Information Governance Procedure Policy

Information Governance Procedures

These are the procedures for data protection and information governance, to meet the requirements of the GDPR, the Data Protection Act 2018 and professional standards. Refer to the Data Protection Overview and Data Protection and Information Security Policy.

General information about the data we process:

Details of the personal data and special category data that we hold are in our Privacy Notice.

How we hold personal data

Personal data is held in hard copy securely at the practice / in digital form on the practice computer / in cloud servers or services / backed up online and via portable hard drive back up.

How we collect personal data

We collect personal data directly from team members or patients by phone, in person, by email, using online forms, from referrals.

How we hold special category data

Special category data is held in hard copy, securely at the practice, / in digital form on the practice computer / in cloud servers or services / backed up online and via portable hard drive back up.

How we collect special category data

We collect special category data directly from team members or patients, by phone, in person, by email, using online forms, from referrals, other.

Lawful basis for processing data

It is necessary to have a valid lawful basis in order to process personal data. Of the six available lawful bases for processing no single basis is ’better’ or more important than the others. We have determined our lawful basis before we began processing, and we document it here.

When we process criminal conviction data or data about offences, we have identified both a lawful basis for general processing and an additional condition for processing this type of data. When recruiting team members, it is a requirement to obtain a criminal record check, but we take care to handle the data appropriately, see the Information Security section below for further information.

The lawful basis for processing data at the practice is found in the Data Protection and Information Security Policy.

The practice offers individuals real choice and control. Our consent procedures put individuals in charge to build customer trust and engagement. Our consent for marketing requires a positive opt-in, we don’t use pre-ticked boxes or any other method of default consent. We make it easy for people to withdraw consent and tell them how and keep contemporaneous evidence of consent. Consent to marketing is never a precondition of a service. There are two types of consent management at the practice and the lawful basis of processing is above:

  1. Consent for treatment is managed; registered patients cannot have their data deleted as it is necessary to retain clinical records according to Record Retention, but they have all of the other data rights


  1. Consent for processing data [by email/by post] for [health awareness/important announcements/products and services/other]

Any consents for marketing that we have, that do not meet the new standards, are being re-consented by referring to:

  • Communication Consent Form
  • Consent for Clinical Photography

Consent procedures
In order to bring our consent for marketing in line with the latest regulations we are re-consenting individuals as follows:

  • [The new granular, opt-in consent details have been added to the medical history form]
  • [Every patient that attends the practice for treatment, consultations or as a new patient is given the new medical history form to complete. In this way we are updating our consent from all patients over the coming months]
  • [We are re-consenting all of our email marketing contacts by asking them to update their profile and choose methods of communication as well as choose subjects that they are interested in]
  • [Other]

Managing individual’s rights
Individuals have the right to access their personal data, correct it, have copies of it, correct errors in it and to restrict processing of it. They also have the right to obtain supplementary information such as how we process their data, what it is used for and to object to specific uses of it. The right of access allows individuals to be aware of, and verify the lawfulness of, processing activities. They also have the right to request we delete data, however this may not always be possible. If an individual contacts the practice about their data they will be provided with the relevant information or actions, as requested:

  • Confirmation that their data is being processed
  • Access to their data
  • Any other supplementary information or actions as found in our Privacy Notice for adults or the Privacy Notice for children

To manage individual’s rights, we use the following procedures:

  • Patients or non-patients may contact us by phone, email or in person to ask us take actions on their data as described above
  • The Practice Manager will respond to the individual, using the same method of communication used by the individual to contact the practice, within 3 working days confirming that their request is being processed
  • If a patient requests a copy of their clinical notes or a non-patient requests a copy of their personal data, they will be provided with a copy free of charge
  • For any additional copies or excessive requests, we will charge a reasonable fee of up to £10 for digital records and £50 for paper records
  • The data request will usually be completed within one month of receiving the request
  • If there are delays due to a complex request the patient will be contacted within 1 month of making the request with the reasons for the delay and the expected delivery date, which must be within 3 months
  • In the communication to the individual they will be informed where to find the Privacy Notice or the Privacy Notice for Children [on the practice website or by contacting the practice]
  • Once the data request has been fulfilled the Practice Manager will enter the details on [the spreadsheet called Data Requests Record, and if the individual is a patient, the details will also be recoded on the clinical record
  • Each year, the Data Requests Record is checked.

Right of access for children
Even if a child is too young to understand an access request, it is still their personal data and does not belong to anyone else such as a parent or guardian. When handling a request for information about a child we always consider if the child is mature enough to understand their rights. If they do, then we consider responding directly to the child rather than the parent. In Scotland, a child aged 12 years or older can make a request on their own behalf. When a child makes a request, they are provided with a copy of the Privacy Notice for Children or told where to access it on the website.

Information about a child may be released to a person with Parental Responsibility, taking into account the best interests of the child. All mothers and most fathers have this responsibility and parents do not lose it if they divorce, although it can be removed by a court. When in doubt about parental responsibility, proof of identity and evidence is requested.  Note: For more information on how a parent can prove that they have parental responsibility see the advice page.

Access requests and mental capacity
For patients who lack the mental capacity to manage their own affairs, an attorney or other person with a Lasting Power of Attorney, or someone appointed by the courts will have the right to access information about the person they represent and make decisions on their behalf. Proof of identity and evidence of power of attorney or court order is always requested. The same applies to a person appointed to make decisions by:

  • The Court of Protection in England and Wales
  • The Sheriff Court in Scotland
  • The High Court in Northern Ireland

Our consent requests are prominent, concise, separate from other terms and conditions and easy to understand, they include:

  • The name of the practice
  • What the consent is for
  • What the practice will do with it
  • That individuals can withdraw consent at any time
  • The opportunity to actively opt in and not use pre-ticked boxes, opt-out boxes or other default settings. Wherever possible we give separate (‘granular’) options to consent to different purposes and different types of processing

We record consent in the clinical records.

Pseudonymisation means transforming personal data so that it cannot be attributed to an individual unless there is additional information.

  • Pseudonymisation – the data can be tracked back to the original data subject
  • Anonymisation – that data cannot be tracked back to the original data subject

Examples of pseudonymisation we use are:

  • We never identify patients in research, patient feedback reports or other publicly available information
  • When we store and transmit electronic data it is encrypted, and the encryption key is kept separate from the data

Right to be informed
We provide ‘fair processing information’, through our Privacy Notice, which provides transparency about how we use personal data. The Privacy Notice is available on our website at ……………………………………… or from the practice in printed form.

Data processors and contracts
Data processors are third parties who processes personal data on our behalf. We have identified who our data processors are, where they store their data and, if it is outside of the EU, that they have suitable arrangements to secure our data that meets the GDPR requirements. The USA has the EU-US Privacy Shield, the companies we use such as Dropbox or Microsoft who store our data in the USA are certified on the Privacy Shield website, we check this by searching for them in the list of companies.

We have an appropriate contract with all of our data processors, we use the Data Processor or Joint Data Controllers agreements for smaller companies when the company does not provide their own contract. Alternatively, the processor will send us their own contract. We have a link to the relative terms for the bigger companies such as Dropbox or Microsoft who are unable to send us individual agreements.

Privacy by design
We implement technical and organisational measures to integrate data protection into our processing activities. Our data protection and information governance management systems and procedures take Privacy by design as their core attribute to promote privacy and data compliance. Privacy Impact Assessments (PIAs) are an integral part of taking a privacy by design approach.  To identify the most effective way to comply with our data protection obligations and meet individuals’ expectations of privacy we review our Privacy Impact Assessment annually using the Sensitive Information Map, PIA and Risk Assessment.

We keep records of processing activities for future reference.

2-Step Backup Procedure

We use three-step backup procedure:

  1. Local backups of important files and data using [an external hard drive]
  2. Cloud (Internet) backup using Databarracks for a backup of our complete server 

All backups are encrypted and password protected for security. 

  1. Local backups of files and data
  • All backups are encrypted
  • Data is backed up every day using an external drive
  1. Cloud (Internet) backup 
  • We use a Databarracks to backup our complete server on a daily basis
  • Each day our IT checks the status of the backup and emails the report which is checked and filed immediately.

Information security

We have appropriate security to prevent the personal data we hold being accidentally or deliberately compromised. It includes technical security, physical security and the plan for appropriate response swiftly and effectively.  To meet this requirement we have policies, procedures, risk assessments and planning which we review annually. Our approach to information security includes:

  • Backup Procedures and Software
  • Subcontractor’s Confidentiality Agreement
  • Information Asset Log
  • Mobile Equipment Terms and Conditions
  • Compliance Monitoring Form
  • Computer and Software Access Log
  • Security Risk Assessment
  • Business Impact Analysis
  • Sensitive Information Map, PIA and Risk Assessment

Electronic security
This electronic security section applies to desktop computers, laptop computers, tablets and smartphones. In networked computer systems it also applies to servers. The IG Lead is also responsible for allocating responsibility to keep any Internet router’s software up to date.

Team members are aware to never click a link in an email unless they are sure of the sender. A common way for cyber-criminals to obtain usernames and passwords is by sending an email that looks like it originates from a well-known bank or other service provider such as PayPal or Netflix. It will have a link that says, ‘click here to reset your password’ and usually has a strong message to drive the action such as ‘take action now, account suspended’.

Inadvertently clicking on an unknown link may install malware on a device or computer, this is how many ransomware attacks are perpetrated. When the link is clicked the ‘ransomware’ may encrypt the computer rendering it useless unless you pay a large amount to the criminals who have sent you the malware. There are many variations of this type of cybercrime and to minimise the risk of it happening team members:

  • Will only log onto sites using the original website of the company concerned, and never from a link in an email
  • Will never click on links in emails unless they are sure of the sender

Requests for money
There are many ingenious ways that money can be stolen using email. These include:

  • An email that seems to come from a friend who is in trouble
  • An email that requests a bill to be paid to a different account than usual, or that ask for a fund transfer for any reason
  • Emails that appear to come from a manager, requesting transfer of funds
  • Emails that ask you to reset bank usernames and passwords
  • Emails that ask for your personal details such as date of birth

Whenever an email like this is received, the team member will contact the sender, in person by telephone to confirm. The team member will only use the telephone number that they can confirm is the correct phone number of the supposed sender.

Important tasks

Our IT Team

  • Monitors our Webroots Secure Anywher antivirus sytem
    • Check that all of their software is up to date, this includes the operating system, e.g. Windows, IOS or Android, and software such as Microsoft Word
    • Other
  • 6-Monthly
    • Check that any Internet routers do not have the default admin password and have the latest software (often called firmware) installed
    • Update internet router and firewall firmware
    • Check that the network does not have any default admin passwords
    • Carry out a test restore of the backup

Password type and storage – notes for reference
The theory of using upper and lower-case letters mixed with numbers and special characters was invented by Bill Burr. Unfortunately, hackers have designed their password cracking software to ‘crack’ this type of password so they are no longer secure. He now advises use of four unrelated words such as ‘moon rapport deckchair towel’.

We recommend that all computer users install a password manager such as 1Password, which helps the user easily manage different passwords for each login. It also completes name and address details or credit card details into a website form saving the user time. Some people are concerned that password managers may be hacked.

The password rules for team members:

  • Only use passwords where they are really needed
  • Are only asked to change their passwords when there is an indication of suspicion or compromise
  • Are careful that nobody is looking over their shoulder when they type in a password
  • Create a password out of four unrelated words with spaces where possible or a minimum of 9 characters with upper and lower-case letters, at least one number and one special character such as £ or &
  • Do not store passwords in plain text on a computer or piece of paper that could be seen by others
  • Do not use common password choices such as “password, 12345, p4ssw0rd, pet names, personal name, date of birth, common words such as cities or football teams with letters or numbers replacing vowels such as m4nch4st4r un1t4d, f1d0 etc. Note that most password manager applications will generate a unique password for you
  • Do not reuse passwords between work and home
  • Do not respond to emails asking for their login or asking them to reset a password unless they have requested the password reset themselves ‘phishing emails’
  • Do not reuse passwords for more than one login
  • Never share a password and or attempt to gain access to a system using someone else’s username and password
  • Report any suspicious emails or activity to the IG lead

Routers and other equipment
The default administrator username and password of our internet router/firewall/practice computers/other electronic equipment has been changed.

The practice encrypts data whenever possible. Encryption scrambles the data and makes it unreadable unless the user has the encryption key. We use encryption in the following situations:

  • Our computers have encryption turned on, in a Mac this is called File Vault, in Windows it is called BitLocker in the Device Encryption section
  • iPhones encrypt data by default, we only use Android phones that have encryption, and this is turned on
  • Whenever we store personal data on a storage device such as a memory stick, DVD, or external drive the data is encrypted, and the encryption key is kept separate
  • Whenever we use a website for business purposes, we check that the browser address bar has a green padlock and says HTTPS instead of HTTP. This means that data sent over the internet is encrypted
  • If we need to send a data file by email, either the file is encrypted first, or we use encrypted email (such as ShareFile by Citrix). The encryption key is sent by [post] to the recipient and never by email

Managing logins and levels of computer access
The IG Lead is responsible for who has access to computers and software, as well as the level of access that is appropriate to their role. The Practice Manager is responsible for setting up users when they join the practice, providing the appropriate level of access such as administrator or team member user and deleting the login when the team members leaves.

Wherever possible two factor authentication is set up for administrator logins. All logins and their level of access are recorded on the Network, Computer and Software Access Log.

Audit trail
Each user is allocated a unique username and password, to identify their use of the software. During training each user is given a copy of the guidelines on the use of the system with their login details. A record is kept of all users given access to the software.

New team members
When a new employee/self-employed dentist, hygienist or therapist or external consultant joins the practice the IG Lead, arranges passwords and access level.

Locum staff
Temporary access is granted on a need to use basis by the IG Lead and is recorded in the Network, Computer and Software Access Log. Temporary logons are deleted or suspended immediately they are no longer required.

Change of user requirements
Changes to access level or suspension of an account are made by the IG Lead and a record is kept of all changes on the Computer and Software Access Log.

Removal of users
As soon as an individual leaves the practice their logons will be removed by the IG Lead.

Review of computer access rights
The IG Lead reviews all access rights on a regular basis. The review is designed to positively confirm all system users and remove any lapsed or unwanted logons.

Postal services and couriers
To ensure that confidential information transferred from the practice by post or courier is done so as securely as is practicable, the practice ensures:

  • Normal post is used for single appointment letters and single referral letters, but for bulk transfers of information, e.g. NHS forms to NHS Dental Services, the practice uses tracked and traced post
  • Envelopes are marked “Private and Confidential”
  • Packaging is “tamper-evident” (i.e. it is immediately obvious if some-one has attempted access to the contents) and protects the contents from any physical damage likely to arise during transit
  • Where necessary, additional controls are applied to protect sensitive information from unauthorised disclosure or modification, e.g. the use of locked containers, locked or access-controlled entry to rooms where post is collected

The practice’s fax machine is in a secure location and when receiving faxes containing confidential information, the practice ensures:

  • The fax is removed from the machine on receipt
  • Where necessary, the sender is contacted to confirm receipt
  • The information in the fax is appropriately dealt with and safely stored, e.g. transferred to the patient record
  • Faxes containing patient information are destroyed securely

Additionally, when practice staff members transfer confidential information by fax they always:

  • Double check the fax number or use stored frequently used numbers in the fax machine to reduce the risk of typing errors
  • Use a fax cover sheet marked “Private and Confidential”
  • Send faxes only to a named person rather than a team
  • Inform the recipient that a fax will be sent, and ask them to confirm receipt
  • Send faxes during an organisation’s working hours when staff are present to receive the fax

Emails received containing patient information are incorporated into the dental record and deleted from the email system on receipt.

The practice is aware that NHS mail is currently the only NHS approved method for sending patient identifiable information by email, but only if both sender and recipient use an NHSmail account, therefore the practice ensures:

  • Where NHSmail is used to send special category data, this is clearly indicated by the word ‘confidential’ in the subject header
  • When sending special category data by ordinary email it is secured with an encrypted email service (SSL System) which encrypts any attachments.

Personal identifiable information is only taken off site when absolutely necessary, in which case the following procedure is followed:

  • Record what information you are taking off site and why, and, if applicable, where and to whom you are taking it
  • Transport information in a sealed container
  • Never leave personal identifiable information unattended
  • Ensure that information is returned back on site as soon as possible
  • Record that the information has been returned

Other forms of information exchange (e.g. text messages, smartphones, etc.)
Personal identifiable information is always sent by means as described above, with the exception of messages that solely relate to appointment scheduling (such as reminders), which may be sent to a patient’s phone or text messaging system if they have previously given permission to use these methods of contact to it.

The secure use of personal information
When working in an area where patient records may be seen we always:

  • Shut / lock doors and cabinets as required
  • Query the status of unaccompanied strangers
  • Know who to tell if anything suspicious or worrying is noted
  • Not tell unauthorised personnel how the security system operates

When using paper patient records we ensure that they are:

  • Tracked if transferred out of the practice, with a note made in the tracking register
  • Returned to the filing location as soon as possible after completion of treatment
  • Stored securely within the practice, arranged so that the record can be found easily if needed
  • Stored closed when not in use so that contents are not seen accidentally
  • Inaccessible to members of the public and not left, even for short periods, where they might be looked at by unauthorised persons

If using electronic records, we:

  • Always log-out of any computer system or application when work on it is finished
  • Not leave a terminal unattended and logged-in
  • Not share logins with other people. If a colleague has a need to access patient records, then appropriate access should be organised for them – this must not be by using your identity
  • Not reveal your password to others
  • Always clear the screen of a previous patient record before seeing the next patient
  • Use a screensaver to prevent casual viewing of confidential information by others

When communicating information about a patient we take care:

  • Not to discuss patient information in public areas
  • If transferring information by phone, or face to face that personal details are not overheard by other people, including staff who do not have a “need to know”
  • Not to leave a confidential message on a patient’s answer-phone, as it might be heard by someone other than the intended recipient
  • If listening to answer-phone messages that they cannot be overheard by unauthorised persons
  • When receiving calls requesting personal information, make sure you verify the identity of the caller (see below) and ask them why they want the information. If in doubt about whether the information can be disclosed, tell the caller you will call them back, and then consult with your manager
  • Not to leave messages containing personal information on notice boards that could be accessed by non-authorised staff
  • To only discuss a patient’s confidential information with either the patient or their authorised representative. Team members are aware that patient confidentiality even extends to whether a patient is registered to the practice or has arranged an appointment for a particular time
  • To obtain written and signed consent from a patient before allowing a family member, or patient representative (e.g. Carer or Personal Assistant (PA)), to book appointments, amend appointments or discuss any matters relating to the patient

When verifying the identity of a caller requesting personal information we:

  • Ask them for their phone number
  • Check that it is the correct number for that individual or organisation
  • If it is, call them back once you have the decision on whether the information can be disclosed

Transferring patient information
If a team member is authorised to transfer patient information they follow the information handling procedures.

Handling and retention of criminal record information – DBS/PVG/Access NI disclosures
The IG Lead ensures that information is kept securely in a lockable fire-resistant cabinet with access strictly controlled and limited to persons who need to have access to this information in the course of their duties. This information is only used for the specific purpose it was requested for and with the applicant’s full consent. Note that it is a criminal offence to share criminal record information with any individual who is not entitled to receive it. However, if the applicant freely gives their consent to the sharing of this information, then an offence has not been committed.

The practice does not retain criminal record disclosure details for longer than is necessary; not exceeding six months after the decision has been made to appoint or for six months from the date the applicant was unsuccessful, to allow for the consideration and resolution of any disputes or complaints (in England, Wales and Scotland, while in Northern Ireland the practices keeps copies of criminal records disclosures).

Preventing unauthorised computer access
When a desktop computer is left unattended, the team member logs off to prevent unauthorised users’ access to it. When leaving a workstation for the day, the team member logs out of the system entirely and closes down the computer.

Audit trails and reporting security breaches
Nearly all of the activity that is performed on a computer can be tracked. Our system suppliers record and enable us to review Internet usage logs. Emails are routinely backed up on the practice’s computer servers. Recorded information will be used to aid an investigation where breaches of security, the law or these guidelines, are suspected. This information is kept confidential, but when used helps to explain innocent situations more often than exposing security breaches.

Information security breaches might involve unauthorised use of equipment or unauthorised access to data. Any breach of security, however small, wastes time and often requires work to be repeated and could be a potential risk to the practice or individuals. If you know or suspect that a breach of information security has occurred, please inform your IG Lead.

Using mobile computing equipment
These procedures outline the appropriate use of portable computer devices and removable media, collectively known as mobile computing equipment when it has been purchased or authorised by the practice.

The procedures take into account the increased risk to personal information posed by this way of working and they complement the procedures and guidelines regarding the protection of patient information.

  • Portable computer devices – includes laptops, notebooks, tablets, and smartphones
  • Removable data storage media – includes any physical item that can be used to store and/or move information and requires another device to access it. For example, DVD, tape, digital storage device (flash memory cards, USB memory sticks, portable hard drives). Essentially anything that data can be copied, saved or written to which can then be taken away and restored on another computer

NOTE: Team members NEVER take patient photographs on a personal smartphone or tablet as this would breach our security and confidentiality policy. Patient photographs are only taken with a phone or tablet that is owned by the practice and specifically kept for the purpose of patient photography.

Only authorised staff have access to mobile computing equipment. Any member of staff allowing access to any unauthorised person deliberately or inadvertently may be subject to disciplinary action. Staff should not use their own (or unauthorised) computing equipment for practice business but they may use a personal mobile phone for the mobile application.

Be aware of security measures in place
To reduce the risk of loss and unauthorised access we have the following measures:

  • Mobile Equipment Terms and Conditions are completed for each mobile computing device provided to a staff member and this person is listed in the Mobile Equipment Log as the nominated responsible owner
  • Encryption is applied to all mobile computing equipment
  • Password protection is setup on laptops and smart phones [and where available Face ID or Fingerprint ID]
  • Everyone with portable equipment must update anti-virus software weekly and run a scan
  • Regular backups are taken of the data stored on the mobile equipment
  • Issue and return of mobile computing equipment is recorded in the Mobile Equipment Log

Team members:

  • Store mobile equipment securely when not in use on and off site, never leave visible in a car
  • Ensure files containing personal or confidential data are adequately protected e.g. encrypted and password protected
  • Virus check all removable media e.g. USB drives, portable hard drives, etc. prior to use
  • Obtain authorisation before you remove mobile equipment from the premises
  • Be aware that software, Intellectual Property and any data files created by you on practice mobile equipment are the property of the practice
  • Report immediately any stolen mobile equipment to the IG Lead. Failure to report a stolen mobile phone could result in significant charges from the phone company
  • Be aware that the security of your mobile computer equipment is your responsibility
  • Ensure that mobile equipment is returned to the practice if you are leaving. Note that a final salary deduction may be made if equipment is not returned

Team members do not:

  • Disable the virus protection software or bypass any other security measures put in place
  • Store patient information on mobile equipment unless the equipment is protected with encryption, and it is absolutely necessary to do so
  • Take personal data or special category data out of the practice without authorisation, this includes clinical record
  • Use the practice’s mobile computer equipment outside the practice premises without authorisation
  • Use a personal mobile computer equipment for practice business
  • Allow unauthorised personnel/friends/relatives to use mobile equipment in their charge
  • Leave mobile equipment in places where anyone can easily steal them
  • Leave mobile equipment visible in the car when travelling between locations
  • Leave mobile equipment in an unattended car
  • Leave mobile equipment unattended in a public place e.g. hotel rooms, train luggage racks
  • Install unauthorised software or download software / data from the Internet
  • Delay in reporting lost or stolen equipment

Personal use of practice email, internet and phones – policy and procedure
We permit the incidental use of internet, and telephone systems to send personal email, browse the internet and make personal telephone calls subject to certain conditions set out below. Personal use is a privilege and not a right. It must be neither abused nor overused and we reserve the right to withdraw our permission at any time. The following conditions must be met for personal usage to continue:

  • Use must be minimal and take place substantially out of normal working hours (that is, during lunch hours, before 9 am or after 5.30 pm)
  • Personal emails must be labelled “personal” in the subject header
  • You must never use webmail such as google mail as this could bypass the practice anti-virus system(although currently as soon as anything is downloaded or accessed our local antivirus system will scan it, including googlemail)
  • Use must not interfere with the team member’s practice commitments
  • Use must not commit the practice to any marginal costs
  • Use must comply with practice policies including the Anti-bullying and Harassment Policy, Equality, Dignity and Human Rights Policy, Data Protection and Information Security Policy and the Social Media Policy

Team members should be aware that personal use of our systems may be monitored and, where breaches of this policy are found, action may be taken under the disciplinary procedure. We reserve the right to restrict or prevent access to certain telephone numbers or internet sites if we consider personal use to be excessive. In general, team members should not:

  • Send or forward private emails at work which they would not want a third party to read
  • Send or forward chain mail, junk mail, cartoons, jokes or gossip
  • Contribute to system congestion by sending trivial messages or unnecessarily copying or forwarding emails to those who do not have a real need to receive them
  • Sell or advertise using our communication systems or broadcast messages about lost property, sponsorship or charitable appeals
  • Agree to terms, enter into contractual commitments or make representations by email unless appropriate authority has been obtained. A name typed at the end of an email is a signature in the same way as a name written at the end of a letter
  • Download or email text, music and other content on the internet subject to copyright protection, unless it is clear that the owner of such works allows this
  • Send messages from another worker’s computer or under an assumed name unless specifically authorised or
  • Send confidential messages via email or the internet, or by other means of external communication which are known not to be secure
  • Keep an email which has been sent to the wrong address in error, it should be returned to the sender

Misuse or excessive use or abuse of our telephone or email system, or inappropriate use of the internet in breach of this policy will be dealt with under our Disciplinary Procedure. Misuse of the internet can, in certain circumstances, constitute a criminal offence. In particular, misuse of the email system or inappropriate use of the internet by participating in online gambling or chain letters or by creating, viewing, accessing, transmitting or downloading any of the following material will amount to gross misconduct (this list is not exhaustive):

  • Pornographic material (that is, writing, pictures, films and video clips of a sexually explicit or arousing nature)
  • Offensive, obscene, or criminal material or material which is liable to cause embarrassment to us or to our patients
  • A false and defamatory statement about any person or organisation
  • Material which is discriminatory, offensive, derogatory or may cause embarrassment to others;
  • Confidential information about us or any of our team members or patients (which you do not have authority to access
  • Any other statement which is likely to create any liability (whether criminal or civil, and whether for you or us) or
  • Material in breach of copyright

Any such action will be treated very seriously and is likely to result in summary dismissal. Where evidence of misuse is found we may undertake a more detailed investigation in accordance with our Disciplinary Procedure, involving the examination and disclosure of monitoring records to those nominated to undertake the investigation and any witnesses or managers involved in the Disciplinary Procedure. If necessary, such information may be handed to the police in connection with a criminal investigation.

Personal mobile telephones
Personal mobiles should be turned off during working hours. Messages will be taken for team members during working hours, but they would not be expected to come to the telephone unless there was an emergency. Personal calls should never be made from reception or in the treatment room if patients could overhear the conversation.

Managing Data Breaches

The GDPR states:

“You only have to notify the relevant supervisory authority of a breach where it is likely to result in a risk to the rights and freedoms of individuals. If unaddressed such a breach is likely to have a significant detrimental effect on individuals – for example, result in discrimination, damage to reputation, financial loss, loss of confidentiality or any other significant economic or social disadvantage”

Notification requirements
The GDPR provides specific breach notification rules, including that we must notify a breach to the relevant supervisory authority the ICO within 72 hours of becoming aware of it. It is recognised that we may have to provide information in phases as our investigation takes place. If the breach is likely to have “a significant detrimental effect on individuals” we will need to notify patients without unnecessary delay. Failure to notify a breach can result in a fine of up to 4% of our total turnover or 20 million Euros. Note that the ICO currently says that a breach should be notified within 24 hours, although this may change.

The IG Lead is responsible for managing data breaches. This data breach management applies to incidents that impact on the security and confidentiality of personal information. These information incidents can be categorised by their effect on patients and their information:

  • Confidentiality e.g. unauthorised access, data loss or theft causing an actual or potential breach of confidentiality
  • Integrity, e.g. records have been altered without authorisation and are therefore no longer a reliable source of information
  • Availability, e.g. records are missing, misfiled, or have been stolen

When a data breach is reported to the practice
It could be reported by an affected patient, by a relative, a member of the public or by a team member, the IG Lead will:

  • Interview the complainant to establish the reason for the complaint and why the practice is being considered responsible
  • Complete the Event Record and Register
  • Investigate according to the information given by the complainant
  • Record findings, e.g. unsubstantiated concern, suspected/potential breach, actual breach, etc.
  • Where necessary, provide written explanation to the patient with formal apology if warranted
  • Take and document appropriate action, e.g. no further action as there is no evidence that information was put at risk, advice/training, disciplinary measures, notification to the authorities etc.

When an Event happens – if it needs recording it is probably a Significant Event and needs Significant Event Analysis (SEA) to determine what went wrong and how to stop it happening again.

Any actual or potential information incident in the practice will be investigated and managed accordingly.

Inadequate disposal of confidential material
This type of incident may lead to a breach of confidentiality and is likely to be reported by a patient affected, a member of the public, or a member of staff. The confidential material could be on paper, hard drive, computer or storage media such as memory card or stick or tapes, etc. If the happens the IG Lead will:

  • Investigate how the information left the practice by interviewing staff and contractors as appropriate
  • Consider the sensitivity of the data and the risk to which the patient(s) have been exposed, e.g. breach of confidentiality, misuse of data
  • Consider whether the patient(s) should be informed and where it is judged necessary, provide written explanation to the patient(s) with formal apology
  • Record findings, e.g. potential breach, actual breach, evidence of misuse, etc.
  • Take and document appropriate action, e.g. advice/training, disciplinary or contractual measures, notification to the authorities etc.

Attempted or actual theft of equipment and/or access by an unauthorised person
This type of incident may lead to a breach of confidentiality, the risk that information has been tampered with, or information not being available when needed, the IG Lead will:

  • Check the Information Asset Log to find out whether equipment is missing
  • Investigate whether there has been a legitimate reason for removal of the equipment (such as repair or working away from the usual base)
  • If the cause is theft, inform the police, ask them to investigate and keep them updated with your findings
  • Interview staff and check the Information Asset Log to establish what data was being held and how sensitive it is
  • If possible, establish the reason for the theft/unauthorised access, such as:
    • Sale of items
    • Access to material to embarrass the practice
    • Access to material to threaten patients (blackmail, stigmatization)
  • Consider whether there is a future threat to security
  • Inform insurers
  • Review the physical security of the practice
  • If there has been unauthorised access to the practice computer system:
    • Ask the system supplier to conduct an audit to determine whether unauthorised changes have been made to patient records
    • Consider whether any care has been provided to patients whose records have been tampered with
    • Check compliance with access control procedures, e.g. ensure passwords haven’t been written down, staff members are properly logging out, etc.
  • Consider the sensitivity of the data and the risk that it has been tampered with or will be misused, in order to assess whether further action is appropriate (e.g. warning patients)
  • If computer hardware or the core software has been stolen, inform system suppliers to enable restoration of system data to new equipment
  • Record findings, e.g. potential breach, actual breach, evidence of tampering, compromised or delayed patient care, etc.
  • Take and document appropriate action, e.g. physical security improvements, advice/training, disciplinary measures, notification to the authorities etc.

Computer misuse by an authorised user
This includes browsing dental records when there is no requirement to do so, accessing unauthorised Internet sites, excessive/unauthorised personal use, tampering with files, etc. The IG Lead will:

  • Interview the person reporting the incident to establish the cause for concern
  • Establish the facts by:
    • Asking the system supplier to conduct an audit of activities of the user concerned
    • Interview the user concerned
  • Establish whether there is a justified reason for the alleged computer misuse
  • Consider the sensitivity of the data and the risk to which the patient(s) have been exposed, e.g. breach of confidentiality, the risk information may have been tampered with and consider whether the patient(s) should be informed
  • Record findings, e.g. breach of confidentiality, evidence of tampering, fraud, carrying on a business, accessing pornography, etc.
  • Take and document appropriate action, e.g. no action as allegation unfounded, training/advice, disciplinary measures, notification to the authorities etc.

Lost or misfiled paper dental records
This type of incident could have a possibly severe impact on patient care as the information within a patient record is incorrect or is not available when required. The IG Lead will:

  • Investigate who last used/had the paper record by interviewing staff and contractors as appropriate
  • Consider whether any care has been provided based on incorrect information within a patient record
  • Consider whether patient care has been delayed due to information not being available
  • Establish whether missing information can be reconstituted, e.g. from electronic records
  • If information within records has been misfiled, ensure it is restored to correct filing order/returned to the correct record
  • Where necessary, (i.e. if care affected) provide a written explanation to the patient with a formal apology
  • Record findings, e.g. compromised or delayed patient care, etc.
  • Take and document appropriate action, e.g. advice/training, disciplinary or contractual measures, notification to the authorities etc.

If a team member discovers a data breach?
If a team member discovers something that could be considered a data breach it is reported to the IG Lead. The following information is entered on the form:

  • The team member’s name
  • The date the incident was discovered
  • Where the incident occurred
  • Details of the incident
  • The decision of the IG Lead as to whether it is reportable or not
  • Any initial actions that were taken – including who the incident has been or will be reported to and the date the report is made
  • Any other information including patient or other correspondence

Notifiable breaches will be reported to the ICO and the Local Area Team within 72 hours following the Notification Requirements above. If necessary the patient/s involved will be informed by letter without delay, advising them of the details of the breach and any actions that they need to take.

Patient concerns and feedback will be handled by the IG Lead.

Data breach notification procedure
The ‘Notification Requirements’ are at the beginning of this section. We await clarification from the ICO about reporting times.

In England NHS dental practices must use the new online Data Protection and Security Incident Reporting Tool. This will report it to the Information Commissioner’s Office, the Department of Health and Social Care and the National Cyber Security Centre.

All practices in Scotland, Wales and Northern Ireland and fully private practices in England should submit a report to the Information Commissioners office using the ICO Security breach notification form. All practices must keep a record of all personal data breaches and record the basic facts, effects of the breach and remedial action.

Lessons learned from a data breach
The practice maintains a register of all incidents occurring. A data breach is considered a Significant Event and is evaluated.

Significant Events and Serious Incidents are discussed at a practice meeting to provide staff with an example of what could occur, how to respond to such events and how to avoid them from happening in the future.

Remote access policy and procedure

Remote access to the practice is necessary for people who do not work from the premises at all times. Authorised users are called hosts, they need to log onto our network using a Virtual Private Network (VPN). To protect confidential personal data, it is necessary to have the highest standards of security. The purpose of this procedure is to minimise:

  • Accidental, unauthorised or inappropriate access to electronic data
  • The chance that the practice network could be compromised
  • Damage to the integrity, availability and confidentiality of the practice network and IT system
  • The possibility of damage to the practice reputation through loss or misuse of data

Our Hosts do not use VPN to logon to our network.  They use a secure software called Splashtop. This is not based on VPN Technology, rather it connects on demand. 

  • The practice network has a BT Business Hub 5 firewall
  • Host logins are recorded in the Network, Computer and Software Access Log
  • Hosts must follow the password rules in this procedure
  • Any IT equipment used to connect using VPN must have the latest software updates, anti-virus software and definitions and weekly virus scans
  • Any IT equipment provided by the practice is for the host’s use only
  • Hosts must protect their username and login, even from family members
  • A host can only connect to the practice VPN using [the computer/laptop supplied by the practice]
  • Any patients’ or team members’ personal data viewed away from the practice must be kept completely confidential and steps taken to ensure that it is not seen by anyone else, special care must be taken in public areas
  • A breach of this policy and procedure may lead to disciplinary action
  • The practice may monitor the use of a host’s VPN to verify compliance with these rules

Staff confidentiality code of conduct

The practice has produced this Staff Confidentiality Code of Conduct to raise staff members’ awareness of their legal duty to maintain confidentiality, to protect personal information and to provide guidance on disclosure obligations.

Personal information is data about patients or staff, in any form (paper, electronic, tape, verbal, etc) from which a living individual could be identified including name, age, address, and personal circumstances, as well as sensitive personal information such as race, health, sexuality, bank account details etc. This code also covers information about deceased patients.

Recognise your obligations
A duty of confidence arises out of the common law duty of confidence, employment contracts and your professional obligation as a registered dental professional. Breaches of confidence and inappropriate use of records or computer systems are serious matters, which could result in disciplinary proceedings, dismissal and possibly legal prosecution. So, you must not:

  • Put personal information at risk of unauthorised access
  • Knowingly misuse any personal information or allow others to do so
  • Access records or information that you have no legitimate reason to look at. This includes records and information about your family, friends, neighbours and acquaintances

Keep personal information private
To keep personal information protected make sure you observe the practice policies and procedures listed in the Data Protection and Information Security Policy.

Disclose with appropriate care
It is the aim of the practice to ensure that patients are adequately informed about the use and disclosure of their personal information. You should be familiar with it and seek advice from the IG Lead if you are unable to answer patients’ questions.

If you are authorised to disclose personal information you should ensure you do so in accordance with information handling procedures and you must only:

  • Share with those with a legitimate right to see/hear the information
  • Transfer in accordance with the practice’s secure transfer methods
  • Disclose the minimum necessary to provide safe care

If you are authorised to disclose information that can identify an individual patient for non-healthcare purposes (e.g. research, financial audit) you must only do so if:

  • You have the patient’s explicit consent
  • The consent is written – to ensure there is no later dispute about whether consent was given

Under the common law duty of confidence, identifiable personal information may be disclosed without consent in certain circumstances, these are:

  • Where there is a legal justification for doing so, e.g. to comply with a statute
  • Where there is a public interest justification – i.e. where the public good that would be achieved by the disclosure outweighs both the obligation of confidentiality to the patient concerned and the broader public interest in the provision of a confidential service

You must refer all requests for disclosure of personal information without the consent of the patient, including requests from the police, to the IG Lead who will consult the medical indemnity provider before releasing the information.

Information disclosure over the phone
Before information can be disclosed a staff member should:

  • Confirm the name, job title, department and organisation of the person requesting the information and the reason for the request if appropriate
  • Take a contact telephone number (e.g. main switchboard number, NOT a direct line or mobile)
  • Check whether the information can be provided. If in doubt tell the enquirer you will call back
  • Provide the information only to the person who has requested it (do not leave messages)
  • Record your name, date and the time of disclosure, the reason for it and who authorised it, details about the medical indemnifier who agreed you could provide it. Record the recipient’s name, job title, organisation and telephone number

Data Opt Out
We do comply with the National data opt-out policy. We do not share confidential patient information for purposes beyond their direct care, such as research or audit. 

Staff Declaration Form

By adding my signature below, I confirm that I have received the Information Governance Procedures. I understand that it is my responsibility to read, understand and comply with the received information and guidelines and to raise any queries or concerns with the Information Governance Lead.

Team member name in capitals