POLICY ON PROCEDURAL
DOCUMENTS
Policy Title:
Executive
Summary:
Policy on Procedural Documents
This policy provides guidance to authors of policies and procedures and staff
in the Trust regarding the template for all Trust policies and procedures.
This document when followed will assist the Trust in meeting it’s
responsibilities with regards to risk management standards.
This policy should be read in conjunction with the Policy Schedule
Supersedes:
V4
Description of Transfer existing policy document into the corporate policy template.
Amendment(s):
Section 3.1a All policies whether Board approved or not use the same policy
template
Section 3.4a Further clarification given on the consultation process ensuring
that all individuals listed in the responsibilities section of the policy are to be
included in the consultation. Additionally, the inclusion of service lines if there is
an operational impact.
Section 3.4 Added requirement that consultation period is sufficient length of
time to allow responses for relevant consultees.
Section 3.7h and Section 5 Strengthened information on how monitoring
performance of the policy should take place through the use and reporting of
Key Performance Indicators
Appendix 1 removal of policy template for policies not approved by Board
This policy will impact on: All Trust policies and procedure documents
Local Specialist Policies (font and control page)
Financial Implications: Limited financial impact. Resources required in terms of policy author’s
time to review their policies to ensure that they meet the standards outlined in this document.
Policy Area:
Document
Trust Wide
Reference:
Version
Effective Date:
5.0
September 2016
Number:
Issued By:
Director of Corporate
Affairs and Governance
Review Date:
Author:
Head of Integrated
Governance
Impact Assessment
Date:
March 2019
APPROVAL RECORD
Consultation:
Approved and Ratified:
Received for information
Consultation:
Approved and Ratified:
Committees / Group
Date
OMT
Governance Managers
Risk Management Sub Committee
Changes approved by trust Safety
Quality and Standards committee
Operational Management Team
Meeting
OMT
Governance Managers
Risk Management Sub Committee
Changes approved by trust Safety
Quality and Standards committee
February15
January 15
03 February 15
March 2016
March 2015
February15
January 15
03 February 15
March 2016
Table of Contents
1. Introduction
2. Purpose
3. Roles and Responsibilities
4. Processes and Procedures
5. Monitoring Compliance with the Document
6. References
7. C
Appendices
Appendix 1
Template for Policies / Strategies
Appendix 2
Standard Operating Procedure Template
Appendix 3
Policy/ Procedure Approval Checklist
Appendix 4
Policy Consultation & Approval / Ratification process
Appendix 5
Policy Control including Archiving
Appendix 6
Policy/Procedures Registration Form
Appendix 7
Equality Impact Assessment Tool
Page
11
Page
12
1. Introduction
East Cheshire NHS Trust is committed to producing procedural documents of a consistent
standard that comply with the recommendations of external agencies by which we are monitored.
This Trust Policy on Procedural Documents describes the framework required to achieve this
consistent standard throughout the organisation.
2. Purpose
The purpose of this document is to provide staff tasked with writing or reviewing a procedural
document with a clear approach to developing, presenting and communicating the document
appropriately during the consultation phase. It also sets out the method for approval, and
awareness raising once the procedural document is operational, with considerations for support
and information to supplement its introduction.
This policy will be used for both local and corporate policies and procedures, as described in
Section 3, for which there is an agreed format and template contained within this policy.
3.0 Responsibilities
Chief Executive
The Chief Executive has overall responsibility for ensuring that the Trust has appropriate policies in
place and that robust monitoring arrangements are in place.
Director of Corporate Affairs and Governance
Director of Corporate Affairs and Governance has the delegated responsibility for ensuring that
appropriate arrangements to ensure robust policy governance across the Trust.
Executive Directors
All Executive Directors are responsible for ensuring that:
a) all policies and procedures produced by a member of their staff meet the requirements
specified in this policy;
b) staff review and update documents within the prescribed review deadlines;
c) if the author of a policy or procedure leaves, or their responsibilities change in relation to a
policy or procedure document, that the Policy Administrator is informed as to who the new
designated responsible person for that document is.
d) any recommendation(s) made by the Risk Management Sub-committee following an audit
of a document, is implemented by the author(s);
e) Ensuring that pre-approval consultation is appropriate and includes named individuals
within the Roles and Responsibilities section
f) Ratifying policies within their delegated area of accountability with the exception of Board
approved policies.
Deputy Director of Corporate Affairs and Governance
Deputy Director of Corporate Affairs and Governance has responsibility for the ensuring effective
policy governance across the organisation, in line with the Policy on Procedural Documents.
This includes ensuring systems are in place for:
a) maintaining a master set of documents on behalf of East Cheshire NHS Trust;
b) providing advice to authors in relation to consultation with the Health Overview and Scrutiny
Committee where the development / review of a document may result in a change in the
level or type of service provided by the Trust.
c) bringing to the attention of the Director of Corporate Affairs and Governance where the
implementation of a document may impact on the Scheme Delegated Powers.
d) ensuring version controlled copies are distributed to nominated leads in Service Lines in a
manner that can be monitored via: i.e. Portable Document Format version published on the
Trust’s public website (if applicable).
e) maintaining the records of audits undertaken by the Risk Management Sub-committee
against this policy.
f) chairing the Trust Risk Management Sub-committee
g) reviewing the Policy on Procedural Documents every 3 years or as required.
h) Providing bi-annual report on activity of Policy Governance to Safety Quality and Standards
Committee, as part of the six monthly Risk Management Sub Committee update.
Head of Integrated Governance
The Head of integrated Governance supports the Deputy Director of Corporate Affairs &
Governance, working closely with the Policy Administrator. A quarterly progress report is produced
and presented to the Risk Management Sub Committee.
Head of Communications, Engagement and Marketing
The Head of Communications, Engagement and Marketing is responsible for liaising with the
Policy Administrator ensuring that there is a system in place whereby:
a) Policies and procedures are published on to the Trust’s public website or where
appropriate, or an appropriate shared internal document repository. Impact assessments
are available on request, where completed.
Deputy Directors / Heads of Service / Clinical Directors
Deputy Directors / Heads of Service / Clinical Directors are responsible for:
a) ensuring that all policies authored by staff within their area of responsibility are developed
and reviewed in line with this policy
b) for having systems in place to monitor key performance indicators, manage non-compliance
and escalate associated risk where appropriate.
c) receiving and responding to policy cascades within designated timescales
d) the onward cascade to staff, of information regarding newly developed and reviewed
documentation received via the Policy Cascade System and maintaining an audit trail of
cascade.
e) acting as consultees for Corporate policies and procedures.
f) ensuring that the Policy Administrator is informed of changes to authorship of documents.
g) Ensuring that local service line procedures are developed as required and subject to
consultation, approval and ratification by the appropriate committee / sub-committee – see
policy schedule. Approval must be formally minuted.
Policy Administrator
The Policy Administrator (Governance Administrator and Subject Access Lead) is responsible for:
a) ensuring the Policy Schedule is maintained and presented to the Risk Management Subcommittee for monitoring the activity of documents.
b) Support nominated Governance Manager to undertake annual audit of compliance.
c) implementing the Policy Cascade System for all newly developed and reviewed
procedural documents and highlighting non-response from services to Governance
Managers.
d) ensuring distribution lists on the Policy Cascade System are maintained and updated
e) receiving all ratified policies/documents from authors.
f) ensuring policy documents are published on to Trust’s website, where appropriate, and
ensuring that obsolete versions of documents are removed.
g) ensuring the Press and PR Manager is informed of newly developed and reviewed policies/
guidance so that notification of this can be published in the organisation’s Team Brief for
staff awareness.
h) producing reports for the Risk Management Sub-committee highlighting policies which may
have exceeded their review dates and any non compliance with the Policy Schedule.
i) receiving notification if the author of a policy, procedure or guidelines document leaves or
their responsibilities change in relation to a policy, procedure or guideline document.
j) maintaining a master set of documents on behalf of East Cheshire NHS Trust
Authors
Authors of policies and procedures are responsible for:
a) ensuring that any document is:







written in line with this policy;
laid out using the corporate style, with all corporate information completed;
impact assessed, for all clinical and operational policies, using the Equality Analysis
(Impact Assessment). This should be undertaken prior to writing/updating the policy to
ensure that any identified impacts can be addressed in the new policy.
obtaining approval for the impact assessment from the trust’s Equality and Diversity
Lead.
appropriately consulted upon prior to being submitted for approval by East Cheshire
NHS Trust; including named individuals within roles and responsibilities section and key
stakeholders and where appropriate respective Safeguarding Leads for Children and
Adults
approved / ratified by the Trust Board or relevant ‘body’ as defined in The Policy
Schedule;
brought to the attention of the Deputy Director of Corporate Affairs and Governance if
the document references, or may impact on, the Scheme of Delegated Powers.
b) for contacting the Deputy Director of Corporate Affairs and Governance for advice as to
whether the Health Overview and Scrutiny Committee needs to be consulted i.e. where the
development/ review of a document may result in a change in the level or type of service
provided by the Trust.
c) for ensuring that once ratified, documents are forwarded in an editable electronic version to
the Policy Administrator for publication on the Trust’s website and if appropriate shared
internal document repository. This will be accompanied by the following the Policy/
Procedure Registration Form (Appendix 6) and the Equality Analysis (Impact Assessment)
(Appendix 7) and the Policy Approval Checklist (Appendix 3).
d) for retaining responsibility for reviewing documents they have produced in the event of any
of the following:



in response to recommendation(s) made by the Risk Management Sub-committee
following an audit of the document.
in response to recommendations following an incident.
by its review date (up to a maximum of five years) or as a result of any of relevant
changes in legislation, national or local guidance or policy.
Consultees
Consultees who may be committee/ group members, patients, staff side, members of the public or
other stakeholders and may have an interest in the policy are responsible for providing the author
with comments and suggesting amendments within timescales set by the committee/ group.
Chairs of Committees/ Groups
Chairs of Committees/ Groups who approve documents are responsible for:
a) ensuring the Policy Approval Checklist (Appendix 3) is completed prior to document
ratification;
b) approving consultation outside of set Committee/ Group meetings, in order to meet
organisational needs for timely approval;
c) signing the checklist to confirm document approved / ratified and sending the checklist to
the author(s).
Line Managers / Supervisors
Line Managers and Supervisors are responsible for:
a) bringing to the attention of their staff, the publication of a new document
b) retaining evidence that the information relating to a newly developed and amended
document has been cascaded within their team / department;
c) ensuring the new document is effectively implemented;
d) ensuring that their staff attend all training identified in respect of a new document.
All East Cheshire NHS Trust Staff
Staff are responsible for:
a) Accessing the relevant procedural documents as directed by their managers
b) Informing their line manager, and where appropriate escalating with the Service Line
management team, failure to receive procedural document information as set out in this
policy.
c) Attending all relevant training as required.
East Cheshire NHS Trust Board
The Trust Board receives assurance via the Safety Quality and Standards Committee that
procedural documents are effectively managed within the organisation, and, where appropriate,
approves/ratifies policy documents.
Safety Quality and Standards Committee
a) The Safety Quality and Standards Committee periodically reviews the Policy Schedule,
which is monitored by the Risk Management Sub-committee and provides assurance to the
Trust Board.
b) The Safety Quality and Standards Committee approves/ratifies policy documents as
required.
Risk Management Sub-committee
The Risk Management Sub-committee is responsible for;
a) auditing policy documents to ensure they meet the Policy on Procedural Documents against
the policy / procedure approval checklist (Appendix 3).
b) reviewing the Policy Schedule, which identifies the responsible committee/ group for the
approval and ratification of documents.
c) identifying when a document will be subject to review.
d) reporting to the Safety Quality and Standards Committee
e) monitor the Key Performance Indicators in this policy.
4.0 Processes and Procedures
4.1
Scope
The scope of this policy includes the following procedural documents;
a) Policy
A policy can be defined as a high level statement of intent or set of principles with
widespread application that provide a basis for consistent decision-making and resource
allocation. Policies produced by external authors / organisations may not comply with all
standards outlined in this policy. Please note all policies produced by the Trust will be
formatted in line with corporate style – see appendix 4
b) Procedure or Standard Operating Procedure
A procedure can be defined as a standardised method of performing clinical or non-clinical
tasks. Procedures, including standard operating procedures, usually have a narrow
application and include a series of actions, or detailed instructions, to be carried out in order
to achieve a safe, effective and consistent outcome.
This policy does not cover the following documents;
c) Protocol
A protocol can be defined as a rigid statement of practice, which will be adhered to: they
allow little flexibility or variation and as such are only suitable for certain, very specific
aspects of practice, where the course of action is universal.
d) Clinical Guideline/ Guidance
A clinical guideline is an evidence-based overview of treatments and diagnostic tests to be
undertaken in certain conditions. They are designed to provide advice, guidance and
direction to staff whilst leaving room for professional judgment, and adaptation, to fit
individual circumstances. To ensure that clinical guidelines are evidence based, support is
offered to authors by the Library Services [email protected] Once updated
guidelines should be sent to policy co-ordination using the registration form (appendix 6).
All clinical guidelines are uploaded to the Clinical Guideline page on the infonet.
e) Strategies (although the same corporate document format, as at Appendix 1, will be used)
A strategy is defined as a plan of action designed to achieve a long-term or overall aim within
the organisation.
3.2
Style and format
Procedures should be formatted in line with the template contained in Appendix 2.
All policies will be in the following format:
a) Clearly marked as draft on each page which will be removed when the policy is ratified
and published.
b) Will be written in Arial size 11 font
c) Will have the title of the policy on the front page in Arial size 26 font
d) Will have the policy control page completed and this will be the second page of the policy
after the front sheet.
e) A contents page will be included and all pages numbered (except front page)
f)
Each page will include a footer detailing in Arial Size 8 Font the name of the author (by
designation), version number and date of publication
g) The document will be numbered sequentially throughout to identify the section and
subsection of text.
h) The policy will be set out using the following subsections as a minimum (extra subsections
can be added if required), they can be in any order according with particular need but it is
recommended that the following order is used to aid with the flow of reading and to ensure
standardisation across the Trust: (If writing a procedure the template in Appendix 2 will be
followed).







Introduction, sets out the reason why the policy is needed
Purpose which is a summary of the purpose of the policy and its aims
Roles and Responsibilities, which details the responsibilities that employees and
committees/ groups have relating to the policy. The policy will clearly state the
organisational responsibilities held by employees of the Trust/others with regards to its
implementation, monitoring and other duties therein. All job titles will be checked when
policies are reviewed to ensure that they remain accurate in title and in responsibility.
Processes and Procedures, which this area sets out the scope of the policy and identifies
the plans that the Trust has in place to implement the policy. It identifies key features
relating to the implementation of the policy such as the competence of staff, safety
considerations, communication issues, training requirements
Monitoring Compliance with the Policy: this section will clearly state how the
performance of the Trust will be monitored following the implementation of the policy. A
number of key performance indicators, which are specific and measurable, will need to be
identified within the policy against which performance will be assessed. Each Key
performance Indicator will identify whose responsibility it is to measure performance, how
often this will take place and where assurance will be provided to (named committee /
group). This section should also include details of review. State clearly the review
arrangements for the policy, when it will be reviewed and who is responsible for undertaking
the review. The review will be undertaken by combining the findings of the performance
review and audit. These findings will identify any changes required to be made to the policy.
References: this section includes links to other related policies, national guidance, web
sites or other relevant source of information
Appendices and any other referenced documentation required such as definitions of terms
used, glossary etc.
k) Policies will be drafted in a trust wide context except those that are classified as other
procedural documents; these will be fit for purpose. A template for policies is outlined in
Appendix 1.
l)
Policies will state what legal, professional or national guidelines are related to it and/or are
drivers for it. Where national guidelines are available these will be incorporated, and duly
referenced, or alternatively, the national guideline issued with the control sheet
acknowledging the fact.
m) Each policy will clearly identify any risks associated with its implementation and use (via the
risk assessment process), and any strategies for managing those risks. The policy control
document will highlight any risk management issues (which may be clinical or non clinical in
nature, including health and safety matters) to be noted by the appropriate Trust risk
management groups (the policy schedule identifies the appropriate groups/committees).
n) Where policies have the potential to be open to fraud of any nature, an electronic copy of
the document will be sent to the Local Counter Fraud Specialist, Kerry Ann Wheat. Tel
0161 206 1911 Mobile 07825 456 226 or by using the email address
[email protected] or [email protected] for assessment. Examples of potential
fraud include policies with a financial element (e.g. claims policy, procurement policy) or
any policy that includes “making or signing” a declaration. The policy will not be sent for
approval/ratification without this being undertaken. This will be indicated on the Policy
Control Sheet as part of consultation.
o) Policies will identify which manager is to be responsible for maintaining the policy. Job titles
will be used.
p) In order to avoid confusion over the writing of dates the following style is to be used “25 Dec
11”
q) Policies will cross reference clearly to other related policies and procedures
r) The first draft copy of the policy will be version 0.1 with all subsequent reviewed/amended
draft documents numbered sequentially. The 0 prefix will be maintained throughout the first
drafting process in order to show the version.
s) The first ratified/published copy of the policy will be version 1.0
t)
As policies enter the review process they are then managed as a draft version of the
version stated on the policy. All amendments as part of the review process will be
numbered sequentially e.g. 1.1, 1.2, and 1.3. The reviewed policy once ratified / published
will then become version 2.0 and the process repeated at the next review using sequential
numbers.
u) Equality Impact Assessment - All clinical and operational policies will be impact assessed to
ensure they do not discriminate on the grounds of race, disability, age, sex, sexual
orientation,
religion or belief, gender reassignment, marriage and civil partnership,
pregnancy and maternity, carers and all other relevant groups. Further information is
available in the Trust’s Equality and Human Rights Policy. Staff should use the
demographic data contained within the template assessment tool to identify possible
impact.
v) A copy of the impact assessment is contained in Appendix 1 and can be downloaded from
the internet
http://nww.eastcheshire.nhs.uk/Trust%20forms/EIA%20template%20June%202014.doc
This document will be placed as the last pages of the policy/procedure.
w) Appendix 1 provides a template for the development of policies in the Trust format. This
template will be used as a minimum. Extra sections can be added as appropriate
depending upon the requirements of the policy/area it covers. In addition there is a standard
operation procedure template that is to be used where appropriate.
x) In order to ensure that all aspects of this policy are addressed a checklist has been
provided for policy writers to assess the policy against in Appendix 3.
3.3
Definitions of terms used
Abbreviations can be used in policy documents providing that it is referenced in full on its first use.
A full glossary of terminology should be included for reference where appropriate.
3.4
Consultation process
a) East Cheshire NHS Trust is committed to partnership working, and as such encourages the
input of both Management and Staff Side representatives into policy development. Whilst
one person/role i.e. chair of a group or committee will be identified as the policy lead,
perhaps because they have an interest or skill in the subject matter, by working with both a
management and staff side representative, a more balanced approach to its development
can be achieved.
Consultation must include all individuals referred to in the responsibilities section of the
policy to ensure that they are aware of their responsibilities and to allow their input /
comment on the document. Where there is an operational impact, relevant service lines
must also be included in the consultation. Appendix 4 describes the process in use.
b) The consultation period must be of sufficient time to allow comment from all relevant
individuals.
3.5
Policy Approval and Ratification process
a) Policies presented for approval will include details of the consultation process followed. This
will be included on the policy control page accompanying the policy. Appendix 4 describes
the process in use.
b) The policy will then be forwarded to the appropriate committee / group (as per the policy
schedule) for ratification on behalf of the board. In some circumstances this may be the
same as the approving committee/ group.
c) Where minor changes are required in a policy or procedure these can be undertaken
without the full ratification process. These changes will be brought to the attention of the
relevant group/ committee and be noted formally.
d) Policies may be ratified outside of committees/ groups by an Executive Director or the Chair
of the approving group should this be required. Circumstances where this process may be
required include; where a delay in ratifying policy may be detrimental to clinical care, staff or
business continuity.
3.6
Procedure Approval and Ratification
a) Service Line procedures should be subject to consultation, approval and ratification by the
appropriate committee / group in line with Policy Schedule. Approval/ ratification must be
evidenced in meeting minutes.
3.7
Communication
a) A key part of communicating the policy is raising awareness to all employees that the new
policy is now in place and operational in the organisation. This will include the following
routes:

3.8
Consider placing an article in Team Brief/Staff Matters describing the policy, any
changes made since the last version, how it will benefit the Trust and when it became
operational. It may be appropriate to deliver briefing sessions/ updates for staff and
managers to introduce new policies and raise awareness of changes to existing
policies.
b) Additionally, all updated policies will be cascaded via Datix to nominated cascade leads
within each service line for onward cascading to their teams.
.
Review arrangements (all policies / procedures)
a) Once ratified all policies and procedures will be reviewed in line with the Trust Policy
Schedule and as detailed on the policy control page. The frequency of review will depend
upon a number of factors namely: what the policy and procedure relates to, the results of
performance reviews and audits, the changes in conditions, situations, personnel in the
Trust making the review date more frequent, changes in best practice, guidance or
legislation and any other factors that may render the policy/procedure out of date.
b) The maximum period that may be placed on a review period is five (5) years.
c) Three months before the policy/procedure is due to expire, the author will be informed and
requested to review, update and re-ratify the document as appropriate.
3.9
Control of the documents including archiving arrangements
a) All policies (excluding those for which public disclosure could impact on the business of the
Trust) will be available on the Trust’s internet site. The author is responsible for sending an
electronic copy of the policy, with registration form (Appendix 6) to the email address: [email protected] approved and ratified by the appropriate committee/
groups (as per the policy schedule).
b) An archive of superseded policies will be maintained for 12 years. Clinical Practice Policies
relating to Children/Maternity will be retained for up to 25 years.
3.10 Associated documentation and references
Many policies and procedures are complex documents designed to deal with complex and
sensitive situations. Therefore specific management guidance notes will sometimes be required to
supplement the policy, in order to aid its use in operational practice.
Guidance notes can be included in the main body of the policy, as an appendix or separate
document, but be aware that both will need to be readily accessible together, so that they can be
read side by side. The contents page will clearly state the appendices used in the document.
Where other guidance documents/information is referenced or where the reader needs to review
other policies/documents in conjunction with the policy in question this should be included within
the reference list and where appropriate in the Executive Summary.
3.11 Implementation of Policy
The policy will be approved and ratified by the Risk Management Sub-committee.
There are no formal training requirements relating to the implementation of this policy although
staff can obtain guidance from any manager within the Corporate Affairs and Governance
Directorate should they have problems/questions when developing their document.
5.0 Monitoring Compliance with the Document
6.1
Compliance with this policy will be monitored against the following key performance indicators:
a)
b)
number of non-Board approved policies that comply with format standards outlined
completion of equality impact assessment for identified sample of approved policies
In addition an annual sample audit will be undertaken to review Trust compliance with the audit
requirements with a minimum of 20 policies.
This policy will be reviewed on a three yearly basis by the Deputy Director of Corporate Affairs and
Governance.
6.0
References
This document should be read in conjunction with the policy schedule.
Appendix 1
TITLE
Policy Title:
Executive
Summary:
Supersedes:
Description of
Amendment(s):
This policy will impact on:
Financial Implications:
Policy Area:
Version
Number:
Issued By:
Author:
Document
Reference:
Effective Date:
Review Date:
Impact Assessment
Date:
APPROVAL RECORD
Committees / Group
Consultation:
Approved by Director:
Ratified by:
Received
for
information:
Date
Table of Contents
1.Introduction
2. Purpose
3. Roles and Responsibilities
4. Processes and Procedures
5. Monitoring Compliance with the Document
6. References
7. Communication
Appendix
Page
11
Page
12
1. Introduction
Sets out the reason why the policy is needed.
2. Purpose
A summary of the purpose of the policy and its aims.
3. Responsibilities
Details the responsibilities that employees and committees/ groups have relating to the policy. The policy
will clearly state the organisational responsibilities held by employees of the Trust/others with regards to
its implementation, monitoring and other duties therein. All job titles will be checked when policies are
reviewed to ensure that they remain accurate in title and in responsibility.
4.
Processes and Procedures
Sets out the scope of the policy and identifies the plans that the Trust has in place to implement the
policy. It identifies key features relating to the implementation of the policy such as the competence of
staff, safety considerations, communication issues, training requirements.
5. Monitoring Compliance with the Document
Clearly state how the performance of the Trust will be monitored following the implementation of the
policy. A number of key performance indicators, which are specific and measurable, will need to be
identified within the policy against which performance will be assessed. Each Key performance Indicator
will identify whose responsibility it is to measure performance, how often this will take place and where
assurance will be provided to (named committee / group). This section should also include details of
review. State clearly the review arrangements for the policy, when it will be reviewed and who is
responsible for undertaking the review.
6.
References
This section includes links to other related policies, national guidance, web sites or other relevant source
of information.
Appendix 1
Appendix 2
Standard Operating Procedure Template
Title of Standard Operation Procedure:
Reference Number:
Version No:
Issue Date:
Review Date:
Purpose and Background
Scope (i.e.
organisational
responsibility)
Vital functions
affected by this
procedure:
Monitoring Compliance
Process to
be used for
monitoring
e.g. audit
Responsible
individual/
committee for
carrying out
monitoring
Frequency of
monitoring
Responsible
individual/
committee for
reviewing the
results
Responsible
individual/
committee for
developing
action plan
Responsible
individual /
committee for
monitoring
action
plan
Escalations (if you require any
further
clarification regarding this
procedure
please contact):
Committees / Group
Date
Consultation:
Approval Committee
Ratified by Committee:
Received for information:
21
Operating Procedure
Additional Information (if appropriate)
Back up information (if appropriate)
Document Change History
Roles and Responsibilities
Abbreviations
References
Standard Operating Procedure Contents listing
Section 1:
Front Page Information
Standard Operating Procedure Number
Version Number
Dates
Approval, authorisation, consultation
Purpose and Background
Scope
Vital Functions affected by procedure
Audit
Escalations
Author
Approval Record
Section 2:
Operating Procedure
Section 3:
Additional Information
Section 4:
Procedure Back up Information
Document Change History
Roles and Responsibilities
Abbreviations
References
Appendix 3 – Policy / Procedure Approval Checklist
Policy being approved:
Date:
Reviewed by:
Format/Content
Present in
Policy
Yes
No
Arial Font
Font size 11
Trust logo on front page
Title of policy on front page
Policy control page completed
Footer of each page details: name of
policy, author and date of publication
Numbered sequentially
Policy statement present – containing
the objectives of the policy
Roles and responsibilities section
present
Implementation section present
Appendices sections as appropriate
Manager responsible identified
Cross referenced to other documents
as appropriate
Impact assessment carried out
Glossary included as appropriate
Appendix 2 Health and Safety Process Flow Chart
Comments
(state if not applicable)
Appendix 4 – Policy Consultation & Approval/Ratification Process
Requirement for new policy or review of policy
identified.
Policy written or reviewed in line with best practice,
local and national guidance by identified policy
author(s)
Consultation: draft policy circulated to identified
individual staff/groups for review/comment
Comments sent to policy author(s) for possible
incorporation in reviewed/new policy
The Policy Schedule will
identify the appropriate groups
or individuals that will need to
be consulted or who will be
responsible for approval
Approval/Ratification: following consultation period
and changes to policy, document sent to appropriate
group/committee for ratification
Minor changes
identified by ratifying
group
Policy ratified
Changes made
Where no committee/group is able to
ratify/approve policy – policy sent to
Executive Director for ratification/approval
Policy control & communication
process commences
Appendix 5
Policy Control Including Archiving
New and Revised Policies
1. Registration Form and new policy received via the [email protected]
email address
2. Policy Administrator checks to ascertain if Control Template is completed with approval
dates and approved Impact Assessment have been added
3. Policy details are added to the spreadsheet and identifying number is allocated
4. Policy is converted to PDF
5. Policy is saved in a new folder in the Policy shared drive in Word and PDF versions
6. Previous policy is archived by cutting and pasting its folder into the new policy’s folder
7. Policy is uploaded under appropriate letter on the internet
8. Registration form returned to author for reference, with upload date added
9. Policy is cascaded via the Datix system to nominated cascaders for each service area and
a copy is sent to the associate directors / service leads for information
Appendix 6
POLICY / PROCEDURE / GUIDELINE REGISTRATION FORM
This form must be used for all new or amended policies, procedures and guidelines,
and those to be withdrawn without replacement
When completing this form, please refer to the Policy on Procedural Documents
available on the Trust internet website, policy section, listed under “Procedural
Documents”
1. Author information for new or amended document
Name:
Job Title:
Service/Dept:
Service Line:
Telephone:
Email address
2. Is this document a….. (Please type YES next to the correct option)
Policy
Other
Procedure
Clinical Guideline
……………………………………………………………………………..
Please send to [email protected]
3. New or Amended Document Information
a Title of document:
b
Effective date
c
Review date
d
Is this a new or reviewed document?
e
To enable accurate archiving of
superseded document to take place
please complete this section if reviewed.
f
g
h
i
j
Which committee / group approved this
document? Please attach a copy of the
minutes as evidence.
Is this document one of the small
number which should NOT be displayed
on the Internet (authors of relevant
policies will be aware of this restriction).
Please clarify the order of wording to be
used when listing the document title on
the Internet. Maximum 7 words.
Keyword metatags for searching:
New
Reviewed
Superseded document FULL title:
Superseded document number (if
known):
Yes
No
Rational for Restricted Publication:
POLICIES ONLY - To enable efficient
cascade of this policy please state the
target groups.
Name:
Date:
Please make sure you include the following as part of the document, without them it cannot
be processed:
1. Control Sheet including the Review Date
2. For clinical and operational policies - how any identified adverse impacts will be
managed should be included in the policy Approved Equality Assessment Form. For
approval contact the Trust’s Equality and Diversity Lead [email protected]
3. Document Checklist
4. Withdrawal Without Replacement
a
Title of Policy/Procedure/ Guideline
& Number if known
b Reason for document withdrawal
c
Name of committee that has
approved withdrawal, without
replacement
Name of Applicant
Date
Please send your completed form with new or updated document
to: [email protected] or call Extension 3823
A copy of this document, with document control section completed, will be emailed to
the person named in (1), as confirmation that the required action has been
undertaken.
Document Control (Governance staff only)
New /Amended Policies / Procedures / Guidelines
Date received
Policy Number allocated
Date uploaded to Internet
(confirmation will be sent to author)
Withdrawn Policies / Procedure / Guidelines
Date received
Date removed from Internet
(confirmation will be sent to author)
Appendix 7
Equality Analysis (Impact assessment)
Please START this assessment BEFORE writing your policy, procedure, proposal, strategy
or service so that you can identify any adverse impacts and include action to mitigate these
in your finished policy, procedure, proposal, strategy or service. Use it to help you develop
fair and equal services.
Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have
equal access.
1. What is being assessed?
Policy on Procedural Documents
Details of person responsible for completing the assessment:
 Name: Lorraine Jackman
 Position: Deputy Director of Corporate Affairs and Governance
State main purpose or aim of the policy, procedure, proposal, strategy or service:
(usually the first paragraph of what you are writing. Also include details of legislation,
guidance, regulations etc. which have shaped or informed the document)
This policy provides guidance to authors of policies and procedures and staff in the Trust regarding
the template for all Trust policies and procedures. This document when followed will assist the
Trust in meeting its responsibilities with regards to effective risk management.
2. Consideration of Data and Research
To carry out the equality analysis you will need to consider information about the people who
use the service and the staff that provide it. Think about the information below – how does
this apply to your policy, procedure, proposal, strategy or service
2.1 Give details of RELEVANT information available that gives you an understanding
of who will be affected by this document
Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West &
Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people
resided in CE and 329,608 people resided in CWAC.
Age: East Cheshire and South Cheshire CCG’s serve a predominantly older population than
the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700
people).
Vale Royal CCGs registered population in general has a younger age profile compared to the
CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people).
Since the 2001 census the number of over 65s has increased by 26% compared with 20%
nationally. The number of over 85s has increased by 35% compared with 24% nationally.
Race:
 In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British
 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK – Poland
and India being the most common


3% of CE households have members for whom English is not the main language
(11,103 people) and 1.2% of CWAC households have no people for whom English is
their main language.
Gypsies & travellers – estimated 18,600 in England in 2011.
Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51%
female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be
transgender and for CWAC 1,500 transgender people will be living in the CWAC area.
Disability:
 In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health
problem or disability
 In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with
dementia in CWAC. 1 in 20 people over 65 has a form of dementia
 Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or
deafness.
 C. 2 million people in the UK have visual impairment, of these around 365,000 are
registered as blind or partially sighted.
 In CE, it is estimated that around 7000 people have learning disabilities and 6500 people
in CWAC.
 Mental health – 1 in 4 will have mental health problems at some time in their lives.
Sexual Orientation:
 CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE
was estimated at18,700, based on assumptions that 5-7% of the population are likely
to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The
Lesbian & Gay Foundation).
 CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were
c. 20,000 LGB people in the area and as many as 1,500 transgender people residing
in CWAC.
Religion/Belief:
The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001
to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying
they had no religion doubled in both areas from around 11%-22%.
 Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester
 Sikh:
0.07% of Cheshire East and 0.1% of Cheshire West & Chester
 Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester
 Hindu:
0.36% of Cheshire East and 0.2% of Cheshire West & Chester

Jewish:
0.16% of Cheshire East and 0.1% of Cheshire West & Chester

Muslim:
0.66% of Cheshire East and 0.5% of Cheshire West & Chester



Other:
0.29% of Cheshire East and 0.3% of Cheshire West & Chester
None:
22.69%of Cheshire East and 22.0% of Cheshire West & Chester
Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester
Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just
over 11% (37,000) of the population in CWAC.
2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or
concerns raised either from patients or staff (grievance) relating to the policy, procedure,
proposal, strategy or service or its effects on different groups?)
No – staff have indicated that this policy is welcomed and supportive. The policy itself highlights
and promotes a requirement for all policies and procedures to be impact assessed in relation to all
aspects of possible discrimination.
2.3 Does the information gathered from 2.1 – 2.3 indicate any negative impact as a
result of this document?
No
3. Assessment of Impact
Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy
or service (part 1) and looked at the data and research you have (part 2), this section asks
you to assess the impact of the policy, procedure, proposal, strategy or service on each
of the strands listed below.
RACE:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, racial groups differently?
Yes  No X
Explain your response:
This policy states that an equality analysis (impact assessment) must be carried out and
relevant groups consulted. This will have a positive impact in identifying any adverse
impacts on any protected group.
_________________________________________________________________________
___
GENDER (INCLUDING TRANSGENDER):
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, different gender groups differently?
Yes  No X
Explain your response:
This policy states that an equality analysis (impact assessment) must be carried out and
relevant groups consulted. This will have a positive impact in identifying any adverse
impacts on any protected group
DISABILITY
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, disabled people differently?
Yes 
No X
Explain your response:
This policy states that an equality analysis (impact assessment) must be carried out and
relevant groups consulted. This will have a positive impact in identifying any adverse
impacts on any protected group
_________________________________________________________________________
_____
AGE:
From the evidence available does the policy, procedure, proposal, strategy or service,
affect, or have the potential to affect, age groups differently?
Yes  No
X
Explain your response:
This policy states that an equality analysis (impact assessment) must be carried out and
relevant groups consulted. This will have a positive impact in identifying any adverse
impacts on any protected group
LESBIAN, GAY, BISEXUAL:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, lesbian, gay or bisexual groups differently?
Yes
 No 
Explain your response:
_________________________________________________________________________
_____
RELIGION/BELIEF:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, religious belief groups differently?
Yes  No X
Explain your response:
This policy states that an equality analysis (impact assessment) must be carried out and
relevant groups consulted. This will have a positive impact in identifying any adverse
impacts on any protected group
_________________________________________________________________________
_____
CARERS:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, carers differently?
Yes  No X
Explain your response:
This policy states that an equality analysis (impact assessment) must be carried out and
relevant groups consulted. This will have a positive impact in identifying any adverse
impacts on any protected group
_________________________________________________________________________
_____
OTHER: EG Pregnant women, people in civil partnerships, human rights issues.
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect any other groups differently?
Yes  No X
Explain your response:
This policy states that an equality analysis (impact assessment) must be carried out and
relevant groups consulted. This will have a positive impact in identifying any adverse
impacts on any protected group_________________________________________________________________________
_____
4. Safeguarding Assessment - CHILDREN
a. Is there a direct or indirect impact upon children? Yes 
No X
b. If yes please describe the nature and level of the impact (consideration to be given to
all children; children in a specific group or area, or individual children. As well as
consideration of impact now or in the future; competing / conflicting impact between
different groups of children and young people:
c. If no please describe why there is considered to be no impact / significant impact on
children
Policy provides a governance framework for the Trust policies and procedures and does not
relate to patient care.
5. Relevant consultation
Having identified key groups, how have you consulted with them to find out their views and
that the made sure that the policy, procedure, proposal, strategy or service will affect
them in the way that you intend? Have you spoken to staff groups, charities, national
organisations etc?
Consultant has taken place with the following staff groups: Heads of Service, Governance
Managers, Risk Management Sub-committee. This includes staff who develop policies and
have a role in ratifying and implementing policies in their service areas.
6. Date completed: January 2015
Review Date: January
2018
7. Any actions identified: Have you identified any work which you will need to do
in the future to ensure that the document has no adverse impact?
Action
Lead
Date to be Achieved
8. Approval
and Diversity
– At this point, you should forward the template to the Trust Equality
Lead [email protected]
Approved by Trust Equality and Diversity Lead:
Date: 2.2.15