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SEPTEMBER 2007

NATIONAL GUIDELINE

No: G199(07)

CONFIDENTIALITY IN RESPECT OF PEOPLE WHO USE OUR SERVICES ANDTHEffi FAMILIES

NATIONAL GUIDELINE ON

Confidentiality in Respect of

People Who Use our Services

and

their Families

Signed: Winifred O'Hanrahan National Chief Executive

Date: (Revised) September 2007

Date to be Implemented: October 2007

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Table of Contents

Page

The Main Principles 2

Informing People who Use our Services 2

Climate of Confidentiality 2

Sharing of Information and Limits of Confidentiality 3

Commitment to Confidentiality 4

Maintenance of Files 4

Privileged Information 5

Contents of Files 5

Access 5

Old Files 5

Reports 5

Reports to Other Agencies 6

Copying of Reports/Notes 6

Faxing Reports/Notes 6

Meetings 6

Verbal Information 7

Information on Computer Files 7

The Use of Video and Audio Taping] 7

Data Bases 7

Health Service Executive Data Base 7

Local Data Base 8

Conclusion 8

Appendix 1 Form: Confidentiality Agreement 10

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CONFIDENTIALITY IN RESPECT OF PEOPLE WHO USE OUR SERVICES AND THEIR FAMILIES.

The Main Principles

Confidentiality refers to the lirnited use of information about people who use our

services and our staff, which is obtained by staff, volunteers and board members

during the course of their work. The duty of confidentiality extends to everybody

within the Brothers of Charity Services.

Informing People who use the Services

When people with an intellectual disability and their families are first referred to

the Brothers of Charity Services the Company's policy on confidentiality should

be explained to them and they should be offered a written copy of the policy.

They should be informed of the type of information which will be kept on file and

on computer and who has access to this in line with the Freedom of Information

Act 1997. They should be assured that the information they disclose will be used

in providing the best possible service for the individual. Only information which is

directly relevant to the provision of a service to an individual should be sought.

This information should be treated with the utmost respect at all times in order to

preserve the individual's right to privacy. Individuals and their families should be

informed that in cases where the Company is proposing the development of new

services or making a case for further developing existing services certain limited

information may be forwarded to the relevant Government Agency/Department.

These principles should be borne in mind at all times when gathering and sharing

information.

Climate of Confidentiality

The duty of con·fidentiality extends to all staff members, volunteers and board

members. The onus is on each Manager/Head of Department to create a climate

of confidentiality in their service community. It is their responsibility to ensure

that all staff, including temporary staff and volunteers are made aware of the

Agency's Policy on confidentiality through appropriate training. Staff should be

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aware of confidentiality at all times. This should include keeping desks clear of

confidential material. It is the responsibility of any person supervising students

and volunteers to ensure that they have been made aware of the Company

policy on confidentiality and make every effort to ensure that the student and

volunteers adhere to it.

Sharing of Information and Limits to Confidentiality

It will be necessary to share information about an individual who uses the

services with staff members on the team providing the service. However, this

should be done on a need to know basis and only when it is in the best interests

of the person . There is an onus on staff not to give personal information unless

permission has been received from the individual and/or family beforehand,

except in exceptional circumstances such as suspected abuse. On occasion it

may be necessary to share information outside of the people directly involved

with the individual in order to obtain advice and consultation. It should be noted

that names should not be used during such consultations. In certain

circumstances the person who uses the service and/or the parent/guardian may

request that a piece of information is not shared and this request should be

complied with except in exceptional circumstances such as suspected abuse.

"Information clearly entrusted for one purpose should not be used for another

purpose without explicit consent. Such information should only be divulged with

the informed consent of the service users (or informant) except where there is

clear evidence of serious danger to the service user, worker, other persons or the

community. Any service user information to be shared must be directly relevant

to and limited to the particular situation about which the information is required".

(IASW'S Code of Ethics).

The right to confidentiality by the informant may be over-ridden in circumstances

of abuse or where there is evidence of serious danger to the person, worker,

other persons or the community. The withholding of information between

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professionals and between organisations is not acceptable where failure to

disclose may have an influence on the future safety and welfare of the person. In

situations of suspected abuse the National Guidelines on the Prevention of

Abuse & the Management of Abuse Allegations should be followed.

Commitment to Confidentiality

All staff employed in the company, all newly recruited staff, students, volunteers,

boards of directors and all those involved in our services should be made familiar

with this policy on confidentiality and sign that they agree to abide by its

principles. See appendix 1. In the case of staff, students and volunteers this

form should be countersigned by a Senior Administrator or her/his equivalent

within the Company.

Maintenance of Files

There should be a specific manner and secure system of maintaining files in line

with the Data Protection Acts 1988 & 2003 and the Freedom of information Act

1997. This system should be monitored by a nominated person. Privileged

information should be kept in accordance with the files policy. Information in the

files should be limited to the information that is relevant to the provision of a

service for that individual.

Files should be kept in a secure filing cabinet which should be locked at night

and when not in use. If a report or draft of a report is being discarded it should

be shredded. There should be a definite tracking system in place at all locations

where files are kept. Any file being removed from this cabinet should be signed

for by the person removing it.

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Privileged Information

There will be occasions when certain information should not be recorded in a file.

This pertains to personal sensitive information relating to an individual and/or that

person's family. This information should be dealt with in accordance with the

Company's policy relation to individuals' Files.

Contents of Files

Information on files should be limited to the information that is relevant to the

provision of a service for that person. Information acquired which is not directly

relevant to the provision of a service to the individual should not be recorded.

Access

Access to files should be restricted to those staff directly involved with the

person. Volunteers and students on summer job schemes should not have

access to files. Locum staff and students on placement with the Brothers of

Charity Services as part of a recognised training course should be allowed

access to files only at the discretion of their supervisor. It is the responsibility of

this person's supervisor to ensure that the person has read the company policy

on confidentiality and has signed a form agreeing to abide by it.

Old Files

Information on people who have left the service will be dealt with in accordance

with the Brothers of Charity Services policy on Service Users Files.

Reports

All reports should state the purpose for which they are written and should note

the names of those to whom they are circulated. They should in the most part

contain factual information or descriptions of direct observations. It should be

clear when professional opinions or judgements are expressed and on what

basis they are formed.

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Reports to Other Agencies

People who use our Services/families should be made aware of and consent in

writing to the information that is being sent to another organisation in relation to

their transfer from the Brothers of Charity Services to another service provider.

All reports should be starnped "Confidential, do not copy this report" .

Copying of Reports/Notes

No report should be photocopied without the permission of the author of the

report. If this person is unobtainable because they are on leave or have left the

organisation permission should be sought from the Head of Department or Head

of Centre. If copies of reports are made they should be numbered. When copies

are circulated at a meeting they should be returned to the Chairperson at the end

of the meeting for shredding.

Faxing Reports/Notes

It is the Brothers of Charity Services policy not to fax reports or other confidential

information on individuals.

This policy may be set aside in exceptional circumstances, only when

• The author has given prior permission for the information to be faxed.

• There has been prior agreement that the person to whom the report is

being faxed will personally receive the fax as it arrives at the destination.

• The individual/parent or guardian has given prior informed consent for

their information to be shared.

Meetings

Personal details about individuals should not be discussed at meetings where it

is not essential or appropriate to the purpose of the meeting. It is the duty and

responsibility of the Chairperson to ensure that confidentiality is not breached

during the meeting. Where people who use the services are part of teams they

should be provided with on-going training in confidentiality.

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Verbal Information

To create a climate of confidentiality staff, students, volunteers and the board of

directors should be aware of where, when and to whom they talk about people

who use the services. Personal information about individuals should not be

discussed in coffee rooms, corridors, or public places. Visitors to the service,

including families, should only be given information about the Service.

Information on Computer Files

The Brothers of Charity Services have National Guidelines on the Data

Protection Acts 1988 and 2003 and these should be followed.

The Use of Video and Audio Taping

The Brothers of Charity Services have National Guidelines on Photographing and

Videoing of Service Users" and these should be followed.

Data Bases

1. Health Service Executive Data Base

The Brothers of Charity Services are required by the Department of Health and

Children to maintain up-to-date records on people who use the services. These

records contain information on level of disability and future needs. People who

use the services, parents or advocates should be made aware that this is

happening and should know what information is being included on the data base.

People who use the services, parent or advocates should be involved in

completing the initial data base form and should be regularly informed of

changes made.

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2. Local Data Base

With the growing use of computers in the Services at local level it is likely that

individual service communities will establish localised data bases. Individuals

establishing such data bases are bound by the Data Protection Acts of 1998 and

2003 and must operate within the regulations of the Acts.

In addition, the following procedures should be adhered to regarding localised

data bases.

1. A committee should be established by the Chief Executive to monitor and

regulate such data bases.

2. An individual wishing to establish a data base must apply to do so to the

Chief Executive through the above Committee. The reason for wishing to

set up a data base, the individuals who will be included in the data base,

and the purposes of which the data will be used must be furnished to the

Committee.

3. Only on approval of the Chief Executive can a data base be established.

4. In ALL cases people who use the services, advocates or families should be

informed of the establishment of a data base and informed consent for an

individual's inclusion should be obtained.

Conclusion

The following are the main points of the National Brothers of Charity Policy.

Each Company is encouraged to develop its own policy.

1. Training on issues to do with confidentiality should be available to all staff

members including temporary staff and volunteers.

2. The written policy on confidentiality should be distributed to all staff

members including temporary staff and members of the board of directors.

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3. Every staff member including temporary staff, students, volunteers and

members of the board of directors should be required to sign a form

agreeing to abide by the Brothers of Charity Services policy on

confidentiality. A sample form is contained in appendix 1 of this document.

4. More education and training should be provided for staff in both the area of

recording information and in the area of legal/legislative considerations.

5. People who use the services, who are included as members of centres or

service teams, should be provided with appropriate training in areas relating

to confidentiality.

6. These guidelines should be read in conjunction with the Brothers of Charity

Services National Guidelines on:

• The Data Protection Acts 1988 & 2003

• Freedom of Information Act 1997

• Photographing and Videoing of Service Users

• Service Users Records and Files

• Use of the internetle-mail

• Service User Complaints and Appeal

7. This policy should be reviewed in three years (2010) or in light of any

relevant legislative change.

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Appendix 1

I have read the Brothers of Charity Services Policy on Confidentiality and I agree to abide by the principles contained therein.

Signed:

Date:

Co-Signed:___________ Senior Administrator (or equivalent)

Date:

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