APPENDIX A FREEDOM OF INFORMATION ACT REQUESTS 1 April 2015 to 31 March 2016 No. of Requests No. of Breaches % Compliance 2015 2016 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 23 22 28 33 25 11 22 26 18 22 18 21 0 0 0 3 1 2 1 4 2 1 0 * 91% 96% 82% 95% 85% 89% 95% * No of requests referred to 0 0 0 1 0 0 1 0 0 0 1 0 internal review No of requests received from ICO 0 0 0 0 0 0 0 0 0 1 0 0 *unable to confirm compliance until 20 working days have lapsed since month end ACCESS TO INFORMATION REQUESTS 1 April 2015 to 31 March 2016 Subject Access Requests (DPA = Living) 2015/16 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 10 19 20 30 13 23 25 20 12 8 17 14 Breaches 0 2 2 1 1 0 3 0 0 1 0 * % of requests that took less than 40 days to be processed 3 rd party DPA requests not subject to timescale e.g. Police/coroner 100 89 90 97 92 100 88 100 100 88 100 * 0 6 6 4 7 11 5 10 8 6 13 3 Requests for Deceased (AHRA) 1 1 2 4 9 4 2 2 2 0 3 2 Breaches 1 0 0 0 0 0 0 0 0 0 0 0 % of requests that took less than 40 days to be processed Other AHRA requests not subject to timescale e.g Wales CHC Requests under Medical Reports Act Disclosures in the Public Interest 100 100 100 100 100 100 100 100 100 0 100 100 4 0 0 0 1 3 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ICO Investigations 0 0 0 0 0 0 0 0 0 0 0 0 *unable to confirm compliance until 40 calendar days have lapsed since month end Page 1 of 15
DATIX INCIDENTS Datix Incidents 2015/16 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Number of IG Incidents 6 8 7 7 11 18 15 8 5 6 11 10 reported INFORMATION SHARING PROTOCOLS as at March 2016 Number of Information Sharing Protocols Total Total number of agreements identified 32 Number formally signed off / complete 7 Number no longer required 4 Number still under development/review 21 AUDIT RECOMMENDATIONS Audit Recommendations Total Outstanding ICO Audit 2014 42 15 CPIP Assessment 2014/15 41 10 Internal Audit 2011-12 (DP, Caldicott, Records Management) - 1 WAO Data backup 4 4 WAO Clinical Coding 6 6 INFORMATION GOVERNANCE POLICIES AND PROCEDURES Information Governance Policies Total Total Number of Policies 20 Number in date and complete 8 Number currently outstanding 12. Overdue for review over 3 months 3. Policy review required within 3 months 6. New / identified for future development 3 COMPLAINTS AND LEARNING 2015 2016 No. complaints received by Patient Experience & Concerns Team relating to IG Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 0 0 0 0 0 0 0 0 0 0 0 Page 2 of 15
DATA QUALITY APPENDIX B NHS Number Validity Page 3 of 15
Page 4 of 15
DATA QUALITY - PTHB CODING COMPLIANCE SOURCE NWIS Powys is achieving the 95% and 98% targets for clinical coding. 2014-2014- 2015-01 2015-2015- 2015-2015- 2015-2015- 2015-2015- 2015-11 12 02 03 04 05 06 07 08 09 10 Number of finished consultant episodes (FCE) 396 403 443 401 445 387 430 415 442 388 477 440 Number of FCE with a Valid Primary Diagnosis 396 403 443 401 445 386 429 414 438 372 438 348 Number of FCE Rolling 12 months 4843 4912 4897 4891 4941 4954 4997 5025 5062 5071 5105 5067 Number of FCE with a Valid Primary 4843 4912 4897 4891 4941 4953 4995 5022 5055 5048 5043 4913 Diagnosis Rolling 12 months % of FCE Coded Monthly 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 99.8% 100.0% 99.8% 100.0% 99.8% 99.3% % of FCE Coded Rolling 12 Months 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.9% 99.9% 99.9% 99.9% 99.9% 99.8% Page 5 of 15
Page 6 of 15
ICT - PTHB UNPLANNED DOWNTIME JANUARY 2016 PTHB - January PCC - January APPENDIX C System DATIX Info Dept SQL Servers Date Down time Reason Site Comment Total system up time (this month). System Date Down time Email 29/01/2016 4 hours Lync 18/01/2016 8 hours Reason NWIS hosted email outage. Hyper-V host rebooted unexpecte dly due Windows updates. Site Total system up time (this Comment month). Issue was a 99% national P1 outage effecting both PCC and PTHB. 99% Ascribe X: & Z: Scropio drives Auditbase Internet RIS Intranet Apex CareStream 20/01/20 16 24 hours Fault with VPN tunnel connecting LWH to WVT network. LWH LWH Llandrindod VPN portal 97% AD/LDAP Page 7 of 15
ChildHealth COHORT DBSWIN LWH Llandrindod Trent Civica 18/01/2016 8 hours e-fin/eproc Hyper-V host rebooted unexpecte dly due Windows updates. 99% LYMCALC Draig ICE PATHOLOG Y WIFI VIXWIN GIS Exchange Email 29/01/20 16 4 hours NWIS hosted email outage. Issue was a national P1 outage effecting both PCC and PTHB. 99.46% Follow you printers 18/01/2016 8 hours Hyper-V host rebooted unexpecte dly due Windows updates. 99% File Storage Myrddin Productio n services 08/01/2016 2 hours 14/01/2016 45 mins Issues during server migrations Issues during server migrations Public access planning ilap database (Northgate) 99% 99% Page 8 of 15
ESR Oracle Financials Firewall on BWM site blocking all network traffic into site. Cisco BWM 99% RADIS II firewall 19/01/20 4 hours issues 16 BWM Hospital Radiology HQ Canisc WCCG Internet SQL CACI Hosting HyperV Hosting DPM SCCM Staff plan 18/01/2016 8 hours Hyper-V host rebooted unexpecte dly due Windows updates. 99% Page 9 of 15
PTHB - Problems affecting general network performance and responsiveness January 2016 ISSUE IMPACT RESPONSE UPDATE link overloaded ( utilisation) Slow response from systems hosted on Bronllys. Slow response from Bronllys to national systems. Timeouts for end users. IP Phones unreliable. Order placed to increase bandwidth to 1GBPS. External Consultants advising on network redesign Waiting on Welsh Government Approval. Signed off by Welsh Government Jan 2016 Reconfiguration work on systems to minimise background traffic transferring during office hours Llandrindod link overloaded ( utilisation) Slow response from systems hosted at Llandrindod. Slow response from Llandrindod to remote systems Order placed to increase bandwidth to 100MBPS Work to be completed by 22nd Jan 2016 Cisco Anyconnect - Talk Talk ISP compatability issues PTHB users who use the Talk Talk ISP at home unable to access the nationally provided VPN system. Under investigation by networks and NWIS. Talk Talk unable/unwilling to assist a great deal when approached by users or by our department. Last update was that Steven Nurse was going to do a home visit to a user to see if he could find a work around on router. Page 10 of 15
System ICT - PTHB UNPLANNED DOWNTIME FEBRUARY 2016 PTHB -Febuary Date DATIX Info Dept SQL Servers Ascribe Scropio Down time Reason Site Comment Slow access Slow access Total system up time (this month). System Email Lync Date Down time Reason PCC - Febuary Site Comment Auditbase Internet RIS Intranet Apex VPN portal CareStream X: & Z: drives AD/LDAP Total system up time (this month). ChildHealth Slow access Trent Page 11 of 15
COHORT Civica DBSWIN e-fin/eproc LYMCALC Draig ICE WIFI PATHOLOGY VIXWIN GIS Slow access Exchange Follow you Email printers Slow access File Storage 99% 22/02/2016 2 hours Mapped drives lost from HQ file server Myrddin ESR Oracle Financials Slow access Slow access Production services Staff plan Page 12 of 15
RADIS II Radiology HQ Slow access Canisc WCCG Internet SQL Slow access CACI Hosting HyperV Hosting DPM SCCM Page 13 of 15
PTHB - Problems affecting general network performance and responsiveness February 2016 ISSUE IMPACT RESPONSE UPDATE link overloaded ( utilisation) Slow response from systems hosted on Bronllys. Slow response from Bronllys to national systems. Timeouts for end users. IP Phones unreliable. Order placed to increase bandwidth to 1GBPS. External Consultants advising on network redesign Waiting on Welsh Government Approval. Signed off by Welsh Government Jan 2016 Cisco Anyconnect - Talk Talk ISP compatability issues PTHB users who use the Talk Talk ISP at home unable to access the nationally provided VPN system. Reconfiguration work on systems to minimise background traffic transferring during office hours Under investigation by networks and NWIS. Talk Talk unable/unwilling to assist a great deal when approached by users or by our department. Last update was that Steven Nurse was going to do a home visit to a user to see if he could find a work around on router. Page 14 of 15
APPENDIX D INFORMATION GOVERNANCE IG MANDATORY TRAINING UPTAKE Directorate/Locality Jan-16 Feb-16 Corporate 66.67% 75.00% Directorate of Finance 77.78% 82.86% Directorate of Mental Health 45.30% 53.45% Directorate of Nursing Services 51.06% 55.32% Directorate of Planning 85.71% 92.86% Directorate of Primary & Community Care 56.67% 57.60% Directorate of Therapies & Health Sciences 60.00% 50.00% Directorate of Workforce & OD 68.29% 65.85% North Locality Management 41.25% 42.96% South Locality Management 55.83% 57.86% Women & Children Directorate 60.65% 65.30% Grand Total 53.61% 56.42% Staff Group Jan-16 Feb-16 Add Prof Scientific and Technic 33.33% 37.88% Additional Clinical Services 45.34% 50.63% Administrative and Clerical 58.38% 63.37% ied Health Professionals 56.52% 61.31% Estates and Ancillary 53.92% 54.15% Healthcare Scientists 100.00% 50.00% Medical and Dental 24.32% 26.32% Nursing and Midwifery Registered 58.79% 59.29% Students 28.57% 28.57% Grand Total 53.61% 56.42% Page 15 of 15