We understand how important it is to keep your personal information safe and secure and we take this very seriously. We have taken steps to make sure your personal information is looked after in the best possible way and we review this regularly.
Please read this privacy notice (‘Privacy Notice’) carefully, as it contains important information about how we use the personal and healthcare information we collect on your behalf.
This Protocol is designed to assist staff with an understanding of their role of chaperone and associated responsibilities.
This policy is designed to protect both patients and staff from abuse or allegations of abuse and to assist patients to make an informed choice about their examinations and consultations.
The Practice is committed to providing a safe and comfortable environment where patients and staff can be confident that best practice is being followed at all times. The safety of everyone is of paramount importance.
In clinical medicine, a formal chaperone is a person who serves as a witness for both a patient and a medical practitioner as a safeguard for both parties during a medical examination or procedure and is a witness to continuing consent of the procedure. Family members or friend may be present but they cannot act as a formal chaperone.
There are two considerations involved in having a chaperone to assist during intimate examinations; namely for the comfort of the patient and the protection of the doctor/nurse from allegations of impropriety.
Examples of an intimate examination include examinations of the breasts, genitalia and the rectum but it also extends to any examination where it is necessary to touch or be close to the patient for example conducting eye examinations in dimmed lighting, taking the blood pressure or palpating the apex beat.
All patients are entitled to have a chaperone present for any consultation, examination or procedure where they feel one is required. Patients have the right to decline the offer of a chaperone. However, the clinician may feel that it would be wise to have a chaperone present for their mutual protection for example, an intimate examination on a young adult of the opposite gender. If the patient continues to decline the doctor will need to decide whether or not they are happy to proceed in the absence of a chaperone. This will be a decision based on both clinical need and the requirement for protection against any potential allegations of improper conduct.
An appropriately trained chaperone is defined as a member of staff who has completed training and who has been assessed as competent by a member of the Practice clinical team. All clinical staff who act as a chaperone have a documented Disclosure and Barring Service check kept on record.
Reception/Admin staff are not routinely DBS checked. They are suitably trained so they develop the competencies required. The surgery has an appropriate risk assessment in place providing a clear rationale as to why. Staff who are not DBS checked, are at no time left alone with a patient and do not look after a child while the patient is being examined.
Consultations Involving Intimate Examinations – If an intimate examination is required, the clinician will:
Clinicians (male and female) should consider whether an intimate or personal examination of the patient (either male or female) is justified, or whether the nature of the consultation poses a risk of misunderstanding.
This should remove the potential for misunderstanding. However, there will still be times when either the clinician, or the patient, feels uncomfortable, and it would be appropriate to consider using a chaperone. Patients who request a chaperone should never be examined without a chaperone being present
The Patient can expect the Chaperone to be:
The positioning of the chaperone will depend on several factors for example the nature of the examination and whether or not the chaperone has to help the clinician with the procedure.
There may be occasions when a chaperone is unavailable (for example on a home visit or when no trained chaperone of the appropriate sex is in the building). In such circumstances the doctor will assess the circumstances and decide if it is appropriate to go ahead. If necessary, the consultation / examination should be rearranged for the patient to a mutually convenient time when a chaperone can be present.
Patients should raise any concerns/make any complaint via the practice’s usual comments/complaints procedure.
Staff must record in the patient record that they have acted as Chaperone and use an appropriate code from the list below:
| Name | Code |
|---|---|
| Chaperone offered | XaEiq |
| Chaperone present | XaEir |
| Chaperone refused | XaEis |
| Chaperone not available | XaMe5 |
| Nurse chaperone | XaF0C |
| Presence of chaperone | XaEip |
A Privacy Notice tells people how organisations use information that they hold about them. The UK General Protection Regulation (UK GDPR) and the Data Protection Act 2018 (DPA 20180, says that we need to provide you with this Privacy Notice and let you know:
The law gives us permission to use your information in situations where we need it to take care of you. Because information about your health is very personal, sensitive and private to you, the law is very strict about how we use it.
So, before we can use your information in the ways we have set out in this Privacy Notice, we have to have a good reason in law, which is called a ‘lawful basis’. Not only do we have to do that, but we also have to show that your information falls into a special group or category, because it is very sensitive. By doing this the law makes sure we only use your information to look after you and that we do not use it for any other reason.
If you would like more information about this please ask to speak to our Data Controller in the first instance, mentioned in this Privacy Notice who will explain this in more detail.
We, at Hanscombe House Surgery, 52A St Andrew Street, Hertford, Hertfordshire, SG14 1JA, are responsible for collecting, storing and handling your information when you register with us as a patient. Because we do this, the law says we are Data Controllers.
We hold information about you such as:
The purpose of the policy is to ensure that all patients (or their representatives) who have the cause to complain about their care or treatment can have freely available access to the process and can expect a truthful, full and complete response and an apology where appropriate. Complainants have the right not to be discriminated against as the result of making a complaint and to have the outcome fully explained to them. The process adopted in the practice is fully compliant with the relevant NHS Regulations (2009) and guidance available from defence organisations, doctors` representative bodies and the Care Quality Commission. Everyone in the practice is expected to be aware of the process and to remember that everything they do and say may present a poor impression of the practice and may prompt a complaint or even legal action.
The general principle of the practice in respect of all complaints will be to regard it first and foremost as a learning process, however in appropriate cases and after full and proper investigation the issue may form the basis of a separate disciplinary action. In the case of any complaint with implications for professional negligence or legal action, the appropriate defence organisation must be informed immediately.
The practice will ensure that there are notices advising on the complaints process conspicuously displayed in all reception/waiting areas and that leaflets containing sufficient details for anyone to make a complaint are available without the need to ask. The practice website and any other public material (Practice Leaflet etc.) will similarly provide this information and also signpost the complainant to the help available through the NHS Complaints Advisory Service.
There are two ways you can make a complaint:
You can complain to the practice (the healthcare provider)
Or
Hertfordshire and West Essex Integrated Care Board
In the event of anyone not wishing to complain directly to the practice the complaint should be made to Hertfordshire and West Essex Integrated Care Board at:
In those cases where the complaint is made to the ICB, the practice will comply with all appropriate requests for information and co-operate fully in assisting them to investigate and respond to the complaint.
Full details of the changes made on 1st July 2023 can be found on the ICB website.
A complaint can be made by or, with consent, on behalf of a patient (i.e. as a representative); a former patient, who is receiving or has received treatment at the Practice; or someone who may be affected by any decision, act or omission of the practice.
A Representative may also be
In all cases where a representative makes a complaint in the absence of patient consent, the practice will consider whether they are acting in the best interests of the patient and, in the case of a child, whether there are reasonable grounds for the child not making the complaint on their own behalf. In the event a complaint from a representative is not accepted, the grounds upon which this decision was based must be advised to them in writing.
The practice “Responsible Person” is Dr Anita Oates. They are charged with ensuring complaints are handled in accordance with the regulations, that lessons learned are fully implemented, and that no Complainant is discriminated against for making a complaint. This person should be a practice Partner (BMA Guidance and Primary Care contracts)
The practice “Complaints Manager” is Mrs Janine Ellis, Practice Manager, and they have been delegated responsibility for managing complaints and ensuring adequate investigations are carried out.
The period for making a complaint is normally:
The practice has discretion to extend these limits if there is good reason to do so and it is still possible to carry out a proper investigation. The collection or recollection of evidence, clinical guidelines or other resources relating to the time when the complaint event arose may also be difficult to establish or obtain. These factors may be considered as suitable reasons for declining a time limit extension, however that decision should be able to stand up to scrutiny.
It is always better to try and deal with the complaint at the earliest opportunity and often it can be concluded at that point. A simple explanation and apology by managerial staff at the time may be all that is required.
A verbal complaint need not be responded to in writing for the purposes of the Regulations if it is dealt with to the satisfaction of the complainant by the end of the next working day, neither does it need to be included in the annual Complaints Return. The practice will however record them for the purposes of monitoring trends or for Clinical Governance and that record will be kept and monitored by management staff. Verbal complaints not formally recorded will be discussed when trends or issues need to be addressed and at least annually, with minutes of those discussions kept.
If resolution is not possible, the Complaints Manager will set down the details of the verbal complaint in writing and provide a copy to the complainant within three working days. This ensures that each side is well aware of the issues for resolution. The process followed will be the same as for written complaints.
On receipt, an acknowledgement will be sent within three working days. This is the opportunity to gain an indication of the outcome the complainant expects and also for the details of the complaint to be clarified. In the event that this is not practical or appropriate, the initial response should give some indication of the anticipated timescale for investigations to be concluded and an indication of when the outcome can be expected.
It may be that other bodies (e.g. secondary care/ Community Services) will need to be contacted to provide evidence. If that is the case, then a patient consent form will need to be obtained at the start of the process and a pro-forma consent form included with the initial acknowledgement for return.
If it is not possible to conclude any investigations within the advised timescale, then the complainant must be updated with progress and revised time scales on a regular basis. In most cases these should be completed within six months unless all parties agree to an extension.
The practice will ensure that the complaint is investigated in a manner that is appropriate to resolve it effectively and proportionate to the degree of seriousness that is involved.
The investigations will be recorded in a complaints file created specifically for each incident and where appropriate should include evidence collected as individual explanations or accounts taken in writing.
This will be provided to the complainant in writing (or email by mutual consent) and the letter will be signed by the Responsible Person or Complaints manager under delegated authority. The letter will be on headed notepaper and include:
The final letter should not include:
The practice will produce an annual complaints report to be sent to the local Commissioning Body (NHSE) and will form part of the Freedom of Information Act Publication Scheme.
The report will include:
Care must be taken to ensure that the report does not inadvertently disclose any confidential data or lead to the identity of any person becoming known.
All complaints must be treated in the strictest confidence and the practice must ensure that the patient etc. is made aware of any confidential information to be disclosed to a third party (e.g. NHSE).
The practice must keep a record of all complaints and copies of all correspondence relating to complaints, but such records must be kept separate from patients’ medical records and no reference which might disclose the fact a complaint has been made should be included on the computerised clinical record system.
Where a complainant becomes unreasonable or excessively rude or aggressive in their promotion of the complaint, some or all of the following formal provisions will apply and must be communicated to the patient by the Responsible Person in writing:
It is important that all complaints made to the practice regarding or involving a locum (Doctor, Nurse or any other temporary staff) are dealt with by the practice and not passed off to a Locum Agency or the individual locum to investigate and respond. The responsibility for handling and investigating all complaints rests with the Practice.
Locum staff should however be involved at an early stage and be advised of the complaint in order that they can provide any explanations, preferably in writing. It would not be usually appropriate for any opinions to be expressed by the Practice on Locum staff. Providing their factual account along with any factual account from the practice is the best way to proceed.
The practice will ensure that on engaging any Locum, the Locum Agreement will include an assurance that they will participate in any complaint investigation where they are involved or can provide any material evidence. The practice will ensure that there is no discrepancy in the way it investigates or handles complaints between any Locum staff and either practice Partners, salaried staff, students or trainees or any other employees.
Local Authority Social Services & National Health Service Complaints (England) Regulations 2009 – S.I. 209, No.309.
NHS Complaints Procedure (England only): Guidance for Primary Care, BMA August 2015.
The practice complies with the Data Protection Act. All information about patients is confidential: from the most sensitive diagnosis, to the fact of having visited the surgery or being registered at the Practice. All patients can expect that their personal information will not be disclosed without their permission except in the most exceptional of circumstances, when somebody is at grave risk of serious harm.
All members of the primary health care team (from reception to doctors) in the course of their duties will have access to your medical records. They all adhere to the highest standards of maintaining confidentiality.
As our reception area is a little public, if you wish to discuss something of a confidential nature please mention it to one of the receptionists who will make arrangements for you to have the necessary privacy.
The duty of confidentiality owed to a person under 16 is as great as the duty owed to any other person. Young people aged under 16 years can choose to see health professionals, without informing their parents or carers. If a GP considers that the young person is competent to make decisions about their health, then the GP can give advice, prescribe and treat the young person without seeking further consent.
However, in terms of good practice, health professionals will encourage young people to discuss issues with a parent or carer. As with older people, sometimes the law requires us to report information to appropriate authorities in order to protect young people or members of the public.
The Freedom of Information Act creates a right of access to recorded information and obliges a public authority to:
The Act covers any recorded organisational information such as reports, policies or strategies, that is held by a public authority in England, Wales and Northern Ireland, and by UK-wide public authorities based in Scotland, however it does not cover personal information such as patient records which are covered by the Data Protection Act.
Public authorities include government departments, local authorities, the NHS, state schools and police forces.
The Act is enforced by the Information Commissioner who regulates both the Freedom of Information Act and the Data Protection Act.
A publication scheme requires an authority to make information available to the public as part of its normal business activities. The scheme lists information under seven broad classes, which are:
You can request our publication scheme leaflet at the surgery.
Under the Act, any individual, anywhere in the world, is able to make a request to a practice for information. An applicant is entitled to be informed in writing, by the practice, whether the practice holds information of the description specified in the request and if that is the case, have the information communicated to him. An individual can request information, regardless of whether he/she is the subject of the information or affected by its use.
Requests must:
Personal data about staff and patients covered under Data Protection Act.
For more information see these websites:
All GP practices are required to declare the mean earnings (eg average) for GPs working to deliver NHS services
to patients at each practice.
The average pay for GPs working at the HANSCOMBE SURGERY in the last financial year before tax and national
insurance is £82,036.
This is for 2 full time GPs and 8 part time GPs who worked in the practice for more than 6 months.
It should be noted that the prescribed method for calculating earnings is potentially misleading because
it takes no account of how much time doctors spend working in the practice, and should not be used to form
any judgement about GP earnings, nor to make any comparison with any other practice.
We aim to keep our surgery clean and tidy and offer a safe environment to our patients and staff and endeavour to keep it clean and well maintained at all times.
Our GPs and nursing staff follow our Infection Control Policy to ensure the care we deliver and the equipment we use is safe.
We take additional measures to ensure we maintain the highest standards:
The people caring for you need access to your health and care record in order to make the best decisions about your diagnosis and treatment. For this to happen more quickly and to improve the care you receive, a new process has been put in place. With your permission, My Care Record will provide health and care professionals directly involved in your care, access to the most up-to-date information about you. To find out more please go to www.mycarerecord.org.uk
In west Essex and Hertfordshire, providers of health and social care services are working more closely together to better co-ordinate the delivery of care to people supported by local commissioners.
My Care Record is a programme which allows people to give health and care professionals their permission to access their medical records during their treatment.
The people caring for you need to access about your health and care record in order to make the best decisions about your diagnosis and treatment. This could include GPs, hospital-based clinicians, nurses, health visitors and social workers.
To enable this to happen more quickly and to improve the care you receive, a new process has been put in place. This will allow your information to be accessed by different health and care organisations, using existing computer systems.
Your record will only be accessed by health and care professionals involved in your care.
Information will only be accessed with your permission – where applicable – and while you are receiving direct treatment by a health and care professional.
Information accessed through My Care Record is treated to the same security standards as all confidential information.
The record accessed is your health and care record. Examples of information that will be available include:
The information available in the record from your care provider is in a chronological order so that your care provider can see a relevant history of your care. They will always update their own care record with any new information. This helps them to make better decisions about your care. Access is only with your explicit permission.
The organisations that could be involved in the service are:
You can tell your care provider if you don’t want them to make your information available by completing a form available on www.mycarerecord.org.uk or by asking your care provider for one. Your record will be edited and no information will be available to access.
My Care Record is simply a reflection of your individual records held by the organisations above and therefore you should contact them directly if you wish to have a copy of the information held about you. The contact details for each organisation’s Data Protection Officer or Team is below.
Please contact your own General Practice directly for a copy of your GP record.
For further information on My Care Record please visit www.mycarerecord.org.uk.
We have allocated a Named Accountable GP for all of our registered patients. If you do not know who your named GP is, please ask a member of our reception team.
Unfortunately, we are unable to notify patients in writing of any changes of GP due to the costs involved.