Agenda Item: Item 21 Report Number: 130/15 Dianthus Building, Wishbone Way, Goldsworth Park, Woking, Surrey GU21 3RT Date 12 January 2015

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1 Agenda Item: Item 21 Report Number: 130/15 Venue: Dianthus Building, Wishbone Way, Goldsworth Park, Woking, Surrey GU21 3RT Date 12 January 2015 North West Surrey CCG Governing Body Title of Report: Prepared by: Presented by: Relative Legislation & Source Documents: Freedom of Information: Corporate Governance Report Prepared by Elaine Stevens Head of Corporate Services and Risk Presented by Yvonne Parish, Director of Corporate Development and Assurance Open This documentation is to note Executive Summary: As part of the CCG Corporate assurance the following updates are presented to the Governing Body to note: Customer Service update Information Governance Freedom of Information Virtual Boardroom Software Governance review Equality and Diversity New Policies Implications: Health Impact: Financial Implications: Legal Implications: Equality & Diversity Communication & Engagement Reputational Implication: Risk Register: None Potential heavy fines for non-compliance To ensure the CCG is working to relevant legislation Patients rights under the NHS Constitution, are adhered to. Not applicable Public engagement is needed as part of this work concerning Customer Service awareness To ensure the local population are confident in the CCG assurance processes 1 Governing Body 12 January 2015

2 Recommendations: The Governing Body is asked to note the report Customer Service The Customer Service function is growing quickly as the local population are using us as a signposting service to other areas of Health and Social Care. A leaflet advertising our service has been distributed to all GP practices and a new section will be included in the soon to be launched, redesigned public facing website. Many of the investigations we get involved with are concerning health service providers within North West Surrey, examples of these are the 111 service, continuing health care funding, how to access IVF treatment, provision of district nursing service, patient transport, counselling provision and other mental health issues. We also receive many calls regarding GP practice and these are passed onto the area team of NHS England. The complaints or issues we receive are always passed onto the appropriate lead organisation managing this service, and we monitor progress of the complaint/issue and ask for a final copy of any investigation to ensure it has been dealt with appropriately. Depending on the issue, this information is passed onto the CCG contract team to be discussed at their monthly provider contract meetings. A more in depth report on activity and learning outcomes has been included the patient experience report being presented at this Governing Body meeting Ombudsman report A complaint (which came in earlier in the year) regarding vitamins and supplements not being available on prescription was escalated to the Public Health Service Ombudsman by the patient. The CCG provided the ombudsman all the evidence relevant to the case and in November 2014 we received a letter from the Ombudsman upholding our decision not to provide particular vitamins and supplements on prescription. The CCG was commended for its process and it was confirmed there was no further action required. Information Governance (IG) The following is an update on various areas of work. IG Toolkit submission: The IG toolkit is due for submission in March 2015 and will be presented to Governing Body at the March meeting for final sign off. The IG action plan is on target, and a meeting was held with the ICT team at the CSU this week to ensure the ICT sections of the toolkit were complete by the 16th January The CCG is working towards Level 3 attainment and is on target to achieve this. 2 Governing Body 12 January 2015

3 IG Policies: Information Governance policies were reviewed in September 2014 and additional guidelines and policies have been written to support third party confidentiality agreements and information sharing protocols. Training: Face to face information governance training has been provided by the CSU. This has given staff an opportunity to discuss any concerns etc. with the subject matter experts. Many staff have completed their training this year in this way, rather than through e-learning. Staff Survey: An IG staff survey is being sent out in the New Year. The results of the survey will be used to support the workplan for 2015 and enable us to target areas of IG that need more awareness, this will also be used as part of the evidence we need for the IG Toolkit. Privacy impact assessments (PIA): Eight privacy impact assessments have been completed to ensure the CCG is compliant with national guidelines. Training and support has been provided by the IG team to ensure PIAs are completed correctly. Information Governance incident: On the 17 th November there was a level 1 incident regarding PCD (personal confidential data) being accepted into the CCG electronically. The incident was investigated and a full report shared with the provider concerned. The incident was kept within the NHS and lessons learnt have already been put in place to ensure this does not happen again. Information Asset Registers: The CSU IG team has been working with staff to ensure all flows of information are recorded and graded. This ensures all information coming in and out of the organisation is managed within the national guidelines. Information data sharing agreements: In order to keep within the law, information data sharing agreements have been signed by the Caldicott Guardian to enable other CCGs and CSUs to use data from NW Surrey. Much of the data goes through the DSCRO: (Data Sharing Commissioning Relationships Office) to be sanitised and anonymised before being passed on to appropriate Business Intelligence teams working across the Surrey Collaborative. Freedom of Information Freedom of Information requests for NW Surrey CCG are managed through South East CSU, but involves many CCG staff providing a response The following is a summary of the quarter 2 report for July to September Qtr /15 Qtr /15 NHS NORTH WEST SURREY FOI REQUESTS The number of requests received has remained steady for the first 2 quarters of the financial year. Targets given within the Freedom of Information Act: 3 Governing Body 12 January 2015

4 The FOI Act 2000 states that applicants should be given a response within 20 working days. Good practice guidance suggests that at least an 85% response should be achieved. The response target achieved by NHS North West Surrey CCG is given below. Response within 20 days: NHS NORTH WEST SURREY Response rate achieved Qtr /15 Qtr /15 98% (63 out of 64 requests) 98% (62 out of 63 requests) Comments It should be noted that only 1 delayed response was responsible for not achieving 100% Of the 63 requests received, 58 of these were round robins where the same request was asked of other CCGs. Whilst most of these round robins were asked of all CCGs, a minority were only interested in a specific area e.g. they were only sent to the Surrey CCGs or SW London CCGs. The following table lists the requests that were specific to NHS North West Surrey. Subject of Request Physical servers (IT) Insurance Contracts Legal claims involving warfarin Vitamin D guidelines Counselling and Psychotherapy Type of Applicant making the request Individual Individual Individual Individual Political Party The following table shows the broad range of FOI s by subject requested. Individual topics have not been given in most cases although the table does reflect the requests received by general subject. Subject of Requests received AQP (Any Qualified Provider) 4 Corporate Information 9 Finance Information 10 Mental health information 5 Prescribing formularies/medicines Management information 4 Primary Care Information 3 Services commissioned 28 Total number 63 4 Governing Body 12 January 2015

5 The following types of groups made the requests received in Quarter 2. Nature of Group making FOI request NHS North West Surrey CCG % Charity/Campaign Groups 9 14% Commercial Organisations 21 33% Individuals 13 21% Media 10 16% Political Parties 3 5% Professional bodies 6 9% Other NHS/Public Authority body 1 1% Total number 63 The Information Commissioner has not informed South East Commissioning Support Unit that any decisions to exempt or withhold information from applicants made to NHS North West Surrey CCG have been referred to his office. The round robin requests take up a significant amount of time, these are now kept as FAQ s and will be used for any future similar requests. Virtual Boardroom Software The CCG has been piloting a web-based board portal used by board members and company secretaries worldwide. Users can access, share and search for organisational documentation from wherever they are, while the automated publishing tool help company secretaries create board packs quickly and simply. Compatible with every tablet computer including Apple I pads, Virtual Boardroom enables all members with a user name and password to access papers for committees and meetings. An internet connection is needed to download the documents, and they can be read and annotated offline just like any other PDF, and with Virtual boardroom's extra layer of PDF encryption security, the documents will be completely safe. A library is also available to store all relevant national and local guidelines, strategies, policies, terms of reference and constitution. Feedback from the trial has proved successful and from January all members of committees will have access to this system to provide a full trial of the system. Once evaluated, the CCG will consider the savings and efficiency of the system before considering purchasing.. The following costs have been given as a guide to manage the 6 main committees 1. Governing Body 2. Clinical Executive 3. Audit and Risk Committee 4. Operational Management Team 5. Quality and Performance Committee 6. Contracts and Finance Committee 250 per committee per quarter = 6000 per annum. 5 Governing Body 12 January 2015

6 There is an option to add sub committees and other meetings to the system at a reduced cost of 500 per year per meeting. This is an all-inclusive price per meeting and includes unlimited usage and users, 24 hour support, initial set-up including training and all system enhancements together with the facility to utilise the free app. In order to work efficiently, and reduce the amount of paper copies at meetings it would mean that staff and members would need the facility of accessing the system through a laptop or I Pad. If using an I Pad there is an app that can be downloaded to enable users to have full facility to annotate etc. The cost of An Apple ipad Air 64GB Wi-Fi Cellular space is DELL Latitude laptop with Office professional Governance Review An interim Company Secretary has been employed to review Governance arrangement across the organisation. Work in progress includes: Reviewing the effective functioning of the Governing Body (GB) and its committees Reviewing the Terms of Reference of the Council of Members and the GB committees Developing an Annual Reporting Plan Developing annual forward plan for the GB and its committees Monitoring compliance with the Standing Orders Monitoring compliance with the Scheme of Reservation and Delegation Ensuring that risk management is robust and the Corporate Risk Register and Assurance Framework provide evidence of controls and assurances that there are no threats to the CCG achieving its strategic/corporate objectives Developing an overarching Standards of Business Conduct Policy, incorporating guidelines on managing Commercial Sponsorship, Gifts and Hospitality and Conflicts of Interest Ensuring that Programme Management Office (PMO) documentation is in line with CCG governance arrangements. Developing an organisation-wide Governance Handbook Preparation for the election of GB members Equality, Diversity and Human Rights progress report This summary gives an update on the work that has been done following the Equality Delivery Service (EDS) assessment and the development of the Equality Objectives In March 2014 a paper was presented to the governing body with the results of the EDS audit that had been undertaken and the proposed Equality Objectives for the organisation. The Equality Objectives included an action plan which has been implemented and the following work has taken place: 6 Governing Body 12 January 2015

7 The Equality and Diversity page on the website has been updated and will continually be added to. Progress on the equality agenda has been included in the annual report for Equality analysis training workshops have been held and to date 12 people have attended the sessions. Further sessions will be organised in Equality analysis has been completed on; The Strategic Commissioning Plan The Quality Strategy The Communications and Engagement Strategy Future strategies requiring an Equality analysis are being identified. As part of the Equality Objectives it was recognised that staff needed to know more about the communities in NW Surrey and so a series of awareness raising workshops were held to help CCG staff and public health colleagues learn and understand more about the communities. Workshops on Carers, Gyspies and Travellers and the Lesbian, Gay, Bisexual and Transgender Community have been held and those who attended reported that the workshops were informative and very useful in increasing their understanding of these communities, their health needs and the challenges they face when accessing health care services. For those who missed the workshops but would like to know more about these communities the presentations are available at N:\Equality and Diversity. An electronic signpost directing staff to further information on each of the protected characteristic groups in the community is also being developed. The EDS summary and grading was presented to the Public and Patient Engagement Forum and we have worked with Healthwatch on an external evaluation of the EDS audit. Healthwatch Surrey agreed that the assessment grading, mostly developing, is a correct reflection of NW CCG's position. The 2015 Work Plan will continue to develop the organisation in this important area. Policies The following policies were presented to the Staff Side Forum for consultation and approved by the Policy Sub Group in November Maternity, Paternity and Adoption Purpose This policy is designed to provide guidance across the organisation for the consistent approach to those intending to take maternity, paternity or adoption leave and promote awareness of their rights and entitlements. Key Changes: Clarifies situation with regard to those on Fixed Term Contracts regarding maternity or adoption pay and return to work. Provides option for outstanding holiday to be paid on return to work if it exceeds 5 day carry over. 7 Governing Body 12 January 2015

8 Provides provision for suspension on pay if following a Risk Assessment no suitable alternative employment is available for the employee or her unborn child Keep in Touch days worked need not be full days to count as KIT days Advises employees where to obtain information regarding Childcare Vouchers Paternity leave regulations to be introduced in Significant detail on eligibility and rules for Ordinary and Additional Paternity Leave. Adoption leave can be requested following 26 weeks service. Reference made to overseas adoption and evidence requirements. Maternity, Paternity and Adoption forms revised. Annual Leave and Special Leave Policy Purpose This policy sets out the principles by which the CCG will ensure a uniform and equitable approach to the calculation of annual leave and general public holiday entitlements. The CCG is committed to helping employees balance the demands of domestic and work responsibilities by the provision of paid and unpaid leave. This policy supports and complements the already approved North West Surrey CCG Adverse Weather and Travel Disruption Guidance. Key Changes: Confirms annual leave is measured in ½ days and for part time staff is recorded in hours. States that it is the responsibility of new employees to provide evidence of their previous service for it to be considered as reckonable for leave purposes. Increases in entitlement take effect from the beginning of the following month. Removes mention of prolonged leave, and requesting of unpaid leave. Up to 5 days may be taken under compassionate leave by agreement with the manager. Specification of Domestic Leave Carers Leave may be granted to those with 26 weeks service. Consideration of IVF leave. Guidance on Adverse Weather Guidance on Sabbatical and employment breaks Guidance on Reserve Forces, Emergency Services, Public/Civic Duties, Witness and Religious Observance. Increases in Parental leave allowance from 13 to 18 weeks and guidance on the application process. 8 Governing Body 12 January 2015

9 Details of how to appeal if a special leave request is rejected Bullying and Harassment at Work Policy Purpose: This policy sets out the principles by which the CCG will promote a working environment in which bullying and harassment are known to be unacceptable and where individuals have the confidence to complain about bullying and harassment should it arise, in the knowledge that their concern will be dealt with appropriately, objectively, quickly, sensitively and fairly. An options paper is attached to this Policy for consideration and response by the Staff Forum. Key Changes: Makes it clear that the CCG s liability may extend to both official business and unofficial social activities as these may be deemed to be an extension of the workplace. Makes it clear that the CCG will investigate any allegations of bullying and harassment regardless of whether the matter has been raised formally or informally. Makes clear that it also includes contractors, agency staff and other non employed staff working at the CCG. Introduces mediation as an option at the informal stage. Flowchart attached. 9 Governing Body 12 January 2015