KINGSTON COMMISSIONING COMMITTEE

KINGSTON COMMISSIONING COMMITTEE Kingston Borough Team LEADS: Tonia Michaelides, Head of Commissioning & Delivery REPORT AUTHOR: Jill Pearse, Head of Governance & Business Support RECOMMENDATION: For discussion & approval ATTACHMENT: AGENDA ITEM: 5 KINGSTON COMMISSIONING COMMITTEE SEMINAR: 7 February 2012 C EXECUTIVE SUMMARY: 2011/12 Quarter 3 Governance Report The purpose of this report is to report on governance issues, compliance with mandatory or statutory requirements, and to flag up areas of risk. It covers the following areas: Equality and Diversity CQC registration Health and safety Whistleblowing Claims Incidents and serious incidents Complaints and PALS Freedom of Information requests Information Governance KEY SECTIONS FOR PARTICULAR NOTE: Care Quality Commission registration: As Kingston PCT is no longer carrying out any regulated activities registration with the CQC is no longer required; the KCC is asked to approve deregistration of services Serious Incidents: NHS Kingston has 3 serious incidents that remain ongoing and are now overdue by more than 6 months. The management of serious incidents by South West London and St. Georges Mental Health Trust has significantly improved. Information Governance: NHS Kingston will be submitting a year end self assessment against the requirements within the Information Governance toolkit. It is currently rated as unsatisfactory and will struggle to achieve a satisfactory rating by 31 st March 2012. Version: Final C - 1

RECOMMENDATIONS: To note the report and To approve the de-registration of NHS Kingston as a provider of services To approve the Terms of Reference for the Kingston Information Governance Steering Group (KIGSG) together with roles and responsibilities. RISKS IDENTIFIED: Information Governance: As above Health and Safety: Currently the Health and Safety function for NHS Kingston at borough level is provided under contract by Your Healthcare, but NHS SW London and the Royal Borough of Kingston also have roles and responsibilities. The key risk is that gaps are not identified or roles duplicated. FINANCIAL IMPLICATIONS: None NATIONAL DOMAINS - TOWARDS AUTHORISATION: All papers to the KCC are assumed to be evidence towards authorisation. Please indicate below all the domains which the paper provides evidence for Clinical focus adding value Patient, carer, community engagement Planning and QIPP delivery Corporate and clinical governance incl. non financial risk management Finance incl. financial risk management Collaborative or joint commissioning, commissioning support Leadership If not, please explain below: EQUALITY IMPACT ASSESSMENT: None PRIVACY IMPACT ASSESSMENT: None no sensitive personally identifiable data was used in the writing of this report. Version: Final C - 2

2011/12 Quarter 3 Governance and Risk Management Report This report covers quarter 3 (October December 2011) and focuses on governance issues, compliance with mandatory or statutory requirements, and to flag up areas of risk. It covers the following areas: Equality and Diversity CQC registration Health and safety Whistleblowing Claims Incidents and serious incidents Complaints and PALS Freedom of Information requests Information Governance EQUALITY AND DIVERSITY NHS Kingston is committed to ensuring equality, diversity, inclusion and human rights are central to the way we commission and deliver healthcare services and how we support our staff. NHS SW London has published the Public Sector Equality Duty (PSED) Report on the cluster website. This incorporates the Kingston PSED report as approved at the last KCC meeting. The Equality Delivery System (EDS) builds on the PSED and has been designed as a tool to support NHS commissioners and providers to deliver better outcomes for patients and communities and better working environments for staff, which are personal, fair and diverse. The EDS applies to people afforded protection, by the Equality Act 2010, from unfavourable treatment because of specified protected characteristics. It is supported by Sir David Nicholson NHS Chief Executive and Chair of NHS Equality & Diversity Council. Within the EDS there are 4 goals each underpinned by a number of outcomes and factors. The 4 goals are: 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership Each organisation needs to assess their level (excelling, achieving, developing or underdeveloped) against each outcome, in consultation with stakeholders including those with protected characteristics. The borough teams are responsible for gathering evidence and coordinating the assessment against Goals 1 and 2; NHS SW London are responsible for doing to same for goals 3 & 4. The protected characteristics are: 1. Age 2. Disability 3. Gender re-assignment 4. Marriage and civil partnership 5. Pregnancy and maternity 6. Race including national identity and ethnicity 7. Religion or belief 8. Sex (that is, is someone female or male) 9. Sexual orientation NHS Kingston, in collaboration with NHS SW London, has been gathering evidence of our current level of achievement against the goals and outcomes identified within the EDS. Stakeholders from protected Version: Final C - 3

characteristic groups have been invited to a workshop in Kingston on 7 th February 2012 when they will consider the proposed assessment of our level of achievement against each of 9 outcomes relating to Goals one and two and identify priority objectives to be addressed in an action plan for 2012/13. A full report will be presented to the next KCC meeting in March 2012. CQC REGISTRATION Your Healthcare, formerly part of NHS Kingston, was created as a mutual co-operative social enterprise on 1st August 2010 to deliver healthcare services to the local community as part of the NHS family. The healthcare services previously provided by NHS Kingston were formally transferred to Your Healthcare but, as a social enterprise it operates under an APMS contract and is not required to register its services, with the exception of Wesley Lodge, until April 2012. As of 16 th December 2011 'Your Healthcare CIC' is now registered by CQC to carry out the regulated activity of 'Accommodation for persons who require nursing or personal care' at one location- Wesley Lodge They may then add further regulated activities as required - for example services under the APMS contract, these are not registerable until April 2012. As Kingston PCT is no longer carrying out any regulated activities registration with CQC is no longer required and the KCC is asked to approve de-registration of services HEALTH AND SAFETY Currently the Health and Safety function for NHS Kingston at borough level is provided under contract by Your Healthcare, but NHS SW London and the Royal Borough of Kingston also have roles and responsibilities. The key risk is that gaps are not identified or roles duplicated. A new NHS SW London cluster Health and Safety Working Group has been established, the aim of which is to provide a forum for staff to raise, discuss and resolve Health and Safety and related issues across NHS South West London, to promote a uniform and streamlined approach to the management of health and safety, ensure best practice is shared and duplication avoided in the management of health and safety. The Health and Safety leads from NHS Kingston and from Your Healthcare are included in the membership of the group. NHS SW London has recently launched a new Health and Safety Policy and this is being reviewed to ensure it is consistent with the current joint policy in place between NHS Kingston and Your Healthcare. WHISTLEBLOWING There were no whistleblowing contacts involving NHSK staff during the third quarter of 2011. CLAIMS From 1 April 2011, NHS SW London - Governance/Risk Management team have taken responsibility for processing and dealing with all existing open claims and any new claims related to the five PCTs. ID Incident date Summary of claim Update (as at end of Jan 2012) Status M11LP 073/00 1 9 Jul 06 Employers liability Back injury sustained whilst lifting a patient Damages agreed - Settled out of court 11/10/11 Closed M11CP 073/00 2 May 2007 Breach of Duty Claimant vs. Kingston Hospital Trust, NHS Kingston & Central Surgery. Trial date expected to be around Mid 2013 Open Delay in diagnosing myeloma Version: Final C - 4

INCIDENTS Cluster reporting arrangements SWL Cluster has approved a revised Incident and Near Miss policy and procedure which was formally agreed by the cluster integrated governance committee, this is available on the NHS South West London website. NHS Kingston 1 incident, as shown in the chart below, was reported for NHSK during the third quarter of 2011. Type Ref Description Action taken Information Governance NHSK31 1011 A laptop belonging to a doctor who works as a GP tutor was stolen from her home. Reported to police and to PCT. Initial assessment completed to verify there was no breach of confidentiality involved. Investigation completed to ensure that there is learning from this incident. SERIOUS INCIDENTS (SIs) Overall Summary Serious incidents (SIs) are reported by individual organisations to NHS London via STEIS and monitored at a cluster level. The chart below shows new SIs by type and organisation as recorded on STEIS during Q3 by organisations for which the Kingston Borough Team has a role. Type of Incident Kingston Hospital NHS Trust Kingston PCT Kingston PCT - Provider SW London & St George's MH Trust Abscond 1 Assault by Inpatient (in receipt) 1 Assault by Outpatient (in receipt) 2 Attempted Suicide by Inpatient (in receipt) 1 Confidential Information Leak 1 1 Homicide by Outpatient (in receipt) 1 Maternity Services - Unexpected admission to neonatal 2 intensive care unit Other 1 Post Mortem 1 Pressure ulcer Grade 3 4 2 Pressure ulcer Grade 4 2 Serious Self Inflicted Injury Inpatient 3 Serious Self Inflicted Injury Outpatient 1 Slips/Trips/Falls 1 Suspected suicide 4 Unexpected Death of Community Patient (in receipt) 1 Unexpected Death of Inpatient (in receipt) 1 Grand Total 8 2 2 19 Version: Final C - 5

The chart below shows the status of on-going serious incidents (as at the end of Q3) reported by organisations for which the Kingston Borough Team has a role. 50 45 40 35 30 25 20 15 10 5 0 Kingston Kingston PCT Hospital NHS Trust Your Healthcare SW London & St George's MH Trust Overdue by > 6 mths Overdue by 3-6 mths Overdue by < 3 mths Submitted (awaiting closure by NHSL) Not yet due NHS Kingston There were two new serious incidents recorded on STEIS for NHS Kingston during Q3, both of these were grade 3-4 pressure sores and have been referred on to the adult safeguarding team. There were 3 incidents carried forward from the previous quarters as shown in the chart below. It is noted that NHS SW London processes require completed reports to be presented to the Management Team at Cluster for discussion and agreement in advance of Joint Boards recommendations, and then sent to NHS London. Suicide Suicide Type of Incident Status Comment Overdue by more than 6 mths. Report completed with Awaiting sign-off action plan in place. Awaiting executive sign off (JH) before submission to NHSL Awaiting sign-off Overdue by more than 6 mths Report completed with action plan in place. Awaiting executive sign off (JH) before submission to NHSL Drug Incident On-going Overdue by more than 6 mths. Pressure Sore Closed Logged on STEIS and closed Pressure Sore Closed Logged on STEIS and closed Your Healthcare Serious incidents are raised and discussed at the YHC quarterly Clinical Quality Review Committee, membership of which includes NHS Kingston Commissioning Manager. Your Healthcare (YHC) reported 2 new incidents in Q3 and had a total of 3 on-going serious incidents at the end the quarter. The report for one of these has been submitted to NHS London and is awaiting feedback or closure. Kingston Hospital Trust Serious incidents are raised and discussed at the KHT monthly Clinical Quality Review Committee, chaired by a Commissioning Manager from the ACU. Version: Final C - 6

8 new incidents were reported in Q3 (11 in Q2) to add to on-going investigations carried forward from previous quarters. 14 cases were closed by NHS London: A total of 19 on-going serious incident investigations were on-going at the end the quarter (25 in Q2). Georges Mental Health Trust (SWL&StG) Serious incidents are discussed at the SWL&StG Clinical Quality Review Committee meetings and separate regular meetings are held specifically to monitor and review SIs. It is noted that the management of Sis has significantly improved over the last 3 quarters. There were 9 SIs overdue at the end of Q3 as compared with 51 at end of Q1 and 20 at the end of Q2. The quality of the reports has also improved; whereas a significant number were returned by NHS London (either because they lacked detail or because there was no evidence of executive sign off) very few are now returned. COMPLAINTS AND PALS NHS Kingston closely monitors the PALs contacts and complaints received from our customers, so that information can used to improve the services that we commission. This process is managed through the PCTs Complaint Policy (available on the PCTs website www.kingstonpct.nhs.uk). Complaints During Q3 the Customer Care Officer received 6 complaints all concerning GP practices this compares to 5 in Q1 and 12 in Q2. A brief description of each is shown in the cart below. Description Patient complaining that GP practice had not known how to treat patient from abroad. Practice had tried to charge for prescription when pt was in possession of EHIC card, Copy of email from patient sent directly to practice. Acknowledged by email, practice asked to provide copy of response. Copy of letter from patient already sent to GP surgery. Complaining of poor service at surgery. Letter from patient dissatisfied her treatment at surgery. Letter from patient giving consent for sister to act on his behalf. Letter describes how patient with learning disability has been treated at GP surgery. GP had branded patient as IV drug user. Complainant wants apology and for GP to undergo training. Consent sought to forward to practice for investigation Email from patient who had difficulty in getting appointment for BCG for baby traveling to South Africa. Patient Advice and Liaison Service (PALS) In Q3 58 PALS contacts were recorded on DATIX and a further 127 calls to the PALS service were received which were either or multiple calls from concerning an ongoing issue, or simple enquiries concerning signposting or directory enquiries etc. The chart below gives an overview of recorded contacts. dental charges Fraud Other Dissatisfied with care Prescriptio ns Registratio n issue Service provision Patient transport Unit Attitude Referals Community Mental Health Team 1 1 2 Dental 4 2 2 8 GP Practices 1 8 5 5 7 4 2 32 NHS Kingston 4 1 1 6 Kingston Hospital 2 1 3 Pharmacy 1 1 Your Healthcare 1 1 (blank) 2 1 1 1 5 Grand Total 2 4 1 19 9 6 8 4 1 4 58 Grand Total Version: Final C - 7

FREEDOM OF INFORMATION REQUESTS With effect from 26th April 2011 all Freedom of Information requests are received, and the final response sent out by NHS SW London. This has added additional steps to the process as NHSK is still required to provide the information for the response and has to maintain duplicate records (Cluster uses a different system that has not yet been rolled out to all the boroughs). A total of 52 FOI requests were received in Q3 (67 in Q2). Responses should be sent out within 20 days of the receipt of the request but the additional steps and reduced resources available at borough level mean that this has been challenging. There were delays both in terms of receiving FOI requests from cluster and in the borough level responses back to cluster. To address these issues it is planned that staff at borough level will be given access to SharePoint in the near future, and a new part-time member of the bank staff started on 17 January 2012 to partially cover an existing vacancy. At the time of writing this report, there were three requests open which had breached the 20 days The chart below shows response times for Q2. INFORMATION GOVERNANCE Kingston is working closely with the Cluster on Information Governance (IG) and there is a South West London framework for IG in place with the Caldicott Guardian and Senior Information Risk Owner (SIRO) roles being at cluster level and cluster level policies under development. However there are some areas where there are considerable differences between the Kingston Borough Team and the rest of the cluster, e.g. IT security. As a result there is agreement that Kingston will complete a separate Information Governance Toolkit submission in March 2012. The Terms of Reference for the Kingston Information Steering Group (KIGSG) together with roles and responsibilities were agreed at the last meeting of the KIGSG and the KCC is asked to approve these as attached (Appendix 1 & 2) The re-configuration of organisations represents many challenges will require considerable input at both at cluster and borough level. There is a high risk that Kingston will not receive an overall satisfactory rating by 31 st March 2011. Version: Final C - 8

The National Information Governance Board (NIGB) recently issued Guidance on Information governance for Transition which includes specific guidance for emerging CCGs. The actions checklist is attached as Appendix 3. Version: Final C - 9

Appendix 1 Terms of Reference Information Governance Steering Group December 2011 Purpose The Kingston Information Governance Steering Group is responsible for ensuring that the Kingston Borough Team, as part of NHS South West London, complies with the legal, ethical and quality standards with regard to obtaining, holding, recording, using and sharing information. It is responsible for ensuring that robust structures, policies, systems and processes are developed and maintained to underpin sound information governance. Key responsibilities of the Information Governance Steering Group To inform the review of management and accountability arrangements for information governance. To develop an IG policy and associated IG implementation strategy and/or maintain the currency of the policy. To prepare the annual information governance assessment for sign off by the Kingston Commissioning Committee. To develop the Information Governance work programme. To ensure that the approach to information handling is communicated to all staff and made available to the public. To coordinate the activities of staff given data protection, confidentiality, security, information quality, records management and Freedom of Information responsibilities. To monitor information handling activities to ensure compliance with law and guidance To ensure that training is made available and taken up by staff as necessary to support their role. Provide a focal point for the resolution and/or discussion of Information Governance issues. To monitor Information Governance toolkit deliverables. Authority & Delegated Powers The Group has the authority to approve Information strategies, policies, assessments, information sharing agreements, reports and action plans prior to formal ratification by the Kingston Commissioning Committee The Group receives its general authority to take decisions from the Kingston Commissioning Committee which will review the group s role authority & delegated powers at least annually. The group has the authority to monitor contractors providing services to the PCT. Accountability Accountable to Kingston Commissioning Committee Reporting Formal report to the Kingston Commissioning Committee annually. Reports, papers, recommendations & action plans etc, as approved by Group, to be sent to Kingston Commissioning Committee for ratification. Minutes of each meeting to forwarded to chair of IGC for information. Permanency Permanent Membership Information Governance Lead (Chair) Head of Governance and Business Support Information Quality Lead - Information Manager IT Security Management Lead (Provided under contract with Your Healthcare): Your Healthcare Board Lead, IT and PMO Version: Final C - 10

Health Records Lead (Provided under contract with Your Healthcare), Lead Business Development, Performance and Assurance Associate Director of Public Health Registration Authority Lead (Provided under contract with Your Healthcare), HR Manager Primary Care Records Management Lead Primary Care lead Governance Support Officer Senior Manager, Finance Freedom of Information & Corporate Records Lead Corporate Affairs Manager Representatives from General Practice: Practice Manager & IT Manager Kingston Hospital Representative - KHT Information Governance Manager Your Healthcare Representative YHC Caldicott Guardian Royal Borough of Kingston Representative, RBK Caldicott Guardian Kingston Collaborative Initiative Representative KCI Service Manager NHS South West London representative Information Governance Manager Members are expected to send deputies if they are unable to attend. Others are welcome to attend meetings at the request of regular group members for relevant agenda items. Chairmanship: Head of Governance and Business Support Quoracy The Group shall be quorate if five or more members are present. One of the five members shall be elected Chair for that meeting if the standing Chairman cannot be present. Frequency of meetings: The Group shall meet at intervals of 6 to 12 weeks. The date of the next meeting(s) shall be agreed whilst the Group is in session. Papers To be sent out electronically at least 3 days in advance and provided in hard copy only when required Openness Policy decisions published on the internet. Minutes to be made available on request Director lead Head of Commissioning and Delivery Management & administration Agenda to be drawn up by Head of Governance in agreement with Director Lead. Agenda items to be forwarded to Head of Governance at least one week in advance of meeting. Agenda & papers to be sent out at least 3 working days prior to meeting. Minutes and meetings to be arranged by the Governance Support Officer. Review of the terms of reference The approved terms of reference shall be reviewed and amended as necessary after one calendar year. Version: Final C - 11

Appendix 2: NHS SW London: Kingston Borough Team Information Governance: Organisation Chart and Roles and Responsibilities (November 2011) SW London Joint Boards SW London Clinical/Integrated Governance Committee SW London Information Governance Steering Group SW London Information Governance Roles Accounting Officer: Anne Radmore, Chief Executive Senior Information Risk Owner (SIRO): Bill Gillespie, Director of Strategy and Performance Caldicott Guardian: David Finch Information Governance Lead: Glyn Jones Registration Authority Manager: Richard Brady Kingston Commissioning Committee Kingston Information Governance Steering Group Kingston Information Governance Roles Information Governance Lead, Data Protection Officer, Information Security Officer & Caldicott contact: Jill Pearse, Head of Governance Freedom of Information Officer & Corporate Records Lead: Jo Dandridge, Business Manager Registration Authority Lead: Nicola Gilbert, HR Manager (Your Healthcare) IT Security Management: Ed Montgomery Board Lead, IT & PMO (Your Healthcare) Information Quality Lead: Brian Roberts, Information Manager Version: Final C - 12

Appendix 3: NIGB Guidance Information Governance for Transition Actions checklist: 1) Map current and new information assets and both internal data flows and transfers of information externally 2) Ensure that you understand the nature and extent of personal data you are responsible for; and your responsibilities as a data controller. 3) Be clear about which organisations are data controllers and which are data processors. 4) Ensure that there are appropriate contractual arrangements with NHS Care providers and those providing NHS funded care 5) Ensure that there is a legal basis for processing both personal and confidential data 6) Maintain oversight and accountability 7) Ensure that all records both health and corporate are managed appropriately particularly for organisations that are closing 8) Ensure secure data transfer 9) New organisations such as Clusters and Clinical commissioning groups must ensure they understand the constraints in which they need to operate during transition in relation to their accountability to PCTs, or SHAs in relation to SHA Clusters, and the need to adhere to Information governance requirements 10) Ensure continuity of service in relation to Registration Authority functions and the administration of Role Based Access Controls, including the independent sector and local authorities. 11) Ensure you inform patients and the public about changes in how services are to be delivered and how their personal and confidential information will be processed and managed 12) Ensure you manage consent and dissent to respect patients choices 13) Use de-identified data for secondary uses or ensure there is a secure legal basis for processing personal data 14) Ensure you manage conflicts of interest effectively Version: Final C - 13