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Access to Social Care Records — People Receiving Care (Wales) 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, and when third parties can have authorised access to a people’s records.

{{org_field_name}}’s policies and procedures on the use and keeping of its records are produced to meet the requirements of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 and accompanying statutory guidance, particularly Regulation 17: Records of Personal Plans, Regulation 59: Records, and Regulation 78: Duty to Ensure There Are Systems in Place for Keeping of Records.

This policy is needed to enable people who use services to exercise their legal and moral rights to have access to the information about them held by {{org_field_name}}. {{org_field_name}} 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, which the person receiving care would follow if they wished to have access to these records.

Principles of Access

People who use services should have access to their own records in line with data protection requirements.

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. The data protection legislation does not give the user the right of access to information about other people.

The implication of the 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 receiving care, and the potential for greater accuracy. Only in rare circumstances should access be refused. The person seeking access to information should have {{org_field_name}}’s policy carefully explained to them.

Any request from people 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 advisers, 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 service, 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 person nominated under the Court of Protection, or who has power of attorney, or is an authorised agent.
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 manager.
12. Relatives, friends and third parties have no automatic right of access to an individual’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 section on Third Party Access.)
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 the care of the service. (See the policy on Applications for Access to a Deceased Individual’s Care Records (Wales).)
14. At the end of service {{org_field_name}} will keep the records in line with its retention policy. People receiving care 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 a 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 Lasting Power of Attorney (LPA) for Health and Welfare, which has been registered with the Court of Protection, to access an individual’s records and information to which a person has right of access; that is where the information contained will help or enable the LPA to carry out their lawful duties. The information requested should be relevant to the best interest decisions that the LPA must make on behalf of the person whom they are representing.

The LPA should make any request in writing (see Resources for a letter template). Where it is reasonable and lawful for the LPA 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 in line with the Social Care Wales: All Wales Induction Framework for Health and Social Care.

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. 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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