Information Governance Policies and Procedures
This Information Government document is a framework that details the management of information within
- Aim and Purpose
- Information Governance Framework Principles for Therapy4stress
- Privacy Notice: Use of Information
- Retention Schedule
- Data Processing
- Data breach
- Subject Access Request
- Right to Erasure
- Safeguarding Your Privacy
Data held by Therapy4stress will be held lawfully and for the retention periods set out in Section B of this policy document.
This document refers to:
- Written Documents
- Hardcopy case notes and files
- Database entries
- Text messages
- Supervision notes
- Visits to the organisations website
- Social media communication
Aim and Purpose
The purpose of this document is to ensure that Therapy4Stress, has a framework that ensures the rights and freedom of individuals in relation to their personal data (Article 1 of the GDPR) and adheres to best practice in the management of client information and business records.
Information Governance sets out the way in which information collated by an organisation is managed and ensures that any information collected;
- is the right information
- is in the right place
- at the right time
- with the right people
- for the right reasons
This is a live document and may be updated at any time to reflect changes in law or growth of the business, and therefore will be revisited regularly to check for any updates. Therapy 4 Stress is fully committed to ensuring clients’ privacy and data protection rights.
For the purpose of this policy Renie Price is the named Data Protection Officer/Controller and Head of Organisation.
Information Governance Framework Principles for Therapy 4 Stress
- Assessment needs for Information Governance (IG) Training have been identified and fully met, with a 75 minute GDPR CPD Course provided by the Clinical Hypnotherapy School (www.clinicalhypnotherapyschool.com) completed. Refresher training is completed every two years.
- Any changes to the business processes and/or operations will be planned and will comply with the framework to ensure any risks to personal and sensitive information are minimised.
- Any data collected is solely for the purpose of providing a person-centred service to an individual client.
- The Caldicott Principles are used to provide guidance in best practice when handling personal data, alongside the ICO’s Office Codes of Practice. (https://www.igt.hscic.gov.uk/Caldicott2Principles.aspx)
- All technology [Microsoft Office products including Outlook] used to store or facilitate information and communication is maintained according to the Data Retention Policy for Therapy 4 Stress.
- All records are identifiable, locatable, retrievable, and intelligible according to regulations set out by GDPR.
- It is the responsibility of the Data Controller to ensure sufficient resources are in place to prioritise adhering to Data Protection Legislation in the business.
- Any electronic devices where personal or sensitive, confidential information is held will be password protected. Individual documents stored electronically will also contain individual passwords.
- Procedures have been put in place to ensure the General Data Protection Regulations are met. These can be found in Section
Privacy Notice: Use of information
In accordance with this data retention schedule there may be occasions when data is not destroyed due to ongoing investigation, ligation or enquiry. The data will be deleted upon confirmation that it is no longer required.
On some occasions anonymised personal data will be retained whereby a client has provided a testimonial for use on the organisations website. When data is non-identifiable GDPR law is no longer applicable. [Non-identifiable means that if this data was, for example, left on a bus, no one, including the data subject would be able to identify that this data was relating to them.]
- Personal information is collated and stored in hardcopy in a locked filing cabinet behind a locked door.
- Any document containing personal data will state “Official-sensitive, private and confidential” clearly.
- All emails will contain a privacy statement.
Under the General Data Protection Regulations (2018), regarding how your personal data is processed, all individuals have;
- the right to be informed;
- the right of access;
- the right to rectification;
- the right to erasure;
- the right to restrict processing;
- the right to data portability;
- the right to object; and
- the right not to be subject to automated decision-making including profiling.
Please note that Therapy 4 Stress does not use automated decision-making tools, including profiling.
When an individual visits www.therapy4stress.com Google analytics are used, this is considered a third party service, to collect information about what visitors do when they click the website, e.g. which page they visit the most. Google analytics only collect non-identifiable data which means neither Therapy4Stress or Google analytic are able to identify who is visiting.
Therapy4stress will always be transparent when it comes to collecting personal data and will be clear about how that data is processed.
JohnLawley.co.uk is a third-party service that hosts the Therapy 4 Stress website. The hosting service also uses anonymised data to collect visitor information such as how long an individual remains on a page of a website. The JohnLawley.co.uk privacy notice can be found here for further information: https://johnlawley.co.uk/privacy-cookies/
Therapy 4 Stress uses third-party providers, to manage some of its social media interactions. Any messages sent to the inbox of social media accounts are stored by the social media platform. Their Privacy notices can be found here:
|Information Asset||Information Owner Asset||Retention||Trigger for Disposal|
|Email (including sent items)||Head of organisation||Annual review period every January, any remaining live data untouched until following review period.||End of retention period|
|Contact details held on mobile devices||Head of organisation||All entries to be deleted prior to decommissioning of mobile device or reissue of device||End of retention period|
|Recordings||Head of organisation||5 years or earlier if consent is withdrawn||End of retention period|
|Images taken||Head of organisation||5 years or earlier if consent is withdrawn||End of retention period|
|Promotional materials||Head of organisation||Until superseded – Consent to be rechecked prior to reissue||End of retention period|
|Paper Diaries||Head of organisation||3 months from the period in which its use ends.||End of retention period|
|Policies||Head of organisation||Until new policy has been put into place||End of retention period|
|Client records including session notes, initial consultation notes and client overview form||Head of organisation||In accordance with CNHC regulation, 8 years after final treatment session has ended. Child records should be held until after 25th birthday, or 26th birthday if aged 17 when treatment ends.||End of retention period|
|Safeguarding records||Head of organisation||In accordance with the current organisations insurance policy, 5 years after final treatment session has ended, unless superseded by new insurance policy.||End of retention period|
|Sat Nav records||Head of organisation||All entries to be deleted prior to decommissioning of mobile device or reissue of device||End of retention period|
|Waiting lists||Head of organisation||Annual review period every January, old waiting list destroyed, and new waiting list developed with any remaining live data transferred to new live document.||End of retention period|
|Continual Professional Development Records||Head of organisation||To be retained when worker is in service and until 8 years afterwards.||End of retention period|
|Worker supervision records||Head of organisation and workers supervisor||To be retained when worker is in service and until 8 years afterwards.||End of retention period|
|Service evaluation records||Head of organisation||Transfer to anonymised data within 6 months of collection.||End of retention period|
|Tax returns||Head of organisation||6 years from the end of the financial period to which they pertain to.||End of retention period|
|Incident/Accident reports||Head of organisation||40 years from date report was closed||End of retention period|
|Insurance policies||Head of organisation||40 years from date policy ended.||End of retention period|
|Complaints||Head of organisation||2 years from complaint being resolved||End of retention period|
|Right to Erasure Request||Head of Organisation||8 years from request being submitted and completed.||End of retention period|
|Subject Access Request||Head of organisation||8 years alongside session notes, or plus 2 years from case closure if request is made after 6 years of storing data.||End of retention period|
Hard copy data will be destroyed via a cross shredding machine owned by the organisation, electronic data will be permanently deleted.
Processing Data at Therapy 4 Stress within the current law:
- In relation to communicating with my clients, the individual has given clear consent for their data to be processed for the specific purpose(s) detailed in the consent form stored in their personal file.
- Processing is undertaken in order to protect the vital interests of the data subject or of another natural person.
- Processing is undertaken for your legitimate interests as specified in Article 9 of the GDPR:
Art.9 GDPR Processing of special categories of personal data
- Processing of personal data revealing racial or ethnic origin, political opinions, religious or philosophical beliefs, or trade union membership, and the processing of genetic data, biometric data for the purpose of uniquely identifying a natural person, data concerning health or data concerning a natural person’s sex life or sexual orientation shall be prohibited.
- Paragraph 1 shall not apply if one of the following applies:
- processing is necessary for the purposes of preventive 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 on the basis of Union or Member State law or pursuant to contract with a health professional and subject to the conditions and safeguards referred to in paragraph 3;
- Personal data referred to in paragraph 1 may be processed for the purposes referred to in point (h) of paragraph 2 when those data are processed by or under the responsibility of a professional subject to the obligation of professional secrecy under Union or Member State law or rules established by national competent bodies or by another person also subject to an obligation of secrecy under Union or Member State law or rules established by national competent bodies.
This means that Therapy 4 Stress does not require consent to hold your data to provide a service but does require your consent to contact you for specific purposes. Participating in the service by attending more than one appointment implies that you agree with the Terms and Conditions provided to you at the commencement of service delivery.
Description of processing
The following is a broad description of the way this organisation/data controller processes personal information. Clients wishing to understand how their own personal information is processed may choose to read the Terms and Conditions for treatment document, which compliments the policies detailed here.
Reasons/purposes for processing information
Therapy 4 Stress processes personal information to enable the provision of Hypnotherapy, to advertise services and to maintain accounts and records.
Type/classes of information processed
Therapy 4 Stress processes information relevant to the above reasons/purposes. This information may include:
- personal details
- family, lifestyle and social circumstances
- goods and services
- financial details
- employment and education details
Therapy 4 Stress also processes sensitive classes of information that may include:
- physical or mental health details
- racial or ethnic origin
- religious or other beliefs of a similar nature
- offences and alleged offences
Therapy 4 Stress processes personal information about:
- business contacts
- professional advisers
All personal and sensitive data held by Therapy 4 Stress is held securely. Electronic data stored on a computer is stored on a password protected computer, in password protected documents held on One Drive. This supports the ability to retrieve data in the event of faults. Hardcopy data is held securely in a locked cabinet behind a locked door.
In the case of a data breach Therapy4Stress shall comply with the regulations set out under Article 33 of the GDPR;
1. In the case of a personal data breach, the data controller shall without undue delay and, where feasible, not later than 72 hours after having become aware of it, notify the personal data breach to the ICO, unless the personal data breach is unlikely to result in a risk to the rights and freedoms of the individual. Where the notification to the ICO is not made within 72 hours, it shall be accompanied by reasons for the delay.
2. The notification referred to in paragraph 1 shall at least:
(a) describe the nature of the personal data breach including where possible, the approximate number of data subjects concerned and the categories (e.g. sessions notes, phone numbers) and approximate number of personal data records concerned;
(b) communicate the name and contact details of the data controller where more information can be obtained;
(c) describe the likely consequences of the personal data breach;
(d) describe the measures taken or proposed to be taken by the controller to address the personal data breach, including, where appropriate, measures to mitigate its possible adverse effects.
4. Where, and in so far as, it is not possible to provide the information at the same time, the information may be provided in phases without undue further delay.
5. The controller shall document any personal data breaches, comprising the facts relating to the personal data breach, its effects and the remedial action taken. That documentation shall enable the supervisory authority to verify compliance with this Article.
6. In the event that a data breach will likely cause a risk to the rights and freedoms of client data, the data controller must communicate the nature of the breach in clear, concise and plain language, to the client/s involved, without delay.
7. If a breach occurs but the data controller has gone to appropriate lengths to protect the data held on the client (e.g. password encryption of electronic files), or if the data controller has taken subsequent action to prevent the risk (e.g. immediately blocking a mobile device) then notifying the client will not be required.
Subject Access Request
A Subject Access Requests (SAR) permits individuals to request a copy of their personal information.
A SAR must be acted upon within one month, at the most within two months, any longer and reasonable reason must be provided. There are no fees unless there is a disproportionate fee to the organisation for sending out the information. Application for SAR should be held alongside session records unless application was made after six years of the end of treatment. In which case the SAR will be held for a further two years after closure of SAR.
A SAR request will include information we hold about you, Therapy 4 Stress will:
• provide a description of it;
• give information as to why we are holding it;
• supply information as to whom it could be disclosed to; and
• provide a copy of the information in an intelligible form.
SAR requests should be put in writing to Therapy 4 Stress. A response may be provided informally over the telephone with your agreement, or formally by letter or email. If any information held is noted to be incorrect an individual can request a correction be made to their own personal information. This should be made in writing to Therapy 4 Stress
Right to Erasure
Any person may put in a request for their personal data to be removed (the ‘right to be forgotten’ or the ‘right to erasure’). In this instance hard copy data will be shredded using a cross shredding machine owned by the organisation and any electronic data will be permanently deleted. The client will be notified of the completion. The request for deletion of data and the confirmation of completion will be held securely until eight years after the request was made.
Therapy 4 Stress hopes to the meet the highest quality standards when processing personal and sensitive data. Complaints can help identify areas for improvement and therefore Therapy 4 Stress would welcome any comments and concerns you may have.
The Information Governance Policy documents were created to be as transparent and understandable as possible. It is not be completely exhaustive of all aspects of data collection. If you would like further information about a specific process, please contact Therapy 4 Stress.
If you feel you would like to make a complaint about how your personal and sensitive data is handled by Therapy 4 Stress, you can contact Therapy 4 Stress directly. In the event that Therapy 4 Stress cannot resolve your complaint to your satisfaction you can contact the Information Commissioners Office on 0303 123 1113.
Safeguarding your privacy
In the event of Renie Price’s death, (the author of this document), my supervisor will contact existing clients and archive any client files in accordance with General Data Protection Regulations.