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Approved by Board of Directors 30th September 2010

RECORDS MANAGEMENT AND INFORMATION GOVERNANCE ANNUAL REPORT

Version 1_0

Presented to Board of Directors 30/09/10

Author: Mrs C. Graham

Presented by: Mrs P. Clarke

For approval


TO: Board of Directors

FROM: Mrs Claire Graham, Head of Corporate Records

DATE: 28/06/2010

SUBJECT: Records Management

PURPOSE

This report sets out the Trust’s position with regard to records management and

information governance during the year 1st April 2009 to 31st March 2010 and the

Information Governance Priorities and Plan for 2010/11. It details the actions made

to progress and improve the Trust’s management of patient and client and

corporate records during this year, and specifically refers to progress to improve

the Trust’s assessed performance against the Controls Assurance Standard for

Records Management.

During 2009/10, the Trust has undertaken considerable work to identify the areas

for improvement within the Records Management arrangements, and has put in

place a range of actions to improve the safety, quality, systems and control of the

Records Management function. This report sets out the work programme delivered

in year and planned for 10/11 and advises Trust Board of the controls and systems

in place to support the implementation and maintenance of good records

management practices which are essential to ensure compliance with Freedom of

Information and Data Protection legislation.

SUMMARY OF KEY POINTS

• The 2009/10 self assessment of the Trust’s position against the Records Management Controls Assurance Standard was substantive and this was verified by Internal Audit.

• Information Requests processed, 2009

• Approval of Trust Publication Scheme: DHSSPS, January 2010

• Closed Records In House Storage Management Project implemented

• Audit of Storage & Security of Patient Identifiable Records

• Audit Programme 2010/11: Retention, Accessibility and Physical Condition of Trust Records

• Data sharing agreement register/ Code of Practice on Confidentiality of Service User Information training implemented


WHICH TRUST CORPORATE OBJECTIVE DOES THIS PAPER PROGRESS OR

CHALLENGE?

Provide safe, high quality care.

P Be a great place to work.

Maximise independence and

choice for our patients and

clients.

Make the best use of resources. P

Support people and

communities to live healthy

lives and improve their health

and wellbeing.

Be a good social partner within our

local communities.

(Indicate which of our key strategic objectives are progressed (P) or

challenged (C))

WHICH TRUST VALUES DOES THIS PAPER PROGRESS OR CHALLENGE?

We will treat people fairly and with

respect.

P We will value and give

recognition to staff and support

their development to improve

our care.

P

We will be open and honest and act

with integrity.

P We will embrace change for the

better.

P

We will put our patients, clients, carers

and community at the heart of what we

do.

P We will listen and learn. P

(Indicate which of Trust values are progressed (P) or challenged (C)


RISKS, CONTROLS AND ASSURANCE

Risk Control Action Assurance

DPA Breach: Internal

& External disclosure

of confidential

information due to non

compliance with policy

& procedures.

Data Protection

programme available

to all staff

(induction/cetis).

Guidance on Intranet.

DP Sub Group

established. Action

Plan being

progressed.

Encryption software.

Adverse incident

process.

DP & Confidentially

Programme – Cetis

being rolled out to all

staff. (Mandatory).

Centralisation of DP

requests process.

Monitoring on going.

Information sharing

guidance in place &

data access form for

signing by 3rd

parties.

Reviewed on monthly

basis at Informatics

Senior Team Meetings.

Records Disposal.

Disposal before

specified date. Non

location of records for

FOI responses. Legal

action against Trust.

Retention longer than

necessary adds costs;

health & safety risk to

staff & breach of DPA

1998 Principle 5.

Trust & PRONI

approved Retention &

Disposal Schedule in

place. Disposal

authorisation

certificate held.

Records Management

strategy, policy and

procedure in place.

Confidential Waste

Disposal contract in

place

A number of legacy

records have been

transferred to secure

records storage. Audit

of patient identifiable

records in

unsupervised facilities

in progress. SMT

approval for robust

adherence to

Schedule secured.

Reviewed on monthly

basis at Informatics

Senior Team Meetings &

quarterly at Records

Management Committee

meetings

REVIEWED BY: Date

Assistant Director of Informatics

SMT

User forums/Community groups whose views have been sought

N/A Date


Records Management & Information

Governance Annual Report 2009/10

and Information Governance Priorities & Plan for

2010/11

28 June 2010 Version 0_8

Directorate of Performance & Reform

Informatics Division


CONTENTS

1.0 Introduction and Background

1

2.0 Requirement of the Records Management Controls Assurance Standard

1

3.0 Corporate Records Structure in the Southern Health & Social Care Trust

2

4.0 Governance Arrangements within the Southern Health & Social Care Trust

2

5.0 Establishment of Information Governance Steering Forum

4

6.0 Risk Register

4

7.0 Information Governance Programme of Work 2009/10

5

8.0 Baseline Assessment of the Records Management Controls Assurance

Standard – March 2009

5

9.0 Information Requests Processed by the Corporate Records Team (2009)

8

10.0 Information Governance Priorities 2010/11 13

11.0 Summary and Conclusion 13 Appendix 1

Abbreviations 14

Appendix 2 Retention, Accessibility and Physical Condition of Trust Records Audit Plan

15

Appendix 3 Retention, Accessibility and Physical Condition of Trust Records Audit Programme 2010-2011

17

Appendix 4

Audit of Storage & Security of Trust Records 18

Approved by Board of Directors 30th September 2010 1

1.0 Introduction and Background The Southern Health & Social Care Trust must provide a high quality records management function and have in place systems and processes to provide assurance of this, both within the organisation and externally. In recognition of the importance of the Records Management function within HSC bodies, the DHSSPS issued a Controls Assurance Standard on Records Management in April 2006 with a requirement for Trusts to achieve ‘substantive’ compliance for 2008/9. This report outlines the assurance process and criteria which must be assessed to achieve compliance with DHSSPS Records Management Controls Assurance Standard. The Plan underpins the Records Management Strategy, highlights progress to date in this area and identifies the Trust’s priorities for 2010/11. 2.0 Requirement of the Records Management Controls Assurance Standard The purpose of the Records Management Controls Assurance Standard is to ensure that all HSC bodies have, “a systematic and planned approach to the management of all records in place within the organisation that ensures, from the moment a record is created until its ultimate disposal, that the organisation can control both the quality and quantity of information it generates: can maintain that information in a manner that effectively services its needs and those of its stakeholders; and it can dispose of the information appropriately when it is no longer required.” (DHSSPS Controls Assurance Standard, 2007). This standard, along with the Risk and Financial management standards, provides the basis for statutory reporting for the Statement of Internal Control as set out by the Department of Finance and Personnel in DAO (DFP) 05/01.


3.0 Corporate Records Structure in the Southern Health and Social Care Trust Following the restructuring process of RPA, a small team of 4.5 WTE has been put in place as follows: Figure 3.1 Southern Trust Corporate Records Structure

The Corporate Records structure is a function which has been set up to ensure compliance and provide advice Trust wide on the following areas:

• Freedom of Information and Environmental Information Regulations;

• Data Protection;

• Controls Assurance Standard;

• Records Management strategy and framework;

• Risk;

• Data Breaches;

• Training and Awareness; and

• Information Governance.

The Corporate Records, IT and IS departments work closely together to implement measures to address risks and to monitor compliance. An example of this collaborative work is the ‘NI Civil Service Data Protection Review and Action Plan’ and ‘Cross Governmental Action Mandatory Minimum Measures: Work Plan (Informatics Dept) 2009’. This improves Information Governance across the Trust, particularly in relation to protecting personal information and data accessibility. 4.0 Governance Arrangements within the Southern Health & Social Care Trust The Information Governance Framework is being revised. An Information Governance Forum is being established and a new reporting structure will be implemented in the Trust in June 2010 as follows:

Head of Corporate Records Band 8A

Corporate Records Manager

Band 6

Corporate Records Officer

Band 4 0.7 WTE

Corporate Records Manager Band 6

Corporate Records

Officer Band 4

0.75 WTE


Figure 4.1 – Directional and Representative Organisational Structure

Trust Board Chief Executive

SMT

Medical Director

(Personal Data Guardian)

Director of Performance & Reform

(Executive Director with

Operational Responsibility for ICT

& Records Management) Governance

Committee

Information Governance Forum

Data Quality

working Group

ICT

Steering

Group

Records

Management

Committee

Research

Governance

Committee

Data

Protection

Clinical

Coding Sub-

Group

Regional Advice, Legislation, Policies & Procedures from ICT

Programme Board, Information Governance Project Board

(DHSSPSNI) etc

Consent

Governance

Group


5.0 Establishment of Information Governance Steering Forum

Figure 5.1 - Information Governance Steering Group Remit

The Information Governance Forum will ensure that the Trust has effective policies, systems and processes in place for record keeping and information handling in accordance with statutory, legal and good practice requirements. The Forum’s remit is specific to patient and client information governance. The Information Governance Forum will be chaired by the Medical Director (Personal Data Guardian) and will steer the work of the following groups:

• Records Management Committee;

• Data Protection Sub Group;

• Research Governance Committee;

• Data Quality Working Group;

• ICT Steering Group;

• Clinical Coding Sub Group; and

• Consent Governance Group.

Record Keeping Committee The Trust has also established a multi disciplinary group to progress the Improving Record Keeping strand of the Trust’s Patient/Client Safety Programme This strand aimed to improve the quality and content of paper based patient/client records through the development of core record keeping standards specific to this Trust. The group: -

INFORMATION

GOVERNANCE

FORUM

Data Quality Working

Group

ICT Steering Group

Clinical Coding Sub-Group

Research Governance

Committee

Records

Management

Committee

Data Protection Sub-

Group

Consent

Governance

Group


- Defined and approved core record keeping standards for the Southern Trust, - Designed an audit tool and applied it to records in order to establish a baseline

compliance with the standards and - Agreed arrangements for reporting on assurance / level of compliance with the

standards. The group proposed four Record Keeping Standards which were approved by the Trust’s Senior Management Team at its meeting on 24th August 2010. The Record Keeping Standard statements relate to the following categories: -

1. Presentation of a Record 2. Content of a Record 3. Involvement of Patient/Client/Carers 4. Consent

6.0 Risk Register Risks for this function are monitored on the Informatics Risk Register monthly and escalated to the Performance & Reform Directorate Risk Register or corporate risk register if deemed amber or above.

7.0 Information Governance Programme of Work 2009/10

The programme of work for 09/10 has focused on the Internal Audit assessment of Records Management Control Assurance Standards and the progressing of recommendations made in 2008/09, including:

• adherence to the Trust Retention & Disposal Schedule;

• transfer of closed records to records stores;

• appraisal of records, information surveys and audits (see Appendix 4: Audit of Security and Storage of Records in Community Hospitals and Buildings);

• measurement of Key Performance Indicators;

• training and awareness; and

• benchmarking and external reviews.


8.0 Baseline Assessment of the Records Management Controls Assurance

Standard – March 2009

Results of 1st Baseline Assessment – 4 November 2009

Criterion Trust %

Score

2009/10

1. Accountability & Responsibility at Board level

90

2. Organisation wide policy & strategy taking account of risk

management

90

3. Senior Management Responsibility

90

4. Management of records in accordance with the Public Records

Act (NI) 1923 and the Disposal of Documents Order No. 167,

1925

80

5. Training in Records Management Procedures

80

6. Monitoring and Review of Records Management Procedures

80

Total Score 85% The Trust’s self assessment score for 2009/10 was 85%: Internal Audit returned a score of 76% which was in the substantive range (70% - 99%). The Internal Audit score was submitted to DHSSPSNI in May 2010. A summary of the key initiatives implemented during the year to achieve substantive compliance with the standard is outlined below. These include key recommendations from the action plan. For ease of reference the description of each criterion is also included. Criterion One - Accountability: responsibility for records management lies at Board Level and clear lines of accountability for records management exist at Board level and throughout the organisation. The Director of Performance and Reform and the Assistant Director of Informatics are the nominated individuals with responsibility for records management. Clear lines of accountability have been established with the appointment of Personal Data Guardians and Heads of Corporate and Health Records. A suite of policies and procedures which outline the responsibilities of staff at all levels is in place. In addition, a reporting mechanism from the Records Management Committee to the Governance Committee ensures that any significant difficulties particularly with regard to attaining the substantive score for Controls Assurance Standards are recorded.


Criterion Two - Organisation wide Policy & Strategy: There is an organisation wide records management policy and strategy in place, supported by a comprehensive and cost effective records management programme. Risk management is also taken into consideration in the records management programme. A Records Management Strategy and Policy which have been approved by Trust Board are in place. A Records Management Procedure is also in place and is regularly reviewed and updated. An Action Plan on progress towards compliance with the Controls Assurance Standard on Records Management is reviewed and monitored by the Records Management Committee and risks are communicated to this forum and escalated as appropriate. Criterion Three – Senior Management Responsibility: A senior manager is responsible for co-ordinating, publicising, implementing and monitoring the records management strategy and reporting on a regular basis to the Board. The Assistant Director of Informatics chairs the Records Management Committee and reports on records management initiatives to SMT on a regular basis. An annual report on work undertaken by the Team to meet compliance with the Controls Assurance Standard is presented to Trust Board on an annual basis. Records management initiatives and developments are reported regularly to all staff via the Trust e-brief publication e.g. CCTV guidance. The content of corporate and departmental induction has been revised to include a greater emphasis on confidentiality issues and the use of the Patient and Health Care Number. All materials are made available on the Trust Intranet. Criterion Four – Management of records in accordance with the Public Records Act (NI) 1923 and the Disposal of Document Order No. 167, 1925. All managers are responsible for ensuring that staff are aware of their personal responsibilities for the creation, use storage, security, confidentiality, transfer and disposal of the organisation’s records. The Trust’s Retention and Disposal Schedule was approved by Trust Board in March 2008 and a Business Case for the robust implementation Schedule across the Trust has been approved by SMT (2009). This means that deceased medical records held by McConnell’s external storage contractor and mental health records which are held in the Trust and exceed the specified retention period are being disposed of. This project underpins the corporate decision to bring all records back in house and reduce the increasing cost of external storage. An audit of patient identifiable records held in unsupervised premises throughout the Trust has been completed. (see Appendix 4: Audit of Security and Storage of Records in Community Hospitals and Buildings). The audit has resulted in the following outcomes:

• departments have undertaken destruction of records held past their retention date;

• high risk records have been identified and secure storage arranged for these e.g. adoption records;

• advice and guidance has been issued to Senior Managers on the Retention and Disposal Schedule and how to store records more efficiently; and

• a Business Case for disposal of the records which are held beyond their retention


dates was drafted for approval by SMT (Feb 2010). The project has initially focused on the disposal of legacy and patient identifiable records which have been located in St Luke’s Hospital basement. Most of these records were uncatalogued. There have been 848 bags of records destroyed from the St Luke’s site since the project began in May 2010.

Criterion Five – Training in Records Management Procedures: All employees receive appropriate training in records management procedures. During 2009/10 as recommended by DHSSPS, a Code of Practice on Confidentiality of Service User Information Working Group has been set up following approval by SMT (February 2009 ) to progress an action plan and communication strategy. This has been achieved and the content of the Code has been communicated to all Heads of Service for cascading to teams. Corporate induction sessions have been revised to include more detail on Data Protection issues as well as use of the Patient & Health Care Number. ‘Frequently Asked Question’ and a suite of guidance on Data Protection have been placed on the Intranet. The content of the Code of Practice has been included in the Trust corporate and departmental induction sessions. In addition, the Trust collaborated with the Beeches Management Centre in the delivery of a Records Management Development Course which several Trust staff attended. An Informatics Course which has recently been designed by the Beeches Management Centre has been rolled out. A Data Protection Sub Group which is chaired by the Head of Corporate Records meets bi monthly. This forum which includes representatives from all directorates includes an information awareness update. Cetis e learning programme has been incorporated in the corporate wide training matrix. Over 3000 staff members have completed the programme which included modules on Data Protection, Records Management, Information Security and Freedom of Information. Criterion Six – Monitoring and Review of Records Management Procedures: An effective monitoring and review process is in place within the organisation. Eight Key Performance Indicators (KPI’s) have been identified and these are monitored and reported to SMT on a monthly and quarterly basis as follows.

KPI 1 availability of records for clinics (monthly) KPI 2 % of records released under the 40 day requirement of DPA (monthly) KPI 3 % of FOI requests responded to within 20 days (monthly) KPI 4 Compliance with Controls Assurance Standard (quarterly) KPI 5 % of staff attending training/awareness sessions (monthly) KPI 6 Number of complaints involving records (monthly) KPI 7 Number of incidents involving records (monthly) KPI 8 Condition/retention/accessibility of records (annually)

In compliance with the controls assurance programme the Trust was audited by Internal Audit in January 2010. Progress toward the objectives contained in the action plan is reviewed and monitored via the Records Management Committee and any significant risks are considered and communicated to SMT as appropriate.


9.0 Information Requests Processed by the Corporate Records Team (2009)

9.1 Background

Freedom of Information (FOI), Environmental Information (EIR), Data Protection Act (DPA) and Access to Health Records (AHR) requests are co-ordinated, processed (FOI) and monitored centrally via the Corporate Records Team. In June 2009 the Corporate Records Team acquired the FOI module of the Datix system which enabled more robust recording and reporting of requests. By marrying the old system and new system the following figures are reported for 2009. (For abbreviations used please see Appendix 1). During 2009, 309 requests for information were handled by the Corporate Records Team under the Freedom of Information Act 2000, EIR 2004, DPA 1998 and Data Protection and Access to Health Records legislation. (20 of these requests had to be closed without a response provided because when asked for further information or fee, the requester did not respond to the Corporate Records Team). Therefore 289 responses were issued in 2009.

Table 1: Requests responded to 2009 by type of request

9.2 Data Protection / Access to Health Records During 2009, 176 requests for records were handled under Data Protection and Access to Health Records legislation by the Corporate Records Team. (19 of these requests had to be closed due to no further response from the requester where further information or fee had been required by the Trust). Of the 157 requests responded to, 12 related to Social Services records and 10 to HR records. The remainder related to health records both in hospital and community settings.

QE 31 Mar

2009

QE 30 Jun

2009

QE 30 Sep

2009

QE 31 Dec

2009

Total

FOI 35 33 32 28 128

DPA 21 40 48 48 157

EIR 0 2 1 1 4

TOTAL 56 75 81 77 289


10

Table 2: Records responded to 2009 under DPA / AHR (quarterly breakdown)

QE

31/03/09

QE

30/06/09

QE

30/09/09

QE

31/12/09

Total

Health Records 15 36 43 41 135

Social Services 2 3 4 3 12

HR Records 4 1 1 4 10

Total 21 40 48 48 157

For requests prior to June 09 (when Datix module was acquired) it is difficult to report on compliance with the 40 calendar day time limit for providing a response. The following chart demonstrates compliance since June 2009:

Chart 1:DPA/AHR Requests Responded to Within 40 Calendar Days

Percentage of DPA / AHR Requests Responded to Within 40

Calendar Days (Since June 09)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09

Month

Perc

en

tag

e

40 + Days

Up to 40 Days

9.3 Freedom of Information During 2009, 133 requests made under the Freedom of Information Act 2000 and Environmental Information Regulations 2004 were handled by the Corporate Records Team. (1 request had to be closed due to no further response from the requester where further information or fee has been required by the Trust). Requests were received by a range of requesters. These have been categorised and are represented on the following chart:


11

Chart 2: Types of Requesters FOI/EIR 2009

Type of Requester FOI/EIR 2009

22%

5%

29%

33%

2%7%

2%

Business

Charity

Media

Member of Public

Student

Trust Staf

Union

The following table is an extract from the Trust KPI return in January 2010 where compliance with responding to FOI requests is measured under the Efficiency and Communication Domain.

Table 3: Compliance with FOI legislation 2009

Baseline at 31/03/09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sept-09

Oct-09

Nov-09

Dec-09

Ave Year to Date

Target Values

KPI10 % of FOI requests responded to within 20 days

93% 75% 86% 100% 73% 93% 86% 86% 57% 78% 81% 100%

Compliance with the 20 calendar day timeframe under Freedom of Information legislation has been rigorously monitored since the Act was introduced. The Trust reports to DHSSPSNI, and internally to the Trust Board and Governance Committee.


12

Chart 3: Breakdown of Response Times FOI/EIR Requests

Response Times FOI/EIR Requests 2009

Up to 20 days

21-25 days

26-30 days

31+ days

The Datix system has enabled a more robust reporting mechanism and the ability to break down further to show Directorate compliance with the timeframe for requests.

Chart 4: FOI/EIR Requests Received by Directorate

FOI/EIR Requests Received by Directorate 2009

0 5 10 15 20 25 30

Acute

Medical

HROD

C&YP

MH&D

F&P

P&R

OPPC

CEO

Dir

ecto

rate

Number of Requests

Series1


13

9.4 Publication Scheme

In May 2009 the DHSSPS issued a letter to the Chief Executives of Health & Social Care (HSC) bodies about the establishment of an Information Governance Project to take forward a number of critical information governance issues in conjunction with HSC representatives. One of these issues was to investigate to what extent organisations were meeting their objectives under the Freedom of Information Act to routinely publish information as required in para 19 of the Act “Publication Schemes”. Having considered the Publication Scheme in the Trust, the Head of DHSSPS Information Management Branch in a letter to the Chief Executive in January 2010 confirmed that “the requirements of the Act and standards defined in the Information Commissioners Model Publication Scheme would appear to be being met”. The DHSSPS asks that the Trust will continue to meet these standards and regularly review the information published. An Action Plan has been drafted to ensure on going population of the Scheme.

10.0 Information Governance Priorities 2010/11 A Controls Assurance Standard Action Plan will be prepared to progress the recommendations arising from the Internal Audit, March 2010. Priority actions for this period are:

• records Audit Plan & Programme (see Appendix 2 & 3);

• data protection;

• training and awareness;

• transfer of person identifiable information;

• ensuring security of records transported between sites

• contributing to review of ‘Good Management, Good Records’ DHSSPS guidance. An audit of records will be carried out by Corporate Records staff in the Southern Health & Social Care Trust and in the Southern Eastern Health & Social Care Trust. This will allow benchmarking between the two Trusts. Areas for audit have been identified and an audit plan with timescales and lead personnel is attached in Appendix 2 and 3. 11.0 Summary and Conclusion This report provides an overview of the developments in the Records Management function during 2009/10 and plans for in 2010/2011, based on the criterion outlined in the Controls Assurance Standard for Records Management, and the Data Protection Review undertaken by DHSSPS. It provides an assurance to the Board that the Information Governance function is recognised as an integral part of good practice and is embedded within the Trust’s governance framework.


14

APPENDIX 1 ABBREVIATIONS

Please note for the purposes of presenting information the following abbreviations are used: FOI Freedom of Information DPA Data Protection Act AHR Access to Health Records EIR Environmental Information Regulations HROD Human Resources and Organisational Development C&YP Children and Young People MH&D Mental Health and Disability F&P Finance and Procurement P&R Performance and Reform OPPC Older People and Primary Care CEO Chief Executive’s Office


15

Appendix 2: Audit Plan

DESCRIPTION OF AUDIT:

RECORDS MANAGEMENT AUDIT

AIM OBJECTIVE:

To assess compliance with ‘Good Management, Good Records’ Guidance (DHSSPS, 2004) by sampling records as follows.

1. Creation of records 2. Physical condition & storage of records 3. Disposal of records 4. Security & confidentiality of Records 5. Records Management strategy & policy 6. Training & awareness

Further objectives of the audit are to:

• facilitate internal and external audit and protect the legal right of the Trust, employees, service users and third parties; and

• to provide evidence so that actions can be taken based on reliable information.

Audit findings to determine:

• if records are held in line with the Trust Retention & Disposal Schedule;

• physical condition of records/ loose papers etc;

• location of the records and availability;

• security and confidentiality;

• if storage conditions are adequate;

• security of transfer and transport of records; and

• whether duplicates exist.

SCOPE: Records designated as ‘closed’ Service User/Client Records May include: Community (District Nursing, Family & Child Care Social Services, Speech & Language Therapy, Dementia Services, Mental Health

Records held within Family & Child Care Departments Service User/Client Records May include: Adoption Foster Care

Records held within Estates Department


16

May include: Buildings and Engineering records, e.g. Bills of Quantity site plans etc Drawings, Indemnity Forms, Surveys, Inspection Reports, Title Deeds, Planning Matters, Personnel Records, Maintenance Records, Contracts and Tenders Records, Inventories, Risk and Health and Safety Records etc.

METHOD: Identify all types of records held within the department (see examples above), held in paper format and select a sample of 15 records for testing. Complete the appropriate Records Management audit checklist, ensuring where necessary that documentary evidence, including outcome of any compliance testing is appended.

SAMPLE TO BE TESTED: 100% of each of the following records types: Service user/Client File Leases/Maintenance Contracts

REPORTING ARRANGEMENTS:

Director of Children & Young People’s Services Director of Performance and Reform – AD of Estates Director of Mental Health & Disability Services Director of Older People and Primary Care

OFFICER UNDERTAKING AUDIT: Name and Designation

RESPONSIBLE MANAGER: Name and Designation

Claire Graham Head of Corporate Records

START DATE:

Sept 2010

17

Appendix 3: Audit Programme 2010 – 2011

Records Management Audits 2010 – 2011 Potential Source Type Scope / Area Date Responsible Officer(s) Report To: Organisational/ Departmental Reviews

Example Example Example Example Example

Community Care/Nursing

Closed Records Community

Community (DN, Family & Child Care Social Services, S&L Therapy, Dementia Services, Mental Health

1 Sept to 31 Nov 2010

Monica McAllister (Head of District Nursing) Ruth Nesbitt (Head of S & L Therapy) Cathy Mawhinney (Head of Community Dementia Ser.) Cathy McPhillips (Community Mental Health Services Manager) Martin Mc Grath (Head of Family Placement Services) Liz Stevenson (Head of Long Term Res. Services)

B Dornan F Rice G Rankin Angela McVeigh

Social Services (Community social work)

Family & Child Care Client Case Files

Adoption Foster Care

1 Oct 2010 to 31 Dec 2010

Mary Logan (Head of Agency Decision Making Services) Niav McCaughey (Head of LAC Services) Michael Hoy (Head of Short Term Res. Services)

B Dornan P Morgan M McIntosh

Estates

Plans/Maps Deeds & Surveys Inspection Insurance Reports contracts & Tenders

1 January 2011 to 30 March 2011

E Farrell A Metcalfe


Appendix 4 Audit of Security and Storage of Records in Community Hospitals and Buildings

Low Risk

High Risk

Records which have now been destroyed

Acute Directorate

FACILITY ROOM Department RECORD TYPE DATE STORAGE & QUANTITY STATE SECURITY OUTCOME

Cardiac Rehab Records 2000-2005 A4 Box x 3 Clean & dry

Appointment register sheets

March 1997 - Feb 2004 A4 Box x 3 Clean & dry

Physio out patient record cards

1988 - 1989

Clinical Waste Bag x 2 Clean & dry

Physio Assessment records - decd ?


Physio Day Hospital records 1991-1992


Day Hospital outpatient discharges

Jan - June 1997 Loose pages x 60 Clean & dry

Day Hospital outpatient discharges

May - Dec 1999 Loose pages x 30 Clean & dry

STH Basement

Physio discharges - Loane House 2004 Loose pages x 30 Clean & dry

Records destroyed from St Luke’s Basement as per Business Case


Diaries 2000 - 2007 A4 Box x 5 Clean & dry

Physio - attendance Book Neck Sprain class ? A4 Book x 1 Clean & dry

Haematology X matching records

1966 - 2005 Various Clean & dry

Laboratory Bone Marrow records - slides

1968-2006 A4 Box x 4 Clean & dry

Laboratory IVF Results ? A4 Folder x 18 Clean & dry

Laboratory Haematology Results 1986-2006 Various Clean & dry

Laboratory Andrology Maintenance Records

2004-2007 A4 Envelope x 7 Clean & dry

Laboratory Blood Grouping Registers 1991-1998 A4 Register x 8 Clean & dry

Laboratory DWCC records

April 2002 -May 2004

Lever Arch File x 2 Clean & dry

Laboratory Miscellaneous haematology records

1999-2003


Laboratory Audit Records 2002-2004


Laboratory Audit Records - loose papers ? A4 Box x 10 Clean & dry

Laboratory A4 Diaries 1994-2004 12 Diaries Clean & dry

Laboratory Haematology Request books 1995-2002 A4 Book x 21 Clean & dry


Laboratory Blood Bank Records - Day Sheets ? 1 shelf (3 feet) Clean & dry

Laboratory Phone Logs Feb 07-Sept 07


Laboratory Blood Bank Daily work sheets

1996-2000

Suspension files x13 Clean & dry

Laboratory Results and sample slides 2007 A4 Envelope x 4 Clean & dry

Laboratory Telephone Log sheets 2006 Lever Arch File x 14 Clean & dry

X-Ray Medical Legals 1992 onwards

4 Drawer filing cabinet x 1 Clean & dry

D Floor Ward Manuals, minutes, accident forms (pt id)

1996-1999 Large Box x 1 Clean & dry

Ward

Private patients books, District Nursing referrrals, Social Services referrals, policies & procedures manuals Large Box x 1 Clean & dry

Ward Manuals, minutes, accident forms (pt id)

1989-1997 Large Box x 1 Clean & dry

Ward

Policies & Procedures manuals, 1 folder accident forms 2000 Large Box x 1 Clean & dry

Ward

SW referrals, physio equipment on loan, Under 17 referral to Health Visiting, private patient property books, district nursing referrals 1997-200 Large Box x 1 Clean & dry

St Luke's

Basement Main

Building R4(5) Dental dental records - patient identifiable ? Various Dirty/untidy


Secondary storage of medical records & A&E records

1974 onwards

Dexion Shelving x 54 Clean & dry

medical records Large Box x 7 Slight Water Damage

Deceased patient records Large Box x 18 Clean & dry

A&E registers (18 books) Old Armagh City Hospital & Tower Hill Hospital

1969 -1983 Large Box x 1 Clean & dry

Geriatric patient records from Old Armagh City Hospital 1959 Large Box Clean & dry Casualty daily appointment diairies - pt information Clean & dry

Armagh Hosp

Portacabin Medical Records

Consultant Reference Books Clean & dry

Records due for destruction destroyed. Weed recommended and implemented.

St Luke's

Basement Main

Building Corrido

r A Medical Records STH death certificates (original book) 1974 A4 Box x 1 Dirty/untidy


Children and Young Peoples Directorate

FACILITY ROOM

Location

(St Luke's) Department RECORD TYPE DATE

STORAGE & QUANTITY STATE

OUTCOME OF FOLLOW-UP VISIT


Child Protection, LAC, Adoption files - closed ? Filing Bay x 11 Clean & dry

Letter to Brian Dornan

Family & Child care - NFA records ?

Wooden shelving x 9 Clean & dry

Dromalane Garage

Child Care Referrals ? Wooden shelving x 6 Clean & dry

Social Services Case Conference Notes (cld include LAC Files)

1988-1992

5 Door filing cabinet (4 shelf) Dirty/untidy

Letter to Brian Dornan

Social Services Miscellaneous filing 1996-1997

1966-1997

4 Door filing cabinet (4 shelf) x1 shelf Dirty/untidy

Social Services Family & Child Care - client files - miscellaneous ? shelves x 5 Dirty/untidy

Social Services Changes & pay reports ? shelves x 2 Dirty/untidy

Speech & Language Therapy Diaries

1994-2005

2 Door filing cabinet (4 shelf) x 1 Dirty/untidy

Speech & Language Therapy SLT Discharges

1990-2005 A4 Box x 24 Dirty/untidy

Child Health Health Visitor Records 1988 onwards A4 Box x 25 Dirty/untidy

Child Health Health Visitor Records 1983-1990


Child Health Health Visitor Records 1984

2 door filing cabinet (2 shelf) x 4 Dirty/untidy

School Health Opthalmic records 1967 onwards A4 Box x 10 Dirty/untidy

STH Portacabin

1

Child Health Baby hearing lists 1998 onwards A4 folders x 3 Dirty/untidy

Memo sent from Claire to Heads of Service regarding the action to be taken to clear this basement


Child Health diaries 1979-1998 28 Diaries Dirty/untidy

Child Health Annual leave cards 1990 A4 Box x 2 Dirty/untidy

Health Visiting Home Visiting Assessment cards 1986 A4 Box x 2 Dirty/untidy

Health Visiting Misc patient referrals 1988-1993

A4 Envelopes x 12 Dirty/untidy

Speech & Language Therapy SLT Discharges

2005-2007 A4 Box x 10 Dirty/untidy

Downstairs Store Social Services SW Casenotes Family Support Teams Various Clean & Dry

Gosford Place

Upstairs Store Social Services Residential records / Home Help / SW / Elderly/F&CC Various Clean & Dry

Letter of recommendations issued to Mary McIntosh- leading a working group to address mgt of CYP records and disposal of records procedure

1st Floor Offices Health Visiting Closed Patient Files Numerous boxes under staff desks Clean & dry Unsafe

Ground Floor Offices School Health School Health closed files 2009

Nowhere to move closed records to - will accumulate 1500 records per year Clean & dry

John Mitchel Place

Disability Team's Store Social Services

Child Health Team Patient Records 1980's + A4 Boxes x Clean & dry Unsafe

Awaiting advice re closed records

St Luke's Kate Courtenay's

Office Social Services

Various old records Armagh Welfare Committee / Adoption records Pre-1948 / Newry Union Minutes

1936 onwards

1 Shelf in 2 door filing cabinet Clean & dry

Transfer to Chestnutt Buildings in preparation for transfer to


PRONI

Ciaran Eastwo

od's Office Social Services

Supervision Notes of Student Social Workers

Ciaran Eastwo

od's Office Social Services Incidents Pink Forms 1995+ 1995+

Ciaran Eastwo

od's Office Social Services Client Files (Bocombra) 1980's + 10 Boxes

Ciaran Eastwo

od's Office Social Services Monthly Report

Bocombra Lodge

Roofspace

Ciaran Eastwo

od's Office Social Services

Diaries / Admissions Registers

Recommendations re use of Retention and Disposal Schedule to be issued

Dental Dental records & dental x-rays ?

4 Drawer filing cabinet x 1 Dirty/untidy

Dental Dental consent forms ? 4 Drawer filing cabinet x 1 Dirty/untidy

Dental Early Years & Nursing Home dental records ? A4 Box x 2 Dirty/untidy

Dental

Diaries,Special needs referrals, POC contact sheets, GA pt charts

2001-2008

2 door filing cabinet x 1 Dirty/untidy

STH

Portacabin 1

Dental Dental consent forms ? A4 Box x 6 Dirty/untidy

Memo from Claire to Heads of Service regarding the action to be taken to clear this basement


Dental Patient dental moulds ? Small Box x 16 Dirty/untidy

Dental Patient GA charts 2004-2007 A4 Box x 10 Dirty/untidy

Dental Diaries 2006-2008 A4 Box x 10 Dirty/untidy

Finance and Procurement

FACILITY ROOM

Location




Corridor A Finance Financial records

1990-1993

Accounts Ledgers x 20 Dirty/untidy

Side Room Finance

finance information - undetermined

1995-2006 Large Box x 35 Dirty/untidy

St Luke's Basement

Main Building

R4 Corrido

r Finance Audit comm papers 1997-2000 A4 Box x 10 Dirty/untidy


Ivybrook Room 2 Finance

Finance Records re elderly clients - closed records

2001-2007

2 Door filing cabinet (4 shelf) x 3 Clean & dry

Letter of recommendations re use of


Finance Foster Care payments up to 2007


Finance Finance Records - deceased elderly clients

2006-2007


Finance Finance Records - Care providers ? A4 Box x 10 Clean & dry

Finance Final Accounts 1994/95 +

Finance FMR Committee 2002 +

Finance SDP / Trust Board 2002 +

Finance Debtors Billing Receipts

Finance Piles of files in no order

Finance 2 door Filing Cabinets x 3 - Not accessible

Lurgan Hospital

Attic Room

on Right

Invoices Paid - In good order

Retention and Disposal Schedule to be issued

Mental Health and Learning Disability

FACILITY ROOM

Location





Medical Records Medical Records patient records

1926 onwards


Hill Building basement Medical Records Learning disability records ?


Basement Main

Building Ward misc - diaries, ward meetings ? Dirty/untidy

St Luke's

Basement Main

Building

R4 Corrido

r Ward 1 Ward returns, ppp books, ward diaries Large Box x 35 Dirty/untidy


Shanlieve House Attic / Shower Rooms Social Services Residential Records 1980's + Clean & dry

Gleann Ri Store Social Services Residential Records 1980's + Clean & dry

Teach Sona Attic / rooms Social Services Residential Records 1980's + Clean & dry

List of queries regarding retention periods addressed. Awaiting advice re closed records storage

John Mitchel Place

Disability Teams Records Store Social Services Adult Learning Disability 1980's +

John Mitchel Place

Disability Teams Records Store Social Services Adult Physical Disability 1980's +

4 drawer filing cabinet x 20

Clean & dry

Advice given regarding retention periods for records and case closure forms. Awaiting advice regarding storage options (Trust records stores?)

Older People and Primary Care Directorate


FACILITY ROOM

Location




2

Elderly Care Records - closed records

2004- date


Elderly Care Records up to 2008


Ivybrook

3

Domiciliary Care Referrals 2005 - 2007

Lever Arch File x 14 Clean & dry No issues

Physiotherapy

Care of Elderly - deceased

records

1992

onwards A4 Box x 3 Dirty/untidy Portacabin 1

Social Services Home help information 1994-1999


STH

Portacabin 2 Podiatry Podiatry discharges ? A4 Box x 9 Dirty/untidy

Memo from Claire to Heads of Service regarding the action to be taken to clear this basement

Speech & Language Strong Room

Speech and Language Therapy Patient Files 1980's +

Strong Room A4 box x 50+ Clean & dry

Awaiting advice regarding storage options (Trust records stores?)

John Mitchel Place

Podiatry Offices Podiatry Patients Files 1980's + Clean & dry


Store Physiotherapy Current Patient Charts 2009+ Shelved Filing Room Clean & dry

DHH Outpatients

Dept

Gym Physiotherapy Patients Charts

various within retention date

9 A4 boxes for off-site storage 8 locked / unlocked filing cabinets Clean & dry

Awaiting advice regarding storage options (Trust records stores?) Major lack of storage space. Hydro


Changing

Room 1 Physiotherapy Patients Charts 13 boxes for off-site storage Clean & dry

Changing

Room 2 Physiotherapy Patients Charts

25 boxes for Armagh Store 7 boxes of Medico Legal records for return to McConnells Clean & dry

"Staff Office" Physiotherapy Patients Charts

8 boxes closed records waiting to be processed on spreadsheet for storage Clean & dry

Pool due to open by end April nowhere to move records out of changing rooms and no staff available to carry out the process involved with transferring records off-site

Main Office Physiotherapy Patients Charts 2008

14 boxes for storage Clean & dry

Corridor Physiotherapy Outpatient Discharges 6 locked cabinets Clean & dry

CAH

Outpatients Dept

Equip Store

Trauma & Orthopaedics Patients Charts

2008/2009

2 x 4 drawer filing cabinets Clean & dry


ACH Outpatients Dept Physiotherapy Patients Charts 2002+ Clean & dry No issues

Lurgan Outpatients Dept Physiotherapy Patients Charts 2006+ Clean & dry No issues

Banbridge Polyclinic Physiotherapy Patients Charts 2009+ Clean & dry No issues

Dungannon Physiotherapy Patients Charts To be visited yet…

Performance and Reform Directorate


FACILITY ROOM

Location




R4 (2) Estates - work order dockets 1988 Small Box x 70 Dirty/untidy St Luke's

Basement Main

Building

R4 (3) Estates Estate records, Assets registers Filing Cabinets Dirty/untidy


Human Resources and Organisational Development Directorate

FACILITY ROOM

Location




Downshire Place

Vacant Building

Filing Room

Human Resources

Staff HR Files / Grievance Folders Various 2 Boxes Clean & Dry

High Risk (Vacant Building)

These were taken to Corporate Records Department for collection by HR. HR have collected (Sarah Moore)

Lurgan Hospital Attic

Room on

Right Human Resources

Staff HR files dating to 1960's 1960's +

4 drawer filing cabinet x 5 Clean & Dry

HR Alerted

Not allocated to any Directorate / Various


FACILITY ROOM

Location




Social Services Closed records 1988-2002 A3 Box Dirty/untidy

Letter to Brian Dornan Portacabin

1

Social Services

Changes books, hospital referrals, T&C Employment

1989-1993


STH

Portacabin 2 Social services

Off duty sheets & Minutes of Team Leader meetings ? A4 Box x 10 Dirty/untidy

Corridor A Biochemistry results 1983 Bag x 1 Dirty/untidy

Corridor A

Birth Registers & mis medical informations

1984 onwards Bag x 1 Dirty/untidy

LA 1 Various Various ? ? Dirty/untidy

LA 2 Various Various ? ? Dirty/untidy

LA 3 Various Various - include Comm Nursing Client Records ? Dirty/untidy

LA 3 (1) Various Various - includes patient information Dirty/untidy



St Luke's Basement

Main Building

LA 3 (4) Room locked - unable to gain entry Dirty/untidy



LA 4 Various Various - includes patient information Dirty/untidy

LA 4 (1) Room locked - unable to gain entry Dirty/untidy


R1

District nursing, community nursing & podiatry returns

1994-1997 1 metal cage Dirty/untidy

R2 Various Various - includes patient information Dirty/untidy

R3 Various Various - includes patient information Dirty/untidy

R2 (A)

4 X 4 drawer filing cabinets - locked 2 large cupboards locked) Dirty/untidy

R4 (1) Various Various- including pt information Dirty/untidy

R4 (2) Acute STH deceased patient records Large Box x 40 Dirty/untidy

R4 (4) Various CEO Records, ward 1 weekly rotas Boxes 38 Dirty/untidy

R4 Corrido

r Maternity Notification of birth records 1980 onwards A4 box x 9 Dirty/untidy

R4 Corrido

r Various

Villa 3 records - pharmacy books, PPP books, stores receipts

2005-2007 Large Box x 6 Dirty/untidy

R4 Corrido

r ? Filing Cabinets - locked - unable to gain access ?

4 Drawer filing cabinet x 5 Dirty/untidy

Gosford Place

Upstairs Store Social Services

SW Casenotes Family Support Teams Various Clean & Dry

Letter of recommendatio


Downstairs Store Social Services

Residential records / Home Help / SW / Elderly/F&CC Various Clean & Dry

ns issued to Mary McIntosh- has set up working group to address mgt of records and disposal of records procedure

Downshire Place

Vacant Building Attic CEO DHSS Circulars Various A4 File x 70 Clean & Dry

Not originals - destroyed