POLICY ON PROCEDURAL DOCUMENTS

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1 POLICY ON PROCEDURAL DOCUMENTS

2 Policy Title: Executive Summary: Policy on Procedural Documents This policy provides guidance to authors of policies and procedures and staff in the Trust regarding the template for all Trust policies and procedures. This document when followed will assist the Trust in meeting it s responsibilities with regards to risk management standards. This policy should be read in conjunction with the Policy Schedule Supersedes: Description of Amendment(s): V4 Transfer existing policy document into the corporate policy template. Section 3.1a All policies whether Board approved or not use the same policy template Section 3.4a Further clarification given on the consultation process ensuring that all individuals listed in the responsibilities section of the policy are to be included in the consultation. Additionally, the inclusion of service lines if there is an operational impact. Section 3.4 Added requirement that consultation period is sufficient length of time to allow responses for relevant consultees. Section 3.7h and Section 5 Strengthened information on how monitoring performance of the policy should take place through the use and reporting of Key Performance Indicators Appendix 1 removal of policy template for policies not approved by Board This policy will impact on: All Trust policies and procedure documents Local Specialist Policies (font and control page) Financial Implications: Limited financial impact. Resources required in terms of policy author s time to review their policies to ensure that they meet the standards outlined in this document. Policy Area: Trust Wide Document ECT Reference: Version Number: 5.0 Effective Date: September 2016 Issued By: Director of Corporate Affairs and Governance Review Date: March 2019 Author: Head of Integrated Governance Impact Assessment Date: February 2015 APPROVAL RECORD Consultation: Approved and Ratified: Received for information Consultation: Approved and Ratified: Committees / Group OMT Governance Managers Risk Management Sub Committee Changes approved by trust Safety Quality and Standards committee Operational Management Team Meeting OMT Governance Managers Risk Management Sub Committee Changes approved by trust Safety Quality and Standards committee Date February15 January February 15 March 2016 March 2015 February15 January February 15 March 2016

3 Table of Contents 1. Introduction 2. Purpose 3. Roles and Responsibilities 4. Processes and Procedures 5. Monitoring Compliance with the Document 6. References 7. C Page 11 Page 12 Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Template for Policies / Strategies Standard Operating Procedure Template Policy/ Procedure Approval Checklist Policy Consultation & Approval / Ratification process Policy Control including Archiving Policy/Procedures Registration Form Equality Impact Assessment Tool

4 1. Introduction East Cheshire NHS Trust is committed to producing procedural documents of a consistent standard that comply with the recommendations of external agencies by which we are monitored. This Trust Policy on Procedural Documents describes the framework required to achieve this consistent standard throughout the organisation. 2. Purpose The purpose of this document is to provide staff tasked with writing or reviewing a procedural document with a clear approach to developing, presenting and communicating the document appropriately during the consultation phase. It also sets out the method for approval, and awareness raising once the procedural document is operational, with considerations for support and information to supplement its introduction. This policy will be used for both local and corporate policies and procedures, as described in Section 3, for which there is an agreed format and template contained within this policy. 3.0 Responsibilities Chief Executive The Chief Executive has overall responsibility for ensuring that the Trust has appropriate policies in place and that robust monitoring arrangements are in place. Director of Corporate Affairs and Governance Director of Corporate Affairs and Governance has the delegated responsibility for ensuring that appropriate arrangements to ensure robust policy governance across the Trust. Executive Directors All Executive Directors are responsible for ensuring that: a) all policies and procedures produced by a member of their staff meet the requirements specified in this policy; b) staff review and update documents within the prescribed review deadlines; c) if the author of a policy or procedure leaves, or their responsibilities change in relation to a policy or procedure document, that the Policy Administrator is informed as to who the new designated responsible person for that document is. d) any recommendation(s) made by the Risk Management Sub-committee following an audit of a document, is implemented by the author(s); e) Ensuring that pre-approval consultation is appropriate and includes named individuals within the Roles and Responsibilities section f) Ratifying policies within their delegated area of accountability with the exception of Board approved policies. Deputy Director of Corporate Affairs and Governance Deputy Director of Corporate Affairs and Governance has responsibility for the ensuring effective policy governance across the organisation, in line with the Policy on Procedural Documents.

5 This includes ensuring systems are in place for: a) maintaining a master set of documents on behalf of East Cheshire NHS Trust; b) providing advice to authors in relation to consultation with the Health Overview and Scrutiny Committee where the development / review of a document may result in a change in the level or type of service provided by the Trust. c) bringing to the attention of the Director of Corporate Affairs and Governance where the implementation of a document may impact on the Scheme Delegated Powers. d) ensuring version controlled copies are distributed to nominated leads in Service Lines in a manner that can be monitored via: i.e. Portable Document Format version published on the Trust s public website (if applicable). e) maintaining the records of audits undertaken by the Risk Management Sub-committee against this policy. f) chairing the Trust Risk Management Sub-committee g) reviewing the Policy on Procedural Documents every 3 years or as required. h) Providing bi-annual report on activity of Policy Governance to Safety Quality and Standards Committee, as part of the six monthly Risk Management Sub Committee update. Head of Integrated Governance The Head of integrated Governance supports the Deputy Director of Corporate Affairs & Governance, working closely with the Policy Administrator. A quarterly progress report is produced and presented to the Risk Management Sub Committee. Head of Communications, Engagement and Marketing The Head of Communications, Engagement and Marketing is responsible for liaising with the Policy Administrator ensuring that there is a system in place whereby: a) Policies and procedures are published on to the Trust s public website or where appropriate, or an appropriate shared internal document repository. Impact assessments are available on request, where completed. Deputy Directors / Heads of Service / Clinical Directors Deputy Directors / Heads of Service / Clinical Directors are responsible for: a) ensuring that all policies authored by staff within their area of responsibility are developed and reviewed in line with this policy b) for having systems in place to monitor key performance indicators, manage non-compliance and escalate associated risk where appropriate. c) receiving and responding to policy cascades within designated timescales d) the onward cascade to staff, of information regarding newly developed and reviewed documentation received via the Policy Cascade System and maintaining an audit trail of cascade. e) acting as consultees for Corporate policies and procedures. f) ensuring that the Policy Administrator is informed of changes to authorship of documents. g) Ensuring that local service line procedures are developed as required and subject to consultation, approval and ratification by the appropriate committee / sub-committee see policy schedule. Approval must be formally minuted. Policy Administrator The Policy Administrator (Governance Administrator and Subject Access Lead) is responsible for: a) ensuring the Policy Schedule is maintained and presented to the Risk Management Subcommittee for monitoring the activity of documents. b) Support nominated Governance Manager to undertake annual audit of compliance. c) implementing the Policy Cascade System for all newly developed and reviewed procedural documents and highlighting non-response from services to Governance Managers. d) ensuring distribution lists on the Policy Cascade System are maintained and updated e) receiving all ratified policies/documents from authors.

6 f) ensuring policy documents are published on to Trust s website, where appropriate, and ensuring that obsolete versions of documents are removed. g) ensuring the Press and PR Manager is informed of newly developed and reviewed policies/ guidance so that notification of this can be published in the organisation s Team Brief for staff awareness. h) producing reports for the Risk Management Sub-committee highlighting policies which may have exceeded their review dates and any non compliance with the Policy Schedule. i) receiving notification if the author of a policy, procedure or guidelines document leaves or their responsibilities change in relation to a policy, procedure or guideline document. j) maintaining a master set of documents on behalf of East Cheshire NHS Trust Authors Authors of policies and procedures are responsible for: a) ensuring that any document is: written in line with this policy; laid out using the corporate style, with all corporate information completed; impact assessed, for all clinical and operational policies, using the Equality Analysis (Impact Assessment). This should be undertaken prior to writing/updating the policy to ensure that any identified impacts can be addressed in the new policy. obtaining approval for the impact assessment from the trust s Equality and Diversity Lead. appropriately consulted upon prior to being submitted for approval by East Cheshire NHS Trust; including named individuals within roles and responsibilities section and key stakeholders and where appropriate respective Safeguarding Leads for Children and Adults approved / ratified by the Trust Board or relevant body as defined in The Policy Schedule; brought to the attention of the Deputy Director of Corporate Affairs and Governance if the document references, or may impact on, the Scheme of Delegated Powers. b) for contacting the Deputy Director of Corporate Affairs and Governance for advice as to whether the Health Overview and Scrutiny Committee needs to be consulted i.e. where the development/ review of a document may result in a change in the level or type of service provided by the Trust. c) for ensuring that once ratified, documents are forwarded in an editable electronic version to the Policy Administrator for publication on the Trust s website and if appropriate shared internal document repository. This will be accompanied by the following the Policy/ Procedure Registration Form (Appendix 6) and the Equality Analysis (Impact Assessment) (Appendix 7) and the Policy Approval Checklist (Appendix 3). d) for retaining responsibility for reviewing documents they have produced in the event of any of the following: in response to recommendation(s) made by the Risk Management Sub-committee following an audit of the document. in response to recommendations following an incident. by its review date (up to a maximum of five years) or as a result of any of relevant changes in legislation, national or local guidance or policy. Consultees Consultees who may be committee/ group members, patients, staff side, members of the public or other stakeholders and may have an interest in the policy are responsible for providing the author with comments and suggesting amendments within timescales set by the committee/ group.

7 Chairs of Committees/ Groups Chairs of Committees/ Groups who approve documents are responsible for: a) ensuring the Policy Approval Checklist (Appendix 3) is completed prior to document ratification; b) approving consultation outside of set Committee/ Group meetings, in order to meet organisational needs for timely approval; c) signing the checklist to confirm document approved / ratified and sending the checklist to the author(s). Line Managers / Supervisors Line Managers and Supervisors are responsible for: a) bringing to the attention of their staff, the publication of a new document b) retaining evidence that the information relating to a newly developed and amended document has been cascaded within their team / department; c) ensuring the new document is effectively implemented; d) ensuring that their staff attend all training identified in respect of a new document. All East Cheshire NHS Trust Staff Staff are responsible for: a) Accessing the relevant procedural documents as directed by their managers b) Informing their line manager, and where appropriate escalating with the Service Line management team, failure to receive procedural document information as set out in this policy. c) Attending all relevant training as required. East Cheshire NHS Trust Board The Trust Board receives assurance via the Safety Quality and Standards Committee that procedural documents are effectively managed within the organisation, and, where appropriate, approves/ratifies policy documents. Safety Quality and Standards Committee a) The Safety Quality and Standards Committee periodically reviews the Policy Schedule, which is monitored by the Risk Management Sub-committee and provides assurance to the Trust Board. b) The Safety Quality and Standards Committee approves/ratifies policy documents as required. Risk Management Sub-committee The Risk Management Sub-committee is responsible for; a) auditing policy documents to ensure they meet the Policy on Procedural Documents against the policy / procedure approval checklist (Appendix 3). b) reviewing the Policy Schedule, which identifies the responsible committee/ group for the approval and ratification of documents. c) identifying when a document will be subject to review. d) reporting to the Safety Quality and Standards Committee e) monitor the Key Performance Indicators in this policy.

8 4.0 Processes and Procedures 4.1 Scope The scope of this policy includes the following procedural documents; a) Policy A policy can be defined as a high level statement of intent or set of principles with widespread application that provide a basis for consistent decision-making and resource allocation. Policies produced by external authors / organisations may not comply with all standards outlined in this policy. Please note all policies produced by the Trust will be formatted in line with corporate style see appendix 4 b) Procedure or Standard Operating Procedure A procedure can be defined as a standardised method of performing clinical or non-clinical tasks. Procedures, including standard operating procedures, usually have a narrow application and include a series of actions, or detailed instructions, to be carried out in order to achieve a safe, effective and consistent outcome. This policy does not cover the following documents; c) Protocol A protocol can be defined as a rigid statement of practice, which will be adhered to: they allow little flexibility or variation and as such are only suitable for certain, very specific aspects of practice, where the course of action is universal. d) Clinical Guideline/ Guidance A clinical guideline is an evidence-based overview of treatments and diagnostic tests to be undertaken in certain conditions. They are designed to provide advice, guidance and direction to staff whilst leaving room for professional judgment, and adaptation, to fit individual circumstances. To ensure that clinical guidelines are evidence based, support is offered to authors by the Library Services ecn-tr.stafflibrary@nhs.net Once updated guidelines should be sent to policy co-ordination using the registration form (appendix 6). All clinical guidelines are uploaded to the Clinical Guideline page on the infonet. e) Strategies (although the same corporate document format, as at Appendix 1, will be used) A strategy is defined as a plan of action designed to achieve a long-term or overall aim within the organisation. 3.2 Style and format Procedures should be formatted in line with the template contained in Appendix 2. All policies will be in the following format: a) Clearly marked as draft on each page which will be removed when the policy is ratified and published. b) Will be written in Arial size 11 font c) Will have the title of the policy on the front page in Arial size 26 font d) Will have the policy control page completed and this will be the second page of the policy after the front sheet. e) A contents page will be included and all pages numbered (except front page) f) Each page will include a footer detailing in Arial Size 8 Font the name of the author (by designation), version number and date of publication

9 g) The document will be numbered sequentially throughout to identify the section and subsection of text. h) The policy will be set out using the following subsections as a minimum (extra subsections can be added if required), they can be in any order according with particular need but it is recommended that the following order is used to aid with the flow of reading and to ensure standardisation across the Trust: (If writing a procedure the template in Appendix 2 will be followed). Introduction, sets out the reason why the policy is needed Purpose which is a summary of the purpose of the policy and its aims Roles and Responsibilities, which details the responsibilities that employees and committees/ groups have relating to the policy. The policy will clearly state the organisational responsibilities held by employees of the Trust/others with regards to its implementation, monitoring and other duties therein. All job titles will be checked when policies are reviewed to ensure that they remain accurate in title and in responsibility. Processes and Procedures, which this area sets out the scope of the policy and identifies the plans that the Trust has in place to implement the policy. It identifies key features relating to the implementation of the policy such as the competence of staff, safety considerations, communication issues, training requirements Monitoring Compliance with the Policy: this section will clearly state how the performance of the Trust will be monitored following the implementation of the policy. A number of key performance indicators, which are specific and measurable, will need to be identified within the policy against which performance will be assessed. Each Key performance Indicator will identify whose responsibility it is to measure performance, how often this will take place and where assurance will be provided to (named committee / group). This section should also include details of review. State clearly the review arrangements for the policy, when it will be reviewed and who is responsible for undertaking the review. The review will be undertaken by combining the findings of the performance review and audit. These findings will identify any changes required to be made to the policy. References: this section includes links to other related policies, national guidance, web sites or other relevant source of information Appendices and any other referenced documentation required such as definitions of terms used, glossary etc. k) Policies will be drafted in a trust wide context except those that are classified as other procedural documents; these will be fit for purpose. A template for policies is outlined in Appendix 1. l) Policies will state what legal, professional or national guidelines are related to it and/or are drivers for it. Where national guidelines are available these will be incorporated, and duly referenced, or alternatively, the national guideline issued with the control sheet acknowledging the fact. m) Each policy will clearly identify any risks associated with its implementation and use (via the risk assessment process), and any strategies for managing those risks. The policy control document will highlight any risk management issues (which may be clinical or non clinical in nature, including health and safety matters) to be noted by the appropriate Trust risk management groups (the policy schedule identifies the appropriate groups/committees). n) Where policies have the potential to be open to fraud of any nature, an electronic copy of the document will be sent to the Local Counter Fraud Specialist, Roger Causer. Tel Mobile or by using the address roger.causer@miaa.nhs.uk for assessment. Examples of potential fraud include policies with a financial element (e.g. claims policy, procurement policy) or any policy that includes making or signing a declaration. The policy will not be sent for approval/ratification without this being undertaken. This will be indicated on the Policy Control Sheet as part of consultation. o) Policies will identify which manager is to be responsible for maintaining the policy. Job titles will be used.

10 p) In order to avoid confusion over the writing of dates the following style is to be used 25 Dec 11 q) Policies will cross reference clearly to other related policies and procedures r) The first draft copy of the policy will be version 0.1 with all subsequent reviewed/amended draft documents numbered sequentially. The 0 prefix will be maintained throughout the first drafting process in order to show the version. s) The first ratified/published copy of the policy will be version 1.0 t) As policies enter the review process they are then managed as a draft version of the version stated on the policy. All amendments as part of the review process will be numbered sequentially e.g. 1.1, 1.2, and 1.3. The reviewed policy once ratified / published will then become version 2.0 and the process repeated at the next review using sequential numbers. u) Equality Impact Assessment - All clinical and operational policies will be impact assessed to ensure they do not discriminate on the grounds of race, disability, age, sex, sexual orientation, religion or belief, gender reassignment, marriage and civil partnership, pregnancy and maternity, carers and all other relevant groups. Further information is available in the Trust s Equality and Human Rights Policy. Staff should use the demographic data contained within the template assessment tool to identify possible impact. v) A copy of the impact assessment is contained in Appendix 1 and can be downloaded from the internet This document will be placed as the last pages of the policy/procedure. w) Appendix 1 provides a template for the development of policies in the Trust format. This template will be used as a minimum. Extra sections can be added as appropriate depending upon the requirements of the policy/area it covers. In addition there is a standard operation procedure template that is to be used where appropriate. x) In order to ensure that all aspects of this policy are addressed a checklist has been provided for policy writers to assess the policy against in Appendix Definitions of terms used Abbreviations can be used in policy documents providing that it is referenced in full on its first use. A full glossary of terminology should be included for reference where appropriate. 3.4 Consultation process a) East Cheshire NHS Trust is committed to partnership working, and as such encourages the input of both Management and Staff Side representatives into policy development. Whilst one person/role i.e. chair of a group or committee will be identified as the policy lead, perhaps because they have an interest or skill in the subject matter, by working with both a management and staff side representative, a more balanced approach to its development can be achieved. Consultation must include all individuals referred to in the responsibilities section of the policy to ensure that they are aware of their responsibilities and to allow their input / comment on the document. Where there is an operational impact, relevant service lines must also be included in the consultation. Appendix 4 describes the process in use. b) The consultation period must be of sufficient time to allow comment from all relevant individuals.

11 3.5 Policy Approval and Ratification process a) Policies presented for approval will include details of the consultation process followed. This will be included on the policy control page accompanying the policy. Appendix 4 describes the process in use. b) The policy will then be forwarded to the appropriate committee / group (as per the policy schedule) for ratification on behalf of the board. In some circumstances this may be the same as the approving committee/ group. c) Where minor changes are required in a policy or procedure these can be undertaken without the full ratification process. These changes will be brought to the attention of the relevant group/ committee and be noted formally. d) Policies may be ratified outside of committees/ groups by an Executive Director or the Chair of the approving group should this be required. Circumstances where this process may be required include; where a delay in ratifying policy may be detrimental to clinical care, staff or business continuity. 3.6 Procedure Approval and Ratification a) Service Line procedures should be subject to consultation, approval and ratification by the appropriate committee / group in line with Policy Schedule. Approval/ ratification must be evidenced in meeting minutes. 3.7 Communication a) A key part of communicating the policy is raising awareness to all employees that the new policy is now in place and operational in the organisation. This will include the following routes: Consider placing an article in Team Brief/Staff Matters describing the policy, any changes made since the last version, how it will benefit the Trust and when it became operational. It may be appropriate to deliver briefing sessions/ updates for staff and managers to introduce new policies and raise awareness of changes to existing policies. b) Additionally, all updated policies will be cascaded via Datix to nominated cascade leads within each service line for onward cascading to their teams Review arrangements (all policies / procedures) a) Once ratified all policies and procedures will be reviewed in line with the Trust Policy Schedule and as detailed on the policy control page. The frequency of review will depend upon a number of factors namely: what the policy and procedure relates to, the results of performance reviews and audits, the changes in conditions, situations, personnel in the Trust making the review date more frequent, changes in best practice, guidance or legislation and any other factors that may render the policy/procedure out of date. b) The maximum period that may be placed on a review period is five (5) years. c) Three months before the policy/procedure is due to expire, the author will be informed and requested to review, update and re-ratify the document as appropriate. 3.9 Control of the documents including archiving arrangements a) All policies (excluding those for which public disclosure could impact on the business of the Trust) will be available on the Trust s internet site. The author is responsible for sending an electronic copy of the policy, with registration form (Appendix 6) to the address: ecntr.policycoordination@nhs.net approved and ratified by the appropriate committee/ groups (as per the policy schedule).

12 b) An archive of superseded policies will be maintained for 12 years. Clinical Practice Policies relating to Children/Maternity will be retained for up to 25 years Associated documentation and references Many policies and procedures are complex documents designed to deal with complex and sensitive situations. Therefore specific management guidance notes will sometimes be required to supplement the policy, in order to aid its use in operational practice. Guidance notes can be included in the main body of the policy, as an appendix or separate document, but be aware that both will need to be readily accessible together, so that they can be read side by side. The contents page will clearly state the appendices used in the document. Where other guidance documents/information is referenced or where the reader needs to review other policies/documents in conjunction with the policy in question this should be included within the reference list and where appropriate in the Executive Summary Implementation of Policy The policy will be approved and ratified by the Risk Management Sub-committee. There are no formal training requirements relating to the implementation of this policy although staff can obtain guidance from any manager within the Corporate Affairs and Governance Directorate should they have problems/questions when developing their document. 5.0 Monitoring Compliance with the Document 6.1 Compliance with this policy will be monitored against the following key performance indicators: a) number of non-board approved policies that comply with format standards outlined b) completion of equality impact assessment for identified sample of approved policies In addition an annual sample audit will be undertaken to review Trust compliance with the audit requirements with a minimum of 20 policies. This policy will be reviewed on a three yearly basis by the Deputy Director of Corporate Affairs and Governance. 6.0 References This document should be read in conjunction with the policy schedule.

13 Appendix 1 TITLE

14 Policy Title: Executive Summary: Supersedes: Description of Amendment(s): This policy will impact on: Financial Implications: Policy Area: Version Number: Issued By: Author: Document Reference: Effective Date: Review Date: Impact Assessment Date: APPROVAL RECORD Consultation: Approved by Director: Ratified by: Received for information: Committees / Group Date

15 Table of Contents 1.Introduction 2. Purpose 3. Roles and Responsibilities 4. Processes and Procedures 5. Monitoring Compliance with the Document 6. References 7. Communication Page 11 Page 12 Appendix

16 1. Introduction Sets out the reason why the policy is needed. 2. Purpose A summary of the purpose of the policy and its aims. 3. Responsibilities Details the responsibilities that employees and committees/ groups have relating to the policy. The policy will clearly state the organisational responsibilities held by employees of the Trust/others with regards to its implementation, monitoring and other duties therein. All job titles will be checked when policies are reviewed to ensure that they remain accurate in title and in responsibility. 4. Processes and Procedures Sets out the scope of the policy and identifies the plans that the Trust has in place to implement the policy. It identifies key features relating to the implementation of the policy such as the competence of staff, safety considerations, communication issues, training requirements. 5. Monitoring Compliance with the Document Clearly state how the performance of the Trust will be monitored following the implementation of the policy. A number of key performance indicators, which are specific and measurable, will need to be identified within the policy against which performance will be assessed. Each Key performance Indicator will identify whose responsibility it is to measure performance, how often this will take place and where assurance will be provided to (named committee / group). This section should also include details of review. State clearly the review arrangements for the policy, when it will be reviewed and who is responsible for undertaking the review. 6. References This section includes links to other related policies, national guidance, web sites or other relevant source of information. Appendix 1

17 Appendix 2 Standard Operating Procedure Template Title of Standard Operation Procedure: Reference Number: Issue Date: Version No: Review Date: Purpose and Background Scope (i.e. organisational responsibility) Vital functions affected by this procedure: Monitoring Compliance Process to be used for monitoring e.g. audit Responsible individual/ committee for carrying out monitoring Frequency of monitoring Responsible individual/ committee for reviewing the results Responsible individual/ committee for developing action plan Responsible individual / committee for monitoring action plan Escalations (if you require any further clarification regarding this procedure please contact): Consultation: Committees / Group Date Approval Committee Ratified by Committee: Received for information: 21

18 Operating Procedure Additional Information (if appropriate) Back up information (if appropriate) Document Change History Roles and Responsibilities Abbreviations References

19 Standard Operating Procedure Contents listing Section 1: Front Page Information Standard Operating Procedure Number Version Number Dates Approval, authorisation, consultation Purpose and Background Scope Vital Functions affected by procedure Audit Escalations Author Approval Record Section 2: Operating Procedure Section 3: Additional Information Section 4: Procedure Back up Information Document Change History Roles and Responsibilities Abbreviations References

20 Appendix 3 Policy / Procedure Approval Checklist Policy being approved: Date: Reviewed by: Arial Font Format/Content Present in Policy Yes No Comments (state if not applicable) Font size 11 Trust logo on front page Title of policy on front page Policy control page completed Footer of each page details: name of policy, author and date of publication Numbered sequentially Policy statement present containing the objectives of the policy Roles and responsibilities section present Implementation section present Appendices sections as appropriate Manager responsible identified Cross referenced to other documents as appropriate Impact assessment carried out Glossary included as appropriate Appendix 2 Health and Safety Process Flow Chart

21 Appendix 4 Policy Consultation & Approval/Ratification Process Requirement for new policy or review of policy identified. Policy written or reviewed in line with best practice, local and national guidance by identified policy author(s) Consultation: draft policy circulated to identified individual staff/groups for review/comment Comments sent to policy author(s) for possible incorporation in reviewed/new policy The Policy Schedule will identify the appropriate groups or individuals that will need to be consulted or who will be responsible for approval Approval/Ratification: following consultation period and changes to policy, document sent to appropriate group/committee for ratification Minor changes identified by ratifying group Policy ratified Changes made Where no committee/group is able to ratify/approve policy policy sent to Executive Director for ratification/approval Policy control & communication process commences

22 Appendix 5 Policy Control Including Archiving New and Revised Policies 1. Registration Form and new policy received via the ecn-tr.policycoordination@nhs.net address 2. Policy Administrator checks to ascertain if Control Template is completed with approval dates and approved Impact Assessment have been added 3. Policy details are added to the spreadsheet and identifying number is allocated 4. Policy is converted to PDF 5. Policy is saved in a new folder in the Policy shared drive in Word and PDF versions 6. Previous policy is archived by cutting and pasting its folder into the new policy s folder 7. Policy is uploaded under appropriate letter on the internet 8. Registration form returned to author for reference, with upload date added 9. Policy is cascaded via the Datix system to nominated cascaders for each service area and a copy is sent to the associate directors / service leads for information

23 Appendix 6 POLICY / PROCEDURE / GUIDELINE REGISTRATION FORM This form must be used for all new or amended policies, procedures and guidelines, and those to be withdrawn without replacement When completing this form, please refer to the Policy on Procedural Documents available on the Trust internet website, policy section, listed under Procedural Documents 1. Author information for new or amended document Name: Job Title: Service/Dept: Service Line: Telephone: address 2. Is this document a.. (Please type YES next to the correct option) Policy Procedure Clinical Guideline Other.. 3. New or Amended Document Information a Title of document: Please send to ecn-tr.policycoordination@nhs.net b c d e f g h i Effective date Review date Is this a new or reviewed document? To enable accurate archiving of superseded document to take place please complete this section if reviewed. Which committee / group approved this document? Please attach a copy of the minutes as evidence. Is this document one of the small number which should NOT be displayed on the Internet (authors of relevant policies will be aware of this restriction). Please clarify the order of wording to be used when listing the document title on the Internet. Maximum 7 words. Keyword metatags for searching: New Reviewed Superseded document FULL title: Superseded document number (if known): Yes No Rational for Restricted Publication: j Name: POLICIES ONLY - To enable efficient cascade of this policy please state the target groups. Date:

24 Please make sure you include the following as part of the document, without them it cannot be processed: 1. Control Sheet including the Review Date 2. For clinical and operational policies - how any identified adverse impacts will be managed should be included in the policy Approved Equality Assessment Form. For approval contact the Trust s Equality and Diversity Lead lynbailey@nhs.net 3. Document Checklist 4. Withdrawal Without Replacement a Title of Policy/Procedure/ Guideline & Number if known b Reason for document withdrawal c Name of committee that has approved withdrawal, without replacement Name of Applicant Date Please send your completed form with new or updated document to: ecn-tr.policycoordination@nhs.net or call Extension 3823 A copy of this document, with document control section completed, will be ed to the person named in (1), as confirmation that the required action has been undertaken. Document Control (Governance staff only) New /Amended Policies / Procedures / Guidelines Date received Policy Number allocated Date uploaded to Internet (confirmation will be sent to author) Withdrawn Policies / Procedure / Guidelines Date received Date removed from Internet (confirmation will be sent to author)

25 Appendix 7 Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Policy on Procedural Documents Details of person responsible for completing the assessment: Name: Lorraine Jackman Position: Deputy Director of Corporate Affairs and Governance State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc. which have shaped or informed the document) This policy provides guidance to authors of policies and procedures and staff in the Trust regarding the template for all Trust policies and procedures. This document when followed will assist the Trust in meeting its responsibilities with regards to effective risk management. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common

26 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC. 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?)

27 No staff have indicated that this policy is welcomed and supportive. The policy itself highlights and promotes a requirement for all policies and procedures to be impact assessed in relation to all aspects of possible discrimination. 2.3 Does the information gathered from indicate any negative impact as a result of this document? No 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No X Explain your response: This policy states that an equality analysis (impact assessment) must be carried out and relevant groups consulted. This will have a positive impact in identifying any adverse impacts on any protected group. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No X Explain your response: This policy states that an equality analysis (impact assessment) must be carried out and relevant groups consulted. This will have a positive impact in identifying any adverse impacts on any protected group DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes No X Explain your response: This policy states that an equality analysis (impact assessment) must be carried out and relevant groups consulted. This will have a positive impact in identifying any adverse impacts on any protected group AGE:

28 From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No X Explain your response: This policy states that an equality analysis (impact assessment) must be carried out and relevant groups consulted. This will have a positive impact in identifying any adverse impacts on any protected group LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes No Explain your response: - RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes No X Explain your response: This policy states that an equality analysis (impact assessment) must be carried out and relevant groups consulted. This will have a positive impact in identifying any adverse impacts on any protected group CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes No X Explain your response: This policy states that an equality analysis (impact assessment) must be carried out and relevant groups consulted. This will have a positive impact in identifying any adverse impacts on any protected group OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No X Explain your response: This policy states that an equality analysis (impact assessment) must be carried out and relevant groups consulted. This will have a positive impact in identifying any adverse impacts on any protected group- 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes No X b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on

29 children Policy provides a governance framework for the Trust policies and procedures and does not relate to patient care. 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? Consultant has taken place with the following staff groups: Heads of Service, Governance Managers, Risk Management Sub-committee. This includes staff who develop policies and have a role in ratifying and implementing policies in their service areas. 6. Date completed: January 2015 Review Date: January Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 8. Approval At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date:

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