MANAGEMENT OF PERSONAL FILES POLICY Executive Director lead Author/ lead Feedback on implementation to Andrew Avery (Interim Director of HR) Liz Thompson (HR Manager) Liz Thompson (HR Manager) Date of draft February 2010 Consultation period Not Applicable Date of ratification April 2010 Ratified by Executive Directors Group Date of issue April 2011 Date for review April 2014 Target audience All SHSC Employees This Policy is stored and available through the SHSC website (www.shsc.nhs.uk) This Policy is based on good practice and complies with legislation. The Policy was previously agreed with the Joint Consultative Forum and was revised in July 2008. It has been transferred to the appropriate format for policies. This Policy was reviewed in April 2011 and will be reviewed before April 2014. 1
Contents Page Flowchart 3 1 Introduction 4 2 Scope of this Policy 4 3 Definitions 4 4 Purpose of this Policy 4 5 Duties 4 5.1 File Creation 4 5.2 Maintenance of Personal File 5 5.3 File Security and Access 5 5.4 Transfer of Personal Files 5-6 5.5 Personal File Management on Termination of an Employee 6 6 Dissemination, storage and archiving 6 7 Training and other resource implications for this policy 6 8 Audit and monitoring 6 9 Implementation Plan 7 10 Links to other policies 7 11 Contact details 7 12 References 7 Appendix A Staff information to be held on personal files 8 1 Personal 8 1.1 Personal details 1.2 Contract of Employment 1.3 Induction Record 1.4 Accident Forms 2 Training 8 2.1 Training 2.2 Policy / procedures 3 Line Management 9 3.1 Annual appraisal / PDR 3.2 Agreed supervision records 3.3 Agreed objectives 3.4 Disciplinary 4 Attendance 9 4.1 Sickness 4.2 Leave 5 General correspondence 9 5.1 General correspondence Supplementary Section A Stage One Equality Impact Assessment Form Supplementary Section B Human Rights Act Assessment Form and Flowchart Supplementary Section C Development and consultation process 10-12 13-14 15 2
PERSONAL FILE PROCEDURE After identification of successful Applicant the recruitment papers of the potential employee are removed from the recruitment file.these papers.will be held by the Recruitment team and will form the basis of the personal file. After all pre-employment checks are completed; this documentation is added to the personnel file. Personal File made up by Recruitment Team Sections Marked Personal/ Training/Line Management/Attendance/General Correspondence Personal File sent to Line Manager by the Recruitment Team on commencement. The details are logged onto a spreadsheet and on receipt of the file the manager is requested to acknowledge receipt Line manager acknowledges receipt and Recruitment Team record receipt form Personal File kept securely in a locked cabinet by Line Manager Following resignation, retirement or termination Personal File returned to the Recruitment Team for scanning. Documentation on Personal File scanned into electronic format by a member of the Recruitment Team 3
MANAGEMENT OF PERSONAL FILES POLICY 1. Introduction This policy sets out a framework for the use of personal files within the Trust. 2. Scope of this policy This Policy applies to all managers of the Trust. 3. Definitions Key Holders person(s) who are responsible for the security and access of personal files. 4. Purpose of this policy This policy enables all personal files for staff to be compiled in a standard format. It gives details of the transfer of files within the Trust and the storage of files following termination of employment. 5. Duties The Management of Personal Files During Employment 5.1 File Creation In accordance with the Trust s Recruitment and Selection Guidance, the Recruitment Team completes and collates the appropriate recruitment documentation which culminates in the creation of a personal file. This will be divided into the 5 sections outlined in Appendix A. This file is retained in Human Resources until: - A signed copy of the contract of employment is returned by the employee The file will be passed to the appropriate named contact in accordance with Directorate/Department instructions. If a signed copy of the contract has not been returned, the manager will be asked to obtain the signed copy of the contract from the employee, so that it may be placed on their personal file. In accordance with good practice advice from the Internal Audit Department a Batch Header is sent with the file(s), detailing the name(s) of the personal file(s) being sent, requesting that this Header be completed and returned by the manager to the Recruitment Team as confirmation of receipt. 4
5.2 Maintenance of Personal File The types of information that should be held on personal files are set out in Appendix A. Advice should be sought from a HR Advisor/ HR Directorate Partner about the appropriateness of including any information not on the list. It is important both for reasons of security and completeness, that all personal information on staff is filed away in date order (most recent at front) in a timely manner. This minimises the chance of breaches of confidentiality and ensures that the file represents an up to date record of an individual s employment. It is suggested that information within a file could be organised into the 5 sections identified in Appendix A, and separated by file dividers. This would make it easier to access attendance information for example, when carrying out the regular reviews of staff absence records. An employment history card can be used in the front of the file to record key personal information, changes in personal circumstances, details of job changes, etc, to provide a readily available source of information to make it easier to deal with queries, and respond to such things as reference requests. Any files removed from the filing system should be returned as soon as possible. A tracer card system should be used when any file is removed from the system to ensure it can be easily located. 5.3 File Security and Access For security reasons personal files should be kept in lockable cabinets or drawers. Files should be locked away when not in use. Files must be replaced immediately after use, if taken out for any reason. Designated key-holders are responsible for ensuring that this process is followed. It is recognised that Directorates/Departments may choose to hold files at different levels in the organisation, to respond to differing management arrangements, geographical spread, etc. It is important then that access to files should be properly controlled. Designated key holders should be clearly identified for each filing system, and ensure that any access is for bona fide reasons. Staff have legal rights of access to their own personal files held by their employers. The Trust takes the view that a file should be made available if an individual makes a request. In such cases managers are advised to ensure the confidentiality of any references provided by a previous employer, which may be on the file (but see Section1.2 of Appendix A) is maintained. Such access to a personal file should be supervised by the manager responsible for the files. Members of the HR Department may require access to personal files from time to time and will provide written confirmation of the request if asked to do so. 5.4 Transfer of Personal Files When a member of staff moves location, Department or Directorate within the Trust, it is the responsibility of their existing manager to deliver the personal file to the new manager, immediately after the last working day of the member of staff concerned. 5
Signed confirmation of the safe receipt of the file should be obtained from the new manager and held for audit purposes. Where delivery by hand proves impossible, transport will arrange a special delivery of files to other work sites, confirmation of receipt should still be requested from the new ( receiving ) manager. If using the post, care should be taken when parcelling the file(s) to ensure that the parcel will remain secure during its journey. The recruitment documentation relating to the new appointment/transfer of the member(s) of staff will be sent by the Recruitment Team to the new ( receiving ) manager, as soon as the necessary processes are completed. It will be necessary for the receiving manager to complete a changes form with the details of the change which has taken place. 5.5 Personal File Management on Termination of an Employee The personal files of staff who have left the Trust should be delivered to the HR Directorate on the last day of employment or as soon as possible thereafter. The personal file should contain annual leave cards/annual leave records so that there is an audit trail to support the annual leave outstanding /owing balance calculations which are recorded on the termination form, Personal files must be retained for a period of 6 years after termination of employment or until the former employees reach 70 years of age, whichever is the later. HR will be responsible for the maintenance and security of a central store for the personal files of staff who have left the Trust. 6. Dissemination, storage and archiving This policy is available on the SHSC intranet and available to all managers and staff. An e-mail will be sent to All SHSC staff informing them of the revised policy The previous version of this policy will be removed from the intranet and replaced with the current version by Human Resources.Managers are also responsible for ensuring hard copies of the previous version are removed from any policy/procedure manuals and files held locally. The previous policy will be removed from the Trust website by Human Resources. Human Resources will keep an electronic copy of the previous policy. Please contact them if a policy is needed 7. Training and other resource implications for this policy This policy is currently in operation. 8. Audit, monitoring and review 1. HR policies are subject to joint monitoring and review between Management and Staff Side in the Trust s Joint Consultative Forum (JCF) 6
2. Recommendations made by Internal Audit may lead to a revision of this policy 9. Implementation plan The policy has previously been implemented. The revised version will be disseminated as above. 10. Links to other policies Contents of the personal files may contain documentation relating to; Grievance Policy Disciplinary Policy Bullying and Harassment Policy Managing Sickness Absence Policy Carer leave Policy Maternity Leave Policy Adoption leave Policy Partner leave Policy Parental Leave Policy Capability Policy Career Break Policy Flexible Working Policy Job Share Policy Performance and Development Review Policy 11. Contact details Human Resources Department is available for support and advice. The contact details are available through the HR portal on the Trust s intranet. 12. References Records Management NHS Code of Practice Data Protection Act 7
Appendix A Staff information to be held on personal files Section 1 Personal 1.1 Personal details Personal Details Name, address, emergency contact numbers etc Personal Details Change Forms Driving Licence Details For Nominated Drives staff are expected to inform their manager of any traffic convictions Professional Registration and Updates if appropriate Copies Of Original Qualifications Certificates relevant to the application 1.2 Contract of Employment Contract of Employment Original Application Form Appointment Details Job Description Review on a regular basis. Post Details Change Forms (where this generates a new contract or a variation letter to original contract these will be sent to the manager under cover of a batch header requesting confirmation of receipt). Bank contract Where appropriate 1.3 Induction Record Trust Local 1.4 Accident Form(s) Section 2 - Training 2.1 Training Statutory Training To include evaluation Other Training To include evaluation Evaluation may be retained in Personal Development File once seen by the manager. 8
2.2 Policy/Procedures Record of those read, understood and signed (where applicable) may also form part of local induction record. Section 3 Line Management 3.1 Annual Appraisal/PDR 3.2 Agreed Supervision Records these records may be held in a separate file To include Ad Hoc supervision. 3.3 Agreed Objectives 3.3 Disciplinary On expiry of Disciplinary warnings, the letter should be retained on the personal file but will not remain live Section 4 - Attendance 4.1 Sickness Statutory Sick Pay Forms Any letters to employee relating to sickness absence Return to Work forms Occupational Health Correspondence Fit to Work Forms 4.2 Leave Annual Leave Record Carer Leave Record Parental Leave (identify Maternity/Paternity and Adoption Leave separately) Study Leave may be included in Section 2 Training Other Leave Records as appropriate e.g. unpaid leave, carer leave Full details may be removed from file after 2 years, but a condensed version must be retained. Section 5 - General Correspondence 5.1 General Correspondence This is a matter for individual line management s judgement 9
May include references for other posts Record of discussions/informal agreements reached about temporary adjustments in hours, problems/issues raises Other correspondence relating to SHSC policies which are not covered above. 10
Supplementary Section A - Stage One Equality Impact Assessment Form Please refer back to section 6.5 for additional information 1. Have you identified any areas where implementation of this policy would impact upon any of the categories below? If so, please give details of the evidence you have for this? Grounds / Area of impact People / Issues to consider Negative (it could disadvantage) Type of impact Race People from various racial groups (e.g. contained within the census) a Gender Male, Female or transsexual/transgender. Also consider caring, b parenting responsibilities, flexible working and equal pay concerns Disability The Disability Discrimination Act 1995 defines disability as a b physical or mental impairment which has a substantial and longterm effect on a persons ability to carry out normal day-to-day activities. This includes sensory impairment. Disabilities may be visible or non visible Sexual Orientation Lesbians, gay men, people who are bisexual b Age Children, young, old and middle aged people b Religion or belief People who have religious belief, are atheist or agnostic or have a philosophical belief that affects their view of the world. Consider faith categories individually and collectively when considering b possible positive and negative impacts. Positive (it could advantage Description of impact and reason / evidence 2. If you have identified that there may be a negative impact for any of the groups above please complete questions 2a-2e below. 2a. The negative impact identified is intended OR 2b. The negative impact identified not intended 2c. The negative impact identified is legal OR 2d. The negative impact identified is illegal OR (see 2e) (i.e. does it breach antidiscrimination legislation either directly or indirectly?) 2e. I don t know whether the negative impact identified is legal or not (If unsure you must take legal advice to ascertain the legality of the policy) 11
3. What is the level of impact? HIGH - Complete a FULL Impact Assessment (see end of this form for details of how to do this) MEDIUM - Complete a FULL Impact Assessment (see end of this form for details of how to do this) LOW - Consider questions 4-6 below 4. Can any low level negative impacts be removed (if so, give details of which ones and how) 5. If you have not identified any negative impacts, can any of the positive impacts be improved? (if so, give details of which ones and how) 6. If there is no evidence that the policy promotes equality and equal opportunity or improves relations with any of the above groups, could the policy be developed or changed so that it does? 7. Having considered the assessment, is any specific action required - Please outline this using the pro forma action plan below (The lead for the policy is responsible for putting mechanisms in place to ensure that the proposed action is undertaken) Issue Action proposed Lead Deadline 12
8. Lead person Declaration: 8a. Stage One assessment completed by :. (name). (signature) (date) 8b. Stage One assessment form received by Patient experience and Equality Team..(date) 8c. Stage One assessment outcome agreed. (sign here).... (Head of Patient Experience and Equality) OR (date agreed) 8d. Stage One assessment outcome need review.. (sign here).... (Head of Patient Experience and Equality).. (date returned to policy lead for amendment) (if review required please give details in text box below) If a full EQIA is required the stage 1 assessment form should be retained and a completed EQIA report submitted to the relevant governance group for agreement by the chair. The chair will forward the completed reports to the Patient Experience and Equality team for publication. Any questions relating to the completion of this form should be directed to the Head of Patient Experience and Equality. 13
Supplementary Section B - Human Rights Act Assessment Form and Flowchart You need to be confident that no aspect of this policy breaches a persons Human Rights. You can assume that if a policy is directly based on a law or national policy it will not therefore breach Human Rights. If the policy or any procedures in the policy, are based on a local decision which impact on individuals, then you will need to make sure their human rights are not breached. To do this, you will need to refer to the more detailed guidance that is available on the SHSC web site http://www.sct.nhs.uk/humanrights-273.asp (relevant sections numbers are referenced in grey boxes on diagram) and work through the flow chart on the next page. 1. Is your policy based on and in line with the current law (including caselaw) or policy? a Yes. No further action needed. r No. Work through the flow diagram over the page and then answer questions 2 and 3 below. 2. On completion of flow diagram is further action needed? No, no further action needed. Yes, go to question 3 3. Complete the table below to provide details of the actions required Action required By what date Responsible Person 14
Human Rights Assessment Flow Chart Complete text answers in boxes 1.1 1.3 and highlight your path through the flowchart by filling the YES/NO boxes red (do this by clicking on the YES/NO text boxes and then from the Format menu on the toolbar, choose Format Text Box and choose red from the Fill colour option). Once the flowchart is completed, return to the previous page to complete the Human Rights Act Assessment Form. 1.1 What is the policy/decision title?.. 1 1.2 What is the objective of the policy/decision?.. 1 1.3 Who will be affected by the policy/decision?.. 1 Will the policy/decision engage anyone s Convention rights? ------ 2.1 Will the policy/decision result in the restriction of a right? 2.2 NO NO Flowchart exit There is no need to continue with this checklist. However, o Be alert to any possibility that your policy may discriminate against anyone in the exercise of a Convention right o Legal advice may still be necessary if in any doubt, contact your lawyer o Things may change, and you may need to reassess the situation Is the right an absolute right? 3.1 YES 4 The right is a qualified right Is the right a limited right? 3.2 Will the right be limited only to the extent set out in the relevant Article of the Convention? 3.3 NO YES 1) Is there a legal basis for the restriction? AND 2) Does the restriction have a legitimate aim? AND 3) Is the restriction necessary in a democratic society? AND 4) Are you sure you are not using a sledgehammer to crack a nut? NO Policy/decision is likely to be human rights compliant BUT Policy/decision is not likely to be human rights compliant please contact the Head of Patient Experience, Inclusion and Diversity. Get legal advice Regardless of the answers to these questions, once human rights are being interfered with in a restrictive manner you should obtain legal advice. You should always seek legal advice if your policy is likely to discriminate against anyone in the exercise of a convention right. Access to legal advice MUST be authorised by the relevant Executive Director or Associate Director for policies (this will usually be the Chief Nurse). For further advice on access to legal advice, please contact the Complaints and Litigation Lead. 15
Supplementary Section C Development and consultation process This policy developed in consultation with the staff side when it was first issued in April 2003. As a result of an internal audit report it has been written in the Policy on Policies format. 16