 working days of the occurrence of the Incident.

1 Risk Management in Healthcare, Dr Geoff Roberts, 2002

Appendix 8.2(iii)

21

YELLOW INCIDENTS

These Incidents represent a Moderate risk and are to be investigated by the ward / team / department in which the Incident occurred. Alternatively a Directorate may designate an investigative lead for any given type of Incident. For example, a Directorate might wish to designate a different investigative lead for drugs Incidents to patient fall Incidents. As a rule of thumb, investigation of Yellow Incidents should take no longer than 1-5 hours. It should involve the investigator talking to those involved to establish the facts of what, how and why the Incident happened. The causal factors should be identified and examined. The investigation report IR3 should be completed within 10 working days of the occurrence of the Incident and passed to the Governance Support Unit following appropriate consideration within the Directorate.

AMBER

INCIDENTS Such Incidents represent a Significant risk and, accordingly, root cause(s) must be established using the general methodology for Root Cause Analysis - see the Adverse Incident Guidance. The Clinical Director/Director should commission the investigation. A designated and suitably trained individual within the Directorate in which the Incident occurred should be nominated to lead and co-ordinate the overall investigation and analysis. There should be support from at least two other individuals, to ensure an adequate range of knowledge, experience and perspectives. A Clinical Review is a peer review conducted by people who were uninvolved in the clinical care of a patient, examining whether the whole clinical context of the patient should have been handled differently. It is a critical component of a robust investigation into all Clinical incidents of this grade. The Clinical Director/Director will nominate the individual who is to lead the Clinical Review. An appropriately detailed investigation and analysis report (see the Adverse Incident Guidance) must be completed within 20 working days of the Incident date. The findings of the investigation must be reviewed by the commissioning Director and the Directorate Governance/Risk Group for formal agreement of the learning points, necessary changes in practice and approval of the risk management action plan. The investigation and analysis report and action plan must then be passed to the Governance Support Unit, for appropriate consideration by the Trust Incidents, Complaints and Claims Review Group (ICCRG)

Appendix 8.2(iii)

22

RED INCIDENTS

Red Incidents are of a very serious nature and represent the highest level of risk. The Chief Executive, with support and advice from the Deputy Chief Executive and Executive Directors, will:

nominate appropriate and suitably trained personnel from across the Trust to form an investigative team and conduct a full investigation (including a Clinical Review, if relevant) and a full Root Cause Analysis, ensuring an adequate range of knowledge, experience and perspectives;

decide if the investigation team is to include a stakeholder representative and give appropriate directions in this respect

ensure the team will have the status and knowledge to make authoritative recommendations

appoint a lead investigator who has received training in root cause analysis set a completion date for the investigation and report and specify arrangements

for formal reporting/review within the Trust upon completion clearly define the cope of the investigation ensure the investigation team shares a

common understanding of the issues. Further information relating to the Investigation Team, Undertaking a Root Cause Analysis and report content/format is contained in the Adverse Incident Guidance.

Appendix 8.2(iii)

23

3. Co-operating With Independent Investigations And/Or Inquiries Required By Relevant Stakeholders 3.1 Pending publication of All-Wales guidance, where any Trust investigation indicates the need

for an independent investigation or inquiry, this will be considered by the Executive Team following consultation with the Mid and West Wales Regional Office and the Service Commissioner.

3.2 The Trust, through the appointed investigation team will identify, co-operate with and and/or liaise where necessary with external stakeholders who might be required to undertake investigations and/or inquiries, independent of the Trust, into the circumstances surrounding a particular adverse patient Incident, or who may be able to assist with the Trust's investigations, inquiries and root cause analysis.

Section E GENERATING RECOMMENDATIONS AND ACTION PLANS 1 Without learning and change, risks will not be reduced and safety and quality cannot be

improved. Right across the Trust, lessons must be learned from individual Adverse Incidents and aggregate reviews (as well as from wider experiences, including feedback from other Trusts, the Welsh Risk Pool, the National Patient Safety Agency, other agencies/bodies, benchmarking and legal cases).

2 Recommendations will be developed by the investigator/investigation team and presented to the Directorate Governance Group and the Trust Incidents, Complaints and Claims Review Group (ICCRG) depending on the grading of the Incident. These Groups will commission the development of an action plan in respect of all recommendations that are accepted.

3 Recommendations should be focused on addressing the root cause(s) of an Adverse Incident i.e. those issues that, if addressed, will prevent the problems from reoccurring. It must contain prioritised actions together with responsibilities, timescales and strategies for measuring the effectiveness of actions.

4 Recommendations must be benchmarked against existing risk management plans and priorities. Any management group or committee considering recommendations must consider relative risk priorities, as recorded within Risk Registers, and must be fully aware of the risk of choosing not to address any recommendations mad.

5 Once recommendations have been accepted, the next step is action planning. In practice, and for all but Red Incidents, these two steps may occur at the same time.

6 Where any actions are not considered to be within the control of a ward / team / department, the Directorate team should facilitate appropriate consideration of the issues within the Directorate and completion of the action plan.

7 Where any actions are not considered to be within the control of the Directorate, this must be clearly stated in the action plan. The GOVERNANCE SUPPORT UNIT will then ensure that the matter is considered by the ICCRG and there is feedback to the Directorate.

8 Further information relating to generating recommendations and action plans is contained in the 'Guidance on the Management, Reporting and Investigation of Adverse Incidents' document.

Appendix 8.2(iii)

24

Section F FEEDBACK TO PATIENTS/RELATIVES/CARERS, STAFF AND TEAMS and SHARING THE LEARNING 1. Patients, Relatives and Carers 1.1 After completion of an investigation, identification of lessons learnt and development of the

action plan, an offer should be made to communicate this information to the patient/relatives/carers.

1.2 This feedback should be offered in the form most acceptable to the patient/relatives/carers. This could be either by way of a written account or a meeting with appropriate staff. Staff/Directorates are able to access advice and assistance from the Executive Directors, and the Governance Support Unit in this respect. This will be especially important where the Incident may have given rise to a complaint or is viewed as a potential legal claim. Advice is also be available from Professional Leads and the Patient Experience Facilitator.

1.3 In most cases there should be a complete disclosure of the findings of the investigation and the actions taken, or planned, to reduce the possibility of reoccurrence. In some cases, information may be withheld or restricted. For example:

• where communicating information will adversely affect the health of the patient • where investigations are pending coronial processes • where specific legal requirements preclude disclosure for specific purposes.

Where any of these may apply, there needs to be discussion with the Medical Director or Executive Director of Nursing.

2. Staff and Teams Involved 2.1 Communication with and feedback to reporting staff and the staff involved in an Adverse

Incident are vitally important, both to support ongoing learning and to give staff an assurance that their efforts as regards reporting Incidents are valuable and contribute to improvement.

2.2 Staff reporting an Incident should, wherever possible, be involved in the process of considering whether an occurrence meets the definition of a reportable Adverse Incident, to ensure transparency and to aid learning.

2.3 If the original grading of the Incident was changed, the reasons for this need to be explained to the person who completed the form.

2.4 Staff reporting an Incident and staff involved in an Incident should receive feedback on: • the outcome of an Incident, if this is not already known • the investigation that was or is to be conducted • the findings of the investigation and the learning points identified • the actions taken or to be taken to reduce the possibility or severity of a reoccurrence

and any changes in work practices. In this respect, participation by the staff in determining these actions is desirable.

2.5 In most instances, it will be the line manager and/or Directorate Risk Co-ordinator who will

have responsibility for such communication and feedback.

3. Sharing the Learning

Appendix 8.2(iii)

25

3.1 The lessons from Incidents almost always have wider applications and implications. Information on Adverse Incidents and the lessons will be shared across the organisation and with relevant external forums e.g. the Welsh Risk Managers Network. Directorates should ensure that they develop and implement processes to use this information to inform staff about any Incidents reported in the Trust that are relevant to their work or workplace.

i SECTION G MONITORING AND REVIEWING THE EFFECTIVENESS OF ACTIONS TAKEN 1 Those individuals, teams or groups with responsibility for actions need to implement actions

within the agreed timescales or report on difficulties being encountered and seek approval for extensions to timescales where necessary.

2 Directorate Governance Groups must monitor implementation and effectiveness of action plans developed following investigation of individual Incidents as well as plans to address risks identified through aggregated analysis.

3 The Governance Support Unit will record Action Plans in the Datix System and will monitor the completion of actions against planned dates in conjunction with Directorates.

4 For Amber and Red Incidents, implementation of the risk management action plan will be more directly monitored by the Governance Support Unit, in conjunction with all appropriate teams/groups and reviewed by the Trust Risk Management Steering Group. Progress will be reported appropriately through the organisation and up to the Trust Board as part of Risk Management Key Performance Indictors.

5 Analyses will be produced from the Datix System to support the consideration of the effectiveness of actions taken.

6 The Risk Management Annual Report will contain a list of all Amber and Red Adverse Incidents and the root cause analyses carried out over the year, together with information on the implementation of improvement strategies.

7 Information relating to clinical aspects will be used to develop appropriate content for the Clinical Governance Annual Report.

SECTION H EXTERNAL REPORTING REQUIREMENTS 1 A number of external organisations/agencies must be contacted when a particular type of

Adverse Incident has occurred. The following section lists these organisations and gives brief information on the mechanisms for reporting. Where indicated, further information and guidance can be found within the 'Guidance on the Management, Reporting and Investigation of Adverse Incidents' document.

2 Regional Office of NHS Wales 2.1 The Mid and West Wales Regional Office must be notified of all Serious/Red Incidents in

accordance with the procedures detailed in Section C.

3 Child Protection - National Public Health Service for Wales / Regional Child Protection Health Forum 3.1 The Trust Named Child Protection Health Professionals will report on Child Protection

incidents, in accordance with the all-Wales procedures.

Appendix 8.2(iii)

26

4 Service Commissioners, NHS Partners, Tertiary and Specialist Providers/Contractors, Social Services, Local Authority Departments 4.1 Except where other specific arrangements or requirements may exist, the Executive Team will

consider and agree the level and nature of communications in respect of any individual, Serious/Red Incident and the extent of any involvement of such partners/stakeholders in the overall Incident management and learning process.

5 The Health and Safety Executive RIDDOR: 5.1 Certain Incidents must be reported in line with the Reporting of Injuries, Diseases and

Dangerous Occurrences Regulations 1995 (RIDDOR).

5.2 The regulations apply a single set of reporting requirements to all work activities, with the main purpose of the regulations being to generate reports to the Health and Safety Executive and to Local Authorities. The reports provide data that is used to indicate where and how risks arise and to identify trends. Enforcing authorities use this data to determine policy, target their activities effectively and to advise employers on strategies to help prevent injuries, ill health and accidental loss/damage.

5.3 A summary of the regulations, definitions and reportable categories are included in the Adverse Incidents Guidance - Section 5.

Ionising Radiation Regulations 1999: 5.4 5.5

Incidents involving radiation exposure will be reported to the HSE by the Directorate of Radiology and Endoscopy and a copy of the report made will be attached to the Adverse Incident Report Form before submission to the Governance Support Unit. Incidents involving radiation exposure must be reported to the Trust’s Radiation Protection Supervisor (the Assistant Director of Radiology & Endoscopy). The Radiation Protection Supervisor will investigate the Incident and inform the Radiation Protection Advisor at the HSE and the and Welsh Assembly Government, if appropriate. The Trust Radiation Protection Supervisor will then ensure that an Adverse Incident Report Form IR1 is completed and submitted.

6 National Patient Safety Agency 6.1 All NHS organisations are required to report Adverse Incidents involving patients to the

National Patient Safety Agency (NPSA) as soon as they are linked to the National Reporting and Learning System (NRLS). This link will occur at some point in 2004.

6.2 The link to the NRLS will be fully automated and the Trust's records of Adverse Incidents involving and affecting patients will be electronically transmitted to NRLS from the Datix System. The Governance Support Unit will manage this, in conjunction with the IT Department, and individual staff or Departments need take no action in this respect.

7 Police and/or Coroner 7.1 There are a number of circumstances in which a death must be reported to the Police and/or

the Coroner. These are detailed in the Trust’s Procedure for Reporting Sudden Unexpected Deaths to the Police or the Coroner.

7.2 Where there is any suspicion that an Adverse Incident involves a potentially criminal act, communication lines must mirror those for reporting serious incidents (Section C) and the Executive Directors will give advice on how the matter should be handled.

8 Medicines and Healthcare Products Regulatory Agency Adverse Drug Reactions and Medicine Defects: 8.1

The reporting of any suspected adverse drug reaction can be made by any professional member of staff using the yellow card system for reporting, which can be found on the back

Appendix 8.2(iii)

27

8.2

page of the BNF. The person making the report should also advise the Chief Pharmacist, who will consider whether an Adverse Incident Report Form IR1 and Drug Error Form IR5 needs to be completed and submitted. Medicine defects, such as cloudiness of liquid or discoloration of medicines, should be reported to the Chief Pharmacist who will advise the all Wales Medicines Quality Controller and complete an Adverse Incident Report Form IR1 as appropriate.

Medical Devices and Equipment: 8.3 Incidents involving medical equipment and devices will be reported to the MHRA as soon as

possible after the Incident, by the Trust MHRA Liaison Officer who will have ensured an adequate investigation of the Incident.

9 Communicable Diseases and Inoculation Injuries 9.1 The Infection Control team will report notifiable Incidents to the Centre for Communicable

Disease Control and will undertake EPINET reporting for inoculation injuries. 10 Serious Hazards of Transfusion (SHOT) 10.1 This is a voluntary reporting scheme to which the Trust submits reports of relevant Incidents.

Wards must inform the Blood Bank of any Blood related Incidents. The Blood Bank staff will investigate the Incident then submit a report to SHOT and ensure the completion and submission of an Adverse Incident Report Form IR1.

11 Welsh Health Estates Fire Incidents: 11.1 The Nominated Fire Officers will report all fire and fire alarm Incidents, including false alarms to

Welsh Health Estates. The relevant Nominated Fire Officer will also report to the Trust Fire Safety Advisor and complete and submit an Adverse Incident Report Form IR1.

Defects and Failures in Buildings and Non-Medical Equipment: 11.2 Site/Directorate managers will report defects or failures in buildings or non-medical equipment

to the Assistant Director of Facilities via a report form, who then investigates the matter and, if appropriate, will make a report to Welsh Health Estates and complete and submit an Adverse Incident Report Form IR1.

12 Environmental Health Agency 12.1 12.2

Estate Managers will investigate and report any Incidents covered by the EHA reporting guidelines to the Assistant Director of Facilities. The Assistant Director of Facilities will review the Incident, submit a report to the EHA, if appropriate, and complete and submit an Adverse Incident Report Form IR1. The Assistant Director of Facilities will notify the Infection Control Team of the Incident, where appropriate. Incidents that would fall within this reporting requirement include the inappropriate disposal of a clinical waste bag to a landfill site or storage facility.

13 Mental Health Act Commission 13.1 Incidents involving Death or the discovery of unlawful detention must be reported to the MHAC

by telephone during office hours on the same day or first thing the following day, by the relevant Directorate Manager, who will then complete and submit the Adverse Incident Report Form IR1.

Appendix 8.2(iii)

28

SECTION I OTHER MECHANISMS FOR DETECTING ADVERSE INCIDENTS

1 Clinical Coding and CHKS Clinical Data Assessment The Executive Directors will consider whether potential Adverse Incidents detected through

clinical coding of patient records and/or CHKS data should be investigated in accordance with policy and procedure and retrospectively recorded.

2 Post-Discharge Reporting It is possible that an Adverse Incident related to treatment in the Trust may only become

evident after a patient has been discharged. Should a patient’s General Practitioner or specialist communicate concerns to the Trust, they should be managed and in accordance with this policy and procedure.

3 Complaints and Patient Satisfaction Surveys The Trust will continue to value, seek and use feedback and information from patients to

improve healthcare and healthcare services. Where a matter that is the subject of a complaint should have been managed and reported as an Adverse Incident but was not, the investigation of the matter will take due consideration of the requirements of this Policy and Procedure, particularly as regards grading, investigation and learning.

4 Legal Claims Made Upon The Trust If an Adverse Incident giving rise to a legal claim (which may be received 3 years or more after

the occurrence) was not reported and investigated as an Adverse Incident at the time, the investigation of the matter will take due consideration of the requirements of this Policy and Procedure, particularly as regards grading, investigation and learning.

5 Adverse Incidents Occurring Elsewhere This is a proactive rather than reactive approach that identifies the potential for an Adverse

Incident occurring elsewhere to occur in the Trust. Some Adverse Incidents occur infrequently and may only be detected once every few years by individual organisations. Details of some serious Incidents and litigation claims occurring elsewhere are available to the Trust via sources such as the Welsh Risk Pool/Welsh Risk Managers Network, various publications and media, legal case reports, coroners' reports, confidential inquiries, the Department of Health, medical defence organisations, etc. After the reporting of an Adverse Incident by one of these sources, the question needs to be asked: “Could this adverse event occur in our organisation?” If it could, it should be recorded on the appropriate level of Risk Register (Directorate or Corporate), analysed, prioritised and risk management actions identified and implemented. It is important that the Trust does not wait to actually experience a serious Adverse Incident before taking appropriate actions. It is anticipated that the National Patient Safety Agency, when fully established, will be the primary source of information on events occurring elsewhere.

APPENDICES

Appendix 8.2(iii)

Appendix 8.2(iii)

30

ADVERSE INCIDENT REPORT FORM (IR1)

Confidential: To be completed in BLACK INK and BLOCK CAPITALS Information relating to the person(s) AFFECTED or INJURED. If no-one has been affected or

injured, please leave blank. If more than one person was affected, use additional sheets

DATE OF INCIDENT: / / TIME OF INCIDENT (24 hr clock) : Title: Mr / Mrs / Miss / Dr / Other (please circle) Male / Female (please circle) Full Name: Address: Post Code: Tel No: Date of Birth / / Injury sustained - where appropriate (eg. laceration/fracture):

Part of body affected:

If above is a patient (circle type)

In / Out / Day / Community patient

Hospital Number:

If above is an employee state title and grade

Payroll number:

If above is not a patient or employee (circle type):

Bank / Agency / Visitor / Volunteer / Contractor / Trainee / Work Experience

If the incident involves an Aggressor state name State Location/Hospital that incident occurred? (eg. PoWH / Pt’s home) State Ward / Department / Area? (eg. Ward 1 / OPD) State Directorate responsible for this incident? (eg. Surgical / LDS) State Specialty responsible for this incident (eg. EMI / Cardiology) State type of area the incident occurred in? (eg. Bathroom / Car Park) DESCRIPTION OF INCIDENT – please give a brief factual description of occurrence, including the names of all individuals involved – continue on separate sheet if required IMMEDIATE ACTION TAKEN: Was the person advised to see: Doctor / Nurse / First Aider / A&E / Own GP Yes No Insert name of individual who dealt with the person affected: State treatment given: Did person affected decline to be seen? Yes No If patient, state name of Consultant responsible for care: If person affected was admitted to hospital due to the incident, state ward / unit:

If person affected is an employee, did they go off work as a result of the incident?

Yes No

Was the person off work for more that 3 days Yes No RIDDOR Number? ETHNIC ORIGIN OF PERSON AFFECTED – Please tick appropriate box

Appendix 2Version 3

Appendix 8.2(iii)

31

White

Mixed

Asian or Asian British

Black or Black British

Chinese or other Ethnic Group

Welsh

Scottish

White & Black Caribbean

Indian

Caribbean

Chinese

Irish White & Black African

Pakistani African Other Please state

English White & Asian Bangladeshi Other Please state

Other Please state

Other Please state

Other Please state

If the incident involved a faulty MEDICAL DEVICE, please complete IR4 and attach to this report. If the incident was a MEDICATION ERROR, please complete IR5 and attach to report

What was the ACTUAL outcome / impact of the Adverse Incident that has occurred? Please refer to ADVERSE INCIDENT PROCEDURE for more detail & cross one of the boxes.

No harm, harm prevented or very

minor harm. No/Little damage, loss up to £1,000

Avoidable short-term, non-

permanent harm or impairment of

health – full recovery in up to

1 month. Damage remedial within 1 month.

No service disruption

Avoidable semi-permanent injury or impairment of health

or damage – recovery in up to 1

year. Damage remedial in up to 1 year. Loss

up to £100,000

Irrecoverable injury or

impairment of health, having a lifelong adverse

effect on lifestyle, quality of life,

physical & mental well being.

Loss of confidence in the Trust.

Resources need to remedy up to £1M

Avoidable loss of life or unnecessary

shortening of life expectancy. Severe loss of confidence in

the Trust. Direct finacial cost over

£1M

What is the overall risk score for a POTENTIAL FUTURE incident – Please cross appropriate box. Likelihood

Rare Unlikely Possible Probable Expected Negligible Green Green Green Green Yellow Minor Green Green Yellow Yellow Amber Moderate Green Yellow Amber Amber Red Major Green Yellow Amber Red Red

Co

nse

qu

en

ce

Critical Yellow Amber Red Red Red

DETAILS OF ANY WITNESSES (attach witness report forms where appropriate: Please Print Name(s): Position

THIS SECTION TO BE COMPLETED BY THE PERSON COMPLETING THE REPORT: Signature of Reporter: CONTACT No: Please Print Name: Position: Date: / / Time (24 hour) :

FORM TO BE SIGNED BY LINE MANAGER OF REPORTER: Signature of Manager: CONTACT No: Please Print Name: Position: Date: / / Time (24 hour) : FORM TO BE AUTHORISED FOR INPUT BY DIRECTORATE RISK CO-ORDINATOR PRIOR

TO BEING FORWARDED TO THE GOVERNANCE SUPPORT UNIT, THQ. Authorisation Signature: CONTACT No: Please Print Name: Position: Date: / / Time (24 hour) :

Further Investigation? Yes No

Appendix 8.2(iii)

Appendix 3

WITNESS REPORT FORM IR2 Confidential

TO BE COMPLETED IN BLACK INK AND BLOCK CAPITALS

WITNESS DETAILS

TITLE: MR / MRS / MISS / DR / OTHER (please delete as appropriate) FULL NAME:

ADDRESS:

POST CODE:

DATE OF BIRTH:

TELEPHONE NUMBER:

PAYROLL NUMBER (if staff):

JOB TITLE & GRADE (if staff):

I WAS WITNESS TO THE INCIDENTS WHICH OCCURRED INVOLVING:

NAME OF PERSON AFFECTED: DATE OF INCIDENT:

TIME OF INCIDENT (24 hr clock):

LOCATION OF INCIDENT SITE / HOSPITAL:

WARD / DEPARTMENT: SECTION / ROOM: EXACT LOCATION (descriptive):

SIGNED: DATE: Page 1 of ….

This form must accompany (stapled to) the associated Trust Incident Report Form

32

Appendix 8.2(iii)

Appendix 4 INVESTIGATION

REPORT FORM IR3 Confidential TO BE COMPLETED IN BLACK INK AND BLOCK CAPITALS

INFORMATION RELATING TO THE PERSON (S) AFFECTED OR INJURED. IF NO-ONE HAS BEEN AFFECTED OR INJURED, PLEASE LEAVE BLANK.

TITLE: MR / MRS / MISS / DR / OTHER (please delete as appropriate) FULL NAME:

ADDRESS:

POST CODE: DATE OF BIRTH: DATE OF DEATH:

DATE OF INCIDENT: TIME OF INCIDENT (24 hr clock): LOCATION OF INCIDENT:

Which Site / Hospital? (eg. POW / Pt’s Home) Which Ward / Department? (eg. Ward 1 / OPD) Which Directorate is Responsible for this incident? (eg. Surgical / LDS) Which Specialty is Responsible for this incident? (eg. EMI / Cardiology)

Consultant or Lead Professional Responsible for the patient’s care:

NOHas the consultant / lead professional been informed of this incident? YES WAS THE PERSON ADMITTED TO HOSPITAL AS A RESULT OF THE INCIDENT?

NOYES IF SO TO WHAT WARD / HOSPITAL?IF THE PERSON WAS A MEMBER OF STAFF, DID THEY GO OFF WORK AS YES NO A RESULT OF THE INCIDENT?

IF SO, HOW MANY DAYS HAS THE MEMBER OF STAFF LOST FROM DaysWORK AS A RESULT OF THE INCIDENT? (If over 3 days, report to RIDDOR)

NOWAS A RISK ASSESSMENT NECESSARY AFTER THE INCIDENT? YES

NOWAS A RISK ASSESSMENT IN PLACE PRIOR TO THE INCIDENT? YES

The investigating manager should investigate the incident to establish the ‘root causes’ and contributory factors of the incident. This will normally lead to the identification of system or person failure. Where necessary, interviews and supporting evidence should accompany this form. This investigation should not delay the implementation of urgent measures to prevent / reduce the risk of recurrence. Such measures taken should be clearly detailed with the name of the responsible

person and the date by which these actions are to be in place, on the action plan below.

33

WAS THE INITIAL GRADING APPROPRIATE? YES NO NEW GRADING TO BE INDICATED ON RISK MATRIX AND COMMENTS BELOW:

Appendix 8.2(iii)

34

What is the overall risk score for a POTENTIAL FUTURE incident – Please cross appropriate box. Likelihood

Rare Unlikely Possible Probable Expected Negligible Green Green Green Green Yellow Minor Green Green Yellow Yellow Amber Moderate Green Yellow Amber Amber Red Major Green Yellow Amber Red Red

C

on

seq

uen

ce

Critical Yellow Amber Red Red Red

Internal Notification: EBME Occupational Health Medical Director Health & Safety Estates Fire Officer Nursing Director Bed Manager Infection Control Clinical Director General Manager Claims Dept HON / AHON Tissue Viability Nurse Directorate Manager Complaints Chief Pharmacist SMTL

External Reporting: RIDDOR (attach copy) Regional Office (WAG) Coroner MHRA Police Next of Kin If police were involved, please insert Crime Number allocated: Date Reported: If reported to RIDDOR, please insert RIDDOR Number allocated: Date Reported:

NB – RIDDOR incidents can be reported online at www.RIDDOR.gov.uk and should be printed prior to submission to forward with this report to GSU

Establish Evidence: Scene Inspection Diagram / sketches Measurements Photographs Witness Forms Risk Assessment Sequence of Events Training Record

Description of evidence collated:

Facts brought about by the investigation – Give simple, clear one-sentence ‘good’ and ‘bad’ facts. Each one should contain only one specific fact (please continue on separate sheet where necessary):

Appendix 8.2(iii)

35

Evidence Analysis - Brief description of incident (summary and facts established):

Causation (see guidance):

Patient Factors Team & Social Factors

Individual Factors Education & Training Factors

Task Factors Equipment & Resource Factors

Communication Factors Working Conditions Factors

Organisational & Strategic Factors

Detail the underlying (root) causes of the incident:

Detail the immediate causes & contributory factors of the incident::

Appendix 8.2(iii)

36

INCIDENT ACTION PLAN

IDENITFIED FAILING / LESSON

ACTION (S) RESPONS-IBILITY (person)

START DATE

PROJE-CTED COMPL DATE

COMPL DATE

COMPL BY (staff)

COST (if known)

MONITOR-ING ARRANGE-MENTS

Appendix 8.2(iii)

Appendix 8.2(iii)

Risk rating after immediate actions: Risk rating after remedial actions:

38

Entered onto Directorate Risk Register? YES NO

Feedback to Staff who Reported Incident:

Date Given:

INVESTIGATOR (S) TO SIGN AND DATE, AND FORWARD TO THE GOVERNANCE SUPPORT UNIT, TRUST HEADQUARTERS

Contact No: Signature:

Please Print Name:

Position: Date: Time:

Contact No: Signature:

Please Print Name:

Position: Date: Time:

Contact No: Signature:

Please Print Name:

Position: Date: Time: Attachments: Witness Form(s): Photographs: Sketches: Other (specify):

Appendix 8.2(iii)

Appendix 5

MEDICAL DEVICE REPORT FORM IR4

Confidential To be completed by Ward or Department involved in the Incident IN BLOCK CAPITALS & Black Ink Name of Reporter ____________________________________________ Job Title ____________________________________________ Department / Hospital ____________________________________________ Date of Incident ____________________________________________ Description of Medical Device: _____________________________________________ Product Type _____________________________________________ Model _____________________________________________ Serial Number _____________________________________________ Asset Number _____________________________________________ Manufacturer/Supplier: _____________________________________________ Current location of device _____________________________________________

To be completed by Ward or Department involved, from information supplied by EBME Contact EBME on Ext 3989 Princess of Wales Hospital, Ext 2300/2105 Neath Port Talbot Does the device bear the “CE” marking. YES/NO/NOT KNOWN___________ Service Records held by _____________________________________________ Date last serviced _____________________________________________ Date Acceptance Tested _____________________________________________

This form must accompany (stapled to) the associated Trust Incident Report Form

39

Appendix 8.2(iii)

Appendix 6

MEDICATION ERROR REPORT FORM IR5

Confidential To be completed by Ward or Department involved in the Incident IN BLOCK CAPITALS & Black ink Date: _____________________________________________________ Time (24 Hour Clock): ____________________________________________ Name of Patient: ____________________________________________ Name of Reporter: ____________________________________________ Job Title: ____________________________________________ Department / Hospital: ____________________________________________ Date of Incident: ____________________________________________ Stage of Error (eg administration / prescribing): _______________________________________ Type of Error (eg allergic reaction / wrong route):______________________________________ Drug Administered: _____________________________________________ Correct Drug : _____________________________________________ Form Administered: _____________________________________________ Correct Form : _____________________________________________ Dose Administered: _____________________________________________ Correct Dose: _____________________________________________ Route Administered: _____________________________________________ Correct Route: _____________________________________________

This form must accompany (stapled to) the associated Trust Incident Report Form

40

Appendix 8.2(iii)

Appendix 7 SERIOUS INCIDENTS – MANAGEMENT REPORTING

NORMAL WORKING HOURS

41

INCIDENT

No Follow standard incident reporting

Procedure Serious

Yes/Maybe

Chief Exec.

Governance Support Unit

Regional Office

Investigation of Incident

Commenced

Executive/Medical Director/Director

Nursing

Lead nominated

Directorate Management

Team

Appendix 8.2(iii)

Appendix 8

SERIOUS INCIDENTS – MANANGEMENT REPORTING OUT OF HOURS

42

Incident

Next Normal Working Day

Follow normal incident

reporting procedure

No Serious

Yes

Executive On-Call

Yes Chief Exec.

WAG Very Serious

Liaise with Senior Ward

Department

Directorate Management

Team & Executive / Medical Director / Director nursing

Governance Support

Unit

Appendix 8.2(iii)

43

Appendix 9 WELSH ASSEMBLY GOVERNMENT

NHS WALES

NOTIFICATION OF A SERIOUS ADVERSE PATIENT INCIDENT

Date and time report made

Reporters Name, Designation and contact details

Name: Job title: Contact details:

When did the incident occur?

Date: Time (24 hr clock):

Where did the incident occur, and where relevant speciality?

Who did it affect and how many? (personal details should not be included)

Brief description of what happened

Appendix 8.2(iii)

44

Brief description of immediate action taken

Media interest (actual or potential)

What other agencies have been informed about this incident?

Any other relevant information

Name of Regional Office official receiving report.

. Signed: Date:

Appendix 8.2(iii)

Originator: Governance Support Unit Date Approved: 23rd January 2008 Approved by: Management Executive Date for Review: 23rd January 2009 Policy ID: 274

ADVERSE INCIDENT GUIDANCE APPLICABLE TO MANAGING, REPORTING, INVESTIGATING, ANALYSING AND LEARNING FROM ADVERSE INCIDENTS RELATED DOCUMENTS: ADVERSE INCIDENT POLICY ADVERSE INCIDENT PROCEDURE This document can be made available in alternative formats or other languages, on request, as is reasonably practicable to do so.

Appendix 8.2(iii)

TABLE OF CONTENTS

Page 1 What Constitutes a Reportable Adverse Incident?

3

2 General Information on Adverse Incident Report Forms and Completion

8

3 Guidance on Investigation and Analysis

10

4 Generating Recommendations, Reports And Action Plans

25

5 HSE Information Sheet - RIDDOR Reporting

29

2

Appendix 8.2(iii)

SECTION 1 WHAT CONSTITUTES A REPORTABLE ADVERSE INCIDENT? 1 General Points

1.1 The principle definitions are contained within the 'Policy and Procedure for Managing,

Reporting and Investigating Adverse Incidents'. This sections aims to give assistance by way of some specific points and examples. The examples should not be considered as representing an exhaustive list

1.2 In accordance with the requirements of Welsh Risk Management Standard 3 - Incident and Hazard Reporting - every department/directorate should develop a specific list of reportable adverse incidents. This list must be made available to all staff as a guide and aid to identifying reportable incidents. The Governance Support will continue to assist departments and directorates to establish or refine specific lists/examples of reportable adverse incidents.

1.3 The examples below have been organised under headings for the purposes of this document only. Staff need not make the effort to allocate incidents to one of these headings/categories - all appropriate classifications are allocated by the Governance Support Unit on receipt of the Adverse Incident Report.

2 'Clinical' Adverse Incidents 2.1 These are incidents relating to any operation, examination or other clinical treatment and care

of a patient, including incidents involving drugs.

• Occurrence of a known complication if there is any view or evidence that there were untoward contributory factors such as:

- there were failings in the informed consent process i.e. the patient was not made aware of or did not understand the risk

- all reasonable and expected actions to contain the risk of complication had not been taken

- there was a lack of supervision or a lack of competence etc • Variance from a defined Clinical Pathway • Failure to diagnose, delay in diagnosis, wrong diagnosis or incorrect patient assessment.

For example: - a female patient with a missed period and severe abdominal pain is not diagnosed as

having an ectopic pregnancy. The ectopic ruptures and a massive transfusion is required.

- a patient repeatedly complains of pain in a specific site but it is assumed to be referred pain or a strain and diagnostic tests on the site are not carried out. It is subsequently discovered that the patient has a fracture/tumour etc in that site.

- examination of a patient’s hand, which had been trapped in machinery, and evidence points to nerve damage but this is missed.

3

Appendix 8.2(iii)

• Any medication error including:

- administration of the wrong drug - incorrect quantity of the right drug - administration to the wrong person - any infusion error

• Adverse drug reaction. For example:

- patient known to be allergic to penicillin but notes not checked and patient not questioned. Patient suffers respiratory arrest.

- anaphylactic reaction to immunisation. - prescription of medication where there are definite contraindications to medication the

patient is already taking. • Health records not available during a consultation. • Communication problems between patient and health care professional that may or have

resulted in treatment complications. • Non-compliance with procedures or protocols that could have or did lead to

harm/loss/damage. This includes failing to take standard preventative actions. For example: - a failure to wear protective personal equipment when handling body fluids - a failure to comply with handwashing procedures

• Defective medical devices or medicines. For example:

- a defective glucose meter than does not bleep - a syringe pump that infuses at the wrong speed

• An operation/procedure on or treatment of incorrect site/body part • Blood transfusion errors and failures of transfusion procedures.

For example: - Blood specimen obtained for cross matching from the wrong patient. Subsequent

transfusion of the right patient results in a massive reaction. • A patient absconding

This does not include occasions when a patient self-discharges against medical advice - this is a matter that should be recorded in patient notes. The term 'abscond' implies leaving without the authorisation to do so, when such an authorisation is required.

• Patient commits, or attempts to commit suicide or homicide, or other form of harm to self

or others • Phenol burn to a patient’s foot during removal of a toenail • Failures in the informed consent process.

For example: - any instance of a Consent form not being signed

4

Appendix 8.2(iii)

• Abnormal cervical smear results not notified to patient.

• Insufficient specimen obtained when performing a cervical smear and a further smear is

not requested • A patient fall (Note: some patient falls will not be 'non-clinical' incidents - see Section 4) • Abduction of a baby/child • A hostage situation • Awareness during anaesthesia.

2.2 Examples of occurrences that need not be reported as adverse incidents are: • any occurrence or circumstance which led to harm that can be considered expected

because it related to the natural cause of the patient's illness or underlying condition UNLESS it is possible or known that there were untoward contributory factors.

• occurrence of expected complications during a procedure, even though this may require

transfer for treatment/monitoring elsewhere, UNLESS there are unexplained factors or it is possible or known that there were untoward contributory factors.

• a member of staff is involved in a road traffic accident on their journey from home to their

normal site of work, or suffers an accident/mishap not on Trust property and not in connection with their employment

3 Child Protection Incidents1

3.1 Incidents of this nature may vary but themes are usually consistent. The following are

examples: • failure to follow Child Protection Procedures • failure to make an appropriate referral to a statutory agency • failure to make a follow-up referral in writing (if this failure leads to a lack of action by

Social Services • failure to provide information to a Child Protection Section 47 enquiry or a Child

Protection case Conference

1 Reflects the All Wales Service Specification for Child Protection, Children Looked After and Related Services (National Public Health Service for Wales), 2004

5

Appendix 8.2(iii)

• failure to pass on child protection concerns and/or make a referral on a tertiary transfer of

a child • failure to share information to safeguard the welfare of a child • failure to act on an allegation of, or incident of abuse by a health professional • health services attempting to investigate child protection issues alone

4 'Non-Clinical' Adverse Incidents 4.1 These are adverse incidents to any person except a member of staff.

A patient fall not associated with the process of treatment or care but the environment of care, or a fall by a member of the public. For example:

- a patient slips on water in the hospital corridor whilst taking a brief stroll - a patient trips over an electric cable whilst cleaning was in progress - a patient suffers injury as a result of bumping into a piece of furniture/equipment that

had been badly positioned

5 Violence & Aggression Adverse Incidents 5.1 • a physical assault on and by any person

• verbal abuse by and directed to any person, if it could have or did lead to a person being affected/threatened by it

• racial harassment • sexual harassment

• threatening or intimidating behaviour (for example, drunken youths behaving aggressively in the A&E Department although there was no physical harm to any person)

5.2 These do not have to be incidents involving staff. Aggressive behaviour of a visitor towards a

patient, for example, is reportable.

5.3 Some patients suffer from conditions whereby their use of abusive language may be regular and routine. The fact that there is use of abusive language or that it is directed at any individual does not make such an episode a reportable incident. If a member of staff, however, considers that they have been inadequately coached to deal with such situations and is suffering from anxiety and stress as a consequence, this would be reportable. If it is believed that the situation is such that there is a risk of such an outcome then a risk assessment should be conducted rather than completion of an adverse incident report form.

5.4 Occurrences of verbal abuse where staff or others do not feel affected by the occurrence should be the subject of Department or Directorate-based reporting and management procedures.

6

Appendix 8.2(iii)

6 Other Staff/Non Staff Adverse Incidents 6.1 These would include:

• needlestick/sharps injuries caused by clinical items • cuts etc from non-clinical items such as broken crockery • slips, trips and falls • manual handling injuries • occupational injuries or ill-health including work-related stress, headaches or eye

strain caused by inadequate lighting etc • contact with hazardous substances e.g. chemicals, biological material, blood

products, body fluids • Injuries sustained by a member of staff whilst at work but only if there was a work-

related trigger or a work-related contributory factor. 7 Fire 7.1 Such incidents include false alarms as well as actual fires, whether thought to be accidental

or wilful/malicious.

8 Equipment 8.1 Such incidents include a defect in or failure of any piece of equipment that is not a medical

device, if that defect or failure could have or did lead to harm/loss/damage. Examples: • burns from catering trolleys • sharp edges on laundry crates/cages

9 Security 9.1 These include potential or actual failures or breaches of security that could have or did lead

to harm/loss/damage. This category includes potential or actual occurrences of fraud.

Examples: • Break-ins at Health Centres • Unauthorised entry to premises • Any thefts • Broken locks

9.2 Physical problems that are deemed as having the potential to give rise to a security breach are reportable to the Estates/Facilities Help Desk and would be an unnecessary duplication if also reported as an adverse incident.

9.3 Behaviour that is considered to have the potential to give rise to a security breach or occurrence of fraud is reportable as an adverse incident but attention must be paid to the need to report to/inform the Trust Counter Fraud Specialist.

7

Appendix 8.2(iii)

10 Other 10.1 Including:

• Disruption of the routine operation of the Trust

• Non-compliance with general Trust policies and procedures that could have or did lead to harm/loss/damage

SECTION 2 GENERAL INFORMATION ON ADVERSE INCIDENT REPORT FORMS AND COMPLETION

1 General Points

1.1 The relevant forms are:

IR1 - Adverse Incident Report form IR2 - Witness Report form IR3 - Investigation Report form (See section 3) IR4 - Medical Device Report form

1.2 Report forms must be readily available and accessible to all. Every department should have a supply. In the event of any difficulty locating a blank form, contact the Department Head, Directorate team or alternatively the Governance Support Unit. Further supplies of forms can be ordered from the Governance Support Unit. There are no pre-printed supplies of Report form IR4, in view of the relatively small number likely to be used. This forms can be downloaded from the Governance Support Unit web page, when required.

1.3 For a single incident there should ideally be only one IR1 form completed. However, there will always be circumstances where more than one report is completed for a single adverse incident, for example, where a report form is completed by a patient and another by a member of staff, or where a witness to an incident is perhaps uncertain whether a form has been completed by the person(s) directly involved and completes a form.

1.4 The team/department/directorate should make every effort to avoid multiple IR1 forms being completed but where this happens, should marry-up any reports relating to one incident and submit them together. The Governance Support Unit will, however, also undertake checks, aided by the Datix System.

1.5 The Governance Support Unit will amalgamate reports into a single adverse incident record within the Datix System, preserving and recording all of the information contained within the reports submitted.

1.6 The reporter should objectively, clearly, accurately and concisely record the facts of the incident. Opinions should not be recorded. At the present time, reports are disclosable in the

8

Appendix 8.2(iii)

event of any litigation. Do not in any way misrepresent the facts - if the incident should in any way become a legal matter this would be construed as perverting the course of justice or perjury and this carries penalties.

1.7 Do not make up anything that you cannot remember. If there are gaps in your account, state that you cannot recall what happened.

1.8 Write your account as soon as possible after the occurrence as memories can fade quite quickly.

1.9 Handwriting must be legible, as the information on the form will need to be transferred to the Datix system by the Governance Support Unit.

1.10 The dates of any staff sickness period relating to the incident must be recorded on the IR1 form, as this is an important aspect for the Trust to monitor. Where the period of sickness is ongoing at the time of form completion or a member of staff commences sickness absence after submission of the form, the Governance Support Unit must be advised so that the incident record can be updated.

1.11 Where Witness reports (IR2) are completed/required, these must be objective, factual reports.

The Witness should sign and date the report and may keep a copy for their own reference.

1.12 Witness reports are not only help to establish facts but can help the Trust to identify anyone involved who may need, or may need additional, support and assistance following the incident.

1.13 Where relevant, Managers should note on the IR1 when that member of staff last received training (e.g. for a lifting incident, note details of the employees Manual Handling training). Managers may also be able to identify whether training requires re-enforcement within the Department.

1.14 Where any Third Party is deemed to have a potential or actual responsibility for any element of the incident, this should be noted on the IR1. For example, an incident that involves equipment left in a dangerous position by a Contractor. It must also be recorded what action has been taken to alert the Third Party to the incident, contact details and any immediate actions taken by the Third Party.

2 How to complete the specific sections of the Adverse Incident Report Forms 2.1 A guide on how to complete the specific sections of the forms is available from the Governance

Support Unit web page.

3 What does the Governance Support Unit do with report forms? 3.1 Report forms are individually reviewed to:

• identify any items of missing information that must be sought • identify issues that may require some form of particular or immediate action that may

not have been instigated at this point • as part of quality-assuring the application of the grading matrix in practice • Ensuring that there have been appropriate communications and reports as required by

this policy and procedure

9

Appendix 8.2(iii)

3.2 The information contained within a report is faithfully recorded in the Datix System. It will be supplemented by any information relating to and following the investigation of the incident.

3.3 More information may be held within a Datix record of an incident than is recorded on the paper report form. This is information used to assist with aggregated analysis of the entire spectrum of incidents.

3.4 Once the information from a report form has been transferred to the Datix record, the Datix identifier will be entered onto the form and it will be returned to the originating Directorate.

4 How should completed report forms be stored and for how long? Managers must comply with WHC (2000) 71, which is available from the Policies tab of the

Trust Intranet site under the title ‘Guidance for Retention and Destruction of Records’ or any subsequent Assembly or Trust guidance issued to reflect the implementation of the Freedom of Information Act.

SECTION 3 GUIDANCE ON INVESTIGATION AND ANALYSIS

1 General Points 1.1 The purpose of investigating and analysing adverse incidents is to identify lessons and make

recommendations for reducing risk for the future.

1.2 The investigation needs to gather information on and answer the following questions: • What happened? • How it happened? • Why it happened?

Integral to this is the need to examine the appropriateness of individual actions and decisions that were taken, given the particular context (whether clinical or non-clinical) and consideration of the alternatives that might have prevented the Incident. Actions can then be developed, planned and implemented that should reduce future reoccurrence and/or reduce the outcome/consequences of any future reoccurrence.

1.3 Adverse incidents in the healthcare setting rarely have a single cause and we must identify all the underlying systems issues and contributory causes / root causes if we are to improve our understanding of how and why incidents occur and put in place effective actions to avoid them in the future.

1.4 Investigations of Green or Yellow incidents should not be lengthy. They should involve the investigator doing little more than talking to those involved to establish the basic facts of what, how and why the incident happened and with such incidents the causal factors should be quickly and easily identified. Some of the tools/techniques described here may be employed, if considered appropriate, but scaling is necessary and important.

1.5 Investigations of Amber or Red incidents will require detailed investigation and analysis.

10

Appendix 8.2(iii)

2 Gathering information and evidence 2.1 Investigators should gather information on all any situations or circumstances that are

considered to be a precursor to the incidents as well as all the consequences of the incident.

2.2 Information should be collected as soon as possible after the incident as memories fade and conditions change. However, investigators must be sensitive to the impact the incident may have had on staff and must consider carefully how and when to approach staff.

2.3 The sources of information, the amount of information and the time spent on information gathering must be determined and scaled according to the complexity and seriousness of the incident.

2.4 The sources of information and evidence that investigators typically use fall into the following categories:

2.5 Interviews, of persons involved and witnesses which, conducted sensitively provide both direct testimony as to what happened as well as an opportunity to check back on any issues arising from examination of the physical and documentary evidence. Point 6 of this section contains tips on Investigative Interviewing, which will be useful for investigations of Amber or Red incidents.

Direct observation both of the place/environment where the incident took place,

procedures etc in practice and any equipment involved which is important to avoid losing importance evidence about the scene, configuration, relationships between parts, etc.;

Layout can be important, especially for incidents involving violence and aggression or use of machinery. Layout should encompass the physical aspects as well as the locations of people. Photographs may be useful in recording factors but NOTE: digital photographs are not admissible evidence if a case should end up in court because they can be enhanced and amended. Only traditional film is admissible in such circumstances. Remove and preserve physical evidence involved such as medical equipment, wherever possible, If equipment needs to be brought back into use, it must be thoroughly examined and photographed and detailed notes of the examination findings made. The Police or Coroner may REQUIRE preservation of the actual physical item for their investigations.

11

Appendix 8.2(iii)

Documentation, which helps establish what should have happened as well as providing evidence of prior risk assessment etc. For example:

- Relevant policies, procedures, guidelines - Clinical records - Audit findings - Alerts - Risk Assessments - Inspections - Maintenance records - Documented expressions of concern - Incident Reports - Claims Data - Minutes of meetings where relevant issues were discussed - Contract documents - Training records

Custom and Practice can help investigators better understand the factors that may have resulted in a vulnerability to the incident occurring. Investigators should speak to people who work in the area/department or have regular contact with it but who were uninvolved in the incident to acquire information regarding general attitudes, how things are done in practice, why and how long it has been that way.

3 Sorting and assembling information/data 3.1 Investigators must put all the information into order, establishing a chronology of events.

This will help to identify any gaps where further fact-finding is necessary. It may also begin to bring problem areas into focus.

3.2 The chronology of events is of utmost importance in an investigation.

3.3 There are a number of methods by which the chronology can be 'mapped out'. These are not detailed here as there are specific means by which relevant staff will be assisted to understand these techniques and acquire the necessary skills to apply them.

3.4 A schedule of all documents gathered and used in an investigation must be retained as part of the investigation papers/file. Copies of the documents should be taken and retained, with the exception of those that are readily accessible should they be needed subsequently, such as patient records. The documents used in an investigation will be required for any subsequent review of the investigation, should that be necessary, and in the event of a Claim.

4 Identify the problems 4.1 Investigators should examine the incident chronology and identify where there would

appear to be issues or problems. These should then be prioritised, as it may be unrealistic and ineffective to attempt a causal analysis on all the issues. It may be necessary to conduct a full causal analysis only on the top six, perhaps.

4.2 Brainstorming is a useful technique for identifying issues that could be the subject of further exploration. Employing a priority scoring system may be helpful in identifying the top six problems for further exploration, where a consensus cannot otherwise be reached.

12

Appendix 8.2(iii)

5 Explore the problems and identify causes 5.1 Here the investigators must aim to identify all the possible or potential contributing factors,

sorted into immediate and underlying/root causes. Whilst human factors should not be forgotten, the focus should be on systems and processes.

5.2 Immediate causes include the patient, the task, the work environment and the people involved, either individually or as part of a multi-disciplinary team. Underlying causes are the management, organisational and institutional context factors that explain why the event occurred. Getting to the root of the problem by identifying the key underlying, or root causes will help ensure development of an improvement strategy that, if properly implemented, should prevent or significantly reduce the risk of recurrence.

5.3 For Green and Yellow incidents the Causal Checklist - Figure 1 - should always be used and this has been incorporated into form IR3. No further analysis need be conducted.

5.4 The checklist is based on University College of London and ALARM protocol for the investigation and analysis of (clinical) incidents, and adapted as the NPSA Contributory Factor Classification Framework. .

5.5 For Amber and Red incidents, the Causal Checklist can equally be used but it is anticipated that further analysis will also be required. Other techniques that are helpful in this stage are: ⊗ Brainstorming ⊗ The Five Why's - repeatedly ask the question ‘why’ to delve deeper into a problem

until no more levels of cause can be identified. ⊗ Construction of a Cause-and-Effect diagram. There are many variations in use and

examples will form part of the Root Cause Analysis training for individuals selected to be investigators across the Trust.

⊗ Barrier Analysis and Change Analysis. Examples will form part of the Root Cause Analysis training for individuals selected to be investigators across the Trust.

5.6 Further information on these techniques is not detailed here as there are specific means by which relevant staff will be assisted to understand these techniques and acquire the necessary skills to apply them.

5.7 Not all contributory causal factors are negative. Some factors may well have helped to mitigate the final outcome and the team should seek to highlight such positive aspects to support the promotion of safe practice.

6 Be credible 6.1 Investigators should not be tempted to use the causal analysis as an opportunity to

identify all of the issues that it may believe have contributed to similar problems in the past (this should be done as part of a subsequent risk assessment). There must be focus on only those factors that shaped the particular problem or outcome being investigated.

6.2 Investigators of Amber and Red incidents should undertake to verify the causal factors that are to be put forward as being significant to the incident. If is does not, credibility may be adversely affected. Furthermore, the result could be the development of an improvement strategy that doesn’t actually address the fundamental causes of the

13

Appendix 8.2(iii)

14

incident and. therefore, has no beneficial impact of the likelihood of a reoccurrence.

7 Retention of Investigation Reports and Documents Used

Compliance with WHC (2000) 71, which is available from the Policies tab of the Trust Intranet site under the title ‘Guidance for Retention and Destruction of Records’ or any subsequent Assembly or Trust guidance issued to reflect the implementation of the Freedom of Information Act, is required. Investigators may provide their investigation files to the Governance Support Unit for electronic storage against the Incident Record. Where this is not done, Investigators must take responsibility for ensuring that all documents gathered and used in an investigation must be retained in an Investigation file, with the exception of those that are readily accessible should they be needed subsequently, such as patient records.

Appendix 8.2(iii)

Figure 1

CAUSAL CHECKLIST

Where any of the listed factors are considered to apply, these should be ticked and details recorded.

FACTOR COMPONENTS BRIEF DETAILS Patient Factors - Factors that are unique to the patient(s) involved in the incident Clinical Condition

Pre-existing co-morbidity Complexity of condition Seriousness of condition Treatability Other

Social factors

Culture/religious beliefs Life style (smoking/drinking/drugs/diet etc) Language Living accommodation (e.g. dilapidated) Support networks Other

Physical Factors Physical state (malnourished, poor sleep pattern etc.)

Other

Mental / Psychological Factors

Motiovation (agenda, incentive) Stress (familiy pressures, financial

pressures etc) Existing mental health disorder Trauma Other

15

Appendix 8.2(iii)

Interpersonal relationships

Staff to patient Patient to staff Patient to patient Inter family - siblings, parents, children Other

Individual (staff) - Factors that are unique to the staff involved in the incident. Physical issues General health (nutrition, diet, fitness etc)

Physical disability (eyesight problems, dyslexia etc)

Fatigue Other

Psychological issues Stress Specific mental health illnesss (e.g.

depression) Mental impairment (illness, pain, alcohol,

drugs etc) Motivation (boredom, complacency, low job

satisfaction etc) Cognitive factors (attention deficit,

distraction, preoccupation, overload) Other

Social Domestic Domestic / lifestyle problems Other

Personality Issues Low self-confidence / over-confidence

Gregarious/ interactive/ reclusive Risk averse / risk taker Other

Team and Social - Factors that may have an effect on the cohesion of the team.

16

Appendix 8.2(iii)

Role Congruence

Are there any issues with parity of understanding

Are there any issues with role definitions being correctly understood?

Are there any issues with the clarity of role definitions?

Other Leadership Clinical leadership

Managerial leadership Clarity and understanding of the leadership

responsibilities Respect afforded to the leader Other

Support and Cultural factors

Support networks for staff Team reaction to adverse events Team reaction to conflict Team reaction to newcomers Team openness Other

Communication - Factors that may have an effect on performance or occurrences Verbal Communication

Clarity of verbal commands / directions Appropriateness of style of delivery to

situation Appropriateness of use of language Appropriateness of person (s) to whom

communicated Appropriateness of communication

channels Other

17

Appendix 8.2(iii)

Written Communication

Ease with which records can be read Adequacy of records storage and

accessibility Comprehensiveness of content Contemporaneous recording Appropriateness of person (s) to whom

communicated Extent of circulation Other

Non-verbal communication

Body language issues (open, closed, aggressive, relaxed etc)

Other

Task/Process - Factors that support and assist the safe and effective performance/delivery of functions Guidelines. Procedures and Policies

Currency Availability at appropriate location /

accessible when needed Unavailable / missing Understandable / usable / realistic Relevant; clear; unambiguous; correct

content; simple Adherence to Appropriately targeted (aimed at right

audience) Other

Decision-making Aids Availability of such aids (e.g. CTG machine, risk assessment tool. fax machine to enable remote assessment of results)

Complete information - availability of test results; history

Access to senior / specialist advice Access to flow charts / diagrams Other

18

Appendix 8.2(iii)

Procedure or Task Design

Design - realistic or flawed? Impact of guidelines on ability to carry out

the task in a timely manner Staff attitude to the procedure/task design Other

Education and Training - Factors that affect the ability of staff to fulfil their responsibilities and respond appropriately to situations Competence (of individual (s) involved)

Adequacy of knowledge Adequacy of skills Length of experience Quality of experience Familiarity with task Testing and assessment Other

Supervision Adequacy of supervision Availability of mentorship Adequacy of mentorship Other

Availability / accessibility

On-the-job training Emergency training Team training Core skills training Refresher courses Other

Appropriateness Content Target audience Style of delivery Convenience of delivery Other

Environment / Working Conditions- Factors that affect the ability to function at an optimum level

19

Appendix 8.2(iii)

Administrative factors Efficiency / reliability of administrative systems / support

Efficiency / reliability of systems for requesting medical records

Efficiency / reliability of systems for ordering drugs

Efficiency / reliability of administrative systems

Other

Design of physical environment

Area design (size, shape, visibility etc) Placement, appropriateness and safety of

equipment / furniture Other

Environment Housekeeping issues (e.g. cleanliness) Temperature Lighting Noise levels Other

Staffing Skill mix Staff to patient ratio Workload / dependency assessment Leadership Use of temporary staff Retention of staff / staff turnover Other

Work load and hours of work

Shift-related fatigue Breaks during work hours Extraneous tasks Social relaxation, rest, recuperation Other

20

Appendix 8.2(iii)

Time Delays caused by system failures or design Time pressures Other

Equipment and Resources- Factors that affect the ability to deliver care to patients or fulfil essential tasks Displays Correctness of information

Consistency and clarity of information Legibility of information Appropriateness of feedback Interference Other

Integrity Working order Appropriateness of size Trustworthiness Effectiveness of safety features Maintenance programme Other

Positioning Placement for use Storage Other

Usability Clarity of controls User manual Familiarity Newly introduced Standardisation Other

Organisational and Strategic - Factors that are inherent in the organisation Organisational structure

Conduciveness to discussion, problems sharing etc

Boundaries for accountability and responsibility

Balance of clinical and managerial models Other

21

Appendix 8.2(iii)

22

Priorities Drive for Safety Focus External assessment Other

Externally imported risks

Use of agencies Agency policies Contractors Equipment loan PFI Other

Safety culture Openness of culture Safety / efficiency balance Rule compliance Example set by leaders Contract Terms and Conditions Other

Appendix 8.2(iii)

• General Tips On Investigative Interviewing2 6.1 Planning ♦ Ensure the location and the facilities are adequate.

♦ Give sufficient notice of the interview and allow a realistic amount of time for the

interview. ♦ Give notification that the interviewee can chose to be accompanied by a staff

representative, colleague or friend not acting in a legal capacity. ♦ As it is very difficult to listen and take adequate notes at the same time, and in the

interest of not missing important points, arrange for a competent person to be present to take notes. Interviews can only be taped with the consent of the interviewee.

6.2. The Start of the Interview ♦ The interview may prove difficult if the interviewee believes that the interviewer(s) does

not have an open mind and an unbiased opinion. Furthermore, the interviewee may be very anxious and this can affect recall of events.

♦ Try to make the interviewee feel as comfortable as possible. Make sure the location of

the interview is not intimidating and has adequate facilities. Welcome the interviewee. All interviewers should introduce themselves and perhaps give brief information about themselves. It is useful to ask the interviewee to give some information about himself/herself.

6.3 Explain the Purpose of the Interview ♦ Ensure the purpose of the interview and the role of the interviewee and interviewer(s) are

explained. The important points to cover are: the need to find out as much as possible about the incident from everyone involved the need to describe everything, no matter how trivial, because the interviewer(s) was not present when the incident occurred

the need to understand how things happened as part of the overall process of learning

the interview is confidential and the information given in the course of the interview will be noted.

6.4 Listening ♦ Allow the interview to describe events from his/her perspective. Don’t interrupt as this

may result in the interviewee tailoring recall to fit with questions and important details may be lost.

♦ Interviewers must attend to their body language so that the interviewee does not gain an

incorrect impression that there is a lack of interest in his/her experience or that the minds

2 Based on Milne R and Bull R (2000). Investigative Interviewing Psychology and Practice. Wiley and Sons

23

Appendix 8.2(iii)

of the interviewers are already made up.

♦ Interviewers must take care not to note only the information they may consider to be important rather then what is actually important.

6.5 Asking Questions ♦ Ask questions when the interviewee has completed his/her account. The questions

should be designed to either clarify points or extract more information. It may be necessary to ask questions related to information that someone other than the interviewee has recounted. Sometimes, interviewees may feel uncomfortable answering such questions but they should be encouraged to speak freely.

♦ If an interviewee states that he/she does not know the answer to a question, this will

have to be respected.

♦ Choose carefully when to ask open or closed questions.

♦ If it has been necessary to pre-prepare questions, ask those after the questions that arise directly from the account given by the interviewee.

♦ It can be useful to repeat back the main points of an answer to the interviewee, to ensure

that the interviewer has not picked up any inaccuracies.

6.6 Closing the Interview ♦ Try to ensure the interview ends on a positive note.

♦ Thank the interviewee for attending and contributing their information. ♦ Ask the interviewee if he/she has any questions. ♦ Double check the interviewees contact details and provide contact numbers for the

interviewers should they wish to talk again or recall additional information.

6.7 Afterwards ♦ Provide the interviewee with a transcript of the interview and ask that he/she signs and

returns one copy and keeps the other for his/her personal records.

7 What is Root Cause Analysis? 7.1 Unless the fundamental, or root causes of adverse incidents are properly understood,

lessons will not be learned and suitable improvements will not be made to secure a reduction in the risk of harm, damage or loss.

7.2 Root Cause Analysis is a tool that aims to identify the most significant causes of a problem, and the actions necessary to eliminate it. Its use is part of the Trust’s effort to build a culture of safety and to move beyond a culture of blame.

7.3 In Root Cause Analysis, influencing and contributing causes (including those that have a

24

Appendix 8.2(iii)

positive effect as well as a negative effect) are identified in a process similar to diagnosis of disease – always with the goal in mind of preventing recurrence. This may give rise to a long list. Root causes represent the earliest points at which action could have been taken to avert the course of the incident or prevent its occurrence altogether. They are the fundamental causes, which if resolved, would eradicate the identified problem or significantly contribute to its resolution. Root causes thus represent significant risks and must be included in the Directorate and/or Corporate risk register.

7.4 Example: - The most immediate cause of an adverse incident could be that a wrong clinical decision

was made. - This wrong judgement may have occurred because pertinent information was not in the

patient's clinical record. - This missing information may be due to the fact that when the patient last visited, the

treating doctor at the time wrote up the patient's consultation, diagnosis and treatment in another patient's record because when the patient walked into his consultation room he did not perform a simple check on the patient's identity by asking him his full name, address and date of birth. Consequently, he did not realise that the records in which he was writing did not match the patient he was with. The lack of a systematic but basic checking procedure was the root cause of the incident.

SECTION 4 GENERATING RECOMMENDATIONS, REPORTS AND ACTION PLANS 1 General Points 1.1 In every case it is necessary to consider recommendations for action against a number of

basic factors:

• is the cause of the incident of a sufficiently serious nature to justify a change in procedures?

• would any change to procedures have an unacceptable impact on the ability to operate a section or service?

• can the cost of any proposed change be justified?

2 Recommendations 2.1 Recommendations should be focused on addressing the root cause(s) of an adverse incident

i.e. those issues that, if addressed, will prevent the problems from reoccurring. It must contain prioritised actions together with responsibilities, timescales and strategies for measuring the effectiveness of actions.

2.2 Whilst focusing on latent issues, recommendations should not ignore the support and professional development needs identified for individual members of staff.

2.3 Recommendations should be accompanied by: views on where responsibility for taking action on a recommendation is considered to lie views on the risk of choosing not to address the recommendations i.e. doing nothing or not

25

Appendix 8.2(iii)

being in a position to address the recommendations.

2.4 Where an investigation reveals a training issue, it is necessary to consider not only what actions must be taken in respect of the individual but also whether there is a need for wider re-enforcement. Where this need is considered to extend beyond the local remit or there are implications for Trust-wide training, these matters should be highlighted and the Governance Support Unit will take these matters forward with relevant parties.

2.5 The identified barriers to learning that were highlighted by An Organisation With a Memory, are repeated in Figure 3 as an aide memoir to the pitfalls that individuals, teams, departments, directorates and the Trust must bear in mind and guard against when developing recommendations (and action plans).

3 Compilation of the Report (Amber and Red incidents only) 3.1 It is worth clarifying here that documents not collected or created for the purposes of litigation

are disclosable. Documents that are disclosable have to be provided to those persons or bodies legitimately requesting them (unless there are specific reasons why they should not be provided). For the avoidance of doubt, documents collected for or recording the investigation of an incident or a complaint, to identify learning and improvement, are disclosable. Queries in this respect can be referred to the Executive Team or the Governance Support Unit.

3.2 A suggested template of contents is given below.

EXECUTIVE SUMMARY Introduction An introduction to the purpose of the report and the commissioning Executive or Committee The Terms Of Reference Contributors The Investigation Team Persons or Teams involved in the incident -(assign all persons directly involved a coded reference e.g. Consultant A, which should then be used throughout the body of the report). Witnesses to the incident Other persons who contributed information to assist the investigation Summary Of The Incident And Its Consequences Summary Of The Immediate Management Of The Incident And Action Taken At The Time Significant Care Delivery Problems and Service Delivery Problems Those having the most direct impact on the course of events or outcome Factors Identified As Root Causes Recommendations

26

Appendix 8.2(iii)

Listed, with person responsible or Committee to which it will be passed for action. Additional Learning Opportunities Include here any positive factors that might be used to improve practice across the organisation

MAIN REPORT

Outline of the Investigation Process This should include the investigative and analysis tools used. Full Chronology of Events The chain of events either as a narrative chronology or a diagrammatic timeline. Care Delivery Problems, Service Delivery Problems or Concerns A list of al the CDPs, SDPs or concerns identified during the investigation. Influencing Factors List all the positive and negative influencing factors identified during the analysis of the CDPs, SDPs or other concerns. This is usually most effectively presented as a table – for example:

POSITIVE FACTORS

NEGATIVE FACTORS

Patient

Individual

Team

Communication

Task/Process

Education/ Training

Environment

Equipment

Management and Organisational

Institutional

4 Action Plans 4.1 Action plans are best presented in tabular form with columns to capture each of the following,

as a minimum:

27

Appendix 8.2(iii)

♦ a description of the action ♦ the name of the person responsible for ensuring execution of the action ♦ a start date ♦ a planned completion date ♦ the mechanisms/processes to monitor the ongoing operation and effectiveness of the

action

28

Appendix 8.2(iii)

SECTION 5: RIDDOR REPORTING

HSE information sheet The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995: Guidance for employers in the healthcare sector

Health Services Sheet No 1

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) require employers and others to report accidents and some diseases that arise out of or in connection with work. These reports enable the enforcing authorities to identify where and how risks arise and to investigate serious accidents. This information sheet explains how RIDDOR applies to the healthcare sector. What needs to be reported? Under RIDDOR you must report some work-related accidents, diseases and dangerous occurrences. This requirement covers all work activities, but not all incidents. The following are reportable if they arise ‘out of or in connection with work’: • Accidents which result in an employee or a self-

employed person dying, suffering a major injury, or being absent from work or unable to do their normal duties for more than three days.

• Accidents which result in a person not at work

suffering an injury and being taken to a hospital, or if the accident happens at a hospital, suffering a major injury.

• An employee or self-employed person suffering

one of the specified work-related diseases.

• One of the specified ‘dangerous occurrences’ –these do not necessarily result in injury but have the potential to do significant harm.

Who should report? Employers, the self-employed and those in control of work premises have duties under the Regulations. The duty to notify and report rests with the ‘responsible person’. This may be the employer of an injured person, a self-employed person, or someone in control of premises where work is carried out. Who the responsible person is depends on the circumstances of the notifiable event as shown in Table 1. Accidents ‘Accidents’ include acts of physical violence to people at work, but not violence to other people, such as patients or visitors. You do not need to report accidents arising directly from the conduct of an operation, examination or other medical treatment, carried out or supervised by a doctor or dentist. For an accident to be reportable it must arise ‘out of or in connection with’ work. Accidents which arise solely from the condition of the injured person are not reportable, neither are suicides.

Table 1 Reportable event Injured person Responsible person Death, major injury, over-3-day injury or disease

Employee at work Employer

Death, major injury or over-3-day injury

A self-employed person at work in premises controlled by someone else

Person in control of the premises

Major injury, over-3-day injury or case of disease

A self-employed person on their own premises

Self-employed person or someone acting on their behalf

Appendix 8.2(iii)

Death, or reportable injury

A person not at work Person in control of the premises

Dangerous occurrence Person in control of the premises

Examples: Reportable accidents Reportable • A confused patient falls from a window on an

upper floor and is badly injured. • A hospital patient is scalded by hot bath water and

has to be moved to a burns unit for treatment. Not reportable • A frail elderly woman falls and breaks her leg,

there are no obstructions or defects in the premises which contributed to the fall.

• A patient commits suicide.

Death or major injuries You need to report the following accidents connected with work: • Your employee (wherever they are working), or a

self-employed person working on your premises is killed or suffers a major injury (including as a result of physical violence).

• Someone not at work is killed or suffers an injury

as a result of an accident and is taken to hospital from the site of the accident.

• Someone not at work is injured in an accident at

a hospital, and suffers a major injury. The different reporting requirements for accidents at hospitals are designed to ensure that accidents which would have required removal to hospital if they had happened elsewhere are reported.

Reportable major injuries include: • Fractures, except to fingers, thumbs or toes. • Amputation. • Dislocation of the shoulder, hip, knee or spine. • Loss of sight (temporary or permanent). • Chemical or hot metal burn to the eye, or any

penetrating injury to the eye. • Injury resulting from an electric shock or

electrical burn, leading to unconsciousness or requiring resuscitation or admittance to hospital for more than 24 hours.

• Acute illness requiring medical treatment, or loss of consciousness resulting from the absorption of any substance by inhalation, ingestion or through the skin or exposure to a biological agent.

• Any other injury which: - leads to: hypothermia, heat-induced illness

or unconsciousness; - requires resuscitation or admittance to

hospital for more than 24 hours; or if the injured person is already in hospital, then the injury would have resulted in admission for more than 24 hours.

A full list of reportable major injuries is on the pad of report forms and in the guide to the Regulations (see back page for details). Over-three-day injuries You must report accidents connected with work (including acts of physical violence) which result in an employee, or a self-employed person working on your premises being away from work or unable to do their normal duties for more than three days (including non-work days).

Examples: Over-3-day injuries • A porter suffers a back injury when lifting a heavy

load and is unable to work for four days. • A receptionist is punched by an angry patient in

Accident and Emergency, suffers severe bruising and is off work for a week as a result of the injury and shock.

• A doctor’s finger is broken when it is trapped by a

closing door, she is unable to do her normal work from Friday until Tuesday.

Diseases You must report any case in which a doctor notifies you in writing that one of your employees is suffering from a disease specified in RIDDOR which is linked with the corresponding activity. Self-employed people need to make their own arrangements to notify any reportable diseases they suffer. Reportable diseases include:

Appendix 8.2(iii)

• Some skin diseases, such as occupational dermatitis.

• Occupational asthma or respiratory sensitisation. • Infections such as hepatitis, tuberculosis,

legionellosis and tetanus. • Any other infection reliably attributable to work

with biological agents; exposure to blood or body fluids or any potentially infective material.

• Other conditions, such as occupational cancer and certain musculoskeletal disorders.

You can find out details about reportable diseases in the guide to the Regulations (see back page for details). Infections For the purposes of RIDDOR, an infection is the entry and multiplication of an infectious agent in the body causing a damaging reaction in the tissue. The infection and the damage caused may give clinical signs and symptoms of disease (‘clinical’ or ‘symptomatic’), or may not be evident (‘sub-clinical’ or ‘asymptomatic’). You need to report a case of infection only when you can reliably attribute it to the work that a person does. Infections which could have been acquired equally easily at work or in the community are not reportable. Colonisation, in other words the presence and multiplication of infectious agents in or on the body, without a damaging reaction in the tissue, is not the same as infection and is not reportable as a disease.

Dangerous occurrences Dangerous occurrences are specified events which may not result in a reportable injury, but have the potential to do significant harm. Reportable dangerous occurrences include the following: • The collapse, overturning or failure of load-

bearing parts of lifts and lifting equipment. • The accidental release of a biological agent

likely to cause severe human illness (a hazard group 3 or 4 pathogen).

• The accidental release of any substance which may damage health.

• The explosion, collapse or bursting of any closed vessel or associated pipework.

• An electrical short circuit or overload causing fire or explosion.

• An explosion or fire causing suspension of normal work for over 24 hours.

A full list is included with the pad of report forms and in the guide to the Regulations (see back page for details).

Examples: Dangerous occurrences Reportable • A patient hoist falls, due to overload. • Asbestos is released from ducting during

maintenance work. • A nurse suffers a needlestick injury from a needle

and syringe known to contain Hepatitis B positive blood.

• A laboratory worker spills a container of formaldehyde.

• A container of a TB culture is broken and releases its contents.

Not reportable • A domestic suffers a needlestick injury, the source

of the sharp is unknown. • A urine specimen container is broken and the

contents are spilled. • A doctor is injured by a sharp containing a

patient’s blood. The patient is not known to have any infection.

Examples: Reportable diseases Reportable • A nurse contracts TB after nursing a patient with

TB. • A laboratory worker suffers from typhoid after

working with specimens containing typhoid. • A nurse suffers asthma and becomes sensitised to

glutaraldehyde after working in a gastroenterology unit.

• A secretary suffers from work-related upper limb disorder.

• A surgeon suffers dermatitis associated with wearing latex gloves during surgery.

• A paramedic becomes Hepatitis B positive after contamination with blood from an infected patient.

Not reportable • A nurse becomes colonised with MRSA after

nursing patients infected with MRSA. • A domestic catches chicken pox. Patients in areas

where she has worked have chicken pox but so does her child.

How to report You must report fatal accidents, accidents resulting in

Appendix 8.2(iii)

major injuries, accidents to people who are not at work and dangerous occurrences to the Incident Contact Centre by telephone, fax, via the Internet or by post without delay. The Incident Contact Centre can be reached as follows: Please send postal reports to the following address: Incident Contact Centre, Caerphilly Business Park, Caerphilly, CF83 3GG. For Internet reports please go to: www.riddor.gov.uk Or alternatively link via the HSE website: www. h s e . g o v. u k By telephone (charged at local call rate): 0845 300 9923 By fax (charged at local call rate): 0845 300 9924 By email: riddor@natbrit.com You will need to give brief details about the business, the injured person and the accident. You should follow up the initial report within ten days by completing an accident report form (F2508) if you have not already done so. You do not need to notify other accidents, but you must report them in writing on the relevant form (F2508) within ten days. Diseases must be notificed in writing (on form F2508A) without delay. Keeping records You must keep a record of any reportable injury, disease or dangerous occurrence. This must include the date and method of reporting; the date, time and place of the event; personal details of those involved, and a brief description of the nature of the event or disease. The record must be kept for three years from the date you record the details. You can keep the record in any form you wish, for example by keeping copies of completed report forms in a file or recording the details on a computer. Consultation Employers should make records kept under RIDDOR available to safety representatives except where they reveal personal health information about individuals. The internal incident reporting systems which underpin RIDDOR reporting are likely to work better if you consult employee representatives when you draw them up. The full text of the Regulations, together with guidance notes, are available in a separate detailed guide A guide to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 L73 ISBN 0 7176 2431 5 from HSE Books. Forms F2508 and F2508A are available in a pad from HSE Books.

HSE priced and free publications are available by mail order from HSE Books, PO Box 1999, Sudbury, Suffolk CO10 2WA Tel: 01787 881165 Fax: 01787 313995 Website: www.hsebooks.co.uk (HSE priced publications are also available from bookshops.) For information about health and safety ring HSE's InfoLine Tel: 08701 545500 Fax: 02920 859260 e-mail: hseinformationservices@natbrit.com or write to HSE Information Services, Caerphilly Business Park, Caerphilly CF83 3GG. You can also visit HSE’s website: www.hse.gov.uk

This guidance is issued by the Health and Safety Executive. Following the guidance is not compulsory and you are free to take other action. But if you do follow the guidance you will normally be doing enough to comply with the law. Health and safety inspectors seek to secure compliance with the law and may refer to this guidance as illustrating good practice.

This publication may be freely reproduced, except for advertising, endorsement or commercial purposes. The information is current at 4/98. Please acknowledge the source as HSE. Printed and published by the Health and Safety Executive 6/01 HSIS1 C50

Appendix 8.2(iii)

Appendix 8.4(i)

The standard pyramid

Corporate socialresponsibility

Occupational health& rehabilitation

Nutrition Physical activity

Health & Tobacco MSD Mentalhealth

Alcohol &substance

misuse

Communication

Employee involvement

Policy deveolopement CORE COMPONENTS

Platinum Standard

Gold Standard

Silver Standard

Bronze Standardle

vel o

f aw

ard

saf ety

Organisational support

2

Appendix 8.4(ii)

CORPORATE HEALTH STANDARD Action Plan

Aim for Gold Standard 2007- 08

Corporate Health Standard Action Plan Page 1 of 27 January 2008

Appendix 8.4(ii)

Core Components – This criteria focuses on the ethos and culture of the organisation

Core Components Action Required Timescale Lead Progress Evidence Organisational Support A commitment to workplace health and well being

at senior management or Board level Monthly monitoring via Health & Well Being Group. Reports to Senior Management Team and agenda items at Board.

Deputy Chief Executive/HR Director, Health & Employee Well Being Group

Health & Well Being Group established and chaired by Senior Manager.Action plan in place. Revised Health at Work Strategy. Staff Charter in place.

Action plan in place monitored by Health & Well Being Group.

Ensure appropriate representation on the Health & Well Being Group.

Completed Assistant Director of HR

Health & Well Being Group well established and chaired by Senior Manager.

Deputy Chief Executive/HR Director is Executive Lead for workplace health and well being. Health & Well Being Group representatives from across the Trust including Occupational Health, H&S and HR.

Develop a Corporate Health Standard Action Plan Completed Assistant Director of HR

Action Plan in place

Action Plan

Corporate Health Standard Action Plan Page 2 of 27 January 2008

Appendix 8.4(ii)

Agree resource for health and well being activity, e.g. budgets or health promotion specialist

2007-2008 Assistant Director of HR

Resource secured. Trust Board approval for the recruitment of a Consultant Clinical Psychologist to deal with complex cases.

Consultant Clinical Psychologist commences employment with the Trust in Jan 2008.

Health and well-being featured in the organisation’s strategy.

Completed Assistant Director of HR

Revised Health at Work Strategy

Draft Strategy

A mechanism for workplace health and well-being activities, reviewed at senior level.

Completed Health & Well Being Group

Reviewed at the Health and Well Being Working Group meetings.

Know your Numbers. Celebrate World Heart Day. Minutes of Meetings

Establish a mechanism for monitoring workplace health and well-being activities

Completed Assistant Director of HR

Health & Well Being Group Meetings

Agenda item at Management Executive/Operational Forum and Trust Board

Workplace health and well-being interventions integrated into core values

October 2007 Assistant Director of HR

Reviewed Staff Charter recently Reviewed Health at Work Strategy and Dignity at Work Policy.

Staff Charter Investors in People Accreditation Staff Handbook

Corporate Health Standard Action Plan Page 3 of 27 January 2008

Appendix 8.4(ii)

Communication Develop prominently sited and regularly updated health and well being notice boards.

Completed Deputy Chief Executive/HR Director Health & Well Being Group

Notice Boards updated regularly – Flu Vaccination. Seeking to establish Lead from each Directorate.

Notice boards and posters are used throughout the Trust to promote health and well being. Displays are created and left in prominent places around the hospitals to promote specific issues.

Disseminate health and well-being information through use of e-mail and posters.

Completed Health & Well Being Group

Health and well-being information is distributed to staff within the Trust via notifications on the Home page of the Intranet site.

It is not normal practice to send global e-mails to all Trust staff due to impracticality and number of staff employed (approx. 7,000). Posters and Intranet. Legislative Changes affecting NHS Pension Scheme leaflet

Staff briefings, for example, workforce briefings, departmental briefings, team briefings

Completed Health & Well Being Group

Discussed at the Operational Forum, within the Directorate

The Trust communication methods of dissemination

Corporate Health Standard Action Plan Page 4 of 27 January 2008

Appendix 8.4(ii)

Management Development meetings and HR Development sessions.

include Newsletters, Open Forum (published dates on Intranet), Union briefings, departmental and Team briefings.

Develop an Employee Health & Well Being Intranet Site

Completed Further development between Oct 2007-March 2008

Assistant Director of HR

The Employee Health & Well being website is a newly created section on the Trust Intranet – more work to be done.

Evidence via Intranet includes information on health and well-being. The Occupational Health Department also have web pages.

A health and well-being newsletter or a section of an existing newsletter

Reviewed monthly at the Health & Well Being Group Meeting

Health & Well Being Group

The Trust Newsletter is distributed several times during the year and is being reviewed to include health and well-being information

Newsletters

Employee suggestion schemes with feedback to employees

Completed P Jones Suggestion boxes in place. Scheme “Help Us to Help You” was launched in May 2007.

Staff informed of outcomes at Operational Forum and via Trust Newsletters/

Corporate Health Standard Action Plan Page 5 of 27 January 2008

Appendix 8.4(ii)

Annual Report

Staff surveys Completed

Deputy Chief Executive/HR Director

Staff surveys undertaken. Action plan to be developed to address areas of concern.

A copy of the NHS Wales Staff Survey 2005 & 2007.

Employee Involvement Systems must be in place to ensure that the employees can receive and provide information.

Completed

Deputy Chief Executive/HR Director, Directorate Heads HR Staff Side Reps

Information is provided to employees via the Trust Induction, staff handbook, Occupational Health department, HR departments, Union office. Bi-monthly Operational Forum meetings and individual directorate meetings established.

Smoking cessation. Intranet, Notice boards Newsletters.

Engagement of employees in consultation Completed Deputy Chief Executive/HR Director, Directorate Heads HR

Staff side representation at JSCC, Operational Forum, Directorate

Newsletter Minutes of meetings E-mail from Deputy Chief Exec confirming

Corporate Health Standard Action Plan Page 6 of 27 January 2008

Appendix 8.4(ii)

Staff Side Reps

Forum meetings.

100% unionised. Health Social Care & Well Being Strategy on Intranet

Participation of employees in health and well-being activities.

Completed Ongoing

All Staff Health and Well Being Events – Know your Numbers/World Heart Day Multi faith room in the Chapel.

Staff are informed of health and well being activities via the Intranet, Notice Boards and Newsletters. Leaflets.

Employees taking responsibility for workplace health and well-being activity

Completed All Staff Operation Exercise Medical Stretch. Football Team Belly Dancing/ Exercise Classes. Golf. Staff Credit Union

Notices Posters Newsletter Bridgend Lifesavers Credit Union & link on Intranet

Policies & Policy Development

A health and safety policy (incl. MSD’s and mental health)

Completed Deputy Chief Executive/HR Director H&S Rep

Draft MSD Guidance Document

Health and safety policy Staff Handbook

A bullying and harassment policy Completed HR Policy in place Dignity at Work policy

A smoking policy Completed Nursing Directorate

Policy in place Smoke Free Policy

An alcohol and substance misuse policy Completed Consultation

HR Staff Side

Draft Policy has been reviewed

Revised Alcohol, Drug &

Corporate Health Standard Action Plan Page 7 of 27 January 2008

Appendix 8.4(ii)

December 2007 Reps and updated

Substance Misuse Policy discussed at Operational Forum on 7 Nov 2007

Policy Development: To have in place systems to inform staff of policy developments and implementation.

Completed HR Staff Side Reps

Open Forum and Trust Newsletters

Policy for the Formulation of Policies

A work life balance policy Completed HR Policy in place

A Work life Balance Policy

A nutrition policy Completed General Manager at Neath Port Talbot Hospital, Facilities Manager

A working group is being spearheaded by Executive Director of Nursing to review nutritional policy for Service provision and the principles are extended to employees

Minutes of meetings

A physical activity policy Completed

HR Policy in Place Physical Activity Policy ratified by Board on 6 Dec 2007

Policy Development: Engagement of staff prior to implementation.

Completed Deputy Chief Executive/HR Director Directorate

All policies are reviewed at the Operational Forum before

Minutes of meetings

Corporate Health Standard Action Plan Page 8 of 27 January 2008

Appendix 8.4(ii)

Heads HR Staff Side Reps

approval.

Staff are engaged in the review of policies Completed Chief Exec, Board Chair Directorate Heads HR Staff Side Reps

Managers and Staff representatives formally contribute to the development and review of policies, e.g., Dignity at Work Policy review. Policies are discussed in partnership via Operational Forum, Health and Safety Committees, Joint Staff Consultative Committee and Management Executive meeting.

Minutes of meetings

Health and Safety Systems to identify health and safety hazards Completed

H&S Rep Risk Lead GSU

The Trust has a Health and Safety Manager and Governance Support Unit.

Examples of Risk Assessments. H& S Procedures in the Trust

Corporate Health Standard Action Plan Page 9 of 27 January 2008

Appendix 8.4(ii)

H&S Action Plan.

Effective risk controls Completed H&S Rep Risk Lead GSU Occupational Health

The Trust has a procedure whereby Departments are required to undertake risk assessments Back care leaflet devised in line with HSE advice Return to work interviews to include risk assessments. H&S training and Violence & Aggression training at Induction.

The Trust complies with the Welsh Risk Pool Standards, examples enclosed. Examples of risk assessments. Manual Handling Policy Back Care Leaflet VDU On Line training Basic Skills Booklet for Domestic Cleaning V&A training slides

Monitoring, Assessment & Review

Recording of sickness absence data Completed

HR Every Directorate

Sickness absence data is recorded via the Electronic Staff Record (ESR)System and is also recorded locally within the Directorates. Quarterly

Examples of Sickness statistics. Trust Annual Report Training Slides used for Management Training in Sickness Absence

Corporate Health Standard Action Plan Page 10 of 27 January 2008

Appendix 8.4(ii)

Directorate Performance Review Meetings with Chief Executive to review Key performance Indicators which include sickness data/targets

2006/2007

Recording of participation levels, for example, staff attending courses, participation rates in health and well-being activities

Completed

HR Directorates

The Corporate Training department holds records of attendees at Induction; Postgraduate department hold records for Junior Doctor Induction; Health and Safety Trainers retain records (Passport system) and individual training records held on Occupational Smart Card for Junior Doctors. The aim is that

Records of attendees for Trust Induction. Record of attendees at Pre-Retirement Course & Programme

Corporate Health Standard Action Plan Page 11 of 27 January 2008

Appendix 8.4(ii)

this will be integrated into the ESR system. Pre-retirement Courses offered to all staff 2 years prior to retirement.

An employee health survey Completed Ongoing Ad hoc

Deputy Chief Executive Ad hoc: Catering Manager Energy/ Environment Manager

Employees participate in surveys including NHS Wales Staff Survey 2005 & 2007.

Restaurant Survey Travel Survey

A staff attitude survey Completed Ongoing Ad hoc

Deputy Chief Executive/HR Director

NHS Wales Staff Survey 2007 distributed in Oct /Nov 2007

Results from 2005 Survey.

Evaluation of specific health and well-being activities

Completed Occupational Health

Evaluation of health and well being activities recorded and actions taken where necessary

Evaluation forms Results of Well-Person Screenings etc.

Results/outcomes of evaluations and surveys to be considered at Board or senior management level.

Completed Ongoing Ad hoc

Deputy Chief Executive/HR Director Staff Side

Results/ Evaluation of surveys discussed and

Travel Plan NHS Wales Staff Survey Quarterly

Corporate Health Standard Action Plan Page 12 of 27 January 2008

Appendix 8.4(ii)

actions taken where necessary

Occupational Health Reports to Management Executive

Structured staff appraisal or performance management

Completed

All Staff

The Trust has a structured performance appraisal (Performance Development Review). From October 2006, the Trust adopted the National NHS KSF system which will be recorded on the EKSF database. Consultant, SAS and Junior Doctor appraisal is in line with national guidance.

Individual performance appraisal/ feedback

Specific Components – This criteria supports staff health promotion and well being

Specific Components Action Required Timescale Lead Progress Evidence Tobacco Smoking Policy in place Completed

Trust Board/ Nursing

Smoking policy in place

Smoke Free Policy

Corporate Health Standard Action Plan Page 13 of 27 January 2008

Appendix 8.4(ii)

Directorate Involvement in No Smoking Day Completed

Occ Health The Trust has participated every year in the event by running articles in newsletters, creating display stands in prominent places etc

Demonstrate continuing commitment e.g., Intranet bulletin date March 12, 2007

Displays leaflets and posters to provide support and information about the health effects of tobacco and second hand smoke

Completed

Occ Health Leaflets and booklets are available from the Occupational Health Department.

Posters on Notice Boards. Booklets available throughout the Trust

Promoting of smoking cessation services Completed

Occ Health Smoking cessation sessions are run via Outpatients department with a linkage to Occupational Health department.

This is a one-to-one service offered, and staff can approach the Nurse.

Staff consulted on development and implementation of smoke free policy

Completed Deputy Chief Executive/ HR Director Staff Side

Policy was developed in partnership with Trade Unions

Policy

Mental Health Bullying and harassment policy in place Completed HR Dignity at Work Staff Charter

Corporate Health Standard Action Plan Page 14 of 27 January 2008

Appendix 8.4(ii)

Promotion Staff Side Reps

Policy which has been reviewed and updated in 2006 in partnership with Union representative.

Dignity at Work Policy & Procedure.

Flexible working practices and family friendly policies in place

Completed HR Staff Side Reps

Work Life Balance - Flexible working policy in place.

Examples include staff working compressed hours, term time working, job-share, flexi-time hours, careers breaks etc.

Has a system in place which enables employees to comment on their job demands, job role and training needs

Completed HR Staff Side Reps

NHS Wales Staff surveys Performance Development Reviews with staff. One to One Supervision sessions.

Job Description and Person Specifications clearly indicate employees’ role, competencies and job limitations. Agenda for Change implementation has further ensured that all roles have a job description and person

Corporate Health Standard Action Plan Page 15 of 27 January 2008

Appendix 8.4(ii)

specification. Appraisal system and KSF systems in place

Is committed to the principles of the HSE’s Management Standards on Stress at Work

Completed Deputy Chief Executive/ Director of Planning H&S Occ Health HR Staff Side Reps

Development of Strategic Group chaired by Director of Planning. Recruitment of new Consultant Clinical Psychologist.

Briefing Paper for Consultant Clinical Psychologist post.

Risk assessment for stress Completed Occ Health H&S

Stress Audits by Occupational Health

Surveys Risk Assessments

Employees have access to confidential support and counselling services

Completed Occ Health

Employees can self refer to the Occupational Health Department

Services of Occupational Health. Occ Health website RCN Services World Mental Health Day Oct 2007 – Newsletter Article

Training is offered to staff and managers on recognising and addressing workplace stressors

Completed Occ Health Training Programme. New Consultant Clinical Psychologist post to deal with

Stress Management – Strategy, Guide and Questionnaire (Learning

Corporate Health Standard Action Plan Page 16 of 27 January 2008

Appendix 8.4(ii)

complex cases inc Stress.

Disabilities) Stress Booklet – (LD) Stress Training Pack used by Occ Health Dept. CIPD Stress at Work – Link on Intranet

System in place to allow staged return to work following a mental health or stress related illness, which could include flexible working, home working etc.

Completed. Further Action on written policy ongoing.

Occ Health HR Staff Side Reps

The Trust supports the use of Rehabilitation leave. Recommend managers refer staff to Occupational Health. Current developing written Rehabilitation Policy which is supported by AfC.

Policy and Guidance

Organisation recognises links between MSDs and mental health problems

Completed Occ Health H&S HR Staff Side Reps

New Consultant Clinical Psychologist post.

Health and Safety Policy Draft MSD Guidance Document for Managers

Corporate Health Standard Action Plan Page 17 of 27 January 2008

Appendix 8.4(ii)

Musculoskeletal disorders

Health and safety policy with specific section on musculoskeletal disorders in place.

Completed H&S Rep Occ Health HR Staff side

Policy in place Health and Safety Policy

Risk assessments for MSDs. Completed H&S Rep Occ Health HR Staff side

Managers conduct risk assessments as and when necessary

Evidence of Risk Assessments

Evidence to show that controls are in place. Completed H&S Rep Oc Health HR Staff side

Managers conduct risk assessments as and when necessary

Evidence of Risk assessments

System in place to allow staged return to work following a MSD related illness, which could include flexible working, home working etc.

Completed H&S Rep Occ Health HR Staff side

The Trust supports the use of Rehabilitation leave.

Specific Examples Policy & Guidance

Information provided to staff with back pain. Completed Physio Department

Leaflet devised and distributed to staff with back pain. Occ Health refer staff direct to the Physio Dept.6 month Secondment for Physio in Occupational Health has been approved by

Advice Leaflet for Staff with Low Back Pain (Physiotherapy Department) Initiatives Listed by the Physiotherapy Dept

Corporate Health Standard Action Plan Page 18 of 27 January 2008

Appendix 8.4(ii)

Board Organisation recognises links between MSDs and

mental health problems. Completed H&S Rep

Occ Health HR Staff side

Review Draft MSD Guidance document New Consultant Clinical Psychologist post.

Draft MSD Guidance Document for Managers

Alcohol and Substance Misuse

Alcohol and substance misuse policy is in place Completed HR Occ Health H&S

Review of policy discussed with Trade Unions at the Operational Forum on 7 Nov 2007.

Policy and re-draft in place

Support and training for managers to recognise issues relating to alcohol and substance misuse

Completed Ongoing – March 2008

Occ Health HR

Launch and raise awareness of new policy. Occupational Health provides support to managers.

Employee Health & Well Being website.

Alcohol and substance misuse policy that clearly prohibits the consumption of alcohol at anytime during the working day

Completed Occ Health HR

No alcohol consumption during the working day.

Policy

Nutrition - Workplaces with Catering Facilities

Provision of a healthy balanced menu using the balance of Good Health Model

Completed Catering Manager

Strategy being developed by Catering Manager. Developing menus, sharing drafts and plans to implement.

Healthy Eating Options. Minutes of meetings.

Corporate Health Standard Action Plan Page 19 of 27 January 2008

Appendix 8.4(ii)

Participation in national events for example 5 a

day Completed Ongoing

Occ Health Catering Manager Head of Dietetics

Promotional events organised and more dates are planned.

Intranet Heart Day Event. Photographs. Participation in Food and Fitness Event June 2007 Christmas Lunches on Intranet

Clearly identified healthy food choices Completed Ongoing

Catering Manager Occ Health

Signage for the Trust.

Healthy Eating Menu Publicity

Provision of information about healthy eating Completed Catering Manager Occ Health

Signage for the Trust.

Posters Leap `Count the Calories Lose the Pounds’ course on Intranet

Suitable facilities for breast feeding mothers Completed Ongoing

Occ Health Plans to identify more facilities

New & Expectant Mothers Policy

4 of the health choice criteria Completed Catering Manager Occ Health

Signage for the Trust.

Posters

Active marketing of healthy choices Completed Catering Manager Occ Health

Programme of nutrition awareness being developed

Menu examples

Healthy vending Completed Catering Manager

Programme being developed. Improvements expected

Healthy meals in vending machines

Training of catering staff Completed Catering All staff have Welsh Food

Corporate Health Standard Action Plan Page 20 of 27 January 2008

Appendix 8.4(ii)

Manager Hygiene certificates – different levels

Hygiene Award

Healthy choices at corporate functions and social events

Completed Catering Manager

Redrafted Menus

Menus

Minimum of 1 event held per year to highlight/raise awareness of healthy choices

Completed Ongoing

Catering Manager

The Trust catering department often run theme days throughout the year.

Participation in World Heart Day. Photographs

Extend policy to contract/catering providers used by organisation

Completed Facilities Manager (Neath Port Talbot Hospital)

Discussions continuing

Booklet

A minimum of eight healthy choice criteria Completed Catering Manager Occ Health

Signage for the Trust.

Posters Heart Foundation booklets

Links with lifestyle screening and support being available for staff wanting to lose weight

Completed Occ Health Discussions with Nutrition Specialists. Well Person Clinic will be launched in Jan 2008. One to one face to face interview for extra support.

Leaflets

A minimum of 12 healthy choice criteria Completed Catering Manager Occ Health

Signage for the Trust.

Posters

Nutrition - Workplaces Refrigerators provided Completed Catering Majority of Photographs

Corporate Health Standard Action Plan Page 21 of 27 January 2008

Appendix 8.4(ii)

without Catering Facilities

Manager areas without staff dining facilities have access to a refrigerator for staff use. Under Review.

Drinking water available at all times Completed Deputy Chief Executive

Drinking water is provided in all work areas.

Photographs

Provision of information about healthy eating Completed/ongoing

Catering Manager Occ Health Employee Well Being Group

In Occupational Health, advice is offered to all new staff post employment health check.

There are posters around the Trust highlighting the benefits of healthy food choices. Nutrition guidelines, leaflets and information available.

Suitable facilities for breast feeding mothers Completed Ongoing

Occ Health/HR

Plans to identify more facilities

New & Expectant Mothers Policy

Participation in national events, for example, 5 a day

Completed Ongoing

Occ Health Catering Manager Head of Dietetics

Promotional events organised and more dates are planned.

Intranet Heart Day Event. Photographs. Participation in Food and Fitness Event June 2007

Healthy vending Completed/ongo Catering Programme Healthy meals in

Corporate Health Standard Action Plan Page 22 of 27 January 2008

Appendix 8.4(ii)

ing Manager

being developed. Improvements expected

vending machines

Healthy choices at corporate functions Completed Catering Manager

Redrafted Menus

Menus

Links with health screening and support available for staff wanting to lose weight

Completed Occ Health Discussions with Nutrition Specialists. Well Person Clinic will be launched in Jan 2008. One to one face to face interview for extra support.

Leaflets

Physical Activity Raise awareness of the health benefits of exercise including walking and cycling

Completed Occ Health HR

Posters are displayed in prominent places in the Trust.

Posters

Provides contact details for local leisure centres/sports clubs

Completed HR The Trust operates the Bridge Card scheme within the Bridgend locality which allows staff discounted rates at local leisure centres and secured discounted rates

This is promoted via the Staff handbook, via the intranet site and displayed on notice boards. Discounted joining fees are also available at local private health clubs in both the Bridgend

Corporate Health Standard Action Plan Page 23 of 27 January 2008

Appendix 8.4(ii)

at leisure centres for staff working within the Neath Port Talbot area

and Neath Port Talbot localities.

Provides information about local safe routes to cycle or walk to work

Ongoing HR Liaising with the Local Health Boards for information.

Posters

Use signage to encourage physical activity during the working day e.g. using stairs instead of lifts.

Completed HR Posters are displayed in prominent places.

Posters

Green travel plan Completed Energy and Environment Manager

The travel plan is being reviewed. Working in partnership to develop Green Travel Plan

Minutes from meetings. Travel Plans.

Provision of/or access to secure cycle racks and shower/changing facilities

Completed Ongoing

Energy and Environment Manager

Secure cycle racks are available in POWH & NPT Hospital sites. Showers are available in clinical areas. There is also a cycle track at the NPT hospital site

Photographs Application for Grant from Sports Council Wales to improve staff shower facilities/ bike racks

Active support – cycle pool, bike purchase Completed Energy and Energy/ Minutes of

Corporate Health Standard Action Plan Page 24 of 27 January 2008

Appendix 8.4(ii)

schemes etc Ongoing Environment Manager

Environment Manager is liaising with Cycle Solutions re bike purchase scheme for the Trust

meetings Email from Payroll confirming Bike Scheme Info

General Health Issues Raise awareness of general health issues appropriate to work force

Completed Occ Health At pre employment health check, and through promotional days. The Trust provides information on Sexual Health i.e. contraception advice, HIV, teenage pregnancy, sexually transmitted infections etc. Provides Flu Vaccinations. Provides free contraception. Health Challenge Wales Regular Events

Posters Intranet Leaflets Flu Vaccine Poster Health Events Calendar 2007 Accessible Information on Health Living & Be Active Challenge Booklets

Corporate Health Standard Action Plan Page 25 of 27 January 2008

Appendix 8.4(ii)

Published Lifestyle screening – targeting groups at risk Completed Occ Health The Occ Health

Dept provides information on men’s health i.e. testicular, prostate, bowel cancer etc. and information for staff on women’s health i.e. cervical, breast, skin, lung and bowel cancers, and osteoporosis. Well Person Clinic to be launched in Jan 2008.

Occ Health Nursing staff undertake health style screening which includes BP testing, cholesterol testing etc. Posters and Intranet.

Occupational health and rehabilitation

Provision of or access to occupational health services

Completed Occ Health All staff have access to the Occupational Health services available. Specialist team of Consultant Physician, nurses, Doctors. Recruitment of a Consultant Clinical

Post employment health check. Employees can self refer. Information available on the Intranet and via Newsletter and leaflets

Corporate Health Standard Action Plan Page 26 of 27 January 2008

Appendix 8.4(ii)

Psychologist who starts in Jan 2008. Physiotherapist has been seconded into Oc Health.

Access to a multi-disciplinary team of health care professionals

Completed Occ Health On-site Occupational Health service based in the Princess of Wales Hospital and Neath Port Talbot Hospital. It is a confidential medical advisory service that aims to safeguard the health, safety and welfare of Trust employees.

Leaflets

Rehabilitation and retention policy Completed Occ Health HR

Implementing staged return to work for employees as necessary.

Policy & Guidance.

Corporate Health Standard Action Plan Page 27 of 27 January 2008

Appendix 8.6

Compliments and Formal Complaints Performance by Directorate, 1.4.07 to 30.11.07

Com

plim

ents

Number Received

NumberAcknow-ledged

Number Acknow-ledged within 2 working

days

% Acknow-ledged within 2 working

days

Number ofResponses

sent

Number of Responses sent within 20 working

days

% of Responsessent within 20 working

days

Number of Responsessent in over 20 working

days

Number ofResponses

still o/s

Anaesthetics and Critical Care 423 1 1 1 100% 1 1 100% 0 0Community & Therapy Services 411 6 6 6 100% 6 6 100% 0 0HR and Operations 110 1 1 1 100% 1 1 100% 0 0Learning Disability Service 21 1 1 1 100% 1 1 100% 0 0Medical Director's Department 0 1 1 1 100% 1 1 100% 0 0Medical Specialties 1259 40 40 40 100% 34 28 70% 6 6Mental Health 765 8 8 8 100% 7 6 75% 1 1Multi Directorate 7 10 10 10 100% 7 5 50% 2 3Pathology 0 2 2 2 100% 2 2 100% 0 0Radiology & Endoscopy 62 3 3 3 100% 3 3 100% 0 0Surgical Specialties 1273 28 28 28 100% 28 22 79% 6 0Women & Children's Services 483 10 10 10 100% 10 8 80% 2 0Totals: 4814 111 111 111 100% 101 84 76% 17 10

Formal Complaints

Appendix 8.7

RISK MANAGEMENT ANNUAL REPORT

2006/07

Incorporating the 2006/7 Key Performance Indicators

Originator: Governance Support Unit Submitted for Approval: November 2007 Approval By:

- 1 -

- 2 -

CONTENTS

Page 1 Purpose

3

2 The Relationship Between Governance, Controls Assurance And Risk Management

3

3 Corporate Arrangements

3

4 The Operational Risk Management Group

3

5 Internal Audit Programme 2005/6

4

6 Welsh Risk Management Standards - WRP Assessment Including introduction of Healthcare Standards

4

7 Welsh Risk Management Standards - Self Assessment

5

8 Actions on Some of our Highest Risks

7

9 A Selection of Other Initiatives and Developments

9

10 National Patient Safety Agency – ‘Seven Steps to Patient Safety’

10

11 Risk Management Training

11

12 Health and Safety

12

13 Incident Reporting

12

14 Clinical Negligence and Personal Injury Claims

24

15 Complaints

27

16 Mortality Rates Linked to Patient Profiles

28

17 Rates of Sickness/Absence

29

18 Status of 2006/7 Actions Plan

31

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1 PURPOSE

1.1 This report provides an update for the Trust and the Board on activities and progress in

2006/7 to ensure the robust, proactive management of risks and the learning of lessons from the risks that occur. It also outlines the principal activities planned for 2007/8.

2

THE RELATIONSHIP BETWEEN GOVERNANCE, CONTROLS ASSURANCE AND RISK MANAGEMENT

2.1

Boards of NHS organisations must satisfy themselves that systems are in place to ensure that risks are assessed and managed ‘efficiently, effectively and economically so as to meet its objectives and to protect patients, staff, visitors and other stakeholders against risks of all kinds’. As part of this process, NHS organisations have to produce a Statement on Internal Control to accompany the annual report and accounts.

2.2 A key element of an effective internal control structure is the identification, evaluation and management of risks. Boards have to create an appropriately structured control environment, ensuring that significant risks are identified, priorities and objectives established and that proper arrangements are in place to support effective information and communication.

2.3 In Wales, NHS organisations have to examine their overall governance arrangements together with the Welsh Risk Management Standards.

3

CORPORATE ARRANGEMENTS

3.1 Corporate arrangements were unaltered from 2005/6.

4

THE OPERATIONAL RISK MANAGEMENT GROUP (ORMG)

4.1

The Operational Risk Management Group replaced the Incidents, Claims and Complaints Review Group (ICCRG) in September 2006 and throughout 2006/07 has monitored the following priorities for the Trust: • Incidents, complaints and claims – receiving and examining reports into serious

events, commissioning investigations, approving admissions and settlements in claims.

• Enforcing the learning of lessons throughout the Trust – approval of action plans in respect of remedial actions in serious incidents, complaints and claims.

• Overseeing the management of all Independent Review Secretariat and Ombudsman requests and responses to reports.

• Overseeing activity in relation to achieving compliance with Welsh Risk Management Standards (WRMS).

• Corporate and Directorate top risk register priorities. • Actions resulting from the commissioning by the group of Root Cause Analyses • NPSA information

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5 INTERNAL AUDIT PROGRAMME 2006/07

5.1 The objective of internal audit is to review the adequacy and effectiveness of the internal control system within the Trust for those areas scheduled in the Periodic Internal Audit Plan, which was agreed with the Trust’s Audit Committee at the commencement of the financial year. The purpose of this report is to provide the Audit Committee with: • An assessment of the adequacy and effectiveness of the internal control system and

the extent to which it may be relied upon by the Board of Directors; • An opinion on the extent to which the audit needs of the Trust have been met; • Details of key audit recommendations that have not yet been implemented fully.

5.2

One of the requirements of the WRMS is that Internal Audit undertakes cyclical reviews of WRMS to verify that a system of internal control exists for specific standards. The WRMS have been incorporated within the Strategic Plan and, are audited annually. For the 2006/07 financial year, internal audit conducted reviews of the five core standards. Figure 1 summarises the Internal Audit findings.

STD TITLE AUDIT RESULT CORE STANDARDS 1 Risk Management Policy and Strategy 100% 2 Risk Profile 100% 3 Adverse Incident and Hazard Reporting 100% 37 Governance 100% 38 Financial Management 100% Figure 1: WRMS reviewed by Internal Audit during 2006/7

6 WELSH RISK MANAGEMENT STANDARDS – WRP ASSESSMENT OF STANDARDS 2006/07

6.1 The Welsh Risk Management Standards were assessed in March 2007. In a change to the assessment process of former years a reduced approach to the assessments took place reflecting the move to aligning standards for healthcare in Wales over the next year. A reduced number of standards were assessed, six of which had reduced assessments focusing on key areas. These were:

o S14: Infection control and prevention o S15: Maternity Services o S18: Mental Health o S23: Nutrition and Catering o S28: Human Resources o S30: Medical Equipment & Devices

Assessment of a further eight standards was completed using the action plans provided by the Trust in October 2006 and January 2007. Thus allowing the assessors to concentrate on areas that scored partial or non-compliance in the previous year’s assessment and also to ensure that maintenance of areas, for example, training and audit are maintained year on year. In depth assessment took place of only two standards, namely Standard 11: Supervision of Staff and Standard 12: Assessing Competence.

Due to the changes in the assessment process introduced for this year’s assessment, it is not possible to compare the results for 2006/7 with those of previous years.

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6.2

The WRP conclusion was that the Trust had performed well in the changed circumstances, achieving an overall score of 78%. Once again, the Trust has some actions/activities highlighted as good practice.

6.3 This year, again a number of examples of good practice were evident throughout the Trust, a number of which, have been highlighted to be shared across Wales, these include:

– Training package developed by supervisors for cleaning staff – Nutritional ward information boxes – Proforma for Patient Group Directives within emergency care – Protected training every afternoon in A&E

STD TITLE

2003/4 RAW

SCORE (%)

2004/5 RAW

SCORE (%)

2005/6 RAW

SCORE (%)

2006/7 RAW

SCORE (%)

1 Risk Management Policy and Strategy 92 98 98 100 2 Risk Assessment & Treatment 100 94 99 100 3 Incident & Hazard Reporting 86 100 100 100 4 Complaints 98 99 99 99 5 Claims Management 88 100 100 100 6 Policies and Procedures 96 97 99 100 7 Records Management 95 94 70 90 8 Communications 91 90 90 88 9 Consent to Treatment 84 86 97 79 10 Clinical Effectiveness & Risk Management 78 72 87 99 11 Supervision of Staff 72 97 97 73 12 Assessing Competence 78 94 72 69 13 Occupational Health and Safety 88 98 96 96 14 Infection Control 80 88 97 85 15 Maternity 82 94 90 91 16 Operating Department Services 87 91 91 95 17 Accident and Emergency 84 89 92 82 18 Mental Health 92 91 99 99 19 Community 85 98 100 98 20 Ambulance N/A N/A N/A N/A 21 Learning Disabilities 80 97 98 98 23 Nutrition & Catering N/A N/A 89 100 28 Human Resources N/A 83 78 58 30 Medical Equipment and Devices 69 71 88 88 31 Medicines Management 88 84 86 84 39 Safeguarding the Welfare of Children N/A N/A 73 80 40 Cleanliness N/A N/A 79 86

WEIGHTED AVERAGE SCORE 81 78 77 78

Figure 2: WRP-Assessed Compliance Scores for WRMS

7

WELSH RISK MANAGEMENT STANDARDS AND HEALTHCARE STANDARDS - SELF ASSESSMENT

7.1 The Trust is mandated to undertake an annual self-assessment of compliance against all of the WRMS. Figure 3 shows the comparative self-assessment scores for Standards 22 onwards since 2003/04.

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7.2 Action Plans for all Welsh Risk Management Standards were developed following publication of the revised Standards applicable for 2006/07. These were submitted to the Welsh Assembly Government prior to the external assessment process in March 2007. In conjunction with the Operational Risk Management Group, the Governance Support Unit monitors progress against the Action Plans and facilitates solutions where implementation requires support.

STD TITLE

2003/4 RAW

SCORE (%)

2004/05 RAW

SCORE (%)

2005/06 RAW

SCORE (%)

2006/07 RAW

SCORE (%)

22 Buildings, Land Plant and Other Non-Medical Equipment

41 97 98 N/A

23 Nutrition & Catering 77 81 WRP WRP 24 Contractors and Contractor Control 58 95 95 96 25 Emergency Planning 82 73 83 97 26 Environmental Management 65 91 98 95 27 Fire Safety 98 76 N/A N/A 28 Human Resources WRP WRP WRP WRP 29 Information Management and

Technology 85 85 91 98

33 Security Management 41 58 85 40 34 Transport 68 96 98 40 35 Waste Management 67 77 81 86 36 Decontamination 89 81 59 80 37 Governance 100 100 100 100 38 Financial Management 100 100 99 100

WEIGHTED AVERAGE SCORE 86 89 90 83

Figure 3: Self-assessment Compliance Scores (for Standards not audited by WRP)

7.3 Healthcare Standards Self-Assessment

The Healthcare Standards were published by the Welsh Assembly Government in May 2005 to “provide a common framework to promote care based on shared values and to establish continuous improvement” as part of the drive to achieve the objectives of Designed for Life. There are thirty-two standards, organised into four domains: The Patient Experience, Clinical Outcomes, Healthcare Governance and Public Health. Some standards have a single criterion but others are divided into up to six criteria. An initial self-assessment against these Standards, based on the retrospective 2006/2007 position, was submitted to Healthcare Inspectorate Wales in June 2007. It is intended that the Healthcare Standards will eventually supersede the Welsh Risk Management Standards, but until that time the existing Trust process of assessing against the Welsh Risk Management Standards (WRMS) will continue alongside the new Healthcare Standards self-assessment process.

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8 ACTIONS ON SOME OF OUR HIGHEST RISKS

8.1 Summaries of actions on the organisations risks are detailed in the Risk Registers or

supporting documents. It is not practical to present information in this report on the actions to control all of the Trust’s highest risks. The following represents a small selection.

Capacity and Demand Issues

8.2 8.3

The 2009 Access Target project assessed demand and capacity issues for Wales. A series of staged targets will be introduced each year to move overall waiting times down towards the 26 week target. Work is continuing in line with the Guide to Practice Modernisation Project and through the Local Delivery Plan process to ensure that waiting lists are managed in an equitable manner. Initiatives in the year to reduce the risk of targets not being met included:

• Orthopaedic “Fast Track” – an initiative to streamline referrals to Orthopaedic services. Patients requiring an operation are identified at initial referral stage without the need for a prior outpatient appointment. This initiative has helped reduce waiting times for orthopaedic surgery and achieve the WAG waiting times targets.

• Introduction of Musculoskeletal service to ensure patients referred with Musculoskeletal complaints are prioritised to the appropriate clinician at the point where the referral is received within the Trust.

• In Rheumatology the development of an e-advice service to GP’s provides immediate expert advice on treatment or medication without the need for referral to an outpatient clinic. This has reduced follow-up appointments and has had a significant impact on waiting times.

• The introduction of a ‘one stop’ hearing aid assessment so that suitable patients referred by their GP’s can now be prescribed a hearing aid at the time of initial assessment. This has assisted in reducing waiting times within Audiology at the Princess of Wales Hospital.

• Radiology reduced waiting times within CT, MRI and Ultrasound by extending the length of the working day in three areas which has resulted in no patient waiting longer than 36 weeks for their diagnostic intervention.

Financial Pressures 8.4 The Trust’s ability to fund the framework for the future of the NHS proposed in Designed

for Life is a significant risk. Efficiency savings alone are not going to be sufficient to pay for the changes required and there is no complementary resource strategy. The challenges faced are set out in ‘Transforming NHS Wales: the Financial Dilemma’. The increases in the cost of healthcare are unrelenting and regular additions to the funding of health services are needed, even to maintain essential services. For the Trust to manage within existing funds, choices will need to be made about the range of services provided and the pace of change will have to be feasible and sustainable. The main cost pressures are healthcare funding and implementing Agenda for Change, medical consultant’s contracts and NICE pronouncements on drugs.

Actions on financial pressures are ongoing and the Resource Plan agreed in 2005/6 was monitored by the Board throughout 2006/7. The plan projected a financial shortfall and detailed the schemes that had been agreed to address the shortfall. Robust mechanisms that had been established to ensure delivery of the necessary savings. The achievements of the schemes were monitored closely and reported throughout the year.

Safe and Sustainable A&E Services

- 8 -

8.5 Developments included: • The opening of a new £2 million Emergency Unit at the Princess of Wales

Hospital, using a range of new ways of working, all of which have been achieved through better use of existing resources.

• Implemented the Minor Injuries and Illness Nurse Training Scheme (MINTS) within the Emergency Department to enhance and extend the role of the nurse, freeing up the medical staff to concentrate on major cases.

• Conducted a collaborative pilot with primary care which involved a GP working as part of the Emergency Department’s medical team at the Princess of Wales Hospital to help identify the potential impact of co-locating primary care practitioners within the department.

Workforce Issues 8.6 Workforce Modernisation

In July 2006, NHS Wales launched ‘Designed to Work’, the workforce and people management strategy to support the delivery of ‘Designed for Life’. Designed for Work aims to get the right people, with the right skills, at the right place and in time in order to deliver a world class, sustainable workforce for NHS Wales. The modernisation of the workforce is essential to ensure that services are delivered in the best way possible. A number of clinically led modernisation projects have been ongoing over the past year and these in turn have created new roles such as Healthcare Assistants, Porters and Physicians Assistants and Assistant Radiographers to provide a new system of assessment and care. Actions • The Trust has established a Workforce Modernisation Board which includes

staff-side representatives and representatives of partner organisations such as Bridgend LHB. The role of the Workforce Modernisation Board is to have an overview of the workforce modernisation agenda across the Trust. It also provides a mechanism for the ongoing governance of amended staff roles.

• During 2006/07 the Trust centralised the recruitment function into a central department and implemented NHS Jobs (www.jobs.nhs.uk), the NHS online recruitment service. This gives the applicants the ability to apply on-line for all vacancies within the Trust. As a result, the recruitment experience is now far easier, cost effective and efficient for both applicants and managers.

• The Trust has continued to benefit from improved recruitment to both new and replacement consultant posts following the continued implementation of the amended Consultant Contract and the strengthening of the Consultant Recruitment Team.

• Work has continued to redesign junior doctor rotas to achieve compliance with the European Working Time Directive target which requires no more than a 56 hour working week for doctors training as of 1st August 2007.

• A Hospital at Night model has been introduced at the Princess of Wales Hospital resulting in a change in the way the hospital is staffed at night and ensuring that the best patient care is delivered during this time. Arrangements are being considered so that this model can be put into place in Neath Port Talbot Hospital if appropriate.

• The Trust has focused on the management of sickness absence over the last year. The overall sickness figure for 2006/07 was 5.86% against a performance target of 4.2% set by the Welsh Assembly Government.

• The Trust introduced a new Electronic Staff Record (ESR) from the Autumn of 2006 which calculates sickness absence using a different formula than previously used and as such the sickness absence figures are not comparable.

• A Sickness Management Group is being established to be chaired by the Deputy Director of Human Resources to review ongoing sickness management issues and share good practice.

- 9 -

Equality and Diversity The Trust has published an Equality, Diversity and Human Rights Statement which affirms the organisation’s determination to build an environment in which staff, patients and the public in the communities served by the Trust feel valued, respected and able to contribute to the quality of the services provided. An Equality Improvement Steering Group and Working Group are in place to provide advice and guidance on all issues relating to Equality and Human Rights. These groups are overseeing the development of a Trust-wide Equality Strategy and Action Plan.

Capacity issues in Mental Health Services 8.7 These include:

• High referral and admission rates in acute Mental Health services • Above average length of stay in EMI • High bed occupancy rates • Inability to treat patients with high level/complex needs Crisis resolution and home treatment teams were established with partner agencies in response to one of the Welsh Assembly’s Goals to modernise mental health service. This has resulted in an effective viable alternative to hospital admission and has reduced pressure on acute mental health wards by enabling patients to be treated more effectively in their own homes.

9

A SELECTION OF OTHER INITIATIVES AND DEVELOPMENTS

9.1 There were a vast number of risk management actions and initiatives in 2005/6, which deserve mention but which cannot practically be included in this report. What follows is a small selection of initiatives and developments in the year.

9.2 The development of Alert Training and the Modified Early Warning Scoring (MEWS) system, which provides an early and accurate predictor for clinical deterioration and supports the management of appropriate cases at ward level, thereby promoting the need for timely admission and discharge of patients to and from Critical Care. The Directorate of Anaesthetics & Critical Care was also successful in securing funding to appoint an Outreach Liaison Nurse who is supporting the implementation of MEWS throughout the Trust.

9.3 The Hospital Sterilisation Disinfection Unit (HSDU) met all external audit standards for Sterilisation and Decontamination as set by the Welsh Assembly Government to ensure procedures are safe and compliant with current legislation.

9.4 During 2006/7 the Trust continued to participate in the National Patient Safety Agency’s “Clean Your Hands” Campaign, which enabled the Trust to meet the requirement to make alcohol hand rubs available at the point of care, so improving hand hygiene and helping to minimise the spread of infection in the hospitals.

9.5 The Directorate of Medical Specialities improved patient care through a project piloted on Ward 6 at the Princess of Wales Hospital by introducing a ‘dedicated handover tool’, protected mealtimes for patients and the establishment of new roles such as housekeeper.

9.6 The “System to Escalate and Monitor” clinical safety on the Neonatal unit, known as STEAM, has received further recognition through winning the Innovation in Neonatology UK Award for the project in November 2006. This assessment tool was devised by staff at the Princess of Wales Hospital to help record and analyse the dependency of patients on the unit to ensure they are cared for appropriately.

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10 NATIONAL PATIENT SAFETY AGENCY- (Patient Safety Alerts)

10.1

NPSA Safer Practice Notice 14, November 2006: Right patient, right blood Blood transfusions involve a complex sequence of activities and to ensure that the right patient receives the right blood there must be strict checking procedures in place at each stage of the transfusion pathway. The Trust has benchmarked its practice against the recommendations set out in the notice, including carrying out an audit of the use of patient identification wristbands, which are a vital part of the checking process. Changes in practice that have already been include:

• Withdrawing compatibility forms which were issued from Blood Bank with units of blood because analysis of national adverse incident data showed that reliance on these forms has been a significant contributory factor in incidents that involved transfusion of incompatible blood.

• Incorporating NPSA competencies and Welsh Blood Service e learning package into the training provided for staff involved in the transfusion pathway. Training is provided for staff who collect Blood Bank and for staff who administer blood transfusions at the patients’ bedside. These programmes will be expanded in 2007/08 to incorporate competency-based assessment

NPSA Safer Patient Notice 16, February 2007: Early identification of failure to act on radiological imaging reports The NPSA reports that patient safety incidents are being caused by a failure to acknowledge and act on radiological imaging reports in a timely way. The Radiology Directorate have compared their existing systems with the recommendation made in the report and have conformed that they already have processes in place to minimise the risk of an abnormal or unexpected result not being acted upon promptly. Radiology reports emphasise critical findings and state the urgency of action required. There is a Red Star system which alerts the clinician who requested the image that urgent review and action is needed. NPSA Safer Practice Notice 17, February 2007: Using bedrails safely and effectively The notice provides advice to improve the safety of patients in hospitals through informing patients and staff about the relative risks of falls and injury with and without bedrails. The Trust has incorporated benchmarking and policy development in response to this notice into its Falls Strategy work programme, focussing on:

• The production of a policy on the appropriate use of bedrails, which covers the key areas required by the practice notice.

• Ensuring that existing training programmes, particularly manual handling training, incorporate the advice.

• Development of an implementation plan for the policy to raise awareness amongst all relevant staff.

• Evaluating the impact of the policy, including undertaking a baseline measurement of the use of bedrails.

NPSA Patient Safety Alert 18, March 2007: Actions that can make anticoagulant therapy safer Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm and admission to hospital. Working towards reducing the risks associated with these medicines is the primary aim of the Thromboprophylaxis & Anticoagulation Committee.

• This year the Committee has targeted its work programme towards developing evidence-based thromboprophylaxis protocols for each specialty,

- 11 -

which will be implemented across the Trust. These protocols have been developed by doctors, pharmacists and nurses working in each specialties, for example Medicine, General Surgery and Gynaecology. The purpose of these protocols is to ensure that the risk of developing a deep vein thrombosis (DVT) or pulmonary embolism (PE) is assessed appropriately for all patients who are admitted to hospital. The protocols will be gathered together as part of the overarching Thromboprophylaxis & Anticolagulation Policy.

• Improving communication between secondary and primary care when patients receiving anticoagulation therapy are discharged from hospital is crucial if the risks related to this part of the patient pathway are to be minimised. New Warfarin Discharge Fax Forms have been developed to bridge the gap until this information can be sent to GPs electronically when patients are discharged.

• Training for junior doctors, nursing staff and pharmacists is being reviewed to incorporate the NPSA competency framework.

11

RISK MANAGEMENT TRAINING

11.1 Provision of information, instruction and training is an important means of achieving competence and helps to ensure safe working practices. It contributes to the Trust’s risk management culture and raises risk awareness at all levels, including senior management and the Board.

11.2 Level 1 Risk Management training forms part of the Trust Multi-Disciplinary Induction and the Corporate Training Department leads action to address non-attendance. Attendances at Trust Multi-Disciplinary Induction are shown in Figure 4.

Figure 4 Attendances at Trust Multi-Disciplinary Induction, as % of

nominations POWH NPTH

2003/4 67% 76%

2004/5 80% 85%

2005/6 73% 72%

2006/7 87% 86%

11.3 Ensuring new staff are appropriately inducted before they start work in their ward or department was the reason for introducing the Common Start Date in January 2006. All new staff now commence on one of two start dates each month and attend a tailored induction programme, incorporating Risk Management training, that introduces them to the organisation, addresses health and safety training and helps them enter their work area with a feeling of belonging to the Trust.

11.4 Medical staff at all levels are able to access the risk management training programme. The Consultant group receives a specific full day session as part of the Consultant Development Programme.

11.5 In addition to supporting Trust Induction, the GSU continued to undertake risk management training for individual departments and directorates and responded to ad hoc requests received.

12 HEALTH AND SAFETY

12.1 Health and Safety issues are overseen by the Trust’s overarching Health and Safety Committee, Chaired by the Director of Planning.

12.2

Key generic achievements 2006/2007

In August 2006 the Trust completed the 2-Year Manual Handling Training Programme.

The expansion of the Refresher Training Programme, ensuring employees

competencies are kept up to date.

Further investment in manual handling equipment for wards and departments with the purchase of an additional fifty electronically operated profiling beds, a range of twelve patient hoists and sixty sets of glide sheets.

The Trust maintained a score of 96% on Standard 13, Occupational Health &

Safety, during this year’s Welsh Risk Management Standards assessment. This demonstrates the Trust’s continuing commitment to health and safety.

13

INCIDENT REPORTING

13.1 The Governance Support Unit (GSU) provided reports and information to groups, committees and Directorates to inform their risk management plans and actions during 2006/07.

Total Number of Reported Incidents

7457 7677 73436723

4940 5127

010002000300040005000600070008000

2001/02 2002/03 2003/04 2004/05 2005/06 2006/07

Incidents reported by year

Figure 5 – Total number of incidents reported per year.

13.2 Figure 5 shows the number of reported incidents from 2001/02 to 2006/07. An extensively revised Adverse Incident Policy and Procedure was introduced early in 2005, with implementation supported by a training programme for staff across the Trust. A specific aim was to clarify the definition of an adverse incident and thereby reduce the reporting of events that do not constitute an adverse incident. This was successful in 2005/06 and continued training and education of employees by the GSU has maintained this success.

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- 13 -

Time Between Incident and Report 13.3 The average number of days between the date of an incident and the date the report is

passed to the Directorate Management Team is a risk management Key Performance Indicator (KPI), monitored by the ORMG. The significant improvement achieved in 2004/05 has been maintained for the period 2006/07 as shown in figure 6.

2002/3 2003/4 2004/5 2005/6 2006/7

Total All Directorates 5.6 2.4 1.0 1.1 1.1

Figure 6. – Average Number of Days Taken to Submit Report to Directorate Management

Ratio of Serious Incidents to Total Incidents 13.4 The ratio of serious incidents to total incidents is a risk management KPI. Following the

introduction of the revised Adverse Incident Policy and Procedure in April 2005, serious incidents are those graded as Red, as defined within the Procedure, either on the actual outcome of the incident or the future risk assessment. This change in approach means that a full, like-for-like comparison with previous years’ data is not possible but Figure 7 shows the data for 2004 to 2007.

13.5 Of the Red incidents in 2006/07, 18 related to unexpected death/suicide. The Mental Health Directorate’s Sentinel Review Group undertake a clinical review into each unexpected death/suicide, recommendations from these reviews form the basis of action plans. In addition, where indicated, Root Cause Analysis investigations also are held into unexpected deaths and reported to the Operational Risk Management for the overseeing of action planning.

2004/5 2005/6 2006/7

Outcome/ Grade

No

Proportion of total

number of reported incidents

No

Proportion of total number of incidents

reported

No

Proportion of total number of incidents

reported

Admission for Treatment or Observation

28 0.42% - - - -

Fatality 20 0.30% - - - - RED - actual outcome

- - 31 0.63% 41 0.79%

RED – future risk assessmt

- - 5 0.1% 2 0.03%

TOTAL 48 0.71% 36 0.73% 43 0.84%

Figure 7: Ratio of Serious Incidents to Total Number of Incidents

Incidents by Type

13.6 Figure 8 (below) shows the number of reported incidents by type. The table incidates increases in the reporting incidents involving Violence and Aggression. This is due, in part to the increasing awareness of staff to ensure such incidents are reported to enable effective actions to be taken by the Trust to prevent recurrences.

0

500

1000

1500

2000

2500

ClinicalIncidents

EquipmentIncidents

H & S Near Misses Non ClinicalIncidents

ObstetricMonitoringTriggers

V & A

Incident by Type

2004/052005/06

2006/07

Figure 8 Number of Reported Incidents by Type.

13.7 Drugs incidents are reported in more detail in following sections.

13.8 Bed Management incidents relate to outlier situations where the patient is placed on a ward that is considered inappropriate given the skills of the staff on that ward etc, also the transfer of patients between the service.

13.9 Examples of improvements implemented as a result of reported incidents include:

• Syringe driver documentation reviewed and piloted in Community and Therapies Directorate supported by staff training for the new documentation and annual audit of compliance. Is this transferable?

• Development of a policy confirming arrangements for the disposal of fetal

remains.

• Implementation of assisted technology which aims to reduce the number of patient falls. Suites 1 and 2 at Tonna Hospital piloted this technology which alerts nursing staff when patients, which have a tendancy to fall, rise from their beds.

• Co-ordination of a multi-agency Suicide Prevention Group and subsequent developmental work on a Suicide Prevention Strategy.

• Funding was secured to replace the air conditioning systems within two theatres at the Princess of Wales Hospital.

• Access to Child Protection Register within the Accident & Emergency Dept.

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Clinical Incidents by Category - 2006/7

0 50 100 150 200 250

Bed Management

Problem during / post procedure

Problem during / post surgery

Problem during / post treatment

Communication Issues

Cross Infection / Infection Control

Diagnosis

Drugs

Equipment

Laterality / Theatre List Discrepancy

Pathology Triggers

Post Mortem on w rong body

Policy / Procedure Non-Compliance

Radiology Triggers

Record Keeping

No review by MO

Failure to recognise severity of patient's condition

Staff ing Issues

Unexpected Death

Waiting time

Incidents

Figure 9 Clinical Incidents by Category

Drug Incidents 13.10 Drugs incidents are subject to review by the Chief Pharmacist, Nurse Director and a

representative of the Prescribing Group. The majority of the incidents reported have resulted in negligible or minor harm to patients. However, some incidents were sufficiently serious as to warrant further investigation and where care delivery problems were identified, for remediable actions to be put in place. Figure 10 below provides a breakdown of the 15 top sub-categories, in which it can be seen that dosage issues continue to dominate the table but incorrect medication administration and missing drug errors have decreased from the previous year.

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Drug Incidents 2005-2007 (Top 15)

27

15

0

6

0

5

0

10

03

0 0

6

0 0

35

1210

7 6 6 5 5 4 4 4 3 3 3 3

0

5

10

15

20

25

30

35

40

ng D

ose A

dmini

stered

Wron

g Med

icatio

n Adm

iniste

red

Wrong D

ose P

rescri

bed

Drugs g

iven t

o Wron

g Pati

ent

Medica

tion P

rescri

bed b

ut no

t Adm

iniste

red

Drugs g

iven t

oo ea

rly / t

oo la

te

Self A

dmini

strati

on in

Additio

n to s

taff A

dmini

stered

Missing

Drug

s

Admini

strati

on of

drug

not a

dequ

ately

supe

rvise

d

Compli

ance

with

relev

ant p

olicy

Inapp

ropria

te Stor

age /

Pac

kagin

g on W

ard

Admini

stered

via I

ncorr

ect R

oute

Wrong p

atien

t

Wrong Q

uanti

ty

Wrong D

rug D

ispen

sed

Category

2005/20062006/2007

Figure 10 Drug Incidents by Category. Medical Equipment Incidents The total number of incidents reported involving medical equipment in 2004/5 were 242. These reduced to 74 in 2005/6 and have again significantly reduced to 26 in 2006/7. Figure 11 shows Medical Equipment by category and compares this years figure with the previous year. The failure or fault reports related to servicing, age of equipment etc. This information is provided to the Medical Devices Committee who monitor and act upon the reporting of such incidents.

- 16 -

Medical Equipment Incidents by Categroy 2005/06 compared to 2006/07

0

2

4

6

8

10

12

14

Conne

cted I

ncorre

ctly

Decon

tamina

tion /

Sterilis

ation o

f Equ

ipmen

t

Defecti

ve / P

oor Qua

lity

Failure

/ Fau

lt Durin

g Use

Fault/F

ailure

durin

g TRANSFER

Missing

Mis-Use

/ Lac

k of T

rainin

g

Packin

g / C

heck

ing P

roblem

s

Unava

ilable

Category

Num

ber o

f inc

iden

ts

2005/06

2006/07

Figure 11 Medical Equipment Incidents

Patient Falls 13.11 Reported patient falls in 2006/7 total 1462, accounting for 28% of total incidents. The

highest level of falls occurred within the Directorates of Integrated Medicine, Mental Health and Community & Therapies.

13.12 55% of falls resulted in no injury, 42% resulted in minor injury and the remainder required medical treatment A site breakdown identified that 31% of falls occurred at the Princess of Wales Hospital, 24% at Neath Port Talbot and 14.6% in the Community Hospitals. The distribution of falls show that falls from a bed or trolley remain the highest type.

13.13 Risk control measures include: • Individual patients risk assessed to determine need for cot sides, degree of

supervision necessary etc. • Wander guards in place where appropriately risk assessed • Monitoring and review of incidents, claims and complaints to establish issues and

lessons that need to be learnt.

13.14 An ongoing review of patient falls is being undertaken by the Trust. The review is lead by the Nurse Director and managed by the Head of Nursing for Integrated Medicine. The review is expected to identify a pathway for the prevention/reduction of patient falls.

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Patient Falls by Location 2006/2007 (Top 20)

151

91 82 78 74 70 68 64 64 62 56 50 4730 27 23 23 23 21 21

020406080

100120140160

Ward D

Suite 1

- Ton

na

Glanna

nt Ward

- Cim

la

Ward E

Ward C

Ward 2

Ward 20

Ward 6

Ward 4

Ward 15

Ward 5

Suite 4

- Ton

na

Morlais

Ward - C

roeso

Cen

tre

Ward 18

Suite 3

- Ton

na

Ty Llw

yd - G

lanrhy

d

Pre Disc

harge

Ward

Llynfi

Ward

- Mae

steg H

ospit

al

Ward G

Bryned

d Ward

- Cim

la

Location

Num

ber o

f fal

ls

Figure 12 Patient Falls by Location

Communications 13.15 Failures in communication resulting from the misunderstanding of a communication or a

total lack of it are one of the major causes of adverse incidents, claims and complaints in the NHS. Ongoing analysis of incidents claims and complaints where poor communications are a contributory factor, and the causes, is a vital part of managing this risk. The need for effective and clear communications is covered within the Trust induction programmes.

13.16 The majority of reported incidents relate to poor communications between staff (see figure 13).There has been a small increase in the number of reported communication incidents, there were 71 reported in 2005/06 and 98 in 2006/07. These tended to be instances were it was felt that there was inadequate communication regarding the movement of patients and a lack of clinical information passed on at shift handover. The Directorates of Medical Specialities, Community & Therapies and Women & Children’s services have the higher proportion of communication incidents and these are reported and actions monitored through their Risk Management committees.

13.17 Risk Management training sessions make reference to the importance of communication particularly when this has a bearing on direct patient care.

Incidents by Directorate and Sub category

staff>staff staff>patient

staff>relative

staff > external agency

patient > staff

relative > staff

external agency >

staff

Patient Attitude / Refusal

of Treatme

nt

Employee Records

Breach of

Confidentiality

Total

ACC 3 0 0 0 0 0 0 0 0 0 3CT 8 1 1 0 1 0 1 1 0 4 17FP 1 0 0 0 0 0 0 2 1 1 5IM 13 1 0 0 1 1 0 0 1 1 18MHS 1 0 0 1 1 1 2 1 0 0 7Path 0 0 0 0 0 0 0 0 0 1 1HR OPS 3 0 0 0 1 0 0 0 0 1 5R&E 2 0 0 0 0 0 0 1 0 1 4SS 1 2 0 1 0 0 1 1 0 2 8WCH 13 7 1 1 3 0 0 5 0 0 30Totals: 45 11 2 3 7 2 4 11 2 11 98

Figure 13 Communication

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Health and Safety Incidents

Health and Safety by Category Comparison 2005/6 - 2006/7

0

50

100

150

200

250

Absco

nding

/ Self

Disc

harge

Allega

tions

mad

e by p

atien

t abo

ut sta

ff mem

ber

Staff c

ontac

t with

objec

t/surf

ace/s

ubsta

nce

COSHH / PPE P

roced

ures

Estates

Staff F

alls

Fire

Staff Il

l Hea

lth at

Work

Manua

l Han

dling

Moving

and H

andli

ng (N

ot Man

ual H

andli

ng)

Policy

/ Proc

edure

Non

-Com

plian

ce

Road T

raffic

Acc

ident

/ Acc

identa

l Veh

icle D

amag

e

Securi

ty

Clinica

l - Nee

dle/S

harps

Non-C

linica

l Sha

rps

2005/062006/07

Figure 14 H&S by Category

13.18 Figure 14 shows the distribution of Incidents recorded as Health & Safety related. Of note, incidents of absconding/self discharge have increased from the 2005/6 period. Security incidents show a slight decrease with majority of incidents occurring at the Princess of Wales and Neath Port Talbot hospital sites. There has been a slight increase in the number of non clinical sharps incidents reported however there has also been a decrease in the number of clinical needlestick/sharps injuries.

Security Incidents 13.19 Security incidents have continued to reduced from 339 in 2004/5 to 194 in 2005/6 to 175

in 2006/7. Thefts and Malicious Damage accounted for 25% of the total security incidents which is a reduction of 6% from the previous year. CCTV surveillance at POWH is unable to cover all areas at one time but the operation of the system and potential improvements are under review.

13.20 Individual security incidents are reviewed within Directorates to identify control actions that need to be implemented. The Princess of Wales Hospital and Neath Port Talbot Hospital also consider security incidents in detail though their Health & Safety Committees.

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Security Incidents by Category Top 10 2006/7

0

5

10

15

20

25

30

35

Burglary / Theft / Breaking &

Entering

Illicit Drugs /Alcohol

UnauthorisedAccess /

Trespassing

Security DoorAccess

Criminal /MaliciousDamage /Vandalism

Loss of PatientProperty

MaliciousVehicle Theft /

Damage

Loss ofProperty (NON

patient)

Possession ofa Restricted

Item

SuspiciousBehaviour

Figure 15 Security incidents by Type

Clinical Sharps Injuries 13.21 Clinical sharps injuries increased to 74 in 2004/5 and again to 77 in 2005/6. However the

number of reported incidents began to decrease and in 2006/7 a total of 71 incidents were reported.

13.22 The Infection Control Team increased in size during 2006/7 and the reduction in related incident reports relating to clinical sharps indicates improvements resulting from the measures implemented by the Infection Control Team in further training of staff in correct disposal of clinical sharps.

Sharps Incidents by Category Comparison 2005/6 - 2006/7

0

10

20

30

40

50

60

Needlestick -clean / unused

Needlestick -dirty / used

Blade - clean /unused

Blade - dirty /used

Incorrectdisposal of

sharps

Clinicalequipment

Butterfly Clipsor needle -dirty/used

2005/06

2006/07

Figure 16 Sharps Incidents by Category

Violence and Aggression Incidents 13.23 Analysis of expected/controlled behaviour such as those from the mental health and

learning disability services is differentiated between reported incidents resulting from

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people without a medical condition associated with violence. Figure 17 shows violence and aggression by Directorate and category not associated with the person’s mental condition.

13.24 The greatest concentration of violence and aggression (not related to the patient’s mental condition) occurred in the Directorate of Medical Specialities, with 87 reported incidents. Many of these incidents are generated through the Emergency Department, 5 but there is also an increase in the number of reported incidents within the medical wards. The implementation of the All Wales Violence & Aggression training continues to support all Trust staff in dealing with these situations.

0

10 20 30 40 50 60 70 80 90

V & A by Category & Directorate Not Related to Pt's Mental Condition

Verbal assault 1 15 2 2 40 4 1 6 2 19 18 Unexpected Death 0 0 0 0 0 1 0 0 0 0 0 Threatening Behaviour / Intimidation 0 7 0 0 15 4 0 1 0 1 5 Sexual assault / harassment 0 2 0 0 0 0 0 0 0 0 0 Self - Harm 0 1 0 0 1 0 0 0 0 0 0 Racial Harassment 0 0 0 0 2 0 0 0 1 0 0 Harassment / Bullying 0 0 0 0 2 0 0 0 0 0 0 Physical assault 0 11 0 1 26 2 0 5 0 6 4 Allegations made by patient about staff member 0 0 0 0 1 0 0 0 0 1 1

Anaesthet ics and Critical

Community &

Therapy

Forensic Psychiatry

Learning Disability Service

Integrated Medicine

Mental Health

Multi Directorat

e

Human Resource

s and

Radiology &

Endoscop Surgical

Specialtie s

Women & Children's Services

Figure 17 V&A by Category & Directorate (Not related to patients’ mental condition)

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0

100

200

300

400

500

600

700

V&A by Category &Directorate related to Pt's Mental Condition

Verbal assault 0 8 3 10 40 1 3 1

Unexpected Death 0 0 0 0 10 0 0 0

Threatening Behaviour / Intimidation 0 6 23 20 159 0 3 0

Sexual assault / harassment 0 0 0 0 8 0 0 0

Self - Harm 0 0 18 2 157 0 1 0

Harassment / Bullying 0 0 1 0 0 0 0 0

Physical assault 1 13 166 35 292 0 2 1

Allegations made by patient about staff member 0 0 0 0 1 0 0 0

A & CC C&T LDS MED MHS HR SURG WCH

Figure 18 V&A by Category & Directorate related to patients’ mental condition The table highlights that the Learning Disabilities and Mental Health Directorates have the highest number of incidents for this category.

RIDDOR Notifiable Incidents 13.25 The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995

(RIDDOR) require employers and others to report accidents and some diseases that arise out of or in connection with work. These reports enable the enforcing authorities to identify where and how risks arise and to investigate serious accidents. Awareness of RIDDOR reportable incidents is reinforced during Risk Management and Incident Reporting training.

RIDDOR Notifiable Incidents by Category Comparison 2005/06 - 2006/07

0

2

4

6

8

10

12

14

16

18

Physic

al as

sault

Staff c

ontac

t with

objec

t/sur

face/s

ubsta

nce

Non-M

edica

l / Non

-Clin

ical E

quipm

ent

Staff F

alls

Manua

l Han

dling

Moving

and H

andli

ng (N

ot Man

ual H

andli

ng)

Non-C

linica

l Sha

rps

2005/062006/07

Figure 19 RIDDOR

- 22 -

- 23 -

Reporting of Incidents by Staff Group

13.26 Figure 20, demonstrates the strong culture of reporting within the Nursing and

Midwifery staff group. There is a continuing need to improve the incident reporting culture of all other staff groups.

13.27 Further analysis confirms that the distribution of the reporting group is identical for both clinical and non-clinical incidents.

Staff Group Number Percentage Administration/Clerical 52 1.04% Ancillary/Porters/Security 147 2.95% Bank/Agency Nursing Staff 6 0.12% Medical/Dental 77 1.55% Nursing/Midwifery 4127 82.89% Other 137 2.75% Scientific/Technical 347 6.97% Senior Manager/Executives 3 0.06% Therapists 83 1.67% Totals 4979 100.00%

Figure 20: Incidents Reported by as a percentage and ratio to staff group numbers, 2006/7

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14 CLINICAL NEGLIGENCE AND PERSONAL INJURY CLAIMS

14.1 The numbers of new clinical negligence claims opened in the year was slightly reduced compared to the previous two years, with the number of personal injury claims made against the Trust remaining similar to those received in 2005/2006 and still representing a decline from previous years.

14.2 Taking into consideration settled claims and the claims that are still being managed, Obstetrics claims continue to dominate the Trust’s Clinical Negligence profile in terms of value. However, the difference in this period is less marked, due to no multi-million pound claims settling during the period. This is a trend replicated across Wales, in part due to claims settlements being delayed whilst the Courts consider the law surrounding the correct inflationary index to apply to the element of settlements that reimburse claimants for purchasing care for the remainder of their lives. It is anticipated that the outcome will result in increased costs to defendants, perhaps by even £1million pounds per claim in some instances. The additional financial pressure brought about by such a development will no doubt require Trusts to continue to champion robust risk management and clinical governance in obstetrics and gynaecology, and during this period it is of note that the Women and Child Services committed in this period to introduce formal competency assessments and training log-books for middle grade staff, in advance of the mandatory scheme set down by their Royal College. Other developments in this speciality area can be found at Tables 4 and 4A, including the introduction of 40 hour consultant cover for labour ward and multi-disciplinary handovers which have been of particular success. The numbers of new Trauma & Orthopaedics claims continues to fall, with a high number of claims also being withdrawn or successfully defended during 2006/2007. Generally, in terms of the numbers of new claims seen during this period, Medical Specialities account for the highest number of new claims and Trauma & Orthopaedics continue to demonstrate a downward trend in claims received.

14.3 The personal injury profile continues to be dominated by slips, trips and falls and injury sustained as a result of accidents involving non-clinical equipment. The numbers of claims regarding physical assaults upon staff have decreased. Whilst the number of clinical sharps incidents are generally decreasing (see figure 16 above), the number of new claims received in this period increased slightly. This may be due to the time delay between date of incident and a date that a claim could be lodged, commonly many months later in personal injury categories.

14.4 Full action plans are developed in response to all claims where care delivery or service delivery problems have been identified and approved by the Operational Risk management Group.

14.5 The table below indicates the costs: damages ratio for clinical negligence claims. As highlighted in the previous two annual reports, single multi-million pound settlements can produce artificially favourable ratios in that period, which would be unlikely to be repeated in future years without a similar settlement.

14. 6 In order to counteract the effect of single large payments, it has been necessary to examine and compare historically the ratios pertaining to lower value claims. Tthe majority of claims settled within the Unit are unchanged during 2006/2007 and the approach adopted by Governance Support Unit in relation to its claims handling continues to result in good performance in this area.

14.7 Costs to damages ratios for personal injury claims for 2005/2006 revealed a downturn that has not been repeated in the overall figures for this year. As discussed in 14.3 above, this is likely to be due to the fewer number of higher value claims settling in this year, where costs to damages ratios are traditionally more favourable for defendants.

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14.8 As with clinical negligence claims, in order to mitigate the effect of the decrease in

higher value personal injury settlements in this period, it has been necessary to look at claims where damages were of lower value (for personal injury cases this was set at £15,000 in order to gather sufficient quantities of data for comparison). In this instance, the figures actually show a continued improvement year on year in the ratio of claimants costs to damages and again could be evidence of more proactive claims management and earlier investigation of incidents within the Governance Support Unit restructure. Defence costs as a percentage of damages has remained static, but it is too early to ascertain whether the change in legal service providers will have any impact on this figure as Morgan Cole cases are still in run off. It is not anticiapted that WHLS will have sole conduct of Trust claims until 2008/2009.

14.9 Whilst benchmarking of this ratio data has not yet been possible across Wales, the English National Health Service Litigation Authority’s publish targets against which the Trust figures compare favourably.

14.10 The current Governance Support Unit structure has been in place since October 2005, with the aim of providing a truly integrated approach to handling incidents, complaints and claims and an early, comprehensive investigation into every adverse event. One of the aims of this approach is to decrease delay during the claims process and avoid duplication of work by external solicitors, hopefully minimising the spend on legal costs. Over the last three years, a total of 225 claims have been opened and examined to ascertain whether it is possible to ascertain the effect of prior involvement by the Governance Support Unit. Of the 225 claims opened since April 2004, 97 or 43% had linked or prior complaints.

- 26 -

- 27 -

Of these 225 claims, the percentage of claims that had already concluded by the time of producing this report was similar in those cases where there was a linked complaint and those without (49 and 55% respectively). In examining the outcomes of claims that could not be defended and where damages were paid within those two groups, it was noted that the claimant’s costs to damages ratio for claims where there was a prior complaint was just 26%, compared with 71% in claims where there was no prior complaint. It was also the case that there were a greater number of settlements within the group of claims with prior complaints (as would be expected given their less speculative nature) and that these were of a higher overall value, which is a trend generally associated with favourable costs to damages ratios. However, even when higher claims settlements were removed from the calculations in the prior complaints group, the ratio only increases to 29%, indicating that there are tangible benefits to investigation under the complaints process being pursued and that this is resulting in increased efficiency at later stages of the redress process.

15 COMPLAINTS

15.1 The Trust welcomes the public’s views on the services it provides and openly encourages patients, relatives and carers to share their experiences. The Trust aims to use information received, wherever possible, to learn lessons and share good practice. The Chief Executive sees all formal letters of complaint and reviews and signs all letters of response. The Deputy Chief Executive undertakes this function in his absence.

15.2 Figure 23 shows the numbers of compliments and formal complaints received in the year in comparison with previous years and performance against the 2-day Acknowledgement and 20-day Response targets. Figure 24 shows formal complaints by Subject.

2002 -2003 2003-2004 2004 - 2005 2005 - 2006 2006 - 2007 Number of Compliments/thanks

3582 4568

3215 2500 6941

Number of Formal Complaints

181 192 213 192 215

% Acknowledged within 2 working days

98% 89% 96% 95% 100%

% Responded to within 20 working days

63% 43% 77% 85% 76%

Figure 23: Compliment and Formal Complaints – Numbers and Performance 02/03 03/04 04/05 05/06 Admission/discharge/transfer arrangements

10 0 0 6 10

Aids/appliances/equipment issues 2 2 4 3 3 Bed Management* - 2 2 0 2 Buildings and facilities 4 0 1 0 3 Clinical treatment 83 52 56 63 62 Communication issues 12 27 35 28 38 Delays and cancellations* - 2 15 4 10 Diagnosis* - 34 26 26 26 (Alleged) Discrimination against a patient**

- - 2 0 0

- 28 -

Drug Issues* - 2 2 2 3 Failure to follow procedures 0 1 0 0 0 Injury to patient* - 2 2 1 5 Mortuary/post mortem issues 1 0 1 0 1 Nursing Treatment* - 16 17 5 15 Patient falls* - 4 2 4 2 Patient’s property/expenses 1 1 0 1 0 Personal records 2 4 2 3 0 Policy decisions 0 0 3 2 2 Privacy and dignity 0 0 0 0 0 Staffing issues 36 29 19 10 8 Transport 1 3 0 2 1 Time Delay/Waiting times 24 11 21 20 15 Ward/department/clinic environment

4 0 0 0

0

Confidentiality *** - - - 1 0 Patient Contact with object/surface/substance ***

- - 1 0 0

Infection Control *** - - - 7 6 Miscellaneous *** - - - 2 0 Referrals between services *** - - - 1 0 Sexual Assault *** - - 2 0 0 181 192 213 192 212 Figure 24: Formal Complaints by Subject

• New categories introduced in 2003/4 * • New category introduced in 2004/5 ** • New category introduced in 2005/6 ***

15.3 Examples of the changes introduced in 2006/7 as a result of lessons learnt from resolved complaints include: Training was rolled out across the Trust for all nursing staff relating to the

implementation of ‘Fundamentals of Care’ which highlights the importance of treating people with respect, ensuring dignity and all aspects of daily living and independence.

Improvements to the level of services provided by the Crisis Intervention Team

alongside the Mental Health support organisation, HAFAL.

The refurbishment of the relatives room within ICU which includes improved availability of information for relatives on how communication is planned.

Tailored Customer Care training for Integrated Medicine wards.

An out of hours guide to good clinical governance was developed.

16 MORTALITY RATES LINKED TO PATIENT PROFILES

16.1 This is a compulsory KPI under Welsh Risk Management Standard 1 and Figure 25 shows

the Trust’s position for 2006/7 compared to 2005/6.

16.2 With regard to 'Deaths Within 30 Days of Emergency Procedure', the NPTH casemix is

- 29 -

derived from the acute medical intake rather than a normal surgical intake.

16.3 The Trust's participation in the CHKS Clinical variance Programme will improve the usefulness of mortality data over time by enabling the Trust to examine high and low probability mortality as opposed to just all mortality.

Figure25: Mortality Rates Linked to Patient Profiles - Awaiting tabular information (Source: Directorate of Information Management)

Bro Morgannwg Bridgend Locality

Neath Port Talbot Locality

Death Within 30 days of suffering MI for patients aged 35-74 Total no. of patients admitted with a primary diagnosis of MI 298 180 118

Total no. of in-hospital deaths within 30 days of admission for MI 12 8 4

% In-hospital death following MI 1/4/06 to 31/03/07 4.03% 4.44% 3.39%

% In-hospital death following MI 2005/2006 4.90% 5.26% 4.31%

Bro Morgannwg Bridgend

Locality Neath Port

Talbot Locality Death Within 30 days of Elective Procedure Total no. of patients admitted for elective procedure1 6117 3924 2193

Total no. of in-hospital deaths within 30 days of elective procedure 11 9 2

% In-hospital death following Elective Surgery 1/4/06 to 31/03/07

0.18% 0.23% 0.09%

% In-hospital death following Elective Surgery 2005/2006

0.30% 0.39% 0.14%

7 RATES OF SICKNESS/ABSENCE

17.1 Action continues to be taken to manage staff sickness and absence rates. The Personnel Directorate monitors these figures and provides reports to aid Directorates. There is also ongoing reporting to the Management Executive and Trust Board.

17.2 Figure 26 shows the percentage of Sickness Absence recorded by the Trust compared to Numbers of Reported Incidents in the period 1/4/06 to 31/3/07. As in previous years, the comparison does not evidence any correlation.

0Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8

Figure 26 Percentage of Sickness Absence Compared to Numbers of Reported Incidents, 1/4/06 to 31/3/07

100

200

300

400

500

Month 9 Month 10 Month 11 Month 120.00%

2.00%

4.00%

6.00%

8.00%

10.00%

- 30 -

SicknessIncidents

18. STATUS OF 2004/6 ACTIONS

ACTION PRIORITY

LEAD (S) DUE DATE STATUS

Annual review and approval of RM Policy and Strategy. Include explicit guidance on risk rating.

High GSU, ORMG

Ongoing

Approved. Consideration of guidance/education resources to support improved risk management skills is part of work on RM Training and Education Programme.

Ongoing incremental development of Risk Registers at Directorate and Trust-wide levels

High Directors

Ongoing Ongoing

Define future principles for content of Trust-wide Risk Register, rationalise content and complete implementation of revised process with risk leads to ensure currency and accuracy maintained

High GSU, Risk Leads, ORMG

Ongoing Ongoing

Monitor and report on progress to implement WRMS action plans for 2006/07

High GSU WRMS Task Leads, ORMG

March 07 Progress reviewed as part of 2006/07 audit. Complete.

Implement revised Incident Management and Reporting Policy and Procedure. Ongoing training for staff across the Trust on use of the revised Incident reporting requirements.

High GSU, Management Executive

April 05 Complete.

Develop a strategy and plan to improve the reporting culture amongst medical staff. As part of NPSA Being Open policy

High CG Team GSU

Ongoing Ongoing.

Implement plans to sustain continued compliance with the Welsh Risk Management Standards.

High Task Leads, Exec Leads

March 2007 Completed.

The root causes of incidents, claims and complaints and risk reduction actions to inform risk assessment and prioritisation and be recorded in risk registers. Implementation of actions will be monitored through reviews of

High Directors, Trust-wide risk leads, GSU

Ongoing Ongoing.

- 31 -

the Risk Register at a Directorate level and by the Risk Management Steering Group / Incident Complaints Claims Review Group. Strengthen feeds from Risk /Incidents /Complaints//Litigation to clinical audit programme

High GSU, Clinical Audit Team

Ongoing General Manager of Medical Director’s Department now a member of the Operational Risk Management Group and feeds to clinical audit managed through this forum.

Continue and Progress the delivery of the modular risk management training programme, expanding on current training activity.

High GSU H&S Team, Infection Control Team, Corporate Training Team

March 2006 Ongoing

Monitor national developments in the management of Clinical Negligence litigation and continue to take account of examples of improved practice in claims management.

Medium GSU

Ongoing Ongoing

Consider means to collect data on risk management and mandatory training in advance of ESR implementation.

Medium Corporate Training Team

September 2004 Central recording of mandatory training. Local recording non-mandatory training.

- 32 -

19. ACTIONS 2006/8

ACTION PRIORITY LEAD (S) DUE DATE STATUS Develop and implement a Trust-wide Learning lessons policy and procedure aimed at building on current good practice, standardising requirements where appropriate and enabling robust evidencing of learning. Development of a Trust-wide learning forum to also be considered as part of this work.

High GSU March 07 Ongoing.

Develop a Being Open policy with the strategy and plan to improve the reporting culture amongst medical staff linking to work on the ‘Saving 100,000 lives’ approach.

High CG Team GSU

April 2007 Complete.

Continue active contribution to NPSA ‘Quality and Quantity’ work that is considering incident reporting issues at a national level and appropriate solutions. In line with this work, review the Trust’s incident classifications and types within the Datix system.

High GSU NPSA timetable for completion of this work is awaited.

Ongoing.

Review incident type definitions and classification within the Datix system with the aim of achieving a closer mirroring of NPSA definitions.

High HSU June 2007 Ongoing.

Continue active contribution to Welsh Assembly Government development of an integrated approach to incidents, complaints and claims and design of a Redress ‘scheme’ for Wales.

High GSU Current timetable is for development of a Welsh Measure under the NHS Redress Act by 2008

Ongoing

Review and re-define Complaints subject and sub-subject codes and lessons and actions codes in Datix to enable improved analysis, monitoring and reporting.

High GSU April 2006 Complete.

Undertake a review of investigation and Root Cause Analysis skills requirements and design the means to deliver.

High GSU July 2007 Complete.

Complete review of Risk Management Training and High GSU January 2007 Complete.

- 33 -

Education Programme prospectus and supporting resources. Conduct a review of requirements for reports from the GSU, to support risk management at all levels of the organisation and implement the necessary revisions.

High GSU March 2007 Complete.

Refine Top Risks reporting through the organisation to the Trust Board.

High GSU April 2007 Complete.

Organise a MAPSAF (Patient Safety Tool) workshop for appropriate staff in the Trust, to inform future Risk Management strategy development.

High GSU January 2007 Ongoing.

Audit compliance with Complaints Policy and Procedure and action findings.

High GSU June 2007 Ongoing.

Audit compliance with Incident Policy and Procedure and action findings.

High GSU June 2007 Ongoing.

Assess feasibility of introducing electronic incident reporting.

Medium GSU June 2007 Ongoing.

Develop Business Case for Devolution of Datix system to Directorates.

Medium GSU July 2007 Ongoing.

Assess feasibility of utilising Datix Risk Register functionality, replacing current spreadsheets.

Medium GSU August 2007 Ongoing.

- 34 -

Appendix 8.8 BRO MORGANNWG NHS TRUST

RECORDS MANAGEMENT GROUP

TERMS OF REFERENCE

Role The purpose of the Records Management Group is to oversee the Records Management agenda, ensuring compliance with all relative and associated Trust Strategies and Policies and legislation. The Group will take a proactive role in driving forward progress in terms of the Trust’s strategy and promote effective records management :

– to support patient care and continuity of care; – to support day-to-day business, which underpins delivery of care; – to support evidence based practice; – to support sound administrative and managerial decision-making, as part of the

knowledge-base for NHS services; – to meet legal requirements, including requests under the Freedom of Information Act – to assist medical and other audits; – to support improvements in clinical effectiveness through research and also support

archival functions by taking account of the historical importance of material and the future needs of research.

A record is anything, which contains information (in any media, e.g. paper, microfiche, audio or video tapes, X-ray images, computer database, email, notes, etc), which has been created or gathered as a result of any aspect of the work of NHS employees – including consultants, agency or casual staff. Functions • To ensure the Trust’s compliance with legislative requirements around the Data

Protection Act, the Freedom of Information Act and other mandatory guidance such as Caldicott and WHC (2000)71 For the Record.

• To effectively discharge clinical & corporate governance responsibilities through Records Management processes

• To oversee the planning and implementation of a smooth migration from paper to electronic records and also developments around the single patient record

• To be responsible for the development and review of the Trust’s Records Management Strategy and for providing a regular update on progress to the Management Executive and annually to the Trust Board.

• To direct the implementation of the Records Management Strategy via action plans approved by the Group, and designate Task and Finish Groups to report progress.

• To set standards for the achievement and maintenance of records in terms of their creation, use, content, access, storage, and disposal.

• To oversee the provision of training available to staff on records management issues and make recommendations for action as necessary.

• To approve any subsidiary documents related to records management issues prior to submission to the Management Executive for approval

• To review and monitor the provision of storage facilities for records within the Trust and the application of retention and destruction policies.

• To receive reports regarding the following key performance indicators to the Operational

Risk Management Group and adopt additional KPIs for regular monitoring as deemed appropriate:

o Number and percentage of patient records available within the locally dictated time frame for Elective Admissions, Emergency Admissions, Outpatient Consultations, Audit And Research

o Number and percentage of potential duplicate records o Number and percentage of patients with a traced NHS number as defined (IHC) o Annual audit of record keeping standards o Numbers of claims incidents, complaints

• To receive reports regarding :- o CHKS – Patient Records and Information Accreditation Programme. o Performance in terms of Welsh Risk Management Standard (WRMS) 7. o Performance in terms of Freedom of Information Act. o Outcomes of clinical audit projects examining the content of clinical records and

their entries. o From local designated records managers as to the implementation of good records

management across the organisation. o To act on information submitted to ORMG with regard to learning lessons and

sharing good practice. Reporting Arrangements

• The Records Management Group shall be a sub committee of the Management Executive Committee reporting quarterly.

• The Records Management Group will report annually to the Trust Board. • The Records Management Group will report to the Healthcare Governance

Committee as appropriate. Membership

• Deputy Chief Executive (Chair will alternate between Medical Director and Deputy Chief Executive) • Medical Director or Deputy Medical Director • Director of Information & Improvement • Nurse Director or Deputy Nurse Director • Director of Planning or Deputy Director of Planning • Head of Administration or Deputy Head of Administration • Associate Director of Information • General Manager or Deputy General Manager, Princess of Wales Hospital • General Manager, Medical Director’s Department • Directorate Manager – Community & Therapies • Directorate Manager – Learning Disabilities • Directorate Manager – Mental Health • Project Manager for Health Records • Associate Director of Finance • Information Governance Manager • Trust – wide Health Records Manager (when post established) • Health Records Department representatives* • Mental Health Act Administrator* * when required

Other Representatives will be invited to attend meetings as required. Quorum

Deputy Chief Executive or Medical Director plus 50% of members must be in attendance

Frequency of Meetings To be held quarterly

Review

The Terms of Reference will be reviewed annually.

Reapproved July 2007

: Meeting of the : Trust Board : 7th February 2008 : AGENDUM NO 9

HEALTHCARE GOVERNANCE REPORT 1. HEALTHCARE STANDARDS SELF-ASSESSMENT 2007/08 The Trust is required to undergo its second Healthcare Standards Assessment, which is due for completion and electronic submission to Healthcare Inspectorate Wales (HIW) by 9th May 2008. The membership of the Project Team established to produce the 2006/07 assessment, has been expanded to take on board the specific and general lessons learnt from that first assessment. In addition, the Project Team now reports directly to the Trust’s Operational Risk Management Group (ORMG), which will operate as the Project Assurance Board for the completion of the 2007/8 assessment. The Project Team has developed a Project Plan for managing the assessment and its sign off. The 32 standards and constituent criteria are unchanged for this year’s assessment. Operational and Executive leads have been assigned to each of the Standards, once again. Operational leads for each Standard and its components have been assigned, once again, who are responsible for the collation of the evidence and narrative to support each criterion, for agreement with relevant Executive Leads. This year, strong directorate involvement at all stages is being sought to ensure that all milestones within the plan are delivered and that the submission encompasses greater depth in terms of directorate action and evidence. Both Bro Morgannwg and Swansea NHS Trusts will need to submit the standards assessment separately (as the assessment is based on 2007/08 evidence). However, the Project Teams and operational leads from the Trusts are working jointly, where possible, to maximise the learning from last year’s assessment and feedback and in the development of the 2008/9 Healthcare Standards Improvement Plan (HCSIP) for the new organisation. The Project Teams will jointly work with HIW and the Clinical Governance Support and Development Unit at WAG in the course of the assessment. The timing of the completion and submission of the assessment currently dictates that the newly-formed Trust Board will need to sign off the submission to HIW. The Board is asked to note this information.

: Meeting of the : Trust Board : 7th February 2008 : AGENDUM NO 10

REPORT OF THE NURSE DIRECTOR

1. DIGNITY IN CARE PROGRAMME FOR WALES BRIEFING REPORT The Dignity and Respect in Care Programme for Wales was launched by the Welsh Assembly Government in October 2007. This new initiative aims to have a health and social care system where there is zero tolerance of abuse and disrespect for older people. Attached as Appendix 10.1 is an outline of the programme of action for the Trust that will be a key component of Fundamentals of Care, Healthcare Standards and the NSF for the Older Person Action Plan. The Board is asked to note the report.

Appendix 10.1

DIGNITY IN CARE PROGRAMME FOR WALES - BRIEFING REPORT

1. INTRODUCTION

The Dignity and Respect in Care Programme for Wales was launched by The Welsh Assembly Government in October 2007. This new initiative aims to have a care system where there is zero tolerance of abuse and disrespect for older people. It will be taken forward as a key component of The National Service Framework for Older People and in particular Standards on Person Centered Care and Age Discrimination. Dignity and respect should of course be the normal expectation for everyone irrespective of age, however the focus of the programme initially for older people as the majority of patients and social services clients are over the age of 60 years. [WAG 2007] Dignity is an essential element of quality of life and consists of many overlapping issues involving respect, privacy, autonomy and self worth, however there is evidence to suggest from a number of inspections and reviews that that older people are still not afforded the level of dignity in care they deserve.

2. PROGRAMME OF ACTION It is evident that existing frameworks, statutory standards, good practice documents and formal responsibilities have already done much to put into place what is needed to support effective delivery of care, but still the experience of some service users demonstrates there is a need for further action. A programme of Action has therefore been determined by the Assembly Government to take effect from 1 October 2007. The plan will be fully integrated with the implementation of all key health and social care strategies and policies and be taken forward over a 3 – year timeframe. The main features of the programme are:

2.1 Awareness Raising

A series of Regional Events were held to raise awareness and understanding of key principles and coordinated through NHS Trust Nurse Directors. The aim is that at local level an Action Plan on Dignity and Respect will be drafted.

2.2 Partnership Working The Assembly Government will take forward action, engaging, statutory, voluntary, independent, research and all other professional sectors, with older people and their representatives being firmly involved.

2.3 Inspection and Review As part of Joint Fundamental Review of NSF for Older People, HIW, CSSIW and WAO will undertake joint thematic reviews on Dignity and report best practice and areas for attention.

2.4 Service Development NLIAH and SSIA will be asked to develop action plans for their respective sectors in 2008 and 2009 to support this work.

2.5 Integration at the Strategic Level At national level the work of the Inspectorates and Development Agencies, will encompass this new emphasis on Dignity and local agencies in responding to these initiatives will also do so.

2.6 Resources £ 2,000 has been made available for each Trust to assist in the facilitation of this programme.

3. IMPLEMENTATION PLAN FOR BRO MORGANNWG TRUST

In order to ensure that the Programme of Action on Dignity and Respect in Care is integrated with other initiatives it will be progressed as part of the NSF for Older People and will be facilitated by the Nursing Directorate. The Nurse Director will oversee the programme and the delegated lead within the Trust is the Deputy Nurse Director. The Implementation Plan for this programme is attached, but in summary includes the following:

3.1 Awareness Raising The Deputy Nurse Director has arranged meetings with Directorates, Senior Nursing Staff and other senior general mangers to inform them of the programme. Awareness sessions for all staff groups have been arranged and will take place in February and March across both sites and satellite Hospitals. These will be facilitated by Deputy Nurse Director, Head of Patient Experience and Senior Nurse for Education.

3.2 Partnership Working

A Task and Finish Group has been established which is multi disciplinary and has patient representation to develop standards for the implementation and monitoring of Dignity and respect. The Nurse Director, Executive Lead for the NSF for Older People and the Trust Older Person’s Champion have been briefed on programme and will inform existing forums such as COPAN [Champion for Older People’s Advisory Network].

3.3 Review and Inspection It is essential that this programme clearly links to Health Care Standards, and evidence is collected. Therefore the Clinical Governance Facilitator working in conjunction with the Governance Support Unit, Directorates and Health Care Standards Leads to ensure progress is captured. A meeting has been arranged with Health Inspectorate Wales to ensure Dignity in Care Plan is fit for purpose.

4. CONCLUSION

The programme within the Trust has already commenced with awareness raising amongst key staff. The Task and Finish Group has been established and will commence in February. The programme will be implemented and monitored by the Deputy Nurse Director and a report will be submitted at the end of March for Management Executive and WAG on how the programme is progressing within the Trust.

2

Appendix 10.1

IMPLEMENTATION PLAN

DIGNITY IN CARE PROGRAMME FOR WALES

Objective

Action

Responsibility

Date Actioned

Awareness Raising To raise awareness and understanding of the key principles underpinning Dignity and Respect in Care, amongst all staff groups and at every level within the organisation

1. Trust to delegate a lead for implementation of programme. 2. Delegated lead to meet with Directorate Teams and Senior Managers to discuss Implementation Plan for programme 3. Two hourly Awareness sessions – arranged across sites and satellite hospitals to include programme presentation from programme lead, patient involvement representatives. It will be Multi-disciplinary

Victoria Franklin Nurse Director Christine Lewis Acting Deputy Nurse Director Christine Lewis Acting Deputy Nurse Director Lynne Jones Acting Snr. Nurse Education

December 07 February 08 Commence February 08 Complete April 2008

CL/jp/140108 1

Standards To develop standards for the implementation and monitoring of Dignity and Respect in Care which will ensure basic quality of care is delivered consistently, ensuring patients are key in process.

1. Task & Finish group developed to identify existing standards and to develop new standards around this Fundamentals of Care. 2. Task & Finish Group will be multi-disciplinary and have two pt representatives. 3. Standards for implementation and monitoring will be agreed by Group and ratified by Executive Board.

Christine Lewis Acting Deputy Nurse Director Christine Lewis Acting Deputy Nurse Director and Paul Jones Head of Patient Experience T&F Group/Exec Board

February 08 February 08 June 08

Partnership Working To ensure this programme reflects and links with other initiatives such as ‘Empowering Ward Managers’ and ‘NSF for Older Persons’, ensuring older people and their representatives are involved

1. Nurse Director & Trust Older Person’s Champion briefed on programme. 2. Patient involvement groups informed

Christine Lewis Acting Deputy Nurse Director Christine Lewis Acting Deputy Nurse Director and Paul Jones Head of Patient Experience

January 08 T&F Group set up January 08

CL/jp/140108 2

3. Patient representatives identified and involved in Task & Finish Group to develop standards and identify measurement for this FOC. 4. Standards will reflect NSF for Older Person and link with all FOC

Christine Lewis Acting Deputy Nurse Director and Paul Jones Head of Patient Experience Christine Lewis Acting Deputy Nurse Director

Complete June 08 June 08

Review & Inspection The Dignity in Care Plan Programme itinerary is to ensure relevant Health Care Standards

1. Healthcare Governance Facilitator to work with GSU to ensure the Dignity in Care Plan becomes core evidence for HCS Improvement Plan. 2. Liaise with HIW to ensure Dignity in Care Plan is fit for purpose. 3. Programme Lead to establish close link to appropriate HCS Leads to ensure progress is captured, documented and fed through as evidence

Alyson Charnock Healthcare Governance Facilitator/ Governance Support Unit Alyson Charnock Healthcare Governance Facilitator/ Christine Lewis Acting Deputy Nurse Director Alyson Charnock Healthcare Governance Facilitator/ Christine Lewis Acting Deputy Nurse Director

March 08 February 08 February 08

CL/jp/140108 3

: Meeting of the : Trust Board : 7th February 2008 : AGENDUM NO 11 REPORT OF THE MEDICAL DIRECTOR 1. CONSULTANT CONTRACT – ALL WALES ANNUAL REPORT

2006/07 This report summarises the second set of Trust Consultant Contract Annual Reports, covering the 12 month period to March 2007. Colleagues will recall that the Trust’s Annual Report submission was reported to the Board in August 2007. Colleagues will recall that the key objectives of the Amended Consultant Contract were to: o Improve recruitment and retention o Reduce the culture of long working hours and improve the work life balance of

Consultants o Support the involvement of Consultants in service modernisation o Identify performance standards against which improvements could be measured. The Executive Summary of the All Wales Report for 2006/07 is attached at Appendix 11.1(i). (The full report can be obtained from Malcolm Otter, O D Project Manager, or via the WAG Pay Modernisation Unit’s website at http://www.pmu.wales.nhs.uk). This demonstrates that: o Average Consultant weekly working hours have continued to reduce o The number of Consultants employed in Wales has continued to increase o Consultant vacancies have fallen further, with a good field of candidates for most

advertised posts o Fewer additional sessions (i.e. above contracted levels) are being paid to Consultants

overall o The balance between Direct Clinical Care (DCC) and Supporting Professional

Activities (SPA) has shifted slightly with a small decrease of average DCC and marginal increase in average SPA sessions over the year. Noting the increased number of Consultants, there has been an overall increase of 3% in clinical capacity and 8% in SPA activity since March 2006

o There is evidence from Trusts that changes in service delivery have been linked to, and / or facilitated by the job planning process.

Work on the development of Consultant Outcome Indicators has continued through the year, with comments from Consultant groups included into the revised survey and reports for 2007. The increasing involvement of Specialty Advisory Groups is welcomed. Although there is significant work still to be done, the reports are to be used in all future Consultant job planning and appraisal reviews.

Progress within Bro Morgannwg Trust was broadly consistent with the trends across Wales as a whole in almost all areas. The relative position of the Trust in relation to the All Wales averages is shown at Appendix 11.1(ii). The increased interest shown by Consultant colleagues in the Trust in completing the COMPASS web survey is encouraging. The recommendations of the All Wales Annual Report are attached at Appendix 11.1(iii). These will be considered initially through the Medical Workforce Group as part of the continuing process of developing the job planning, appraisal and related implementation issues. In due course, these will need to be considered jointly with Swansea NHS Trust as part of the amalgamation processes. The Board is asked to note the content of the All Wales Consultant Contract Annual Report for 2006/07. 2. CONSULTANT APPOINTMENTS At recent Advisory Appointment Committees the following appointments were made:

• Dr Paulo Antoniazzi was appointed to the post of Consultant Anaesthetist. • Dr Adam Cookson was appointed to the post of Consultant Chemical Pathologist. • Dr Karthikeyan Chelliah was appointed to the post of Consultant Anaesthetist. • Dr Vijayalakshmi Varadarajan was appointed to the post of Consultant Anaesthetist.

Further details are attached at Appendix 11.2 The Board is asked to note these appointments. 3. DATA PROTECTION AND CONFIDENTIALITY POLICY The attached policy as Appendix 11.3 aims to provide a robust mechanism for ensuring that patient and staff personal data is kept confidential and secure. This policy was re-approved by the Management Executive in January 2008. The Board is asked to ratify the policy.

Appendix 11.1(i)

Consultant Contract All Wales Annual Report 2006/07

Executive Summary The aims of the amended Consultant Contract introduced in December 2003 were to reduce Consultant working hours, improve Consultant recruitment, and engage Consultants in service modernisation. Annual Reports are the second stage in the Assembly’s 3-stage approach to benefits realisation pending Consultant Outcome Indicators (COIs) being able to deliver useful and usable information. This report summarises findings from the second round of Trust Annual Reports, and includes for the first time joint views of Local Negotiating Committees (LNCs) as well as Trusts, and progress on developing COIs. The key findings are as follows:- Average Consultant weekly working hours were 41.5 hours at March 2007, a reduction of 1.4 hours over March 2006, and down from 45.6 hours in December 2003. The number of Consultants employed across Wales was 2,023 at March 2007, an increase of 120 on March 2006, and a rise of 27% since September 2003. Consultant vacancies were running at 3.0% at March 2007, compared with 5.4% in March 2006 and 9.5% in September 2003. Most Trusts report being able to fill most posts with a good field of candidates, and half consider recruitment to have improved in the past year. The vast majority of Consultants have an agreed Job Plan, which had been reviewed in the previous 12 months. LNCs and Trusts consider Consultants to be quite well or very well engaged in the job planning process. Just over 2,500 additional sessions were being paid to Consultants in March 2007, 450 less than in March 2006. Consultants were receiving an average payment of just over 1 additional session for DCC and SPA activity, a reduction of 20% on the previous year. Escalator payments were virtually eliminated by March 2007, with only 16 remaining compared to 530 in March 2006. Otherwise, other than payment of the agreed all-Wales rate for Waiting List Initiative sessions, all Trusts were paying plain time rates for any additional work they required.

The average split between DCC and SPA sessions was 8.2 to 2.4 in March 2007, a decrease of 0.3 DCCs, and a marginal increase in SPAs over the year. The net service delivery effects across Wales, taking account of the increased number of Consultants, were an extra 3% in capacity to undertake DCC activity, and an extra 8% in SPA activity, which in effect is an additional investment in service quality, over March 2006. Trusts are increasingly looking to assess the specific benefits from SPA activity. COIs were launched in September 2005, with the first set of reports shared with Consultants in July 2006. Considerable work was undertaken to take on board Consultant comments about the appropriateness of indicators in many specialties in time for the July 2007 reports. This work has been enhanced by the engagement of national Specialty Advisory Groups. 61% of Consultants participated in the 2007 Consultant On-line Survey, adding considerably to the information contained in reports. The emphasis will now be on addressing clinicians’ concerns about data quality and beginning to use reports in all Consultant job planning or appraisal meetings. Trust 2007 Annual Reports quoted increasing evidence of changes in service delivery and clinical practice at local level which job planning had contributed or facilitated, and that job planning was increasingly embedded. Trust databases showed considerable evidence of changes to job plans in the past year.

Appendix 11.1(ii)

All Wales Consultant Contract Annual Report 2006/07

Statistical Indicators - Relative Position of Bro Morgannwg NHS Trust compared to All Wales Report

All Wales Bro Morgannwg Comments

Range Average Job plans agreed / reviewed 79 – 100% 90% Bro Morgannwg job plans not

completed due to effects of planned service changes still to be resolved

Sessions Change from 2006

Change from 2006

DCC’s 6.6 – 9.1 8.2 -3% 8.6 -4% SPA’s 1.9 – 2.8 2.4 +2% 2.3 +7% Total 10.3 – 11.6 11.1 -2.6% 11.1 -2.6% Hours worked (job plans) 38.6 – 43.7 41.5 -3% 41.6 -3% Paid Additional Sessions 0.2 – 1.5 1.2 -21% 1.2 -6%

Progress in Bro Morgannwg broadly consistent with the trends across Wales

Compass On-line Survey 12 – 93% 61% 57% 56% 34% Increase from 34% in 2006 to 56%, compared to increase in all Wales averaged from 57% to 61%

Vacancy Levels Sept 03 Mar 06 Mar 07 R&R

RatingDifficult to fill Specialties

Bro Morgannwg 18 9 4 2* Learning Disabilities, Psychiatry, Cardiology Wales 178 102 60 2* Range across Wales, but specialties quoted most often are:

Haematology, Histopathology, Community Paediatrics, Psychiatry, Learning Disabilities

* Recruitment and Retention Rating 2 – ‘Ability to fill most posts with a good field of candidates, but difficulties in a few specialties. This is the median rating across Wales, quoted by all except 2 Trusts.

Appendix 11.1(iii)

All Wales Consultant Contract Annual Report – Recommendations To be reported on in Trust’ 2008 Consultant Contract Annual Reports:- Recommendation 1: The key findings of this report to be widely shared with Trusts, Consultants, the BMA, and other key stakeholders;

Recommendation 2: Specific issues arising from Trust Annual Reports to be followed up, fed back, and addressed;

Recommendation 3: Trusts to continue to develop job planning locally, including the further development of COIs; Recommendation 4: Compass reports to be discussed in the next (August 2007 onwards) round of job plan review meetings, at least in terms of their format and to identify any specific concerns the Consultant may have about data quality in their individual report; Recommendation 5: Trusts to be ensure that job planning is embedded in their local service management arrangements, and linked to their overall service modernisation processes, where this is not already the case; Recommendation 6: Trusts to be able to demonstrate evidence of a further reduction in the hours of the Consultants required working week, where these have not already reached their optimal level; Recommendation 7: Any remaining previously unrecognised additional sessions attracting escalator payments to be eliminated by March 2008; Recommendation 8: Trusts to review the benefits from SPA activities as part of the job planning process, and be able to demonstrate evidence for assessing their benefits for both the service and individual Consultants; Recommendation 9: Trusts to confirm arrangements with their audit services to review compliance with their formal Consultant Contract Audit Reports, and for ongoing implementation of the amended contract including establishing service benefits; Recommendation 10: Trusts to identify a further range of specific examples of service improvements related to job planning, and give a range of further examples expected in the following year; Recommendation 11: Trusts to include a joint assessment of the degree of engagement of their clinicians with the job planning process locally with their local Consultant representative body.

Appendix 11.2

APPOINTMENT OF CONSULTANT ANAESTHETIST BRO MORGANNWG NHS TRUST

At an Advisory Appointments Committee held on Thursday 20TH December 2007, Dr Paulo Antoniazzi was appointed to the post of Consultant Anaesthetist. Dr Antoniazzi graduated from the University College, London in 1992 with a BSc in Anatomy with Basic Medical Sciences and went on to gain his MB BS in 1995. He obtained his FRCA in 2004. He went on to obtain his CCT in October 2007. Dr Antoniazzi’s basic medical training commenced in August 1995 as a House Officer in Medicine at Gloucester Royal Infirmary and then a three month placement as a House Officer in Urology at the Whittington Hospital, London and a three month placement within General Surgery at the same hospital. He was appointed as an SHO in A&E at Lister Hospital, Stevenage in August 1996 and he then undertook a 12 month post as an SHO in Anaesthesia at the Tunbridge Wells Hospital, Kent. He moved to the Royal Sussex County Hospital in Brighton where he rotated through Anaesthetics and Intensive Care for 18 months. He then undertook a Staff Grade position in Paediatric Anaesthesia at the same hospital, between August 1999 and September 2000. Between December 2000 and 2001, Dr Antoniazzi moved to New Zealand as a Registrar in Anaesthetics at Whangarei Hospital and then a 6 month post as a Registrar in Anaesthetics at Green Lane Hospital in Auckland. He returned to the UK in March 2002 for a 6 month placement as an SpR in Anaesthetics at West Wales General Hospital in Carmarthen. He then returned to the University Hospital of Wales between September 2002 and March 2004. Between March 2004 and March 2005 he worked as an SpR in Anaesthetics at Morriston Hospital and then between March 2005 and January 2006 at the Princess of Wales Hospital. Dr Antoniazzi elected to undertake an Off-Rotation Training (ORT) project and took up the position of Provisional Fellow & Associate Lecturer in Anaesthesia at the Royal Brisbane & Women’s Hospital (RBWH) Australia from January 2006 until January 2007. Dr Antoniazzi returned to the UK in January 2007 and currently works as a Specialist Registrar in Anaesthesia at the University Hospital of Wales where he has been employed since February 2007. He gained his CCT in August 2007. He will commence employment with Bro Morgannwg NHS Trust in April 2007.

Appendix 11.2

APPOINTMENT OF CONSULTANT CHEMICAL PATHOLOGIST- BRO MORGANNWG NHS TRUST

At an Advisory Appointments Committee held on Monday 10th December 2007, Dr Adam Cookson was appointed to the post of Consultant Chemical Pathologist. Dr Cookson graduated from University of St. Andrews with an Honours Degree in Physiology in 1990 and then went on to gain his MB Bch in Biochemistry & Psychology from University of Wales College of Medicine in 1995. Dr Cookson took up the post of House Officer at East Glamorgan General Hospital from August 1995 until February 1996, followed by House Officer in Surgery at Glan Clwyd Hospital, Rhyl from February 1996 until August 1996. He then undertook the post of SHO in Nephrology at University Hospital Cardiff from August 1996 to February 1997. From February 1997 until August 1999 he undertook the post of SHO in General Medicine at Morriston Hospital, Swansea rotating through the specialties of Nephrology, Neurology, Haematology and Cardiology. Dr Cookson undertook a 12 month post as Senior SHO in General Medicine at Royal Glamorgan Hospital from August 1999 to August 2000. He commenced as an SHO in Haematology at the University Hospital Wales Cardiff from August 2000 until December 2000, followed by a post as an SHO in General Medicine specialising in Stroke Unit/Care of the Elderly/General Medicine from December 2000 to August 2001 before undertaking an SHO post in Medical Biochemistry from August 2001 until December 2001. Dr Cookson was subsequently appointed as a Specialist Registrar in Chemical Pathology and Metabolic Medicine at the University Hospital of Wales on 18th December 2001. This has provided direct laboratory and clinical experience of Chemical Pathology. Dr Cookson will commence as a Consultant Chemical Pathologist at Bro Morgannwg NHS Trust from March 2008.

Appendix 11.2

APPOINTMENT OF CONSULTANT ANAESTHETIST BRO MORGANNWG NHS TRUST

At an Advisory Appointments Committee held on Thursday 20th December 2007, Dr Karthikeyan Chelliah was appointed to the post of Consultant Anaesthetist. Dr Chelliah graduated from the Madurai University India in 1990 with an MBBS and gained a Diploma in Anaesthesia from Madras University India in February 1994. He obtained his FFARCI from the Royal College of Anaesthetists, RCSI Dublin in September 2003. His CCT is due in March 2008. Dr Chelliah’s basic medical training commenced in Madras, India in October 1995, as a Registrar in Anaesthetics at Stanley Medical College until May 1996. Dr Chelliah moved to the UK in October 1996 where he undertook a post as an SHO in Anaesthesia for North Middlesex University Hospital Trust until March 1998. He then took up a post as SHO (Anaesthetics) for Royal Wolverhampton Hospitals NHS Trust at Newcross Hospital from March 1998 until June 1999 followed by a 12 month post as a Senior SHO at George Elliot Hospital, Nuneaton until May 2000. From May 2000 Dr Chelliah commenced as a SpR rotating between the City Hospital, Birmingham, Worcestershire Royal Hospital, Queen Elizabeth Hospital & Selly Oak Hospital Birmingham until May 2001. He then undertook a Staff Grade Doctor post at the County Hospital, Hereford until September 2004. Dr Chelliah recommenced as a Specialist Registrar in May 2004 rotating through the Royal Gwent Hospital, University Hospital of Wales, Princess of Wales Hospital and Morriston Hospital until March 2007. He then undertook the post of Specialist Registrar/Research Associate in Preoperative Assessment and CPX Testing for Cardiff University, based at the University Hospital, a post which he holds to date. He will commence employment with Bro Morgannwg NHS Trust in April 2008.

Appendix 11.2

APPOINTMENT OF CONSULTANT ANAESTHETIST BRO MORGANNWG NHS TRUST

At an Advisory Appointments Committee held on Thursday 20th December 2007, Dr Vijayalakshmi Varadarajan was appointed to the post of Consultant Anaesthetist. Dr Varadarajan graduated from Pune University India in 1993 with an MBBS and obtained her FRCA from The London College of Anaesthetists, in December 2002. Her CCT is due in February 2008. Dr Varadarajan’s basic medical training commenced June 1993 as a House Officer in Anaesthetics at Pune Medical College, India until July 1994, this was followed by 12 months as a SHO on rotation in Anaesthetics & General Surgery at Nanavati Hospital & Research Centre, Mumbai until November 1995. Dr Varadarajan moved to the UK where she took up a Clinical Attachment post in Anaesthesia at Cardiff Royal Infirmary from August 1997 until December 1997. She then took up a post as SHO (Anaesthetics) at Cardiff Royal Infirmary from February 1998 until December 1998, followed by a post as an SHO on rotation at South Trent School of Anaesthesia, Leicester Royal Infirmary from October 1998 until December 2000. In January 2001 Dr Varadarjan commenced an SpR rotation commencing at Glan Clwyd Hospital where she worked until June 2002. She then moved to the University Hospital of Wales in July 2002 until December 2002. Dr Varadarajan was out of programme for six months from January 2003 to June 2003 and then returned to the training programme in July 2003, once again at the University Hospital of Wales, where she remained until May 2006. During her time at University Hospital of Wales she undertook a six month placement as a flexible trainee as a Research Associate in Neuro-Vascular. In June 2006 she rotated to the Princess of Wales Hospital until February 2007 and then returned for a final placement at the university Hospital of Wales between March and October 2007. Dr Varadarajan currently works as a Locum Consultant Anaesthetist at the University Hospital of Wales where she has been employed since November 2007, her job involves sessions at both University Hospital of Wales and Llandough Hospital. She will commence employment with Bro Morgannwg NHS Trust in April 2008.

Originator: Medical Director’s Department Date Approved: 23rd January 2008 Approved by: Management Executive Date for Review: 23rd January 2011 Policy ID: 531

DATA PROTECTION AND CONFIDENTIALITY POLICY “This document can be made available in alternative formats or other languages, on request, as is reasonably practicable to do so”.

Appendix 11.3

CONTENTS Page No. 1 Policy Objectives 3 2 Introduction 3 - 4 3 Definitions 4 - 5 4 Compliance 5 5 Additional Responsibilities 5 - 6 6 Protecting patient identifiable information 6 - 7

7 Incident reporting 7 8 Informing patients effectively 7 - 10 9 Disclosing information with appropriate care 10 -11 10 Procedural guidelines for disclosing patient 11-15

identifiable information

11 Sharing patient identifiable information: 15-16 Information sharing protocols

Appendix 1

Related procedural guidelines and Standards 17 Appendix 2

Contacts for further information 18 Appendix 3

Caldicott Principles 19 Appendix 4

Summary of Legislation 20-23

Appendix 5 Police request form 24

Appendix 11.3

This policy should be read in conjunction with the Professional Codes of Practice, IT Security Policy, Consent to treatment or examination policy, WRMS 7: Records Management, WHC (2003) 50: Guidance on protocols for sharing information, Wales Accord for Sharing Personal Information, Media Strategy, Child Protection Policy and, in the case of Health Records Staff, the Trust’s Procedural Guidelines for Health Records Staff. 1 Policy objectives

The objectives of this policy are to ensure that:

Patient identifiable information is protected from unauthorised access and disclosure

All legal, regulatory and professional requirements are met Patients are fully informed about how the personal information they

provide will be recorded and used. Appropriate information is provided to the correct person, when it is

needed.

2 Introduction Patients entrust us with sensitive and patient identifiable information relating to their health and other matters when they seek treatment. They do so in confidence and they have the legitimate expectation that staff will respect their privacy and act appropriately. In some circumstances patients may lack the capacity to extend this trust but this does not diminish the duty of confidence. The fundamental principle is that a patient’s health records are made by the health service to support the patient’s healthcare. One consequence of this is that information that can identify individual patients must not be used or disclosed for purposes other than healthcare without the individual’s explicit consent, some other legal basis, or where there is a robust public interest or legal justification to do so. Procedural guidelines for disclosure of patient identifiable information can be found in Section 10 of this policy. The Data Protection Act (1998) and associated legislation, compels the NHS to handle patient identifiable information in an appropriate and legal manner. This means ensuring that all patient identifiable information is processed fairly, lawfully and as transparently as

3

Appendix 11.3

possible so that the public understand the reasons for processing their personal information, give their consent for any disclosure and use of that information, gain trust in the way the NHS handles information and understand their rights to access the information held about them. A summary of the relevant legislation is provided in Appendix 4 of this policy. A duty of confidence arises when one person shares information with another (for example, patient to health professional) in circumstances where it is reasonable to expect that the information will be held in confidence. It is a legal obligation derived from common law; a requirement established within professional codes of practice and a requirement within Trust employment contracts linked to disciplinary procedures. The Trust will do all it can to protect the confidentiality and integrity of all the information in its care at all times. Controls exist to regulate access to patient information to minimise the risk of its improper or illegal use.

The Trust is held accountable through clinical governance procedures, for continuously improving confidentiality and security procedures governing access to and storage of personal information. The Healthcare Governance Committee, in conjunction with the Records Management Group, oversees the development of this policy and reports to the Trust Board on matters relating to patient confidentiality.

3 Definitions 3.1 Patient identifiable information

Key identifiable information includes the patient’s name, address, full postcode, date of birth, NHS number and local patient identifiable codes as well as photographs, videos, audio tapes or other images of patients.

3.2 Anonymised information

This is information which does not identify an individual directly, and which cannot reasonably be used to determine identity. Anonymisation requires the removal of all key identifiable information referred to in 4.1 and any other detail or combination of details that might support identification.

Once information is effectively anonymised it is no longer confidential and may be used with relatively few constraints. However, it should be remembered that in some circumstances a patient might be identified directly or indirectly from other information. For example,

4

Appendix 11.3

rare diseases, drug treatments or statistical analyses, which have very small numbers of patients, within a small population, may allow individuals to be identified. Particular care must be taken in these circumstances to limit access and circulation of the information to minimise the likelihood of the patient being identified inadvertently.

4 Compliance Confidentiality is an obligation for all staff. Breach of confidence, inappropriate use of health records or abuse of computer systems may lead to disciplinary measures being taken. It may also bring into question professional registration and could result in legal proceedings.

5 Additional responsibilities

5.1 Caldicott Guardian

The Medical Director is the Caldicott Guardian for the Trust, he is responsible for ensuring that patient confidentiality procedures are maintained, particularly with regard to ensuring that when patient identifiable information is shared, the six Caldicott Principles are adhered to (Appendix 3). The Caldicott Guardian function is devolved to the Information Governance Manager with regard to day-to-day operational matters. The Caldicott Guardian’s approval must be obtained before any patient identifiable information is disclosed to a third party “in the public interest”. (See section 10)

5.2 Head of IT Security The Head of IT Security has overall responsibility for monitoring IT security across the organisation. In addition, he is responsible for ensuring that all systems that hold personal information, have a System Security Policy (SSP), and that the documents are up to date.

5.3 Managers 5.3.1 All Managers must maintain an awareness of standards and procedures

relating to confidentiality of personal information.

5.3.2 Managers must ensure that an ‘Application for New IT User Account’ form is completed for each member of staff.

5.3.3 Managers must ensure that all job descriptions include the standard

confidentiality clause.

5

Appendix 11.3

5.3.4 All staff must be made aware by their managers of the legal requirements relating to confidentiality of personal information, which must be met.

5.3.5 Managers must ensure that all staff are appropriately trained in the use

of all records management systems relevant to their job.

5.3.6 Managers are responsible for ensuring that the relevant staff passwords to access electronic records systems are immediately disabled if a member of staff leaves the Trust’s employment.

6 Protecting patient identifiable information 6.1 Keeping patient identifiable information physically secure 6.1.1 Staff working with patient identifiable information must exercise all

reasonable precautions in their working environment to protect that information from unauthorised access, misuse, damage or theft. They must comply with existing security procedures so that access to these areas is restricted to authorised staff where possible, for example, access to Health Records Libraries is restricted to authorised Health Records staff only.

6.1.2 Care must be taken to ensure that manual health records not filed in

their usual filing system are formally booked out and returned as soon as possible after use. When not in file, manual records should be stored closed, in a secure location within the clinical area or office so that the contents are not seen accidentally.

6.1.3 In general patient records/information should not be taken off Trust

premises. However, it is recognised that it will be necessary to take patient identifiable information on domiciliary or treatment visits outside the Trust at times. For some staff this will be part of their everyday practice due to the nature of the service they provide. In these circumstances, it is the health care professional’s personal responsibility to ensure that the security of this information is not compromised in any way. Portable computers, disks, CDs, and any paper-based records must not be left in unattended vehicles or in easily accessible areas at any time. Ideally, all files and portable computers should be kept under lock and key when not in use. Secure boxes or sealed envelopes should be used to transport manual health records.

6.1.4 All correspondence containing personal information must be addressed

to a named recipient. This means that personal information must be addressed to a named individual or designated post holder.

6

Appendix 11.3

Internal mail containing personal information should be sent in a sealed envelope and marked “Confidential”. External mail should be sent as above and by Recorded Delivery or Courier.

6.1.5 Disposal of confidential material. All paper material containing confidential and/or personal data must be disposed of appropriately i.e. by shredding or depositing in confidential waste sacks or confidential waste bins. 6.2 Keeping patient identifiable information electronically secure

Access to the Trust’s Patient Administration System (PAS), Patient Information Management System (PIMS) and all other computer systems that hold patient identifiable information, is restricted to authorised users only. In line with the requirements of the IT Security Policy, all staff must complete an “Application for New user Account” form before they are allowed access to the appropriate computer systems necessary to their role. All users are allocated unique passwords to access these systems and are personally responsible and accountable for the usage of their passwords. The IT Security Policy details the responsibilities of staff in relation to security of information held on the Trust’s computer systems. All staff who use these systems must comply with the requirements of that policy.

6.2 Controls relating to suppliers The Trust Manager responsible will ensure that the following items are addressed with any suppliers:

Responsibilities with respect to legal matters such as Data Protection Act (1998) legislation.

Restrictions on the copying and disclosure of information. Measures to ensure the return or destruction of information and

other assets at the end of the contract. Any physical protection measures required. Mechanisms to ensure security measures are followed. Physical access to offices or buildings as required. Arrangements for reporting and investigating security incidents. Arrangements for the destruction of confidential waste.

7 Incident reporting 7.1 Actual breaches of confidentiality, or risks of potential breaches, must

be notified to the Line Manager as soon as they occur. An incident form must be completed and forwarded to the Governance Support Unit in line with the Trust’s Incident Reporting Procedure.

7

Appendix 11.3

7.2 The Caldicott Guardian will be informed, by the Governance Support

Unit, of all incidents related to breaches of confidentiality so that he can ensure that an investigation is carried out and lessons learned to prevent a recurrence.

7.3 In addition, serious breaches of confidentiality occurring out of normal

working hours should be reported to the on-call Manager who will contact the Caldicott Guardian at the earliest opportunity.

8 Informing patients effectively

Patients must be made aware that the information they give may be recorded, may be shared in order to provide them with care, and may be used to support local clinical audit work to monitor the quality of care provided. It is important that patients are given reassurance that their information will be treated in strictest confidence at all times by all Trust staff who need access to it.

8.1 Be familiar with the information provided to patients In order to inform patients properly, staff must themselves be familiar with the content of patient information leaflets, posters and other materials, which deal with confidentiality and the way information is used and shared.

. 8.2 Check patients’ understanding

Staff must check that patients have had the opportunity to read and understand the information provided, ask any questions they may have and know who to contact for further advice*. It is important to recognise the different communication needs of patients. Difficulty in communicating for whatever reason, such as disability, illiteracy, cultural issues or language difficulties, does not remove the obligation to help people understand. *The Medical Director, as Trust Caldicott Guardian, is designated as the point of contact enquiries about confidentiality.

8.3 Make it clear when information is being recorded or accessed.

Patients must be made aware that information is being recorded or health records accessed. This may require no more than a comment such as “Let me make a note of that in your file” and will generally occur naturally as part of the interaction with the patient.

8.4 Make it clear when information is being disclosed or when it

may be disclosed to others

8

Appendix 11.3

It must be recognised that patients may know little about the NHS and other agencies such as social services and how they work together on a day to day basis. Staff must ensure that patients know when information is disclosed to be used more widely, and how this affects their care. There are certain Acts of Parliament that require disclosure of patient identifiable information. Court orders may also require disclosure. Even though the patient cannot prevent disclosure in these cases, they must normally be informed that this is taking place.

8.5 Check that patients are aware of the choices available in

respect of how their information may be used or shared. Patients have the right to choose whether or not to agree (consent) to information that they have provided in confidence being used or shared beyond what they understood to be the case when they provided the information, unless there is legal justification or robust public interest basis to do so. In some cases, it may not be possible to restrict information disclosure without compromising care. This would require careful discussion with the patient, but ultimately the patient’s choice must be respected. Where patients insist on restricting how information may be used or shared in ways which compromise the health service’s ability to provide them with high quality care, this should be documented in the patient’s record. It should be made clear to the patients that they are able to change their mind at a later stage.

8.6 Use of information for teaching purposes

Ideally, anonymised information should be used for teaching purposes but, if the use of patient identifiable information is unavoidable, explicit consent must be obtained from the patient or their parent or guardian. It must be emphasised that this principle applies equally to paper-based health records, electronic records, recordings and images.

8.7 Sensitive information If it is clear that the information being recorded is particularly sensitive to the patient concerned, staff should be explicit about what is being recorded and ask the patient directly if they are happy for that information to be shared.

8.8 Children and young people Young people aged 16 or 17 are presumed to be competent for the purposes of consent to treatment and are therefore entitled to the same duty of confidentiality as adults. Children under the age of 16 who have the capacity and understanding to take decisions about their

9

Appendix 11.3

own treatment (“Gillick competent” children) are also entitled to make decisions about the use and disclosure of information they have provided in confidence. (They may be receiving treatment which they do not want their parents to know about). However, where a competent young person or child is refusing treatment for a life threatening condition, the duty of care would require confidentiality to be breached to the extent of informing those with parental responsibility. In other cases, consent to disclose or share patient identifiable information should be sought from a person with parental responsibility for the child.

8.9 Where patients are unable to give their consent If a patient is unable to give their consent or communicate a decision due to their physical or mental condition, the health professionals concerned must take decisions about the use of information. This needs to take the patient’s best interests and any previously expressed wishes into account. Each situation must be judged on its merits. A record of the patient’s incapacity to give their consent must be made in the health record. Only as much information as needed to support their care should be disclosed. In cases where the patient is thought to lack capacity reference must be made to the Mental Capacity Act 2005 – Code of Practice

9 Disclosing information with appropriate care 9.1 Identify enquirers

Staff should check that any callers, by telephone or in person, are who they claim to be. Seek official identification or check identity by calling them back using an independent source for the telephone number. Check also that they have a legitimate right to have access to the information. Blaggers. Blaggers are individuals who are paid to gain personal information about patients or staff from the Trust illegally. If you are not sure of the identity of the individual making the enquiry do not give them information until you have verified their identity.

9.2 Share the minimum information necessary It is important to consider how much information is needed before disclosing it. This must be balanced against the need to provide safe care and the consequences of missing information. Providing the whole casenote is generally unnecessary and may constitute a breach of confidence. The six Caldicott Principles should be followed (Appendix 2).

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Appendix 11.3

9.3 Ensure appropriate standards are applied in respect of e mails, faxes and surface mail. Care must be taken, particularly with confidential clinical information, to ensure that the means of transferring it from one location to another are as secure as they can be.

9.3.1 Patient identifiable information should ideally not be communicated via e mail at all and certainly not to e mail addresses outside the Trust since secure encryption is not available at present.

9.3.2 Any electronic transfer of patient identifiable information, for example

to national audit projects and surveillance projects, must be approved by the Caldicott Guardian and the Head of IT Security and carried out using secure means set up specifically for that purpose.

9.3.3 If patient identifiable information must be faxed to ensure that the

information is received as quickly as possible, staff must confirm that the receiving fax is in a secure location and that receipt of the information will be acknowledged. Information must not be left unattended in a Trust fax machine at any time. (see Policy on Transmission of information by Fax) .

9.3.4 Care must be taken to ensure that any patient identifiable information

sent by surface mail is sealed securely and sent to the correct recipient. For example, staff must ensure that contact details for patients and their GPs are up to date before any correspondence is sent. When using “window envelopes”, letters must be folded in such a way that no information other than the name and address of the recipient is visible in the window.

9.4 Follow any established information sharing protocols

Staff must work within these protocols where they exist. (See 11 below)

10 Procedural guidelines for disclosing patient identifiable information

10.1 Information to patients (Subject Access)

Requests for information under the provision of the Data Protection Act 1998 should be directed to the appropriate Health Records Department where procedural guidelines are in place to facilitate the process.

11

Appendix 11.3

10.2 Information to relatives, carers and others Confidential information should only be discussed with relatives or other persons after written consent has been obtained from the patient. If it is not possible to obtain consent due to the incapacity of the patient the information must be given in the patient’s best interest. Staff must emphasise to the recipient that the information is being given in confidence and ensure that this is fully understood. Patient consent or the recipient’s understanding must be recorded appropriately in the patient’s health record.

10.3 Complaints procedure

Staff must obtain the patient’s consent to gain access to their health records in order to investigate a complaint made against the Trust. Access is restricted to the information covering the period the complaint is concerned with. The patient is also required to provide their consent if someone is making a complaint on their behalf.

10.4 Police inquiries Whilst police have no general right of access to health records there are a number of statutes which require disclosure to them and some that permit disclosure (See Appendix 5 (9)). These have the effect of making disclosure a legitimate function in the circumstances they cover. Enquiries from the police should be in writing on Form F339 (see Appendix 6)In the absence of a requirement to disclose information the patient’s express consent or a Court Order (see 9.9) must be obtained unless a robust public interest justification can be established. Staff should seek advice from the Health Records Manager or the Information Governance Manager before releasing any information.

10.5 Common Law and the Public Interest Under common law, staff are permitted to disclose personal information in order to prevent and support detection, investigation and punishment of serious crime and/or to prevent abuse or serious harm to others where they judge, on an individual case basis, that the public good that would be achieved by disclosing the information outweighs the obligation of confidentiality to the individual patient, and the public interest in the provision of a confidential service.

The definitions of “serious crime” and “serious harm” are not entirely clear. Requests for information, which require such judgements to be made, should be referred to the Medical Director.

10.6 Child Protection

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Appendix 11.3

Research and experience has shown that keeping children safe from harm requires professionals and others to share information: about a child’s health and development and exposure to possible harm; about a parent who may need help to, or may not be able to care for a child adequately and safely; and about those who may pose a risk of harm to a child.

Professionals can only work together to safeguard children if there is an exchange of relevant information between them. This has been recognised in principle by the courts. Any disclosure of personal information to others must always, however have regard to both common and statute law.

Normally, personal information should only be disclosed to third parties (including other agencies) with the consent of the subject of that information and wherever possible consent should be obtained. However in some circumstances e.g. suspected Fabricated or Induced Illness, it would undermine the prevention or detection of a crime, consent may not be possible or desirable but the safety and welfare of a child must be the first consideration when making decisions about sharing information.

The law permits the disclosure of confidential information necessary to safeguard a child or children in the public interest: that is, the public interest in child protection may override the public interest in maintaining confidentiality. Disclosure should be justifiable in each case, according to the particular facts of the case, and legal advice should be sought in cases of doubt. (Reference – Safeguarding ChildrenWorking Together under the Children Act (2006) Welsh Assembly Government and the Children Act 2004) Advice regarding confidentiality should also be sought from the Child Protection Team within the Trust or the Information Governance Manager.

10.7 Vulnerable Adults Many of the data protection issues surrounding the disclosure of information in relation to vulnerable adults can be avoided if the informed consent of the individual has been sought and obtained. Consent must be given freely after the alternatives and consequences have been fully explained.

If the information is classified as sensitive, consent to disclose it must be explicit. Particular care must be taken to explain exactly what information may be disclosed and why this is considered necessary.

Informed consent can only be obtained when the vulnerable adult is able to fully understand and participate in the discussion i.e. “has capacity”. Information cannot be disclosed if a vulnerable adult who

13

Appendix 11.3

has capacity refuses to give their consent, as long as there is no risk to others and no crime has been committed.

Where disclosure of information is necessary for the prevention or detection of crime, to protect public safety or to protect the rights and freedoms of others, the law does permit the disclosure of confidential information in the public interest even when informed consent has not been sought or has been sought and refused. Information shared must always be on a need to know basis and always remain pertinent to the specific situation. In these circumstances it is important that it is made clear to the alleged victim, and their relatives/carers where appropriate, that in these cases it is necessary for information to be shared with other agencies, such as the police, due to the potential risk to others. (Reference – South Wales Inter-Agency Policy and Procedures for the Protection of Vulnerable Adults)

10.8 Mental Health Sharing information is often vital in Mental Health Services to provide coordinated Health and Social Care to an individual. Information sharing protocols should provide a framework for the lawful, secure and confidential sharing of information.(see Section 11 of this policy). Local information sharing protocols should clarify the purposes of why and how patient identifiable information is shared and identify the legal basis on which this information is shared, which in turn will help build the good working relationships that lead to trust and effective communication. Unless there are statutory or other (exceptional) overriding reasons for doing so, confidential, person identifiable information should not be disclosed without the informed consent of the individual. There are occasions where there is a legal obligation to disclose personal information (see Appendix 4.9) There are also exceptions to obtaining consent under the provisions of Section 60 of the Health and Social Care Act 2001, ie. in the interest of patients or the wider public good (see Appendix 4.3).

10.9 Medical information for solicitors and insurance companies

In the course of litigation or insurance claim processing, solicitors or insurance companies may request medical information relating to the claim from the patient’s health record. It must be established that the person requesting the information is representing the patient for whom medical information is sought and that the patient has given their signed consent to release the information. Any report must not make reference to a third party unless they have also given their consent for the information to be released. Any such requests are subject to DPA(98) and should be referred to the Governance Support Unit

10.10 Court Orders The courts, some tribunals and persons appointed to hold enquiries have legal powers to require disclosure of confidential information. In

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Appendix 11.3

the event that a patient’s medical details are required in the course of legal proceedings, a court order may be issued to release information . A formally issued court order directed by a judge or other presiding officer is the only instruction that must be obeyed in these cases. Verbal or written requests from lawyers or court officials are not sufficient. All such, requests for release of information will be dealt with by the Governance Support Unit.

10.11 Deceased patients

Disclosure of medical information relating to a deceased patient may only be undertaken where the third party who is to receive the information is proven to be the executor of the deceased’s estate or has taken out letters of administration. Requests from insurance companies for information to process claims will only be fulfilled if they are accompanied by written authority from the executor. Release of information in these circumstances is subject to the requirements of the Access to Health Records Act 1990.

10.12 Release of information to the media Under normal circumstances there will be no basis for disclosure of confidential and identifiable information to the media. However, occasionally Trust staff may be asked for information about individual patients in response to particular circumstances such as following a major incident or where a patient or their relative is publicly complaining about the treatment and care provided.

In accordance with the Trust’s Media Strategy, during normal working hours any such requests must be directed to the General Manager or Head of Administration who will obtain explicit consent from the patient where practicable. Outside these times, requests should be referred to the on-call Manager

11 Sharing patient identifiable information with others: Information sharing protocols

The Caldicott Report “Review of Patient Identifiable Information” raised concerns about the management of NHS records, in respect of all patient-identifiable information which passes between NHS organisations, other than for direct care. The Caldicott Committee established 6 clear principles to be used in the handling of confidential patient information. (Appendix 3) Each NHS organisation has appointed a Caldicott Guardian who is responsible for ensuring that these principles are adhered to.

The principles are the basis of good practice in sharing information between teams and across professional and organisational boundaries.

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Appendix 11.3

They should underpin formal arrangements between organisations where it is necessary to share patient identifiable information in order to provide co-ordinated care for individuals. Such formal arrangements must be documented in the form of an Information Sharing Protocol (ISP) drawn up and approved by the Caldicott Guardian in accordance with the guidance set out in WHC (2003) 50: Guidance on Protocols for Sharing Information which can be accessed on the Welsh Assembly Government website via the HOWIS, and the Wales Accord for Sharing of Personal Information (WASPI). Information on WASPI may be found at: http://www.wales.nhs.uk/sites3/Documents/702/WASPI%5Ftier1%5F%5Flang%3Den.pdf Information cannot be shared under Information Sharing Protocol arrangements unless individuals have given their consent for that information to be shared. Support for developing ISPs is available from the Information Governance Manager, Medical Director’s Department.

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Appendix 11.3

Appendix 1

Related procedural guidelines and Standards

1 Procedural Guidelines The following Procedural Guidelines are provided to support staff in complying with this policy:

• Procedural Guidelines on “Subject Access” under the Data Protection Act 1998 • Security & Confidentiality Of Patient Information • Release of Original Case Notes • Release of Confidential Information • Release of Case Notes / Information to the Police • Release of Medical Notes / Indication of Sensitive Material • Confidentiality of Computerised Patient Information • Transmitting Patient Identifiable Information via Facsimile • Transmitting Patient Identifiable Information via e Mail

2 Standards WRMS 7: Records Management The purpose of this standard is to ensure that the organisation has effective procedures for the compilation, completion, use, storage, retrieval and disposal of records, in place and they are regularly monitored. WRMS 8 Communications The purpose of this standard is to ensure that the healthcare organisation has structures, policies and procedures in place, which will promote good communications both internally and externally to the organisation. CHKS Patient Records & Information Management Accreditation Programme (PRIMAP) The CHKS Healthcare Accreditation and Quality Unit (HAQU) programme provides a quality assurance tool for hospitals by setting out the framework of standards which need to be in place to ensure the capacity to provide a high quality service and to ensure that this is consistently reproducible. HAQU are now responsible for the Patient Records and Information Management Accreditation Programme (PRIMAP), which replaced the Accreditation and Development of Health Records Programme (ADR) managed by CASPE Research, at the end of 2006. The standards have been extensively revised and updated to reflect best practice in healthcare and are designed to help organisations to continually improve the quality of their patient records and information management. Changes and developments in best practice guidance on information managements and confidential handling of patient-related information have influenced changes to the standards.

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Appendix 2

Contacts for further information For further information on issues covered by this policy please contact::

Bruce Ferguson, Medical Director/Caldicott Guardian

Vicki Franklin, Nurse Director

Anne Biffin, General Manager Medical Director’s Department, Trust HQ

Dorian Edwards, Information Governance Manager, Trust HQ

Dawn Davies, Head of Governance Support Unit

Wendy Jones, Head of Administration, Trust HQ

Chris Phillips, Head of IT Security

Jennifer Nagle, Health Records Manager

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Appendix 11.3

Appendix 3

Caldicott Principles Justify the purpose(s).

Every proposed use or transfer of patient-identifiable information within or from an organisation should be clearly defined and scrutinised, with continuing uses regularly reviewed by an appropriate Guardian.

Don’t use patient-identifiable information unless it is absolutely

necessary. Patient-identifiable information items should not be included unless it is essential for the specified purpose(s) of that flow. The need for patients to be identified should be considered at each stage of satisfying the purpose(s).

Use the minimum necessary patient-identifiable information.

Where use of patient-identifiable information is considered to be essential, the inclusion of each individual item of information should be considered and justified so that the minimum amount of identifiable information is transferred or accessible as is necessary for a given function to be carried out.

Access to patient-identifiable information should be on a strict need-

to-know basis. Only those individuals who need access to patient-identifiable information should have access to it, and they should only have access to the information items that they need to see.

Everyone with access to patient-identifiable information should be

aware of their responsibilities.

Action should be taken to ensure that those handling patient-identifiable information – both clinical and non-clinical staff – are made fully aware of their responsibilities and obligations to respect patient confidentiality.

Understand and comply with the law.

Every use of patient-identifiable information must be lawful.

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Appendix 11.3

Appendix 4

Summary of Legislation There are various Acts of Parliament covering disclosure of personal information. Some of these restrict disclosure of information whilst others require or permit disclosure. 1 Data Protection Act 1998 (DPA98) The Data Protection Act applies to all personal identifiable information regardless of how it is collected and stored. It applies equally to electronic and paper records. The Director of Information Management is the nominated Data Protection Officer for Bro Morgannwg NHS Trust. The Act defines personal data as that which relates to a living individual who:

Can be identified from that data or From that data and any other information which is in the possession

of, or likely to come into the possession of a data controller. Data is defined as information which is:

Processed automatically or recorded with the intention to process

automatically or Recorded as, or with the intention that it be, part of a manual

“relevant filing system”. Contained in a health record.

A health record, for the purpose of the Act is one which relates to the physical or mental health of an individual, which has been made by or on behalf of a health professional in connection with the care of that individual and includes all paper and computer records whenever created. The Act sets out these 8 principles must be followed.

First Principle Personal data shall be processed fairly and lawfully and, in particular, shall not be processed unless:-

At least one of the conditions of Schedule 2 is met, and

In the case of sensitive personal data, at least one of the conditions in Schedule 3 is also met

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Appendix 11.3

Second Principle Personal data shall be obtained for only one or more specific and lawful purposes, and shall not be further processed in any manner incompatible with that purpose or those purposes.

Third principle Personal data shall be adequate, relevant, and not excessive in relation to the purpose or purposes for which they are processed.

Fourth Principle Personal data shall be accurate and, where necessary, kept up to date.

Fifth Principle Personal data processed for any purpose or purposes shall not be kept for longer than is necessary for that purpose or purposes.

Sixth Principle Personal data shall be processed in accordance with the rights of data subjects under this Act. Seventh Principle Appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental loss or destruction of, or damage to, personal security.

Eighth Principle Personal data shall not be transferred to a country or territory outside the European Economic Area, unless that country or territory ensures an adequate level of protection for the rights and freedoms of data subjects in relation to the processing of personal data. Further information about the DPA98 can be found at the Information Commissioner’s website www.ico.gov.uk

Since 1st March 2000, the DPA98 has been the route by which personal records such as health records, can accessed by data subjects, (patients in the case of health records), whether they are held in electronic or paper format. This is termed Subject Access. Please refer to Trust Procedural Guidelines for release of Patient Information under the Act for further information. 2. Human Rights Act 1998 (HRA98) Article 8 of the HRA98 establishes a right to “respect for private and family life”. This underlines the duty to protect the privacy of individuals and preserve the confidentiality of their personal records. Current understanding is that compliance with the DPA98 and the common law of confidentiality should satisfy Human Rights requirements.

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Appendix 11.3

3. Health & Social Care Act 2001:Section 60 Section 60 of the Health & Social Care Act 2001 provides a temporary, 12 month exception and allows disclosure and use of confidential patient information in specified circumstances where it is not currently practicable to satisfy the common law confidentiality obligations. This temporary measure will apply only until anonymisation or appropriate recording of consent can be implemented. Information provided to Cancer Registries and the Public Health Laboratory Service are covered by Section 60 in this way. In practice this means that consent does not need to be obtained in these cases but the DPA98 still applies. 4. Freedom of Information Act 2000 The general right of access to recorded information held by public authorities provided by this Act does not apply to patient identifiable data. Under the Act, all personal identifiable information is covered by an “absolute exemption” since it is subject to Data Protection Act (1998) rights.

5. Access to Health Records Act 1990 With the implementation of the Data Protection Act 1998 the only relevance of this Act is in relation to the records of deceased patients. It permits access to the records of deceased patients by their personal representative or those with a claim arising out of the death of the individual concerned. This right of access can be negated if a note to that effect is included within the record prior to death e.g. as part of an advance directive. 6. Access to Medical Reports Act 1988 The aim of this Act is to allow individuals to see medical reports written about them, for the purpose of employment or insurance, by any doctor attending them in a ‘normal’ doctor / patient capacity. This right can be exercised either before or after a report is sent. 7. Public Records Act 1958 When an individual has died, it is unlikely that information relating to them remains legally confidential. However, an ethical obligation to the relatives of the deceased exists and health records of the deceased are public records and governed by the provisions of the Public Records Act 1958 8. Computer Misuse Act 1990 The following are offences under this Act:

Unauthorised access to computer material. Unauthorised access with intent to commit or facilitate commission of

further offences. Unauthorised modification of computer material.

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Appendix 11.3

9. Legally required to disclose Some statutes place a strict requirement on clinicians or other staff to disclose information. Care should be taken to disclose only the information required to comply with and fulfil the purpose of the law. If staff believe that complying with a statutory obligation to disclose information will cause serious harm to the patient or another person they inform the Medical Director’s Department of their concern. Should seek legal advice be deemed necessary, it will be obtained via the Governance Support Unit. The main requirements to disclose are detailed on the DoH website at http://www.doh.gov.ipu/confiden and include:

• Notification of births and deaths • Notification of poisonings etc. under the provision of the Factories Act

1961 and of the Control of Substances Hazardous to Health Regulations 1994 (COSHH)

• Notification under the provisions of the Abortion Act 1967 (as amended)

• Notification of drug addicts under the provisions of the Misuse of Drugs Act 1971

• Notification of infectious diseases • Human Fertilisation and Embryology (Disclosure of Information) Act

1992 • The Abortion Act 1967 • Duty to give information which may lead to the identification of a driver

under section 168 of the Road Traffic Act 1972

10. Legally permitted to disclose Legislation may also create a statutory gateway that allows information to be disclosed by a NHS body where previously it might have been unlawful to do so. This sort of permissive gateway generally stops short of creating a requirement to disclose information so the common law obligations of confidentiality (see 5.1) must still be satisfied, as must the requirements of the Data Protection Act 1998 (see 9.1). An example of such a gateway is Section 115 of the Crime & Disorder Act 1998. Details of current statutory gateways can be found at http://www.doh.gov.ipu/confiden

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Appendix 11.3

Appendix 5

South Wales Police Heddlu De Cymru

THIS REQUEST FOR INFORMATION MUST BE TREATED AS CONFIDENTIAL.

To: _______________________________ _______________________________

Data Protection Act, 1998 – Section 29(3)

I am making enquiries for the purpose(s) of:-

*(a) the prevention or detection of crime

*(b) the apprehension or prosecution of offenders

Nature of enquiry: ____________________________________________________________

The information sought is needed to ______________________________________________

I confirm that the personal data requested are required for that/those purpose(s) and failure to provide the information will, in my view, be likely to prejudice that/those purpose(s). Signed ____________________Rank ________________ Name _________________________________ Date ________________

(Block Capitals)

Countersigned ___________________________________

(not below the rank of Inspector)

* Delete as appropriate

One copy to be submitted to the Data Protection Office, Headquarters for information.

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Appendix 11.3