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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Caldicott Principles and Patient Information Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} adheres to the Caldicott Principles in managing, sharing, and protecting patient information. The policy aims to promote a balance between protecting individuals’ confidential information and ensuring that appropriate data is shared for the delivery of safe and effective care. This policy complies with the Regulation and Inspection of Social Care (Wales) Act 2016, Data Protection Act 2018, General Data Protection Regulation (GDPR), and CIW best practices.

2. Scope

This policy applies to all staff, volunteers, and external professionals handling patient-identifiable information within {{org_field_name}}. It covers how information is recorded, stored, shared, and accessed to ensure compliance with legal and ethical obligations. This policy extends to any third-party organisations with whom data is shared and includes procedures for handling patient requests regarding their data.

3. The Caldicott Principles

{{org_field_name}} adopts the following Caldicott Principles as a foundation for handling patient information:

1. Justify the Purpose – Every proposed use or transfer of patient-identifiable information must be clearly defined and justified. This includes ensuring that data sharing is essential for care provision and not for administrative convenience.
2. Use Only When Absolutely Necessary – Patient information should only be used where it is essential for care provision. Any unnecessary access or sharing of information is strictly prohibited.
3. Use the Minimum Necessary – The least amount of personally identifiable data should be used to fulfil the purpose, reducing risk exposure.
4. Access on a Need-to-Know Basis – Only those with a legitimate need should have access to patient information, ensuring controlled and secure access at all times.
5. Everyone with Access Must Understand Their Responsibilities – All staff must be trained in information governance and confidentiality, ensuring they fully understand their responsibilities.
6. Comply with the Law – Legal and regulatory requirements for data protection must be met, including compliance with GDPR and the Data Protection Act 2018.
7. The Duty to Share Can Be as Important as the Duty to Protect – Information should be shared where it is necessary for safe and effective care, ensuring that privacy concerns do not result in delays in medical interventions.
8. Ensure No Undue Barriers to Information Sharing – Excessive concerns over confidentiality must not prevent information from being shared where necessary for patient safety.

4. Recording and Storing Patient Information

• Accurate Record-Keeping:
  • All records must be accurate, up to date, and factual.
  • Amendments should be recorded transparently to maintain an audit trail.
• Secure Storage:
  • Physical records are stored in locked cabinets with restricted access.
  • Electronic records are password-protected, encrypted, and backed up regularly.
• Retention and Disposal:
  • Patient records are retained in accordance with legal retention periods.
  • Confidential waste is disposed of securely via shredding or data-wiping, with documentation of disposal procedures maintained for auditing purposes.

5. Sharing Patient Information

• With Internal Staff:
  • Information is shared on a need-to-know basis to ensure continuity of care and to enhance multidisciplinary teamwork.
• With External Agencies:
  • Information is shared only when legally required or necessary for patient safety (e.g., CIW, NHS, safeguarding teams).
  • Data-sharing agreements are in place with external organisations to ensure compliance with confidentiality requirements.
• With Families and Advocates:
  • Information is shared with families only with the consent of the patient or in their best interests, following established legal frameworks.
  • Where a resident lacks capacity, the principles of the Mental Capacity Act 2005 apply, and decisions will be made in their best interests.

6. Patient Rights and Data Subject Requests

Residents have the right to:

• Access their records upon request within the legally required timeframe.
• Request corrections to inaccurate information in their records.
• Withdraw consent for data sharing (unless overridden by legal obligations in safeguarding cases).
• Be informed about how their information is used and stored, including access to the organisation’s data protection policies.
• Request deletion of their data where applicable under GDPR guidelines.

7. Data Breaches and Incident Reporting

• Identifying a Data Breach:
  • Unauthorised access, loss, or sharing of patient information is classified as a breach and must be managed accordingly.
• Reporting and Managing Breaches:
  • All breaches must be reported to the Data Protection Officer immediately for assessment and remedial action.
  • The Information Commissioner’s Office (ICO) is notified where necessary within statutory timeframes.
• Corrective Actions:
  • Investigations are conducted to determine the cause of the breach and prevent recurrence.
  • Staff involved in breaches will receive additional training and disciplinary action may be taken where necessary.

8. Staff Training and Responsibilities

• Mandatory Training:
  • All staff must complete annual training on data protection and confidentiality, with refresher courses offered when regulatory changes occur.
• Confidentiality Agreements:
  • Staff must sign confidentiality agreements as part of their employment contract, reinforcing the importance of data security.
• Role of the Caldicott Guardian:
  • {{org_field_name}} has a designated Caldicott Guardian responsible for overseeing information governance, ensuring compliance, and addressing ethical concerns related to patient data use.

9. Compliance and Monitoring

• Regular Audits:
  • Information governance audits ensure compliance with data protection regulations and highlight areas for improvement.
• CIW Compliance:
  • CIW inspections assess adherence to patient confidentiality and information-sharing practices, with findings incorporated into the care home’s continuous improvement strategy.
• Policy Review:
  • This policy is reviewed annually to reflect regulatory changes and best practices, ensuring continued compliance with legislative frameworks.

10. Related Policies

This policy should be read in conjunction with:

• CHW34 – Confidentiality and Data Protection (GDPR) Policy
• CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CHW42 – Communication and Engagement with Service Users and Families Policy
• CHW31 – Disciplinary and Grievance Policy (in case of breaches by staff)

11. Policy Review

This policy will be reviewed annually or sooner if there are changes in legislation, regulatory requirements, or organisational needs. Any updates will be communicated to all staff through training sessions and policy briefings to ensure continued compliance and best practice adherence.

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.