This Policy supersedes the following Policy, which must now be destroyed :

Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Removable Media: Data Encryption Policy NTW(O)30 Lisa Quinn Executive Director of Performance and Assurance Sue Proud Information Governance Manager Trust-wide Policy Group Date ratified January 2015 Implementation Date February 2015 Date of full implementation February 2015 Review Date February 2018 Version number V06 Review and Amendment Log Version V06 Type of Change Annual Review Date Jan 2015 Description of Change Annual Review This Policy supersedes the following Policy, which must now be destroyed : Document Number NTW(O)30 V05.1 Title Removable Media: Data Encryption Policy

Removable Media: Data Encryption Policy Section Contents Page No. 1 Introduction 1 2 Purpose 1 3 Duties, Accountability and Responsibilities 2 4 Definition of Terms Used 3 5 Procedure / Process 3 6 Identification of Stakeholders 5 7 Training 5 8 Implementation 6 9 Fair Blame 6 10 Fraud, Bribery and Corruption 6 11 Monitoring Compliance 6 12 Associated Documents 7 13 References 7 Standard Appendices attached to Policy A Equality Analysis Screening Toolkit 8 B Training Checklist and Training Needs Analysis 10 C Monitoring Tool 12 D Policy Notification Record Sheet - click here Appendices listed separate to Policy Appendix No: Description Issue No: Issue Date Review Date 1 SIRO Approval Form 1 Feb 15 Feb 18 2 Removable Media: Data Encryption Policy- Summary 1 Feb 15 Feb 18

Practice Guidance Notes (PGN) listed separate to Policy PGN No: Description Issue No: Issue Date Review Date RM-PGN- 01 Secure Use of Unencrypted Audio Recording Equipment 1 Feb 15 Feb 18

1 Introduction 1.1 The NHS Chief Executive has directed that there should be no transfers of unencrypted person confidential data (PCD) held in electronic format across the NHS. This is the default position to ensure that patient and staff personal data are protected. Any data stored on a PC or other removable device in a non-secure area or on a portable device such as a laptop, PDA or mobile phone must also be encrypted. This is also now a requirement across all public sector organisations set by the Cabinet Secretary. 1.2 Across the private and public sectors, there have been a number of reports concerning portable media, containing personal information which have been stolen from vehicles, dwellings or left in inappropriate places without being protected adequately. The Information Commissioner has formed the view that in future, where such losses occur and where encryption software has not been used to protect the data, enforcement action will be pursued. 1.3 The Information Commissioners Office (ICO) states that portable and mobile devices including magnetic media, used to store and transmit personal information, the loss of which could cause damage or distress to individuals, must be protected using approved encryption software which is designed to guard against the compromise of information. This view has been fully endorsed by the NHS and all Trusts have been given mandatory directives in this respect. 1.4 Personal information, which is stored, transmitted or processed in information, communication and technical infrastructures, must also be managed and protected in accordance with the organisation s Security Policy and using best practice methodologies such as using the International Standard ISO / IEC 27002:2005. 1.5 (the Trust / NTW) has adopted the nationally procured NHS encryption solution to address this requirement, in part. 1.6 A further solution of fully encrypted USB memory sticks, in conjunction with device port control has also been deployed. 2 Purpose 2.1 To prevent unauthorised disclosure, modification, removal or destruction of NHS information, and disruption to NHS business activities and potentially distressing consequences of the loss of sensitive information. 2.2 All removable media for use on information systems containing person identifiable and other confidential data owned or operated by the Trust are covered by this Policy and must be encrypted using the NHS approved standard. 1

2.3 What data is classed as confidential? 2.3.1 Any piece of data, written or electronic and including visual images and audio recordings, which individually or with another piece of data, can positively identify a person. 2.3.2 Any commercially confidential or sensitive data including financial records, risk registers or tender documents. 2.4 What is removable media? All equipment used to store Trust data must belong to the Trust. Storage and transportation of such data is not permitted on personally owned equipment. Additionally, floppy disks, personal mobile phones and PDA s are not permitted for this purpose. 2.4.1 Removable media include but is not limited to tapes, floppy discs, removable or external hard disc drives, laptops, USB memory sticks, optical discs DVD and CD-rom, solid state memory devices including memory cards, mobile phones, PDA s, cameras / camcorders etc. 2.4.2 This Policy deals only with the encryption of removable media and does not apply to electronic messages sent by email. Securing confidential email messages is covered within the scope of the Acceptable Use of Email, Intranet and Internet Policy. 3 Duties, Accountability and Responsibilities Responsibility for implementation and compliance to this Policy lies with the Chief Executive; The Executive Director of Performance and Assurance as Senior Information Risk Owner (SIRO) has delegated responsibility from the Chief Executive All staff, including agency, temporary, voluntary, support staff and contractors who are permitted to use removable media in the performance of their duties, must apply the Data Encryption Policy in accordance with NHS Information Governance guidelines; The Director of Informatics is responsible for ensuring that the Trust has appropriate data encryption capabilities in order to protect data that is processed on removable media; The Director of Informatics is responsible for assuring that the data encryption functionality and policies used with removable media have been implemented correctly, are of appropriate strength and fit for purpose 2

Trust Directors, Managers and staff in collaboration with the information Governance Team are responsible for the dayto-day management and oversight of removable media used within their work areas to ensure this Policy is followed. The Caldicott and Health Informatics Group have responsibility for overseeing day to day compliance with this Policy and for investigating breaches; Failure to comply with this removable media data encryption policy may endanger the information services of the Trust and may result in disciplinary or criminal action. NTW(O)30 4 Definition of Terms Used 4.1 Encryption 4.1.1 Encryption is specialist software that uses a complex set of mathematical algorithms and encryption keys to scramble data. Where the required software and encryption keys are available, data can be read as normal. However, without the software and keys, information is unusable 4.2 Removable Media 4.2.1 Removable media include but is not limited to tapes, Floppy discs, removable or external hard disc drives, laptops, USB memory sticks, optical discs DVD and CD-rom, solid state memory devices including memory cards, mobile phones, PDA s, cameras / camcorders etc. 4.3 Information Commissioner 4.3.1 The Information Commissioner has been appointed by the Government to regulate the information related legislation in the UK, including the Data Protection Act 1998 and the Freedom of Information Act 2000. 4.4 Person Confidential Data 4.4.1 Any piece of data, including visual images and audio recordings, which individually or with another piece of data, can positively identify a person. 5 Procedure / Process 5.1 Departments within the Trust must adopt a structured approach to the identification, implementation and management of their local data encryption needs. This will normally comprise six stages: Perform Risk Assessment and identify outline data encryption needs; 3

Apply the Trust data encryption procedure; Establish local roles and responsibilities; Define how data encryption will operate within the local infrastructure and with business partners including business impact analysis; Implement and monitor deployed solution effectiveness; Seek advice where necessary 5.1.1 This process will be supported by the Informatics Department. 5.1.2 Data intended for storage or transportation on removable media must be considered for its sensitivity and potential impacts if lost, stolen or otherwise compromised. Individuals are responsible for assessing the risks and ensuring that all personal and confidential data is encrypted. 5.1.3 It must be noted that unencrypted person confidential data must not under any circumstances be stored or transported on any form of portable media, unless this has been formally approved by the Caldicott and Health Informatics Group and recorded in the Trust Risk Register for review by Board Level Groups. Where there is a clinical need, it is the responsibility of individuals to obtain consent, using the template at Appendix 1. 5.1.4 Encryption is specialist software that uses a complex set of mathematical algorithms and encryption keys to scramble data. Where the required software and encryption keys are available, data can be read as normal. However, without the software and keys, information is unusable. Encryption will allow the Trust to control access to its sensitive information held on portable media and protect it from unauthorised access. 5.1.5 The use of freeware, shareware or personal encryption software that is not supported by the Trust is not permitted, as it may not comply with the NHS recommended standards. 5.1.6 A Risk Assessment in accordance with NHS Information Governance guidance and the Trust Risk Management Strategy will determine if that data should be encrypted. Where the data is to be encrypted, this should be done using the Trust approved and supplied encryption solution. 5.1.7 In the first instance, the need to place sensitive information on removable media, whether encrypted or not, should also be considered. 5.1.8 The Trust will ensure that adequate guidance will be provided to staff in the use of encryption tools, and for the handling of encrypted removable media. 4

5.1.9 Where encrypted removable media is to be shared with another party, care must be taken to ensure that the intended recipient has the correct technical capability to decrypt the data on receipt and this should be established in advance of any sharing of media. 5.1.10 A summary of the Policy can be found at Appendix 2. 5.2 Encryption Key 5.2.1 The pass-phrase or decryption key used for encryption / decryption purposes must be sufficiently long and complex to prevent the encrypted information from attack. The decryption pass-phrase or key must never be sent with encrypted removable media. The use of the Trust s encryption solution will ensure that this requirement is met. 5.3 Home Working / Using Trust Information on Personal Equipment 5.3.1 The encryption solution will only be applicable to Trust owned equipment. Under no circumstances must staff create documents containing person confidential data on personally owned equipment. If staff have a business need to work from home on sensitive documents, an encrypted Trust laptop or approved encrypted USB memory stick must be used, or application made for remote access to the Trust network, via the IT Services Helpdesk. 5.3.2 Trust standard encrypted USB memory sticks can be ordered via the IT self-service link on the Intranet 6 Identification of Stakeholders 6.1 This is an existing Policy which has only minor changes that do not relate to operational and / or clinical practice therefore did not require a full consultation process. 7 Training 7.1 Training for this Policy is delivered where necessary by the Information Governance Team to the IAO s and IAA s. 7.2 Through consultation including Trust-wide Caldicott and Health Informatics Group and Group Business Meeting it has been ensured that: Full consideration has been given any training needs that have been identified during the development of a Policy; A full Trust-wide Training Needs Analysis has been undertaken, including who this will effect what level of training is required, how often training should be undertaken and any resource implication. 5

8 Implementation 8.1 Taking into consideration all the implications associated with this Policy, it is considered that a target date of February, 2015 is achievable for the contents to be implemented across the Trust. 8.2 This will be monitored as outlined in Appendix C, Monitoring Tool. 9 Fair Blame 9.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken. 10 Fraud, Bribery and Corruption 10.1 In accordance with the Trust s Policy NTW(O)23 Fraud, Bribery and Corruption Policy, all suspected cases of fraud and corruption should be reported immediately to the Trust s Local Counter Fraud Specialist or to the Executive Director of Finance. 11 Monitoring 11.1 Responsibility for monitoring compliance with this Policy locally lies with Directors and Line Managers. 11.2 The Information Governance Team will monitor compliance with this Policy through observation, spot checks and through incident management in line with the Trust Incident reporting process. 11.3 Any compliance issues will be reported to the line managers concerned and may be handled through staff disciplinary processes or contractual arrangements. 11.4 Incident Reporting 11.4.1 All incidents involving the loss of data whether encrypted or unencrypted must be reported immediately to the Information Governance department and dealt with in accordance with the Trust incident reporting procedure (See Trust Policy, NTW(O)05 - Incident Reporting and Procedures). 6

12 Associated Documents NTW(O)05 - Incident Policy, (including the management of Serious Untoward Incidents and associated Practice Guidance Notes (PGNs)); NTW(O)09 - Management of Records Policy (and associated PGNs); NTW(O)29 - Confidentiality Policy (and associated PGN); NTW(O)33 - Risk Management Policy; NTW(O)35 - Information Security Policy; NTW(O)36 - Data Protection Policy; NTW(O)44 - Visual Imaging and Audio Policy (and associated PGN); NTW(O)45 - Acceptable Use of Email, Intranet and Internet Policy (and associated PGN); NTW(O)55 - Information Risk Policy; NTW(O)62 - Information Sharing Policy. 13 References http://www.hscic.gov.uk/ www.ico.gov.uk Department of Health circulars on Removable Media. 7

Appendix A Equality and Diversity Impact Assessment Screening Tool Equality Analysis Screening Toolkit Names of Individuals involved in Review Date of Initial Screening Review Date Sue Proud August 2009 November 2014 Service Area / Directorate Trust-wide Policy to be analysed NTW(O)30 Removable Media: Data Encryption Policy Is this policy new or existing? Existing What are the intended outcomes of this work? Include outline of objectives and function aims This Policy has been created to ensure the security and confidentiality of data held by the Trust. Its purpose is to ensure that all staff are aware and adhere to the conditions of the National Safety Directive issued by the NHS nationally, and encryption of removable media mandated. Who will be affected? e.g. staff, service users, carers, wider public etc Staff. Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them Disability Sex Race Age Gender reassignment (including transgender) Sexual orientation. Religion or belief Marriage and Civil Partnership Pregnancy and maternity Carers Other identified groups How have you engaged stakeholders in gathering evidence or testing the evidence available? Though standard Policy consultation mechanisms. 8

How have you engaged stakeholders in testing the policy or programme proposals? Though standard Policy consultation mechanisms. For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: Though standard Policy consultation mechanisms. Summary of Analysis Considering the evidence and engagement activity you listed above please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life. Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic Eliminate discrimination, harassment and victimisation Advance equality of opportunity Promote good relations between groups What is the overall impact? Addressing the impact on equalities From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? NO If yes, has a Full Impact Assessment been recommended? If not, why not? Manager s signature: Sue Proud Date: November 2014 9

Appendix B Communication and Training Check List for Policies Key Questions for the accountable committees designing, reviewing or agreeing a new Trust Policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHSLA etc. Please identify the risks if training does not occur. No this is an existing Policy In order to comply with Data Protection Legislation, a directive has been issued by the NHS nationally, and encryption of removable media mandated Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. Trust-wide It is essential that all staff groups working with confidential / personal data are made aware of the Policy and the personal responsibilities associated with the national directive Team Brief, CEO Bulletin, Intranet, face to face training, E-learning Information Governance Manager 10

Appendix B continued Training Needs Analysis Staff/Professional Group Type of training Duration of Training Frequency of Training All staff who work with person confidential data Training on the use of removable media devices and adherence to Policy / PGN Depends on individual member of staff When required Copy of completed form to be sent to: Training and Development Department, St. Nicholas Hospital Should any advice be required, please contact:- 0191 223 2216 (internal 32216) 11

Appendix C Monitoring Tool Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, Policy Authors are required to include how monitoring of this Policy is linked to Auditable Standards / Key Performance Indicators will be undertaken using this framework. NTW(O)30 - Removable Media data Encryption Policy - Monitoring Framework Auditable Standard / Key Performance Indicators 1. The Trust will ensure that all removable media and portable devices are encrypted, where possible. Staff will be aware of their responsibilities and advice given where requested Frequency / Method / Person Responsible Where incidents occur this will be monitored on a weekly basis by the Information Governance Team Bi-monthly Information Governance Incident Reports submitted to CHIG, through IG Highlight Report Where Results & Any Associate Action Plan Will Be Reported To and Monitored; (this will usually be via the relevant Governance Group) Caldicott and Health Informatics Group 2. Where encryption cannot be applied to removable media or portable devices, Board approval will be obtained and / or a risk raised. Users advised to seek approval through CHIG. The IG Team will monitor this on a quarterly basis through the Minutes of the CHIG Meeting and routine updating of Risk Registers. A report will be presented to the CHIG on an annual basis. Caldicott and Health Informatics Group The Author(s) of each Policy is required to complete this monitoring template and ensure that these results are taken to the appropriate reporting governance group as above in line with the frequency set out. 12