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Access to Social Care Records ― People Receiving Care (Scotland) Policy

Policy Statement

This policy sets out the values, principles and procedures underpinning this care provider’s approach to enabling people who use services to have access to their records and other information held by the service about them. It is written in line with the national health and social care standards set out in My Support, My Life, particularly standards emphasising that all care should be person-centred and in line with their wishes and preferences and those under Standard 4: “I have confidence in the organisation providing my care and support”.

Policies are needed that enable people to exercise their legal and moral rights to have access to the information about them held by {{org_field_name}}. The service has no authority over records kept by other agencies involved with the person receiving care, but it assumes that these agencies will have their own policies and procedures in accordance with the prevailing legislation, which the person would follow if they wished to have access to these records.

Principles of Access

People who use services have a right to see what has been written about them as recorded by {{org_field_name}}.

Any access to records must always be considered in terms of {{org_field_name}}’s confidentiality policy. This means that such information must not be made available to other people and anyone else mentioned in the records should have their identity protected. There is no right of access to other people’s personal data.

The implication of data protection legislation is that records are shared with the individuals concerned as they are made. This allows for openness, agreement between worker and person using the services, and the potential for greater accuracy. Only in rare circumstances should access be refused. The person seeking access to information should have the policy carefully explained to them.

Any request from individuals for access to their personal file must be discussed with the registered manager, who takes the decision as to what may or may not be shared.

Specific Guidelines

1. {{org_field_name}} is accountable to the person for all information it holds about them; staff are responsible for recording on personal files and any information sharing in line with the provider’s policies.
2. Managers external to {{org_field_name}} do not normally have access to people’s files, but may need to do so for specific purposes such as undertaking a quality review, conducting an investigation or following up a complaint.
3. Any information in the file that is in a restricted information section cannot be shared. The marking of information in the file should be supported by a reason for it being regarded as confidential. Where the request for information is concerned with legal action, the matter should be referred to {{org_field_name}}’s legal advisors, who can decide whether access to the information can be given.
4. Information should not be given where it might result in the risk of serious harm, of any form, to the person or someone else, including a staff member.
5. Information should not be given if it is concerned with the prevention or detection of crime or apprehension or prosecution of offenders, if it would prejudice one of these purposes.
6. Personal health information can only be given following consultation with the health professional concerned. However, health information which arises from information within {{org_field_name}}’s experience of working with the person using the services, but not from health professionals, may be accessed.
7. Where the information concerns health matters, the health professional must be contacted and their opinion given as to whether the giving of the health information would pose any risk to the individual seeking the information or to any third party. Where such risk is indicated, the information should be edited.
8. Legal advice is privileged information and should not be disclosed, as are court reports. The person seeking access may nominate, giving their permission in writing, an agent to acquire the information for them.
9. Where the person concerned is a young person under 14 years of age, it would be expected that their parent or guardian would be nominated to have access on their behalf.
10. People who are unable to manage their own affairs because of mental illness or mental disability may be represented by a legal representative.
11. The person should give notice in writing that they wish to have access to their records when these records are not held within {{org_field_name}}. Staff should discuss any request for access with the service’s manager.
12. Relatives, friends and third parties have no automatic right of access to a person’s confidential records and will need to obtain the consent of the person who uses the services or follow the corresponding procedures if the person lacks mental capacity to give their consent before they can have access to them. (See Third Party Access to an Individual’s Records below.)
13. There is a separate policy in the case of relatives or representatives who seek to have access to the records of a person who has died in {{org_field_name}}.
14. At the end of service {{org_field_name}} will keep the records in line with its retention policy. People who use services can apply to access (or retain copies) of their records subject to data protection requirements in relation to any personal data found of third parties, which should then be edited.

Third Party Access to an Individual’s Records (Subject Access Request (SAR))

It is permissible in some instances to allow requests from a third party to have access to an individual’s records. Where the person has mental capacity, their consent will always be needed. Where the person might lack the capacity to give their consent, the request might be allowed under certain circumstances.

{{org_field_name}} accepts that it is reasonable for someone with a power of attorney, for example, to access someone’s records and information to which a person receiving care has right of access; that is where the information contained will help or enable the attorney to carry out their lawful duties. The information requested should be relevant to the best interest decisions that the attorney must make on behalf of the person they are representing.

The attorney should make any request in writing. Where it is reasonable and lawful for the attorney to access the information, a formal agreement will then be reached on the means of access, which will also follow confidentiality and data protection principles and procedures.

Training

All staff receive training in the access to records policy at induction and whenever changes need to be made to it.

Note:

{{org_field_name}}’s policy on access to records can be included as part of its general policy on records and record keeping or as a separate policy, which is described as follows. It should also be used with reference to the Data Protection and Compliance with the General Data Protection Regulation (England, Scotland, Wales) Policy.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Next Review Date: {{next_review_date}}

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