Pain Pals CIC

Complaints Policy

Renewed 09/2027

1. Purpose of This Policy

Pain Pals GY CIC (“the Organisation”) is committed to providing safe, inclusive, and high‑quality support to all members, volunteers, staff, and partners. We recognise that concerns or dissatisfaction may arise, and we welcome feedback as an opportunity to learn, improve, and strengthen trust.

This policy sets out:

• How individuals can raise complaints

• How the Organisation will respond

• The steps taken to ensure fairness, transparency, and accountability

• How complaints are recorded, monitored, and used to improve services

2. Scope

This policy applies to:

• Members and service users

• Volunteers

• Staff (paid or unpaid)

• Visitors

• External partners or organisations

It covers complaints about:

• Conduct or behaviour

• Service delivery

• Safeguarding concerns

• Accessibility or inclusion

• Decisions made by staff or volunteers

• Organisational processes or policies

Safeguarding concerns follow the Safeguarding Policy and may bypass the complaints process if immediate risk is present.

3. Principles

Pain Pals GY handles complaints according to the following principles:

• Respect and dignity – all complainants are treated fairly and without judgement

• Accessibility – complaints can be made verbally or in writing

• Timeliness – complaints are acknowledged and addressed promptly

• Confidentiality – information is shared only with those who need to know

• Impartiality – complaints are investigated objectively

• Protection from retaliation – individuals will not be disadvantaged for raising concerns

• Learning and improvement – complaints inform service development

4. What Is a Complaint?

A complaint is any expression of dissatisfaction about:

• The Organisation’s actions or decisions

• The behaviour or conduct of staff or volunteers

• The quality, safety, or accessibility of services

• How someone has been treated

Complaints may be made informally or formally.

5. How to Make a Complaint

5.1 Informal Complaints

Many concerns can be resolved quickly through informal discussion.

Individuals may raise concerns with:

• A volunteer

• A session facilitator

• A coordinator

• A director

Where possible, informal complaints will be addressed within 7 working days.

5.2 Formal Complaints

If the issue cannot be resolved informally, or the complainant prefers a formal process, they may submit a complaint:

• In writing (email or letter)

• Verbally (which will be recorded by staff)

• Through an advocate or support worker

Formal complaints should include:

• Name and contact details

• Details of the complaint

• Dates, times, and people involved

• Desired outcome (if known)

Formal complaints will be acknowledged within 7 working days.

6. Complaints Process

Stage 1: Initial Review

A designated manager or director will:

• Review the complaint

• Clarify details if needed

• Decide whether the issue is suitable for informal resolution or requires investigation

Outcome provided within 14 working days.

Stage 2: Investigation

If investigation is required:

• An impartial investigator will be appointed

• Relevant individuals may be interviewed

• Records, policies, and evidence may be reviewed

Investigations aim to be completed within 28 working days, though complex cases may take longer.

Stage 3: Outcome

The complainant will receive:

• A summary of findings

• Any actions taken

• Any changes to practice or policy

• Information on how to escalate if unsatisfied

Outcomes may include:

• Apology

• Staff or volunteer training

• Changes to procedures

• Mediation

• Disciplinary action (if appropriate)

7. Escalation Procedure

If the complainant is dissatisfied with the Stage 3 outcome, they may request a review by the Board of Directors.

The Board will:

• Reassess the investigation

• Consider whether procedures were followed

• Provide a final decision within 28 working days

This decision is final within the Organisation.

If the complaint relates to safeguarding, discrimination, or legal matters, external agencies may be contacted, including:

• Local Authority Safeguarding Team

• Police

• Information Commissioner’s Office (ICO)

• Companies House (for governance concerns)

8. Complaints Involving Safeguarding

Any complaint that includes:

• Abuse

• Neglect

• Harm

• Exploitation

• Serious misconduct

will be treated as a safeguarding concern and follow the Safeguarding Policy. Safeguarding complaints may bypass normal timelines to ensure safety.

9. Confidentiality

All complaints will be handled confidentially. Information will only be shared with:

• Individuals involved in investigating the complaint

• Safeguarding leads (if relevant)

• External agencies when legally required

Records will be stored securely in line with the Record Retention & Information Management Policy.

 10. Record Keeping

Pain Pals GY will maintain a Complaints Register including:

• Date of complaint

• Summary of issue

• Actions taken

• Outcome

• Whether safeguarding was involved

Retention periods:

• General complaints: 6 years

• Complaints linked to medical information: 10 years

• Complaints linked to safeguarding: Lifetime retention

11. Learning & Improvement

The Organisation will:

• Review complaints quarterly

• Identify patterns or recurring issues

• Update policies, training, or procedures as needed

• Report anonymised findings to the Board

12. Review of Policy

This policy will be reviewed annually or sooner if:

• Legislation changes

• A serious complaint occurs

• New services or activities are introduced

Pain Pals GY CIC

Visiting Clients Homes Policy

08/2026

1. Purpose of This Policy

Pain Pals GY CIC (“the Organisation”) occasionally provides support to individuals in their own homes. This policy ensures that home visits are carried out safely, respectfully, and professionally, with clear procedures for managing challenging behaviour and protecting volunteers and staff through robust lone‑working practices.

The aims of this policy are to:

• Ensure the safety and wellbeing of volunteers, staff, and clients

• Provide clear guidance for planning, conducting, and reviewing home visits

• Establish boundaries and expectations for behaviour

• Support trauma‑informed, disability‑aware practice

• Ensure compliance with safeguarding, health & safety, and lone‑working procedures

2. Scope

This policy applies to:

• Staff (paid or unpaid)

• Volunteers

• Directors

• Contractors or partners conducting home visits on behalf of Pain Pals GY

It covers:

• Scheduled home visits

• Welfare checks

• Support sessions delivered in a client’s home

• Any situation where a representative of Pain Pals GY enters a private residence

3. Principles

Pain Pals GY conducts home visits according to the following principles:

• Safety first – volunteers and staff must never be placed at unnecessary risk

• Respect and dignity – clients are treated with kindness, patience, and professionalism

• Boundaries – clear limits protect both clients and volunteers

• Trauma‑informed practice – recognising triggers, communication needs, and lived experience

• Accessibility and inclusion – adapting visits to meet diverse needs

• Transparency – visits are planned, recorded, and reviewed

4. Planning a Home Visit

4.1 Pre‑Visit Requirements

Before any home visit:

• A coordinator must know about the visit

• The client’s known needs, risks, and history must be reviewed

• Volunteers must be briefed on boundaries and expectations

• The Lone Working Policy must be followed at all times

4.2 Information Required

Volunteers must have:

• Full name and address of the client

• Contact number

• Purpose of the visit

• Known risks (behavioural, medical, environmental)

• Emergency contact details

• Expected duration of visit

4.3 Communication

Volunteers must:

• Inform a coordinator when they arrive and leave

• Keep a charged mobile phone accessible

• Agree a check‑in time if the visit exceeds one hour

5. Conduct During Home Visits

5.1 Professional Boundaries

Volunteers must:

• Maintain professional behaviour at all times

• Avoid personal, financial, or emotional entanglement

• Not accept gifts of significant value (all gifts received must be documented)

• Not provide medical advice or clinical interventions

• Not enter bedrooms unless essential for client safety

5.2 Respecting the Home Environment

Volunteers must:

• Treat the home with respect, regardless of condition

• Avoid judgemental language or behaviour

• Ask permission before moving items

• Ensure the client feels safe and in control

5.3 Safety Awareness

Volunteers must:

• Position themselves near an exit

• Avoid rooms with no clear escape route

• Leave immediately if they feel unsafe

• Follow the Lone Working Policy at all times

• Report any concerns to their line manager

6. Managing Challenging Behaviour

Pain Pals GY recognises that clients may experience distress, frustration, trauma responses, or behavioural challenges. Volunteers must respond calmly, professionally, and safely.

6.1 Types of Challenging Behaviour

• Raised voice or shouting

• Verbal aggression or intimidation

• Emotional distress or dysregulation

• Disinhibition or inappropriate comments

• Refusal to follow safety instructions

• Behaviour linked to pain, trauma, neurodivergence, or mental health

6.2 De‑escalation Techniques

Volunteers should:

• Remain calm and speak slowly

• Use non‑confrontational language

• Offer reassurance and clear boundaries

• Allow time for the client to regulate

• Suggest a break or pause in the conversation

• Avoid physical contact unless necessary for safety

6.3 When Behaviour Becomes Unsafe

If behaviour escalates to:

• Threats

• Physical aggression

• Sexualised behaviour

• Severe emotional dysregulation

• Damage to property

• Any situation where the volunteer feels unsafe

The volunteer must:

• End the visit immediately

• Leave the property calmly and quickly

• Contact the coordinator or Safeguarding Lead

• Follow the Lone Working Policy emergency procedures

6.4 Post‑Incident Actions

Volunteers must:

• Complete an Incident Report within 24 hours

• Record factual details only

• Attend a debrief with a coordinator

• Review whether future home visits are appropriate

• Laise with outside organisations such as the police

7. Safeguarding During Home Visits

Any safeguarding concern must be reported immediately to the Safeguarding Lead.

Examples include:

• Signs of abuse or neglect

• Coercion or control by another person

• Unsafe living conditions

• Disclosures of harm

• Children present in unsafe situations

Safeguarding concerns override all other procedures.

8. Lone Working Requirements

This policy must be read alongside the Lone Working Policy, which includes:

• Mandatory check‑ins

• Emergency procedures

• Restrictions on entering certain environments

• Prohibition on visits after dark unless authorised

• Requirements for two‑person visits when risk is identified

Volunteers must follow all lone‑working rules without exception.

9. Record Keeping

Pain Pals GY will maintain:

• Staff Visit Records

• Risk assessments

• Incident reports

• Safeguarding records

Retention periods:

• General visit records: 6 years

• Records involving medical information: 10 years

• Safeguarding records: Lifetime retention

10. Review & Monitoring

The Organisation will:

• Review home visit risks, when needs arise

• Update procedures based on incidents or feedback

• Provide additional training where needed

• Ensure volunteers feel supported and safe

Pain Pals GY

Anti- Harassment and Bullying Policy

09/2023

1.               Policy Statement

1.1            The Company wishes to provide a stimulating and supportive working environment which will enable its staff to fulfil their personal potential. Such an environment cannot exist where any member of staff is subjected to bullying, harassment, intimidation, aggression, victimisation or coercion.

1.2            We recognise that harassment and victimisation is unlawful under the Equality Act 2010. Harassment or victimisation on the grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation is unacceptable and will not be tolerated.

1.3            The Company will be responsible for ensuring all staff/volunteers understand the rules and policies relating to the prevention of harassing and bullying behaviour at work and during work-related social events.

1.4            The Company recognises that personal harassment can exist in the workplace and that this can seriously affect employees' working lives by interfering with their job performance or by creating a stressful, intimidating and unpleasant working environment. Employees should feel empowered to raise any complaints or concerns if they see or experience inappropriate behaviour.

1.5            The Company will treat all complaints of harassment and bullying seriously and will investigate them promptly and in confidence. We recognise that we have a duty to implement this policy and all employees are expected to comply with it.

1.6            We will also endeavour to review this policy at regular intervals in order to monitor its effectiveness.

2.               Harassment and Bullying

2.1            There is no legal definition of bullying but, broadly speaking, bullying at work may be defined as unwanted behaviour that is:

         2.1.1 offensive, intimidating, malicious, aggressive or insulting; or

         2.1.2 an abuse or misuse of power that undermines, humiliates or causes physical or emotional harm to an individual.

2.2            Under the Equality Act 2010, there are three types of harassment:

2.2.1 sexual harassment, i.e., unwanted behaviour of a sexual nature;
2.2.2 harassment related to certain protected characteristics, i.e. age, disability, gender reassignment, race, religion or belief, sex and sexual orientation;
2.2.3 less favourable treatment as a result of harassment related to sex, sexual harassment or gender reassignment.

2.3            In order to be considered as harassment, the unwanted behaviour must have:

                     2.3.1 violated the individual’s dignity; or

        2.3.2 created an intimidating, hostile, degrading, humiliating or offensive environment for the individual .      

2.4            Bullying or harassment may be persistent or an isolated incident, obvious or subtle, face-to-face or indirect.

2.5            Examples of behaviour which may constitute harassment or bullying include (but are not limited to):

2.5.1  spreading malicious rumours;

2.5.2  professional or social exclusion;

2.5.3  insulting behaviour;

2.5.4  unwelcome sexual advances or physical contact;

2.5.5  unfounded threats relating to job security;

2.5.6  calculated undermining of a staff members competence, for example through a consistently unreasonable or unfair workload or overbearing supervision;

2.5.7  physical assault;

2.5.8  abusing a position of power;

2.5.9  blocking promotion or access to development opportunities;

2.5.10   verbal abuse, threats, derogatory name-calling, inappropriate banter, ridicule, insults and offensive or embarrassing jokes;

2.5.11   cyber-bullying e.g., sending offensive emails, texts or visual images, or posting embarrassing images on social media;

2.5.12   derogatory graffiti/insignia or display of derogatory or offensive material; and

2.5.13   inciting others to commit any of the above.

2.6            A worker does not actually need to possess the relevant protected characteristic in order to make a complaint of harassment. A staff member can complain of unlawful harassment if they have experienced:

2.6.1  harassment because they are related to, or associate with, an individual who possesses a relevant protected characteristic; or

2.6.2  harassment by a colleague with the mistaken belief that they possess a relevant protected characteristic.

3.               Unlawful Grounds of Harassment or Bullying

The Company reiterates that it will not tolerate any instance of harassment or bullying, regardless of the grounds. This Policy will equally apply to work-related events even if they occur away from the normal workplace. The following are expressly unlawful grounds by which a person may experience harassment:

3.1            Sex

This is behaviour that is unwanted or unwelcome that could be seen as sexual or to do with an individual’s gender e.g., sexist jokes. This might also include sexually suggestive jokes or innuendo, unnecessary touching or suggestions that sexual favours may advance their career.

3.2            Gender Reassignment

Harassment or bullying on the grounds that a person intends to undergo gender reassignment, is currently undergoing gender reassignment or has already undergone gender reassignment.

3.3            Race

Harassment or bullying on the grounds of race, colour, ethnicity or nationality. This might include offensive remarks about an individual’s race, ethnic or national origin or ridicule/assumptions based on racial stereotypes.

3.4            Disability

Bullying or harassment on the grounds of a person’s disability. This might include making assumptions or jokes/offensive remarks based on an individual’s disability.

3.5            Sexual Orientation

Bullying or harassment on the grounds of a person’s sexual orientation, applying equally to “same sex” orientation, “opposite sex” orientation and “both sexes” orientation. This might include ‘outing’ an individual without their permission or asking intrusive questions about their private life.

3.6            Religion or Belief

                     Harassment or bullying on the grounds of a person’s religion or beliefs. This might include derogatory remarks made about a particular item of clothing or jewellery worn by an individual as a symbol of their religion.

3.7            Age

Harassment on the grounds of a person’s age, applying equally to all people regardless of age e.g., banter or jokes that make fun of older people or demean their abilities.

4.               Reporting Harassment

4.1            Staff/volunteers have the right to complain if they are treated in a way that they believe constitutes harassment or bullying.

4.2            Staff/volunteer members who make a genuine complaint under this policy will not be subjected to any unfavourable treatment or victimisation as a result of making the complaint.

5.               Third party harassment

5.1            The Company also operates a zero-tolerance policy in relation to harassment of one of its employees by a third party, such as a service user or member from an outside organisation. All employees are encouraged to report any instances of harassment involving a third party in line with the reporting procedure, set out below.

5.2            If an allegation of harassment by a third party proves to be well-founded, steps taken by the Company may include:

5.2.1  warning the individual about the inappropriate nature of their behaviour;

5.2.2  banning the individual from the Company’s premises; and

5.2.3  reporting the individual’s actions to the police.

6.               Procedure for Complaints

6.1            Any employee who feels that they have been subjected to harassment or bullying by any other member of staff/volunteer, should raise the matter as soon as reasonably practicable.

6.2            Employees can raise a complaint informally and/or formally. They should contact their line manager or another manager in the absence of that manager or where their complaint is against that specific manager.

6.3            Before raising a formal complaint, the employee is encouraged to talk directly and informally to the person whom they believe is harassing him or her, using the informal procedure below. It may be that the person whose behaviour is causing offence is genuinely unaware that their behaviour is unwelcome or causing distress and that a direct approach can resolve the matter without the need to use the formal procedure.

6.4            Informal Procedure

6.4.1  If the employee feels able to do so, they should speak up at the time when they feel harassed or bullied. It is important to be direct and for the employee member to state explicitly that they feel they are being harassed and that the behaviour is unacceptable to them. The employee can also discuss the matter with another colleague or their line manager and ask them to speak to the harasser on their behalf.

6.4.2  Alternatively, if the employee feels unable to speak to the harasser directly, they could write a letter to them which clearly identifies the offending behaviour and requests that it stops immediately. The staff member should sign and date any such letter and ensure that a copy is kept for any possible future formal complaint. It is also advisable that the employee member keep an ‘incident diary’ of any offending behaviour.

6.4.3  Where the informal procedure has not resolved the situation, an employee may make a complaint and formal grievance.

6.5            Formal Procedure

6.5.1  Any employee who feels that they have been subjected to harassment or bullying may at any time decide to deal with the issue through formal procedures (using the Company’s grievance procedure), regardless of whether informal steps have been taken or not.

6.5.2  When bringing a complaint of bullying or harassment, the employee member should state:

·        The name of the person whose behaviour is believed to amount to bullying or harassment;

·        The behaviour that is causing offence, with specific examples;

·        Dates and times when incidents of harassment or bullying occurred;

·        The names of any employee who witnessed any incidents;

·        Details of any action the staff/volunteer member has taken to try and address the bullying/harassment.

6.5.3  The Company will investigate any complaint thoroughly and fairly.

6.5.4  An employee accused of harassment or bullying will be informed of the exact nature of the complaint against them and given a full opportunity to give their version of events.

6.5.5  During the investigation, the Company reserves the right to suspend or temporarily redeploy either the employee making the complaint of harassment or bullying, or the employee suspected of harassment or bullying. Suspension will be on full pay and is not a disciplinary sanction. As soon as the investigation is complete, the Company will inform the staff member suspected of bullying or harassment of the outcome and decide if it is appropriate to start disciplinary proceedings.

6.5.6  On conclusion of the investigation, a report of the findings will be submitted to the manager who will hold the grievance meeting. The employee who has made the complaint will be invited to attend a meeting to discuss the matter. The meeting will be held in accordance with the Company’s grievance policy.

6.5.7  If, following the hearing, it is decided that the allegation is well- founded, the harasser will be subject to disciplinary action up to, and including, dismissal in accordance with the Company’s disciplinary procedure.

6.5.8  The Company is committed to ensuring staff/volunteer are not discouraged from using this procedure and no employee will be victimised for having brought a complaint.

7.               Victimisation

7.1            Victimisation takes place when an employee is treated unfavourably as a result of raising a complaint to do with a protected characteristic.

7.2            Similarly, an employee who supports or assists another member of staff/volunteer to raise such a complaint is subjected to victimisation if they are treated unfavourably.

8.               Consequences of Breach

8.1            Harassment is a disciplinary offence and will be dealt with according to the Company’s disciplinary procedure. Bullying, harassment, victimisation or discrimination may constitute gross misconduct, punishable by summary dismissal without notice.

8.2            Employees should bear in mind that harassment or bullying may also constitute a criminal offence punishable by a fine and/or imprisonment.

9.               Responsibilities of staff and Managers

9.1            The Company requires its staff to behave appropriately and professionally at all times.

9.2            All employees are responsible for their own behaviour and should ensure that they comply with this Policy at all times.

9.3            All managers are responsible for implementing this Policy and bringing it to the attention of employees.

9.4            Any complaints under this Policy bought to the attention of a manager must be dealt with promptly, confidentially, fairly and consistently.

 9.5            All incidents of harassment and bullying will be reported to the service manager.

9.6            Any form of harassment or victimisation may lead to disciplinary action up to and including dismissal if it is committed:

9.6.1  in a work situation;

9.6.2  during any situation related to work, such as a social event; or

9.6.3  against a colleague or other individual connected to the employer outside of a work situation, including on social media.

10.            Support and Advice

10.1        The Company will arrange counselling and mediation where appropriate.

10.2        The Company will work in conjunction with trade unions in addressing unacceptable and/or inappropriate behaviour.

11.            Confidentiality

11.1        The Company will treat any complaint received under this Policy confidentially.

11.2        All employees involved with an investigation are required to respect the need for confidentiality.

11.3        The Company will maintain records of investigations into alleged incidents of harassment or bullying and the outcome of the investigations. These records will be maintained in confidence and in line with the Company’s Data Protection Policy.

11.4        Any breaches in confidentiality will be subject to disciplinary action.

 12. Policy Review

This policy will be reviewed:

• Every two years

• After any serious incident

• When legislation or best practice changes

Safeguarding Policy

Pain Pals GY CIC.

04/2023

This Policy applies to all staff and volunteers of the CIC. In this Policy, “volunteers” means and includes the CIC directors, members and all other volunteers.

1.               Commitment to safeguarding

1.1    Those who receive services or participate in the activities provided by Pain Pals GY or are beneficiaries of the CIC or who come onto Pain Pals GY premises are referred to in this Policy as its service users and beneficiaries.  

1.2    Service users and Beneficiaries may be at risk due to age, illness or disability. The CIC is committed to working in their interests, to promote their welfare, and to put in place safeguards and measures to protect them. In providing services, activities and benefits for service users and beneficiaries, the CIC will endeavour at all times to minimise risk to them and to ensure that they are as safe as the CIC can make them.

1.3    The CIC aims to protect all of its service users and Beneficiaries from any act or behaviour of any member of staff or volunteer which, whether deliberately or unknowingly on the part of that member of staff or volunteer, gives rise to harm or ill treatment.

1.4    Such harm or ill treatment includes abuse (physical, sexual, emotional, discriminatory, institutional or organisational, financial or material), neglect, or impairment of the health or development of the CIC service users and Beneficiaries.

1.5    The CIC also aims to ensure the provision to them of safe and effective care  and to promote the well-being and welfare of its service users and Beneficiaries.

1.6    The CIC recognises that it has a duty to act on reports or suspicions of abuse or neglect. It adopts a “zero-tolerance” policy of abuse within the CIC.

1.7    The CIC maintains a Safe Working Practice Guidance. It includes:

(a)   Staff training in safeguarding

(b)   Safeguarding risk assessments

(c)   Recording and Reporting

The CIC will ensure that the Guidance is implemented by all within the CIC and, for that purpose, it will ensure that its staff and volunteers have read and understood it.

1.8    The CIC will work in partnership with local / national agencies to put in place appropriate procedures for reporting, making referrals, and accessing training and specialist support, as and when required.

2.               Safe recruitment

2.1    To aim to protect its Service users and Beneficiaries, the CIC will seek to recruit staff and volunteers using appropriate procedures, safeguards and checks.

2.2    The CIC will take up to two references for all employee roles prior to appointment.

2.3    The CIC will provide an induction programme for all new volunteers and staff, and appropriate training and ongoing/refresher training for them at regular intervals, to enable all volunteers and staff to undertake their roles safely, effectively and confidently. The induction will make it clear to them that they have an obligation to implement this Policy and to learn about protection issues and their related responsibilities.

2.4    Where the CIC should do so, it will use the Disclosure & Barring Service (“DBS”) checks to help it to assess suitability of a candidate for a particular volunteer or staff role which is treated by the DBS as Regulated Activity and is therefore subject to a barring list check. In relation to a post or role which is eligible for an enhanced DBS check, where it considers it appropriate it will carry out an enhanced DBS check. The CIC will assess any criminal record information that is disclosed in line with its data protection and equalities recruitment of ex-offender’s policies.

2.5    The CIC will regularly review its recruitment and other human resources procedures in response to changes in legislation and systems external to the CIC, e.g. DBS and barring list checks.

3.               Volunteers

3.1    All volunteer roles will be supported by a Volunteer Co-ordinator /Supporter.

3.2    Volunteers will be treated equally alongside paid staff, and all volunteers will be offered the same opportunities for advancement, responsibility, training and gaining qualifications, and acknowledgement for their contribution to the CIC.

3.3    In turn, volunteers will be required to adhere to the applicable parts of the Code of Conduct (Staff and Volunteers) at all times as a representative of the CIC. Before they take up their role, they will each be given a clear description of the requirements and responsibilities of their role and the member of staff or trustee recruiting them will discuss their role with them, to ensure that they understand what is expected of them.

3.4    Any volunteer roles, which would be Regulated Activity if unsupervised, will be appropriately supervised in accordance with statutory guidance.

4.               Safeguarding Officer

4.1    The CIC appointed Safeguarding Officers as from 28/08/2026 are

Lead safeguarding officer: Helen Hartley 07825001507

Deputy Safeguarding officer: Colin Begley 07930251717

Safeguarding Officer. They will have access to appropriate training to support them in these roles.

4.2    They will be available to all staff, volunteers and services users and Beneficiaries to speak to when they have any concerns, issues, or complaints regarding the safety, well-being or conduct of service users Beneficiaries, volunteers or staff.

4.3    The Safeguarding Officers and Deputy Safeguarding Officer will liaise with appropriate local and national agencies, contribute to appropriate policies, maintain records, keep confidentiality, adhere to and promote this Policy within the CIC, and support or provide access to support for individuals suffering harm or abuse.

5.               Awareness of harm and abuse within the CIC

5.1    All incidents of harm to any Service user or Beneficiary will require an appropriate response to reduce risks and improve the CICs services and activities.

5.2    Harm is caused by accidents, deliberate abuse (physical, psychological, sexual, emotional, financial), neglect (deliberate or not) or factors such as bullying, prejudicial attitudes, or a failure to enable a person to participate in activities that are open to most of their peers. It can also include abuse via use of ICT facilities (e.g. grooming, bullying via the internet).

5.3    Deliberate acts of harm (physical, psychological, sexual, emotional and financial) and neglect are abuses against the person. Those acts will incur disciplinary proceedings and require reports and referrals to social services, the police, other professional bodies, and the DBS if the act is by someone in Regulated Activity. If a criminal offence is thought to have been committed by any staff member or volunteer, the police will be informed. 

6.               Confidentiality

All reports and logs (including personnel records) will be kept securely and confidentially according to the CICs Data Protection Policy and Confidentiality Policy or in line with the DBS Code of Practice for Registered Bodies if appropriate, until or unless it is necessary to share this material with the agencies named above. Information will be shared by the CIC on a “need-to-know” basis only.

7.               Reports of possible or actual harm

7.1    The CIC supports and encourages all Service users, Beneficiaries, volunteers and staff to promptly speak up and contact the Safeguarding Officer or Deputy Safeguarding Officer where there is a concern (i.e. a worry, issue or doubt about practice or about treatment of a Service user, Beneficiary or colleague, or their circumstances), or a disclosure (i.e. information about a person at risk of or suffering from Significant Harm) or an allegation of an incident or a possibility that a volunteer or staff member has caused harm or could cause harm to a person in their care.

7.2    Staff or volunteers can report, and have a responsibility to report, something that they become aware of if they suspect or discover that it is not right or is illegal or if it appears to them that someone at work is neglecting their duties, putting someone’s health and safety in danger or covering up wrongdoing. They may become aware of any of these things from what they see or hear or from something another person has disclosed to them.

7.3    In the first instance the staff or volunteer making a report should speak to their line manager who will then liaise with the Safeguarding Officer, Deputy Safeguarding Officer or the CIC member with appropriate responsibility. However, if the report implicates their line manager, the staff member or volunteer making the report should instead speak directly to Safeguarding Officer or Deputy Safeguarding Officer.

7.4    The CIC prefers that anyone should use internal processes whenever possible to make a report as above, but this does not prevent them from making a report or referral, in their own right as a private individual, to statutory agencies such as social services or the police.

7.5    The CIC cannot promise confidentiality to staff or volunteers making an internal report (to the Safeguarding Officer, Deputy Safeguarding Officer, the CICs members with appropriate responsibility or their line manager) where it is has to be shared with any statutory agencies.

7.6    The CIC also supports its staff or volunteers to raise concerns or to disclose information, which they believe shows malpractice - whistle-blowing (disclosure in the public interest).

8.               Safeguarding Officer’s action 

Where there is risk of Significant Harm to any Service user Beneficiary, volunteers or staff, the Safeguarding Officer and Deputy Safeguarding Officer have the power to act as necessary and, in particular, as follows:

-  log all conversations regarding the issue

-  sign and request signatures on reports and statements

-  confidentially seek advice from expert sources

-  share concerns (with consent where required and appropriate) internally with senior staff / Chair of the Board of trustees

-  share concerns and make referrals to external agencies such as social services or the police, as appropriate to the circumstances

-  make a referral to the DBS regarding staff or volunteers in Regulated Activity whose conduct is harmful to Service users, Beneficiaries and refer them to DBS when they are removed from Regulated Activity.

 9.               Communication by the CIC about safeguarding and this Policy

9.1        All staff and volunteers have an obligation to learn about protection issues and their related responsibilities.

9.2        The CIC will communicate this Policy (using appropriate methods, formats and language to communicate the substance of it) to all of its staff, volunteers, and Service users, Beneficiaries and their families / carers, and it will also make it available to the public. Karen Lovejoy the CICs Secretary will be responsible to the Board members for communicating this Policy to them.

9.3        To encourage everyone involved in the CIC to understand that safeguarding is the business of everyone, and to assist all staff and volunteers to learn about protection issues and their related responsibilities, the CIC will hold meetings open to all staff and volunteers about safeguarding presentations to staff and volunteers about safeguarding policy and procedures][place safeguarding on the agenda for meetings of the Board of members and provide other opportunities for discussion about issues and concerns, policy and procedures to reflect, review and to continue to learn and improve in relation to the CICs safeguarding responsibilities.

10.            Implementation of this Policy

10.1    This Policy must be followed by all staff and volunteers of the CIC and must be promoted by all of its members and senior staff. Failure to follow it will be treated as a very serious matter.

10.2    This Policy needs to be read in conjunction with the following policies and procedures of the CIC:

Safe Working Practice Guidance

Health & Safety Policy

Lone working Policy

Code of Conduct (Staff and Volunteers)

Data Protection Policy

Confidentiality Policy

Equal Rights and Diversity Policy

Complaints Policy

Whistle Blowing Policy

11.            Adoption, coming into effect, and review, of this Policy

11.1    This Safeguarding Policy was approved by the Board of members for Pain Pals GY 03/09/2025 It also comes into force on that date.

11.2    The Board will, as appropriate, monitor and enforce this Policy,

11.3    The Board will revise this Policy from time to time. The next date for review of this Policy is 03/09/28

12. Review of Policy

This policy will be reviewed annually or sooner if:

• Legislation changes

• A serious complaint occurs

• New services or activities are introduced

Pain Pals GY CIC

Suicide and Self-Harm Response Policy

09/2026

1. Purpose

This policy sets out how Pain Pals GY responds safely, ethically and consistently when a person expresses suicidal thoughts, intent, plans, or engages in self‑harm. It ensures:

• The safety and wellbeing of participants, volunteers and staff.

• Clear, trauma‑informed procedures for responding to distress.

• Appropriate escalation to professional services.

• Compliance with safeguarding duties and legal responsibilities.

• Boundaries that protect both the individual and the organisation.

2. Scope

This policy applies to:

• Directors

• Staff

• Volunteers and peer supporters

• Sessional workers

• Anyone delivering or supporting Pain Pals GY activities

It covers:

• Disclosures of suicidal thoughts

• Disclosures of self‑harm

• Observed behaviour indicating risk

• Crisis situations during groups, 1‑to‑1 support, online sessions or digital communication

3. Principles

• Safety first: Immediate risk is prioritised above all other considerations.

• Trauma‑informed practice: Responses must be calm, non‑judgemental and supportive.

• Non‑clinical role: Pain Pals GY does not provide crisis intervention or therapy; we support people to access appropriate services.

• Boundaries: Staff and volunteers must stay within their role and avoid taking on responsibility for someone’s safety.

• Collaboration: Where possible, decisions are made with the individual, respecting autonomy.

• Confidentiality with limits: Information is kept private unless there is a risk of serious harm.

• Documentation: All incidents must be recorded accurately and promptly.

4. Definitions

Suicidal ideation

Thoughts about wanting to die, feeling hopeless, or wishing life would end.

Suicidal intent

A stated desire to act on suicidal thoughts.

Suicidal plan

Specific details about how, when or where someone intends to harm themselves.

Self‑harm

Any intentional act of harming oneself, regardless of suicidal intent.

Imminent risk

A situation where someone is at immediate danger of harming themselves.

5. Roles and Responsibilities

Directors

• Ensure this policy is implemented and reviewed.

• Oversee safeguarding and serious incident reporting.

• Support staff and volunteers following a crisis.

Staff and Volunteers

• Respond calmly and safely to disclosures.

• Follow the procedures in this policy.

• Escalate concerns promptly.

• Record incidents accurately.

• Maintain professional boundaries.

Safeguarding Lead

• Provide guidance during and after incidents.

• Decide when external services must be contacted.

• Ensure follow‑up actions are completed.

6. Responding to Suicide or Self‑Harm Concerns

6.1 General approach

When someone expresses suicidal thoughts or self‑harm:

• Stay calm and present.

• Listen without judgement.

• Acknowledge their feelings.

• Avoid minimising or offering quick fixes.

• Do not promise confidentiality.

• Follow the steps below.

6.2 Assessing immediate risk (non‑clinical)

Pain Pals GY does not conduct clinical assessments, but staff and volunteers may ask simple, supportive questions to understand urgency:

• Are they thinking about harming themselves?

• Do they feel able to stay safe right now?

• Have they taken any steps to harm themselves?

• Is anyone with them who can help keep them safe?

These questions are used only to guide next steps, not to diagnose.

6.3 If there is imminent risk

Imminent risk includes:

• A stated intention to act now or very soon.

• A clear plan and access to means.

• Self‑harm currently happening.

• The person is unable to agree to stay safe.

Actions:

1. Stay with the person (in person or online) until help is arranged.

2. Contact emergency services.

3. Inform the safeguarding lead as soon as possible.

4. Record the incident after the situation is safe.

Volunteers and staff must not transport individuals themselves or attempt physical intervention.

 6.4 If there is significant but not immediate risk

Examples:

• Suicidal thoughts without a plan.

• Self‑harm that is not life‑threatening.

• The person feels unsafe but is willing to seek help.

Actions:

1. Acknowledge their distress and listen.

2. Encourage them to contact professional support.

3. Offer to help them identify safe people or services.

4. Inform the safeguarding lead.

5. Record the incident.

6.5 If risk is low or the person is seeking emotional support

Examples:

• Thoughts of hopelessness.

• Past self‑harm.

• No current intent or plan.

Actions:

1. Provide supportive listening.

2. Encourage ongoing support from appropriate services.

3. Share information about Pain Pals GY boundaries.

4. Inform the safeguarding lead if appropriate.

5. Record the concern if it affects safety or wellbeing.

7. Online and Digital Communication

• If someone expresses suicidal intent during an online group or message, the same procedures apply.

• If they leave the session abruptly after expressing risk, attempt to contact them once to check safety.

• If they cannot be reached and risk appears imminent, escalate to emergency services.

• Volunteers must not engage in extended private crisis conversations.

8. Confidentiality and Information Sharing

Pain Pals GY respects confidentiality except when:

• There is risk of serious harm to the individual or others.

• A safeguarding duty requires escalation.

• Emergency services need information to respond.

Information shared must be:

• Relevant

• Necessary

• Proportionate

• Documented

9. Boundaries and Limitations

Pain Pals GY does not:

• Provide crisis intervention

• Offer clinical risk assessments

• Guarantee availability outside scheduled sessions

• Take responsibility for someone’s ongoing safety

Staff and volunteers must:

• Avoid making promises they cannot keep

• Avoid giving personal contact details

• Avoid lone crisis management

• Maintain professional distance while being compassionate

10. Recording and Reporting

All incidents involving suicide or self‑harm must be recorded:

• As soon as possible after the event

• Using the organisation’s incident form

• Including factual, objective information

• Including actions taken and who was informed

The safeguarding lead will:

• Review the incident

• Decide on follow‑up actions

• Report serious incidents to directors

• Report externally if required by law or funders

11. Support for Staff and Volunteers

Responding to suicide or self‑harm can be emotionally challenging. Pain Pals GY will provide:

• Debriefing after incidents

• Access to supervision

• Additional training where needed

• Clear boundaries to prevent burnout

12. Training Requirements

All staff, volunteers and sessional workers must receive training in:

• Suicide and self‑harm awareness

• Trauma‑informed communication

• Safeguarding procedures

• Boundaries and role clarity

• Incident reporting

Training will be refreshed regularly.

13. Policy Review

This policy will be reviewed:

• Every two years

• After any serious incident

• When legislation or best practice changes

Pain Pals GY

Health and Safety

Arrangements and Procedures

06/2023

1. Supervision

2. Risk Assessments

3. Workplace & Site Safety, and Welfare

4. Control of Substances Hazardous to Health

5. Asbestos

6. Manual Handling

7. First Aid

8. Accident Reporting

9. Electricity

10. Noise

11. Vibration

12. Working at Height

13. General Work Equipment

14. Fire

15. Computer Screens

16. Personal Protective Equipment

         ARRANGEMENTS AND PROCEDURES

1.               Training and Supervision

It will be the policy of Pain Pals GY (“the Business”) that health and safety information relevant to the activities at hand is given to all staff/volunteer members and sub-contractors.

Ongoing training will be provided to ensure that employees at all levels are:

·        competent to carry out their duties, to operate specialist tools, plant and work equipment; and

·        aware of their health and safety responsibilities.

Decisions relating to ongoing training of staff/volunteer members will be reviewed on a regular basis. The person with day to day responsibility for Health and Safety will be responsible for identifying and implementing health and safety training needs.  Records of the training will be kept on each staff members individual file.

Checks will be made to ensure that sub-contractors are competent to carry out the tasks allocated to them and that they have health and safety management systems in place appropriate to their work.

2.               Risk Assessments

(Reg. 3 Management of Health and Safety at Work Regulations, 1999)

The Management Team will ensure that all hazardous work activities undergo a suitable and sufficient Risk Assessment.  Upon the establishment of the level of risk, preventative measures will be introduced, maintained and revised as needed.

3.               Workplace Safety and Welfare

(The Workplace (Health, Safety and Welfare) Regulations 1992; Construction (Design & Management) Regulations 2015)

The management will ensure that all workplaces meets the health, safety and welfare needs of all those who will use them, including contractors, and wherever appropriate, people with disabilities. Where works are to take place where members of the public have access, measures will be taken to ensure that they are not adversely affected.  

4.               Control of Substances Hazardous to Health

(COSHH 2002)

Where needed, Risk Assessments and all Material Safety Data Sheets of substances used will be kept at the Business’ office.  From the Risk Assessments the Management will instigate the principles of good practice for the control of exposure as detailed in Schedule 2A Regulation 7(7).   No staff/volunteer member will introduce any substance without the specific consent of their Line manager.

5.               Asbestos

(Control of Asbestos at Work Regulations 2012)

In the event that any substance suspected to be, or containing, asbestos is found during the course of the Business’ works, all works in the area will cease immediately to avoid any exposure.  Work will be suspended in that area until the substance has been identified and if appropriate made safe/removed by specialist contractors. No works will be carried out that may disturb suspect substances without a suitable Asbestos Survey having been done by a specialist contractor. 

6.               Manual Handling

(Manual Handling Operations Regulations, 1992)

The designated H&S person will assess all manual handling operations within the workplace, and where possible change the nature of any task or provide mechanical aids in order to reduce or lighten the manual handling of loads.  They will ensure that adequate Risk Assessments are carried out to identify hazards associated with manual handling and ensure that where needed, lifting aids are provided. 

7.               First Aid

(Health and Safety (First Aid) Regulations, 1981)

The designated H&S person shall ensure that all staff/volunteer members have access to adequate First Aid provision, provided to them during their induction.  The level of cover shall be determined by risk assessment.

(See First Aid Policy)

8.               Accident Reporting

(Reporting of Injuries, Diseases, Dangerous Occurrences Regulations 2013)

All accidents and incidents will be recorded in an accident book and personal details kept secure to comply with Data Protection legislation. Any reportable accidents, incidents, or dangerous occurrences will be reported to the HSE.

9.               Electricity

(Electricity at Work Regulations, 1989)

It is the policy of the Business that wherever possible, all hand tools will be battery powered or 110v.  Where this is not possible a Residual Current Device (RCD) will be used.

 10.            Noise

(Control of Noise at Work Regulations, 2006)

The person in charge of a working area/site will ensure that noisy works do not cause a nuisance to others in the vicinity of their works area. They will always ensure that suitable ear protection is freely available to anyone who needs it.

11.            Vibration

(Control of Vibration at Work Regulations 2005)

The designated H&S person will ensure that where the use of vibration causing hand tools cannot be reduced, suitable safeguarding procedures are brought in, including where appropriate, anti-vibration gloves. 

12.            Working at Heights

(Work at Heights Regulations 2005)

Where the business activities involve ‘work at height’ the designated H&S person will assess the task beforehand and will consider the most suitable means of access. Suitable control measures such as exclusion zones will be put in place to ensure the safety of any others who will be in the vicinity.

13.            General Work Equipment

(The Provision and Use of Work Equipment Regulations (PUWER) 1998) (Lifting Operations and Lifting Equipment Regulations (LOLER) 1998)

It will be the designated H&S person’s responsibility to ensure:

·        Suitable equipment is supplied for the tasks to be done (Reg. 4)

·        That the equipment will be maintained in an efficient state, in efficient working order and in good repair (Reg. 5)

·        That all equipment and plant shall be inspected as required by Regulation 6

·        That those tasked with using the equipment are competent to use it. (Regs. 8 & 9)

14.            Fire

(The Regulatory Reform (Fire Safety) Order 2005)

It will be the responsibility of the designated H&S person to ensure adequate fire extinguishers are available at all work locations. All fire extinguishers are to be checked annually by a specialist contractor.

15.            Computer screens

(The Health and Safety (Display Screen Equipment) Regulations, 1992)

The designated H&S person will ensure suitable assessments are carried out for all persons who use display screen equipment. The assessments will consider the amount of time a person uses a VDU and the work done, the usability of their workstation and general working environment.

16.            Personal Protective Equipment (PPE) 

(The Personal Protective Equipment at Work Regulations (PPE) 1992)

The designated H&S person will ensure that all individuals have access to a sufficient supply of PPE when required.

Pain Pals GY

Environmental, Social and Governance Strategy

07/2024

1.               What are Environmental, Social & Governance (ESG) Issues?

Growing concerns about social and environmental issues in society as well as more attention being given to corporate governance issues and increasing legal obligations on companies, has led to greater interest in how companies are governed, overseen and should operate to ensure that they carry on their business and behave in a responsible way. Specifically, companies are increasingly expected to consider purpose as well as profit, and the future of our planet and its peoples. All these various issues are collectively referred to as ESG.

Each ESG issue is usually placed under one of the following headings: environmental, social and governance issues. Each issue is a discrete area but increasingly they are collectively grouped together and considered under the title, ESG.

ESG issues include, amongst other things, climate change and greenhouse gas emissions; energy efficiency and resource depletion; emissions to air, water and land pollution and waste; health and safety considerations; diversity, inclusion and equal pay; stakeholder and community engagement; bribery and corruption; conflicts of interest and anti-money laundering.

ESG will however mean different things to different companies depending on their size and the sector they operate in.

2.               Why have an ESG strategy?

ESG issues have recently assumed greater prominence and importance by regulators, employees, customers and other CIC members Currently SMEs are outside the scope of any specific ESG related disclosures in the UK[1], however failure to tackle ESG issues that are relevant to SME companies may lead to, amongst other things, regulatory enforcement as well as posing a litigation, physical, commercial, financial and reputational risk to a company, that might adversely affect its sustainability. In addition, there is a growing trend for ESG requirements and compliance by a company to be a pre-requisite for it to contract with other parties.

Considering this, and to minimise any potential risks, SMEs may wish to put in place an ESG strategy, commensurate with its size and sector focus, setting out the type of organisation that it aspires to be.

3.               What should an ESG strategy cover?

For most SMEs, an ESG strategy will involve putting in place a framework of various policies and practices to cover amongst other things:

·        Directors/Staff/Volunteers;

·        customers;

·        suppliers;

·        health & safety;

·        environment; and the community

How ESG affects each of these different areas and how each is dealt with by a business will depend on the importance that the business attributes to each one.

This ESG strategy is, by its very nature, generic, but highlights the key areas that businesses should focus on when determining their ESG strategy.[2]

ESG Strategy:

1)     Introduction

We are, Pain Pals GY

The Company aims to implement the highest environmental, social and governance (ESG) standards appropriate to its size and sector. The prosperity of the Company and of the communities within which it operates requires a commitment by it to the sustainable management of its activities.

Rapidly developing legal and voluntary frameworks, CIC members demands and increasing environmental concerns, all mean that ESG is fast becoming a top priority for businesses. To keep pace with this change, the Company wishes to:

• keep abreast of the most up to date information available to it;

• understand the risks and opportunities ESG presents; and

• take action to ensure that the Company continues to satisfy CIC members and places itself in the best position for long term, sustainable development.

It is recognised that a failure to tackle ESG issues that are relevant to the Company may lead to, amongst other things, regulatory enforcement as well as to pose a litigation, physical, commercial, financial and reputational risk to the Company that may adversely affect its sustainability and resilience.

The directors of the Company already have a duty under Section 172 of the Companies Act 2006, to promote its success. This means that each of its directors must act in the way they consider, in good faith, would promote the success of the Company for the benefit of its members as a whole.

However, in addition, the directors have decided to develop a robust and transparent ESG strategy that goes further than this Companies Act duty and affects and enhances all areas of the Company’s business in line with ESG issues, namely Community projects, events, support of service users and the local community at large.

The Company wishes to adopt this strategy as a framework for how the directors will manage ESG issues relevant to the Company’s business.

  2) ESG Audit

The Company is a SME and operates in the Volunteer Community interest companies sector.

In the first instance, it will carry out a comprehensive ESG audit and material risk assessment across its business to establish:

• what ESG means for the Company;

• which stakeholders should be consulted; and

• an ESG baseline.

Materiality

The Company considers the following to be material to it:

Environmental Commitments

·  Energy use and efficiency — Track annual energy bills, choose renewable tariffs where possible, reduce unnecessary usage, and ensure any shared premises follow good practice.

·  Travel impact — Encourage low‑carbon travel for staff and volunteers (public transport, car‑sharing, remote meetings). Record travel patterns annually.

·  Sustainable procurement — Prioritise suppliers with ethical or environmental credentials for printing, catering, IT, and training materials.

·  Digital sustainability — Reduce unnecessary cloud storage, choose efficient hosting, and avoid energy‑intensive digital practices.

·  Waste reduction — Minimise printing, recycle materials, and avoid single‑use items at events.

·  Community environmental stewardship — Demonstrate care for the local area (Great Yarmouth) through litter‑free events, accessible venues, and responsible use of public spaces

Social Commitments

·  Accessibility and inclusion — Ensure all services, training, and events are accessible to disabled people, neurodivergent people, and those on low incomes.

·  Affordability and equity — Commit to keeping resources low‑cost or free for people on benefits or outside NHS pathways.

·  Volunteer wellbeing and fair treatment — Clear expectations, safe working conditions, training, and support for unpaid volunteers.

·  Safeguarding — Strong safeguarding policies for vulnerable adults, with transparent reporting routes.

·  Community impact — Show how your activities improve wellbeing, reduce isolation, and support people who fall through gaps in statutory care.

·  Data ethics — Responsible handling of sensitive health‑related information, privacy protection, and transparent consent practices.

Governance Commitments

·  Leadership responsibility — Name who oversees ESG (e.g., founder or a designated trustee).

·  Decision‑making with ESG in mind — Show how environmental and social impacts are considered when planning services, hiring, procurement, or partnerships.

·  Ethical conduct — Anti‑discrimination, anti‑harassment, and conflict‑of‑interest statements.

·  Transparency — Annual reporting on what you’ve done, what you plan to improve, and what is realistically outside your capacity.

·  Continuous improvement — Commit to reviewing ESG priorities annually based on capacity, funding, and community needs.

Additional ESG Elements Especially Relevant to Pain Pals GY

·  Commitment to lived‑experience leadership — Recognise the value of people with chronic pain, disability, or trauma shaping your services.

·  Protection of intellectual property — State that Pain Pals GY materials cannot be reproduced or altered without permission (aligns with your existing stance).

·  Low‑cost community support — Explicitly embed affordability and accessibility as part of your social governance.

·  Trauma‑informed practice — Ensure all volunteers and staff follow trauma‑aware communication and support principles.

·  Local partnership ethics — Work only with partners who respect inclusion, accessibility, and community wellbeing

Members

The Company will consult with:

Its members, staff, volunteers, service users and local community

Baseline

It is important to identify an ESG baseline. The Company shall identify existing policies, processes and practices it already has in place that consider matters closely aligned with ESG.

The following policies, processes and practices are considered relevant:

Environmental policy

Health and safety

Waste management policy

Local impact studies

Quality assurance policy

These policies will be assessed for their usefulness in relation to ongoing ESG related activity and may also be useful to establish which ESG areas the Company should prioritise and which CIC members it should consult.

3) ESG objectives and framework

Having caried out a thorough ESG audit as set out above, the Company will identify its priority areas and set out its ESG objectives. It will implement an ESG framework based on these priorities through new policies, processes and practices relevant to the Company’s size and sector.

4) New ESG Policies etc

The new policies, processes and practices the Company will implement will include:

An ESG policy which incorporates the Company’s priority ESG areas and ESG objectives.

5) Board Terms of Reference & ESG Committee

The Company aims for its board of directors to achieve the highest board standards. It already has robust and transparent legal and professional standards in place but also aims to incorporate relevant ESG considerations into the board’s terms of reference. This will include ESG matters becoming a routine consideration in the board’s decision-making process going forward and the Company putting in place a committee to specifically consider ESG matters and advise the board accordingly.

A Community of Practice (CoP) is defined as: “A group of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.”1 CoP's are usually informal, self-organising, and span across departments with members distributed throughout an organisation

6) Updating Existing Policies

The Company has implemented several policies appropriate to its business that consider [staff, volunteers, service users, suppliers, health & safety, the environment and the community]. To bring these policies in line with the Company’s ESG strategy and ESG requirements [and its proposed new ESG policy document], it will update

Environmental policy

Health and safety

Waste management policy

Local impact studies

Quality assurance policy

7) Measuring and Reporting

The directors will regularly review, measure and report to members at suitable intervals on the Company’s progress in implementing its ESG strategy.

 8) Policy review

• This policy will be reviewed at least every two years, or sooner if:

  • There are significant changes in law, regulation or best practice.

  • New services or projects introduce different training needs.

  • Feedback or incidents indicate that changes are required.

• Updates will be approved by the Board of Directors and communicated to all staff, volunteers and sessional workers.

Pain Pals GY

Data Protection Policy

09/2023

1.               Introduction

This Policy sets out the obligations of Pain Pals GY, a company registered in England under number 15923465, whose registered office is at 28 Thurne Rise, Martham, Great Yarmouth, Norfolk, NR294PU. (“the Company”) regarding data protection and the rights of Staff, Service users and contacts (“data subjects”) in respect of their personal data under Data Protection Law. “Data Protection Law” means all applicable legislation in force from time to time in the United Kingdom applicable to data protection and privacy including, but not limited to, the UK GDPR, the Data Protection Act 2018 (and regulations made thereunder), and the Privacy and Electronic Communications Regulations 2003 as amended, and any successor legislation.

This Policy sets out the Company’s obligations regarding the collection, processing, transfer, storage, and disposal of personal data. The procedures and principles set out herein must be followed at all times by the Company, its staff members, agents, contractors, or other parties working on behalf of the Company.

2.               Definitions

  “consent”

means the consent of the data subject which must be a freely given, specific, informed, and unambiguous indication of the data subject’s wishes by which they, by a statement or by a clear affirmative action, signify their agreement to the processing of personal data relating to them;

“data controller”

means the natural or legal person or organisation which, alone or jointly with others, determines the purposes and means of the processing of personal data. For the purposes of this Policy, the Company is the data controller of all personal data relating to Staff, service users and contacts used in our business for our commercial purposes;

“data processor”

means a natural or legal person or organisation which processes personal data on behalf of a data controller;

“data subject”

means a living, identified, or identifiable natural person about whom the Company holds personal data;

“EEA”

means the European Economic Area, consisting of all EU Member States, Iceland, Liechtenstein, and Norway;

“personal data”

means any information relating to a data subject who can be identified, directly or indirectly, in particular by reference to an identifier such as a name, identification number, location data, an online identifier, or to one or more factors specific to the physical, physiological, genetic, mental, economic, cultural, or social identity of that data subject;

“personal data breach”

means a breach of security leading to the accidental or unlawful destruction, loss, alteration, unauthorised disclosure of, or access to, personal data transmitted, stored, or otherwise processed;

“processing”

means any operation or set of operations performed on personal data or sets of personal data, whether or not by automated means, such as collection, recording, organisation, structuring, storage, adaptation or alteration, retrieval, consultation, use, disclosure by transmission, dissemination or otherwise making available, alignment or combination, restriction, erasure or destruction;

“pseudonymisation”

means the processing of personal data in such a manner that the personal data can no longer be attributed to a specific data subject without the use of additional information, provided that such additional information is kept separately and is subject to technical and organisational measures to ensure that the personal data is not attributed to an identified or identifiable natural person; and

“special category personal data”

means personal data revealing racial or ethnic origin, political opinions, religious or philosophical beliefs, trade union membership, health, sexual life, sexual orientation, biometric, or genetic data.

3.               Scope

3.1            The Company is committed not only to the letter of the law, but also to the spirit of the law and places high importance on the correct, lawful, and fair handling of all personal data, respecting the legal rights, privacy, and trust of all individuals with whom it deals.

3.2            The Company’s Data Protection Officer is Service Manager Helen Hartley. The Data Protection Officer is responsible for administering this Policy and for developing and implementing any applicable related policies, procedures, and/or guidelines.

3.3            All Staff members are responsible for ensuring that all agents, contractors, or other parties working on behalf of the Company comply with this Policy and, where applicable, must implement such practices, processes, controls, and training as are reasonably necessary to ensure such compliance.

3.4            Any questions relating to this Policy or to Data Protection Law should be referred to the Data Protection Officer. In particular, the Data Protection Officer should always be consulted in the following cases:

a)               if there is any uncertainty relating to the lawful basis on which personal data is to be collected, held, and/or processed;

b)               if consent is being relied upon in order to collect, hold, and/or process personal data;

c)               if there is any uncertainty relating to the retention period for any particular type(s) of personal data;

d)               if any new or amended privacy notices or similar privacy-related documentation are required;

e)               if any assistance is required in dealing with the exercise of a data subject’s rights (including, but not limited to, the handling of subject access requests);

f)                if a personal data breach (suspected or actual) has occurred;

g)               if there is any uncertainty relating to security measures (whether technical or organisational) required to protect personal data;

h)               if personal data is to be shared with third parties (whether such third parties are acting as data controllers or data processors);

i)                 if personal data is to be transferred outside of the UK and there are questions relating to the legal basis on which to do so;

j)                 when any significant new processing activity is to be carried out, or significant changes are to be made to existing processing activities, which will require a Data Protection Impact Assessment;

k)               when personal data is to be used for purposes different to those for which it was originally collected;

l)                 if any automated processing, including profiling or automated decision-making, is to be carried out; or

m)             if any assistance is required in complying with the law applicable to direct marketing.

4.               The Data Protection Principles

This Policy aims to ensure compliance with Data Protection Law. The UK GDPR sets out the following principles with which any party handling personal data must comply. Data controllers are responsible for, and must be able to demonstrate, such compliance. All personal data must be:

4.1            processed lawfully, fairly, and in a transparent manner in relation to the data subject;

4.2            collected for specified, explicit, and legitimate purposes and not further processed in a manner that is incompatible with those purposes. Further processing for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes shall not be considered to be incompatible with the initial purposes;

4.3            adequate, relevant, and limited to what is necessary in relation to the purposes for which it is processed;

4.4            accurate and, where necessary, kept up to date. Every reasonable step must be taken to ensure that personal data that is inaccurate, having regard to the purposes for which it is processed, is erased, or rectified without delay;

4.5            kept in a form which permits identification of data subjects for no longer than is necessary for the purposes for which the personal data is processed. Personal data may be stored for longer periods insofar as the personal data will be processed solely for archiving purposes in the public interest, scientific or historical research purposes, or statistical purposes, subject to implementation of the appropriate technical and organisational measures required by the UK GDPR in order to safeguard the rights and freedoms of the data subject;

4.6            processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction, or damage, using appropriate technical or organisational measures.

5.               The Rights of Data Subjects

The UK GDPR sets out the following key rights applicable to data subjects:

5.1            The right to be informed;

5.2            the right of access;

5.3            the right to rectification;

5.4            the right to erasure (also known as the ‘right to be forgotten’);

5.5            the right to restrict processing;

5.6            the right to data portability;

5.7            the right to object; and

5.8            rights with respect to automated decision-making and profiling.

6.               Lawful, Fair, and Transparent Data Processing

6.1            Data Protection Law seeks to ensure that personal data is processed lawfully, fairly, and transparently, without adversely affecting the rights of the data subject. Specifically, the processing of personal data shall be lawful if at least one of the following applies:

a)               the data subject has given consent to the processing of their personal data for one or more specific purposes;

b)               the processing is necessary for the performance of a contract to which the data subject is a party, or in order to take steps at the request of the data subject prior to entering into a contract;

c)               the processing is necessary for compliance with a legal obligation to which the data controller is subject;

d)               the processing is necessary to protect the vital interests of the data subject or of another natural person;

e)               the processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the data controller; or

f)                the processing is necessary for the purposes of the legitimate interests pursued by the data controller or by a third party, except where such interests are overridden by the fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child.

6.2            If the personal data in question is special category personal data (also known as “sensitive personal data”), at least one of the following conditions must be met:

a)               the data subject has given their explicit consent to the processing of such data for one or more specified purposes (unless the law prohibits them from doing so);

b)               the processing is necessary for the purpose of carrying out the obligations and exercising specific rights of the data controller or of the data subject in the field of employment, social security, and social protection law (insofar as it is authorised by law or a collective agreement pursuant to law which provides for appropriate safeguards for the fundamental rights and interests of the data subject);

c)               the processing is necessary to protect the vital interests of the data subject or of another natural person where the data subject is physically or legally incapable of giving consent;

d)               the data controller is a foundation, association, or other non-profit body with a political, philosophical, religious, or trade union aim, and the processing is carried out in the course of its legitimate activities, provided that the processing relates solely to the members or former members of that body or to persons who have regular contact with it in connection with its purposes and that the personal data is not disclosed outside the body without the consent of the data subjects;

e)               the processing relates to personal data which is manifestly made public by the data subject;

f)                the processing is necessary for the conduct of legal claims or whenever courts are acting in their judicial capacity;

g)               the processing is necessary for substantial public interest reasons, on the basis of law which shall be proportionate to the aim pursued, shall respect the essence of the right to data protection, and shall provide for suitable and specific measures to safeguard the fundamental rights and interests of the data subject;

h)               the processing is necessary for the purposes of preventative or occupational medicine, for the assessment of the working capacity of an employee, for medical diagnosis, for the provision of health or social care or treatment, or the management of health or social care systems or services on the basis of law or pursuant to a contract with a health professional, subject to the conditions and safeguards referred to in Article 9(3) of the UK GDPR;

i)                 the processing is necessary for public interest reasons in the area of public health, for example, protecting against serious cross-border threats to health or ensuring high standards of quality and safety of health care and of medicinal products or medical devices, on the basis of law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject (in particular, professional secrecy); or

j)                 the processing is necessary for archiving purposes in the public interest, scientific or historical research purposes, or statistical purposes in accordance with Article 89(1) of the UK GDPR (as supplemented by section 19 of the Data Protection Act 2018) based on law which shall be proportionate to the aim pursued, respect the essence of the right to data protection, and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

7.               Consent

If consent is relied upon as the lawful basis for collecting, holding, and/or processing personal data, the following shall apply:

7.1            Consent is a clear indication by the data subject that they agree to the processing of their personal data. Such a clear indication may take the form of a statement or a positive action. Silence, pre-ticked boxes, or inactivity are unlikely to amount to consent.

7.2            Where consent is given in a document which includes other matters, the section dealing with consent must be kept clearly separate from such other matters.

7.3            Data subjects are free to withdraw consent at any time and it must be made easy for them to do so. If a data subject withdraws consent, their request must be honoured promptly.

7.4            If personal data is to be processed for a different purpose that is incompatible with the purpose or purposes for which that personal data was originally collected that was not disclosed to the data subject when they first provided their consent, consent to the new purpose or purposes may need to be obtained from the data subject.

7.5            If special category personal data is processed, the Company shall normally rely on a lawful basis other than explicit consent. If explicit consent is relied upon, the data subject in question must be issued with a suitable privacy notice in order to capture their consent.

7.6            In all cases where consent is relied upon as the lawful basis for collecting, holding, and/or processing personal data, records must be kept of all consents obtained in order to ensure that the Company can demonstrate its compliance with consent requirements.

8.               Specified, Explicit, and Legitimate Purposes

8.1            The Company collects and processes the personal data set out in Part 24 of this Policy. This includes:

a)               personal data collected directly from data subjects and

b)               personal data obtained from third parties.

8.2            The Company only collects, processes, and holds personal data for the specific purposes set out in Part 24 of this Policy (or for other purposes expressly permitted by Data Protection Law).

8.3            Data subjects must be kept informed at all times of the purpose or purposes for which the Company uses their personal data. Please refer to Part 15 for more information on keeping data subjects informed.

9.               Adequate, Relevant, and Limited Data Processing

9.1            The Company will only collect and process personal data for and to the extent necessary for the specific purpose or purposes of which data subjects have been informed (or will be informed) as under Part 8, above, and as set out in Part 24, below.

9.2            Staff members, agents, contractors, or other parties working on behalf of the Company may collect personal data only to the extent required for the performance of their job duties and only in accordance with this Policy. Excessive personal data must not be collected.

9.3            Staff members, agents, contractors, or other parties working on behalf of the Company may process personal data only when the performance of their job duties requires it. Personal data held by the Company cannot be processed for any unrelated reasons.

10.            Accuracy of Data and Keeping Data Up-to-Date

10.1        The Company shall ensure that all personal data collected, processed, and held by it is kept accurate and up-to-date. This includes, but is not limited to, the rectification of personal data at the request of a data subject, as set out in Part 17, below.

10.2        The accuracy of personal data shall be checked when it is collected and at yearly intervals thereafter (while the individual continues receiving a service). If any personal data is found to be inaccurate or out-of-date, all reasonable steps will be taken without delay to amend or erase that data, as appropriate.

11.            Data Retention

11.1        The Company shall not keep personal data for any longer than is necessary in light of the purpose or purposes for which that personal data was originally collected, held, and processed.

11.2        When personal data is no longer required, all reasonable steps will be taken to erase or otherwise dispose of it without delay.

11.3        For full details of the Company’s approach to data retention, including retention periods for specific personal data types held by the Company, please refer to our Data Retention Policy.

12.            Secure Processing

12.1        The Company shall ensure that all personal data collected, held, and processed is kept secure and protected against unauthorised or unlawful processing and against accidental loss, destruction, or damage. Further details of the technical and organisational measures which shall be taken are provided in Parts 25 to 30 of this Policy.

12.2        All technical and organisational measures taken to protect personal data shall be regularly reviewed and evaluated to ensure their ongoing effectiveness and the continued security of personal data.

12.3        Data security must be maintained at all times by protecting the confidentiality, integrity, and availability of all personal data as follows:

a)               only those with a genuine need to access and use personal data and who are authorised to do so may access and use it;

b)               personal data must be accurate and suitable for the purpose or purposes for which it is collected, held, and processed; and

c)               authorised users must always be able to access the personal data as required for the authorised purpose or purposes.

13.            Accountability and Record-Keeping

13.1        The Data Protection Officer is responsible for administering this Policy and for developing and implementing any applicable related policies, procedures, and/or guidelines.

13.2        The Company shall follow a privacy by design approach at all times when collecting, holding, and processing personal data. Data Protection Impact Assessments shall be conducted if any processing presents a significant risk to the rights and freedoms of data subjects (please refer to Part 14 for further information).

13.3        All employees, agents, contractors, or other parties working on behalf of the Company shall be given appropriate training in data protection and privacy, addressing the relevant aspects of Data Protection Law, this Policy, and all other applicable Company policies.

13.4        The Company’s data protection compliance shall be regularly reviewed and evaluated by means of Data Protection Audits.

13.5        The Company shall keep written internal records of all personal data collection, holding, and processing, which shall incorporate the following information:

a)               the name and details of the Company, its Data Protection Officer, and any applicable third-party data transfers (including data processors and other data controllers with whom personal data is shared);

b)               the purposes for which the Company collects, holds, and processes personal data;

c)               the Company’s legal basis or bases (including, but not limited to, consent, the mechanism(s) for obtaining such consent, and records of such consent) for collecting, holding, and processing personal data;

d)               details of the categories of personal data collected, held, and processed by the Company, and the categories of data subject to which that personal data relates;

e)               details of any transfers of personal data to non-UK countries including all mechanisms and security safeguards;

f)                details of how long personal data will be retained by the Company (please refer to the Company’s Data Retention Policy);

g)               details of personal data storage, including location(s);

h)               detailed descriptions of all technical and organisational measures taken by the Company to ensure the security of personal data.

14.            Data Protection Impact Assessments and Privacy by Design

14.1        In accordance with the privacy by design principles, the Company shall carry out Data Protection Impact Assessments for any and all new projects and/or new uses of personal data which involve the use of new technologies and where the processing involved is likely to result in a high risk to the rights and freedoms of data subjects.

14.2        The principles of privacy by design should be followed at all times when collecting, holding, and processing personal data. The following factors should be taken into consideration:

a)               the nature, scope, context, and purpose or purposes of the collection, holding, and processing;

b)               the state of the art of all relevant technical and organisational measures to be taken;

c)               the cost of implementing such measures; and

d)               the risks posed to data subjects and to the Company, including their likelihood and severity. 

14.3        Data Protection Impact Assessments shall be overseen by the Data Protection Officer and shall address the following:

a)               the type(s) of personal data that will be collected, held, and processed;

b)               the purpose(s) for which personal data is to be used;

c)               the Company’s objectives;

d)               how personal data is to be used;

e)               the parties (internal and/or external) who are to be consulted;

f)                the necessity and proportionality of the data processing with respect to the purpose(s) for which it is being processed;

g)               risks posed to data subjects;

h)               risks posed both within and to the Company; and

i)                 proposed measures to minimise and handle identified risks.

15.            Keeping Data Subjects Informed

15.1        The Company shall provide the information set out in Part 15.2 to every data subject:

a)               where personal data is collected directly from data subjects, those data subjects will be informed of its purpose at the time of collection; and

b)               where personal data is obtained from a third party, the relevant data subjects will be informed of its purpose:

i)                 if the personal data is used to communicate with the data subject, when the first communication is made; or

ii)               if the personal data is to be transferred to another party, before that transfer is made; or

iii)              as soon as reasonably possible and in any event not more than one month after the personal data is obtained.

15.2        The following information shall be provided in the form of a privacy notice:

a)               details of the Company including, but not limited to, contact details, and the names and contact details of any applicable representatives and its Data Protection Officer;

b)               the purpose(s) for which the personal data is being collected and will be processed (as detailed in Part 24 of this Policy) and the lawful basis justifying that collection and processing;

c)               where applicable, the legitimate interests upon which the Company is justifying its collection and processing of the personal data;

d)               where the personal data is not obtained directly from the data subject, the categories of personal data collected and processed;

e)               where the personal data is to be transferred to one or more third parties, details of those parties;

f)                where the personal data is to be transferred to a third party that is located outside of the UK, details of that transfer, including but not limited to the safeguards in place (see Part 31 of this Policy for further details);

g)               details of applicable data retention periods;

h)               details of the data subject’s rights under the UK GDPR;

i)                 details of the data subject’s right to withdraw their consent to the Company’s processing of their personal data at any time;

j)                 details of the data subject’s right to complain to the Information Commissioner’s Office;

k)               where the personal data is not obtained directly from the data subject, details about the source of that personal data;

l)                 where applicable, details of any legal or contractual requirement or obligation necessitating the collection and processing of the personal data and details of any consequences of failing to provide it; and

m)             details of any automated decision-making or profiling that will take place using the personal data, including information on how decisions will be made, the significance of those decisions, and any consequences.

16.            Data Subject Access

16.1        Data subjects may make subject access requests (“SARs”) at any time to find out more about the personal data which the Company holds about them, what it is doing with that personal data, and why.

16.2        Staff members wishing to make a SAR should do using a Subject Access Request Form, sending the form to the Company’s Data Protection Officer at 28 Thurne Rise, Martham, Great Yarmouth, Norfolk, NR294PU.

16.3        Responses to SARs must normally be made within one month of receipt, however, this may be extended by up to two months if the SAR is complex and/or numerous requests are made. If such additional time is required, the data subject shall be informed.

16.4        All SARs received shall be handled by the Company’s Data Protection Officer

16.5        The Company does not charge a fee for the handling of normal SARs. The Company reserves the right to charge reasonable fees for additional copies of information that has already been supplied to a data subject, and for requests that are manifestly unfounded or excessive, particularly where such requests are repetitive.

17.            Rectification of Personal Data

17.1        Data subjects have the right to require the Company to rectify any of their personal data that is inaccurate or incomplete.

17.2        The Company shall rectify the personal data in question, and inform the data subject of that rectification, within one month of the data subject informing the Company of the issue. The period can be extended by up to two months in the case of complex requests. If such additional time is required, the data subject shall be informed.

17.3        In the event that any affected personal data has been disclosed to third parties, those parties shall be informed of any rectification that must be made to that personal data.

18.            Erasure of Personal Data

18.1        Data subjects have the right to request that the Company erases the personal data it holds about them in the following circumstances:

a)               it is no longer necessary for the Company to hold that personal data with respect to the purpose(s) for which it was originally collected or processed;

b)               the data subject wishes to withdraw their consent to the Company holding and processing their personal data;

c)               the data subject objects to the Company holding and processing their personal data (and there is no overriding legitimate interest to allow the Company to continue doing so) (see Part 21 of this Policy for further details concerning the right to object);

d)               the personal data has been processed unlawfully;

e)               the personal data needs to be erased in order for the Company to comply with a particular legal obligation.

18.2        Unless the Company has reasonable grounds to refuse to erase personal data, all requests for erasure shall be complied with, and the data subject informed of the erasure, within one month of receipt of the data subject’s request. The period can be extended by up to two months in the case of complex requests. If such additional time is required, the data subject shall be informed.

18.3        In the event that any personal data that is to be erased in response to a data subject’s request has been disclosed to third parties, those parties shall be informed of the erasure (unless it is impossible or would require disproportionate effort to do so). 

19.            Restriction of Personal Data Processing

19.1        Data subjects may request that the Company ceases processing the personal data it holds about them. If a data subject makes such a request, the Company shall retain only the amount of personal data concerning that data subject (if any) that is necessary to ensure that the personal data in question is not processed further.

19.2        In the event that any affected personal data has been disclosed to third parties, those parties shall be informed of the applicable restrictions on processing it (unless it is impossible or would require disproportionate effort to do so).

20.            Objections to Personal Data Processing

20.1        Data subjects have the right to object to the Company processing their personal data based on legitimate interests, for direct marketing (including profiling), and processing for scientific and/or historical research and statistics purposes.

20.2        Where a data subject objects to the Company processing their personal data based on its legitimate interests, the Company shall cease such processing immediately, unless it can be demonstrated that the Company’s legitimate grounds for such processing override the data subject’s interests, rights, and freedoms, or that the processing is necessary for the conduct of legal claims.

20.3        Where a data subject objects to the Company processing their personal data for direct marketing purposes, the Company shall cease such processing promptly.

20.4        Where a data subject objects to the Company processing their personal data for scientific and/or historical research and statistics purposes, the data subject must, under the UK GDPR, demonstrate grounds relating to his or her particular situation. The Company is not required to comply if the research is necessary for the performance of a task carried out for reasons of public interest.

21.            Direct Marketing

21.1        The Company is subject to certain rules and regulations when marketing its services.

21.2        The prior consent of data subjects is required for electronic direct marketing including email, text messaging, and automated telephone calls subject to the following limited exception:

21.3        The right to object to direct marketing shall be explicitly offered to data subjects in a clear and intelligible manner and must be kept separate from other information in order to preserve its clarity.

21.4        If a data subject objects to direct marketing, their request must be complied with promptly. A limited amount of personal data may be retained in such circumstances to the extent required to ensure that the data subject’s marketing preferences continue to be complied with.

22.            Personal Data Collected, Held, and Processed

The following personal data is collected, held, and processed by the Company (for details of data retention, please refer to the Company’s Data Retention Policy):

• Client Name, address, phone number, email.

• Next of Kin, Name, phone number, email. 

• Date of birth 

• National insurance number 

• NHS number

• Blue badge number

• GP Name, address, phone number, email. 

• Medical records

• Personal letters and documents 

• Support notes 

• Safeguiarding and risk assessments 

23.            Data Security - Transferring Personal Data and Communications

The Company shall ensure that the following measures are taken with respect to all communications and other transfers involving personal data:

23.1        All emails containing personal data must be marked “confidential”;

23.2        Personal data may be transmitted over secure networks only; transmission over unsecured networks is not permitted in any circumstances;

23.3        Personal data may not be transmitted over a wireless network if there is a wired alternative that is reasonably practicable;

 23.4        Personal data contained in the body of an email, whether sent or received, should be copied from the body of that email and stored securely. The email itself should be deleted. All temporary files associated therewith should also be deleted.

23.5        Where personal data is to be transferred in hardcopy form it should be passed directly to the recipient

23.6        All personal data to be transferred physically, whether in hardcopy form or on removable electronic media shall be transferred in a suitable container marked “confidential”;

24.            Data Security - Storage

The Company shall ensure that the following measures are taken with respect to the storage of personal data:

24.1        All electronic copies of personal data should be stored securely using passwords.

24.2        All hardcopies of personal data, along with any electronic copies stored on physical, removable media should be stored securely in a locked box, drawer, cabinet, or similar;

24.3        All personal data stored electronically should be backed up on a flash dive with backups stored onsite and offsite. All backups should be marked confidential and password protected.

24.4        No personal data should be stored on any mobile device (including, but not limited to, laptops, tablets, and smartphones), whether such device belongs to the Company or otherwise without the formal written approval of the service manager and, in the event of such approval, strictly in accordance with all instructions and limitations described at the time the approval is given, and for no longer than is absolutely necessary;

24.5        No personal data should be transferred to any device personally belonging to an employee, agent, contractor, or other party working on behalf of the Company and personal data may only be transferred to devices belonging to agents, contractors, or other parties working on behalf of the Company where the party in question has agreed to comply fully with the letter and spirit of this Policy and of the applicable Data Protection Law (which may include demonstrating to the Company that all suitable technical and organisational measures have been taken);

25.            Data Security - Disposal

When any personal data is to be erased or otherwise disposed of for any reason (including where copies have been made and are no longer needed), it should be securely deleted and disposed of. For further information on the deletion and disposal of personal data, please refer to the Company’s Data Retention Policy.

26.            Data Security - Use of Personal Data

The Company shall ensure that the following measures are taken with respect to the use of personal data:

26.1        No personal data may be shared informally and if a staff member, agent, contractor, or other party working on behalf of the Company requires access to any personal data that they do not already have access to, such access should be formally requested from the service manager.

26.2        No personal data may be transferred to any staff member, agent, contractor, or other party, whether such parties are working on behalf of the Company or not, without the authorisation of the service manager.

26.3        Personal data must be handled with care at all times and should not be left unattended or on view to unauthorised staff member, agents, contractors, or other parties at any time;

26.4        If personal data is being viewed on a computer screen and the computer in question is to be left unattended for any period of time, the user must lock the computer and screen before leaving it;

26.5        Where personal data held by the Company is used for marketing purposes, it shall be the responsibility of service manager to ensure that the appropriate consent is obtained and that no data subjects have opted out, whether directly or via a third-party service such as the TPS;

27.            Data Security - IT Security

The Company shall ensure that the following measures are taken with respect to IT and information security:

27.1        All passwords used to protect personal data should be changed regularly and should not use words or phrases that can be easily guessed or otherwise compromised. All passwords must contain a combination of uppercase and lowercase letters, numbers, and symbols. All software used by the Company is designed to require such passwords.;

27.2        Under no circumstances should any passwords be written down or shared between any staff member, agents, contractors, or other parties working on behalf of the Company, irrespective of seniority or department. If a password is forgotten, it must be reset using the applicable method. IT staff do not have access to passwords;

27.3        All software (including, but not limited to, applications and operating systems) shall be kept up-to-date. The staff member shall be responsible for installing any and all security-related updates after the updates are made available by the publisher or manufacturer, unless there are valid technical reasons not to do so;

27.4        No software may be installed on any Company-owned computer or device without the prior approval of the service manager;

28.            Organisational Measures

The Company shall ensure that the following measures are taken with respect to the collection, holding, and processing of personal data:

28.1        All staff members, agents, contractors, or other parties working on behalf of the Company shall be made fully aware of both their individual responsibilities and the Company’s responsibilities under Data Protection Law and under this Policy, and shall be provided with a copy of this Policy;

28.2        Only staff members, agents, contractors, or other parties working on behalf of the Company that need access to, and use of, personal data in order to carry out their assigned duties correctly shall have access to personal data held by the Company;

28.3        All sharing of personal data shall comply with the information provided to the relevant data subjects and, if required, the consent of such data subjects shall be obtained prior to the sharing of their personal data;

28.4        All staff members, agents, contractors, or other parties working on behalf of the Company handling personal data will be appropriately trained to do so;

28.5        All staff members, agents, contractors, or other parties working on behalf of the Company handling personal data will be appropriately supervised;

28.6        All staff members, agents, contractors, or other parties working on behalf of the Company handling personal data shall be required and encouraged to exercise care, caution, and discretion when discussing work-related matters that relate to personal data, whether in the workplace or otherwise;

28.7        Methods of collecting, holding, and processing personal data shall be regularly evaluated and reviewed;

28.8        All personal data held by the Company shall be reviewed periodically, as set out in the Company’s Data Retention Policy;

28.9        The performance of those staff members, agents, contractors, or other parties working on behalf of the Company handling personal data shall be regularly evaluated and reviewed;

28.10     All staff members, agents, contractors, or other parties working on behalf of the Company handling personal data will be bound to do so in accordance with the principles of Data Protection Law and this Policy by contract;

28.11     All agents, contractors, or other parties working on behalf of the Company handling personal data must ensure that any and all of their staff members who are involved in the processing of personal data are held to the same conditions as those relevant employees of the Company arising out of this Policy and Data Protection Law;

28.12     Where any agent, contractor or other party working on behalf of the Company handling personal data fails in their obligations under this Policy that party shall indemnify and hold harmless the Company against any costs, liability, damages, loss, claims or proceedings which may arise out of that failure;

29.            Transferring Personal Data to a Country Outside the UK

29.1        The Company may, from time to time, transfer (‘transfer’ includes making available remotely) personal data to countries outside of the UK. The UK GDPR restricts such transfers in order to ensure that the level of protection given to data subjects is not compromised.

29.2        Personal data may only be transferred to a country outside the UK if one of the following applies:

a)               The UK has issued regulations confirming that the country in question ensures an adequate level of protection (referred to as ‘adequacy decisions’ or ‘adequacy regulations’). Since 1 January 2021, transfers of personal data from the UK to EEA countries have continued to be permitted. Pre-existing EU Commission adequacy decisions in effect as at 31 December 2020 are also recognised, subject to ongoing review by the UK Government.

b)               Appropriate safeguards are in place including binding corporate rules, standard contractual clauses approved for use in the UK, an approved code of conduct, or an approved certification mechanism. Standard contractual clauses include the International Data Transfer Agreement issued by the Information Commissioner’s Office and the International Data Transfer Addendum to the current EU Commission Standard Contractual Clauses (set out in the Annex of Commission Implementing Decision (EU) 2021/914 of 4 June 2021), issued by the Information Commissioner’s Office. (Contracts entered into on the basis of the old EU Commission Standard Contractual Clauses prior to 21 September 2022 will continue to provide appropriate safeguards until 21 March 2024.)

c)               The transfer is made with the informed and explicit consent of the relevant data subject(s).

d)               The transfer is necessary for one of the other reasons set out in the UK GDPR including the performance of a contract between the data subject and the Company; public interest reasons; for the establishment, exercise, or defence of legal claims; to protect the vital interests of the data subject where the data subject is physically or legally incapable of giving consent; or, in limited circumstances, for the Company’s legitimate interests.

30.            Data Breach Notification

30.1        All personal data breaches must be reported immediately to the Company’s Data Protection Officer.

30.2        If a staff member, agent, contractor, or other party working on behalf of the Company becomes aware of or suspects that a personal data breach has occurred, they must not attempt to investigate it themselves. Any and all evidence relating to the personal data breach in question should be carefully retained.

30.3        If a personal data breach occurs and that breach is likely to result in a risk to the rights and freedoms of data subjects (e.g., financial loss, breach of confidentiality, discrimination, reputational damage, or other significant social or economic damage), the Data Protection Officer must ensure that the Information Commissioner’s Office is informed of the breach without delay, and in any event, within 72 hours after having become aware of it.

30.4        In the event that a personal data breach is likely to result in a high risk (that is, a higher risk than that described under Part 32.3) to the rights and freedoms of data subjects, the Data Protection Officer must ensure that all affected data subjects are informed of the breach directly and without undue delay.

30.5        Data breach notifications shall include the following information:

a)               The categories and approximate number of data subjects concerned;

b)               The categories and approximate number of personal data records concerned;

c)               The name and contact details of the Company’s data protection officer (or other contact point where more information can be obtained);

d)               The likely consequences of the breach;

e)               Details of the measures taken, or proposed to be taken, by the Company to address the breach including, where appropriate, measures to mitigate its possible adverse effects.

31.            Implementation of Policy

This Policy shall be deemed effective as of the date below. No part of this Policy shall have retroactive effect and shall thus apply only to matters occurring on or after this date.

32. Review of This Policy

This policy will be reviewed annually or sooner if legislation changes, safeguarding guidance updates, or organisational needs evolve.