Insert Document Title Here
V1.0
Date
Considerations before completing this document
Undertaking a meaningful deliberation of how this policy/strategy/plan affects people (patients, staff and public) is important in the context of ensuring we work towards providing good treatment and outcomes for all, and treating people according to their individual needs. In order to do this, particular consideration needs to be given to understanding and responding to the needs of people based on their characteristics such as sex, race, disability, age, etc, Consideration should also be given to groups of people who may experience health inequalities e.g. the homeless, to try to reduce those poorer health outcomes. To do this adequately, requires careful consideration of the Equality Impact of this document before you start.
· Does this affect people? If no, the EIA is not needed. Record “This is not a person-related document” on the EIA form
· If yes, how will you consult with affected people to get their views? (Think about staff groups, local community groups, networks, etc.)
· Could particular protected groups be more affected than others? If so, how will you mitigate this? (you won’t know this if you haven’t consulted)
· Why is this a good idea? Is there research to support it?
· What information is available relating to the local population, patient information (e.g. attendance, DNAs) and staff (workforce data) which will support this document?
Particular attention should be given to:
Protected characteristicsAge
Gender (including transgender)
Sexual orientation
Religion or Belief
Ethnicity
Disability
Pregnancy/maternity
Marriage/Civil Partnership (workforce only) / Groups who experience health inequalities
People who may be 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
This will aid your completion of the Equality Impact Assessment which must be completed alongside the document. Training supporting the effective completion of EIAs is available via ESR or for help and advice please read the Equality Impact Assessment Policy available here or contact the Human Rights, Equality and Inclusion Lead
Summary.
This should be a flow chart that describes the process and shows the accountable person or group at each stage.
For guidance on how to produce a flow chart refer to Appendix 1 of:
Guidance on Producing Mobile Summary Guidance for the RCHT Mobile Guidelines Website - available via the RCHT Intranet.
An example of a policy flow chart can be found in the:
Policy for the Development and Management of Knowledge, Procedural and Web Documents (The Policy on Policies)
Table of Contents
Summary. 3
1. Introduction 5
2. Purpose of this Policy/Procedure 5
3. Scope 5
4. Definitions / Glossary 5
5. Ownership and Responsibilities 5
5.5. Role of the Managers 6
5.6. Role of the XXX Group/Committee 6
5.7. Role of Individual Staff 6
6. Standards and Practice 6
7. Dissemination and Implementation 6
8. Monitoring compliance and effectiveness 7
9. Updating and Review 8
10. Equality and Diversity 8
10.3. Equality Impact Assessment 8
Appendix 1. Governance Information 10
Appendix 2. Initial Equality Impact Assessment Form 13
This table can be automatically updated by:
Right Click on the table
Select ‘Update Field’
Update ‘Entire Table’
To ensure that new headings are included in the table they must be formatted in the same way as the existing headings. This is most easily achieved by using the ‘Format Painter’ function to copy one heading style to a new heading.
1. Introduction
1.1. This section should provide an overview of the importance and role of the subject covered by the document. If the document is created in support of a parent policy/procedure then this should be referenced.
1.2. This version supersedes any previous versions of this document.
1.3. Data Protection Act 2018 (Also Known as General Data Protection Regulations – GDPR) Legislation (if applicable)
Should you write a document that relates to or contains information relating to the handling of or entries in health or corporate records, then consideration should be given to the GDPR regulations and how this applies within the document. If your policy does include records/capturing information, a paragraph needs to be inserted at the beginning of the document under section 1.
The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in.
The DPA18 covers how the Trust obtains, hold, record, use and store all personal and special category (e.g. Health) information in a secure and confidential manner. This Act covers all data and information whether held electronically or on paper and extends to databases, videos and other automated media about living individuals including but not limited to Human Resources and payroll records, medical records, other manual files, microfilm/fiche, pathology results, images and other sensitive data.
DPA18 is applicable to all staff; this includes those working as contractors and providers of services.
For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team
2. Purpose of this Policy/Procedure
2.1. This should provide an explanation of the intent/purpose of the document and the rationale for its development. Where appropriate, reference should be made to statutory or legal requirements or to evidence-based good practice. An outline of the objectives and intended outcomes should be provided for the process or system being described.
2.2. Next Paragraph.
2.2.1. Sub Paragraph
3. Scope
3.1. Who does this policy/procedure apply to, i.e. who will have to implement, or be affected by, this policy/procedure.
3.2. Next Paragraph.
4. Definitions / Glossary
4.1. A list and description of the meaning of the terms used in the context of the document should be provided if it is considered necessary.
4.2. Next Paragraph.
5. Ownership and Responsibilities
5.1. This section should give a detailed overview of the strategic and operational roles responsible for the development, management and implementation of the policy/procedure.
5.2. This section should be a quick reference point for all staff to look at and understand if they have a role to play in the implementation of this policy and what that role is. A good rule of thumb is to check that everyone you later go on to mention in this policy should be identified in this section.
5.3. Normally a responsible executive officer should be identified; a responsible reporting group (e.g. Trust Board, Medicine Practice Committee, Operational Management Group) should be identified, then key lead professionals, professional groups and so on. Here are some headings to get started with:
§ lead executive
§ *responsible reporting* group
§ *lead professional*
§ *sub groups*
§ divisional management team
§ line-managers
§ *specialist staff*
§ clinical and non clinical staff members
5.4. The listing should include details of the groups or committees, as well as individuals, e.g.
5.5. Role of the Managers
Line managers are responsible for:
§ XXX.
§ XXX.
5.6. Role of the XXX Group/Committee
The XXX Group/Committee is responsible for:
§ XXX.
§ XXX.
5.7. Role of Individual Staff
All staff members are responsible for:
§ XXX.
§ XXX.
6. Standards and Practice
6.1. This section may use more relevant wording and is used to provide details and information describing the practices, systems, and processes staff are expected to follow in order to comply with the procedural document.
6.2. Next Paragraph.
6.2.1. Sub Paragraph
6.2.2. Next Sub Paragraph
7. Dissemination and Implementation
7.1. A brief summary on how the document will be disseminated should be included, together with details of any special arrangements that may be required or help in aiding retrieval. If the document replaces a previous version the summary should refer to archiving arrangements and any process in place ensuring staff are aware of the new version.
7.2. This section should also describe the arrangements for implementing the policy, e.g. provision of training and support for staff; series of roadshows; etc. If there is a training need associated with this policy the author must ensure that this is noted on the Governance Coversheet above and also ensure that the Learning and Development department are aware of this need.
8. Monitoring compliance and effectiveness
This part must provide information on the processes and methodology for monitoring compliance with, and effectiveness of, the policy/procedure using the table below.
Element to be monitored / What part of the process do you intend to monitor (you may intend or need to monitor all of it)Lead / Who will lead on this aspect of monitoring?
Tool / What tool will be used to monitor/check/observe/asses/inspect/authenticate that everything is working according to this key element from the approved policy?
Attach the tool to the policy or no one will know what you are monitoring.
Frequency / How often is the need to monitor each element?
How often is the need to complete a report?
How often is the need to share the report?
Individualise the timeframe(s)
Reporting arrangements / Who or what committee will the completed report be sent to.
How will each report be interrogated to identify the required actions and how thoroughly should this be documented in e.g. meeting minutes.
The lead or committee is expected to read and interrogate the report to identify deficiencies in the system and act upon them
Consider stating this responsibility in committee terms of reference
Acting on recommendations and Lead(s) / Which committee, department or lead will undertake subsequent recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes?
Required actions will be identified and completed in a specified timeframe
Consider stating this responsibility in committee terms of reference
Change in practice and lessons to be shared / How will system or practice changes be implemented the lessons learned, and how will these be shared.
Possible wording to use for this column.
Required changes to practice will be identified and actioned within … (state a specific time frame). A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders
9. Updating and Review
9.1. This section covers information regarding the review process. All policy documents should be reviewed no less than every three years. Where appropriate, the author may set a shorter review date.
9.2. Revisions can be made ahead of the review date when the procedural document requires updating. Where the revisions are significant and the overall policy is changed, the author should ensure the revised document is taken through the standard consultation, approval and dissemination processes.
9.3. Where the revisions are minor, e.g. amended job titles or changes in the organisational structure, approval can be sought from the Executive Director responsible for signatory approval, and can be re-published accordingly without having gone through the full consultation and ratification process.
9.4. Any revision activity is to be recorded in the Version Control Table as part of the document control process.
10. Equality and Diversity
10.1. All new and revised documents (excluding Human Resource documents) must acknowledge adherence to the Trust agreed equality and diversity statement by inclusion of the following:
This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.
10.2. All Human Resources policies must include, or refer to, the following employment statement:
Royal Cornwall Hospitals NHS Trust is committed to a Policy of Equal Opportunities in employment. The aim of this policy is to ensure that no job applicant or employee receives less favourable treatment because of their race, colour, nationality, ethnic or national origin, or on the grounds of their age, gender, gender reassignment, marital status, domestic circumstances, disability, HIV status, sexual orientation, religion, belief, political affiliation or trade union membership, social or employment status or is disadvantaged by conditions or requirements which are not justified by the job to be done. This policy concerns all aspects of employment for existing staff and potential employees.
10.3. Equality Impact Assessment
10.4. All public bodies have a statutory obligation to undertake Equality Impact Assessments on all policy documents. This must be undertaken by the author using the agreed Equality Impact Assessment Template. The completed assessment is to be added to the end of the policy document as an appendix prior to it being ratified.
10.5. The Initial Equality Impact Assessment Screening Form is at Appendix 2.
NB: References and Associated Trust Documents
Up-to-date references, including details of supporting or associated Trust or Cornwall Health Community documents, must be listed in the Governance Information table at Appendix 1.
Appendix 1. Governance Information
Document TitleDate Issued/Approved: / Date signed
Date Valid From: / Date document becomes effective
Date Valid To: / No more than 3 years from approval
Directorate / Department responsible (author/owner): / Name of author and Job Title
Contact details: / Number in full, not extension only
Brief summary of contents
Suggested Keywords: / Use this section to suggest keywords to be added by the Uploader to aid document retrieval.
Target Audience / RCHT / CPFT / KCCG
ü
Executive Director responsible for Policy: / Job Title
Date revised:
This document replaces (exact title of previous version): / Title of Previous Version OR New Document
Approval route (names of committees)/consultation: / Do not list all individuals just committees/groups e.g. EMT, RCHT all user email etc
Divisional Manager confirming approval processes / Head of relevant Division
Name and Post Title of additional signatories / If none enter ‘Not Required’
Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings / {Original Copy Signed}
Name:
Signature of Executive Director giving approval / {Original Copy Signed}
Publication Location (refer to Policy on Policies – Approvals and Ratification): / Internet & Intranet / ü / Intranet Only
Document Library Folder/Sub Folder / e.g. Clinical / Infection Prevention & Control
Links to key external standards / Governance Team can advise
Related Documents: / Reference and Associated documents
Training Need Identified? / Yes / No – Select ‘Yes’ if any staff will need to carry out training to achieve successful implementation of this policy and also state that the Learning and Development department have been informed.
Version Control Table