Policies and Procedures

This page contains all of the Policies and Procedures that the surgery is publishing. Please click a link on the left to view that document.

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Policy for using a chaperone

Tuesday 15th September 2015 15:47

Aim:
This policy is designed to:

protect both patients & staff from abuse or allegations of abuse
assist patients to make an informed choice about their examinations & consultations Policy:
clinicians (male & female) should consider whether:
- an intimate or personal examination of the patient (either male or female) is justified, or
- whether the nature of the consultation poses a risk of misunderstanding
the patient should be given a clear explanation of what an examination will involve
always adopt a professional & considerate manner; be careful with humour as a way of relaxing a nervous situation as it can easily be misinterpreted
ensure that the patient is provided with adequate privacy to undress & dress
ensure that a suitable sign is clearly on display in each consulting or treatment room offering the chaperone service if required
consider whether it is appropriate to offer a chaperone
patients who request a chaperone should never be examined without a chaperone being present; where a chaperone is not available, the consultation/examination should be rearranged for a mutually convenient time when a chaperone can be present. Note:

complaints & claims have not been limited to male doctors with female patients
there are many examples of alleged homosexual assault by female & male doctors
consideration should also be given to the possibility of a malicious accusation by a patient

should the occasion arise when a chaperone is needed for a home visit the following procedure should still be followed

Who Can Act as a Chaperone?:

a variety of people can act as a chaperone in the practice but where possible a chaperone should be a clinical staff member familiar with procedural aspects of personal examination

where suitable clinical staff members are not available, the examination should be deferred

should a decision be made that non-clinical staff will act in this capacity, the patient must both agree to the presence of a non-clinician in the examination, & be at ease with this

the staff member should be trained in the procedural aspects of personal examinations, comfortable in acting in the role of chaperone, & confident in the scope & extent of their role

instruction will be given on where to stand & what to watch & instructions to that effect will be laid down in writing by the practice

Confidentiality:

The chaperone should only be present for the examination itself, & most discussion with the patient should take place while the chaperone is not present
patients should be reassured that all practice staff understand their responsibility not to divulge confidential information.

Click here to link to the latest GMC guidelines for intimate examinations: http://www.gmc-uk.org/guidance/ethical_guidance/21170.asp

Procedure:

the clinician will contact reception to request a chaperone
should a chaperone not be available, the clinician may offer to delay the examination, as long as the delay would not have an adverse effect on the patient's health, to delay the examination
if a clinician wishes to conduct an examination with a chaperone present but the patient does not agree to this, the clinician must clearly explain why they want a chaperone to be present
the clinician may choose to consider referring the patient to a colleague who would be willing to examine them without a chaperone, as long as the delay would not have an adverse effect on the patient's health
the clinician will record in the notes that the chaperone is present & identify the chaperone
the chaperone will:

enter the room discreetly & remain in the room until the clinician has finished the examination
normally attend inside the curtain at the head of the examination couch & watch the procedure

to prevent embarrassment, the chaperone should not enter into conversation with the patient or GP unless requested to do so, or make any mention of the consultation afterwards
the chaperone will make a record in the patient's notes after examination; the record will state that there were no problems or give details of any concerns or incidents that occurred
the patient can refuse a chaperone: this must be recorded in the patient's medical record

Readcodes for patient records:

9NPO chaperone offered
9NP2 chaperone refused
9NP1 chaperone present
9NP4 chaperone not available

Privacy Notice

Monday 7th June 2021 16:34

How we use your personal information

This notice explains why the GP practice collects information about you and how that

information may be used.

Health care professionals who provide you with care maintain records about your health and any treatment or care you have received previously (e.g. NHS Trust, GP Surgery, Walk-in clinic, etc.). These records are used to help to provide you with the best possible healthcare. NHS health care records may be electronic, on paper or a mixture of both, and we use a combination of working practices and technology to ensure that your information is kept confidential and secure. Records this GP Practice hold about you may include the following information;

Details about you, such as your name, address, carers, legal representatives and emergency contact details
Any contact the surgery has had with you, such as appointments, clinic visits, emergency appointments, etc.
Notes and reports about your health • Details about your treatment and care
Results of investigations such as laboratory tests, x-rays, etc.
Relevant information from other health professionals, relatives or those who care for you

To ensure you receive the best possible care, your records are used to facilitate the care you receive. Information held about you may be used to help protect the health of the public and to help us manage the NHS. Information may be used within the GP practice for clinical audit to monitor the quality of the service provided.

Some of this information will be held centrally and used for statistical purposes. Where we do this, we take strict measures to ensure that individual patients cannot be identified. Sometimes your information may be requested to be used for research purposes – the surgery will always gain your consent before releasing the information for this purpose.

Risk Stratification

Risk stratification data tools are increasingly being used in the NHS to help determine a person’s risk of suffering a particular condition, preventing an unplanned or (re)admission and identifying a need for preventive intervention. Information about you is collected from a number of sources including NHS Trusts and from this GP Practice. A risk score is then arrived at through an analysis of your de-identified information using software and is only provided back to your GP as data controller in an identifiable form. Risk stratification enables your GP to focus on preventing ill health and not just the treatment of sickness. If necessary your GP may be able to offer you additional services. Please note that you have the right to opt out of your data being used in this way.

Medicines Management

The Practice may conduct Medicines Management Reviews of medications prescribed to its patients. This service performs a review of prescribed medications to ensure patients receive the most appropriate, up to date and cost effective treatments. This service is provided to practices within Cornwall through Kernow Clinical Commissioning Group.

How do we maintain the confidentiality of your records?

We are committed to protecting your privacy and will only use information collected lawfully in accordance with:

Data Protection Act 1998 and General Data Protection Regulation 2016 Human Rights Act 1998
Common Law Duty of Confidentiality
Health and Social Care Act 2012
NHS Codes of Confidentiality, Information Security and Records Management
Information: To Share or Not to Share Review

Every member of staff who works for an NHS organisation has a legal obligation to keep information about you confidential.

We will only ever use or pass on information about you if others involved in your care have a genuine need for it. We will not disclose your information to any third party without your permission unless there are exceptional circumstances (i.e. life or death situations), where the law requires information to be passed on and / or in accordance with the new information sharing principle following Dame Fiona Caldicott’s information sharing review (Information to share or not to share) where “The duty to share information can be as important as the duty to protect patient confidentiality.” This means that 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 the Caldicott principles. They should be supported by the policies of their employers, regulators and professional bodies.

Who are our partner organisations?

We may also have to share your information, subject to strict agreements on how it will be used, with the following organisations;

NHS Trusts / Foundation Trusts
GP's
NHS Commissioning Support Units
Independent Contractors such as dentists, opticians, pharmacists
Private Sector Providers
Voluntary Sector Providers
Ambulance Trusts
Clinical Commissioning Groups
Social Care Services
Health and Social Care Information Centre (HSCIC)
Local Authorities
Education Services
Fire and Rescue Services
Police & Judicial Services
Voluntary Sector Providers
Private Sector Providers
Other 'data processors' which you will be informed of

You will be informed who your data will be shared with and in some cases asked for explicit consent for this happen when this is required. We may also use external companies to process personal information, such as for archiving purposes. These companies are bound by contractual agreements to ensure information is kept confidential and secure.

Access to personal information

You have a right under the Data Protection Act 1998 to request access to view or to obtain copies of what information the surgery holds about you and to have it amended should it be inaccurate. In order to request this, you need to do the following:

Your request must be made in writing to the Practice Manager – for information from the hospital you should write direct to them
There may be a charge to have a printed copy of the information held about you if the request is deemed ‘excessive’
We are required to respond to you within one month
You will need to provide two forms of identification including one photo ID (ie passport or driving license) and one form proving proof of address (utility bill) so that records can be verified and your records located

Objections / Complaints

Should you have any concerns about how your information is managed at the GP, please contact the Practice Manager. If you are still unhappy following a review by the GP practice, you can then complain to the Information Commissioners Office (ICO) via their website (www.ico.gov.uk).

If you are happy for your data to be extracted and used for the purposes described in this privacy notice then you do not need to do anything. If you have any concerns about how your data is shared then please contact the practice.

Change of Details

It is important that you tell the person treating you if any of your details such as your name or address have changed or if any of your details such as date of birth is incorrect in order for this to be amended. You have a responsibility to inform us of any changes so our records are accurate and up to date for you.

Notification

The Data Protection Act 1998 requires organisations to register a notification with the Information Commissioner to describe the purposes for which they process personal and sensitive information. This information is publicly available on the Information Commissioners Office website www.ico.org.uk The practice is registered with the Information Commissioners Office (ICO).

Who is the Data Controller?

The Data Controller, responsible for keeping your information secure and confidential is: Meneage Street Surgery, 100 Meneage Street, Helston, TR13 8RF.

Complaints

Should you have any concerns about how your information is managed by the Practice please contact the Practice Manager at the following address: Meneage Street Surgery, 100 Meneage Street, Helston, TR13 8RF. If you are still unhappy following a review by the Practice you can then complain to the Information Commissioners Office (ICO). www.ico.org.uk, casework@ico.org.uk, telephone: 0303 123 1113 (local rate) or 01625 545 745

Privacy Notice - Direct Care (routine care and referrals)

Monday 7th June 2021 16:37

Plain English explanation Meneage Street Surgery keeps data on you relating to who you are, where you live, what you do, your family, possibly your friends, your employers, your habits, your problems and diagnoses, the reasons you seek help, your appointments, where you are seen and when you are seen, who by, referrals to specialists and other healthcare providers, tests carried out here and in other places, investigations and scans, treatments and outcomes of treatments, your treatment history, the observations and opinions of other healthcare workers, within and without the NHS as well as comments and aide memoires reasonably made by healthcare professionals in this practice who are appropriately involved in your health care.

When registering for NHS care, all patients who receive NHS care are registered on a national database, the database is held NHS Digital, a national organisation which has legal responsibilities to collect NHS patient data.

GPs have always delegated tasks and responsibilities to others that work with them in their surgeries, on average an NHS GP has between 1,500 to 2,500 patients for whom he or she is accountable. It is not possible for the GP to provide hands on personal care for each and every one of those patients in those circumstances, for this reason GPs share your care with others, predominantly within the surgery but occasionally with outside organisations. If your health needs require care from others elsewhere outside this practice we will exchange with them whatever information about you that is necessary for them to provide that care. When you make contact with healthcare providers outside the practice but within the NHS it is usual for them to send us information relating to that encounter. We will retain part or all of those reports. Normally we will receive equivalent reports of contacts you have with non NHS services but this is not always the case.

Your consent to this sharing of data, within the practice and with those others outside the practice is assumed and is allowed by the Law.

People who have access to your information will only normally have access to that which they need to fulfil their roles, for instance admin staff will normally only see your name, address, contact details, appointment history and registration details in order to book appointments, the practice nurses will normally have access to your immunisation, treatment, significant active and important past histories, your allergies and relevant recent contacts whilst the GP you see or speak to will normally have access to everything in your record.

You have the right to object to our sharing your data in these circumstances but we have an overriding responsibility to do what is in your best interests. Please see below.

We are required by Articles in the General Data Protection Regulations to provide you with the information in the following 9 subsections.

1) Data controller contact details	Lesley Searle, Practice Manager
2) Data Protection Officer contact details	To be confirmed
3) Purpose of the processing	Direct Care is care delivered to the individual alone, most of which is provided in the surgery. After a patient agrees to a referral for direct care elsewhere, such as a referral to a specialist in a hospital, necessary and relevant information about the patient, their circumstances and their problem will need to be shared with the other healthcare workers, such as specialist, therapists, technicians etc. The information that is shared is to enable the other healthcare workers to provide the most appropriate advice, investigations, treatments, therapies and or care.
4) Lawful basis for processing	The processing of personal data in the delivery of direct care and for providers’ administrative purposes in this surgery and in support of direct care elsewhere is supported under the following Article 6 and 9 conditions of the GDPR: Article 6(1)(e) ‘…necessary for the performance of a task carried out in the public interest or in the exercise of official authority…’. Article 9(2)(h) ‘necessary for the purposes of preventative or occupational medicine for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services...” Organisations and their employees will also respect and comply with their obligations under the common law duty of confidence
5) Recipient or categories of recipients of the processed data	The data will be shared with Health and care professionals and support staff in this surgery and at hospitals, diagnostic and treatment centres who contribute to your personal care.
6) Rights to object	You have the right to object to some or all the information being processed under Article 21. Please contact the Data Controller or the practice. You should be aware that this is a right to raise an objection, that is not the same as having an absolute right to have your wishes granted in every circumstance
7) Right to access and correct	You have the right to access the data that is being shared and have any inaccuracies corrected. There is no right to have accurate medical records deleted except when ordered by a court of Law
8) Retention period	The data will be retained in line with the law and national guidance. https://digital.nhs.uk/article/1202/Records-Management-Code-of-Practice-forHealth-and-Social-Care-2016 or speak to the practice.
9) Right to complain	You have the right to complain to the Information Commissioner’s Office, you can use this link https://ico.org.uk/global/contact-us/ or calling their helpline Tel: 0303 123 1113 (local rate) or 01625 545 745 (national rate) There are National Offices for Scotland, Northern Ireland and Wales, (see ICO website)

Privacy Notice - National screening programmes

Monday 7th June 2021 19:22

DRAFT

Plain English explanation

The NHS provides national screening programmes so that certain diseases can be detected at an early stage. These currently apply to bowel cancer, breast cancer, aortic aneurysms and diabetic retinal screening service. The law allows us to share your contact information with Public Health England so that you can be invited to the relevant screening programme.

More information can be found at: https://www.gov.uk/topic/population-screening-programmes or speak to the practice

1) Data Controller contact details	Lesley Searle, Practice Manager, Meneage Street Surgery, 100 Meneage Street, Helston, TR13 8RF
2) Data Protection Officer contact details	To Be Confirmed
3) Purpose of the processing	The NHS provides several national health screening programs to detect diseases or conditions earlier such as; cervical and breast cancer, aortic aneurysm and diabetes. More information can be found at https://www.gov.uk/topic/population-screening-programmes. The information is shared so as to ensure only those who should be called for screening are called and or those at highest risk are prioritised.
4) Lawful basis for processing	The sharing is to support Direct Care which is covered under Article 6(1)(e); “necessary… in the exercise of official authority vested in the controller’ And Article 9(2)(h) ‘necessary for the purposes of preventative or occupational medicine for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services...”
5) Recipient or categories of recipients of the shared data	The data will be shared with [insert name of local service providers]
6) Rights to object	You have the right to object to this processing of your data and to some or all of the information being shared with the recipients. Contact the Data Controller or the practice. For national screening programmes: you can opt so that you no longer receive an invitation to a screening programme. See: https://www.gov.uk/government/publications/opting-out-of-the-nhs-population-screening-programmes Or speak to your practice.
7) Right to access and correct	You have the right to access the data that is being shared and have any inaccuracies corrected. There is no right to have accurate medical records deleted except when ordered by a court of Law.
8) Retention period	GP medical records will be kept in line with the law and national guidance. Information on how long records can be kept can be found at: https://digital.nhs.uk/article/1202/Records-Management-Code-of-Practice-for-Health-and-Social-Care-2016 Or speak to the practice.
9) Right to Complain.	You have the right to complain to the Information Commissioner’s Office, you can use this link https://ico.org.uk/global/contact-us/ or calling their helpline Tel: 0303 123 1113 (local rate) or 01625 545 745 (national rate) There are National Offices for Scotland, Northern Ireland and Wales, (see ICO website)

Privacy notice for legal requirements to share data

Monday 7th June 2021 16:42

How your information is shared so that this practice can meet legal requirements

The law requires Meneage Street Surgery to share information from your medical records in certain circumstances. Information is shared so that the NHS or Public Health England can, for example:

plan and manage services;
check that the care being provided is safe;
prevent infectious diseases from spreading.

We will share information with NHS Digital, the Care Quality Commission and local health protection team (or Public Health England) when the law requires us to do so. Please see below for more information. We must also share your information if a court of law orders us to do so.

NHS Digital

NHS Digital is a national body which has legal responsibilities to collect information about health and social care services.
It collects information from across the NHS in England and provides reports on how the NHS is performing. These reports help to plan and improve services to patients. · This practice must comply with the law and will send data to NHS Digital, for example, when it is told to do so by the Secretary of State for Health or NHS England under the Health and Social Care Act 2012.
More information about NHS Digital and how it uses information can be found at: https://digital.nhs.uk/home

Care Quality Commission (CQC)

The CQC regulates health and social care services to ensure that safe care is provided.
The law says that we must report certain serious events to the CQC, for example, when patient safety has been put at risk.
For more information about the CQC see: http://www.cqc.org.uk/

Public Health

The law requires us to share data for public health reasons, for example to prevent the spread of infectious diseases or other diseases which threaten the health of the population.
We will report the relevant information to local health protection team or Public Health England.
For more information about Public Health England and disease reporting see: https://www.gov.uk/guidance/notifiable-diseases-and-causative-organisms-howto-report

We are required by law to provide you with the following information about how we handle your information and our legal obligations to share data.

Data Controller contact Details	Lesley Searle, Practice Manager
Data Protection Officer contact details	To be confirmed
Purpose of the processing	Compliance with legal obligations or court order.
Lawful basis for processing	The following sections of the GDPR mean that we can share information when the law tells us to. Article 6(1)(c) – 'processing is necessary for compliance with a legal obligation to which the controller is subject…' Article 9(2)(h) – 'processing is necessary for the purpose of preventative…medicine…the provision of health or social care or treatment or the management of health or social care systems and services...'
Recipient or categories of recipients of the processed data	· The data will be shared with NHS Digital. · The data will be shared with the Care Quality Commission. · The data will be shared with our local health protection team or Public Health England. · The data will be shared with the court if ordered.
Rights to object and the national data opt-out	There are very limited rights to object when the law requires information to be shared but government policy allows some rights of objection as set out below. NHS Digital · You have the right to object to information being shared with NHS Digital for reasons other than your own direct care. · This is called a ‘Type 1’ objection – you can ask your practice to apply this code to your record. · Please note: The ‘Type 1’ objection, however, will no longer be available after 2020. · This means you will not be able to object to your data being shared with NHS Digital when it is legally required under the Health and Social Care Act 2012. Public health · Legally information must be shared under public health legislation. This means that you are unable to object. Care Quality Commission · Legally information must be shared when the Care Quality Commission needs it for their regulatory functions. This means that you are unable to object Court order · Your information must be shared if it ordered by a court. This means that you are unable to object.
Rights to access and correct	You have the right to access your medical record and have any errors or mistakes corrected. Please speak to a member of staff or email your request to letters.meneagestreet@nhs.net We are not aware of any circumstances in which you will have the right to delete correct information from your medical record; although you are free to obtain your own legal advice if you believe there is no lawful purpose for which we hold the information and contact us if you hold a different view.
Retention period	GP medical records will be kept in line with the law and national guidance. Information on how long records are kept can be found at: https://digital.nhs.uk/article/1202/Records-Management-Code-ofPractice-for-Health-and-Social-Care-2016 or speak to the practice.
Right to complain	You have the right to complain to the Information Commissioner’s Office. If you wish to complain follow this link https://ico.org.uk/global/contact-us/ or call the helpline 0303 123 1113

GDPR Notice