DCW62-Caldicott Principles and Patient Information Policy

Registration Number: {{org_field_registration_no}}

Caldicott Principles and Patient Information Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} upholds the highest standards of confidentiality, integrity, and lawful processing of patient information in line with the Caldicott Principles, UK GDPR, and Care Inspectorate Wales (CIW) regulations. This policy sets out clear procedures for handling patient data securely, maintaining confidentiality, and ensuring that information is shared appropriately to protect service users’ rights and privacy.

This policy ensures compliance with:

The Caldicott Principles (Revised 2020) – Best practice guidance for handling patient-identifiable information.
The UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018 – Defines legal responsibilities for protecting personal data.
The Health and Social Care (Quality and Engagement) (Wales) Act 2020 – Reinforces the duty of candour and transparency in data handling.
The Social Services and Well-being (Wales) Act 2014 – Promotes a person-centred approach to managing patient information.
The Regulation and Inspection of Social Care (Wales) Act 2016 – Requires regulated care providers to maintain confidentiality and secure records【32】.
Care Inspectorate Wales (CIW) Regulations – Establishes standards for protecting patient information in social care【35】.

2. Scope

This policy applies to:

All employees, including care staff, managers, and administrative personnel.
External contractors, volunteers, and agency staff handling patient information.
Patient-identifiable data in electronic, paper, or verbal format.

It covers:

Understanding the Caldicott Principles.
Staff responsibilities in handling patient information.
How and when patient data can be shared.
Ensuring compliance with GDPR and legal requirements.
Data security measures and breach reporting.
Training and competency requirements.

3. The Caldicott Principles

The Caldicott Principles provide a framework for managing patient information securely and ethically. {{org_field_name}} ensures that all staff understand and apply these principles:

Principle 1: Justify the Purpose for Using Confidential Information

Patient information should only be used when necessary and for a clear purpose, such as care provision or safeguarding.
All data requests must be assessed to determine if disclosure is appropriate.

Principle 2: Use Confidential Information Only When Absolutely Necessary

Staff must only access patient data that is relevant to their role.
Non-identifiable information should be used whenever possible (e.g., anonymised case studies).

Principle 3: Use the Minimum Necessary Confidential Information

Only the essential details should be shared (e.g., for GP referrals, medication changes).
Excessive data collection is prohibited under GDPR regulations.

Principle 4: Access to Confidential Information Should Be on a Strict Need-to-Know Basis

Staff must not access patient records unless required for their duties.
Access permissions are role-specific, limiting unnecessary exposure to sensitive information.

Principle 5: Everyone Must Understand Their Responsibilities

All staff must sign a confidentiality agreement as part of their contract.
Staff must complete mandatory Caldicott and GDPR training annually.

Principle 6: Comply with the Law

All data processing activities must comply with UK GDPR and the Data Protection Act 2018.
Any breach of confidentiality is reportable to the Information Commissioner’s Office (ICO) if required.

Principle 7: The Duty to Share Information Can Be as Important as the Duty to Protect It

In some cases, sharing information is necessary for safeguarding, medical care, or legal requirements.
Staff must follow the Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13) when reporting concerns【34】.

Principle 8: Inform Patients About How Their Information Is Used

Service users must be informed about how their data is collected, used, and stored.
Privacy notices must be provided in accessible formats.

4. Responsibilities of Staff in Handling Patient Information

4.1 Responsibilities of the Registered Manager

Ensure compliance with Caldicott, GDPR, and CIW regulations.
Monitor staff training and confidentiality agreements.
Oversee data security audits and ensure secure storage of records.

4.2 Responsibilities of Care Staff

Follow confidentiality and data protection procedures at all times.
Only access patient information relevant to care delivery.
Report any suspected data breaches or unauthorised access.

4.3 Responsibilities of the Data Protection Officer (DPO)

📌 Data Protection Officer: {{org_field_data_protection_officer_first_name}} {{org_field_data_protection_officer_last_name}}.
Oversee compliance with data security policies.
Investigate data breaches and manage ICO reporting.

5. Sharing Patient Information Safely

5.1 When Can Patient Information Be Shared?

Patient-identifiable data can only be shared:

With the service user’s consent for care coordination.
For safeguarding concerns (following CIW and local authority procedures).
When legally required by regulatory bodies or law enforcement.

5.2 Secure Methods of Sharing Data

Encrypted emails must be used when sharing patient information electronically.
Telephone discussions should be conducted in private settings.
Paper records must be transported securely and never left unattended.

5.3 Documenting Data Sharing

Any disclosure of patient information must be recorded, including who requested it, why, and how it was shared.
Service users should be informed when their information is shared unless legally exempt.

6. Data Security and Breach Reporting

6.1 How Data is Stored

Electronic records are stored in secure, password-protected systems.
Paper records must be kept in locked filing cabinets.
Staff must log out of systems when not in use to prevent unauthorised access.

6.2 What Constitutes a Data Breach?

A data breach includes:

Loss of patient files or unauthorised disclosure.
Hacking or cyber-attacks on electronic records.
Sending confidential information to the wrong recipient.

6.3 Reporting a Data Breach

Report the breach immediately to the Data Protection Officer.
The DPO assesses the impact and determines if ICO notification is required.
The breach is documented, and corrective action is taken to prevent recurrence.

7. Staff Training and Compliance

All staff must complete Caldicott and GDPR training upon induction.
Annual refresher training is mandatory for all employees.
Regular compliance audits ensure best practices are maintained.

8. Monitoring and Compliance

The Registered Manager and DPO conduct regular audits to ensure compliance.
Service user feedback is reviewed to assess transparency and consent management.
CIW inspections assess confidentiality and patient data security【35】.

9. Related Policies

This policy should be read in conjunction with:

Confidentiality and Data Protection (GDPR) Policy (DCW34).
Whistleblowing (Speaking Up) Policy (DCW29).
Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13)【34】.
IT and Cybersecurity Policy (DCW40).

10. Policy Review

This policy will be reviewed annually or sooner if required by legislative changes, CIW regulations, or operational needs.

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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