The web version of this document is the only version that is maintained. Any other copies should therefore be viewed as ‘uncontrolled’ and as such, may not necessarily contain the latest updates and amendments.

DOCUMENT CONTROL

Version: V8.4

Ratified by: Covid-19 Gold Command

Date ratified: 7 April 2020

Name of originator/Author: Director of Corporate Assurance

Name of responsible committee/individual:

Director of Corporate Assurance

Unique Reference Number: 270

Date issued: 21 May 2020

Review date: March 2020

Target Audience Board of Directors; Accountable Directors; Procedural Document Authors; Chairs of Policy approval groups with delegated authority for approval of procedural documents; and, any other individual or group with a responsibility for developing procedural documents

Description of change Due to the Covid-19 Pandemic Gold Command agreed a review extension from September 2020 to March 2021

Policy and Procedural Documents (Development and Management)

Policy

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Section

CONTENTS

Page No

Procedural Document Approval Journey/Flow Chart 3

1. Introduction – the importance and role of all procedural documents

4

2. Purpose and rationale for the development of the policy 4

3. Scope 5

4. Responsibilities, accountabilities and duties 5

5. Procedure for the development of trust procedural documents

13

6. Training implications 20

7. Monitoring arrangements 21

8. Equality impact assessment screening 21

9. Links to any associated documents 22

10. References 22

11. Appendices 23

Appendix 1 Definitions of Terms 24

Appendix 2 Development of Procedural Documents 27

Appendix 3 Template Equality Impact Assessment 35

Appendix 4 Template Policy document 40

Appendix 5 Template Standard Operating Procedure (SOP)/Procedure used within a Policy Manual

48

Appendix 6 New Procedural Document Request Form 50

Appendix 7 Template Tracking Document 52

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For Clarification/Guidance please contact Corporate Assurance Policy Officer

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1 Introduction – The Importance and Role of all Procedural Documents

This document and the underpinning suite of policies and procedures are in place to provide support and guidance to staff in fulfilling their roles at the Trust and ensuring that they are carried out in a safe and effective manner. The objective of such documents is to provide clarity to the way in which staff are expected to perform and to highlight the authority and responsibility of those staff involved to allow for a smooth and efficient process to occur. It is important for the Trust to ensure through such documents that it also complies with any relevant legislation and external guidance and considers national best practice.

2 Purpose and Rationale for the Development of the Policy

The purpose of this policy is: To provide an approved framework and template procedural document to facilitate a consistent, structured and systematic approach to the development and management, removal of, and extension to review dates of procedural documents which supports best practice. To set out the arrangements for the control of procedural documents essential for compliance with governance standards, and to promote standardisation in the provision of safe and effective care and the management of risk. These control measures will:

Provide staff with access to up-to-date Trust procedural documents.

Facilitate the review of all procedural documents within an agreed time frame, which will be a maximum of 5 Years from the most recent date of approval. However all new procedural documents should be reviewed within 12 – 18 months of issue to ensure they are working effectively.

Avoid duplication of procedural documents.

Facilitate cross referencing to associated documents.

Allow for the maintenance of a register/database of all ratified Trust procedural documents.

Provide for the on-going maintenance of a procedural document Library and archive, in which documents will be added to, have been replaced by a revised version or have been withdrawn.

Allow for the on-going monitoring of the use of, and compliance with procedural documents.

Identify and allow for a reduction in inequality through use of the Equality Impact Assessment (EIA) Screening Tool.

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3 Scope

This document applies to and is relevant across the following services/departments:-

Doncaster, Rotherham, North Lincolnshire and Children’s Care Groups

All corporate services.

Other documents e.g. collaborative/multi agency/regional policy documents to which the Trust has adopted may be referred to in procedural documents (and via hyperlinks where available).

4 Responsibilities, Accountabilities and Duties

While the Trust governance arrangements aim to provide a co-ordinated approach to the development of procedural documents throughout the organisation, there are individuals and Committees who have specific responsibilities and duties in relation to the policy as detailed below:

4.1 Chief Executive

The Chief Executive is accountable for there being a structured approach to procedural document development and management in place. Although responsibility for procedural document development may be delegated to other officers, accountability remains with the Chief Executive.

4.2 Accountable Directors, Policy Groups with Delegated Authority for

Approval

Trust procedural documents are categorised as set out in the table below. Each category has an identified Accountable Director and an identified Committee/Group with authority/delegated authority from the Board of Directors for approval of procedural documents. These Committees/Policy Groups are responsible for ensuring governance arrangements are in place for the review and approval of procedural documents for which they are accountable.

Table 4.2

Policy Title or Category Accountable Director Policy Committee/Group with Delegated Authority for Approval

Reservation of Powers/ Scheme of Delegation

Finance and Performance Board of Directors

Constitution (including Standing Orders)

Finance and Performance Board of Directors and Council of Governors

Standing Financial Instructions

Finance and Performance Board of Directors

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Table 4.2

Policy Title or Category Accountable Director Policy Committee/Group with Delegated Authority for Approval

Procedural Documents (Development and Management) Policy

Corporate Assurance Board of Directors

Risk Management Framework

Corporate Assurance Board of Directors

Performance Management Framework

Corporate Assurance Board of Directors

Learning from Deaths Policy: The Right Thing to do

Executive Medical Director Board of Directors

Clinical

Admissions

Care, Treatment and Assessment

Discharge/Transfer

End of Life Care

Infection Prevention and Control

Safeguarding

Service Specific

Wound Management

Nursing and Allied Health Professionals/

Executive Medical Director

Clinical Policies Review and Approval Group

Mental Health Legislation Nursing and Allied Health Professionals

Mental Health Legislation Committee

Prescribing and Medicines management

Medical Director Clinical Policies Review and Approval Group

Emergency Planning Chief Operating Officer Corporate Policy Approval Group

Estates and Facilities Finance and Performance Corporate Policy Approval Group

Finance Finance and Performance Corporate Policy Approval Group

Human Resources (Employment)

Workforce and Organisational Development

Corporate Policy Approval Group

Health Safety and Security Finance and Performance Corporate Policy Approval Group

Information

Health Informatics

Information Governance

Information Management

Health Informatics Corporate Policy Approval Group

Learning and Development (Education)

Workforce and Organisational Development

Corporate Policy Approval Group

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Table 4.2

Policy Title or Category Accountable Director Policy Committee/Group with Delegated Authority for Approval

Patient Experience Nursing and Nursing and Allied Health Professionals

Corporate Policy Approval Group

Patient Safety Nursing and Nursing and Allied Health Professionals

Clinical Policies Review and Approval Group

Records Management Health Informatics Corporate Policy Approval Group

Research Governance Executive Medical Director Corporate Policy Approval Group

4.2.1 The Accountable Directors are responsible for:

Upholding the requirements set out in this policy

The development and management of the policies for which they are identified as the Accountable Director as set out above in line with this policy.

Identifying an Author for the development or review of procedural documents.

Identifying which procedural documents require approval by the Board of Directors.

Procedural documents being reviewed and ratified in accordance with the time scale specified at the time of approval (should not exceed 5 years), in order that all Trust procedural documents remain current.

Scheduling procedural documents for approval to the relevant Policy Committee/Group with delegated authority for approval.

Seeking advice from the Local Counter Fraud Specialist in relation to potential fraud issues to ensure the procedural document is robust and will be legally robust should any deviation from it be utilised in a fraud investigation. Failure to ensure appropriate links will render the Trust vulnerable in such circumstances and may lead to an inability to seek appropriate sanctions.

4.2.2 The Chairs of Committees/Policy Groups with Delegated Authority

for Approval of procedural documents are responsible for:

Confirming that all procedural documents have been reviewed by the Policy Review Panel

Clearly recording decision making in the minutes of meetings in respect of: o The approval of procedural documents which meet the

requirements set out within this policy. o The approval of procedural documents subject to

recommendations.

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o The referral of procedural documents not ratified and which require further work back to the Accountable Director and the Procedural Document Author with an indicative timescale for completion.

o The approval of review date extensions. o Removal of procedural documents from the Procedural

Document library. o Temporary adoption of urgent procedural documents in

instances where a lack of immediate change to working practices can be detrimental to clinical, care, staff, or business continuity. The review should be completed retrospectively.

4.3 Corporate Assurance Policy Officer

The Corporate Assurance Policy Officer is responsible for:

The management, implementation and continuous monitoring of the implementation of this policy; The Procedural Documents (Development and Management) Policy.

Monitoring that new and revised procedural documents meet the requirements set out in this policy, informing Accountable Directors where this is not the case and advising on the changes required.

Reviewing procedural documents prior to their approval at the relevant approving group through the Policy Review Panel, to ensure that they are in line with the requirements of this policy (see Procedural Document Approval Journey Flow Chart).

Monitoring that the procedural document approval process is in line with the requirements set out within this policy, liaising with Chairs of committees/groups with delegated authority for approval as required.

Establishing and maintaining an effective system for the control of procedural documents, including:

The electronic register/database of procedural documents. The Library archive on the Trust shared L: drive. Tracking Documents system (see template Appendix 7)

including; version control process/ to aid tracking and retrieval; and, archiving and retrieval arrangements.

Finalising the Document Control box on the front cover of all procedural documents submitted for publication on the Trust website. (This provides a key source of assurance for version control, archiving and approval).

Arranging for the publication of procedural documents on the Trust website following approval and the removal and archiving of previous versions.

Instructing the Communications Department at the earliest opportunity (on a monthly basis) to notify all staff via Daily Emails (all users) of the development and issue of;

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o New procedural documents o New versions of existing procedural documents o Removal of procedural documents from the Trust Procedural

Document Library

Monitoring procedural document review dates and providing the Accountable Director with a quarterly status report (which allows a minimum of 6 months’ notice) of documents requiring review.

Incorporating any procedural documents requiring approval or review by the Board of Directors into the Trusts Annual Board cycle via the Board Secretary.

Making recommendations to the Accountable Director where monitoring identifies failure of the controls, and assisting with the development and implementation of action plans.

Undertaking a yearly audit of the procedural document pages of the Trust website, and providing the results and any recommendations to the Executive Management Team via the Director Corporate Assurance.

4.4 Clinical Effectiveness Lead

The Clinical Effectiveness Lead is responsible for: Providing advice and guidance to Clinical Policy Authors/Leads/

clinical staff on the development and review of clinical procedural documents as required.

Coordinating the reviews of clinical documents through to approval. This includes the process prior to their approval at the Policy Review Panel, to approval and forwarding for publishing on to the Policy website, ensure that they meet the requirements of this policy (see Procedural Document Approval Journey/Flow chart).

Providing status/exception reports to the Care Group Triumvirate, and Clinical Policies Review and Approval Group on clinical procedural document approval.

4.5 Procedural Document Coordinators

A Coordinator is a key point of contact who liaises between authors and the Corporate Assurance Policy Officer in the management of the review/update of procedural documents within their service. They will:- o Receive Procedural Document monthly status reports notifying them

of procedural document review dates. o Signpost Authors to this policy and process. o In conjunction with the Accountable Director will liaise with authors to

ensure reviews are commenced no later than 6 months prior to the document review date.

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o Liaise with Authors to ensure updated and ratified documents are provided for publishing on to the Trust Policy Library/Archive.

4.6 Procedural Document Authors

All authors must comply with the guidance and templates contained in this Policy. Lead Authors will be identified by the Accountable Director who will oversee the Author undertaking the following tasks: The development and/or review of procedural documents in line

with the requirements of this policy. A Procedural Document Approval Journey Flowchart is provided to support this process.

Before commencing development or review Authors should assess whether:- o Before a new procedural document is developed the Author

will check that a procedural document does not already exist, and is not covered by the Royal Marsden Suite of Policies. The Trust subscribes to this suite of policies which is primarily applicable to all areas of acute hospital inpatient care. Where applicable these policies should be used as opposed to the creation of new Trust policies.

o The document is still required or whether redundant and could be removed from the Trust Policy Library/circulation?

o The content could be incorporated within an existing policy? o If a new document is required could this be generated to fit

across a broader scope than first anticipated? (Could it fit across the whole organisation?)

o Is this document purely for local practice – i.e. a Local Working Protocol? See Section 2.1.1.8.

Authors are responsible for ensuring that the document is written in

the approved style and format as detailed in Section 5.

Using the track changes or similar function when reviewing an existing procedural document in order that changes can be identified and discussed when presented for approval/approval.

Being aware of any changes in legislation, practice or national

guidance, and incorporating this into the procedural document. (NB. Where the legal position is not clear, the Author will discuss this with the Accountable Director, who may decide to seek advice from the Trust’s Solicitors).

Ensure that the content does not infringe copyright permissions.

Assess the procedural document considering any risk or potential

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adverse consequences for the Trust and providing guidance on how to minimise these.

Test the robustness of the procedural document through a

consultation process with as many relevant stakeholders as appropriate. See Section 5.4.4.

Consider any training implications arising from the procedural

document and discuss this with the Head of Learning, Development and Education.

Complete an equality impact screening assessment (equality

analysis) when required.

Seek advice from the Local Counter Fraud Specialist in relation to potential fraud issues to ensure the procedural document is robust and will be legally robust should any deviation from it be utilised in a fraud investigation. Failure to ensure appropriate links will render the Trust vulnerable in such circumstances and may lead to an inability to seek appropriate sanctions. (The Local Counter Fraud Specialist is a member of the Policy Review Panel).

Present the draft procedural document to the Policy Review Panel

for review, completing any agreed amendments before presentation to the relevant approving group and subsequent Committee/Group for formal approval. For Clinical documents this is coordinated by the Clinical Effectiveness Lead.

Contacting the relevant committee/group administrator to include the final document onto the next available approving committee/group agenda, along with a completed Tracking document, equality impact assessment (and cover sheet for Board of Directors meetings only).

Completing any amendments agreed subject to approval before

submission to the Corporate Assurance Policy Officer for publication. Document should be submitted for publication within 2 weeks of approval. (Clinical documents are provided via the Clinical Effectiveness Lead)

4.7 Managers

Managers are responsible for:

Implementing the requirement for new or revised procedural documents to be fully operational within their services within a period of 3 months.

All staff they manage being aware of how to access the Trust’s procedural documents.

Including any procedural documents relevant to their area of work

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in their local induction for new staff. Identifying any staff training needs in relation to the implementation

of new or revised procedural documents and bringing these to the attention of the Head of Learning, Development and Education.

Assisting in the monitoring and audit of procedural document implementation within their area of work.

4.8 All Staff (including those listed above)

All staff have a responsibility to work in line with the Trust’s ratified procedural documents and should:

Be aware of how to access them.

Be aware of those which are relevant to their area of work.

Act in accordance with them.

Attend any training which is offered in relation to them.

Report to their Manager any issues affecting compliance with them, in order that these can be taken account of.

Seek authorisation to develop a new procedural document from the Accountable Director before proceeding.

4.9 Policy Review Panel:

The Panel is part of the procedural document approval/governance process. It is intended to ensure that all procedural documents are written, formatted, approved and reviewed in accordance with the Procedural Documents (Development and Management) Policy.

The Panel will review ALL Trust procedural documents and advise Procedural Document Authors on any required changes before formal approval at a Trust approved committee/group.

Policy Review Panel shall consist of the following roles:-

o Anti-Crime Specialist o Clinical Effectiveness Lead o Equality and Diversity Lead o Head of Learning, Development and Education o Mental Capacity Act Lead o Corporate Assurance Policy Officer o Other specialist(s) as required

4.10 Head of Learning, Development and Education

The Head of Learning, Development and Education is responsible for:

Considering any training implications identified by the procedural

document Author and planning the provision of an appropriate training programme, in close liaison with Managers. Authors have a responsibility of working with and liaising with the Head of Learning, Development and Education to assess how best the learning needs may be addressed

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Including any completed training needs analysis which covers mandatory, statutory, safety training and training essential to role on the Trusts Training Needs Analysis matrix.

4.11 Equality and Diversity Lead

The Equality and Diversity Lead is responsible for:

Advising Document Authors on completing an EIA.

Approving completed EIA’s before the document is presented for final approval.

Publication of approved procedural document EIA’s on the Trust website.

4.12 Communications Department

The Communications Department is responsible for notifying all staff via the Trust’s Daily Emails of the development and issue of:

New procedural documents.

Amended versions of existing procedural documents.

Procedural documents which have been removed from the Trust Policy Library/Archive.

Contact details for queries about procedural documents will also be provided.

5 Procedure for the Development of Trust Procedural Documents 5.1 Development of a new Procedural Document

The decision as to whether a new procedural document is developed rests with the relevant Accountable Director. Individuals identifying a need for a particular procedural document should:

Check against the Royal Marsden Suite of Policies for Clinical procedural documents.

Check against any collaborative/multi agency/regional policy to which the Trust has signed up to.

Check against national policy and recommendations.

Contact the Corporate Assurance Policy Officer to check against the Trust Electronic Register/Database of procedural documents, to ensure it is not duplicating other work locally.

Complete a Procedural Document Request Form and discuss with the Accountable Director the justification and support for:- o developing the new document; o how it links with service priorities;

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o the potential to extend this to cover across other services and or across the Trust;

o confirm that implementation is achievable within the resources of the service/organisation.

In some cases the development of a procedural document will have been recommended by an external body (e.g. Care Quality Commission) and this should be noted within the document in the introduction section.

5.2 Review Arrangements with Timescales

At least 6 months prior to the scheduled review date for procedural documents, the Corporate Assurance Policy Officer will notify the Accountable Director.

All Trust procedural documents will be reviewed within a maximum period of 5 years. Reviews or amendments of some procedural documents will be initiated earlier than this due to feedback received through monitoring processes and/or due to changes in the regulatory framework, national policy guidance, emerging best practice or the model of service provision etc. Where the review process exceeds the agreed review date the published document remains the Trust approved document until the review process is completed and the revised document ratified and published. Where the review of a procedural document breaches the agreed review date by 3 months the Corporate Assurance Policy Officer will notify the Accountable Director. Patient Group Directives (PGD) supplied to cover seasonal sessions. These PGDs are generally supplied by Public Health England, are not to be tampered with other than to insert authorisation to use information and are set to cover a season start date and expiry date. These PGDs are to be removed from the Trust Library on their expiry date without requiring additional approval for their removal.

5.3 Consultation process

The Procedural Document Tracking Document shown in Appendix 7 will be used to record the development and consultation process and all responses received, including whether these have resulted in amendments to the policy and if not, why. Drafts of procedural documents will be circulated to the identified stakeholders by the Procedural Document Author identifying a timescale for response and a named contact to respond to. The decision on the involvement of stakeholders will be taken on a case by case basis by the Procedural Document Author in consultation with

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the Accountable Director/senior management, depending upon the nature of the procedural document being developed or reviewed.

5.4 Identification of stakeholders

The involvement of staff, trade unions, relevant groups, committees and external stakeholders including service users and carers is central to the development and review of effective procedural documents, and to the success of their subsequent implementation. The following table provides guidance on relevant stakeholders that should be considered as part of the consultation process: Document Category Type of Stakeholder

Clinical:

Admission/Access to Services,

Care Treatment and Assessment,

Discharge/Transfer,

End of Life Care)

Infection Prevention and Control,

Prescribing and Medicines Management,

Safeguarding,

Service Specific,

Wound Management

Care Group Triumvirate*1

Clinical Effectiveness Lead

Equality and Diversity Lead

Health, Safety & Security Team

Human Resources/Organisational Development Team

Infection Control Team

Information Governance Team

Medicines Management

Mental Capacity Act Lead

Mental Health Act Manager

Patient Advice and Complaints Team

Patient Safety Team

Safeguarding Adults/Children Team

Emergency Planning Care Group Triumvirate*1

Estates and Facilities

Estates and Facilities Care Group Triumvirate*1

Information Technology

Finance Care Group Triumvirate *1

Counter Fraud Specialists

Health, Safety & Security Team

Information Governance

Mental Capacity Act Lead

Human Resources

Care Group Triumvirate *1

Clinical Effectiveness Lead

Counter Fraud Specialist

Equality and Diversity Lead

Staff Side

Health, Safety & Security

Care Group Triumvirate *1

Clinical Effectiveness Lead

Counter Fraud Specialist

Equality and Diversity Lead

Human Resources/Organisational Development Team

Information Governance Team

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Document Category Type of Stakeholder

Mental Capacity Act Lead

Patient Advice and Complaints Team

Patient Safety Team

Information/ Records Management

Care Group Triumvirate *1

Clinical Effectiveness Lead

Counter Fraud Specialist

Human Resources/Organisational Development Team

Learning and Development

Care Group Triumvirate*1

Subject Specific

Mental Health Legislation (including Mental Capacity Act)

Care Group Triumvirate *1

Clinical Effectiveness Lead

Equality and Diversity Lead

Patient Experience Care Group Triumvirate *1

Patient Safety Care Group Triumvirate *1

Health Safety and Security

Research Governance Care Group Triumvirate *1

*1for wider circulation/consultation with operational staff.

In addition to the list above the policy Author must consider any other relevant department/service where the implementation of the procedural document will impact as part of the consultation process. Drafts of a document may be circulated on more than one occasion, depending on the nature and complexity of the procedural document. Consultation on policies that will have impact on working practices and patterns of work for employees will be consulted on with the Trust Staff Council. Consultation on policies that will impact particular groups of external stakeholders should be consulted upon with those concerned.

5.5 Policy Review Panel

Before the procedural document is presented for formal approval the Procedural Document Author (for clinical documents this task is/may be performed by the Clinical Effectiveness Lead) must ensure that the final draft procedural document is presented to the Policy Review Panel to be checked that it has been written, formatted, approved and reviewed in accordance with the Procedural Documents (Development and Management) Policy. The Panel will advise the Procedural Document Author (for clinical documents the Clinical Effectiveness Lead) with a Policy Review Panel Outcome which lists any required changes or recommendations which should be incorporated within the procedural document before approval at a Trust approval committee/group. (see section 4.9 for additional

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information). Should these changes and or recommendations not be incorporated, the reasons why they have not been incorporated should be noted on the Tracking Document.

5.6 Procedural Document Approval Process

All reviews to any procedural document, including those where a review confirms that no changes are required, must be ratified according to the process set out above.

Certain procedural documents require approval by the Board of Directors and the responsibility for these documents rests with the Accountable Director. See table in 4.2 Accountable Directors. Responsibility for approval of procedural documents has been delegated by the Board of Directors to groups as set out in section 4.2 of this policy with the exception of those requiring approval by the Board of Directors. A Tracking Document is to be completed recording the approval journey. This is to ensure a uniform approach to document development and management is maintained. When procedural documents are submitted for approval a completed Tracking Document should accompany it. (See Appendix 7 Tracking Document template). The approving Committee/group will either;

approve the procedural document,

approve it subject to recommendations,

not approve it.

5.6.1 Ratified procedural documents - The Procedural Document Author (for clinical documents this task is performed by the Clinical Effectiveness Lead) will be forwarded to the Corporate Assurance Policy Officer to update the register/database and publish on to the Trust Library, archive and website. This action is to be completed within 2 weeks of the approval date.

5.6.2 Procedural documents ratified subject to recommendations - The Procedural Document Author (for clinical documents this task is performed by the Clinical Effectiveness Lead) will amend the procedural document and will then be forwarded to the Corporate Assurance Policy Officer for action as above.

5.6.3 Procedural documents not ratified will be returned to the Procedural

Document Author for further work. 5.6.4 A minor amendment is defined as the correction of a small spelling

mistake, expanding an acronym, amendment to contact person or details. This should be applied for by using a Tracking Document stating the change. Both the procedural document and the Tracking Document

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should be forwarded to the Corporate Assurance Policy Officer for recording and publishing. This change does not require formal approval.

5.6.5 A major amendment to a procedural document must be ratified by the

responsible approving Group. The review date of the policy will not change until a full review of the document is completed and approved by the committee/group responsible.

A major amendment is defined as any change to content of the document that would alter the previously approved procedure and/or defined roles and responsibilities.

5.6.6 Extension to Review Date

To apply for an extension to a review date, this should be requested using a Tracking Document detailing the:

Request for extension and period of extension.

Why it is being requested.

Consultation.

Associated risks. This is submitted to the appropriate Group for approval.

5.6.7 Removal of document from Trust Library/Archive To apply for a document to be removed, this should be requested using a Tracking Document detailing the:

The request for removal.

Why it is being requested?

The Consultation.

Where content has been incorporated elsewhere (if appropriate).

Any associated risks.

This is submitted to the appropriate Group for approval.

5.6.8 Version Control

Once ratified all procedural documents will be version numbered to aid tracking and retrieval and/or specific version. Version numbers must be included in the document control box on the front cover of the procedural document. The Corporate Assurance Policy Officer will manage the version control process via the Electronic Register/Database, version control and archiving and retrieval arrangements.

Draft Procedural Documents

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The first draft of a document must start at 0.1 and then progress through revisions by incrementing the number to the right of the point e.g. 0.2, 0.3 etc.

Ratified Procedural Documents

Once ratified the version number of a new procedural document must start at version 1.0. A revised document must follow in numerical order from the last ratified version e.g. version 1.0 become version 2.0.

Amendments

If a minor amendment to a procedural document (not a full review) is required the Corporate Assurance Policy Officer must be notified by the Procedural Document Author (for clinical documents this task is performed by the Clinical Effectiveness Lead), the version number will be amended to indicate the change by incrementing the number to the right of the decimal point i.e. version 2.1 and the document re-published. If the amendment is a major change involving a major amendment which is defined as any change to content of the document that would alter the previously approved procedure and/or defined roles and responsibilities, the version number is amended to indicate the change by incrementing the number to the left of the decimal point i.e. version 1.0 becomes version 2.0.

Review of Procedural Documents

When a procedural document has undergone a complete review (review of the contents, roles and responsibilities, procedure, equality impact assessment, consultation etc.), and has been ratified by the responsible approval group the version number will be amended to indicate the change by incrementing the number to the left of the decimal point i.e. version 1.0 becomes version 2.0.

5.6.9 Communication, Dissemination and Implementation

All procedural documents will be publicised via the Communications Daily Emails on a monthly basis and made available to staff via the Trust website in read only files. It is accepted that following approval of a procedural document there needs to be an allowance of time before it becomes fully operational in order to allow appropriate dissemination within the Trust. It is therefore expected that any procedural document will be fully operational within 3 months of the date of approval unless otherwise notified.

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Implementation issues and training needs should be identified for each new, amended and reviewed procedural document as an integral part of the review process. Where it has been identified by the Procedural Document Author that relevant groups of staff require training, a training needs analysis is to be completed to detail how these training needs will be addressed. Where this affects Mandatory/Statutory/essential to role training, the document Author should inform the Head of Learning, Development and Education.

5.6.10 Procedural Document Control and Archiving Arrangements

The Corporate Assurance Policy Officer is responsible for maintaining the Electronic Register/Database of Trust procedural documents and for auditing this against the procedural document pages of the Trust website annually to confirm the system is working.

They will remove and archive obsolete and/or superseded procedural documents from the Trust website and replace with a revised version where appropriate, with a new version number. Previous versions of procedural documents will be archived electronically, by the Corporate Assurance Policy Officer in order that they can be easily retrieved when required. The Electronic Register/Database of Trust procedural documents, Library and archive will be stored on a shared drive with defined, limited access by members of the Corporate Assurance Team in order to provide suitable cover arrangements.

5.6.11 Retrieving procedural documents from archive

Documents due review/amendment can be retrieved from the archive when required by contacting the Corporate Assurance Policy Officer or another member of the Corporate Assurance Team.

6. TRAINING IMPLICATIONS

There are no specific training needs in relation to this policy, but the following individual and groups need to be familiar with its contents: Board of Directors; Accountable Directors; Procedural Document Authors; Chairs of Trust Policy and Planning Committees/Groups with delegated authority for approval of procedural documents; and, any other individual or group with a responsibility for, developing procedural documents.

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7. MONITORING ARRANGEMENTS

Area for Monitoring

How Who by Reported to Frequency

Monitoring compliance with:

Style and format

Explanation of any terms used

Consultation process

Approval process

Associated documents

Supporting references

An audit of procedural document Tracking Documents for a sample of approved documents.

Corporate Assurance Policy Officer

Executive Management Team/Board of Directors

Annual

Review of all procedural documents prior to final approval

Policy Review Panel

Document Policy Authors

On-going

Control of documents, including archiving arrangements

Audit of register/ database of documents against

Trust website pages

Corporate Assurance Policy Officer

Executive Management Team/Board of Directors

Annually

Review arrangements

Report on the management of procedural documents detailing; documents reviewed and approved; scheduled for review; exception report on policies exceeded their review date.

Corporate Assurance Policy Officer

Executive Management Team/Board of Directors

Quarterly

8. EQUALITY IMPACT ASSESSMENT SCREENING

The completed Equality Impact Assessment for this Policy has been published on this Policy’s webpage on the Trust website.

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8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the Court. Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

Indicate How This Will Be Achieved

All individuals involved in the implementation of this policy should do so in accordance with the Principles of the Mental Capacity Act 2005.

9. LINKS TO ANY ASSOCIATED DOCUMENTS

Information Governance Policy and Management Framework (includes Data Protection Policy content)

Mental Capacity Act 2005 Policy;

Risk Management Framework;

Royal Marsden Manual online (available to staff only)

10. REFERENCES

The NHS Constitution for England https://www.gov.uk/government/publications/the-nhs-constitution-

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for-england/the-nhs-constitution-for-england

Equality Act 2010 11. APPENDICES

Appendix 1 Definitions of Terms Appendix 2 Development of Procedural Documents Appendix 3 Template Equality Impact Assessment Appendix 4 Template Policy document Appendix 5 Template Standard operating Procedure /Procedure for

use in Policy Manual Appendix 6 New Procedural Document Request Form Appendix 7 Template Tracking Document

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APPENDIX 1

DEFINITION OF TERMS 1 Types of Procedural Documents 1.1 The term Procedural Document is used as a global term to cover the

various types of documents commonly developed and used within the Trust. Procedural documents must be ratified by a Trust Group with delegated authority for approval and once implemented all staff are to work to them. For the purpose of this policy the following definitions apply:

1.2 Business Continuity Plans

Business Continuity Plans are a framework to ensure the resilience of an organisation and business to any eventuality, to help ensure continuity of service to key users; patients/service users and the protection of the NHS brand and reputation.

1.3 Framework

A framework is a set of ideas, principles, agreements or rules that provide the basis or outline for the management of a particular issue.

1.4 Strategy A strategy is a long term plan of action (usually covering three to five years) which is designed to achieve stated goals or objectives. It is usually a broad statement which outlines how the organisation plans to reach the intended outcome. The Trust policies and procedures are in place to support the achievement of the strategy.

1.5 Patient Group Direction (PGD)

PGDs are documents permitting the supply of prescription-only medicines (POMs) to groups of patients, without individual prescriptions. Healthcare workers using PGDs should be sufficiently trained to be able to supply and administer POMs.

1.6 Policy A policy is a statement of intent, describing the approach or course of action the Trust is taking with regard to a particular issue. Policies are underpinned by relevant evidence based procedures and guidelines and enable managers and staff to make correct decisions, work effectively and comply with relevant legislation and Trust aims and objectives. Policies must be achievable and must demonstrate how they are to be implemented. Each policy should have a purpose and specific steps (procedures) as to how the policy is to be implemented.

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1.7 Standard Operating Procedure (SOP)

A SOP is an agreed set of instructions for performing a particular task. SOPs require to be overarched by one Trust ratified Policy.

1.8 Local Working Instructions

A Local Working Instruction is a document that is not ratified through the corporate approval process and is not retained on the Procedural Document Web Library/Archive. The use of this document is at local level where a matter/subject/process only relates locally to one service or is specific internally to a department. E.g. Finance procedures that are only applicable to the finance team. Management of a Local Working Instruction is the responsibility of the Accountable Director or designated senior manager with approval being recorded through a designated approving group. The review of this document is recorded and maintained at this designated level in line with the Formulation of Operational Policies/Local Working Instructions SOP. Any document that is to be used more broadly, across more than one service, or where there is a statutory/legal requirement, should be retained within the corporate approval process and be included within the Procedural Document Web Library/archive. Any such document would not be titled a Local Working Instructions.

1.9 Policy Manual

A Policy Manual is an overarching (web based) Policy where procedures are hyperlinked within Section 5 and Appendices are hyperlinked within Section 11 of the overarching policy. This method has been devised to reduce duplication and make accessing subject detail quicker. See Section 5.3.

1.10 Procedure A procedure is a series of actions conducted in a certain order or manner. A procedure sits within a policy manual

2 Coordinator

A coordinator is a key point of contact within a service/ policy category who coordinates procedural document reviews/updates with authors.

3 Acceptable terms for people accessing Trust services

The term ‘patient’ is most commonly used within Trust procedural documents in order to be consistent with the national approach, however

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‘service user’ may also be used as an alternative. Use of either of these terms should be restricted to either one, not both within a document.

4 Care Group Triumvirate

Where the term ’Care Group Triumvirate’ is used this includes the Care Group Director, the Associate Medical Director (Lead Consultant – Children’s Care Group) and Associate Nurse Director.

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APPENDIX 2 Development of Procedural Documents

1 The Style and Format of Procedural Documents

All procedural documents will be:

Written in a style which is concise and clear, using unambiguous terms and language.

Presented in a Standard template for use with all procedural documents is provided as appendices.

Referenced using the Harvard referencing system. 2 Content of a Policy (see Appendix 4) 2.1 Front cover

This should be set out as shown in Appendix 4. The Document Control box provides a key source of assurance for version control, archiving and approval.

2.2 Contents Page

This may not be required depending on the length and complexity of the document. If it is a short document it can be deleted from the template.

2.3 Introduction (Section 1)

This section must be completed for all documents. It is used to introduce the topic and includes references to and applicability of any relevant legislation, national policy guidance and external agency recommendations.

2.4 Purpose (Section 2)

This section must be completed for all documents and should outline the objectives and intended outcomes of the process/system being described.

2.5 Definitions/Explanation of Terms Used (Section 2.1)

Include a list of definitions/explanation of any terms used that may require an explanation/clarification.

2.6 Scope (Section 3)

This section must be completed for all documents and the target audience and the activities covered by the document clearly stated. When completing this section, Procedural Document Authors should bear in mind that there will be some procedural documents developed for a specific service or staff group. Where different aspects of a topic are

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covered by more than one policy, it will be helpful to indicate this in this section.

2.7 Responsibilities, Accountabilities and Duties (Section 4)

This section must be completed for all documents and should be divided into subsections, providing an overview of the individual, departmental and committee duties including levels of responsibility for document development. Duties may include: accountabilities of Directors; committees; specialist staff; and, Authors with responsibility for procedural documents.

2.8 Procedure/Implementation (Section 5) This section must be completed for all documents, and is the section where the actual procedural guidance is set out. For some documents this may only be a brief section. More lengthy procedural guidance should be presented in subsections to make it easier for the user of the document to refer to.

2.9 Training Implications (Section 6)

This section must be completed for all documents.

Where training needs are identified in relation to the procedural document, a Training Needs Analysis (TNA) must be completed, using the agreed template shown in Appendix 4.

Mandatory and Statutory (Risk Management) Training. Procedural documents in key subject areas in relation to risk which incorporate aspects of training must be included within the organisations training needs analysis. Details are provided in the Trust Mandatory and Statutory Training Policy and Associated Training Needs Analysis (TNA).

Where training is not required, the Procedural Document Author should provide details of how staff will be made aware of the policy and its implications for their working practice as detailed below.

2.9.1 Standard statement where no training is required, but where

awareness is required

There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents:

Board of Directors

Accountable Directors

Procedural Document Authors

Chairs of Trust Policy and Planning Committees/Groups with delegated authority for approval of procedural documents

Any other individual or group with a responsibility for, or an interest in, developing procedural documents

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Any other individual or group with a responsibility for implementing the contents of this policy

As a Trust policy, all staff to be made aware of the key points that the policy covers. Staff can be made aware through (examples below):- Please amend as appropriate

Continuous Professional Development sessions

Communications Daily Email

One to one meetings / Supervision Local Induction

Posters Group supervision

Team meetings Practice Development Days

Special meetings

2.10 Monitoring Arrangements (Section 7)

A model template for the monitoring section of procedural documents is shown in section 7 of Appendix 4 and must be completed for all documents. This section should set out how implementation of the procedural document will be monitored. Monitoring provides assurance that prescribed systems are working and involves collecting information that will help answer questions about the Trust’s systems, including: - Are we managing the risk? - How well are we doing? - Are we doing the things we said we should? - Are we making a difference in doing those things? - Where can we find the evidence?

For some, but not all procedural documents, audit will be used to monitor implementation. Other methods of monitoring which may be used are:

Annual reports

Complaints analysis

Compliance with legislation and national standards, e.g. Care Quality Commission.

Dashboards/Adherence to Key Performance Indicators (KPIs)

Focus groups

Health record checks

Health and safety inspections and environmental audits

Incident reports

Routine data collection

Spot checks

Staff record checks

Staff surveys

Training evaluation

Training records

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2.11 Equality Impact Assessment Screening (Section 8)

The Equality Act 2010 replaces the previous anti-discrimination laws with a single act. One of the key measures of the Act was the Public Sector Equality Duty (PSED) which came into force on the 5th April 2011. The Equality Duty is a duty on public bodies and others carrying out public functions, it ensures that public bodies consider the needs of all individuals in their day to day work – in shaping polices, in delivering services and in relation to their own employees. The Equality Duty is supported by specific duties set out in regulations which came into force on 10 September 2011; these specific duties require public bodies to publish relevant, proportionate information demonstrating their compliance with the Equality Duty. To this end Trust staff complete and publish the Equality Impact Assessment (EIA) on all policies, services, strategies and events taking into consideration not only the 9 protected characteristics but also a category to consider other people who may be disadvantaged for other reasons (Disadvantaged Groups). The Protected Characteristics covered by the Equality Duty are:

Age

Disability

Gender Reassignment

Marriage and Civil Partnership (but only in respect of eliminating unlawful discrimination)

Pregnancy and Maternity

Race (includes ethnic or national groups, colour or nationality)

Religion or Belief (includes lack of religion or belief)

Sex

Sexual Orientation

Not included in the Act but included for people who fall into ‘Inclusion Health’ groups who experience difficulties in accessing, and benefitting from the NHS. ‘Inclusion Health’ was defined in a Social Care Task Force and Department of Health publication of 2010. These other Disadvantaged groups typically include but are not restricted to:

People who are homeless

People who live in poverty

People who are long-term unemployed

People in stigmatised occupations (such as women and men involved in prostitution)

People who misuse drugs

People with limited family or social networks

People who are geographically isolated

The overall aim of an assessment is to identify where the service, policy, strategies or event has an adverse impact upon any particular group or community so that action can be taken to minimise or remove the

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detrimental impact if deemed necessary. Or if there is a positive impact which can be shared in order to spread Best Practice and lessons learnt across the organisation. An EIA should be completed for all policies and strategies and when any of these are revised or reviewed. Completed EIA’s must be approved by the Equality and Diversity Department before the document is presented for formal approval to the approving committee/group.

For assistance and additional guidance on completing the EIA, please contact the Equality and Diversity Department on 01302 796473.

The completed Equality Impact Assessment will be published alongside the corresponding policy on the Trusts Policy Webpage.

2.11.1 Privacy, Dignity and Respect (Section 8.1)

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). The wording of the procedural document should indicate how this will be met.

2.11.2 Mental Capacity Act Statement (Section 8.2)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the Court. Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the rights of the individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

2.12 Links to Any Associated Documents (Section 9)

This section should provide details of any documents which are referred

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to at any point in the document, in order that the user can refer to these for further guidance as required. The full title of the associated document and where it can be located should be recorded.

2.13 Referencing (Section 10)

References provide an evidence base for procedural documents. The Harvard style will be used to provide a uniform approach to referencing, as set out in the table below:

Type of Literature Referenced

Reference Style

Books Books are listed by Author, date, title and publisher, e.g. Stewart R (2002) Evidence-based Management – a practical guide for health professionals Radcliffe Medical Press

Journals Journals are listed by Author, date, title of article, title of journal, part number, page number (beginning of article – end of article) e.g. Moore S and Munro M (1990) The Newman System Model Applied to the Mental Health Nursing of Older Adults Journal of Advance Nursing 15, 293-299

Chapters in Edited Books

Quote the Author and date of the chapter then follow it with the book reference e.g. Samson C, 1970 Problems of Information Studies in History. In S Store, ed Humanities information research. Sheffield CRUS 1980, pp 44-68

Electronic Information

The referencing of a CD-Rom or website is similar to a book or journal. The Author, date and title are used with the full address of the web page. (This can be copied from the address box). At the end of the web address the date you accessed the page should be included as web pages are often modified or removed

Copyright If using content from other sources copyright permission should be checked prior to its inclusion. If obtained reference should be made alongside the copyrighted content.

2.14 Appendices (Section 11)

List the Appendix numbers and titles of any appendices. If no appendices are to be included please state ‘None’. This reflects that all sections of the document have been addressed and or included as opposed to the document being incomplete.

3 Standard Operating Procedures

A Standard Operating Procedure (SOP) is an agreed set of instructions for performing a particular task that is overarched by an approved policy or procedure. In some instances the overarching policy or procedure may be a regionally agreed collaborative document to which the Trust has

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signed up to. Responsibility for approval of Standard Operating Procedures has been delegated by the Board of Directors to committees/groups as set out in section 4.2 of this policy. Standards Operating Procedures will include as a minimum:

3.1 Title of the Standard Operating Procedure (Procedure for use in

Policy Manual) 3.2 Document Control Box;

Version number

Approved by: name of approval group

Date of approval; date of approval

name of originator/Author

name of responsible committee/individual

date issued

review date

target audience 3.3 Aim of the procedure (Section 1)

To outline the objectives and intended outcomes.

3.4 Scope (Section 2)

Detail any specific area the SOP applies to.

Include the target audience, relevance to specific services or staff group and the activities covered and exclusions (if any).

3.5 Link to overarching policy or other appropriate document (Section 3)

Only one document can overarch a SOP and the overarching details should be reflected within the Policy/document. Should the overarching policy/procedure be a regionally agreed/collaborative document this should be referenced. If the overarching document has an associated Equality Impact Assessment (EIA) the SOP does not require its own. If the overarching document does not have an associated EIA then one should be created.

3.6 Procedure (Section 4)

State procedural instruction detailed in a basic step by step process. SOPs are by definition a basic description of instructions to be taken. More lengthy procedural guidance should be considered for inclusion in the overarching procedural document.

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3.7 Appendices (Section 5)

Any appendices should be inserted in this section. If there are no appendices, please state so.

See Appendix 5 – Template for the Development of a Standard Operating Procedure.

3.8 Policy Manual A Policy Manual is an overarching mainly web based Policy where procedures are hyperlinked within Section 5 of the overarching policy. This method has been devised to reduce duplication and make accessing detail quicker. The content of the overarching policy will be common across all Section 5 Procedures. The (Manual) Procedure template is based on a SOP template but may contain section headings from a Policy which are subject specific. All appendices within the manual will be given consecutive numbering and be listed within Section 11 Appendices within the overarching policy. Only appendix titles/hyperlinks will be stated in the procedure. The overarching policy and procedures will have their own version numbering and be reviewed independently.

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APPENDIX 3

EQUALITY IMPACT ASSESSMENT This Equality Impact Assessment (EIA) provides evidence that the business division/directorate has considered the Public Sector Equality Duty (PSED) detailed in the Equality Act 2010 and strives to uphold the general duties to:

Eliminate unlawful discrimination, harassment and victimisation

Advance equality of opportunity

Foster good relations The form is intended to guide and prompt you about the questions you need to think about at the first instance, when implementing a service/policy/strategy/event. The assessment takes into consideration each of the “protected characteristics” listed in the Equality Act 2010, and should be used to inform any relevant decision about the service/policy/event if it is found to be contrary to the duty imposed in the Act.

Care Group / Corporate Services: Service:

Can be multiple if it is a collaborative piece of work or referred to as Trust-wide if it encompasses all areas.

Policy:

Name of Service/Title of Policy or Strategy, Name of Event:

Event:

E.g. ‘Consent to Examination or Treatment Policy’ or ‘Listen to Learn Network Event’

Strategy:

Equality Impact Assessment Undertaken by: Date undertaken:

Name of lead person(s) undertaking the EIA and the first point of contact for queries. Ideally this document should not be completed in isolation and should have team input.

Questions

1. What are the main aims and purposes of the Policy / Service / Event or Strategy?

Use section 2 of the policy as a guide.

To deliver x, to promote x, to inform x, to set standards x…in line with the Trust’s strategic objectives, to ensure service sustainability by x.

State here also whether the policy/strategy is new, existing or under review.

2. Who is involved in delivering the service, implementing the policy or strategy / organising the event? (i.e., partnerships, stakeholders or agencies)

Refer to section 4 of the policy

3. What information / data or experience can you draw on to provide an indication of the potential inclusive / exclusive results of delivering this service or event / implementing the policy or strategy to different groups of people and the different

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needs of people with protected characteristics in relation to this policy / service / event or strategy?

• Use sections 9 and 10 of the policy as a guide

Engagement and consultation with staff and/or service users

• Comparative service/policy/strategy/event which the impact can be modelled on

• Relevant monitoring data

• Feedback/actions arising from e.g. complaints, MP letters, serious incidents, steering groups

Protected Characteristics

Positive Impact Negative Impact Reasons for Impact

Age

E.g. how do we engage with older and younger people? Are there any recruitment/retention issues? Does this take an ‘all-age’ approach?

Disability

Consider, for example, access to buildings/services, the way services are delivered, compliance with Accessibility Information Standard.

Gender reassignment

Consider what issues there are for men, women and those in the transgender community or undergoing gender reassignment e.g. responsibilities for dependants, issues for carers, employment issues.

Marriage and civil partnership

Ensuring fair policies and procedures to prevent e.g. A newly married candidate not being hired as the interviewer believes they will be focussed on starting a new family rather than their career

Pregnancy and maternity

E.g. are reasonable adjustments being made in the workplace? Are parents being supported

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Protected Characteristics

Positive Impact Negative Impact Reasons for Impact

to return to work?

Race

Consider the potential to affect racial groups differently – are we providing an equal opportunity to access? E.g. providing translation/interpreting services, understanding the needs of different cultures/communities, the Workforce Race Equality Standard (WRES), collecting the relevant data/information if we do not currently have it.

Religion or belief

What is the likely impact? e.g. dietary needs, religious holidays, customs, opportunity for worship etc.

Sex

Consider the provision of male / female staff ratio's with regards to patient choice and privacy and dignity.

Sexual Orientation

Consider the provision for inclusive services for people from LGBT communities. Think about tackling barriers and health inequalities e.g. higher rates of breast cancer in lesbian women.

Disadvantaged groups

What other factors have an impact? E.g. lower income families, poor education, lack of housing and communities with higher health inequalities. Are you thinking about innovative ways to engage with these groups?

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4. What positive impacts are there for this policy / service / event or strategy to better meet the needs of people with protected characteristics?

• Promotes equality

• Promotes good relations between different groups

• Ensures information about, and access to, services

• Ensures that services are inclusive and cater to the needs of the local population

Ensures that staff have a working environment that is sensitive to their particular “protected characteristics” and where there is equal opportunity for development, support and progression at all levels

5. What action would be needed to ensure the policy / service / event or strategy overcomes:

Discriminatory negative impacts

Exclusion

Failure to meet the needs of people from across the protected characteristics and opportunities for promoting equality and inclusion are maximised.

• Consult data from a previous similar policy/service/event/strategy

• Engage beforehand with a representative sample of the group of people the policy/service/event/strategy is likely to impact

• Don’t view the EIA as a one-off exercise, ensure appropriate monitoring is in place to review the impact

*Reminder, ensure that any options for alleviating an adverse impact for a particular group does not in turn create an adverse impact for another group*

6. Recommended steps to avoid discrimination and ensure opportunities for promoting equality and inclusion are maximised. Include:

Options for action Explanation if no further action is

required

Lead responsible

for overseeing

actions

Timescales Costs (where

applicable)

use section 6 of the policy as a guide to complete

7. Monitoring and reporting arrangements of EIA, for policies and strategies refer to

section 7 of the Policy for the Development and Management of Procedural Documents.

For services / events please include the following:

How the equality impact of the service will be monitored

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Frequency of monitoring

How the monitoring results will be used and where they will be published;

Who will be responsible for reviewing monitoring results and initiating further action where required

Any changes that have been made to remove or reduce any negative impacts as a result of conducting the equality impact assessment?

Any action points should be included in Care Group / Corporate action plans, with monitoring and review processes.

Is further work / consultation required? If yes, please explain how this is to be carried out and the time frame for completion.

Yes No

The Equality Impact Assessment will be reviewed in line with changes to services, client or staff groups, legislation or policy review.

Name:

Authors name

Designation:

Your job title

Signature:

Date:

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APPENDIX 4

TEMPLATE FOR THE DEVELOPMENT OF POLICY DOCUMENTS

Instructions on how to complete the policy document template are written through this template in blue italics – please ensure you delete these

instructions before the policy document is finalised and put forward for approval.

DOCUMENT CONTROL:

Version: Insert version number – check previous version with Corporate Assurance Policy Officer

Approved by: Insert name of group with authority to approve this policy – check Procedural Documents (Development and Management) Policy.

Date approved: Insert the date the policy was approved by the approving committee/group

Name of originator/author: Insert the job title (not the name) of the document Author

Name of responsible individual:

Insert the name of the committee/group responsible for this document i.e. implementation and monitoring.

Unique Reference number: If not already inserted, will be inserted by Corporate Assurance Policy Officer

Date issued: The Corporate Assurance Policy Officer will complete this box on the day the policy is loaded onto the website.

Review date: Insert the month and year the policy is due for review – usually this will be 3 years from the ratified date unless otherwise agreed.

Target Audience Insert an overview of who this document is for i.e. clinical or non-clinical staff, all staff, managers etc.

Description of change

Insert Document Title (short and snappy) ending in document type i.e. Policy

(font 18)

(If required add additional text under the title to complete the description)

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Section

CONTENTS

Page No

1. INTRODUCTION Insert relevant

page numbers

2. PURPOSE

3. SCOPE

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

5. PROCEDURE/IMPLEMENTATION

5.1 Insert Sub Headings as required

6. TRAINING IMPLICATIONS

7 MONITORING ARRANGEMENTS

8. EQUALITY IMPACT ASSESSMENT SCREENING

8.1 Privacy, Dignity and Respect

8.2 Mental Capacity Act

9. LINKS TO ANY ASSOCIATED DOCUMENTS

10 REFERENCES

11 APPENDICES

Appendix 1 – Definitions/Explanations of Terms Used

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(Use font 12 and page numbering page x of y format. Left align section and sub section numbers and indent section title. Text to be indented to align under the section title) 1. INTRODUCTION

XXX

2. PURPOSE XXX

3. SCOPE

XXX This document applies to and is relevant across the following services/departments/Care Groups:-

Insert

Insert

With the exception of; insert here any services that are specifically excluded or state ‘no exceptions’.

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES XXX

5. PROCEDURE/IMPLEMENTATION XXX

5.1 XXX XXX

6. TRAINING IMPLICATIONS There are two choices regarding training implications so choose the one that applies to this document and delete the others: Option 1 - Trust training implications model template Use this format below where specific training needs are identified - see section 5.2.9 of the Procedural Documents (Development and Management) Policy.

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POLICY TITLE

Staff groups requiring training

How often should this be undertaken

Length of training

Delivery method

Training delivered by whom

Where are the records of attendance held?

DO NOT USE THE TERM “AD HOC”

Electronic Staff Record system (ESR)

Option 2 – Trust Standard Training Statement Where no specific training needs are identified Insert the following standard statement and adapt as required – see section 5.2.9 of the Procedural Documents (Development and Management) Policy.

“There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents: (INSERT LIST OF ROLES WHO NEED TO BE FAMILIAR WITH THE DOCUMENT) and any other individual or group with a responsibility for implementing the contents of this policy). As a Trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through: (ENTER AWARENESS RAISING METHODS TO BE CONSIDERED, examples below.) A variety of means such as;

All user emails for urgent messages One to one meetings / Supervision

Continuous Professional Development sessions

Posters

Daily email (sent Monday to Friday) Practice Development Days

Group supervision Special meetings

Intranet Team meetings

Local Induction

The following statement may be included if appropriate. The Training Needs Analysis (TNA) for this policy can be found in the Training Needs Analysis document which is part of the Trust’s Mandatory Risk Management Training Policy located under policy section of the Trust website.

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7. MONITORING ARRANGEMENTS

Area for Monitoring How Who by Reported to Frequency

A model template for the monitoring section of procedural documents is shown above and must be completed for all documents. This section must set out how implementation of the procedural document will be monitored. Monitoring provides assurance that prescribed systems are working and involves collecting information that will help answer questions about the Trust’s systems, including:

Are we managing the risk?

How well are we doing?

Are we doing the things we said we should?

Are we making a difference in doing those things?

It is important that the frequency and detail of the monitoring process is specified and that it can realistically be achieved.

8. EQUALITY IMPACT ASSESSMENT SCREENING -

The policy Author will need to complete an Equality Impact Assessment Screening Tool as part of the development or review of the procedural document. If you require any advice on completing the EIA you can contact the Equality and Diversity Lead. You must send the EIA and a copy of the draft policy to the Policy Review Panel where the Equality and Diversity Lead is a panel member, for approval before the policy is put forward for approval by the authorised committee/group. Record this consultation on the Tracking Document (see appendix 7). The following statement and link is to be added to Section 8.

The completed Equality Impact Assessment for this Policy has been published on this policy’s webpage on the Trust Policy Library/Archive website.

8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all

Indicate how this will be met

Consider any issues regarding the content of this policy in relation to privacy, dignity and respect and detail how these will be met.

If there are no issues identified

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procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

please state:

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the Court.

Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

Indicate How This Will Be Achieved

All individuals involved in the implementation of this policy should do so in accordance with the Principles of the Mental Capacity Act 2005.

9. LINKS TO ANY ASSOCIATED DOCUMENTS

This section should provide details of any documents which are referred to at any point in the document, in order that the user can refer to these for further guidance as required. XXX

10. REFERENCES

References provide an evidence base for procedural documents. The Harvard style will be used to provide a uniform approach to referencing, as set out in the Procedural Documents (Development and Management) Policy on page 17. XXX

11. APPENDICES

If there are no appendices, please state ‘none’. If there are, please insert any appendices to the policy on the next page. (Once the policy document has been completed and you have consulted with the relevant people you must notify the relevant administrator of the approving Group that the document needs to be presented to the next meeting for approval.

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The committee/group will need an electronic copy of the following documents usually a week in advance of the meeting: a completed cover sheet, the policy document with track changes if reviewed, a copy of the approved Equality Impact Assessment Screening Tool and a completed copy of the Tracking Document. The policy Author is usually expected to present the policy document for approval unless alternative arrangements have been made.)

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Appendix 1 Definitions/Explanation of Terms Used

XXX

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APPENDIX 5

TEMPLATE FOR THE DEVELOPMENT OF STANDARD OPERATING PROCEDURES

Instructions on how to complete the policy document template are written through this template in blue italics – please ensure you delete these

instructions before the policy document is finalised and put forward for approval.

DOCUMENT CONTROL:

Version: Insert version number – check previous version with Corporate Assurance Policy Officer

Ratified by: Insert name of Group with authority to approve this policy – check the Procedural Documents (Development and Management) Policy.

Date approved: Insert the date the policy was approved by the approving committee/group

Name of originator/ Author:

Insert the job title (not the name) of the document Author

Name of responsible individual:

Insert the name of the committee/group responsible for this document i.e. implementation and monitoring.

Unique Reference Number:

If not already inserted will be inserted by the Corporate Assurance Policy Officer prior to publication.

Date issued: The Corporate Assurance Policy Officer will complete this box on the

day the policy is loaded onto the website.

Review date: Insert the month and year the policy is due for review – usually this will be 3 years from the ratified date unless otherwise agreed.

Target Audience Insert an overview of who this document is for i.e. clinical or non-clinical staff, all staff, managers etc.

Description of change

Insert Document Title (short and snappy) ending in document type i.e. Standard

Operating Procedure /

Procedure (Manual) (font 18)

(If required add additional text under the title to complete the description)

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1. AIM (This section must be completed to outline the objectives and intended outcomes of the procedure being described). XXX

2. SCOPE (This section must be completed to include the target audience, relevance to specific services or staff group and the activities covered by the SOP). XXX

3. LINK TO OVERARCHING POLICY (This section to reference the title of the overarching procedural document that references the SOP). XXX

4. PROCEDURE (This section is where the actual procedural instructions are detailed in a basic step by step process. Standard operating procedures are by definition a basic description of instructions to be taken and should be restricted to one page. More lengthy procedural guidance should be considered for inclusion in the overarching procedural document). XXX

5. APPENDICES (If any? If none, state ‘none’.) XXX

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APPENDIX 6

New Policy/Procedural Document Request Form (To be completed BEFORE COMMENCING THE DEVELOPMENT OF A NEW POLICY/ PROCEDURAL DOCUMENT additional to those listed on the RDaSH Policy Library)

1. Policy/Procedural Document Title:

2. Author(s) Name(s):

3. Author(s) Role(s):

4. Contact Tel Nos:

5. Contact Email Address(s):

6. Care Group/Corporate Service (Please insert):

7. Will this be a Trust wide or local specific policy/procedural document?

Trust wide or Local/Service Specific?

Locality/Service to be involved:

If the policy/procedural document is not to be applicable Trust wide, please indicate the reasons why:

Have you considered and discussed whether this could/ should be an informal document managed locally e.g. Local Working Instruction or Pathway?

Yes No

What was the outcome of that discussion?

8. Document type being requested: (Please state)

Policy Standard Operating Procedure

Patient Group Direction Policy Manual/ Procedures

Local Working Instruction

If a SOP please state title of overarching policy

9. Main Aims/Objectives of the Procedural Document

Please identify any factor which is influencing the decision to request a procedural document and what do you want to achieve; i.e.

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national requirement, compliance/ legislation/ recommendation, contractual/ Commissioner requirement, area of concern:

(Continue on separate sheet if necessary)

10. Please state the expected dates of the consultation period

Start: Completion:

11. Do you require any support? Yes No

If yes, please state what support you require:

Advice on how to undertake the consultation process

Guidance on how to complete the required paperwork

Guidance on who to involve

Other (please specify):

12. Name/Signed (requestor):

Job title (requestor):

Date:

13. Approval

Has this (potential) policy/ procedural document been discussed and approved by your Care Group/ Governance Group/ Service?

Yes No

Name of Director who has approved the progression of this Policy/ Procedural document?

Date approved:

What to do next:-

Clinical – Provide an authorised copy of this form by post to: Clinical Effectiveness Lead, Chestnut View, Tickhill Road Site, Doncaster or email; Donna Perry / Karen Samuels-Hannan

Corporate – Provide an authorised copy of this form to your head of service and the Corporate Assurance Policy Officer Wendy Myers

Clinical Policies Review and Approval Group (CPRAG)/ Corporate Policy Approval Group (CPAG) USE ONLY: Date received: / / CPRAG/ CPAG (decision) Meeting Date: ….. / ….. / ….. Decision/Outcome: Approved |Declined

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APPENDIX 7

Tracking Document

GUIDANCE

This Tracking document is to be used to record a document’s review/approval journey. It should be shared with approving groups as the journey progresses to assure consultation contributors/approving committee/group members that the procedural document has been developed/ or reviewed in accordance with the Procedural Document (Development and Management) Policy.

Corporate Authors - will progress procedural documents through their ratification journey.

Clinical Authors – will progress documents via the Clinical Effectiveness Lead.

It should be noted that procedural documents that require their review anniversary to be extended or the document is to be removal from the Library (and Archived) should be shared/consulted on to ensure relevant feedback is received.

See the table below which identifies which sections of this Tracking Document are required for the specific approval journey. Delete ‘not required’ sections before proceeding.

Policy SOP/ Procedure/ PGD

Reason for Development

Sections to be used

New 1, 2, 3a, 4, 1, 2, 3b, 4

Anniversary Review 1, 2, 3a, 4, 1, 2, 3b, 4

Amendment Minor 1,

Major 1, 2, 4,

Removal from Library/Archive or review extension

1, 2, 4,

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Tracking Document

(1) About the Document

a) Document Title Insert the title of the document being developed or under review.

b) Document Type Patient Group Direction

Policy

Policy Manual

Procedure

Standard Operating Procedure

c) Document version number being reviewed.

Please state if this is a new document in development or if a current document, which version number is being reviewed.

d) Category of Document :

Which Library category will the document be stored in i.e. Clinical/Infection Control or Corporate/Finance

e) Name of Lead Author, job role and contact details:

Insert the name, job role and contact details of the document Lead Author

f) Accountable Director: Insert the name and job role of the accountable director for the document.

g) Purpose:

(Why are we doing this/ what is being requested?)

State reason:

- New document development - Complete Procedural Document Request Form before proceeding any further

- Review Anniversary

- Amendment (state what requires changing/ bringing up to date? i.e. Statement, principles, legislation, strategy guidance, national policy) (briefly state reason)

- Removal from Library/Circulation/demote to ‘local working instruction’

- Other

h) What are the key changes from the previous edition/version?

i) What is the risk/ likelihood of significant changes in the next year(s) that will affect this document?

j) Scope: Who is to follow this procedural document/Target Audience?

k) Document title – is this to change?

If so, please state current title and title after change.

l) If the document is to be REMOVED from the Policy Library – where (elsewhere) is the document content included?

Is the information out of date/has it been incorporated within another document – if so which document?

m) If this document is to have its review date extended please address the following before proceeding:-

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o Current policy remains valid and in line with current practice

o An extension does not present any clinical or operational risks

o Procedures are in place to underpin the document until ratification

o The Governance Structure within the document is in line with the Trusts current structure

o The roles and responsibilities are aligned to reflect the current structures and job titles within the Trust

o Staff are aware of the potential revised document review date

n) Any other Comments/Information?

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(2) Consultation

Members of Authorship Group (where relevant): Insert the name(s) of the people involved in the development or review of the procedural document - this can be individuals and/or group.

Names Titles

Press tab key to create more rows

Please provide details of the consultation journey (i.e. Individuals/groups consulted)

This checklist must be completed and given to the approving committee/group and confirm that the procedural document has been developed/reviewed/appropriately consulted, in accordance with the policy for development and management of procedural documents. If there are any reasons why the process has not been followed please indicate this in the comments section.

Group or Individual Date requested and method

Comments made Were amendments made in response to the comments? If not, explain why?

Insert the names/job titles of the people who have been consulted in the development or review of the policy. Continue to add detail as the document proceeds through the consultation journey

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Please provide details of the consultation journey (i.e. Individuals/groups consulted)

This checklist must be completed and given to the approving committee/group and confirm that the procedural document has been developed/reviewed/appropriately consulted, in accordance with the policy for development and management of procedural documents. If there are any reasons why the process has not been followed please indicate this in the comments section.

Group or Individual Date requested and method

Comments made Were amendments made in response to the comments? If not, explain why?

Press tab key to create more rows

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(3a) Checklist – Policy (please delete this section if using Checklist 3b)

Checklist for the Review and Approval of Procedural Documents

Yes/No/

N/A

Comments/Detail

This document is not always accompanied by the procedural document. Please provide succinct information.

1 Front Page

1.1 Title The title should commence with a short and snappy title and if required be followed by a full detailed title.

Document Control Box:-

1.2 Version: Please liaise with Policy & Standards Officer

1.3 Date Ratified This is the meeting date when the document as ratified. Can only be inserted towards the end of the journey.

1.4 Name of Originator/Author Insert Job role of lead author.

1.5 Name of Approving Group/ Committee Insert name of Approving Group/ committee.

1.6 Date issued: Leave blank – for use by Policy & Standards Officer

1.7 Review Date: Insert review month/year anniversary

1.8 Target Audience Insert description of target audience

2 Development Process - Have the following been considered as part of the development of this document:

2.1 Mental Capacity Act If the document is in relation to patients the standard MCA statement template should be included. In addition the MCA Lead should be contacted as part of the consultation.

2.2 Privacy, Dignity and Respect Unsure? – seek guidance from Equality & Diversity service

2.3 Safeguarding Unsure? – seek guidance from the Safeguarding team.

2.4 Fraud This is included as part of the Policy Review Panel.

2.5 Infection Prevention and Control Unsure? - seek guidance from the IPC team.

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Checklist for the Review and Approval of Procedural Documents

Yes/No/

N/A

Comments/Detail

This document is not always accompanied by the procedural document. Please provide succinct information.

2.6 Training Requirements

2.6.1 If mandatory training identified has the Head of Learning, Development and Education been involved?

2.6.2 If Profession specific/Team and or service specific identified, how will this training requirement be brought to their attention?

e.g. Team Meetings, Supervision, CPD Activities (Daily Email via the Policy & Standards Officer)

3 Content

3.1 Is the policy written in a style which is concise and clear?

See RDaSH Intranet. http://nww.intranet.rdash.nhs.uk/ Communications/RDaSH Style Guide (with the exception that procedural documents should generally use single line spacing).

3.2 Is the policy written in the approved template?

4 Introduction

Does this section introduce the topic and include references to and applicability of any relevant legislation, national policy guidance, external agency recommendations, definitions and explanation of terms used?

5 Purpose

Does this section outline the objectives and intended outcomes of the process/system being described?

6 Scope

Are the target audience and activities

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Checklist for the Review and Approval of Procedural Documents

Yes/No/

N/A

Comments/Detail

This document is not always accompanied by the procedural document. Please provide succinct information.

covered by the document clearly stated?

7 Responsibilities, Accountabilities and Duties

7.1 Does this section provide an overview of the individual/departmental/service/ including levels of responsibility for document development?

7.2 Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation?

8 Process for Monitoring Compliance

8.1 Are there measurable standards to support monitoring compliance of the document?

8.2 Has any plan to use clinical audit been discussed with the Clinical Audit Department and included in the Trust Clinical Audit Forward Programme?

9 Equality Impact Assessment Screening

Has an Equality Impact Assessment (EIA) been completed as part of the document development/review process?

Review of the EIA takes part during the Policy Review Panel. (not required for PGD, nor SOP as this uses the EIA from the overarching policy stated within the SOP).

10 Links to any associated documents

Are local/organisational supporting documents referenced?

11 Referencing

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Checklist for the Review and Approval of Procedural Documents

Yes/No/

N/A

Comments/Detail

This document is not always accompanied by the procedural document. Please provide succinct information.

11.1 Are key references cited?

11.2 Are the references cited in full using the Harvard referencing style?

e.g. Jones R (2016) Mental Health Act Manual, eighteenth Edition, Sweet and Maxwell.

12 Approval/Ratification

If appropriate, have the Policy Forum (joint Human Resources/Staff Side Committee) (or equivalent) approved the document?

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3b Checklist – SOP/ Procedure (Please delete this section if using Checklist 3a)

Checklist for the Review and Approval of Procedural Documents

Yes/No Comments

1 Front Page

1.1 Title The title should commence with a short and snappy title and if required be followed by a full detailed title.

Document Control Box:-

1.2 Version: Please liaise with Policy & Standards Officer

1.3 Date Ratified This is the meeting date when the document as ratified. Can only be inserted towards the end of the process.

1.4 Name of Originator/Author Insert Job role of lead author.

1.5 Name of Approving Group/ Committee Insert name of Approving committee.

1.6 Date issued: Leave blank – for use by Policy & Standards Officer

1.7 Review Date: Insert review month/year anniversary

1.8 Target Audience Insert description of target audience

2 Development Process - Have the following been considered as part of the development of this document:

2.1 Mental Capacity Act If the document is in relation to patients the standard MCA statement template should be included. In addition the MCA Lead should be contacted as part of the consultation.

2.2 Privacy, Dignity and Respect Unsure – seek guidance from Equality & Diversity service

2.3 Safeguarding Unsure – seek guidance from the Safeguarding team.

2.4 Fraud This is included as part of the Policy Review Panel.

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Checklist for the Review and Approval of Procedural Documents

Yes/No Comments

2.5 Infection Prevention and Control Unsure - seek guidance from the IPC team.

2.6 Training Requirements

2.6.1 If mandatory training identified has the Head of Learning, Development and Education been involved?

2.6.2 If Profession specific/Team and or service specific identified, how will this training requirement be brought to their attention?

e.g. Team Meetings, Supervision, CPD Activities (Daily Email is supplied via the Policy & Standards Officer)

3 Aim

Is the Aim of the document clear? Has the Aim objectives and intended outcomes of the SOP been described.

4 Scope

Are the target audience and activities covered by the document clearly stated?

Include target audience, relevance to specific services or staff group and the activities covered by the SOP.

5 Link to Overarching Policy/Procedure

5.1 Does this section state the current title of the RDaSH overarching procedural document that references the SOP?

5.2 Is this SOP is to be overarched by a Regional (or other procedural document?)

If this SOP is overarched by a regional (other) Procedural document please state why this is necessary?

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(4) Approval/Ratification

(4.1) Responsible Group (if any)

Name of Responsible Group/ Committee:

Date of Responsible Group/ Committee Meeting:

Insert the date when the procedural document was presented for approval.

List names and designation of Group members

This information is required to confirm how widely the consultation has been.

Recommendations/changes: If approved subject to recommendations please state each of the changes required, the action taken, who by and the date completed. If not approved please state reason and recommendation.

Completed by Name of person completing this record

Date this information was recorded:

Date recorded.

Changes/Recommendations incorporated within procedural document

List any recommendations/changes being rejected for inclusion

Incorporated by: Name of author or delegated person completing the incorporated information

Date: Date completed

(4.2) Policy Review Panel (PRP)

Name of Responsible Panel: Policy Review Panel

Date of Responsible Panel Meeting:

This panel meets remotely. Please use date when this information was recorded (below).

List names and designation of Group members

Corporate Assurance Policy Officer

Clinical Effectiveness Lead

Equality and Diversity Lead (Equality and Diversity Assistant)/Deputy Director HR/OD

Anti-Crime Specialist

Mental Capacity Act Lead

Head of Learning, Development and Education

Other Specialist

Recommendations/changes: If approved subject to recommendations please state each of the changes required, the action taken, who by and the date completed. If not approved please state reason and recommendation.

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(4.2) Policy Review Panel (PRP)

Completed by Name of person completing this record

Date this information was recorded:

Date recorded.

Changes/Recommendations incorporated within procedural document

List any recommendations/changes being rejected for inclusion

Incorporated by: Name of author or delegated person completing the incorporated information

Date: Date completed

(4.3) Approving Group/ Committee

Name Approving Group/ Committee

Date Approving Group/ Committee Meeting:

Insert the date when the procedural document was presented to the Policy Review Panel

List names and designation of Group members

This information is required to confirm how widely the consultation has been.

Recommendations/changes: If approved subject to recommendations please state each of the changes required, the action taken, who by and the date completed. If not approved please state reason and recommendation.

Completed by Name of person completing this record

Date this information was recorded:

Date recorded

Changes/Recommendations incorporated within procedural document

List any recommendations/changes being rejected for inclusion

Incorporated by: Name of author or delegated person completing the incorporated information

Date: Date completed