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					                                                      South Western Ambulance Service NHS Trust - Strategies/Policies/Procedures 2008/09
Version 1.17 February 2009
Policies reviewed by the Board go in                                       Revisions:      1st         2nd revision      In progress   No previous      Overdue
full only at their 3rd annual review                                                     revision                                       revision
(otherwise a briefing paper is
provided detailing any changes)

                                                                                                                                                                                                Impact
Document                                                                  Requirement                                                                                              Original               Impact
                                                                                                     Lead Manager /      Development    Approval                          Last                 Assess
(policies to the Board are only        Content in brief                   (ALE, S4BH, Lead Dept                                                      Next review date              Approval             Assess ment
                                                                                                        Contact             Group        Group                          Revision              ment Part
presented in full at 3 year review)                                       CNST, Other)                                                                                               Date                  Part 2
                                                                                                                                                                                                  1
Strategic Direction                       5 year strategic direction      ALE/FT        CEO         Director of Finance Dir            Board             Oct-08                     Mar-07    Pending   Pending/N/A
                                              from2007 to 2012                                      and Performance
Business Plan (5 Year -                  5 year business plan based       FT / ALE      Finance     Director of Finance FT Steering    Board             Feb-09                     Jul-07    Pending   Pending/N/A
Integrated)                              upon the strategic direction                               and Performance
Environmental Policy (inc                      To be confirmed            ALE           JE          Estates Manager     Dir            Board             Feb-09                     Jan-08    Yes       Pending
Green Transport)
Estates Strategy                       5 year strategy for the planning FT/ ALE         Finance     Estates Manager     FT Steering    Board             Feb-09                     Jun-07    Yes       Pending
                                           and management of Trust
                                                      Estate
Business Continuity Policy                  Plans to keep business                      Ops         Resilience Manager BCG             Board             Mar-09                     Jan-08    Yes       Pending
                                       functions operating in the event
                                               of a critical incident
Business Plan (annual)                   Annual business plan based ALE                 Finance     Director of Finance Dir            Board             Mar-09                     Apr-07    Pending   Pending/N/A
                                        upon the targets for each year                              and Performance
                                                of the 5 year plan
Code of Conduct for Staff (inc         Expectations of behaviour by all ALE             CEO         Head of             Dir            Board             Mar-09          Mar-08     Jan-07    Pending   Pending/N/A
Gifts and Hospitality)                   staff including acceptance of                              Governance
                                       gifts and hospitality (forms); and
                                       rules about intellectual property

Code of                                 Expectations of behaviour by      ALE           CEO         Head of             Dir            Board             Mar-09          Mar-08     Jan-07    Pending   Pending/N/A
Conduct/Accountability for              members of the Trust Board                                  Governance
NHS Boards
Equality & Diversity Strategy          Strategy describing the Trust's    ALE/legislatio Ops        HR Business         E&D            Board             Mar-09                     May-07    Yes       Pending
                                          approach to Equality and        n                         Manager
                                          Diversity including impact
                                          assessment; and terms of
                                             reference for the E&D
                                                   Committee
Freedom of Information Act              Document providing details of     Information  Gov          Information         TPfIT          Board             Mar-09                     Mar-06    Yes       Pending
Publication Scheme                        all information available to    Commissioner              Governance
                                       enquirers on the website or by                               Manager
                                                   application
ICT Security Policy                     Policy on information security:                 ICT         Head of ICT         Dir            Board             Mar-09          Mar-08     Mar-07    Pending   Pending/N/A
                                          accountability framework;
                                           principles of security for
                                        systems and usage; incidents
                                         and weaknesses; business
                                                    continuity
ICT Strategy                           Strategy for the management of                   ICT         Head of ICT         ICT Prog Brd   Board             Mar-09          Mar-08     Dec-06    Pending   Pending/N/A
                                           the Trust's Information,
                                       Communications & Technology
                                                     services




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                                                                                                                                                                                             Impact
Document                                                                  Requirement                                                                                           Original               Impact
                                                                                                   Lead Manager /       Development    Approval                        Last                 Assess
(policies to the Board are only       Content in brief                    (ALE, S4BH, Lead Dept                                                   Next review date              Approval             Assess ment
                                                                                                      Contact              Group        Group                        Revision              ment Part
presented in full at 3 year review)                                       CNST, Other)                                                                                            Date                  Part 2
                                                                                                                                                                                               1
Information Governance Policy         Guidance on Data Protection,        Information  Gov        Information          Gov            Board           Mar-09          Mar-08     Mar-07    Pending   Pending/N/A
                                         Freedom of Information,          Commissioner            Governance
                                               Confidentiality                                    Manager
                                      legislation/regulation and trust
                                           processes for records
                                      management and disclosure of
                                                 information
Information Governance                    Strategy for information        Information  Gov        Information          Gov            Board           Mar-09          Mar-08     Mar-07    Pending   Pending/N/A
Strategy / Action Plan                governance including: records       Commissioner            Governance
                                      management; Data Protection;                                Manager
                                          Freedom of Information

Risk Management Process               Process for the development of CNST             Gov         Risk Manager         Gov            Board           Mar-09          Jan-08     Jan-07    Pending   Pending/N/A
                                              Trust risk registers
Risk Management Strategy                     Trust strategy on the     CNST           Gov         Risk Manager         Gov            Board           Mar-09          Jan-08     Jan-07    Pending   Pending/N/A
                                       management of risk including
                                         risk registers; and terms of
                                          reference for Governance
                                         Committee and Health and
                                                Safety Group
Standing Orders, Financial            Standing Orders and Financial Statutory         Finance     Deputy Director of   Audit          Board           Mar-09          Mar-08     Mar-07    Pending   Pending/N/A
Instructions, Reservation and          Instructions for the conduct of                            Finance
                                           the Trust Board and any
Delegation of Powers
                                            powers it may delegate

Annual Health Check                    Process for declaration of trust   S4BH        Gov         Corporate            Dir            Board           Apr-09          Apr-08     May-07    Yes       N/A
                                      compliance with core Standards                              Governance
                                       for Better Health; key national                            Manager
                                       standards; and use of financial
                                                  resources
Assurance Framework                        Framework setting out          ALE         CEO         Head of              Dir            Board           Apr-09          Mar-08     Mar-07    Yes       N/A
                                         assurance evidence of the                                Governance
                                        Trust achieving its objectives
Health Promotion for                    Strategy for the promotion of     S4BH        H&S         Health, Safety &     Gov            Board           Apr-09                     Mar-08    Pending   Pending/N/A
Employees Strategy                      health and wellbeing of Trust                             Security Manager
                                                 employees
PALS Policy                           Guidance on the Patient Advice      ALE         Comms       Head of PR and      Dir             Board           Apr-09          Apr-08     Sep-07    Pending   Pending/N/A
                                             and Liaison Service                                  Strategic
                                                                                                  Communications
Business Planning Policy               Policy on approach to setting                  Finance     Director of Finance Dir             Board           May-09                     May-08    Pending   Pending/N/A
                                       Trust objectives and business                              and Performance
                                       plan, templates for: business
                                         planning cycle; directorate
                                       business plan; business case
                                            assessment; planning
                                          flowchart; business case
                                                  templates
Incident Reporting Policy             Guidance on identification and CNST             Gov         Risk Manager         Gov            Board           May-09         May-08      Mar-07    Pending   Pending/N/A
                                            reporting of incidents;
                                      investigation; incident decision
                                      tree; risk assessment; incident
                                                 report form

Integrated Governance                  Strategy for the integration of    S4BH        Gov         Head of              Gov            Board           May-09         May-08      May-07    Pending   Pending/N/A
Strategy (inc Clinical                  governance functions: risk,                               Governance
                                       health and safety, compliance
Governance)

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                                                                                                                                                                                             Impact
Document                                                                    Requirement                                                                                         Original               Impact
                                                                                                     Lead Manager /     Development    Approval                        Last                 Assess
(policies to the Board are only       Content in brief                      (ALE, S4BH, Lead Dept                                                 Next review date              Approval             Assess ment
                                                                                                        Contact            Group        Group                        Revision              ment Part
presented in full at 3 year review)                                         CNST, Other)                                                                                          Date                  Part 2
                                                                                                                                                                                               1
Annual Report                          Report on the business of the ALE                Comms       Head of PR and     Dir            Board           Jun-09          Jun-08     Jun-07    Yes       Pending
                                       Trust for the preceeding year,                               Strategic
                                          produced at the year end                                  Communications
Capability Policy                        Policy setting out capability                  HR          HR Business        PPPG           Board            Jul-09         Jul-08     Jun-07    Yes       Pending
                                         process: principles; informal                              Manager
                                            action; investigations;
                                        suspension; hearings; action;
                                          decisions; review; appeal;
                                          procedure; failure to meet
                                       required standards; managers
                                           with authority to dismiss
Childcare Strategy                      Childcare strategy including:                   HR          HR Business        PPPG           Board            Jul-09                    Jun-08    Yes       N/A
                                       benefits; framework for action                               Manager
                                      (childcare vouchers, tax credits,
                                           childcare co-ordinator);

Complaints Policy                      Guidance on management of CNST                   Comms       Head of PR and     Dir            Board            Jul-09         Jul-08     Sep-07    Pending   Pending/N/A
                                      complaints and appreciations;                                 Strategic
                                            and lessons learned                                     Communications
Disciplinary Policy                    Policy setting out disciplinary                  HR          HR Business        PPPG           Board            Jul-09         Jul-08     Jul-07    Yes       N/A
                                       process including: principles;                               Manager
                                      informal action; investigations;
                                        suspension; representation;
                                      hearings; penalties; dismissal;
                                      settlement; review of conduct;
                                         records; role of HR; Police
                                      enquiries/criminal proceedings;
                                       appeals; process documents


Equality and Diversity Policy         Policy on equality and diversity                  HR          HR Business        PPPG           Board            Jul-09                    Jul-07    Yes       Pending
                                       including: principles; genuine                               Manager
                                        occupational qualifications;
                                        cultural and religious needs;
                                         recruitment and selection;
                                         training and development;
                                            terms and conditions;
                                           complaints/grievances;
                                      malicious complaints; roles of
                                                key personnel

Fleet (and Transport) Policy                  To be confirmed               S4BH        Fleet       Fleet Operations   Dir            Board            Jul-09                    Jun-08    Pending   Pending/N/A
                                                                                                    Mgr
Flexible Working Policy                  Policy on flexible working                     HR          HR Business        PPPG           Board            Jul-09                    Jun-07    Yes       Pending
                                      including: principles; eligibility;                           Manager
                                      part time/job shares; voluntary
                                         reduced hours; flexi-time;
                                      practical arrangements; refusal




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                                                                                                                                                                                              Impact
Document                                                                   Requirement                                                                                           Original                Impact
                                                                                                    Lead Manager /       Development    Approval                        Last                 Assess
(policies to the Board are only       Content in brief                     (ALE, S4BH, Lead Dept                                                   Next review date              Approval             Assess ment
                                                                                                       Contact              Group        Group                        Revision              ment Part
presented in full at 3 year review)                                        CNST, Other)                                                                                            Date                   Part 2
                                                                                                                                                                                                1
Grievance Policy                        Policy on process for making                   HR          HR Business          PPPG           Board            Jul-09         Jul-08     Jun-07    Yes       N/A
                                          and handling a grievance                                 Manager
                                      including: witnesses; time limits;
                                        decisions; grievances against
                                           CEO; failure to resolve
                                      collective grievances; grievance
                                                  procedure




Infection Control Policy and                 Guidance on infection         CNST        Clinical    Director of Urgent   Gov            Board            Jul-09         Nov-08     Mar-07    Pending   Pending/N/A
Strategy (Guidance and                       prevention and control                                Care and Clinical
                                            including: cleaning and                                Services
Procedures inc Waste
                                       decontamination; linen; clinical
Management and Linen                    waste; care of the deceased;
Arrangements)                         infectious disease; infestations;
                                        infectious patients; biological
                                                  warfare; major
                                            outbreaks;antimicrobial
                                          prescribing; hand hygiene;
                                         sharps; aseptic techniques;
                                              occupational health
Patient and Public Involvement              Strategy for stakeholder       ALE         Comms       Head of PR and       Dir            Board            Jul-09         Jul-08     Mar-07    Pending   Pending/N/A
& Community Engagement                        involvement in trust                                 Strategic
                                       development, including LInKs,                               Communications
Strategy
                                          Compacts, OSCs, patient
                                          surveys, staff engagement
Policy on Policies (needs               Policy on the development of       CNST        Gov         Risk Manager         Gov            Board            Jul-09         Nov-08     Jul-07    Pending   Pending/N/A
simplifying)                             Trust procedural documents
                                           including policy template
Retirement Policy                      Policy on retirement including:                 HR          HR Business          PPPG           Board            Jul-09                    May-08    Yes       Pending
                                         early retirement; flexing into                            Manager
                                            retirement; preparation;
                                         extension of service; vacant
                                            posts; awards; form for
                                              extension of service
Safeguarding Policy                   Policy on safeguarding children      CNST        Clinical    Safeguarding         Gov            Board            Jul-09         Jul-08     Jul-07    Pending   Pending/N/A
                                         and adults, child protection,                             Manager
                                          domestic violence, mental
                                          health, and relevant forms

Staff Involvement Policy              Policy on involving staff in trust               HR          HR Business          PPPG           Board            Jul-09                    May-08    Yes       N/A
                                       business including: principles;                             Manager
                                       communication; working with
                                         unions, other healthcare
                                      organisations, and communities

Continuous Professional                    Strategy for continuous         ALE         Education   Training Business    Dir            Board           Sep-09                     Sep-08    Pending   Pending/N/A
Development Strategy                     professional development                                  Manager
                                       including creation of portfolios




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                                                                                                                                                                                            Impact
Document                                                                 Requirement                                                                                           Original               Impact
                                                                                                  Lead Manager /       Development    Approval                        Last                 Assess
(policies to the Board are only       Content in brief                   (ALE, S4BH, Lead Dept                                                   Next review date              Approval             Assess ment
                                                                                                     Contact              Group        Group                        Revision              ment Part
presented in full at 3 year review)                                      CNST, Other)                                                                                            Date                  Part 2
                                                                                                                                                                                              1
Recognition Agreement (trade            Policy on arrangements with Legislation      HR          HR Business           JNCC          Board           Sep-09          Sep-08     Sep-07    Yes       Pending
Union)                                    Trade Unions including:                                Manager
                                      recognised unions; negotiation;
                                      representatives; subscriptions;
                                      variations; list of unions; JNCC
                                       and PPPG terms of reference

Training & Education Policy               Details of training courses    CNST        Education   Head of Education     Gov           Board           Sep-09          Nov-08     Sep-07    Pending   Pending/N/A
                                         available to clinical and non                           and Training
                                                 clinical staff
Clinical Effectiveness Strategy        Clinical Effectiveness Strategy               Clinical    Director of Urgent    Gov           Board           Nov-09                     Nov-08    Pending   Pending/N/A
                                        including: vision; national and                          Care and Clinical
                                        local best practice guidelines;                          Services
                                             education/workforce;
                                       research/audit; clinical records
                                         and information; clinical risk;
                                      resources; partnership working;
                                       culture; strategic development


Dignity at Work Policy                 Guidance on harassment and CNST               HR          HR Business           Dir/Gov       Board           Nov-09          Nov-08     Mar-07    Yes       Pending
(formerly Harassment &                 bullying including: examples;                             Manager
                                       confidential advice; informal
Bullying)
                                      and formal action and appeals;
                                        malicious complaints; and
                                            procedural guidance

Public Health Strategy                      Public Health strategy     S4BH          Comms       Head of PR and        Gov           Board           Nov-09          Nov-08     Nov-07    Pending   Pending/N/A
                                           including: key targets;                               Strategic
                                         demographic intelligence;                               Communications
                                            supporting strategies;
                                      implementation structures; local
                                                health profiles
Stress Management Policy                     Guidance on stress        HSE           H&S         Health, Safety &      H&S           Board           Nov-09          Nov-08     Nov-07    Pending   Pending/N/A
                                             management; stress                                  Security Manager
                                        management standards; risk
                                        assessment; Staff Wellbeing
                                                    Group
Communication and Media                  Guidance on internal and      ALE, CNST     Comms       Head of PR and     Gov              Board           Jan-10          Jan-09     Jan-08    Pending   Pending/N/A
Strategy                                  external communications                                Strategic
                                                                                                 Communications
Counter Fraud and Corruption              Policy on reporting fraud      ALE and     Finance     Local Counterfraud Audit            Board           Jan-10          Jan-09     Nov-07    Pending   Pending/N/A
Policy                                including: responsibilities; and   LCFS                    Specialist
                                              further guidance
Finance Strategy - medium             5 year strategy for the planning   FT / ALE    Finance     Director of Finance                 Board           Jan-10          Jan-09     Jul-07    Yes       N/A
term                                     and management of Trust                                 and Performance
                                            financial resources
Performance Management                Process for ensuring objectives    ALE         Finance     Director of Finance Dir             Board           Jan-10                     Jan-09
Strategy                                 are cascaded through all                                and Performance
                                                  functions




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                                                                                                                                                                                         Impact
Document                                                                 Requirement                                                                                        Original               Impact
                                                                                                  Lead Manager /    Development    Approval                        Last                 Assess
(policies to the Board are only       Content in brief                   (ALE, S4BH, Lead Dept                                                Next review date              Approval             Assess ment
                                                                                                     Contact           Group        Group                        Revision              ment Part
presented in full at 3 year review)                                      CNST, Other)                                                                                         Date                  Part 2
                                                                                                                                                                                           1
Procurement Strategy                  Procurement strategy including:                Finance     Procurement       Dir            Board           Jan-10          Jan-09     Jan-08    Pending   Pending/N/A
                                        aims and principles (inc e-                              Manager
                                      procurement); service/function
                                      analysis including principles of
                                         sustainability, price, stock
                                           keeping; maintenance;
                                          developments; business
                                                 continuity

Workforce Plan                             Workforce plan for the        ALE         HR          HR Business       Dir            Board           Jan-10          Apr-08     Apr-07    Yes       N/A
                                            forthcoming year                                     Manager




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