Threshold Method of Measurement Frequency of monitoring Consequence of Breach. S3 Percentage of eligible staff who have had an enhanced CRB within 3 years 100% Number of staff who have been checked by CRB/ Number of clinical and other identified staff Monthly Percentage of staff who have received awareness training in the mental capacity act 100% No. of staff who have received Mental Capacity Act awareness training/ No. of clinical and other identified staff Monthly Information governance Information Governance Toolkit Assessment (IGTA) Scores – Covering all requirements necessary for N3 connection (Applicable to all providers using N3 connection – for other Providers, this will be developed) The Commissioner IG Lead will be involved in the validation process. Level 2 on all requirements with action plans for improvement. Annual validation panels must take place to assess IG Toolkit evidence. IGTA scores submitted to Connecting for Health – to be reported to Commissioner. Annual in line with IGTA submission Recovery plan to be brought to Performance Meeting following breach IG Training – % of staff trained 100% of all staff involved in contract within 2 weeks of start date. Records of mandatory training Quarterly Recovery plan to be brought to Performance Meeting following breach NHS Number Completeness – % of patients with assigned NHS number which is used routinely in all clinical correspondence and communication 95% of patients (may need a phased target during first year) NHS Number completeness reports Monthly Recovery plan to be brought to Performance Meeting following breach
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