Policy: P3 - West London Mental Health NHS Trust€¦ · Policy P3 First Date of Issue: January 2003 This is current version P3/10 February 2015 Version: P3/10 Ratified by: Trust

West London Mental Health NHS Trust Page 1 of 26 Policy P3 First Date of Issue: January 2003 This is current version P3/10 February 2015

Version: P3/10

Ratified by: Trust Management Team

Date ratified: 11th February 2015

Name and Title of Author: Policy Administrator

Accountable Director: Medical Director

Governance Committee: Trust Management Team

Date issued: 27th February 2015

Review date: February 2018

Target audience: All staff Trust wide

Disclosure Status B Can be disclosed to patients and the public

EIA N/A

Sustainability form

Other Related Documents SFI

Policy: P3

Policy Development Implementation

Monitoring & Review


Equality & Diversity Statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all relevant policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed.

Sustainable Development Statement

The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed.


P3 – Policy Implementation Monitoring and Review Version Control Sheet

Version Date Title of Author Status Comment

P3/01 Jan 03 Board Secretary N/A New Policy

P3/02 Oct 07 Board Secretary ED 11.10.07 Substantial revision

P3/02 15/10/07 Board Secretary consultation 8 week consultation ends 7th Dec 07

P3/03 04/01/08 Board Secretary Revised Policy in circulation

P3/04 23/11/2010 Board Secretary and Policy Review Group

Revised Policy issued

Substantial revision to the Policy content. Revised Policy as a working document from 6th Aug 10 - under consultation until 3rd Sept 10 Policy Presented to 22nd November Policy Review Group for Approval – approved.

P3/05 09/02/2011 Board Secretary and Policy Review Group


Jan 11 Policy revised to include the use of “Working Documents”. Presented to 31st Jan 11 Policy Review Group for approval – approved.

P3/06 To be inserted

Deputy Director of Nursing

Revised policy issued

Sep 11. Substantial policy revision to facilitate NHSLA level 2 achievement, remove reference to the Policy Review Group, give absolute responsibility to ED’s and governance groups for policy approval, dissemination, implementation and monitoring. To be submitted to 14th Sept TMT for approval To be resubmitted to October TMT for approval 2011

P3/06 12.10.2011 Trust Management Team


12th October 2011 Policy approved by TMT

P3/07 13.03.2012 16.03.2012

TMT TMT

Revised Revised following NHSLA Assessors visit and advice. Ratified by TMT on 14th March 2012

P3/08 17.10.12 TMT Revised Minor amendment made to comply with NHSLA Assessment. To be presented at October TMT for approval.

P3/09 20.09.13 Planning, Policy & NHSLA Lead

Revised Revised process agreed for a 6 month pilot

P3/10 Policy Administrator Revised Policy Revised to reflect process changes


Contents

Section Page

1 Flowchart 5

2 Introduction (including purpose) 6

3 Scope 6

4 Definitions 6

5 Duties 6-9

6 Systems/Documentation 9

7 Content, Style and Format 9

8 Consultation 10

9 Policy Approval 11

10 Policy Review 11

11 Document Control including Archiving Arrangements 12

12 Equality Impact Assessment & Sustainable Development Impact Assessment

12

13 Dissemination and Implementation 13

14 Training 13

15 Monitoring 13

16 Fraud Statement 14

17 Review Cycle 14

18 Glossary of Terms/Acronyms 14

19 References (External) 14

20 Associated Documents (Internal) 14

Appendices

Appendix 1 Policy Template 15-22

Appendix 2 Trust Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions

23

Embedded documents on Front Sheet

Sustainability Screening


1. FLOWCHART - WLMHT POLICY DEVELOPMENT / REVIEW PROCESS

Policy administrator sends the policy author the: (i) current policy; (ii) instructions on How to Write a Policy and the expected content (general headings); (iii) EIA template, if required; (iv) Sustainability screening template, if required; (v) planned date when the draft policy should be placed on Exchange for consultation; and (vi) planned date when the draft policy should be presented to TMT for ratification.

Exchange notifies policy administrator and ED that a policy is due for review in 6 months

(a) Policy author drafts policy and presents it to the responsible Board sub-committee for its comments and its approval for consultation

(b) Policy Author completes EIA (if required) and obtains the Diversity Lead’s approval of the completed form

(c) Policy Author completes Sustainability form (if required) and obtains the Sustainability Manager’s approval of the completed form

(d) Policy Author sends approved draft of the policy and evidence of sub-committee’s approval to policy administrator for Exchange consultation

Policy Author sends final policy draft to responsible Board sub-committee for its approval

Policy Administrator puts policy out for 2-4 weeks consultation on the Exchange

Following consultation completion, Policy Administrator returns draft policy plus any comments received during consultation to Policy Author

(i) Policy Author revises policy to incorporate relevant comments received during consultation.

(ii) Policy author writes to staff who have commented to let them know if their comments were incorporated and, in particular, if not, why not

Policy Author obtains approval from Responsible Executive Director (ED) to present policy to TMT for ratification, completes ‘Policy sign-off’ and ‘Policy significant changes’ cover sheets

and sends policy plus the completed ‘sign off’ and ’cover sheet’ to Policy Administrator

Responsible ED presents policy to TMT for ratification and, subsequently, informs Policy Administrator of the outcome

Policy administrator uploads ratified policy onto Exchange, communicates to Monday Matters and uploads on to Trust website at www.wlmht.nhs.uk

http://www.wlmht.nhs.uk/


2. INTRODUCTION 2.1 This document provides a framework for the formation, control and distribution of all

Trust policies, associated procedures and supporting documents (collectively known as ‘policy and procedural documents’) to ensure consistency across the Trust.

2.2 This policy should be read in conjunction with the policy guidance which details how to

develop and write a policy using the template and headings. 2.3 Copies of current Trust-wide policies, procedures and supporting documents can be

obtained either from the Trust intranet (the Exchange) or from the Trust website. 2.4 Copies of previous versions of Trust-wide policies, procedures and supporting

documents can be obtained from the policy administrator.

3. SCOPE 3.1 This policy applies to all Trust procedural documents, clinical or non-clinical. A

procedural document can be a policy, procedure, guideline or standard.

4. DEFINITIONS

Policy A Policy is a statement of the principles and aims that underpin a practice.

Procedure A Procedure describes a process that must be followed without deviation. Guideline A Guideline is a description of a ‘best practice’ way to work.

Standard A Standard is a measurable target for achievement and must be based on

evidence.

Definitions should be listed in all procedural documents where there may be ambiguity

5. DUTIES

5.1 Board 5.1.1 The Board has overall responsibility for ensuring robust documentation describing

governance arrangements for approving policy and strategy documents as prescribed in the Trust Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions (see Appendix 2).

5.2 Executive Director 5.2.1 Named Executive Directors are accountable for overseeing the development, approval

and implementation of policy and procedural documents that fall within their portfolio ensuring those documents contain practical guidance on key Trust practices and reflect good and best practice. These duties may be delegated to a named CSU/ Directorate group, but the Executive Director will remain accountable.


5.2.2 For those policies for which they are responsible, the responsible Executive Director will appoint a policy author to either write a new or revise an existing policy.

5.2.3 The Medical Director is the Executive Director responsible for this Policy 5.3 Policy Author 5.3.1 The policy author is responsible for developing or reviewing a policy or procedural

document. 5.3.2 The policy author will receive a ‘policy pack’ from the policy administrator and will ensure

all the documentation is completed within the suggested deadlines, particularly those that relate to the dates for consultation on the Exchange and those for ratification by TMT meeting. The policy pack will include a ‘Policy Author’s checklist’ (see appendix 3) and a ‘Policy - Significant Changes’ sheet (see appendix 4), both of which should be completed in the course of the policy/ document review and, once completed, returned to the policy administrator (see para 5.3.8, below).

5.3.3 The policy author will review and update the policy and present the draft revised policy to

the responsible board sub-committee for its comments and its approval to put the draft revised policy out for wider consultation.

5.3.4 The policy author will update the policy and send to the policy administrator the final draft

policy for consultation on the Exchange. 5.3.5 The policy author will decide to which individuals and Trust groups (e.g. ‘Service User &

Carer Experience sub-committee’) the draft policy should be presented for consultation and will make their own arrangements to present the policy to those groups and individuals for consultation.

5.3.6 Following the end of the Exchange consultation period, where possible, the policy author

will feed back to all those people who made comments during the consultation and inform them whether the policy will be revised to take into account their comments or if not, why not.

5.3.7 The policy author will then revise the policy and send this next draft of the revised policy back again to the Board sub-committee for its approval.

5.3.8 Following receipt of the Board sub-committee’s approval, the policy author will present

the draft policy to the responsible executive director (ED) for his/her approval to present the draft revised policy to TMT for ratification. If, at this stage, the ED makes further changes to the policy, the amended policy must be sent back to the Board sub-committee for its approval of the changes.

5.3.9 Following receipt of ED approval, the policy author will complete both the ‘Policy sign-off’

and the ‘Policy significant changes’ sheets and send the policy plus the completed ‘Policy sign off’ and ’Policy significant changes’ sheets to the policy administrator.


5.4 Trust Management Team 5.4.1 The Trust Management Team (TMT) is responsible for the ratifying all Trust-wide

policies, except those for which Board are response, as specified in the Trust Standing Orders/ Standing Financial Instructions. In the course of ratifying a policy, TMT will confirm both the Board sub-committee responsible for the policy (see para 5.5 below) and the ED responsible for the policy.

5.5 Board sub-committees 5.5.1 The Board sub-committee to which TMT has allocated a policy is responsible for being

consulted on and, subsequently, endorsing the content of a relevant policy, procedure or guidance document.

5.5.2 Also, the responsible Board sub-committee is responsible for monitoring compliance with

a policy e.g. by receiving periodic reports from a person nominated by the responsible ED to provide such a report. The responsible Board sub-committee should insert in its workplan the future dates when it is due to receive compliance monitoring reports for the various policies for which it is responsible.

5.6 Clinical Service Units (CSUs) 5.6.1 Each CSU is responsible for ensuring any of its own CSU-wide policies and procedures

are kept current, are reviewed by their due date and have been ratified by their own CSU SMT.

5.6.2 Also, each CSU is responsible for distributing all Trust-wide policies to its CSU staff,

ensuring it has in place suitable arrangements for policy implementation, for monitoring compliance with those policies and for reporting on that level of compliance.

5.7 Policy Administrator 5.7.1 The policy administrator is responsible for administrating the Trust policy development,

management and review process, as described in this document. 5.7.2 Upon receipt of an Exchange alert identifying a policy as due for review in four months

(or, for new policies, once notified of the name of the policy author) the policy administrator will send the policy author a ‘Policy Pack’ containing the: (i) current policy; (ii) instructions on How to Write a Policy and the expected content; (iii) EIA template, if required; (iv) Sustainability screening template, if required; (v) planned date when the draft policy should be placed on Exchange for consultation; and (vi) planned date when the draft policy should be presented to TMT for ratification.

5.7.3 For each of their meetings, the policy administrator will provide each Board sub-

committee with details of the current status of each of its policies e.g. policies due for imminent review, policies out for consultation and policies in progress.

5.7.4 On a monthly basis, the policy administrator will send to each CSU/ Directorate SMT

details of newly-approved policies, any changes to policies and policies under consultation.


5.7.5 The policy administrator will work with a policy author to ensure a policy complies with this process and that the policy author meets the deadlines for policy review, consultation and final approval.

5.7.6 The policy administrator will upload approved policies, procedures and guidelines onto

the Exchange and the Trust website (www.wlmht.nhs.uk) and, also, liaise with the Communications Department to keep staff notified of policy changes e.g. via Monday Matters.

5.7.7 Once a policy or procedure is updated, the previous version will be placed in an archive,

which is maintained by the policy administrator.

5.8 Staff Side 5.8.1 Staff side, through the Terms and Conditions subgroup of the Trust Partnership Forum,

in particular, will assist in the development and review of HR policies and promote consultation on those policies.

5.9 Diversity Lead

The Diversity Lead is responsible for approving the Equality Impact Assessment (EIA) for any policies that require an EIA to be carried out. The consultant will liaise, if necessary, with a policy author and approve any associated Equality Impact Assessment (EIA) form, once they are satisfied the form has been completed correctly.

5.10 Sustainability Manager

The Sustainability Manager is responsible for approving the Sustainability Form for any policies that require a sustainability assessment to be carried out. The Sustainability Manager will liaise, if necessary, with a policy author and approve any associated Sustainability form, once they are satisfied the form has been completed correctly.

5.11 All Staff

All staff have a responsibility to review policies that are out for consultation and to comment. All staff must ensure they are familiar and comply with any policies that are applicable to their posts.

6. SYSTEMS / DOCUMENTATION

6.1 Staff can access all policies, procedures and guidelines either via the Exchange or, if

they do not have access to the Exchange, via their manager. Searches, using the policy search engine, are best carried out by using minimal criteria e.g. to find ‘M12 Mandatory Training’ policy, search using the word ‘Training’ only.

6.2 Staff and public can also access ‘policies’ (only those policies that are disclosable to the

public) via the Trust website www.wlmht.nhs.uk 6.3 Archived policies, procedures and guidelines can be obtained only from the Policy

Administrator




7. CONTENT, STYLE AND FORMAT 7.1 All policy and procedural documents must be typed in Arial 12 point not aligned, and

with main content headings in bold Arial 14. Sub-headings should be in Arial 12 point and underlined. Page numbers should be numbered and the total number of pages in the document stated. All paragraphs must be numbered.

7.2 All policy and procedural documents should be written in Plain English in a style which is

concise and clear using unambiguous terms and language. Acronyms should be avoided but if used a Glossary must be included with acronyms described. Documents should be short and streamlined. Where possible every policy should start with a process flowchart to include timescales, systems and responsibilities. Where a flowchart is not appropriate then a summary page with key bullet points will suffice.

7.3 In order to ensure that policy documents have a consistent corporate format and

appearance, a standard template must be used for all policies. Current templates are available on the Exchange by selecting “Governance & Risk”, “Policies and Procedures” and then under “Useful Resources select “Templates”. The standard headings must not be deleted. All sections must be completed – use N/A (not applicable) where relevant. Associated Trust documents should be referenced where applicable.

7.4 All new policies will be given a unique reference, which must be obtained from the Policy Administrator. When existing policies are being revised, the next reference number in the sequence will be used e.g. ‘P3/09’ will be followed by ‘P3/10’.

8. CONSULTATION

8.1 Following approval by the responsible Board sub-committee, formal consultation on a draft policy will take place both via the Trust intranet (The Exchange) and directly with appropriate internal and external stakeholders. Those stakeholders are likely to include:

other Board sub-committees, Trust groups and CSU Senior Management Teams

Trust staff via CSUs and Trust Exchange

Trust Partnership Forum and Terms and Conditions subcommittee

Service Users

Specialist advisors e.g. HR professionals

Trust partners, such as the local authority

Commissioners 8.2 The policy author, in discussion with the Executive Director if necessary, will determine

the period of consultation if outside of the recommended times. Formal consultation may not be required if the amendment(s) relates only to changes in legislation or very minor changes that have no impact on the policy process.

8.3 Following a formal period of consultation on the Exchange the policy will be returned to

the author along with any comments added. Where feasible, the policy author will write to any staff or individuals who have commented on the draft to let them know if their comments were incorporated or, if not, the reason why.


8.4 Table A below provides details of consultation periods.

Table A

Description Consultation Period

Policy with minimal changes 1-2 weeks

New Policy or revised policies on a 3 year cycle 4 weeks

8.5 In exceptional circumstances, the TMT will approve a draft policy as a ‘Working

Document’, i.e. prior to full ratification, for the purposes of ensuring the risk which the policy is intended to address, continues to be effectively controlled. Eg MAPPA Policy. A ‘Working Document’ must be reviewed within 6 months.

8.6 In cases of mandating national directives or legislation, consultation may not always be deemed necessary.

9. POLICY APPROVAL 9.1 The Responsible Executive Director has overall accountability for policies which fall

within their portfolio. The responsible Board sub-committee for a policy, or one of the sub-committee’s sub-groups, should discuss, review and approve a policy before its final ratification by TMT.

9.2 Table B below describes the approval Groups / Committees

Table B

Policy category Approved by

Policies prescribed in Trust Standing Orders/Standing Financial Instructions

Board

Trust-wide policies (other than those stated in the category above)

Trust Management Team

Directorate-specific, Clinical Service Unit (CSU)-specific or service-specific policies, procedures, guidelines and standards check links to parent policies

CSU Senior Management Team

Trust-wide procedures and guidelines Trust Board sub-Committees and their sub-groups


10. POLICY REVIEW

The following applies to all policy and procedural documents, 10.1 New Policy

For new policies. the review date will be three years unless otherwise stated. 10.2 Existing Policy 10.2.1 Planned Reviews – Trust-wide Policies

The Exchange will automatically notify the Policy Manager/Administrator and the Executive Director 6 months prior to a policy review date expiring. The Policy Administrator will send the policy author the current policy, an EIA and/or sustainable screening form (if required), guidance on how to complete the policy documentation and dates when the policy is required for consultation and for ratification by the TMT, (see Flowchart). For any queries or requests for a new policy author the policy manager will liaise with the Executive Director.

10.2.2 Unplanned or Interim Reviews – Trust-wide Policies:

The responsible Executive Director (either themselves or following a recommendation by the responsible Trust Board sub-committee/sub group etc.) may identify the need to alter a policy prior to its scheduled review date. In such circumstances, the Policy Administrator will use the ‘check out’ process on Exchange and will follow the usual ‘policy review’ process. The next date of review for such policies may remain the original review date or change to three years from the date of review. The Executive Director will decide on the new review date, dependent on the change that was required to the policy.

11. DOCUMENT CONTROL, INCLUDING ARCHIVING ARRANGEMENTS

The following applies to all procedural documents. 11.1 Register/Library of Policy Documents

To ensure all staff have access to current documents, the Policy Administrator will ensure all current versions of Trust-wide policies, procedures and guidelines are available on the Trust Intranet (The Exchange), with superseded versions archived. Only policies are published on the Trust website www.wlmht.nhs.uk

11.2 Archiving Arrangements

The Policy Administrator is responsible for archiving Trust-wide and service specific documents as well as maintaining a record of all archived policy documents. Master (hard) copies of the archived documents which are not available electronically will be stored within the Governance Team and available via the Policy Administrator.

12. EQUALITY IMPACT ASSESSMENT AND SUSTAINABLE DEVELOPMENT IMPACT ASSESSMENT



12.1 Equality Impact Assessments (EIAs) are completed to demonstrate that the Policy has been reviewed to ensure that different groups are not placed at a disadvantage relative to other groups. This is not a legal requirement but is considered good practice. The Diversity Consultant has issued a recommended policy list where an EIA must be completed. This list can be found on the Exchange ‘Policies & Procedures’ webpage.

12.2 As part of the policy review process, the Policy Author will review the existing EIA to

ensure it is adequate. Once the final draft of the policy is ready, the policy author should sign it and sent it to the Diversity Lead who will review the EIA and, if it is adequate, approve it. The approved EIA and the final draft of the policy should be submitted to the appropriate Board sub-Committee or sub group.

12.3 It is a policy authors’ responsibility to ensure that a policy has an approved EIA prior to

the policy’s submission to TMT for ratification 12.4 For all new policies and policy reviews, the policy author will undertake a Sustainable

Development Screening Assessment, if appropriate, to determine if the policy and resulting actions it delivers may impact on the Trust in terms of sustainable development. This is not a legal requirement but is considered best practice. A list of policies which are likely to require a sustainable screening form is available on the Exchange ‘Policies & Procedures’ webpage.

13. DISSEMINATION AND IMPLEMENTATION 13.1 Once policy documents have been approved, they are placed on the Trust Intranet (The

Exchange), WLMHT external website and communicated to the Communications Team for Monday Matters by the Policy Administrator. The Policy Administrator will also send a policy report to the CSUs/Directorates every month for their SMT meetings with details of policies out for consultation and list of policies which have been ratified by the TMT. Policies are a routine agenda item on SMT meetings and will then be cascaded down via CSU Governance Groups or Directorate team meetings

13.2 The Policy Author will take responsibility for ensuring the policies are implemented and

monitored in each CSU / Directorate. They will contact the relevant CSU / Directorate lead dependant on the content of the policy e.g. HR policies would be the Directorate / CSU HR Business Partner, Clinical Practice Policies would be the CSU Clinical Lead or Senior Nurse, dependant on the policy.

13.3 The CSU Director has overall responsibility for policy implementation within their unit but

the policy leads are responsible for ensuring the systematic implementation and compliance of policies and procedures within their area and collating and storing monitoring reports. This should be done via agreed processes in each Clinical Service Unit.

13.4 The relevant Board sub-committee or sub group will receive routine reports in relation to

policy compliance monitoring and, in the event of finding instances of prolonged non-compliance, will report the matter to the Executive Director, who will ensure that


appropriate action is taken both to correct any shortcomings and to ensure future policy compliance.

14. TRAINING 14.1 The policy author must detail in a policy whether (mandatory or optional) training is

available to those who are required to comply with a policy’s requirements and, if so, from where the training can be obtained.

14.2 There is no training available to assist users comply with the requirements of this policy. Any advice needed on how to comply with the requirements of this policy, in the first instance, should be directed to the policy administrator.

15. MONITORING 15.1 Every policy must contain details of how compliance with that policy’s particular

requirements will be monitored. 15.2 Those details should include:

(i) how the monitoring will be carried out; (ii) who will do the monitoring; (iii) the frequency of monitoring; and (iv) to whom the monitoring results will be presented.

15.3 Compliance with the requirements of this policy with be monitored by the Head of Risk,

Health and Safety randomly several policies that have been developed in the course of the year (their content, style, format, consultation carried out, completion of a Policy Author ‘sign-off’ sheet, ratification, etc) and presenting a report of his findings to TMT.

16. FRAUD STATEMENT N/A 17. REVIEW CYCLE

This policy will be reviewed every three years unless agreed otherwise by TMT.

18. GLOSSARY / ACRONYMS

EIA Equality Impact Assessment NHSLA National Health Service Litigation Authority TMT Trust Management Team CSU Clinical Service Unit HR Human Resources Trust Intranet The Exchange SMT Senior Management Team ED Executive Director


19. REFERENCES

Health and Social Care Act 2001 The Race Relations Act 1976 (as amended by the Race Relations (Amendment) Act 2000) The Disability Discrimination Act 1995 amended 2005 The Gender Recognition Act 2004 The Civil Partnership Act 2004 Employment Equality (Religion or Belief) Regulations 2003 Employment Equality (Sexual Orientation) Regulations 2003 Sex Discrimination (Gender Reassignment) Regulations 1999 The Human Rights Act 1998 The Sex Discrimination Act (as amended) 1975 The Equal Pay Act (as amended) 1970 Promoting Equality and Human Rights in the NHS - A Guide for Non-Executive Directors of NHS Boards (2005) Department of Health Mental Health Act 1983 and Mental Health Act 2007 Mental Capacity Act 2005 Data Protection Act 1998 Freedom of Information Act 2000 Climate Change Act 2008 NHS Sustainable Development Strategy – Sustainable Development in the NHS

20. ASSOCIATED DOCUMENTS

F2 Fraud Policy I5 Information Governance Policy SFI West London Mental Health NHS Trust current Standing Orders,

Reservation and Delegation of Powers and Standing Financial Instructions (this is the Trust associated document audit tool


Policy: Insert Policy no.

Insert Policy Name

APPENDIX 1

Version:

Ratified by:

Date ratified:

Title of Author:

Title of responsible Director

Governance Committee

Date issued:

Review date:

Target audience:

Disclosure Status A Not to be disclosed to patients or the public or B Can be disclosed to patients and the public

EIA / Sustainability

Other Related Procedure or Documents:

Insert Policy Number


Equality & Diversity statement

The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all relevant policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed

Sustainable Development Statement

The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed


Policy Name & Number

Version Control Sheet

Version Date Title of Author Status Comment


Content Page Nos

1. Flowchart

2. Introduction (includes purpose)

3. Scope

4. Definitions

5.

5.1

5.2

5.3

5.4

5.5

Duties

Chief Executive

Accountable Director

Managers

Specific Staff for Policy

All Staff

6. Systems and Recording

7. Process Heading

8. Process Heading

9. Process Heading

10. Training

11. Monitoring

12. Fraud Statement (if required)

13. References

14. Supporting documents

15. Glossary of Terms/Acronyms

16. Appendices


1. FLOWCHART

Insert

2. INTRODUCTION

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3. SCOPE

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4. DEFINITIONS

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5. DUTIES

5.1 Chief Executive

The Chief Executive is responsible for ensuring that the Trust has policies in place and complies with its legal and regulatory obligations.

5.2 Accountable Director

The accountable director is responsible for the development of their allocated policies. They must also contain all the relevant details and processes as per P3. They are also responsible for trust-wide implementation and compliance with the policy.

5.3 Managers

Managers are responsible for ensuring policies are communicated to their teams / staff. They are responsible for ensuring staff attend relevant training and adhere to the policy detail. They are also responsible for ensuring policies applicable to their services are implemented.

5.4 Policy Author

Policy Author is responsible for the timely development or review of a policy as well as ensuring the implementation and monitoring is communicated effectively throughout the Trust via CSU / Directorate leads and that monitoring arrangements are robust.


5.5 Local Policy Leads

Local policy leads are responsible for ensuring policies are communicated and implemented within their CSU / Directorate as well as co-ordinating and systematically

filing monitoring reports. Areas of poor performance should be raised at the CSU / Directorate SMT meetings.

5.6 Specific Staff for Policy

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5.7 All Staff

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6. SYSTEMS AND RECORDING

6.1 Where recorded

6.2 When recorded

6.3 Recorded by who

7. PROCESS

7.1 Process Heading

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7.2 Process Heading

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7.3 Process Heading

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8. PROCESS

8.1 Process Heading

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8.2 Process Heading

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8.3 Process Heading

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9. PROCESS

9.1 Process Heading

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9.2 Process Heading

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9.3 Process Heading

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10. TRAINING

Start typing here (also include reference to M12 Training Needs Analysis where

applicable)

11. MONITORING

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12. FRAUD STATEMENT

Not applicable to all policies (N/A)


13. REFERENCES (EXTERNAL DOCUMENTS)

This policy should be read in conjunction with the following:

Xxxxxxx

Xxxxxxx

14. SUPPORTING DOCUMENTS (TRUST DOCUMENTS)

Xxxxxxx

Xxxxxxx

15. GLOSSARY OF TERMS / ACRONYMS

16. APPENDICES.

Appendix 1

Appendix 2


APPENDIX 2

Standing Financial Instructions

SFI (please follow link)

http://theexchange/sorce/apps/sorce_doc_manager/Actions/view_doc.asp?docid=37781&revid=39939


Appendix 3

Policy Author checklist

Yes No Comments

1

Have you put the policy in the most up-to-date format, ensuring that all

sections of the template have been completed, and no sections have

been removed (see P3 template)?

2Have you correctly numbered the policy version, ensuring it Is the next

consecutive policy version to the one currently on the Exchange

3

In preparing (or reviewing) this policy, which Board sub-committees /

governance groups have you consulted and when? (tick as appropriate)

If none, please state why

(If none, please state why here)

Date consulted

Board

Finance & investment

Quality Assurance

Trust Management Team

High Secure CSU SMT

Specialist & Forensic CSU SMT

Local Services CSU SMT

Patient Safety & Safeguarding

Service User & Carer Experience

Medicines Management

Trust Partnership Forum

Physical Healthcare Meeting

Safeguarding Adults

Safeguarding Children

Trust Records & Information Governance Group

Informatics sub-committee

Infection Control & Patient Environment Group

4

Has the document been out for consultation on the Exchange?

(Contact Caroline Maben if this has not yet been done and you want this to happen)

If not, please state why

5

Have you incorporated, as necessary, any feedback that you received

from the consultations and provided feedback to those who made

comments?


6

Have you completed the 'Monitoring' section of the policy in accordance

with the instructions of the Responsible Board sub-committee?


7

Does this version of the policy have an associated approved Equality

Impact Assessment i.e. which has been approved by the Diversity

Department?


NB Approved Equality Impact Assessments that were carried out on previous versions

of the policy are not acceptable

8

Does this version of the policy have an associated approved Sustainable

Development Screening Template i.e. which has been approved by the

Sustainable Development Manager?


NB Approved Sustainable Development Screening Templates that were carried out on

previous versions of the policy are not acceptable

9

Have you received Executive Director approval of the final draft of the

policy/ document?

If yes, please state when and if not, please state why

10

Have you prepared and attached to the final draft of the policy the sheet

summarising the key changes to the previous version of the policy?


POLICY AUTHOR POLICY REVIEW/ COMPLETION CHECKLIST


Appendix 4

‘Policy – significant changes’ template

1. Policy title

2. Policy version number

3. Policy Author

(a) Scope

(b) Definitions

(c) Duties

(d) Systems and recording

(e) Processes

(f) Training

(g) Monitoring

SIGNIFICANT CHANGES MADE TO THIS POLICY

e.g. None

e.g. Head of Risk, Health and Safety

e.g. Policy Development, Implementation, Monitoring, and Review, P3

e.g. None

e.g. P3/10

4. Significant changes made to the various policy sections:

(if 'none', write 'none')

e.g. (i) Deletion of reference to the Policy Manager post and any associated

duties

(ii) Responsible Executive Director and Policy Author now responsible for

aranging draft policy sub-committee consultation and draft policy TMT

ratification

(iii) Head of Risk, Health and Safety responsible for monitoring compliance with

this particular policy requirements, reporting findings to TMT, the Responsible

Committee

e.g. None

e.g. (i) Responsible Executive Director and Policy Author between them now

responsible for aranging consultation on this draft policy (and, from now on, any

and all policies) with any sub-committees or groups and, also, responsible for

arranging TMT ratification of this draft policy (and, from now on, any and all

policies), keeping the Policy Administrator informed of the consultation and

ratification outcomes

(ii) Implementation Plan template no longer required

(iii) Monitoring template no longer required. The arrangements for monitoring

compliance with the requirement of this policy (and, from now on, any and all

policies) are now described within the policy, in the 'Monitoring' section of the

policy

e.g. None

e.g. New and full policy requirements monitoring arrangements inserted