DATA PROTECTION AND GDPR POLICY – Raedan Institute 

1. Introduction and Purpose 

1.1 Policy Statement 

Raedan Institute is committed to protecting the privacy and security of personal data in compliance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018 (DPA 2018). 

This policy sets out our approach to data protection and the legal requirements we must meet. It applies to all personal data we process regardless of format (electronic or paper-based) or location. 

1.2 Scope 

This policy applies to: 

  • All trustees, employees, volunteers, and contractors of Raedan Institute 
  • All personal data processed by or on behalf of Raedan Institute 
  • All locations, systems, and processes where personal data is held or processed 

1.3 Purpose 

This policy aims to: 

  • Ensure compliance with UK data protection law 
  • Protect the rights of individuals whose data we process 
  • Establish clear responsibilities and procedures 
  • Minimise risks of data breaches and non-compliance 
  • Promote a culture of data protection awareness 
  • Provide guidance for staff and volunteers 

1.4 Related Policies 

This policy should be read alongside: 

  • Privacy Policy (external-facing) 
  • Cookie Policy 
  • Information Security Policy 
  • Safeguarding Policy 
  • Confidentiality Policy 
  • Records Management and Retention Policy 
  • Data Breach Response Plan 
  • Subject Access Request Procedure 
  • Acceptable Use Policy (IT) 
  • CCTV Policy 

2. Legal Framework 

2.1 Applicable Legislation 

Raedan Institute complies with: 

Primary Legislation: 

  • UK General Data Protection Regulation (UK GDPR) 2021 
  • Data Protection Act 2018 (DPA 2018) 
  • Privacy and Electronic Communications Regulations (PECR) 2003 (as amended) 

Sector-Specific Legislation: 

  • Children Act 1989 and 2004 
  • Care Act 2014 
  • Education Act 1996 
  • Equality Act 2010 
  • Freedom of Information Act 2000 
  • Charities Act 2011 
  • Safeguarding Vulnerable Groups Act 2006 

Statutory Guidance: 

  • Working Together to Safeguard Children (2023) 
  • Keeping Children Safe in Education (2023) 
  • Information Sharing: Advice for Practitioners (2018) 
  • Guide to the UK GDPR (ICO) 

2.2 Regulatory Oversight 

We are regulated by: 

  • Information Commissioner’s Office (ICO) – data protection supervisory authority 
  • Charity Commission – charity governance and accountability 
  • Local Safeguarding Partnerships – safeguarding compliance 
  • NACCC – Contact Centre accreditation and standards 
  • JCQ/Examination Boards – examination centre requirements 

2.3 Registration 

Raedan Institute is registered with the ICO as a data controller. 

Registration Number: 00019565851 
Renewal Date: 04/03/2025 

We maintain accurate ICO registration covering all our processing activities and update it promptly when changes occur. 

3. Data Protection Principles 

We process all personal data in accordance with the seven principles of UK GDPR: 

3.1 Lawfulness, Fairness, and Transparency 

Lawfulness: We process personal data only where we have a valid legal basis (consent, contract, legal obligation, vital interests, public task, or legitimate interests). 

Fairness: We process data in ways people would reasonably expect and not in ways that have unjustified adverse effects. 

Transparency: We are clear, open, and honest about how we use personal data. Our Privacy Policy explains our processing in accessible language. 

Staff Responsibilities: 

  • Identify and document the legal basis before processing 
  • Provide privacy information at point of collection 
  • Ensure processing aligns with reasonable expectations 
  • Never process data in deceptive or misleading ways 

3.2 Purpose Limitation 

We collect personal data for specified, explicit, and legitimate purposes and do not process it in ways incompatible with those purposes. 

Staff Responsibilities: 

  • Clearly define purposes before collecting data 
  • Collect only data necessary for specified purposes 
  • Do not use data for unrelated new purposes without consent or legal basis 
  • Review purposes regularly and delete data when purposes are fulfilled 

Compatible Processing: Further processing for archiving, research, or statistical purposes may be compatible if appropriate safeguards exist. 

3.3 Data Minimization 

We collect and process only the personal data that is adequate, relevant, and limited to what is necessary for our purposes. 

Staff Responsibilities: 

  • Review what data is truly necessary before collection 
  • Avoid collecting “nice to have” data 
  • Regularly review data held and delete unnecessary information 
  • Design forms and systems to request minimum necessary data 
  • Question requests for excessive data 

Practical Examples: 

  • ✓ Collect date of birth for age verification 
  • ✗ Collect full date of birth when only age range needed 
  • ✓ Collect emergency contact details 
  • ✗ Collect emergency contact’s employment details 

3.4 Accuracy 

We take reasonable steps to ensure personal data is accurate, kept up to date, and rectified or deleted without delay when inaccurate. 

Staff Responsibilities: 

  • Verify accuracy at point of collection 
  • Encourage individuals to check and update their information 
  • Implement processes for regular data review and updates 
  • Promptly correct inaccuracies when notified 
  • Delete or mark as inaccurate data that cannot be verified 

Data Quality Checks: 

  • Annual review of active service user records 
  • Verification at key points (enrolment, re-registration, annual reviews) 
  • Data cleansing exercises removing duplicates and outdated records 

3.5 Storage Limitation 

We retain personal data only for as long as necessary for the purposes for which it was collected, in accordance with our Retention Schedule. 

Staff Responsibilities: 

  • Understand retention periods for different data types 
  • Review data regularly against retention schedules 
  • Delete or anonymize data when retention period expires 
  • Document reasons for retaining data beyond standard periods 
  • Securely destroy data at end of retention 

Our Retention Schedule (summary – see full schedule in Records Management Policy): 

  • Educational records: Until age 25 or 6 years after service (whichever longer) 
  • Safeguarding records: Until age 25 minimum, potentially longer 
  • Financial records: 7 years 
  • Employment records: 6 years after employment ends 
  • CCTV: 30 days unless required for investigations 

3.6 Integrity and Confidentiality (Security) 

We process personal data securely using appropriate technical and organizational measures to protect against unauthorized or unlawful processing, accidental loss, destruction, or damage. 

Staff Responsibilities: 

  • Follow all information security policies and procedures 
  • Use strong passwords and never share credentials 
  • Lock screens when away from desk 
  • Store paper records in locked cabinets 
  • Only access data necessary for your role 
  • Report security incidents immediately 
  • Complete annual data protection training 

Security Measures (see section 7 for details): 

  • Access controls and user permissions 
  • Encryption of sensitive data 
  • Secure disposal of confidential waste 
  • Regular backups and disaster recovery 
  • Physical security of premises and records 

3.7 Accountability 

We are responsible for demonstrating compliance with data protection principles through documented policies, procedures, training, and audits. 

Staff Responsibilities: 

  • Follow this policy and related procedures 
  • Complete mandatory data protection training 
  • Maintain accurate records of processing activities 
  • Report non-compliance or concerns 
  • Cooperate with audits and reviews 

Accountability Measures: 

  • Data Protection Officer appointed 
  • Data Protection Impact Assessments (DPIAs) for high-risk processing 
  • Records of Processing Activities maintained 
  • Regular audits and compliance reviews 
  • Board oversight and governance 

4. Roles and Responsibilities 

4.1 Board of Trustees 

Overall accountability for data protection compliance. 

Responsibilities: 

  • Approve data protection policies 
  • Ensure adequate resources for compliance 
  • Receive regular compliance reports from DPO 
  • Review data protection risks in risk register 
  • Ensure data protection is embedded in governance 
  • Champion data protection culture 
  • Demonstrate accountability to regulators and stakeholders 

4.2 Chief Executive Officer / Senior Management 

Operational responsibility for data protection implementation. 

Responsibilities: 

  • Implement policies and procedures 
  • Allocate resources and assign responsibilities 
  • Support the Data Protection Officer 
  • Ensure staff training and awareness 
  • Address non-compliance promptly 
  • Report breaches and issues to trustees 
  • Embed data protection in organizational culture 
  • Lead by example 

4.3 Data Protection Officer (DPO) 

Contact: [email protected] 

Expert advisory role providing guidance and oversight. 

Responsibilities: 

  • Advise on data protection obligations and compliance 
  • Monitor compliance with UK GDPR and this policy 
  • Provide training and awareness programs 
  • Conduct Data Protection Impact Assessments (DPIAs) 
  • Maintain Records of Processing Activities (RoPA) 
  • Act as contact point for ICO and data subjects 
  • Advise on data breaches and oversee response 
  • Conduct audits and compliance reviews 
  • Update policies to reflect legal changes 
  • Report to board on compliance status 

Independence: The DPO operates independently and reports directly to the highest management level. They must not be dismissed or penalized for performing DPO duties. 

4.4 Service Managers / Department Leads 

Day-to-day compliance within their areas. 

Responsibilities: 

  • Implement data protection policies in their service/department 
  • Ensure staff understand and follow procedures 
  • Identify data protection training needs 
  • Conduct DPIAs for new projects or changes 
  • Maintain accurate records of processing 
  • Report incidents and near-misses to DPO 
  • Review data quality and retention regularly 
  • Address subject access requests promptly 
  • Promote data protection culture in their teams 

4.5 All Staff, Volunteers, and Contractors 

Individual responsibility for protecting personal data. 

Responsibilities: 

  • Comply with data protection policies and procedures 
  • Complete mandatory training 
  • Process personal data only when authorized 
  • Follow security procedures (passwords, clear desk, etc.) 
  • Access only data necessary for your role 
  • Respect confidentiality 
  • Report data breaches, incidents, or concerns immediately 
  • Cooperate with audits and investigations 
  • Ask for guidance when uncertain 

Key Message: Data protection is everyone’s responsibility. If you handle personal data, you must understand and follow this policy. 

4.6 Data Processors (Third Parties) 

Contractual obligations to process data only on our instructions. 

Requirements: 

  • Process data only according to written instructions 
  • Implement appropriate security measures 
  • Maintain confidentiality 
  • Assist with subject access requests and other rights 
  • Notify us of data breaches without undue delay 
  • Delete or return data when contract ends 
  • Demonstrate compliance with UK GDPR 

We maintain a register of data processors and review contracts regularly. 

5. Legal Bases for Processing 

We process personal data only where we have a lawful basis under Article 6 UK GDPR. We identify and document the legal basis before processing begins. 

5.1 Consent (Article 6(1)(a)) 

Definition: The individual has given clear, informed, and freely given consent for specific purposes. 

When we use it: 

  • Marketing communications (newsletters, fundraising appeals) 
  • Photographs and videos for promotional purposes 
  • Optional surveys and feedback 
  • Sharing case studies with funders (identifiable information) 
  • Non-essential cookies (analytics, functionality) 

Requirements for valid consent: 

  • Freely given: No coercion, pressure, or negative consequences for refusing 
  • Specific: Separate consent for different purposes 
  • Informed: Clear explanation of what they’re consenting to 
  • Unambiguous: Positive opt-in (not pre-ticked boxes) 
  • Provable: We must be able to demonstrate consent was given 

Obtaining consent: 

  • Use clear, plain language 
  • Separate consent from other terms and conditions 
  • Allow granular choices (e.g., email vs. post) 
  • Make it as easy to withdraw as to give 
  • Keep records of when, how, and what consent was given 

Withdrawing consent: 

  • Individuals can withdraw consent any time 
  • Withdrawal doesn’t affect past processing 
  • We must honour withdrawal promptly 
  • If consent is our only legal basis, we must stop processing 

Children’s consent: 

  • Under 13: Parental consent required (except safeguarding/counselling) 
  • 13-17: May consent themselves if mature enough to understand 

Staff responsibilities: 

  • Document consent clearly 
  • Review consent regularly (refresh if stale) 
  • Make withdrawal options clear 
  • Don’t assume old consent covers new purposes 

5.2 Contract (Article 6(1)(b)) 

Definition: Processing is necessary to perform a contract with the individual or to take steps at their request before entering a contract. 

When we use it: 

  • Enrolling individuals in educational services 
  • Delivering tuition, counselling, Contact Centre, or other contracted services 
  • Processing payments and managing accounts 
  • Communicating about services (schedules, cancellations) 
  • Examination entries and administration 

Requirements: 

  • Must be genuinely necessary for the contract 
  • Cannot be used as excuse to collect unnecessary data 
  • Doesn’t apply to third-party beneficiaries (e.g., children don’t have contracts – parents do) 

Staff responsibilities: 

  • Collect only data genuinely needed for service delivery 
  • Explain why data is necessary for the contract 
  • Don’t rely on contract for non-essential processing 

5.3 Legal Obligation (Article 6(1)(c)) 

Definition: Processing is necessary to comply with legal obligations. 

When we use it: 

  • Statutory safeguarding duties (reporting concerns to social services, police) 
  • Financial record-keeping (7 years for HMRC) 
  • Health and safety compliance 
  • Charity Commission reporting 
  • Examination board requirements (JCQ regulations) 
  • Court orders and legal proceedings 
  • DBS checking for regulated activities 
  • Responding to ICO or other regulatory investigations 

Requirements: 

  • Legal obligation must be clear and specific 
  • We must be the entity with the legal duty 

Staff responsibilities: 

  • Understand legal obligations affecting your role 
  • Process data as required by law even without consent 
  • Document the legal obligation 

5.4 Vital Interests (Article 6(1)(d)) 

Definition: Processing is necessary to protect someone’s life or critical wellbeing. 

When we use it: 

  • Medical emergencies (sharing health information with paramedics) 
  • Immediate safeguarding threats (child at imminent risk) 
  • Life-threatening situations 

Requirements: 

  • Only when truly necessary to protect life 
  • Cannot rely on vital interests if another legal basis applies 
  • Primarily for emergencies where consent cannot be obtained 

Staff responsibilities: 

  • Use only in genuine emergencies 
  • Document circumstances clearly 
  • Inform individuals afterward when possible 

5.5 Public Task (Article 6(1)(e)) 

Definition: Processing is necessary for tasks in the public interest or exercising official authority. 

When we use it: 

  • Safeguarding functions (statutory duty to safeguard) 
  • Providing education meeting statutory requirements 
  • Working in partnership with local authorities 
  • Contact Centre services (facilitating child contact as public benefit) 

Requirements: 

  • Must have a basis in UK law or statutory guidance 
  • Must be in public interest 
  • Common for charities delivering public services 

Staff responsibilities: 

  • Understand statutory functions and guidance 
  • Document public task basis clearly 
  • Don’t assume all charitable activities qualify 

5.6 Legitimate Interests (Article 6(1)(f)) 

Definition: Processing is necessary for our legitimate interests or those of a third party, unless overridden by the individual’s rights and freedoms. 

When we use it: 

  • Fraud prevention and security 
  • Network and information security 
  • CCTV for security and safeguarding 
  • Internal administration and record-keeping 
  • Improving services through feedback analysis 
  • Fundraising for charitable purposes (with opt-out) 
  • Direct marketing to existing service users (soft opt-in with opt-out) 
  • Asserting or defending legal claims 

Three-part test (Legitimate Interests Assessment – LIA): 

  1. Purpose test: Is there a legitimate interest? 
  1. Necessity test: Is processing necessary for that interest? 
  1. Balancing test: Do individual’s rights override the interest? 

We document LIAs for all processing relying on legitimate interests. 

Requirements: 

  • Cannot use for processing children’s data for marketing/profiling 
  • Must conduct balancing test fairly 
  • Individuals have absolute right to object (we must stop unless compelling grounds) 

Staff responsibilities: 

  • Don’t assume processing is in legitimate interests 
  • Consult DPO before relying on legitimate interests 
  • Complete LIA before processing 
  • Respect objections promptly 

5.7 Special Category Data – Additional Conditions 

For special category data (health, ethnicity, religion, etc.), we need both an Article 6 legal basis AND an Article 9 condition: 

Article 9 conditions we use: 

(a) Explicit consent: For counselling disclosures, photographs showing ethnicity/religion, optional equal opportunities monitoring 

(b) Employment, social security, social protection: For employee health data, benefits assessments 

(g) Substantial public interest: For safeguarding, preventing fraud 

(h) Health or social care: For counselling, health assessments, medical needs 

(i) Public health: For pandemic response, health emergencies 

(j) Archiving, research, statistics: For anonymized research (with safeguards) 

Staff responsibilities: 

  • Treat special category data with extra care 
  • Identify both Article 6 basis and Article 9 condition 
  • Minimize processing of special category data 
  • Apply enhanced security measures 

5.8 Criminal Offence Data 

Processing data about criminal convictions/offences requires both Article 6 legal basis and official authority or appropriate Article 10 safeguards. 

When we process criminal data: 

  • DBS checks for staff/volunteers (official authority) 
  • Safeguarding records (substantial public interest) 
  • Risk assessments for Contact Centre (safeguarding) 

Staff responsibilities: 

  • Very limited processing (only where legally authorized) 
  • Strict access controls 
  • Enhanced security and confidentiality 

6. Individual Rights 

We respect and facilitate the rights of individuals under UK GDPR. All staff must understand these rights and how to respond to requests. 

6.1 Right to be Informed 

What it means: Individuals have the right to know how their data is used. 

How we comply: 

  • Provide Privacy Policy on website and at premises 
  • Give privacy information at point of collection (registration forms, consent forms) 
  • Use clear, plain language appropriate for audience 
  • Explain purposes, legal bases, retention, rights, and recipients 
  • Provide information without delay (at collection for direct collection, within one month for indirect collection) 

Staff responsibilities: 

  • Provide privacy information when collecting data 
  • Point individuals to full Privacy Policy 
  • Explain processing in accessible language 
  • Answer questions about data use 

6.2 Right of Access (Subject Access Request – SAR) 

What it means: Individuals can request copies of their personal data and supplementary information. 

How we comply: 

  • Respond within one month (extendable by two months for complex requests) 
  • Verify identity before disclosing data 
  • Provide free copies (charge only for unfounded/excessive requests) 
  • Give data in accessible, structured format 
  • Include supplementary information (purposes, legal bases, retention, recipients, rights) 

Staff responsibilities: 

  • Recognize SARs (any request for personal data, regardless of wording) 
  • Forward SARs to DPO immediately 
  • Assist in locating and compiling data 
  • Never alter or delete data in response to SAR 
  • Respond promptly to DPO requests for information 

SAR Procedure: 

  1. Receive request and forward to DPO 
  1. DPO verifies identity and clarifies scope 
  1. DPO coordinates search across all systems/locations 
  1. Relevant staff compile data from their areas 
  1. DPO reviews and redacts third-party data if necessary 
  1. DPO prepares response with supplementary information 
  1. Response sent within one month 

Exemptions: 

  • Legal professional privilege 
  • Management forecasts 
  • Negotiations with data subject 
  • Third-party confidentiality (redact third-party data unless consent given or reasonable to disclose) 
  • Manifestly unfounded or excessive requests 

Safeguarding considerations: 

  • May withhold data if disclosure would cause serious harm to child/individual 
  • Balance parental rights with child’s rights and maturity 
  • Seek legal advice for complex safeguarding SARs 

6.3 Right to Rectification 

What it means: Individuals can request correction of inaccurate or incomplete data. 

How we comply: 

  • Correct inaccurate data without undue delay 
  • Complete incomplete data (including supplementary statements) 
  • Notify third parties we’ve shared data with (unless impossible or disproportionate) 
  • Respond within one month 

Staff responsibilities: 

  • Accept rectification requests from any channel 
  • Verify facts before making corrections 
  • Update all systems/locations where data appears 
  • Document corrections and reasons 
  • Notify DPO of significant rectifications 

Limitations: 

  • We may challenge rectification if we believe data is accurate 
  • Some data cannot be changed (e.g., historical examination results – controlled by exam boards) 
  • May add supplementary statement if facts are disputed 

6.4 Right to Erasure (‘Right to be Forgotten’) 

What it means: In certain circumstances, individuals can request deletion of their data. 

When it applies: 

  • Data no longer necessary for purposes collected 
  • Consent withdrawn (where consent was legal basis) 
  • Objection upheld (no overriding legitimate grounds) 
  • Data processed unlawfully 
  • Legal obligation requires erasure 
  • Data collected from child for online services 

When it doesn’t apply (we can refuse): 

  • Legal obligation to retain (e.g., financial records, safeguarding) 
  • Necessary for legal claims 
  • Public interest (archiving, research, statistics) 
  • Exercising/defending legal rights 
  • Public health purposes 

Staff responsibilities: 

  • Forward erasure requests to DPO 
  • Don’t delete data without DPO authorization 
  • When authorized, delete from all systems/backups 
  • Document erasure and reasons 
  • Notify third parties if we’ve shared data 

Retention overrides erasure: Most of our data is subject to statutory retention periods that override erasure rights (safeguarding, education, financial). We explain this clearly when declining erasure requests. 

6.5 Right to Restrict Processing 

What it means: In certain circumstances, individuals can request we stop using their data (but still store it). 

When it applies: 

  • Accuracy is contested (while we verify) 
  • Processing is unlawful but individual prefers restriction to erasure 
  • We no longer need data but individual needs it for legal claims 
  • Objection raised (pending verification of our legitimate grounds) 

What restriction means: 

  • We store the data but don’t process it 
  • We can process with consent, for legal claims, to protect others, or for public interest 
  • We lift restriction when circumstances resolve 

Staff responsibilities: 

  • Forward restriction requests to DPO 
  • Mark restricted data clearly in systems 
  • Don’t process restricted data (except as permitted) 
  • Notify individual before lifting restriction 

6.6 Right to Data Portability 

What it means: Individuals can receive their data in structured, machine-readable format and transmit to another controller. 

When it applies: 

  • Processing is based on consent or contract 
  • Processing is automated 

When it doesn’t apply: 

  • Paper records or manual processing 
  • Processing based on legal obligation or public task 
  • Third-party data mixed with individual’s data 

Staff responsibilities: 

  • Forward portability requests to DPO 
  • Provide data in common format (CSV, JSON, XML) 
  • Include only data subject’s own data (not third-party data) 
  • Transmit directly to new controller if technically feasible 

Our approach: 

  • Provide in CSV or PDF format 
  • Include data subject provided and data generated about them 
  • Exclude derived or inferred data 
  • Exclude opinion or professional judgments 

6.7 Right to Object 

What it means: Individuals can object to processing, and we must stop unless we have compelling legitimate grounds. 

Direct marketing: Absolute right to object – we must stop immediately with no exceptions. 

Legitimate interests/public task: We must stop unless we demonstrate compelling legitimate grounds overriding individual’s interests, or processing is for legal claims. 

Staff responsibilities: 

  • Honor marketing objections immediately (no delay, no questions) 
  • Forward other objections to DPO for assessment 
  • Don’t process while objection is assessed 
  • Respect upheld objections promptly 

Our approach: 

  • Make objecting easy (unsubscribe links, simple processes) 
  • Maintain “do not contact” suppression lists 
  • Document objections and our response 
  • Balance rights fairly for non-marketing objections 

6.8 Rights Related to Automated Decision-Making 

What it means: Individuals have rights not to be subject to solely automated decisions with legal/significant effects. 

Our practices: 

  • We do NOT currently use automated decision-making or profiling with legal/significant effects 
  • If we introduce such processing, we will:  
  • Update Privacy Policy 
  • Obtain consent or establish another lawful basis 
  • Provide rights to human intervention, contest decision, and obtain explanation 
  • Conduct DPIA 

Staff responsibilities: 

  • Don’t implement automated decision-making without DPO approval 
  • Report any algorithmic or AI-based tools to DPO 

6.9 Facilitating Rights – General Procedures 

Receiving requests: 

  • Accept requests by any channel (email, phone, letter, in person) 
  • Don’t require specific forms or formats 
  • Recognize requests regardless of wording (“Can I have my data?”, “Delete my information”) 

Identity verification: 

  • Verify identity to prevent unauthorized disclosure 
  • Request ID documents if first request or identity unclear 
  • Balance security with accessibility 

Timescales: 

  • One month from receipt (extendable to three months for complex/multiple requests) 
  • Inform individual if extension needed, with reasons 
  • Count from receipt of identity verification if required 

Fees: 

  • Usually free 
  • May charge reasonable fee for manifestly unfounded/excessive requests 
  • May charge for additional copies beyond first SAR 

Refusals: 

  • Explain reasons clearly 
  • Inform of right to complain to ICO 
  • Inform of right to judicial remedy 
  • Document decision 

Third-party data: 

  • Redact third-party personal data (names, contact details) unless:  
  • Third party consents 
  • Reasonable to disclose without consent 

7. Data Security 

We implement appropriate technical and organizational measures to protect personal data against unauthorized or unlawful processing, accidental loss, destruction, or damage. 

7.1 Security Principles 

Confidentiality: Only authorized individuals can access personal data. 

Integrity: Personal data is accurate, complete, and protected from unauthorized modification. 

Availability: Authorized users can access data when needed (subject to backup and disaster recovery). 

Resilience: Systems can withstand and recover from security incidents. 

7.2 Risk-Based Approach 

Security measures are proportionate to: 

  • Sensitivity of data (special category data gets enhanced protection) 
  • Volume of data 
  • Context of processing 
  • Potential impact of breach 
  • State of the art and cost of implementation 

7.3 Technical Measures 

Access Controls: 

  • Unique user accounts (no shared logins) 
  • Strong password requirements (minimum 12 characters, mix of types) 
  • Multi-factor authentication for remote access and sensitive systems 
  • Role-based access (principle of least privilege) 
  • Regular review and removal of unused accounts 
  • Automatic logout after inactivity 
  • Audit logs of access and changes 

Network Security: 

  • Firewalls protecting network perimeter 
  • Anti-virus and anti-malware on all devices 
  • Regular security updates and patches 
  • Intrusion detection/prevention systems 
  • Secure Wi-Fi with WPA2/WPA3 encryption 
  • Network segmentation where appropriate 
  • Secure remote access (VPN) 

Data Protection: 

  • Encryption of data in transit (SSL/TLS for websites, encrypted email for sensitive data) 
  • Encryption of data at rest (full disk encryption on laptops, encrypted cloud storage) 
  • Encryption of backup media 
  • Pseudonymization/anonymization where possible 

System Security: 

  • Regular security updates and patching 
  • Endpoint protection on all devices 
  • Application whitelisting where feasible 
  • Secure configuration baselines 
  • Security testing (vulnerability scans, penetration tests) 

Data Backup and Recovery: 

  • Regular automated backups (daily for critical systems) 
  • Backups stored securely offsite or in cloud 
  • Encrypted backup media 
  • Regular restore testing 
  • Business continuity and disaster recovery plans 

Email and Communications: 

  • Spam and phishing filters 
  • Email encryption for sensitive data 
  • Clear email security guidance for staff 
  • Caution with attachments and links 
  • Verification procedures for payment requests 

Mobile Devices and Remote Working: 

  • Mobile Device Management (MDM) for organizational devices 
  • Encryption of mobile devices 
  • Remote wipe capability for lost/stolen devices 
  • Secure remote access to systems 
  • Clear remote working policies 
  • VPN for accessing organizational data remotely 

7.4 Organizational Measures 

Policies and Procedures: 

  • This Data Protection Policy 
  • Information Security Policy 
  • Acceptable Use Policy (IT) 
  • Clear Desk Policy 
  • Password Policy 
  • Data Breach Response Plan 
  • Incident Management Procedures 

Staff Training and Awareness: 

  • Mandatory data protection training for all new staff/volunteers 
  • Annual refresher training 
  • Specific training for roles handling sensitive data 
  • Regular security awareness communications 
  • Phishing simulation exercises 
  • Clear escalation procedures for concerns 

Physical Security: 

  • Locked offices and storage areas 
  • Access control to buildings (key/fob systems) 
  • Visitor sign-in and escort procedures 
  • CCTV monitoring 
  • Locked filing cabinets for paper records 
  • Secure destruction of confidential waste (cross-cut shredding) 
  • Clear desk policy (no sensitive data left visible) 
  • Screen privacy filters where appropriate 

Third-Party Management: 

  • Due diligence on processors before engagement 
  • Data Processing Agreements with clear security obligations 
  • Regular review of processor security practices 
  • Contractual right to audit processors 
  • Notification requirements for sub-processors 
  • Incident notification clauses 

Change Management: 

  • Security implications assessed for all changes 
  • Testing before deployment 
  • Change approval processes 
  • Rollback capabilities 

Monitoring and Auditing: 

  • Regular access log reviews 
  • Monitoring for unusual activity 
  • Periodic security audits 
  • Penetration testing (as budget allows) 
  • Compliance reviews 

7.5 Specific Security Measures by Data Type 

Special Category Data (health, ethnicity, religion, etc.): 

  • Enhanced access restrictions 
  • Encryption mandatory 
  • Separate storage where feasible 
  • Additional training for handlers 
  • Regular audits of access 

Safeguarding Information: 

  • Highly restricted access (need-to-know basis) 
  • Encrypted storage 
  • Separate filing systems 
  • Transmission only via secure methods 
  • Strict confidentiality 
  • Enhanced audit trails 

Financial Data: 

  • PCI-DSS compliance for card data (we minimize card data processing) 
  • Encrypted storage and transmission 
  • Limited retention 
  • Segregation of duties 

Children’s Data: 

  • Enhanced protections reflecting higher risks 
  • Strict access controls 
  • Parental engagement 
  • Age-appropriate transparency 

7.6 Staff Responsibilities 

All staff must: 

  • Use strong, unique passwords (don’t reuse passwords) 
  • Never share passwords or login credentials 
  • Lock screens when away from desk (Windows+L or Ctrl+Alt+Del) 
  • Log out at end of day 
  • Report lost/stolen devices immediately 
  • Don’t write down passwords 
  • Be cautious with emails (verify senders, don’t click suspicious links) 
  • Only access data necessary for your role 
  • Don’t use personal devices for work data (unless authorized and protected) 
  • Report security concerns or incidents immediately 

Clear Desk Policy: 

  • No personal data left visible when desk unattended 
  • Lock away paper files at end of day 
  • Don’t leave printouts at printers 
  • Secure laptops/tablets when not in use 
  • Shred confidential waste (cross-cut shredder) 

Confidential Waste: 

  • Shred any document containing personal data 
  • Don’t put personal data in general waste 
  • Use locked confidential waste bins 
  • Contracted secure shredding service for bulk destruction 

7.7 Bring Your Own Device (BYOD) 

Use of personal devices for work is discouraged. If essential: 

  • Must be authorized by line manager and DPO 
  • Device must meet security requirements (password, encryption, anti-virus) 
  • Access limited to specific approved systems 
  • Remote wipe must be enabled 
  • Personal and work data must be separated 
  • Device may be checked for compliance 
  • All organizational data must be deleted when employment ends 

7.8 Encryption 

When encryption is required: 

  • Laptops and mobile devices (full disk encryption) 
  • Removable media (USB drives, external hard drives) 
  • Email containing special category or sensitive data 
  • Cloud storage 
  • Backups 

Approved encryption: 

  • BitLocker (Windows) 
  • FileVault (Mac) 
  • TLS 1.2 or higher for data in transit 
  • AES-256 for data at rest 

7.9 Password Management 

Password requirements: 

  • Minimum 12 characters 
  • Mix of uppercase, lowercase, numbers, symbols 
  • No dictionary words, names, or common patterns 
  • Unique (don’t reuse across systems) 
  • Changed if compromised 

Password managers: 

  • Approved password managers may be used 
  • Master password must be very strong 
  • Enable two-factor authentication 

Multi-factor authentication (MFA): 

  • Required for remote access 
  • Required for access to sensitive systems 
  • Encouraged for all accounts supporting MFA 

7.10 Data Loss Prevention 

Preventing data loss: 

  • Regular backups 
  • Version control 
  • “Save early, save often” culture 
  • Cloud sync for critical documents 
  • Testing backups regularly 

Preventing data theft/leakage: 

  • USB port restrictions (where feasible) 
  • Email attachment size limits and scanning 
  • Data Loss Prevention (DLP) tools (as budget allows) 
  • Monitoring for unusual data transfers 
  • Confidentiality agreements 

8. Data Sharing and Transfers 

8.1 General Principles 

We share personal data only when: 

  • Necessary and proportionate 
  • We have legal basis and lawful grounds 
  • Appropriate safeguards are in place 
  • Recipients are informed of confidentiality and security obligations 
  • Sharing is documented 

Staff responsibilities: 

  • Never share data without authorization 
  • Verify recipient identity and authority 
  • Use secure transmission methods 
  • Document sharing (what, why, who, when) 
  • Minimize data shared (only what’s necessary) 

8.2 Statutory Sharing (Safeguarding) 

Legal basis: Legal obligation, vital interests, public task 

Recipients: Social services, police, LADO, Cafcass, courts 

When: Safeguarding concerns, child protection, risk of serious harm 

Process: 

  1. Identify concern requiring sharing 
  1. Consult Designated Safeguarding Lead (DSL) 
  1. Document decision to share (reasons, what, who) 
  1. Share necessary information securely 
  1. Record sharing and recipient’s response 
  1. Follow up as required 

Key principle: Safeguarding overrides confidentiality and data protection when necessary to protect children or vulnerable adults. 

8.3 Professional Sharing (With Consent or Legal Basis) 

Recipients: Schools, GPs, therapists, social workers, examination boards 

When: Coordinating care, educational transitions, health referrals, examination administration 

Process: 

  1. Obtain consent (unless legal basis exists without consent) 
  1. Explain what will be shared and why 
  1. Share minimum necessary information 
  1. Use secure methods (encrypted email, secure portal, hand delivery) 
  1. Verify recipient identity 
  1. Document sharing 

8.4 Organisational Sharing (Data Processors) 

Recipients: IT providers, cloud services, payment processors, email services, shredding companies 

Requirements: 

  • Written Data Processing Agreement before sharing 
  • Processor must process only on our instructions 
  • Adequate security measures required 
  • Confidentiality obligations 
  • Assistance with rights requests 
  • Breach notification obligations 
  • Deletion/return of data at contract end 

DPO maintains register of processors 

8.5 Research and Fundraising Sharing 

Recipients: Grant-making trusts, researchers (academic or internal) 

Requirements: 

  • Anonymization/pseudonymization where possible 
  • Explicit consent for identifiable case studies 
  • Clear purposes and limitations 
  • Ethical approval for research 
  • Secure data sharing agreements 
  • Limited retention and destruction after use 

8.6 International Transfers 

General rule: We primarily process data within UK. International transfers require additional safeguards. 

When we transfer internationally: 

  • Cloud services with international servers 
  • International teacher training (Academica Mentoring) 
  • Examination boards with international operations 

Safeguards: 

  • UK GDPR-compliant Standard Contractual Clauses (SCCs) 
  • Adequacy decisions (for approved countries) 
  • Binding Corporate Rules (BCRs) of processors 
  • Appropriate safeguards documented 

Process: 

  1. Identify need for international transfer 
  1. Assess destination country protections 
  1. Implement appropriate safeguards (SCCs, adequacy) 
  1. Document transfer and safeguards 
  1. Inform individuals in Privacy Policy 
  1. Review transfers regularly 

Prohibited: 

  • Transfers to countries without adequate protections and no safeguards 
  • Transfers in breach of UK export controls or sanctions 

8.7 Secure Sharing Methods 

Email: 

  • Encrypt emails containing special category or sensitive data 
  • Use secure email services (NHS.net for health data) 
  • Verify recipient address before sending 
  • Use BCC for bulk emails (protect recipients’ addresses) 
  • Password-protect attachments with sensitive data (send password separately) 

Physical documents: 

  • Hand delivery in sealed envelope 
  • Tracked delivery services for valuable/sensitive data 
  • No identifiable data in window envelopes 
  • Record delivery 

Secure portals: 

  • Use approved secure file sharing services 
  • Encrypt before upload 
  • Set access permissions and expiry dates 
  • Notify recipient separately (not in same email as link) 

Prohibited methods: 

  • Unencrypted email for special category data 
  • Personal email accounts for work data 
  • Unsecured cloud services (Dropbox, personal Google Drive, etc.) 
  • Unencrypted USB drives sent by post 
  • Fax (except encrypted fax where essential) 

9. Data Protection Impact Assessments (DPIAs) 

9.1 What is a DPIA? 

A DPIA is a process to identify and minimize data protection risks of a project or processing activity. It’s a key tool for accountability and demonstrating compliance. 

9.2 When DPIAs are Required 

Mandatory for: 

  • Systematic and extensive profiling with significant effects 
  • Large-scale processing of special category data 
  • Systematic monitoring of publicly accessible areas (extensive CCTV) 
  • New technologies with high privacy risks 
  • Processing likely to result in high risk to individuals 

Good practice for: 

  • New projects involving personal data 
  • Significant changes to processing 
  • New technologies or systems 
  • Sensitive processing (even if small scale) 

Examples requiring DPIA: 

  • Implementing new CRM or database system 
  • New CCTV installation (if extensive) 
  • Launching new service collecting health data 
  • Implementing AI or automated decision-making 
  • Large-scale data analytics or profiling 

9.3 DPIA Process 

Step 1: Identify need for DPIA 

  • Use DPIA screening questions 
  • Consult DPO if uncertain 

Step 2: Describe processing 

  • What data? (types, sources, volume) 
  • Why? (purposes, legal basis) 
  • How? (systems, processes, flows) 
  • Who? (recipients, processors) 
  • When? (start date, duration, retention) 

Step 3: Assess necessity and proportionality 

  • Is processing necessary for purpose? 
  • Is there less intrusive alternative? 
  • Is data minimized? 
  • Are purposes clear and specific? 

Step 4: Identify risks 

  • What could go wrong? 
  • What would be the impact on individuals? (likelihood x severity) 
  • Consider: unauthorized access, loss, disclosure, excessive collection, inaccuracy, function creep 

Step 5: Identify measures to reduce risks 

  • Technical measures (encryption, access controls, etc.) 
  • Organizational measures (policies, training, audits) 
  • How do measures reduce risks? 
  • Are residual risks acceptable? 

Step 6: Integrate outcomes 

  • Implement identified measures 
  • Update project plans and designs 
  • Ensure ongoing compliance 

Step 7: Document and sign off 

  • Complete DPIA form 
  • DPO reviews and approves 
  • Senior management signs off 
  • Keep under review (update if processing changes) 

9.4 Consulting ICO 

If DPIA identifies high residual risks that cannot be mitigated, we must consult ICO before processing. 

Process: 

  1. Complete DPIA thoroughly 
  1. Document risks and mitigation attempts 
  1. Submit to ICO with DPIA and supporting information 
  1. Await ICO advice (8 weeks, extendable to 14) 
  1. Implement ICO recommendations before processing 

9.5 Staff Responsibilities 

Project managers and service leads: 

  • Identify when DPIA is needed 
  • Contact DPO to initiate DPIA 
  • Provide information about processing 
  • Implement risk mitigation measures 
  • Update DPIA if processing changes 

DPO: 

  • Provide DPIA guidance and support 
  • Review and approve DPIAs 
  • Maintain DPIA register 
  • Advise on high risks and mitigation 
  • Consult ICO when necessary 

10. Records of Processing Activities (RoPA) 

10.1 What is RoPA? 

Article 30 UK GDPR requires controllers to maintain written records of processing activities. This is a key accountability measure. 

10.2 What We Record 

For each processing activity: 

  • Name and contact details of controller (Raedan Institute) 
  • Purposes of processing 
  • Categories of data subjects (service users, employees, donors, etc.) 
  • Categories of personal data (contact details, health data, financial data, etc.) 
  • Categories of recipients (schools, social services, examination boards, etc.) 
  • International transfers (if any) and safeguards 
  • Retention periods 
  • Security measures (general description) 

10.3 Format 

We maintain RoPA in spreadsheet/database format with separate entries for distinct processing activities (e.g., educational services, counselling, Contact Centre, employment, fundraising). 

10.4 Responsibilities 

DPO: 

  • Maintain RoPA 
  • Update as processing changes 
  • Review annually 
  • Make available to ICO on request 

Service managers: 

  • Notify DPO of new processing or changes 
  • Provide information for RoPA entries 
  • Review RoPA entries for their areas annually 

10.5 Review 

RoPA is reviewed: 

  • Annually (full review) 
  • When new processing begins 
  • When significant changes occur 
  • Before audits or ICO inspections 

11. Data Breaches 

11.1 What is a Data Breach? 

A breach of security leading to accidental or unlawful destruction, loss, alteration, unauthorized disclosure of, or access to, personal data. 

Examples: 

  • Lost or stolen laptop, phone, USB drive containing personal data 
  • Email sent to wrong recipient 
  • Unauthorized access to systems or files 
  • Ransomware attack encrypting data 
  • Paper records lost or stolen 
  • Confidential waste not shredded 
  • Unauthorized disclosure of information 
  • Hacking or cyber-attack 
  • Data sent to wrong person by post 
  • Database left publicly accessible online 

Not just cyber incidents: Physical breaches (lost files, wrongly addressed post) are equally important. 

11.2 Reporting Breaches Internally 

All staff must report potential breaches immediately: 

To whom: Data Protection Officer and line manager 

How: Email [email protected] with subject “URGENT: Data Breach” or phone 07725974831 

When: Immediately upon discovery (don’t delay to investigate yourself) 

What to report: 

  • What happened? (facts known) 
  • What data was affected? (types, volume, sensitivity) 
  • Who was affected? (individuals, numbers) 
  • When did it happen? 
  • How did you discover it? 
  • What actions have been taken? 

Don’t: 

  • Delay reporting while trying to fix it yourself 
  • Assume it’s not serious enough to report 
  • Assume someone else will report it 
  • Try to cover it up 

Remember: Early reporting enables faster containment and reduces harm. There is no penalty for reporting suspected breaches that turn out not to be breaches. There is serious penalty for not reporting genuine breaches. 

11.3 Breach Response Process 

DPO coordinates response: 

Step 1: Containment (immediate) 

  • Stop the breach if ongoing 
  • Secure affected systems/data 
  • Prevent further loss or damage 
  • Preserve evidence 

Step 2: Assessment (within 24 hours) 

  • Gather facts (what, when, how, who affected) 
  • Assess severity and likelihood of harm to individuals 
  • Consider: volume of data, sensitivity, identifiability, who can access it, consequences 
  • Determine if breach must be notified to ICO and/or individuals 

Step 3: Notification (if required) 

To ICO (if likely to result in risk to individuals): 

  • Within 72 hours of becoming aware 
  • Via ICO online reporting tool 
  • Include: description, categories and numbers affected, consequences, measures taken/proposed, DPO contact 

To individuals (if likely to result in high risk): 

  • Without undue delay 
  • In clear, plain language 
  • Include: description, consequences, measures taken/proposed, contact point 
  • Directly to individuals (not via public notice unless disproportionate effort) 

Step 4: Investigation 

  • Determine root cause 
  • Identify failures or weaknesses 
  • Assess effectiveness of existing measures 

Step 5: Remediation 

  • Implement fixes to prevent recurrence 
  • Update policies/procedures if needed 
  • Provide additional training 
  • Review and improve security measures 

Step 6: Documentation 

  • Record all breaches in breach register (even if not notified to ICO) 
  • Document: facts, effects, remedial action 
  • Provide to ICO on request 
  • Learn lessons for future 

11.4 Examples of Breach Responses 

Example 1: Lost encrypted laptop 

  • Containment: Report to IT to disable remote access 
  • Assessment: Data encrypted, low risk of access 
  • Notification: Not required (encryption mitigates risk) 
  • Remediation: Replace laptop, reinforce laptop security procedures 

Example 2: Email to wrong recipient (special category data) 

  • Containment: Request recipient delete/return email, confirm deletion 
  • Assessment: Sensitive data, one recipient, high risk 
  • Notification: ICO within 72 hours, affected individual immediately 
  • Remediation: Email verification procedures, training on checking recipients 

Example 3: Ransomware attack 

  • Containment: Isolate infected systems, engage IT support 
  • Assessment: Potential loss of access, possible exfiltration, high risk 
  • Notification: ICO within 72 hours, individuals if data exfiltrated 
  • Remediation: Restore from backups, security review, patch vulnerabilities, staff training 

11.5 Prevention 

Prevention is better than cure. We prevent breaches through: 

  • Security measures (section 7) 
  • Staff training and awareness 
  • Regular audits and testing 
  • Clear procedures and policies 
  • Culture of vigilance and reporting 

11.6 Staff Responsibilities 

Prevent breaches: 

  • Follow all security policies 
  • Be vigilant and careful with data 
  • Think before clicking, sending, or sharing 
  • Secure devices and documents 
  • Report risks and near-misses 

Report breaches: 

  • Immediately upon discovery 
  • No matter how small 
  • Even if uncertain 
  • Preserve evidence 

Learn from breaches: 

  • Participate in investigations 
  • Implement lessons learned 
  • Share knowledge with colleagues 

12. Training and Awareness 

12.1 Mandatory Training 

All staff and volunteers must complete: 

  • Data protection induction training (before accessing personal data) 
  • Annual data protection refresher training 
  • Role-specific training (for roles handling sensitive data) 

Training covers: 

  • UK GDPR principles and requirements 
  • Individual rights and how to respond 
  • Security procedures (passwords, clear desk, encryption, etc.) 
  • Recognizing and reporting data breaches 
  • This policy and related procedures 
  • Consequences of non-compliance 

Format: 

  • Online modules (e-learning) 
  • Face-to-face sessions (for complex topics) 
  • Practical scenarios and case studies 
  • Assessment/quiz (must pass to confirm understanding) 

Records: 

  • Training records maintained 
  • Completion tracked 
  • Refreshers scheduled automatically 
  • Gaps addressed promptly 

12.2 Role-Specific Training 

Additional training for: 

DPO and senior management: 

  • Advanced GDPR training 
  • DPIAs and LIAs 
  • Breach management 
  • ICO liaison 
  • Regulatory updates 

Designated Safeguarding Leads: 

  • Information sharing in safeguarding 
  • Balancing confidentiality with protection 
  • Multi-agency working 
  • Recording and retention 

IT staff: 

  • Technical security measures 
  • Encryption and access controls 
  • Incident response 
  • Security testing 

Staff handling sensitive data (counselling, Contact Centre, etc.): 

  • Extra confidentiality requirements 
  • Special category data handling 
  • Secure storage and transmission 
  • Professional boundaries 

Managers approving DPIAs and processing changes: 

  • DPIA process and requirements 
  • Risk assessment 
  • Legal bases for processing 
  • Accountability 

12.3 Ongoing Awareness 

Beyond formal training, we promote awareness through: 

  • Regular bulletins and updates 
  • Posters and reminders at premises 
  • Team meeting discussions 
  • Case studies of breaches (anonymized, external examples) 
  • Simulated phishing exercises 
  • Data protection champions in each team 
  • Annual Data Protection Week activities 

12.4 Induction 

All new starters receive: 

  • Data protection policy and procedures 
  • Privacy information (they’re data subjects too as employees/volunteers) 
  • Security guidance (passwords, clear desk, etc.) 
  • Induction training before accessing personal data 
  • Signed acknowledgment of understanding obligations 

12.5 Specialist Support 

Access to: 

  • DPO for advice and guidance 
  • External legal advice (when needed) 
  • ICO guidance and helpline 
  • Professional networks and forums 

13. Monitoring and Auditing 

13.1 Purpose 

We monitor and audit to: 

  • Verify compliance with this policy and UK GDPR 
  • Identify risks and areas for improvement 
  • Demonstrate accountability 
  • Detect breaches or non-compliance 
  • Provide assurance to trustees, regulators, and stakeholders 

13.2 Internal Audits 

Annual compliance audit: 

  • Review all processing activities against RoPA 
  • Check documentation (DPIAs, consent records, contracts) 
  • Test security controls (access controls, encryption, etc.) 
  • Review training completion 
  • Check breach register and responses 
  • Assess policy compliance 
  • Sample transactions and records 
  • Interview staff 

DPO conducts audits with support from service managers 

Findings reported to: 

  • Senior management 
  • Board of Trustees 
  • Improvement actions agreed and tracked 

Audit schedule: 

  • Annual full audit 
  • Ad hoc audits when risks identified 
  • Pre-emptive audits before major changes 

13.3 Access Monitoring 

IT systems: 

  • Audit logs reviewed regularly 
  • Unusual access patterns investigated 
  • Failed login attempts monitored 
  • Privileged access audited more frequently 

Physical access: 

  • Key/fob issuance tracked 
  • Access to restricted areas logged 
  • Visitor records reviewed 

13.4 Data Quality Checks 

Regular reviews: 

  • Accuracy of service user records 
  • Completeness of essential data 
  • Outdated or stale data identified 
  • Duplicates merged or removed 
  • Retention schedules applied 

Service managers responsible for data quality in their areas 

13.5 Policy Compliance Checks 

DPO spot-checks: 

  • Privacy information provision at point of collection 
  • Consent records (valid, documented, refreshed) 
  • Data sharing documentation 
  • Secure disposal of confidential waste 
  • Clear desk compliance 
  • Subject access request handling 

13.6 Third-Party Audits 

We may commission: 

  • Independent data protection audits 
  • IT security assessments (penetration testing, vulnerability scans) 
  • ISO 27001 or Cyber Essentials certification audits (if pursuing) 

13.7 ICO Inspections 

If ICO inspects: 

  • Cooperate fully and promptly 
  • Provide requested documentation 
  • Facilitate access to systems and staff 
  • Address findings seriously 
  • Implement recommendations 
  • Report progress to ICO as required 

13.8 Reporting 

DPO provides: 

  • Annual compliance report to trustees 
  • Quarterly updates to senior management 
  • Breach summaries and lessons learned 
  • Audit findings and action plans 
  • Regulatory developments and implications 

Board receives: 

  • Annual data protection report 
  • Significant breaches or ICO communications 
  • Data protection risks for risk register 
  • Assurance on compliance 

14. Accountability and Governance 

14.1 Demonstrating Compliance 

We demonstrate compliance through: 

Documentation: 

  • This policy and related policies 
  • Records of Processing Activities (RoPA) 
  • Data Protection Impact Assessments (DPIAs) 
  • Legitimate Interest Assessments (LIAs) 
  • Data Processing Agreements with processors 
  • Consent records 
  • Subject access request logs 
  • Breach register 
  • Training records 
  • Audit reports 

Processes: 

  • Privacy by design and default 
  • DPIAs for high-risk processing 
  • Regular reviews and audits 
  • Breach notification procedures 
  • Rights request handling 
  • Third-party due diligence 

Culture: 

  • Board and senior management commitment 
  • Data protection champions 
  • Open discussion of issues 
  • Learning from incidents 
  • Continuous improvement 

14.2 Privacy by Design and Default 

Privacy by Design: We build data protection into projects from the outset, not as an afterthought. 

When designing new processing, services, or systems: 

  • Conduct DPIA early in planning 
  • Minimize data collection (collect only what’s needed) 
  • Provide clear privacy information 
  • Build in security (encryption, access controls) 
  • Limit retention (automatic deletion) 
  • Enable individual rights (portability, erasure) 
  • Default to privacy-protective settings 

Privacy by Default: Systems and processes default to the most privacy-friendly settings. 

Examples: 

  • Opt-in (not opt-out) for marketing 
  • Minimal data fields in forms (not comprehensive) 
  • Need-to-know access (not open access) 
  • Short retention (not indefinite) 
  • Anonymization where possible (not identifiable) 

14.3 Data Protection Officer (DPO) Independence 

The DPO must be independent to provide objective advice and oversight. 

Safeguards: 

  • Reports directly to highest management level 
  • Not dismissed or penalized for DPO work 
  • No instructions regarding DPO duties 
  • No conflicts of interest (doesn’t determine purposes/means of processing) 
  • Adequate resources and time 
  • Access to all processing activities and systems 
  • Included in decision-making on data protection matters 

14.4 Board Oversight 

Trustees’ data protection responsibilities: 

  • Approve data protection policies 
  • Receive annual compliance reports 
  • Oversee data protection risks in risk register 
  • Ensure adequate resources for compliance 
  • Champion data protection culture 
  • Hold senior management accountable 
  • Respond to serious breaches or ICO actions 

Data protection on board agenda: 

  • Annual compliance review 
  • Significant breach reports 
  • ICO correspondence 
  • Major processing changes (new systems, services) 
  • Data protection risks 

14.5 Risk Management 

Data protection risks in organizational risk register: 

  • ICO enforcement action (fines, orders) 
  • Data breaches (reputational damage, financial cost) 
  • Non-compliance with safeguarding duties 
  • Loss of trust and confidence 
  • Legal claims from individuals 
  • Inadequate security 

For each risk: 

  • Likelihood and impact assessed 
  • Mitigation measures identified 
  • Residual risk evaluated 
  • Risk owner assigned 
  • Regular review 

14.6 Contracts and Agreements 

Data Processing Agreements (DPAs) with processors: 

  • Processing only on documented instructions 
  • Confidentiality of personnel 
  • Security measures appropriate to risk 
  • Sub-processor approval and contracts 
  • Assistance with rights requests and DPIAs 
  • Data breach notification (without undue delay) 
  • Deletion or return of data at contract end 
  • Audit and inspection rights 
  • Compliance with UK GDPR 

Template DPA maintained by DPO 

All processor contracts reviewed before signing 

14.7 Records and Documentation 

We maintain records of: 

  • All processing activities (RoPA) 
  • DPIAs and LIAs 
  • Data breaches (even if not reported to ICO) 
  • Subject access requests and responses 
  • Other rights requests (rectification, erasure, etc.) 
  • Complaints and resolutions 
  • Consent (when, how, what, who) 
  • Data sharing (who, what, why, when) 
  • Training completion 
  • Audits and reviews 
  • Policy approvals and updates 

Retention: Data protection records kept for 7 years minimum (demonstrate compliance) 

Location: Centralized repository managed by DPO 

15. Non-Compliance and Enforcement 

15.1 Consequences of Non-Compliance 

For Raedan Institute: 

  • ICO fines (up to £17.5 million or 4% of annual turnover) 
  • ICO enforcement notices (requiring actions) 
  • ICO warnings and reprimands 
  • Criminal offenses for serious breaches 
  • Civil claims from individuals 
  • Reputational damage 
  • Loss of trust and confidence 
  • Service suspensions or restrictions 
  • Loss of accreditations or registrations 
  • Regulatory investigations 

For individuals (staff/volunteers): 

  • Disciplinary action (warning, suspension, dismissal) 
  • Criminal prosecution (for serious offenses like unlawfully obtaining data) 
  • Professional consequences (for regulated professionals) 
  • Personal liability in exceptional cases 

15.2 ICO Enforcement Powers 

The ICO can: 

  • Conduct investigations and audits 
  • Issue information notices (requiring information provision) 
  • Issue assessment notices (requiring audit cooperation) 
  • Issue enforcement notices (requiring actions to comply) 
  • Issue reprimands and warnings 
  • Impose fines (up to £17.5 million or 4% of turnover) 
  • Prosecute criminal offenses 
  • Issue public statements 

We cooperate fully with ICO: 

  • Respond promptly to information requests 
  • Facilitate audits and investigations 
  • Implement recommendations 
  • Report progress on actions 

15.3 Internal Disciplinary Process 

Non-compliance with this policy is a disciplinary matter: 

Examples of misconduct: 

  • Unauthorized access to personal data 
  • Sharing data inappropriately 
  • Failing to report data breach 
  • Ignoring security procedures 
  • Deliberate destruction or alteration of data 
  • Using data for unauthorized purposes 

Process: 

  1. Incident identified or reported 
  1. Initial investigation to establish facts 
  1. Disciplinary meeting with staff member 
  1. Decision and sanction (if appropriate) 
  1. Appeal processes available 
  1. Learning and improvement 

Sanctions may include: 

  • Verbal or written warning 
  • Additional training 
  • Enhanced supervision 
  • Suspension of access to systems 
  • Suspension or dismissal (for serious breaches) 

Gross misconduct (dismissal without notice): 

  • Deliberate unauthorized disclosure 
  • Deliberate data destruction 
  • Using data for personal gain 
  • Identity theft or fraud 
  • Serious breach for malicious purposes 

15.4 Reporting Non-Compliance 

Staff should report non-compliance: 

  • To line manager or DPO 
  • Anonymously via whistleblowing procedure if preferred 
  • Without fear of retaliation 

Whistleblowing protection: 

  • Protected disclosure under Public Interest Disclosure Act 
  • No detriment for reporting genuine concerns 
  • Confidentiality maintained where possible 

We take reports seriously: 

  • Investigate thoroughly and fairly 
  • Take action to address issues 
  • Provide feedback to reporter (where possible) 
  • Learn and improve 

16. Policy Review and Updates 

16.1 Review Schedule 

This policy is reviewed: 

  • Annually (scheduled full review) 
  • When legislation changes (e.g., amendments to UK GDPR, new statutory guidance) 
  • When processing changes significantly (new services, major system changes) 
  • Following serious incidents or ICO actions 
  • Following audit recommendations 
  • When best practice evolves 

Next scheduled review: January 2026 

16.2 Review Process 

DPO leads review: 

  1. Review current policy against legal requirements and guidance 
  1. Consult with staff and managers on practical issues 
  1. Review incident logs, audits, and feedback 
  1. Identify improvements and updates needed 
  1. Draft updated policy 
  1. Consult senior management and board 
  1. Approve updated policy 
  1. Communicate changes to all staff 
  1. Update training materials 
  1. Publish updated policy 

16.3 Version Control 

Each version: 

  • Numbered (e.g., 1.0, 1.1, 2.0) 
  • Dated 
  • Approved by Board 
  • Change summary documented 
  • Previous versions archived 

Current version: 1.0 (January 2, 2025) 

16.4 Communication of Changes 

Staff informed of updates via: 

  • Email announcement 
  • Team meetings 
  • Training updates 
  • Policy portal/shared drive 
  • Induction for new starters 

Significant changes: 

  • Highlighted in communications 
  • Additional training if needed 
  • Reasonable implementation time 

17. Related Documents 

17.1 External-Facing Documents 

  • Privacy Policy (for service users and website visitors) 
  • Cookie Policy 
  • Terms and Conditions 
  • Service-specific privacy notices (e.g., Contact Centre, counselling) 

17.2 Internal Policies and Procedures 

  • Information Security Policy 
  • Acceptable Use Policy (IT) 
  • Clear Desk Policy 
  • Password Policy 
  • CCTV Policy 
  • Records Management and Retention Policy 
  • Safeguarding Policy 
  • Confidentiality Policy 
  • Whistleblowing Policy 
  • Complaints Policy 
  • Freedom of Information Policy (if applicable) 

17.3 Procedures and Guidance 

  • Data Breach Response Plan 
  • Subject Access Request Procedure 
  • DPIA Procedure and Template 
  • Legitimate Interests Assessment Template 
  • Data Sharing Protocols 
  • Secure Disposal Procedures 
  • Third-Party Due Diligence Checklist 
  • Data Processing Agreement Template 
  • Consent Recording Guidance 
  • Privacy Notice Templates 

17.4 Forms and Templates 

  • Subject Access Request Form 
  • DPIA Template 
  • Legitimate Interests Assessment Template 
  • Data Breach Report Form 
  • Data Sharing Agreement Template 
  • Consent Form Templates 
  • Privacy Notice Templates 

18. Definitions and Glossary 

Personal Data: Information relating to an identified or identifiable living individual (e.g., name, email, ID number, online identifier, or factors specific to their identity). 

Special Category Data: Sensitive personal data requiring extra protection: racial/ethnic origin, political opinions, religious/philosophical beliefs, trade union membership, genetic data, biometric data (for identification), health data, sex life, or sexual orientation. 

Processing: Any operation on personal data, including collection, recording, organization, storage, alteration, consultation, use, disclosure, erasure, or destruction. 

Data Controller: Organization determining the purposes and means of processing personal data (Raedan Institute). 

Data Processor: Organization processing personal data on behalf of the controller (e.g., our IT provider, cloud storage provider). 

Data Subject: The individual whose personal data is being processed. 

Consent: Freely given, specific, informed, and unambiguous indication of the data subject’s agreement to processing (usually by statement or clear affirmative action). 

Data Protection Officer (DPO): Person responsible for advising on and monitoring data protection compliance. 

Data Protection Impact Assessment (DPIA): Process to identify and minimize data protection risks of processing, particularly high-risk processing. 

Legitimate Interests Assessment (LIA): Assessment of whether processing is necessary for legitimate interests and whether these override the individual’s rights. 

Records of Processing Activities (RoPA): Written record of processing activities required under Article 30 UK GDPR. 

Data Breach: Breach of security leading to accidental or unlawful destruction, loss, alteration, unauthorized disclosure, or access to personal data. 

Pseudonymization: Processing data so it can no longer be attributed to a specific individual without additional information kept separately. 

Anonymization: Irreversibly removing identifiers so data can never be linked back to an individual (no longer personal data). 

Encryption: Converting data into code to prevent unauthorized access (only readable with decryption key). 

Subject Access Request (SAR): Request by individual to access their personal data. 

UK GDPR: UK General Data Protection Regulation 2021 (retained EU law adapted for UK). 

DPA 2018: Data Protection Act 2018 (supplements UK GDPR). 

ICO: Information Commissioner’s Office (UK supervisory authority for data protection). 

PECR: Privacy and Electronic Communications Regulations 2003 (governs electronic marketing, cookies, etc.). 

19. Contact and Further Information 

19.1 Internal Contacts 

Data Protection Officer: Mr Mohamed Sidat 
Email: [email protected] 
Phone: 07725974831 

Chief Executive Officer / Senior Management: Mr Mohamed Sidat 
Email: [email protected] 
Phone: 07725974831 

Designated Safeguarding Lead: Mr Mohamed Sidat / Juwayriyah Dhabhelia / Aisha Khalifah 
Phone: 07725974831 

19.2 External Contacts 

Information Commissioner’s Office (ICO): 
Wycliffe House 
Water Lane 
Wilmslow 
Cheshire SK9 5AF 
Helpline: 0303 123 1113 
Website: www.ico.org.uk 
Report a concern: www.ico.org.uk/make-a-complaint 

Charity Commission: 
Website: www.gov.uk/government/organisations/charity-commission 
Tel: 0300 066 9197 

19.3 Useful Resources 

ICO Guidance: 

  • Guide to UK GDPR: www.ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr 
  • Data Protection Self-Assessment Toolkit 
  • ICO Checklists and Templates 

Government: 

  • Data Protection Act 2018: www.legislation.gov.uk/ukpga/2018/12 
  • Information Sharing Guidance: www.gov.uk/government/publications/safeguarding-practitioners-information-sharing-advice 

Sector Resources: 

  • NCVO Data Protection Guidance for Charities 
  • Small Charities Coalition Resources 
  • NACCC Data Protection Guidance 

20. Policy Approval 

This Data Protection and GDPR Policy has been approved by the Board of Trustees of Raedan Institute. 

Approved by: Board of Trustees, Raedan Institute  

Date of Approval: January 2, 2025 

Signature of Chair of Trustees: Mr Mohamed Sidat 

Print Name: Mr Mohamed Sidat 

Next Review Date: September 1st, 2025