Annual report 2012-13 - West London Mental Health NHS Trust

Information governanceA revision (version 10) of the informationgovernance self assessment was published byConnecting for Health in June 2012. In anticipationof this revision a comprehensive informationgovernance work plan was put in place in April2012 which was reviewed when informationgovernance toolkit version 10 was published.The medical director is executive lead forinformation governance in addition to being thetrust Caldicott Guardian. The director of finance/ deputy chief executive is the senior informationresponsible officer.The trust has achieved a score of 71%(satisfactory) for 2012/13. Internal audit hasassessed a sample of the scores that we selfassessedto give additional assurance.NHS organisations are also required to include intheir annual reports details of serious incidentsinvolving data loss or breach of confidentiality.There were no such major incidents in WestLondon Mental Health NHS Trust in 2012/13.Other personal data-related incidents in2012/13:Category Nature of incident TotalI Loss of inadequately protected electronic equipment, devices or paper 0documents from secured NHS premisesII Loss of inadequately protected electronic equipment, devices or paper 0documents from outside secured NHS premisesIII Insecure disposal of inadequately protected electronic equipment, 0devices or paper documentsIV Unauthorised disclosure 5V Other 11“Other” covers minor potential internal breaches of confidentiality where there are no actual personal data losses.When incidents are reported they are reviewed and appropriate action taken and any wider lessonslearned shared.6. Review of effectivenessAs accountable officer, I have responsibilityfor reviewing the effectiveness of the systemof internal control. My review is informed in anumber of ways:1. The head of internal audit provides me with anopinion on the overall arrangements for gainingassurance through the assurance frameworkand on the controls reviewed as part of theinternal audit work.Opinion on the effectiveness ofthe system of internal controlBased on the work undertaken in 2012/13,significant assurance can be given thatthere is a generally sound system ofinternal control, designed to meet theorganisation’s objectives, and that controlsare generally being applied consistently.2. Executive directors within the organisation whohave responsibility for the development andmaintenance of the system of internal controlprovide me with assurance.3. The assurance framework itself provides mewith evidence that effectiveness of controls thatmanage risks to the organisation achieving itsprincipal objectives have been reviewed.4. Registration with the CQC - the trust isregistered with the Care Quality Committeewith no conditions.I have been advised on the implications of theresult of my review of the effectiveness of thesystem of internal control by the followingcommittees within the trust:• Audit committee• Quality committee• Finance & investment committee• Trust management teamThe board will continue to review progress aspart of eliminating weakness and ensuring that aprocess of continuous improvement is in place inthe trust in 2013/14 through the following actions:• Work towards NHSLA level 2 accreditation.• Improve staff engagement processes andarrangements.• Consider the recommendations of the Francisreport in the context of this organisation andimplement any required improvements.• Embed new, strengthened arrangements forgovernance and nursing leadership.• Establish a senior leadership developmentprogramme.• Through our quality action plan and priorities,ensure service users are treated with the highestlevels of dignity, compassion and respect.• The timely implementation of any internal andexternal audit recommendations.SignedDate 29/05/2013Steve Shrubb Chief Executive, Accountable Officer50 Annual Report 2012/201351