BOARD OF DIRECTORS PAPER COVER SHEET. Meeting date: 22 February Title: Information Security Policy

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1 BOARD OF DIRECTORS PAPER COVER SHEET Meeting date: 22 February 2006 Agenda item:7 Title: Purpose: The Trust Board to approve the updated Summary: The Trust is required to have and update each year a policy covering Information Security matters. The enclosed existing policy has been reviewed and is now submitted to the Trust Board for approval Recommendation: Board to approve the attached Information Security policy Prepared by: S Martin Presented by: Mike Stevens, Director of Finance & Information This report covers: (Please tick relevant box below) Healthcare Standards Monitor (CORE please specify which standard) Healthcare Standards Finance (DEV T please specify which standard) Service Development Performance Management Strategy Local Delivery Plan Business Planning Assurance Framework X Complaints Other (Please specify) MS Part I (vs. 1.4) Page 1 of 15

2 INFORMATION SECURITY POLICY Post holder responsible for Policy: Directorate / Department responsible for Policy: Wendy Ware IMT Services Contact details: Date written: January April 2005 Date revised: Approval route (names of committees): Information Committee IMT Shared Services Committee Date of final approval: Date due for revision: Date policy becomes live: This document replaces: Controlled Document This document has been created following the Royal Devon & Exeter NHS Foundation Trust Policy on the creation of policies, procedures, protocols, guidelines and standards. It should not be altered in any way without the express permission of the author or their representative. MS Part I (vs. 1.4) Page 2 of 15

3 Document Location This document is only valid on the day it was printed. The source of the document can be found on the Trust s Internet at and Trust Comex site IM&T. Revision History Date of this revision: 1 st April, 2005 Date of Next revision: August 2006 Ver. Date Author Status Issued to Ver. Date Author Status Issued To /11/2003 P.Page First Draft for discussion RD&E Shared IM&T Services W.Ware T.Dymond S.Moses J.Treadwell M.Holley J.Smith /07/2004 P.Page Second Draft for discussion RD&E Shared IM&T Services W.Ware RD&E Information Committee Membership /02/2005 J Treadwell Review of discussions No one yet J Treadwell Final Draft for ratification Information committee and internal audit J Treadwell Product of ratification As above Next Revision Due: Approvals This document requires the following approvals. Project Role Name Title Organisation Name Title Information Committee Approved on MS Part I (vs. 1.4) Page 3 of 15

4 Contents Document Location... 3 Revision History... 3 Approvals... 3 Executive Summary... 5 Statement of Intent Introduction The need for a security policy Statement Scope Security management Objective Organisation management Security Policy Awareness Auditors Purchase of Information Systems Access to secure computer facilities Disposal of Equipment and Media Information Storage Information Backup Business Continuity Information Transmission and Networks Local and Wide Area Networks Web Services (Internet & ) Notification of Staff Changes Security of third party access to organisation s data Desktop Policy Use and Installation of Software Passwords Blank Screen Policy Clear Desk Policy Management of Manual Records...12 Appendices Appendix A...13 List of Policies...13 Appendix B...14 List of relevant legislation...14 MS Part I (vs. 1.4) Page 4 of 15

5 Executive Summary The Trust's revised sets the framework within which information will be managed. It demonstrates to all staff, the Trust s determination that information will be processed within a secure and confidential environment. The commonly accepted definition of Information Security is that it consists of: Confidentiality: This is the prevention of unauthorised access to information and data by individuals from both inside and outside the organisation. Integrity: Information Systems function correctly and do not give rise to erroneous information either accidentally or maliciously. The requirement for integrity also includes protecting system and data from destruction. Availability: This is concerned with ensuring that both systems and data are available at all times when they are needed by the organisation. There is a reference to all relevant legislation within the policy. The Trust's Policy also covers other areas such as Computer Access Controls (both in terms of physical environment and computer applications) and Disaster Recovery. Statement of Intent Trust patients, clients and other stakeholders have a right to expect that their personal data will only be examined either by people directly involved in their care and treatment, or by people who are involved in the monitoring and evaluation of that care, or by people requiring to complete processes that are necessary for the orderly functioning of the NHS. In addition, other records (including staff records, etc.) not directly related to patients and clients, required to be kept and managed by the Trust will only be accessed by appropriately designated personnel. That same group of stakeholders have a right to expect that the Trust will manage all information assets in such a manner that security threats are minimised by the use of best practice and adherence to statutory procedures. In recognition of the changes underway in the NHS and the effects of that these changes might have on Confidentiality and Security, this policy will be reviewed regularly, in the first instance months from implementation. MS Part I (vs. 1.4) Page 5 of 15

6 1. Introduction 1.1 The need for a security policy The organisation holds and manages a great deal of personal and confidential data relating to patients, the public and employees of the NHS. Increasing reliance is placed on computers to store and manipulate this information and with the ever-easier ways by which information can be passed around via the organisation s and other connected networks. It is important that a consistent approach is adopted to safeguard the organisation s information in the same way that other more tangible assets are secured, with due regard to the highly sensitive nature of some information held on both electronic and manual systems. This document describes the organisation s policy on information security and employees responsibilities for security of information held both manually and on computers. The is consistent with and supports the organisation s policies, procedures and existing methods of working, including Standing Orders and Standing Financial Instructions which take precedence on any specific issue, and is in accordance with NHS national guidance. A Staff Checklist (Acceptable use document) is in Appendix C. It is intended to help employees focus on the key areas that are likely to affect them on a day-to-day basis. The checklist should only be used once the itself is understood. A list of accompanying Policies which explain various aspects of this policy in greater detail are included in the appendices, for example: NHSNet Code of Connection Agreement Staff Checklist The Caldicott Principles Policy Fax Policy Staff Code of Conduct for using Portable Devices Procurement Policy Disposal of Equipment and Confidential Materials Policy Protocol for Sharing Information across Organisations Handling Requests for Access to Information from Agencies Handling with Requests for Access to Information from Patients & Staff Guidance To GP Appraisers relating to Data Protection and Caldicott 1.2 Statement The organisation s policy aims to ensure that:- All of the organisation s Information Systems are secure and confidential. In particular that MS Part I (vs. 1.4) Page 6 of 15

7 these are operated in accordance within NHS guidance, BS7799, Caldicott Guidance and relevant legislation. All staff are aware of this policy, the need to ensure appropriate secure and confidential handling of all personal and business sensitive information and their responsibilities in maintaining information security. Procedures to detect and resolve security breaches are in place. Failure by any employee of the Organisation to adhere to the policy and its guidelines will be viewed as a serious matter and may result in disciplinary action. Where employees believe that it is not possible to meet the policy and associated guidelines this must be brought to the attention of the Information Governance Manager and action agreed and notified to the appropriate management level within the organisation. 1.3 Scope This policy applies to: All Trust employees whilst engaged in work for the Trust at any location. Other persons working for the Trust or persons engaged on Trust business. All usage by anyone granted access to Trust information, whether it be manual records such as case notes or electronic access to the Trust network. 2. Security management 2.1 Objective To establish the management structure for Information Systems security within the organisation. 2.2 Organisation management Security is everybody's business and therefore it is everybody s responsibility to ensure information is, as appropriate, confidential, accurate and available to authorised users. This section describes the different areas of responsibilities for ensuring that the organisation s data remain secure. There is a clear division of responsibilities between the Board, Directors, IT Managers, Information Governance Manager, Line Managers, System Managers and Employees. Board Responsibilities The Trust Board has overall responsibility for all matters relating to security. All matters concerning security should be referred to the Information Governance Committee or equivalent. Directors, Heads of Departments and other line managers Directors and Heads of Departments should: MS Part I (vs. 1.4) Page 7 of 15

8 ensure that all current, new and temporary staff are instructed in their security responsibilities. ensure that all their staff using computer systems/media are trained in their use. ensure that no unauthorised staff are allowed to access any of the organisation s computer systems or information stores as such access could compromise information integrity. determine which individuals are to be given authority to access specific information: levels of access to specific systems should be on a job function need, independent of status. ensure that the IM&T Services are notified of new employees to allow access rights to be appropriately established from effective dates for shared mailboxes and shared data folders. inform system administrators of new employees to authorise appropriate access to information systems. inform system administrators and IM&T services when staff leave in order to terminate access. authorise new information systems and liaise with IM&T services over the appropriate level of security. implement procedures to minimise the organisation s exposure to fraud, theft, or disruption of its systems; such as segregation of duties, dual control or staff rotation in critical susceptible areas. ensure that current documentation is always maintained for all critical job functions to ensure continuity in the event of individual unavailability. ensure that all staff sign confidentiality (non-disclosure) undertakings as part of their contract of employment. report information security breaches to Information Governance Manager. Information Governance Manager The Information Governance Manager for the organisation is responsible for the implementation and enforcement of the and has organisational security management responsibilities for: monitoring and reporting on the state of Information security within the organisation. ensuring that the is implemented throughout the organisation. developing and enforcing detailed procedures to maintain information security. ensuring compliance with relevant legislation. reporting security issues to the Deputy Director of IMT. providing an advisory service on information security and information governance. IM&T Manager(s) - The IM&T Manager(s) should: understand the risk to the computer assets and the information that is held on them. deploy appropriate security measures to reduce the threat and to reduce the impact of a threat that materialises. ensure periodic security reviews by systems managers as appropriate. ensure that new information systems provide an adequate level of security. System Managers - System Managers, are required to ensure compliance with the organisations and thereby maintain controls to provide: recommend and implement appropriate levels of access for staff/users. provide training for staff. MS Part I (vs. 1.4) Page 8 of 15

9 liaise with IM&T services over 3 rd party access. collaborate with internal audit over system security reviews. manage upgrades to systems in partnership with IM&T services. Staff - Employees, including those under contract and agency staff, are: responsible for conforming to the. required to bring to their manager or Information Governance Manager's attention areas of concern regarding information security. Security Incident Management - All staff are responsible for ensuring that no actual or potential security breaches occur as a result of their actions. Staff will report breaches through the Incident Reporting mechanism. The organisation will investigate all suspected / actual security breaches and report to the appropriate bodies. A breach is defined as any incident which compromises the 3 tenets of security confidentiality, integrity and availability. 2.4 Security Policy Awareness New starters will be made aware of the policy at the organisation s corporate induction. Staff will be made aware that if they have concerns about security that there are adequate processes for them to make those concerns known. As part of the induction: All staff will be required to read and sign a code of conduct agreement covering access to network, and data shares. All new staff will sign confidentiality (non-disclosure) undertakings as part of their contract of employment. 2.7 Auditors The organisation s policy, its implementation and systems will be subject to periodic review by both internal and external auditors, the recommendations from which will normally be implemented unless an alternative action plan is agreed with management. Any major security incident is liable to be referred to the auditors for investigation. 4 Purchase of Information Systems 4.1 All staff will liaise with IM&T services over the procurement and implementation of information systems. 5 Access to secure computer facilities There is a need to protect the organisation s equipment and systems against loss or damage and ensure availability of information systems. All access to computers located within the organisation s properties must be restricted through the use of the same precautions that are taken for other valuable assets of the organisation. Such restrictions include perimeter security, making sure that security doors are closed properly, blinds drawn, and that any door entry codes are changed regularly. MS Part I (vs. 1.4) Page 9 of 15

10 5.1.2 Disposal of Equipment and Media Computer assets must be disposed of in accordance with the Trusts Disposal of IT Equipment Policy and standing financial instructions. This includes removable computer media, such as tapes and disks and printed reports. All data storage devices will be purged of sensitive data prior to disposal Information Storage All personal data should be stored securely in line with the principles of the Data Protection Act 1998 and Caldicott guidelines. Further details may be found in Appendices A & B All staff must comply with Data Protection Act 1998 and must not be allowed to access information until line managers are satisfied that they understand and agree these responsibilities. This should be included in all contracts of employment. Information that is no longer required should be disposed of or archived securely and in line with the organisation s relevant policy listed below. Databases holding personal data will have a defined security and system management documentation for access, records and reports. This documentation must include a clear statement as to the use, or planned use of the personal information, which is cross-referenced to the Data Protection Notification. Appropriate security measures should be taken to safeguard information held in this way. This is the responsibility of the System Administration Information Backup Sensitive information must not be stored on individual drives on PCs. This area is covered by the organisation s data storage policy Business Continuity All designated sensitive and critical systems will have a written back-up procedure and disaster recovery plan. This is required to counteract interruptions to business activities and to protect critical business processes from the effects of major failures or disasters. This is the responsibility of the System Administrator. 5.2 Information Transmission and Networks Local and Wide Area Networks Through connection to the organisations network it is possible to receive and forward information to other users of the network and other organisations networks using, for example, electronic mail. Should employees receive, identify how to, or gain access to unauthorised information on any networks then this event must be reported to the Information Governance Manager. MS Part I (vs. 1.4) Page 10 of 15

11 All computer files, transferred from other networks (including public access networks such as the 'Internet') and removable media must be checked for viruses before use within the organisation. Files stored on the network will be checked daily. No equipment will be connected to the network until advised by IM&T services that the system is ready for use. Employees must inform the IM&T Services Helpdesk if a virus attack is detected or suspected Web Services (Internet & ) Internet Staff using the Internet must ensure they comply with the organisation s Internet and policies. Copies of the signed code of connection forms will be stored on staff personnel files Notification of Staff Changes The Human Resources department will provide a leavers list each month to advise IM&T Services about staff changes affecting computer access (for example job function changes / leaving department or organisation) so that access rights may be amended or deleted, from effective dates Security of third party access to organisation s data Written agreement must be received from all external contractors and non-nhs parties that they agree to treat all information confidentially and that information will not be disclosed to unauthorised individuals. This agreement should also include a signed declaration that they understand the relevant legislation should they need to access sensitive information stored on a computer system. A security log must be maintained of all access to the organisation s network by external organisations for system support purposes. The Central Systems Team will hold this log. 5.3 Desktop Policy Use and Installation of Software This is covered by the organisation s software policy Passwords Passwords have a role in protecting systems from unauthorised access and are most effective when they: carry no meaning are not names, nor easily guessable are changed regularly and are not related to previous passwords are a minimum of 8 characters are a mixture of letters, numbers and symbols MS Part I (vs. 1.4) Page 11 of 15

12 are kept secret are not PASSWORD, VISITOR, GUEST or similar are not shared should be memorable, preferably through a cryptic association with the user This policy will ensure proper auditing of accesses made can be maintained and security of original user account is not compromised Blank Screen Policy Windows screen saver with password protection enabled will be used on all PCs with time-out set to ten minutes. Users need to set this protection up on their desktop. This does not apply to machines used by multiple users Clear Desk Policy Any confidential information must be placed out of sight, in locked cabinets/drawers when not in use. Likewise all offices/rooms which contain personal data should be locked when not in use. 5.4 Management of Manual Records Storing, archiving and disposing of manual records will be dealt with in accordance with the Trust s Records Management policy. MS Part I (vs. 1.4) Page 12 of 15

13 Appendices Appendix A List of Policies policy Internet policy Fax policy Portable device use policy Procurement policy Disposal of equipment and confidential materials policy Protocol for sharing information across organisations Handling requests for access to information from agencies Handling requests for access to information from patients and staff Data storage policy Software policy Generic user policy Records management policy Mail and internet filtering policy Anti Virus Policy External access to systems policy MS Part I (vs. 1.4) Page 13 of 15

14 Appendix B List of relevant legislation Copyright patents and designs act 1998 Computer misuse act 1990 Data protection act 1998 Freedom of information act 2000 Human Rights Act 1998 Health & Safety at Work Act 1974 Regulation of Investigatory Powers Act 2000 Health & Social Care Act 2000 MS Part I (vs. 1.4) Page 14 of 15

15 Appendix C Staff Checklist - Acceptable Use Document Usernames and Passwords: You have been issued with a unique username and password. They provide access to the Internet, and computer network. Do not disclose them to anyone, or write them down. Their use is monitored and misuse could lead to disciplinary action. Computer Network, NHSNet and Internet Access: The Trust is obliged to provide all staff with access to the Internet which it routinely monitors. Access is provided for access to clinical information, and for the efficient running of the Trust. Any inappropriate use may result in the withdrawal of an individual's password and/or disciplinary action. Use of The Trust is obliged to provide all staff with access to an individual mailbox. This account is primarily for business use but can be used for limited personal use. should not be used either to subscribe to any non-work related newsletters/bulletins or to further the distribution of chain letters or similar unsolicited messages. If an individual is unavailable it may be necessary for IT Support Staff to arrange for other access to the mailbox for business purposes. Use of any other service (e.g. Hotmail) is not supported by the Trust and must not be used for Trust business as they are not secure and you may place sensitive data at risk by using them. Downloading Files/Installing Software: Unauthorised software must not be downloaded to or used on Trust PCs. If you are in any doubt check with IT Support. All media must be scanned for viruses prior to any transfer of files or data to a Trust PC. This includes floppy disks, CDs and memory sticks. Electronic Document Storage: A secure area on a central server is provided for your use. Whenever you log on, it appears as your Z: drive. All work related documents and files must be stored on this. Security: If you believe that your username and password have been compromised, change your password and advise IT Support. All PCs and are protected by Anti Virus software. However, if you think that your system is infected contact IT Support immediately. If you suspect any inappropriate use of the Trust's PCs, , network, etc. Contact IT Support. MS Part I (vs. 1.4) Page 15 of 15

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