Information Governance Lead

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1 Peninsula Community Health Information Governance Policy Title: Information Governance Policy Procedural Document Type: Policy Reference: CO-IG-P04 CQC Outcome: Version: 2.0 Approved by: Information Governance Sub Committee Ratified by: Clinical Quality and Safety Committee Date ratified: Freedom of Information: Name of originator/author: Information Governance Lead Name of responsible team: Finance Review Frequency: 3 yearly Review Date: Target Audience: All staff, third parties, contractors Executive Signature (Hard Copy Only): Registered in England and Wales No: Registered office: Peninsula Community Health CIC, Sedgemoor Centre, Priory Road, St Austell PL25 5AS Quality care, closer to you Peninsula Community Health is a not for profit Community Interest Company responsible for providing NHS adult community health services in Cornwall and the Isles of Scilly

2 Contents 1 Introduction Definitions Duties Standards and Practice Legal Compliance Information Security Information Quality Assurance Openness Risk Management Strategy Implementation Implementation & Dissemination Training and Support Document Control & Archiving Arrangements Equality Impact Assessment Process for Monitoring Effective Implementation Associated Documentation References Please Note the Intention of this Document This Information Governance policy provides an overview of the organisation s approach to information governance (IG); details about the IG management structures within the organisation and a guide to the policies and procedures in use. Implementation of this policy will help to ensure: That the principles of Information Governance are clearly understood; Personal identifiable data is managed in accordance with legislation and national standards; Roles and responsibilities are clearly defined and staff informed of those who can provide advice and support. Review and Amendment Log Version No Type of Change Date 1 New February 2013 Description of change New policy 2 Review Oct 2015 Updated contact details, relevant policies, IGSC TOR and reference links 2 of 25

3 1 Introduction Information Governance is a framework to bring together all of the requirements, standards and best practice that apply to the handling of information. It allows organisations and individuals to ensure that information is accurate, dealt with legally, securely and efficiently in order to deliver the best possible care. Information is a vital asset, in terms of both the clinical management of individual service users and the efficient management of services and resources. It plays a key part in clinical governance, service planning and performance management. It is therefore of paramount importance that information is efficiently managed, and that appropriate policies, procedures and management accountability provide a robust governance framework for information management. Peninsula Community Health CIC (PCH) aims to work collaboratively with partner agencies to ensure any information governance issues which span more than one organisation are handled effectively and appropriately. To support this policy, PCH will create and maintain policies and procedures to support compliance with the requirements contained in the Department of Health s Information Governance Toolkit (IGTK) see section 7 for details of relevant supporting policies. This policy covers all aspects of information within the organisation, including but not limited to: Patient/client/service user information Personnel information Organisational information This policy covers all aspects of handling information, including (but not limited to): Structured record systems paper and electronic Transmission of information , post, fax and telephone This policy covers all information systems purchased, developed and managed by or on behalf of the organisation, and any individual directly employed or otherwise by the organisation. This policy is linked to the Information Governance (IG) Strategy. 3 of 25

4 2 Definitions Information Governance a framework that details how organisations must manage information about people and business. Information Governance Toolkit A self assessment on line tool developed by the Department of Health (DoH) that all organisations delivering NHS services are required to complete on an annual basis and to achieve level 2 compliance across all requirements in line with the NHS standard contract. The DoH provide the Care Quality Commission with an annual report of organisation s compliance results, from which the CQC may then carry out random audits of an organisation s toolkit submission. The results are also available to the public through the toolkit website, which provides the public with assurance that organisations manage their information in a secure manner. Statement of Internal Control - All organisations that wish to use NHS Connecting for Health services, including the N3 network, must complete the IG Statement of Compliance process. The IG Toolkit is part of this process, in that organisations must carry out an annual assessment, evidence their compliance with the requirements and accept the IG Assurance Statement which confirms the organisation s commitment to meeting and maintaining the required standards of information governance. Personal Identifiable Information (PID) - data relating to a living individual who can be identified either from the data, or from the data in conjunction with other information in the possession of the data controller. Sensitive Information Data Protection Act 1998 definition: means personal data consisting of information as to a. the racial or ethnic origin of the data subject, b. his political opinions, c. his religious beliefs or other beliefs of a similar nature, d. whether he is a member of a trade union (within the meaning of the [1992 c. 52.] Trade Union and Labour Relations (Consolidation) Act 1992), e. his physical or mental health or condition, f. his sexual life, g. the commission or alleged commission by him of any offence, or h. any proceedings for any offence committed or alleged to have been committed by him, the disposal of such proceedings or the sentence of any court in such proceedings. Data Subject - the individual person who is the subject of any relevant personal data 4 of 25

5 Data Controller - a person who (either alone or jointly or in common with other persons) determines the purposes for which and the manner in which any personal data are, or are to be, processed. Data Processor - in relation to personal data, means any person (other than an employee of the data controller) who processes the data on behalf of the data controller. Processing - means obtaining, recording, holding of the information or carrying out any operation or set of operations on the data including adapting, altering, retrieving, disclosing, dissemination, and consulting. Safe Haven processes that ensure that person identifiable and commercially sensitive data is transferred in a safe and secure manner. 3 Duties All information used in PCH is subject to handling by individuals and it is necessary for these individuals to be clear about their responsibilities. PCH must ensure that support and appropriate education and training are provided for all staff. To manage its obligations PCH will issue policies and procedures ensuring information is processed and shared correctly. All staff, whether permanent, temporary, voluntary or contracted, and contractors are responsible for ensuring that they are aware of and comply with the requirements of PCH s procedural documents. Failure to follow this and the associated policies and procedures will result in PCH enforcing its disciplinary procedure. Managers are responsible for ensuring that policies and supporting standards and guidelines are built into local processes and that there is on-going compliance. Key responsibilities include: Ensuring staff are aware of, and act upon, PCH s procedural documents. Implementing the procedural documents for the areas in which they apply. Notifying all new and existing staff on how to access procedural documents and ensuring that access is easily available. Ensuring that all staff members are aware of their responsibility in maintaining compliance with PCH procedural documents. The Chief Executive, as Accountable Officer for PCH, has overall accountability for IG in PCH and is required to provide assurance, through the Statement of Internal Control (SIC), that all risks relating to information are effectively managed. 5 of 25

6 The Chief Executive also ensures that the roles of Senior Information Risk Owner (SIRO) and Caldicott Guardian are assigned and supported. Caldicott Guardian is responsible for confidentiality management and decisions on patient data. The Senior Information Risk Owner provides the board-level lead on IG and is responsible for managing PCH information risk. Providing advice and assurance to the to the Accountable Officer on the content of the annual SIC with regard to information risk. The SIRO is responsible for providing leadership and guidance to PCH s Information Asset Owners and ensuring that the organisations Information Asset Register is maintained. The SIRO is supported by Information Governance Lead and the Information Governance Manager. Information Governance Lead is responsible at Corporate level for Information Governance. Information Governance Manager is responsible at the operational level, providing guidance and advice on information governance, including records management, and data protection issues conforming with legislative requirements and national standards. The IG Manager is supported by the Information Governance Team. Information Asset Owners (Service Leads/Locality Managers) are responsible for the information assets in their Service/Business Unit. Key responsibilities include: Maintain an Information Asset Register which will feed into the Corporate Information Asset Register. Know what information the Asset holds, what enters and leaves it and why information flow mapping. Reports IG related risks via Datix Risk Module for review by the SIRO. Ensure that there is a Business Continuity Plan is in place and that staff have easy access to it. Access control to the information asset approves/authorises individuals access to information and carries out regular checks on the access and use of information. Approves and minimises information transfers while achieving business purposes. Approves and oversees disposal mechanisms for information when there is no further requirement for it. 6 of 25

7 The IAO s are supported on a daily basis by Information Asset Assistants (Locality Administrators/Service Lead support). IT Security Team (Cornwall IT Shared Services) The IT Security Team is responsible for all aspects of information security and risk management. The IT Security Manager Information Governance, provides Policy/IG/Risk Management support on meeting the IT aspects of the IG Toolkit. The IT Security Manager Operational (RA Manager), provides technical day to day support. The PCH Board is responsible for ensuring that sufficient resources are provided to support the requirements of the IG Strategy and Policy. The Clinical Quality and Safety Committee (CQSC) is responsible, on behalf of the Board, for approval the minutes of the Information Governance Sub Committee (IGSC) and to ratify IG policies approved by the IGSC. The Information Governance Sub Committee (IGSC) is responsible for overseeing and advising on IG issues; ensuring the IG improvement plan is maintained and monitored against the requirements of the IG toolkit through the coordination of different workstreams; developing and maintaining policies, standards, procedures and guidance, coordinating IG in PCH and raising awareness of IG. The IGSC Terms of Reference can be found at Appendix 1. 4 Standards and Practice PCH undertakes to implement information governance effectively and will ensure the following: Information will be protected against unauthorised access; Confidentiality of information will be assured; Integrity of information will be maintained; Information will be supported by the highest quality data; Regulatory and legislative requirements will be met; Business continuity plans will be produced, maintained and tested; Information governance training will be available to all staff as necessary to their role; All breaches of confidentiality and information security, actual or suspected, will be reported and investigated. PCH recognises the need for an appropriate balance between openness and confidentiality in the management and use of information. PCH fully supports the principles of corporate governance and recognises its public accountability, but equally places importance on the confidentiality of, and the 7 of 25

8 security arrangements to safeguard, both personal information about patients and staff and commercially sensitive information. PCH also recognises the need to share patient information with other health organisations and other agencies in a controlled manner consistent with the interests of the patient and, in some circumstances, the public interest. PCH will ensure that when sharing information with another organisation that the patient has given consent or there is another legal justification for the sharing and that assurances are in place to confirm that the receiving organisation will handle the information in accordance with the legislative and national requirements, through one or more of the following ways:- Level 2 compliance of the Information Governance Toolkit; Data Protection notification with the Information Commissioner; Data Processing Contract; Information Sharing Protocol/Agreement Checks and agreements are managed through the Information Governance Team and Information Asset Owners. PCH Safehaven Guidelines for fax transmissions, transporting PID and sharing information by post are available through the intranet document library for staff to display in their area. Any changes to these terms will be communicated to staff. Pseudonymisation is a method which disguises the identity of patients by creating a pseudonym for each patient identifiable data item. This allows patient linking analysis needed within secondary uses. Sharing of data for these reasons must be carried out via the Information Team. Staff should only have access to the data that is necessary for the completion of the business activity which they are involved in. This is reflected in the Caldicott Principles; access should be on a need to know basis. This principle applies to the use of PID for secondary or non-direct care purposes. By de-identification users are able to make use of patient data for a range of secondary purposes without having to access the identifiable data items. PCH believes that accurate, timely, and relevant information is essential to deliver the highest quality health care. As such it is the responsibility of all clinicians and managers to ensure and promote the quality of information and to actively use information in decision making processes. There are 5 key interlinked strands to the IG policy: Legal compliance Information security Quality assurance Training and awareness Openness 8 of 25

9 4.1 Legal Compliance Peninsula Community Health ensures legal compliance by: Treating all person identifiable information relating to service users as confidential except for occasions where it is in receipt of a Court Order or where it is deemed in the wider public interest, or for a statutory right; Understanding that service users have the right to request access to information relating to their own health care, their options for treatment and their rights as service users. Disclosure of such information will be in line with the Data Protection Act (for living individuals) and Access to Health Records Act (for deceased individuals); Treating all person identifiable information relating to staff as confidential except where national policy on accountability and openness requires otherwise or, except for occasions where it is in receipt of a Court Order or, where it is deemed in the wider public interest, or for a statutory right; Establishing and maintaining policies and procedures to ensure compliance with Data Protection, Common Law Duty of Confidentiality, the NHS Code of Confidentiality and Human Rights Legislation; Ensuring effective confidentiality and security practice of its staff through induction and annual mandatory training and contract of employment clauses; Undertaking or commissioning annual assessments and audits of its compliance with legal requirements. 4.2 Information Security Peninsula Community Health will: undertake risk assessments to determine appropriate security controls are in place for existing or potential information systems; promote effective confidentiality and security practice to its staff through policies, procedures, induction and training; ensure that all transfers of information into, and out of PCH are in compliance with anonymisation/pseudonymisation principles where appropriate, safe haven guidance and information security standards; establish and maintain incident reporting procedures and will monitor and investigate all reported instances of actual or potential breaches of confidentiality and security; use and or commission through shared services BS ISO/IEC 27001: 2005, BS ISO/IEC 27002: 2005 BS : 2005 as the basis of its information security management arrangements. In addition, the Information Governance Toolkit shall form the basis of the Trust s Information Security Management System (ISMS); seek to undertake or commission annual assessments and audits of its information and IT security arrangements. 4.3 Information Quality Assurance Peninsula Community Health will: 9 of 25

10 Establish and maintain policies and procedures for information quality assurance based on the principals of high quality information being: o Complete o Accurate o Reliable o Accessible o Timely Undertake or commission annual assessments and audits of its information quality. Expect Managers to take ownership of, and seek to improve, the quality of information within their services. Wherever possible, information quality should be contemporaneously recorded, or assured at the point of collection. Set data standards through clear and consistent definition of data items, in accordance with national standards. Promote information quality and effective records management through policies, procedures, induction and training. Health records standards have been set through the identification of best practice and in accordance with national standards and initiatives. undertake or commission annual assessments and audits of its health record management systems. develop an Information Lifecycle Management Strategy (incorporated into the Records Management Policy), together with policies for the management of its manual and electronic corporate records. Managers are expected to ensure effective records management within their service areas 4.4 Openness Peninsula Community Health CIC is not a public body and as such is not subject to the Freedom of Information Act However, in the interest of the public and PCH s Code of Openness, non-confidential information about the organisation and its services is available to the public through a variety of media, including the organisations web site. PCH have also agreed to work with the Commissioning body to answer any requests placed on them under their statutory duty. All requests for information should be directed to the Information Governance Service, details of appropriate staff is detailed in Appendix 4. PCH will undertake or commission annual assessments and audits of its policies and arrangements for openness. Procedures will be put in place to ensure that patients have appropriate access to information relating to their own health care, their options for treatment and their rights as patients. PCH will have clear procedures and arrangements for liaison with the press and broadcasting media. 10 of 25

11 5 Risk Management Strategy Implementation 5.1 Implementation & Dissemination This document will be launched through the weekly bulletin and added to the Documents Library on the NHS Cornwall Intranet site under Information Governance for all staff to access. 5.2 Training and Support The national requirement is that 95% of ALL staff must have successfully completed Information Governance training between April and March each financial year. All staff carry out Induction training on appointment and part of that training covers Information Governance. Thereafter, staff are contractually bound to complete annual refresher Information Governance training. Training is available via: e-learning either through the National Learning Management System (NLMS) or through the NHS IG Training Tool. Classroom based sessions delivered by the training department or locality based trainers. Ad hoc bespoke training provided by the IG Team. In addition to mandatory annual refresher training, staff are encouraged to review and complete, as appropriate to their roles and responsibilities, further specialised training available through the NHS IG Training Tool. Details of the course content can be found on the PCH Intranet webpage; Resources; Information Governance and the training brochure. 5.3 Document Control & Archiving Arrangements Once ratified, this policy will be loaded to the documents library. Any previous versions will be electronically archived by the Policy Administrator in the electronic Policy Drive Archive Folder. A signed hard copy of the policy will be forwarded to the Policy Administrator and an electronic copy will be saved by the Policy Administrator in the electronic Policy Drive. Further copies of current and archived policies can be obtained from the Policy Administrator including versions in large print, Braille and other languages. 5.4 Equality Impact Assessment Peninsula Community Health aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. As part of its development, this strategy and its impact on equality have been assessed. The assessment is to minimise and if possible remove any disproportionate impact on employees on the grounds of race sex, disability, age, sexual orientation or religious belief. No detriment was identified. 11 of 25

12 6 Process for Monitoring Effective Implementation The IGSC will, through the Information Governance Toolkit, monitor information governance standards and processes across the organisation throughout the year and will develop an going work plan to address any areas for improvement or development. The IGSC will commission and review an annual external audit report and make any necessary improvements and or develop an action plan prior to final IGTK submission on 31 st March each year. Ad hoc audits will be carried out across the organisation as and when required and or in response to IG related reported incidents. 7 Associated Documentation The following list details the policies that support the IG Strategy and Policy. The list it is not exhaustive and further policies may be added to the document library according to legislative and national standard requirements. Acceptable Use Audio, Photographic and Video Recordings Confidentiality Code of Conduct for Employees Consent Data Protection Data Quality Disposal This policy defines what is acceptable and not acceptable use when using the Cornwall IT systems and the consequences of failing to follow the policy. To provide clear guidelines and associated template forms regarding audio, photographic and video recordings, in line with legal requirements, for the staff of Peninsula Community Health to utilise The Confidentiality Code of Conduct for Employees is a key document for all staff. The Code provides guidance for staff around the areas of consent, confidentiality and information sharing. Information about the Caldicott Principles and the Data Protection Principles is included. This policy provides guidance to staff regarding consent in a clinical setting. The Data Protection Policy details how the organisation will meet its legal obligations under the Data Protection Act 1998, and explains the eight principles of the Data Protection Act. The policy also provides guidance on individual s rights under the Act Details the organisations expectations of data quality management from all staff and the national standards the organisation is required to meet. This policy lays out the process that must be followed for the disposal of any IT related equipment The Policy and Procedure details how to ensure effective and appropriate use of to reduce the risk of adverse events by setting out the rules governing the sending, receiving, and storing of , including patient 12 of 25

13 Forensic Readiness Incident Management Information Risk Management Information Security IT Network Security IT System Level Security Malicious Software Mobile IT Security NHS Number identifiable and commercially sensitive data; establishing PCH and user rights and responsibilities for the use of the system; promoting awareness of and adherence to current legal requirements and NHS information governance standards. The Forensic Readiness Policy sets out the action that will be taken by the organisation in the event of an information security incident where digital evidence is required. This policy sets out the roles and responsibilities of all staff in relation to incidents and the arrangements for reporting and management of all incidents, including near misses and serious untoward incidents. This policy lays down the framework for a formal information risk management programme within PCH by explicitly establishing responsibility for information risk management and its oversight, information risk identification and analysis processes and planning for information risk mitigation. The Information Security Policy sets out the security management arrangements for the protection of patient records and key information systems This Policy describes the technical and operational controls in place to protect the organisations information and provides the guidance and reassurance that will enable employees and staff seconded to, or commissioned in discharging their duties responsibly and with confidence when using the organisations network and information systems; ensuring that the information and data is kept accurate, relevant, safe and secure, complete and confidential at all times. The policy provides a framework for staff that have managerial responsibility for PCH owned IT systems; this includes SystmOne, ICS, Software of Excellence and the Community Matrons database. The policy is required as part of the work required for Information Asset management. This policy is aimed at raising awareness amongst staff; and by complying with the policy and associated antivirus procedures, the risks to the Trusts of loss of service availability and data loss or corruption can be minimised The purpose of this policy is to prevent unauthorised disclosure, modification, removal or destruction of the organisations information assets, and disruption to business activities. The NHS Number policy sets out how the organisation will ensure that the correct NHS number is recorded for each active patient and used routinely in clinical communications and documentation. 13 of 25

14 Privacy Impact Assessments Records Management Record Retention Registration Authority Risk Safehaven Server Back Up Subject Access Requests Use of Live Data This policy sets out how the organisation ensures that changes to policy, procedures and commissioned services are assessed to ensure that they do not adversely impact upon patient confidentiality. A full assessment process, form and guidance note is attached. This Policy sets out how the organisation will manage its records effectively and ensure procedures are in place for the creation, use, storage, retention, tracking, availability, audit, retrieval and disposal of both its corporate/business and health records, in whatever format and media they are presented This schedule lists in alphabetical order the organisations records, as part of a particular function. The retention periods reflect the guidance from the NHS Records Management: Code of Practice Part 2. This will support the trusts compliance with the provisions of the Data Protection Act 1998, Access to Health Records Act 1990 and the Freedom of Information Act This schedule should be read in conjunction with the PCH Records Management Policy and PCH Confidential Waste Policy The NHS Smart Card and Registration Authority Policy sets out the responsibilities of the Registration Authority which issues and maintains electronic smart cards. Risk management strategy and risk assessment process within 1 document and will enable PCH to ensure staff manages risks according to the objectives of the organisation and includes reference to the assurance framework To provide guidance to ensure that personal information is handled in accordance with the Caldicott Regulations 1998, Data Protection Act 1998 and meets the requirements of the Information Governance Toolkit. To set out safeguards and procedures to ensure strict controls apply where personal or confidential information is handled. This Policy and Procedure sets out how staff will manage Subject Access Requests (SAR s) effectively and ensure procedures are in place to deal with subject access requests under The Access to Health Records Act 1990 (AHR), The Access to Medical Reports Act 1988 (AMR) and The Data Protection Act (DPA) Procedure to be followed when the requirement to use real or live data in the testing process for a new or revised information system 14 of 25

15 8 References National Web Pages IG Toolkit; Information Governance Alliance; Confidentiality; Security; Codes of Practice; HSCIC Data Flows including secondary uses; HSCIC Notice; IG Framework requirements; IG FAQ including Caldicott 2 report and recommendations; HSCIC Guide to Confidentiality and sharing data; NHS Constitution, including IG commitments; ew.aspx NHS Care Records Guarantee (commitments); Information Commissioners website and Data Protection Manual; The Data Protection Act The Freedom of Information Act Records Management: NHS Code of Practice dguidance/dh_ of 25

16 The Human Rights Act Access to Health Records Act Caldicott review of Patient Identifiable Information dguidance/dh_ Organisation webpages General access to safehaven fax numbers, privacy impact assessment form, safehaven procedures, NHS IG Training Tool nformation-governance.htm IG Training page; g-training.htm Subject Access Request Page; subject-access-request.htm Think Privacy confidentiality page; Sharing data page HSCIC Guide to Confidentilaity, Code of practice on Confidential Information, Confidentiality and information sharing for direct care leaflet, letter to CE s from dept of health; sharing-patient-information.htm Patient consent page How we use your health records leaflet and order code, poster, privacy impact assessment form; patient-consent.htm PALS data for staff; 16 of 25

17 Appendix 1: IGSC Terms of Reference Peninsula Community Health Information Governance Sub-Committee Terms of Reference 1. Purpose To oversee and provide leadership throughout the organisation for information governance ensuring compliance with regulatory body requirements and statutory responsibilities, fulfilling the requirements of administrative law, common law duty of confidentiality and to provide appropriate assurance that the organisation s responsibilities in relation to Information Governance are being met, in particular with the Operating Framework for the NHS, Informatics requirements. 2. Constitution and Accountability Peninsula Community Health Board Clinical Quality and Safety Committee Information Governance Sub Committee The Information Governance Sub Committee (herein referred to as IGSC ) operates under delegated authority from the Clinical Quality and Safety Committee (herein referred to as CQSC ). The IGSC is authorised to liaise with other internal and county committees, working groups and programme boards in order to promote Information Governance issues. 17 of 25

18 3. Membership The membership of the IGSC is as follows: Chair: Medical Director Janine Glazier (SIRO) Deputy Chair: IM&T Modernisation Lead Rachel Blewett (IG Lead) Members: Acting Director of Operations/Caldicott Guardian Jo Beer Locality Manager Anita Cornelius Information Governance Manager Gina Matthews IT Security Manager (advisory) Andrew Mann Representative from Therapy Service Roz Collins Representative of Matrons Margaret West Professional Lead for District Nursing Sara Reid Representative from HR/Training Annie Wing Representative from Communications Rebecca Biddle Information Manager Jo Wake 4. Quoracy and Attendance The committee shall be quorate when four members (one must be a member of the Board and one must be from the Information Governance team) are in attendance. When members are not able to attend deputies must be sent to represent them. A delegated deputy will not be empowered to make decisions. Additional members may be co-opted onto the sub-committee either as additional members of or for the duration of specific projects. 5. Meeting Frequency and Administration Meetings will be held quarterly with extra ordinary meetings being held at the Chair s request. Items for the agenda must be submitted two weeks prior to meetings. The agenda and any working papers will be circulated one week prior to meetings. Minutes and actions will be forward to the CQSC for agreement, to support a culture of openness and accountability and for the ratification of policy documents. All documentation produced by the committee shall be provided in electronic form using standard software applications and versions. The committee will endeavour to restrict paper documentation where possible to reduce costs and protect the environment. 18 of 25

19 Copies of documents will be retained in line with organisation policy. 19 of 25

20 6. Reporting Quarterly The IGSC will provide minutes and actions to the CQSC for approval and will seek ratification of policy documents. As Requested Annually The IGSC Chair will provide a report to the Board providing assurance that management and accountability arrangements are adequate and that future changes in the IG agenda are reported in a timely manner. The IGSC Chair will provide an annual Information Governance report, which will include details of serious untoward incidents involving actual or potential loss of personal data or breach of confidentiality and information risks. 7. Roles and Responsibilities The committee has responsibility for setting strategy encompassing all aspects of Information Governance and providing assurance to PCH Board that statutory and regulatory requirements are met. To ensure that the organisation achieves a minimum level of compliance, within specified timescales, against all IG Toolkit requirements: o Information Governance Management o Confidentiality and Data Protection Assurance o Information Security Assurance o Clinical Information Assurance o Secondary Use Assurance o Corporate Information Assurance And to sign off the Information Governance Toolkit return prior to submission in line with the timetable issued each year. To ensure that the organisation has effective policies and management arrangements covering all aspects of information governance in line with the current legislation, NHS guidance/policies and professional codes of practice. To provide support, advice and assistance to the Caldicott Guardian and SIRO. 20 of 25

21 To receive and consider reports into breaches of confidentiality and security and where appropriate undertake or recommend remedial action and when appropriate recommend, to the SIRO, declaration of a Serious Incident and participate in investigations. Communicate and assist in embedding information governance developments and standards to staff and appropriate forums. Scrutinise and review identified IG related risks and advise appropriate mitigation or acceptance. Ensure effective reporting of information governance matters to the CQSC, who in turn report to the Board. To review and approve policy in relation to IG prior to submission to the CQSC who will ratify on behalf of the Board. Ensure requirements of Information Governance are incorporated into training strategy and compliance is monitored. To ensure there is a robust framework for management of Information Assets including clear processes for the addition and removal of assets accompanied by regular audit to provide assurance that an asset register is accurate. To establish an Information Governance improvement plan, secure the relevant resources and monitor implementation of the plan. To assist the Senior Information Risk Owner (SIRO) in producing appropriate information for Board reports and in the preparation of an annual Information Governance Statement of Compliance. To ensure that the organisation develops and maintains an appropriate framework for the management and protection of information, which is appropriately supported by information asset owners and administrators. To liaise with other organisation groups/committees through work programmes in order to promote Information Governance and good practice. 8.0 Committee Review The terms of reference and committee membership shall be reviewed at least annually to ensure that it meets the organisations business needs and that the group is discharging its responsibilities as agreed in these terms of reference. 21 of 25

22 22 of 25

23 Appendix 2 : The Data Protection Act & Caldicott Report Principles The Data Protection Act Principles state that personal information: Shall be processed and used fairly & lawfully; Shall not be used in any manner incompatible with the purpose for which it has been obtained; Shall be adequate, relevant and not excessive in relation to the purpose or purposes for which they are used; Shall be accurate; Shall not be kept for longer than is necessary; Shall be used in accordance with the rights of the individual; Appropriate measures shall be taken against unauthorised disclosure; Shall not be transferred to a country or territory outside the European Economic Area with inadequate levels of protection for the rights and freedoms of the person in relation to their information.* * HSCIC states that no PID is to be sent outside the UK without a separate further contract. NHS Caldicott Report Principles Principle 1. Justify the purpose(s) for using confidential information Every proposed use or transfer of personal confidential data within or from an organisation should be clearly defined, scrutinised and documented, with continuing uses regularly reviewed, by an appropriate guardian. Principle 2. Don't use personal confidential data unless it is absolutely necessary Personal confidential data items should not be included unless it is essential for the specified purpose(s) of that flow. The need for patients to be identified should be considered at each stage of satisfying the purpose(s). Principle 3. Use the minimum necessary personal confidential data Where use of personal confidential data is considered to be essential, the inclusion of each individual item of data should be considered and justified so that the minimum amount of personal confidential data is transferred or accessible as is necessary for a given function to be carried out. Principle 4. Access to personal confidential data should be on a strict need-to-know basis Only those individuals who need access to personal confidential data should have access to it, and they should only have access to the data items that they need to see. This may mean introducing access controls or splitting data flows where one data flow is used for several purposes. 23 of 25

24 Principle 5. Everyone with access to personal confidential data should be aware of their responsibilities Action should be taken to ensure that those handling personal confidential data - both clinical and non-clinical staff - are made fully aware of their responsibilities and obligations to respect patient confidentiality. Principle 6. Comply with the law Every use of personal confidential data must be lawful. Someone in each organisation handling personal confidential data should be responsible for ensuring that the organisation complies with legal requirements. Principle 7. The duty to share information can be as important as the duty to protect patient confidentiality Health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by these principles. They should be supported by the policies of their employers, regulators and professional bodies. 24 of 25

25 Appendix 3: Key IG Staff Contact Details Job/Name Contact No Postal Address Information Governance Department Tel: / / Fax: Peninsula Community Health CIC IG Team Large Meeting Room Camborne Redruth Community Hospital Reduth Cornwall Caldicott Guardian Senior Information Risk Owner TR15 3ER Sedgemoor Centre Priory Road St Austell PL25 5AS Sedgemoor Centre Priory Road St Austell PL25 5AS 25 of 25

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