Policy for Policies Control sheet by f34q4h6

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									                                                                    Ridgeway Partnership




                               Policy for Policies
                                 Control sheet
Executive Board recommends Trust Board to accept the Policy for Policies and confirms
that it is in accordance with legislation and best practice’.
Status new or review:                               New
Policy owner:                                     Deborah Lawrenson, Company
                                                  Secretary
Contact Details:                                  01865 228104
                                                  Deborah.lawrenson@ridgeway.nhs.uk

Sponsoring Director:                              Jenny Vaux, Director of Business
                                                  Development and Corporate Support
Contact Details:                                  01865 228121
                                                  Jenny.vaux@ridgeway.nhs.uk

Date last reviewed:                               NA – new policy
Approved By:                                      Trust Board
Date Approved:                                    February 2009
Next Due for Revision:                            February 2011
Date Policy Becomes Live:                         March 1st 2009
Policy number:                                    GOV/001/02/09
Equality Impact Assessment in place               Yes

Summary of key updates since the last review      NA - new policy
Further comments to be considered at the time
of ratification for this policy (i.e. National
policy, Legislation and consultation across
SHA).

Compliance with –                                 Requirements for E & D are picked up
  • Mental Health Act                             in the EIA template developed for all
  • Equality and Diversity                        policies.
  • Human Rights Act
  • CNST
  • NHSLA
  • CSCI
  • National Service Frameworks
  • Employment legislation


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   •    Standards for Better Health
   •    Quality Accounts
   •    Freedom of Information Act
   •    Data Protection Act
   •    Health and Safety Act

Compliance with Monitor expectations:               None at this stage – will be built in
                                                    post authorisation if required
Training needs analysis:                            No specific training required. Policy
                                                    for Policies will be cascaded via the
                                                    line management route and the
                                                    Company Secretary will be available
                                                    to speak to team meetings and key
                                                    approval groups if required.
Consultation process followed:                      Developed in consultation with an
                                                    organisation wide policy review group
Is public or service user consultation required     established specifically to undertake a
– if so consult with Company Secretary for          review of policy procedures and
approach to be used:                                process during 2008.
                                  Version Information
Version No.       Updated By          Updated On    Description of Changes
       1.0    Deborah Lawrenson February 2009 New policy
       1.1    Deborah Lawrenson        April 2009   Revisions    to      meet      NHSLA
                                                    requirements




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                                RIDGEWAY PARTNERSHIP

                       (Oxfordshire Learning Disability NHS Trust)

                                Policy for Policies


                      POLICY FOR POLICIES (FEBRUARY) 2009
                (Policy development, review and ratification process)



Table of contents
Page 2    1 Introduction

Page 2    2 Fit with Trust’s vision or strategic objectives

Page 2    3 General Policy statements

Page 5    4 Fit with other key documents such as Quality Strategy

Page 5    5 Links to national agenda/policy or legislation

Page 5    6 Detail on any benchmarking

Page 6    7 Background to development of the policy, detail on any collaboration or
            Consultation

Page 7    8 Communications and Training Plan and monitoring arrangements

Page 7    9 Supporting templates

Page 8    References

Page 8    APPENDICES




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                     POLICY FOR POLICIES (FEBRUARY) 2009
               (Policy development, review and ratification process)


1.    Introduction

1.1   The Policy for Policies provides a framework for the development, approval,
      management and review of policies and assurance to the Trust Board that there is
      a robust policy management process in place and being followed. It will be
      reviewed every two years and updates on progress will be provided to Trust Board
      as part of the Chief Executive’s Report.

1.2   Management of the policy review process is the responsibility of the Company
      Secretary, Head of Corporate Services with day to day support provided by the
      Executive Assistant, Corporate Services.

1.3   Annex 1 roles and responsibilities
      Annex 2 provides templates for the policy itself and its control sheet
      Annex 3 provides detail on the RAG system
      Annex 4 Flow charts of the development and review process
      Annex 5 EIA for this policy

1.4   The following RAG system will be used to manage policy reviews (See Annex 3
      for more detail)

      Green - The Policy is up to date

      Amber - The Policy is due for review in the next four months

      Red -    The Policy is out of date and there is no planned date for its review

      Purple - The Policy is critically urgent and must be reviewed immediately due to:
                •    Impact on patient/service user care
                •    It being a requirement for the Trust tender applications

2     Fit with Trust’s vision or strategic objectives

2.1   Policy development is an important element of the Trust governance and
      assurance processes. Robust policies support the organisation in its aim to be a
      leader in its field.

3     General Policy statements

3.1   All policies should:
      •    Aim to provide a trust-wide perspective, to have been developed as a result of
          appropriate consultation, and to be evidence based and reflect best practice
          see ‘Excellence in Policy Making’ (DOH)
      •   Be developed corporately. Local policies should not be developed but there

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           may be local protocols or procedures to complement an overarching policy:

           o Local procedures may only be developed where these do not conflict with
             trust wide policies or procedures and should be made with agreement of
             the approving committee/board.
           o Any local protocol or procedure related to the overarching policy must
             make specific reference to the over-arching policy.

      •    Be reviewed in a timely and planned manner to ensure they are safe, legal
           and up to date
      •    Be submitted to the relevant committee/board for approval which will ensure
           that there are no duplications or conflicts with other policies
      •    Be presented by the policy owner to the approving committee.
      •    Be reviewed every two years, unless new legislation or circumstances require
           an earlier review.
      •    Follow the template provided as closely as possible. This document has been
           developed using the template. All existing policies should use the template at
           the point of their next review and will not be amended retrospectively.

3.2   It is anticipated that the policy development process, for a new policy, should take
      2-3 months. The policy owner with support from a ‘sponsoring Director’ will identify
      the need to develop a new policy or revise an existing one.

      In the case of new policies the Company Secretary will provide advice as to which
      group should be used as the approval mechanism if this is not already identified.
      Process:
      •   Approval given to develop the policy
      •   Appropriate consultation then takes place
      •   Final approval given
      •   Dissemination/cascade
      •   Updated on intranet/website
      •   Training corporately led or locally determined as required

3.3   Summary of roles and responsibilities (full detail is available in annex 1)

      Approving committees will:

      •    Agree an implementation plan for policies approved and will determine training
           and development needs
      •    Be responsible for developing forward review plans, for all policies reviewed
           by that body, at the start of the financial year and provided to Executive Board
           via the Executive Assistant
      •    Be responsible for approving any training workbooks, procedures and
           guidelines associated with the development of the policy
      •    Agree who will take over ownership of a policy when a policy owner moves
           either to a new role or leaves the Trust. This should be conveyed to the
           Executive Assistant for the purposes of updating the central log and intranet.

      The Policy owner will:

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      •   Be responsible for all updating associated with the policy and associated
          documents, in line with templates.
      •   Be responsible for ensuring that the updated copy replaces the previous
          version on the intranet, via the Executive Assistant
      •   Be responsible for rolling out any associated training

      The Executive Assistant will:

      •   Maintain a central log of policies
      •   Keep the intranet/website updated with the latest policies
      •   Manage the RAG system including cascading reminders of upcoming review
          dates
      •   Provide updates on progress to Executive Board and Trust Board.

3.4   Record management

      In order that a complete record exists of all of the Trust policies:

      •   A central computerised database of all Trust policies will be developed
          (refining the existing system) and will be maintained on the Trust’s intranet.
      •   The Policy owner will ensure that the policy, once formally approved is entered
          onto the database, via the Executive Assistant, within two weeks of its final
          approval.
      •   A master copy of control sheets will be held by the Executive Assistant in
          order to register policies and track review dates.
      •   The frequency within which each policy should be reviewed will be included in
          the Control Sheet and registered by the Executive Assistant
      •   A bring forward system will be operated by the Executive Assistant in order to
          alert policy owners and their sponsoring Director to forthcoming policy review
          dates. An alert will be provided a minimum of four months prior to a upcoming
          review date.

3.5   Dissemination, implementation and monitoring

      Once a policy is approved notification will be given to staff, via the next available
      issue of the Managers Bulletin, but not more than two weeks of a policy being
      approved and the Executive Assistant being notified by the approving bodies.

      The policy owner and sponsoring director retain overall responsibility for ensuring
      that there are effective dissemination and implementation processes in place for
      both new and revised policies at a local level, via line managers. This should
      include monitoring implementation with audits and data relating to the minimum
      requirements. Monitoring is normally proactive, designed to highlight issues before
      an incident occurs, and should consider both positive and negative aspects of the
      process.

      The policy owner and the sponsoring director are responsible for ensuring that
      effective monitoring mechanisms are clearly expressed within the policy in accord
      with NHSLA Risk Management standards. This includes:


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      a) A description of how compliance with the policy will be assessed i.e.
          measured, proactively monitored and what the evaluation process(es) will be;

      b) Where monitoring identifies deficiencies action plans must be drawn up and
          changes made to reduce risk to an acceptable level (as expressed in the policy
          itself);

      c) Specify where the monitoring of implementation will be reported and how often
          such reporting will occur.

4     Fit with other key documents such as Quality Strategy

      Not applicable

5     Links to national agenda/policy or legislation

5.1   Racial equality; disability; gender; sexuality; age and diversity

      All policies will receive an equality impact assessment during their development in
      respect to equality issues and compliance with antidiscrimination legislation. The
      EIA form is attached at Annex 5.

      The EIA should be signed off by the Company Secretary and should be included
      with the policy at the point of approval and appended to the document on both the
      intranet site and any hard copies.

6     Detail on any benchmarking

6.1   A review of the approach taken by other NHS Foundation Trust has taken place in
      order to develop the templates provided and the policy for policies developed
      against ‘Excellence in Policy Making’ (DOH) see section 6.3 for details.

6.2   Those developing and reviewing policies are asked to take this guidance into
      consideration when carrying out their reviews.

6.3   Good Policy Making

      •   Is driven by patient or population centred goals that users support and that will
          deliver tangible improvements to the service/society.

      •   Adopts SMART goals- specific, measurable, achievable, realistic and timed.

      •   Tests the goals and the policy for its impact on the whole system of health and
          social care and ensures a coherent, integrated set of policies that support an
          agreed strategy.

      •   Is evidence based or where evidence does not exist is built from a strong
          consensus of support from key stakeholders.

      •   Develops policy with the full involvement of users, practitioners, managers, and
          others who may be implicated or have expertise to offer- from the outset and
          throughout the process.

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      •   Scopes the subject widely at the outset to see the opportunities, implications,
          risks and constraints. - Including existing good practice in the UK and
          internationally.

      •   Is based on a sound understanding of current provision, practice and
          performance and relevant trend analyses including the variability across
          geographical areas.

      •   Assesses for environmental, social, health and economic impacts using an
          approved methodology.

      •   Seeks to ensure a good user/carer experience by giving due regard to
          standards, equal opportunities, diversity, plurality and flexibility.

      •   Creates policy that is fit for implementation and will deliver the required results
          in the requisite time – having addressed capacity issues, workforce, finance ,
          IMT, communications etc

      •   Imposes no unnecessary burdens on front line service providers and devolves
          as much as possible to the front line

      •   Clarifies roles and responsibilities so that the DH only does that which it has to
          do and the reporting and accountability requirements are proportional and
          justifiable.

      •   Expresses policy in simple, plain English and succinctly, - with drafts checked
          for interpretation and appropriateness with those for whom it is designed.

      •   Has been anticipated in business planning and is resourced to ensure good
          programme and project management
      ref:- ‘What is excellence in policy making?’ (Department of Health internal good
      practice guidance February 2003)

7     Background to development of the policy, detail on any collaboration or
      consultation

7.1   In 2008 the Trust Board asked that a review of policies, process and procedures
      take place with the view of developing a more streamlined approach to the policy
      approval process, with robust plans for reviewing outdated policies and that all
      statutory, legislation driven policies are either in place or factored into forward
      planning.

7.2   A Trust-wide policy review group has been working to develop the approach
      outlined in this paper and it has been approved by Executive Board and Trust
      Board.

7.3   The devolving of decision making for policies to specific groups will ensure that
      discussion takes place at the appropriate level and that policies can be approved in
      a more systematic and efficient way. Each ‘approval group’ will be expected to
      develop a forward plan for policy review at the start of each year and this should
      build in necessary consultation and development time.


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8     Communications and Training Plan and Monitoring arrangements

8.1   This policy for policy will be shared with the organisation via the Managers Bulletin
      and cascaded via the line management route.

8.2   All new or revised policies will also be communicated via the Managers Bulletin, (in
      line with existing practice) by the Executive Assistant, within 2 weeks of the EA
      being informed by the approving committee of the approval and the final copy
      being provided.

8.3   Line Managers will be responsible for cascading the policies to their staff and
      identifying any personal training needs and for ensuring local compliance.

8.4   Directorate/team administrators will be responsible for downloading policies from
      the intranet and holding a folder containing hard copies of relevant policies in their
      areas of work, at the direction of their Heads of Teams.

8.5   The policy owners will be responsible for providing any additional documents to the
      Executive Assistant if they need to be posted on the website – for example model
      documents for staff to fill in details (that need to be in word downloadable format).

8.6   Monitoring

      a)   Describe how compliance with the policy will be:
           i)     Measured (e.g. via audits, discussion reflected in team minutes, activity
                  indicators demonstrating delivery of policy – training data, Personal
                  Development Plans (PDP’s) in place/reviewed, inclusion in quality visit
                  assessment forms etc)

           ii)    Proactively Monitored (how often do you check the measures identified in
                  (i) above, when looking at measurements, what level being achieved
                  indicates success, failure or gaps in implementation ), and

           iii)   What the evaluation process(es) will be; (i.e. how are you calculating or
                  assessing the measurements you are using to assess implementation –
                  purely a numerical score, a mixture of qualitative feedback through
                  monitoring visits plus numerical indicators or sampled questionnaire
                  responses)

      b)   Where monitoring identifies deficiencies (how will you use / manipulate the
           information to identify corrective actions, who will or should implement the
           corrective actions, when do the actions have to be implemented by?)

      c)   Specify where the monitoring will be reported and how often such
           reporting will occur (i.e. the Directorate Senior Management Team every
           quarter or yearly?, the H&S committee twice a year? To Trust Board once a
           year in the Chief Executive report?)

9     Supporting templates

9.1   Templates are provided in Annex 2. This document has been produced using the
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       templates.

       Alternative formats to the template may only be used where variation of language,
       size and format assists those with particular needs. This facility will be agreed and
       arranged through each committee/board as necessary and noted in the control
       cover sheet to the policy.

9.2    The policy reference number for all policies will be issued by the Executive
       Assistant Corporate Services who will maintain a central log of control sheets. The
       policy reference number will comprise of a prefix as follows:

              CLP           Clinical Policies
              ICP           Infection Control Policies
              MMP           Medicines Management Policies
              HR            Human Resources
              HS            Health and Safety Policies
              FIN           Finance policies
              IM&T          Information Management and Technology policies
              GOV           Governance Policies
              E&D           Equality and Diversity policies

       The prefix will be followed by a 3-digit policy number and creation date (2 digit
       month and 2 digit year). All numbers will be separated by slashes (Policy
       category/Policy Number/Month of creation/Year of creation).

       The new numbering system will be applied to policies approved from this point.

       REFERENCES

       •   WHAT IS EXCELLENCE IN POLICY MAKING? (Department of Health internal
           good practice guidance February 2003)

       APPENDICES
       Annex 1 - Roles and Responsibilities
       Annex 2 – Templates
       Annex 3 – RAG system
       Annex 4 – Flow charts for development and review process
       Annex 5 - EIA


Annex 1 Roles and Responsibilities


Role of Sponsoring Director and Policy Owner

Initial Proposal - The requirement for policy development may be initiated at any
point in the Trust but all policies will require a Sponsoring Director.

Identifying Sponsoring Director The Sponsoring Director will be identified at the
beginning of the process. It is usually clear from the type of policy required which of


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the Directors should take this role. In cases where there could be any doubt, the
Chief Executive will identify the Director who will be asked to take this responsibility.

Responsibility - The Sponsoring Director will be a member of the Executive Board
and will take responsibility for ensuring that the overall process is followed correctly.
During the development phase and prior to submission for approval the Policy Owner
will be responsible for providing assurance to the Sponsoring Director that the policy:

•   meets the requirements of legislation/regulatory frameworks
•   meets the needs of the Trust
•   is in accordance with the Strategic Direction and identifies how it will contribute to
    the achievement of the Trust’s agreed key targets
•   sets out clearly any core values or principles espoused by the policy
•   contains a high level summary setting out the policy objectives and targets
•   sets out roles and responsibilities for delivering the new policy
•   Identifies all the implications for the Trust of the new policy (particularly
    operational, clinical and financial) and devises methods for dealing with these
    implications. This may include, but not necessarily be limited to:
        o revenue and/or capital impact
        o non-recurrent impact
        o impact on patients and carers
        o impact on staff (ie training)
        o governance or legislative issues (ie systems and outcomes)
        o equality and diversity audit (ie any negative impact. on specific groups e.g.
            the elderly, ethnic minorities etc) and that an Equality Impact Assessment
            has been carried out and is attached to the policy
        o identifies all the differing (and sometimes mutually exclusive) issues raised
            during the policy
        o development and suggests acceptable ways of dealing with them
        o is implemented effectively
        o is evaluated appropriately against pre-set performance targets
        o is amended as necessary following evaluation

Role of Policy development group

If the Policy Owner, with support from their Sponsoring Director feels it is appropriate
for a group to be established or for an existing group within the Trust to take on the
task of developing the policy he or she will set out terms of reference, a timescale
and if necessary suggested membership of the group. This will enable individuals
who have a close interest and or expertise in a subject to be involved in the
development of policy from its inception. The group’s work will be to cover the issues
identified above and to ensure that if necessary other individuals’ views are
canvassed and incorporated into the policy as it is being drafted. This stage of the
process is largely about seeking individual input to policy development.

Role of approving committees and boards

The approval groups in the Trust will be the Trust Board, Executive Board, Audit
Committee, Risk and Governance Committee, Remuneration Committee and HR


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Policy Review Group. No other groups have delegated authority for approving
policies.

The role of approving groups is to ensure that the objectives identified above have
been delivered, that the policy has been properly developed and is ready for
implementation and wider circulation.

When a policy meets one or more of the following criteria it must be considered at
Trust Board level:

   •   The policy has been developed as a result of a serious incident occurring
       within the Trust
   •   The policy has been developed as a response to a significant policy change
       received from external sources
   •   There are major operational, financial or staffing issues associated with the
       policy
   •   During its development, significant differences of opinion have emerged which
       have not been resolved by discussion at the approving committee/board
   •   The formal consultation process has revealed some significant professional
       issues which have not been resolved by discussion at the approving
       committee/board.

Roles of Company Secretary and Executive Assistant

The Company Secretary is responsible for the overall policy process and shall
ensure, via the Executive Assistant Corporate Services that:

   •   The Policy Control Sheet for each policy is registered centrally
   •   The review date for each policy is recorded on a brought forward system and
       duly notified to the policy owner and Sponsoring Director in a timely manner
   •   That approved policies are placed on the intranet and website within two
       weeks of approval and notification is given in the next available edition of the
       Managers Bulletin
   •   That, in consultation, with Heads of relevant teams, that all appropriate
       policies are in place

Role of Team Leaders and Heads of Departments

Heads of Teams shall be responsible for:

   •   Ensuring that departmental administrators maintain hard copies of relevant
       policies in central reference areas, accessible by all members of the team by
       downloading information from the intranet.
   •   Local dissemination of policies takes place, any training required is followed
       through and that a permanent record of this is maintained and provided to the
       L& D team for central training purposes and accessible on request from
       Corporate Services or the relevant approving committee/board




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Annex 2

                    Policy Control sheet and Policy templates


 Any policies coming to the Board for endorsement should come with the wording
  ‘Executive Board recommends Trust Board to accept the [insert name] policy’.


                                 Name of Policy
  Status new or review:
 Policy owner:
 Contact Details:
 Sponsoring Director:
 Contact Details:
 Date last reviewed:
 Approved By:
 Date Approved:
 Next Due for Revision:
 Date Policy Becomes Live:
 Policy number:
 Equality Impact Assessment in place
 Summary of key updates since the last
 review
 Further comments to be considered at
 the time of ratification for this policy
 (i.e. National policy, Legislation and
 consultation across SHA).
 Compliance with –
   • Mental Health Act
   • Equality and Diversity
   • Human Rights Act
   • CNST
   • NHSLA
   • CSCI
   • National Service Frameworks
   • Employment legislation
   • Standards for Better Health
   • Quality Accounts
   • Freedom of Information Act
   • Data Protection Act
   • Health and Safety Act

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  Compliance with Monitor expectations:
  Training needs analysis:
  Consultation process followed:

  Is public or service user consultation
  required – if so consult with Company
  Secretary for approach to be used:
                                Version Information
  Version No. Updated By      Updated On Description of Changes




POLICY TEMPLATE



                            Name of Policy and Month/Year
Table of contents
Page 2    1 Introduction
Page      2 Fit with Trust’s vision or strategic objectives
Page      3 General Policy statements
Page      4 Fit with other key documents such as Quality Strategy
Page      5 Links to national agenda/policy or legislation
Page      6 Detail on any benchmarking
Page      7 Background to development of the policy, detail on any collaboration or
            consultation
Page      8 Communications and Training Plan
Page      9 Supporting templates
Page      References
Page      APPENDICES




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                                                 Annex 3 Policy Review RAG system

Status   Descriptor                        Further details



Green    The Policy is up to date and When policies are approved the authorising group should let corporate services know so
         not due for review within the that the intranet can be updated and the organisation informed.
         next three months



Amber    The Policy is up to date and If the policy isn’t reviewed after the four month reminder it will move to red and has
         not due for review within the another three month grace before it is suspended.
         next three months



Red      The Policy is out of date and All policies which are currently out of date, and without a review date identified, have
         there is no planned date for been put on as red. Most are from 2005/06. All red policies must be reviewed before
         its review                    March 2010.

         Note – once a review date         Authorising committees will be asked to provide an action plan by the end of March 2009
         has been identified and if this   outlining when the outstanding policies will be brought up to date by March 2010.
         does not happen with 3
         months of that date the policy    These should be done in order of priority with those having impact on patient care coming
         will  be    suspended       ad    first along with policies which are requirements for our tender processes.
         removed from the system.          Staff will be kept informed when policies have been suspended.




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Purple   The Policy is critically urgent All purple policies must be updated by April 2009.
         due to:
                                         Subsequent purple policies will have priority of place on the action plans of the relevant
         • Impact on patient/service approving committees AND as soon as they are identified as purple they MUST be
            user care                    reviewed and updated within 3 months maximum.

         •   It being a requirement for Advice will also be provided by the Company Secretary on the action plans if it is felt that
             the       Trust    tender priority is not appropriately assigned or followed through.
             applications
                                        Updates on progress against the policy for policies and the action plans (most particularly
                                        in terms of red and purple policies) will be provided to the Executive and progress
                                        reported quarterly at Trust Board.




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Annex 4 Flowcharts of development process for existing and new policies




                                 1 ORIGINATOR                                    DEVELOPMENT

                              Review date reminder                             Policy ‘owner’ carries
                                provided to Policy                              out review and any
                              Owner and ‘sponsoring
                                                                               relevant consultation
                                    Director)




                                                       Review process for EXISTING
                                                                policies
          TRAINING                                                                                            SCRUTINY
                                                    Review group to develop annual
         Either planned                                                                                 Policy discussed at the
      corporately by Policy
                                                    action plan for bringing through                      relevant approvals
     owner or identified by                        policies (using the RAG system). To                  group – if the policy is
         Line Managers                               be provided to Co Sec an Exec                       urgent it should be
                                                       Assistant in April each year                        classed as Purple




                                DISSEMINATION
                                                                                     APPROVAL
                                Intranet/website
                              updated - cascade via                               At approval
                              Managers Bulletin/line                            committee/board
                                    managers




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                                         1 ORIGINATOR                                       APPROVAL FIRST STAGE

                                        Need for new policy                                   Approval to develop
                                       identified – Co Sec to                                received - ‘sponsoring
                                     advise on approval group                                  director’ identified




                                                         Approval/review Process for NEW
        REVIEW                                                                                                                         DEVELOPMENT &
                                                                     policies                                                          SCRUTINY- Policy
At document review date                                                                                                                 developed with
move to existing policies                            Review group to develop annual action                                          appropriate consultation
         cycle
                                                    plan for bringing through policies – to be
                                                    provided to Co Sec and Exec Ass in April
                                                                    each year




                     TRAINING                                                                                           APPROVAL SECOND
                                                                                                                             STAGE
             Training rolled out where
                    appropriate                                                                                       Policy taken to approving
                                                                                                                       group for final sign off

                                                                    DISSEMINATION

                                                                Intranet/website updated,
                                                                   cascade via Managers
                                                                  Bulletin/line managers




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    Annex 5 Equality Impact Assessment template (offered to Board on request though this has been seen at all Board meetings in
                                                2008 and therefore is well known by the Board)

                                                        Ridgeway Partnership
                                                      Equality Impact Assessment

    Policy/Function Name: Policy for Policies

    Names of persons completing Assessment: Deborah Lawrenson
                                                    (Please print names)

    Lead Director for Policy/Function: Jenny Vaux, Director of Business Development and Corporate Services

    Date of Policy/ Function: February 2009

    Policy/Function review date: February 2011

    When completed this Assessment should be attached to the policy/function and distributed accordingly.



The main aims and impacts of
                                                                           Brief description/explanation
     the policy/function


1. What is the purpose of the   The Policy for Policies provides a framework for the development, approval, management and review of
policy/function/development?    policies and assurance to the Trust Board that there is a robust policy management process in place and
                                being followed. It will be reviewed every two years and updates on progress will be provided to Trust
                                Board as part of the Chief Executive’s Report.




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The main aims and impacts of
                                                                             Brief description/explanation
     the policy/function


2. Who is intended to benefit          The whole organisation in terms of providing a robust framework for developing and reviewing policies.
from the policy/function/              Service users in terms of impact of policies in general.
development?

(Who are the target group? Who         The Trust Board in terms of its strategic role and in receiving assurance that a robust policy process is in
will benefit directly or indirectly?   place and being followed.

3. Is there any adverse impact (s) No
from the policy/function/
development on individuals from
the following groups - service
users, staff, carers, members of
the public - in relation to need,
equal treatment,
inclusion/exclusion - based on:

   a) Age

   b) Gender (male/female)

   c) Learning Disability

   d) Mental Health need

   e) Sensory Impairment



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                                                                                                                          Ridgeway Partnership



The main aims and impacts of
                                                                         Brief description/explanation
     the policy/function

   f) Physical Disability

   g) Race, Ethnicity, Religion,
      Spiritual belief (including
      other belief),Language or
      Culture

   h) Sexual Orientation

   i) Any Long Term condition


4. Is responsibility shared with    It is the responsibility of the Company Secretary to manage the overall policy review process however the
another department to deliver the   policy outlines the specific delegated responsibility elements to:
policy/function/development?
How is this managed?                   •   Policy owners

                                       •   Sponsoring Directors

                                       •   Policy review and approval groups

                                       •   Line Managers

                                       •   Departmental Administrators




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                                                                                                                         Ridgeway Partnership



The main aims and impacts of
                                                                         Brief description/explanation
     the policy/function


5. Has anyone been involved in       Yes a Trust wide policy review group was established in the summer of 2008 to guide development of this
the development of the               overall policy process.
policy/function/development?

 If so, who, e.g. service users,
staff, professional groups, H&S
Executive, stakeholders,
partners?

How were they involved?

Should anyone else have been
involved – if so how will they now
be consulted?


6. What information has helped       None specifically however feedback has been received from HR, Finance, Information and Governance
towards the Equality Impact          and with regard to its development.
Assessment? E.g. Audit reports,
feedback from groups/
committees, surveys etc.


7. Which groups of service users, The Policy Review Group set up for the purpose of developing this approach, which has cross
staff, carers, members of the     organisational representation and Executive Board.


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                                                                                                                             Ridgeway Partnership



The main aims and impacts of
                                                                           Brief description/explanation
     the policy/function

public, stakeholders, partners,
have been consulted with during
this assessment?

What information have they           Detail on policies and policy requirements within their own areas.
provided?



8. Is there any evidence that        No
some people may have different
expectations of the policy/
function/development? E.g.
different racial groups, people
with a disability, people with
different religious beliefs, or on
the grounds of age, gender, or
sexuality.



9. Is more information required?     No – the policy for policies sets out the expectations of individuals and groups going foward.

If so, what information and how
will you get it?




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                                                                                                              Ridgeway Partnership


10. Action Plan

What Action is required as    Who is responsible for          When will the action be          When will the policy/
result of this assessment?    implementing this action?       implemented by?                  function be re-assessed
                                                                                               for any adverse impact?




Monitor and review            The Company Secretary and       The next progress report to go   For the next progress report
implementation                the Executive Assistant         To Executive Board and Trust     to Executive Board and
                                                              Board                            Trust Board which will be
                                                                                               quarterly




Please send this form to Deborah Lawrenson, Company Secretary, for signing off and publishing on the Trust website.

This Assessment is completed and any adverse impacts have been identified and action agreed.



Name________________________________ Date_____________




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