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Document Title Visual Imaging and Audio Recording Policy

Reference Number CNTW(O)45

Lead Officer

Lisa Quinn,

Executive Director of Commissioning and Quality Assurance

Author(s) (name and designation)

Angela Faill, Head of Information Governance and Medico Legal.

Ratified by Business Delivery Group

Date ratified Dec 2019

Implementation Date Dec 2019

Date of full implementation

Dec 2019

Review Date Dec 2022

Version number V07

Review and Amendment

Log

Version Type of Change

Date Description of Change

This Policy supersedes the following document which must now be destroyed:

Document Number Title

NTW(O)45 – V06.5 Visual Imaging and Audio Recording Policy

CNTW(O)45

Visual Imaging and Audio Recording Policy

Section Contents Page No.

1 Introduction 1

2 Purpose 1

3 Duties, Accountability and Responsibilities 2

4 Definition of Terms 2

5 Procedure/Process 3

6 Identification of Stakeholders 8

7 Training 9

8 Implementation 9

9 Fair Blame 9

10 Fraud, Bribery and Corruption 9

11 Monitoring 9

12 Associated Documents 10

13 References 10

Standard Appendices – attached to policy

A Equality Analysis Screening Toolkit 11

B Training Checklist and Training Needs Analysis 13

C Audit Monitoring Tool 15

D Policy Notification Record Sheet - click here

Appendices – listed separate to Policy

Appendix 1 Consent Form for Audio Visual Recording

Practice Guidance Note – listed separate to Policy

PGN No. Description

VIA-PGN-01 PGN for taking patients photographs within inpatient settings to maintain patient safety

VIA-PGN-02 Visual/Audio Recording of a Clinical Consultation

https://www.cntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

CNTW(O)45

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust CNTW (O) 45 – Visual Imaging and Audio Recording Policy – V07-Dec 19

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1 Introduction 1.1 This Policy outlines staff responsibilities towards service users, other staff and

members of the public with regard to the use of visual and audio recordings and to ensure that all recording that takes place is done:

For a clear purpose,

With full consent of all service users, staff and the public,

With appropriate control of use, storage and transportation. 2 Purpose 2.1 To prevent unauthorised disclosure of person identifiable data (PID) held by

the Trust. 2.2 Visual and audio recording can be beneficial in clinical care, to assist in

treatment, to record changes, for teaching purposes and the first priority must be to protect the interests and well-being of individual service users and to keep information about them confidential.

2.3 Any person undertaking recording of a service user does so on the

understanding that all visual images and audio recording produced will be regarded as health records. They are therefore entitled to the same degree of protection and confidentiality as written health records giving regard to the principles of the Data Protection Act 2018. (See Records Management Policy – CNTW (O) 09).

‘Recording’ includes video and audio recording and the taking of digital and photographic images for the purposes of treatment/ assessment of service users, staff assessment/supervision, research, staff training and clinical audit.

The Policy does not refer to the taking of images for the purposes of Trust publicity, the recording of social events or stories conducted by the media. Consent for these purposes must be obtained via the Communications Department.

Health Professionals should always ensure that they make clear in advance to the service user the purpose(s) of the recording. Explicit consent for that purpose must be obtained from the service user prior to any recording. The recording must not be used for any other purpose without further consent from the service user. (See paragraph 6.2 for more detail on capacity to consent).

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3 Duties, Accountability and Responsibilities

Responsibility for implementation and compliance to this Policy lies with the Chief Executive and the Corporate Decisions Team.

The Executive Director of Commissioning and Quality Assurance as Senior Information Risk Owner (SIRO) has delegated responsibility from the Chief Executive.

Associate Directors must ensure ownership for implementation throughout their respective Locality Care Groups.

Line Managers in collaboration with the Corporate Decisions Team and the Caldicott and Information Governance Group (CIGG) are responsible for the day-to-day management and oversight of removable media used within their work areas to ensure this policy is followed.

This Policy applies to all employees of the Trust, temporary staff, volunteers, contract and agency staff and any other persons working on behalf of the Trust.

4 Definition of Terms

Visual Image: Any photographic image captured on a camera, video recorder or camcorder, including those integral to mobile phones etc.

Audio recording: Any voice recording made on magnetic or digital media.

Mental Capacity: The ability to make informed decisions for oneself.

Digital recording: Electronically held recordings, both visual and audio.

NHS Records Management Code of Conduct: A Code of Conduct issued by the Department of Health, which includes in Part 2, the NHS Retention of Records Schedule.

Information Commissioner: Appointed by the Government to regulate information related legislation in the UK, including the Data Protection Act 2018, and the Freedom of Information Act 2000.

Encryption: Encryption is specialist software that uses a complex set of mathematical algorithms and encryption keys to scramble data. Where the required software and encryption keys are available, data can be read as normal. However, without the software and keys, information is unusable.

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Video Conferencing: Video conferencing is a communication medium involving a computer, video camera, and network connection (an intranet or the internet for example). It allows a connection combining both voice and picture between two or more people. This allows meetings in a face-to-face format that eliminates the necessity of travel.

5 Procedure/Process. 5.1 Recordings made for Clinical Care.

There must be a fully justifiable purpose for the recording of a service user to be carried out.

A Trust owned and approved digital device must be used. Use of equipment owned by staff is not permitted, including mobile phones.

When recording a consultation, the service user’s explicit consent must be obtained and this can be recorded in a progress note outlining the discussions held. A consent form (Appendix 1 CNTW(C)05 – App3-Consent Form 3A ClientPtParentAgree –Vid-AudV05 – Nov 19) can be completed as an alternative to the progress note then uploaded as a document to RiO. This consent form will need to reference the discussions with patient (i.e. in ensuring informed consent has been given) that have been recorded within a progress note.

Recordings made for clinical purposes form part of the health record. When considering the disclosure of such recordings normal standards of confidentiality for health records apply.

Where recording is required as an integral part of a research project, this must be specifically included in the research protocol and consent must be considered within the application for ethical approval.

A recording made in the course of treating or assessing a service user may not be used for any other purpose, without obtaining the service user’s explicit consent.

No recording should compromise the service user’s privacy and dignity.

Recordings made for training purposes form part of the clinical staff training record, and are not an element of the health record. Such recordings should be held in accordance with the guidelines in the NHS Records Management Code of Practice and retention schedule.

Trust owned Smart Phones must not be used to take photographs of individuals.

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5.2 Approval to Record

Within specific services, the principle to use recording must be approved by the Team Manager/Supervisor or Head of Service, appropriate to the purpose of the recording.

In all cases the person responsible for the recording must complete the Checklist on the Consent Form (See Appendix 1).

The service user must sign the Consent Form and it must be countersigned by the relevant clinician.

A copy should be made of the consent form and given to the service user to keep for reference. The original should be filed in the health record.

Where disability or illness prevents a service user from giving informed consent or where the service user lacks capacity, normal protocols should be observed. If necessary advice may be obtained on consent issues from the Head of Information Governance and Medico Legal. A note should be recorded in the health record of the factors taken into account in assessing the service user’s capacity.

Where group work is being recorded the consent of all individual participants must be obtained.

Where children who lack the understanding to consent are to be recorded, permission must be obtained from a parent or person with parental responsibility. People agreeing to recordings on behalf of others must be given the same rights and information as service users acting on their own behalf. Consent should be sought from children aged between 13 and16 if they have the capacity and understanding to consent to recording. A note should be made in the patient’s health record of the factors taken into account in assessing the child’s capacity. If a child is not willing for recording to be carried out, their wishes must be respected, regardless of the consent of a person with parental responsibility.

Once consent has been obtained consideration should be given as to whether the service user may require a period to reflect and possibly reconsider before recording actually takes place. Service users must know that they are free to stop the recording at any time and that they are entitled to view or listen to it if they wish, before deciding whether to give consent to its use. If the service user decides that they are not happy for any recording to be used, it must be destroyed. Where this forms part of the health record application must be made to the Health Records Department via the Subject Access Procedure, in accordance with the Data Protection Act 2018.

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5.3 Video Conferencing

Video Conferencing will not normally be recorded but minutes of the meeting should be made if a record of proceedings is required. If a video or audio recording is to be made, participants should be made aware. If Video Conferencing is used for meetings involving Clinical cases, explicit consent of the service users must be obtained and recorded in the health records.

Security in the room containing the Video Conferencing equipment must be observed at all times. A notice to this effect should be displayed prominently. Additionally, a sign should be attached to the door warning of the presence of recording equipment within the room.

5.4 Digital Recording

Digital recordings are easier to copy, manipulate and distribute than traditional recording.

Where digital photography is to be used to record images of service users, due care must be given before the start of the project to ensure that the quality of the image is adequate for its purpose.

Images of service users must not be taken off Trust premises unless encrypted on suitable Trust portable media, (such as an encrypted laptop or encrypted USB memory stick), and these must be stored securely at all times. They must not be transferred to staff’s own personal computers or mobile devices. Advice may be sought from the Information Governance Team.

5.5 Storage and Retention

Traditional film processing, analogue voice and VHS is not permitted.

Patient related recordings, under the requirements of the Data Protection Act, must be kept only for as long as the purpose for which they were obtained (see below) and must be available for disclosure to the patient if requested.

Recordings taken for assessment or treatment of patients should be destroyed as confidential waste at the end of the agreed period as specified on the Consent Form, and within the retention guidelines set out below.

If the recording forms part of the health history of the patient the following will give guidance on the minimum retention period.

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Mental Health Records must be kept for 20 years after no further treatment considered necessary, however, as the NHS Records Management Code of Practice states that Clinical Psychology records are set at a retention period of 30 years the Trust will retain all Mental Health and Clinical Psychology Records for a period of 30 years OR 8 years after service user’s death except Learning Disability records which will be retained for 10years after death. However advice should be sought from the Information Governance and Medico-Legal Team before any records are destroyed.

Counselling records 30 years

Photographic records 30 years

Child and Adolescent 30 years

Full NHS retention guidelines can be found at: http://www.dh.gov.uk/assetRoot/04/13/31/97/04133197.pdf

o When considering storage of images on magnetic and digital media, staff should be aware of shelf life, and make every effort to ensure that clinical data is not corrupted or damaged. Where necessary an additional copy should be made as a backup. Additional copies must be stored securely on Trust premises.

o Still photographs should be stored as a hard copy in the health record,

and the image deleted from the equipment.

Recordings made for assessment or treatment must be referenced within the service user’s health record stating the date(s) when the recording had taken place and the location of where the recording is stored.

Each time the recording is accessed an entry should be made in the progress notes on RiO in the service user’s health record. The entry should state the date the recording was accessed, by whom and for what purpose. This will be used to verify compliance with the terms of the service user’s consent.

Depending on the medium, recordings should be kept where possible with the service user’s health records, and recorded on RiO in accordance with procedure (See PGN). For example, a hard copy of photographs taken for the assessment or treatment should be filed within the service user’s health record in the secure pouch designed for this purpose.

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Other patient recordings must be kept systematically and securely and there must be an effective tracing system to link the recordings to the correct records.

Images of service users must not be left on the camera. Staff who share digital equipment are professionally accountable for those images and responsible for erasing images from the camera as soon as the images are completed and before passing equipment to colleagues.

Staff must not use their own personal photographic equipment for taking clinical images, including mobile phones.

Cameras containing images must not be transported off Trust premises. Images may be transferred to a fully encrypted device such as an encrypted laptop. If this is not an option practically, the risk must be assessed and recorded in the departmental Risk Register, and appropriate Executive Director approval obtained. The NHS national directive states that Board level approval must be obtained.

Equipment and recordings must be stored securely at all times on Trust premises.

All recordings both audio and visual, when due for destruction must be treated in a confidential manner. Advice on how to securely destroy all forms of magnetic media can be found on the Trust Intranet at:

http://nww1.CNTW.nhs.uk/services/?id=5984&p=5539&sp=5545

Alternatively advice can be sought from the Information Governance Team at:

[email protected]

It is not permitted to lend, sell, hire or provide for research any recordings or images to external bodies OR remove them permanently from Trust premises without permission from the Trust Board.

Recordings undertaken to provide evidence of staff training where the organisation is outside the Trust (for example, the University) will be covered by the provider’s Policies and Protocols. Staff should ensure explicit consent of the patient is obtained. Patients must be aware of the purpose of the recording and the fact that the recording will be disclosed to and retained by the external body. If in any doubt, advice should be sought prior to any recording, from the Trust’s Caldicott Guardian or Information Governance and Medico Legal Team.

http://nww1.ntw.nhs.uk/services/?id=5984&p=5539&sp=5545

mailto:[email protected]

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5.6 Recordings by Service Users/Relatives/Carers

Occasions may arise when the service user, their relative or carer may wish to record a consultation or conversation with a health professional;

There should be no restrictions on the recording taking place provided that:

The recording is done openly and honestly.

The recording process itself does not interfere with the consultation.

The provision to the service user of such a record will not adversely affect their treatment.

If it is a relative/carer who wishes to make the recording, then the full consent of the service user must be obtained and recorded in the service user’s health records.

If the service user is unable to consent then the recording cannot take place until a capacity assessment is carried out.

A note should be made in the service user’s health record that a particular

consultation or conversation was recorded.

The service user/relative and should be reminded of the confidential nature of the recording and the need to ensure that it is their responsibility to keep it secure.

No recordings by service user, relative or carer should be done within a ward/department setting. Guidance should be sought from the Information Governance Team.

6 Identification of Stakeholders 6.1 This is an existing Policy which has only minor changes that do not relate to

operational and/or clinical practice therefore did not require a full Trust-wide consultation process.

North Locality Care Group

North Cumbria Locality Care Group

Central Locality Care Group

South Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

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Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

7 Training 7.1 Training for this Policy is delivered where necessary by the Information

Governance Team to the IAO’s and IAA’s. 7.2 Where additional training is required it is the responsibility of both managers

and staff to ensure that this is undertaken and that attendance is verified and recorded.

8 Implementation 8.1 Taking into consideration all the implications associated with this Policy, it is

considered that a target date of December 2019 is achievable for the contents to be implemented across the Trust.

8.2 This will be monitored by the Trust-wide Policy Group during the review

process. If at any stage there is an indication that the target date cannot be met, then the Group will consider the implementation of an Action Plan.

9 Fair Blame 9.1 The Trust is committed to developing an open learning culture. It has endorsed

the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

10 Fraud, Bribery and Corruption

10.1 In accordance with the Trust’s CNTW (O) 23 – Fraud, Bribery and Corruption Policy, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

11 Monitoring

11.1 Responsibility for monitoring compliance with this Policy locally lies with Associate Directors.

11.2 The Information Governance Team will monitor compliance with this Policy through observation, spot checks and through incident management in line with the Trust Incident reporting process.

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11.3 Any compliance issues will be reported to the Line Managers concerned and may be handled through staff disciplinary processes or contractual arrangements.

11.4 Incident Reporting

All incidents involving the loss of data whether encrypted or unencrypted must be reported immediately to the Information Governance Department and dealt with in accordance with the Trust Incident Reporting Procedure (See Trust Policy, CNTW (O) 05 - Incident Reporting and Procedures).

12 Associated Policy/PGN Documentation

CNTW(O)28 - Information Governance Policy

CNTW (O)36 - Data Protection Policy

CNTW(O)29 - Confidentiality Policy

CNTW(O)09 - Records Management Policy

CNTW(C)05 - Consent to Examination and Treatment Policy

CNTW(O)33 - Risk Management Policy

CNTW(O)05 - Incident Policy

CNTW(O)35 - Information Security Policy

CNTW(O)44 - Acceptable Use of Email Policy

CNTW(O)30 - Removable Media Data Encryption Policy

CNTW(O)55 - Information Risk Policy

CNTW(O)62 - Information Sharing Policy

CNTW(O)63 - IT Procurement Policy

CNTW(O)65 – Acceptable use of Intranet and Internet

IT Security Handbook 13 References

https://digital.nhs.uk/

www.ico.gov.uk

Department of Health circulars on Removable Media

http://www.ico.gov.uk/

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Appendix A

Equality and Diversity Impact Assessment Screening Tool

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Angela Faill December 2019 December 2022

Trust-wide

Policy to be analysed Is this policy new or existing?

NTW(O)45 Visual Imaging and Audio Recording Policy V07

Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

The Policy has been created to:

Advise staff of their responsibilities towards service users, other staff and members of the public with regard to the use of visual and audio recordings and to ensure that all recording that takes place is done:

For a clear purpose;

With full consent of all service users, staff and the public; With appropriate control of use, storage and transportation.

Who will be affected? e.g. staff, service users, carers, wider public etc

Staff, service users, carers and the wider public.

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability Not applicable

Sex Not applicable

Race Not applicable

Age Not applicable

Gender reassignment

(including transgender)

Not applicable

Sexual orientation. Not applicable

Religion or belief Not applicable

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Marriage and Civil Partnership

Not applicable

Pregnancy and maternity Not applicable

Carers Not applicable

Other identified groups Not applicable

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Though standard policy consultation mechanisms.

How have you engaged stakeholders in testing the policy or programme proposals?


For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:


Summary of Analysis Considering the evidence and engagement activity you listed above please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

N/A

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

Not applicable

Advance equality of opportunity Not applicable

Promote good relations between groups Not applicable

What is the overall impact? Not applicable

Addressing the impact on equalities Not applicable

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? No

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Angela Faill Date: December 2019

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Appendix B

Communication and Training Check list for policies

Key Questions for the accountable Committees designing, reviewing or agreeing a new Trust Policy

Is this a new policy with new training requirements or a change to an existing policy?

No this is an existing policy.

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

N/A

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc.

Please identify the risks if training does not occur.

To ensure adherence to the Data Protection Act 2018 and the DOH National Directive.

Potential loss of data and inappropriate use of equipment.

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

It is essential that all staff groups working with confidential / personal data are made aware of the Policy and the personal responsibilities associated with the national directive.

Is there a staff group that should be prioritised for this training / awareness?

All staff working with Video or Audio Recording equipment

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning

Team brief, CEO Bulletin, Intranet, face to face training, E learning, Staff IT Handbook.

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs

Head of Information Governance and Medico Legal.

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Appendix B – continued

Training Needs Analysis

Staff/Professional Group

Type of training Duration of Training

Frequency of Training

Staff who use Visual Imaging and Audio Equipment

Specialist training on the use of Visual Imaging and Audio Equipment and adherence to Policy / PGN

Depends on member of staff

When required

Should any advice be required, please contact:- 0191 245 6777 (internal 56777) Option 1

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Appendix C

Monitoring Tool

Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, Policy Authors are required to include how monitoring of this Policy is linked to Auditable Standards / Key Performance Indicators will be undertaken using this framework.

CNTW(O)45 – Visual Imaging and Audio Recording Policy - Monitoring Framework

Auditable Standard / Key Performance Indicators

Frequency / Method / Person Responsible

Where results and any Associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group)

1 All incidents and breaches of the Policy must be clearly and accurately recorded

The Information Governance Team will provide a bi-monthly Highlight Report covering Information Governance Incidents to Caldicott Information Governance Group (CIGG).

Caldicott Information Governance Group (CIGG).

2. All equipment used must be asset tagged and recorded on Trust Asset Register

Annual audit of Asset Register to ensure all equipment is asset tagged. Audit to be carried out by Information Governance Department and results will be fed back via Report to Caldicott Information Governance Group (CIGG).

Caldicott Information Governance Group (CIGG).

The Author(s) of each Policy is required to complete this monitoring template and ensure that these results are taken to the appropriate reporting governance group as above in line with the frequency set out.