Procedures Policy

Policy for confidentiality and access to records

We uphold the trust placed in us by our residents through the following protocol.

Referenced Documents

All (CP’s) - Care Plan

To be read in conjunction with Staff Handover Record and General Data Protection Regulation which came into force in May 2018


The manager, senior staff and all care staff


  1. Staff must not disclose details relating to residents to any person outside the Home without the prior consent of the resident/their family, except where this is necessary in law or in the interests and wellbeing of others
  2. Managers who are provided with information that is highly sensitive or confidential about an individual (eg medical prognosis) must not divulge such information to direct care staff without the express consent of the resident or their family
  3. Access to records must only be provided to authorized personnel and to individual residents in accordance with the General Data Protection Regulation which came into force in May 2018
  4. This confidentiality protocol is conveyed to residents through our Terms and Conditions Statement, which is provided to all clients before admission and signed as accepted and understood by them or their representatives as a condition of acceptance by both parties
  5. Failure to comply with this protocol will result in disciplinary procedures being invoked

Information, which must be shared with the Manager

  1. Any information regarding the client’s health or social care or sensitive information given in confidence from the client to the carer who could pose a danger or threat to the client must be shared with the Manager. This procedure forms part of the staff induction process and is included in the Staff Handbook
  2. Employees cannot be offered confidentiality when they are the subject of investigation under the Protection of Vulnerable Adults
  3. All clients’ medical and personal information is kept in a locked filing cupboard, accessible only to the Manager or Senior Officer in charge
  4. All members of staff are trained in this protocol as part of their induction programme

This is the procedure to be followed

  1. Information which might be classed as Confidential
  2. The manager is responsible for identifying information which is classed as "Confidential" within the home

    The likely areas to be considered for classification as "Confidential" are

    • Paper records
    • Computerised systems - sometimes called Electronic Retrieval Systems
    • All staff records including: supervision, appraisal, or personal performance details
    • All information relating to disciplinary action or investigations
    • All recruitment information
    • Marketing strategies and analysis information
    • All resident records including: tenancy information and financial information
    • Conversations which have been overheard
    • General Issues of Confidentiality

    Confidential information held by the home might be considered in one of the following ways

    • "Absolute Confidentiality" - where the information is never recorded in any way, never discussed aurally or shared with anyone else (e.g. doctor, patient or priest and confessions)
    • "Relative Confidentiality" - where information supplied and held is used in a responsible way, for the benefit of the resident or member of staff concerned and safeguards against misuse are in place
  3. Due to the nature of the services provided in care homes, Absolute Confidentiality cannot be guaranteed
  4. The manager should ensure that residents and staff are aware that, whilst the home will treat information received as confidential, the manager has a legal responsibility to disclose to an enforcing agency any information which might indicate that an illegal act has taken place
  5. Each member of staff should be made aware of this procedure as part of the induction process and should receive a clear, written description of their responsibilities to ensure its application in the home
  6. Each resident should be made aware of this procedure as part of the admission process and should receive a clear, written explanation of how confidentiality is maintained and their right to access information relating to themselves.
  7. All records made should be factual and use only information supplied directly to the person who is doing the recording

Paper Records

  1. Paper records that contain information about an individual should be kept confidential
  2. Reproduction of information should be carried out only following appropriate authorisation
  3. All paper files should be held securely within the home and should not be left where unauthorised people may have access nor should they be shown to unauthorised individuals. Under no circumstances should residents’ records be displayed in their bedrooms
  4. Any document marked "Confidential" should not be shown to any person who is not on the document distribution list
  5. All records should normally remain on site at the home. If records need to be sent outside the home, the manager should ensure that a secure and appropriate method is employed

Electronic Records

  1. All records that are held by electronic means must be protected by a suitable and effective back-up and retrieval system
  2. Back-up records should be held as securely as the originals and the manager should ensure that the information is erased or destroyed when no longer required
  3. The manager should ensure that staff use security measures such as passwords and "read-only" access to prevent unauthorised access to information held within the home
  4. Computers should not be left unattended with potentially sensitive information "live" on the screen
  5. The storage of information and control of access to it should be maintained so as to comply with current legislation and the Data Protection Act 1988
  6. Access to electronic data stored in the home should be restricted to those people authorised by the manager
  7. Confidential information should not normally be sent via e-mail unless the recipient is able to ensure security of receipt


  1. Information will be given by telephone only when there is no other practical means of relaying the information required
  2. Confirmation that an individual is a resident in the home will not normally be given over the phone without permission from the resident concerned
  3. Confidential information should not be given over the the phone to anyone except in the following circumstances:
    • In an emergency to the emergency services operator
    • When requested by a care professional involved in the care of, and known by, the resident
    • Where there is no other practical means by which the information can be relayed
  4. If the telephone is used to relay information, the caller must be able satisfactorily to prove their identity and the right to information being requested
  5. Confidential information should never be sent by fax machine due to the lack of security guarantees at the recipient’s fax machine


  1. In conversation with a resident, staff should never make reference to another resident
  2. The manager should ensure that all staff are made aware of the need to respect the content of conversations with people who are not employed in the home. These people are not bound by the same rules of confidentiality and care should be taken to ensure that this procedure is not breached accidentally
  3. The manager should ensure that staff do not conduct conversations which may (or may not) be of a confidential nature in corridors or general communal areas

The Right to Access Information

  1. Residents have the right to access information held in any format which relates to themselves
  2. Each resident has a Resident’s File and a Resident’s Care Plan, which contains all personal information held in paper format by the home. Each resident can access this information at any reasonable time or by arrangement with the manager
  3. Requests to access personal records should be recorded in the Staff Handover Record
  4. The manager should ensure that they are able to furnish a resident who so requests with a list of other paper-based documents which contain information regarding the resident’s health or welfare within the home
  5. The manager should be aware of any enforcing agency which has a right of entry into the home and has a right to access any information
  6. Where the weekly charges are paid other than by the resident, the "purchaser" does not necessarily have the right to access personal information
  7. Information will be given only in circumstances where the purchaser can prove their entitlement to access the information or the resident gives their written consent

Date Reviewed: June 2018