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Policy for the Development, Authorisation, Dissemination and of 33 Control of Strategies, Policies and Procedures

YMDDIRIEDOLAETH GIG CEREDIGION A CHANOLBARTH CYMRU CEREDIGION AND MID WALES NHS TRUST

POLICY FOR DEVELOPMENT, AUTHORISATION, DISSEMINATION AND CONTROL OF STRATEGIES, POLICIES,

AND PROCEDURES

Author Corporate Services Officer Equality impact High Original Date October 2000 This Revision August 2005

Equality assessment done No

Next Review Date August 2008 Review Body Risk Management Committee Approved by Trust Board Policy Number CP12 Date of Approval October 2000 Classification Corporate

Policy for the Development, Authorisation, Dissemination and Control of Policies, Procedures and Guidelines

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Policy for Development, Authorisation, Dissemination and Control of Strategies, Policies and Procedures

CONTENTS Page Number 1. Introduction 3 1.1 Objectives 3 2. Scope 3 3. Definitions 4 3.1 Strategy 4 3.2 Policy 4 3.3 Procedure 4 4. Roles and Responsibilities 4 4.1 Chief Executive Officer 4 4.2 Head of Corporate Services 4 4.3 Deputy Director of Nursing 4 4.4 Corporate Services Officer 4 4.5 Policy Authors 5 4.6 Line Managers 5 4.7 All Staff 5 5. Organisation of Strategies, Policies and Procedures 5 6. Development and Format (including review) 6 6.1 Document format 6 6.2 Equality requirements 7 6.2.1 Initial screening 7 6.2.2 Full assessment 8 6.3 Consultation 8 6.4 Approval process 8 6.5 Dissemination process 9 6.6 Review process 9 7. Equality 10 8. Training 10 9. Dissemination 10 10. Freedom of Information Act 11 11. Records Management 11 12. Review 11 13. Monitoring 11 14. Discipline 11 Appendix A Equality Assessment Process Flowchart 12 Appendix B Equality Impact Assessment Questionnaire 13 Appendix C Dimensions of Social Difference 26 Appendix D Policy Approval Flowchart 27 Appendix E Review Process 28 Appendix F Template Policy (including standard clauses) 29 Appendix G Harvard Style Bibliographies and References 32 Appendix H Policy Submission Form 33


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1. Introduction To ensure the Trust provides a robust and clear governance framework within which service delivery can occur, the Trust needs to develop and implement strategies, policies and procedures that are appropriate and practical. The control of strategies, policies and procedures is essential in achieving compliance with legislative, governance and controls assurance requirements. The recent changes in equality legislation, especially the Race Relations (Amendment) Act 2000, mean the Trust must take concerted action to identify and eliminate inequality. Developing policies and practices that ensure all individuals are treated equally, is the first step towards delivering health services that are patient focused and effective. In order to achieve this, the Trust is committed to scrutinising the way in which it discharges its functions and develops its strategies, policies and procedures. In addition to the need to identify and eliminate inequality, the control of strategies, policies and procedures is essential in achieving compliance with corporate and clinical governance standards and with relevant controls assurance measures. Organisations have a statutory duty to have in place appropriate strategies, policies and procedures to comply with relevant legislation to enable staff to fulfil the requirements of their role safely and competently. In addition, there needs to be an effective process for managing and reviewing these policies and procedures on a regular basis to ensure they are safe, legal and efficient. The Welsh Risk Pool requires that Trusts establish and maintain a compendium of policies, procedures and guidelines. These should be in a standard format, reviewed at specific intervals, dated and appropriately approved. The main purpose of strategies, policies and procedures is to identify and eliminate inequality, determine the strategic direction for the relevant area and to standardise practice and service delivery to reflect the best available evidence thereby reducing unjustified variations hence improving quality. Having effective, up to date and easily followed policies, procedures and other guidance documents minimises risk to patients, employees and the Trust. 1.1 Objectives To ensure that staff have access to the most up to date copies of Trust-wide, directorate and

departmental documents To ensure that all policies in use are current and relevant and have been reviewed within the

last three years To ensure equality assessment is completed and appropriate actions taken to ensure the

identification and elimination of inequality To ensure that systems exist to monitor the use of and compliance with agreed policies,

procedures, protocols and guidelines To avoid duplication To develop and maintain a database of policies, procedures, protocols and guidelines and

relevant information To establish a corporate style and ensure all policies and procedures are of a consistently high

standard To maintain an archive of past policies, procedures, protocols and guidelines for reference and

legal requirements. 2. Scope This policy applies to all Trust staff in all Trust locations and sets out the route to be followed when developing or updating policies, procedures or guidelines and introducing them as appropriate within the Trust.


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3. Definitions 3.1 Strategy A long term plan designed to achieve particular goals or objectives. A strategy is often a broad statement of an approach to accomplishing these desired goals or objectives and can be supported by policies and procedures. 3.2 Policy A policy is a statement of intent, describing the approach or course of action the Trust is taking in respect of a particular issue. Policies are underpinned by relevant evidence based procedures and guidelines and enable management and staff to make correct decisions, work effectively and comply with relevant legislation and Trust aims and objectives. Policies must be achievable and must demonstrate through the aims and objectives how the policy statement is to be achieved. Policies must be approved by the relevant Trust body and once implemented are mandatory on all staff. Each policy should have a purpose and specific steps (procedures) as to how the policy is to be accomplished. 3.3 Procedure A procedure is a documented series of actions, performed in an orderly manner, to achieve a desired outcome. This will ensure that all concerned undertake the task in an agreed and consistent way. 4. Roles and Responsibilities 4.1 Chief Executive The CEO has overall responsibility for ensuring the Trust has appropriate strategies, policies and procedures in place to ensure the Trust works to best practice and complies with all relevant legislation. 4.2 Head of Corporate Services The Head of Corporate Services is responsible for ensuring a database of policies and procedures is maintained and that the documents are readily accessible to all relevant staff. They are also responsible for ensuring appropriate distribution and review of Trust policies, procedures, protocols and guidelines. 4.3 Deputy Director of Nursing The Deputy Director of Nursing is responsible for ensuring that all clinical policies are maintained and updated by liaising with the appropriate policy author(s) and will provide advice and assistance to those developing clinical policies, procedures, protocols and guidelines. The Deputy Director of Nursing is also the lead for the Welsh Risk Pool standard on Policies and Procedures. 4.4 Corporate Services Officer The Corporate Services Officer will: Ensure that the Trust database is maintained by regular policing and review Ensure appropriate systems for dissemination of agreed policies


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Administer the approval process in line with this Policy Ensure strategies, policies, procedures, guidelines and protocols are posted on the Trust’s

websites as appropriate Work with staff without access to the intranet to ensure they have access to relevant

documentation Provide advice and assistance as required Maintain a record of the results of the equality assessments

4.5 Authors of Strategies, Policies and Procedures It is the responsibility of the author of a strategy, policy or procedure to: Ensure that strategies, policies and procedures are implemented appropriately and, where

necessary, audit the compliance with those documents. Ensure appropriate review of the documents, either in line with the review timescale set at the

time of approval or as a result of changes to practice, organisational structure or legislation. Ensure appropriate consultation has taken place with the relevant individuals and groups Ensure the guidance provided in this Policy is followed Ensure the necessary equality assessment has been carried out prior to the document entering

the approval process (see Appendix D) Maintain an archive of the previous versions of any revised or reviewed policy, procedure and

guideline documents 4.6 Line managers All line managers are responsible for: Ensuring all strategies, policies, procedures, protocols and guidelines are accessible for all

their staff Ensure staff have read and understood the relevant strategies, policies, procedures, protocols

and guidelines Ensure systems exist to identify staff training needs on the implementation of new and

updated strategies, policies, procedures, protocols and guidelines 4.7 All staff All staff must ensure that their practice is in line with the current strategies, policies, procedures and guidelines in use across the Trust and specific to their areas of work. Information regarding the failure to comply with the policy (e.g. lack of training, inadequate equipment) must be reported to the Line Manager and the incident reporting system used where appropriate. 5. Organisation of Strategies, Policies and Procedures The diverse nature of health care means there will be a large number of strategies, policies and procedures in place. Some will apply across the Trust and be relevant to all staff, and others will be specific to certain areas or activities. The Trust has a duty to ensure that staff are aware of and have access to strategies, policies and procedures relevant to their area of responsibility. Managers need to ensure that staff are aware of all strategies, policies and procedures that are relevant to them. For ease of reference, policies will be listed and numbered under the following headings (categorisation is for convenience and does not indicate that a policy is applicable only to a particular staff group): Corporate Strategies – e.g. Risk Management Strategy or Clinical Governance Strategic

Framework


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Corporate Policies – e.g. Standing Orders, Complaints Policy and Procedure, Major Incident Plan, Records Management Policy

Clinical – e.g. Consent to Treatment, Blood Transfusion, Admission and Discharge Human Resources – e.g. Disciplinary Policy, Grievance Policy and Procedures, Supervision

of Clinical Staff and Assessing Competence Policy, Uniform Policy Health and Safety – Includes policies from the Health and Safety and Security Manuals Infection Control – all policies included in the Infection Control Manual and policies relating

to the operation and activities of the Infection Control Team. Finance – e.g. Fraud Policy and Response Plan, Financial Procedures Procurement – policies related to supplies and procurement Information Management and Technology – policies relating to IM&T, e.g. E-mail Policy,

PC Security Policy, Data Quality Policy Health Records – e.g. Access to Health Records Policy, Transportation of Health Records

Policy Child Protection – policies that make up the Child Protection Manual

An index of Trust Strategies, Policies and Procedures will be maintained by Corporate Services along with a database that will be developed and maintained to manage the review process. The database will become a central register for all strategies, policies and procedures in the Trust. 6. Development and Format (including review) Corporate Services must be notified when a new policy is being developed. This will ensure the central register is kept up to date, the strategy, policy or procedure will be assigned to the appropriate group and the appropriate number. When a requirement for a new strategy, policy or procedure is identified, the initiator must, in the first instance, review existing strategies, policies and procedures, to ensure that the issues are not already covered and avoid duplication. The initiator should also consider whether an amendment or addition to an existing strategy, policy or procedure, is more appropriate than a new stand alone document. The language used should be plain English, using short sentences and where possible avoiding technical terms. If technical terms are used, they should be explained using a glossary or footnotes. The names of individuals will not be contained within strategies, policies and procedures. Individuals with particular responsibilities will be identified by their job title only. All strategy, policy and procedure development should be undertaken in line with current legislation, national and professional guidance e.g. Freedom of Information Act, Welsh Health Circulars, NICE guidance or NMC guidance. They should also be based on sound evidence and be appropriately referenced. 6.1. Document Format A document template has been developed to provide guidance on what information should be contained in policies and procedures along with some standard clauses that can be used as appropriate (See Appendix F). This template indicates fields that are mandatory. It also contains the standard front cover which is to be applied to Trust strategies, policies and procedures. Below are some specific points regarding formatting: Electronic format Microsoft Word Front cover As per template (appendix F)


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Font Arial or Times New Roman point 12 size Tables and charts Arial or Times New Roman (size as appropriate) Alignment Left Line spacing Single Underlining None (unless for websites) Headers and footers Arial or Times New Roman point 9 size – must include name of

strategy, policy or procedure (left aligned) and page numbers Page numbers Page x of y or page x (right aligned) Referencing style Harvard (see appendix G) 6.2 Equality Requirements Developing policies and practices that ensure individuals are treated equally is the first step towards delivering health services that are patient focussed and effective. This requires the Trust to take action to identify and eliminate inequality. Undertaking equality impact assessment in relation to all relevant policies and practices provides a means of doing this. The equality impact assessment process has been developed to help promote fair and equal treatment in the delivery of health services. It is intended to enable the Trust to identify and eliminate detrimental treatment caused by the adverse impact of health service strategies, policies and procedures upon groups and individuals for reasons of race, gender, disability, sexuality, age, religion and language. In accordance with the equality assessment chart in Appendix A, strategies, policies and procedures will undergo a two stage assessment as part of their development. It is the responsibility of the policy author to complete the equality assessments. The toolkits are to be completed electronically and the results of the assessments will be published on the intranet and internet sites. Strategies, policies and procedures do not affect everyone in the same way. By making sure at an early stage of their development that they will not have unfavourable effects on some groups, or by taking steps to mitigate these effects, will enable the Trust to: Ensure, as far as possible, that strategies, policies and procedures recognise the diverse needs,

circumstances and concerns of the people who will be affected by them Be aware of any inequalities between different racial groups that could arise, directly or

indirectly, as a result of a proposed strategy, policy or procedure, and consider alternative ways of achieving its aims

Make sure any services you provide meet the needs of all racial groups Make your policy-making process more rigorous, by anticipating the way your proposed

strategy, policy or procedure is likely to work in practice, and by avoiding any negative effects it might have on some groups

6.2.1 Initial Screening The initial screening arm of the assessment comprises of stages 1 and 2 of the questionnaire included as Appendix B. This has been developed by the NHS Centre for Equality and Human Rights as a result of the need to assess all policies and functions to support the review of Race Equality Schemes. This screening is usually based on existing information and data that the organisation already has. At this stage the information may only provide estimates or signs of unequal impact.


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6.2.2 Full Assessment The full assessment involves a thorough and robust process of examining all aspects of the strategy, policy or procedure through the principles of equality and forecasting its likely effects on different groups. The NHS Centre for Equality and Human Rights has developed an Impact Assessment tool that will be used by the Trust to ensure it is not unlawfully discriminating and is promoting equal opportunities and good race relations. The questionnaire is attached in Appendix B; the full guidance document is available via the Intranet site or the Corporate Services Officer. 6.3. Consultation All strategies, policies and procedures should be developed in consultation with their target audience involving appropriate managerial and clinical staff and staff representation. All new strategies and policies or significantly revised strategies and policies should be the subject of consultation within the Directorate Structure and with relevant professional groups and/or individuals. The Trust will undertake to develop a mechanism to involve patients and members of the public where appropriate. This will strengthen the stakeholder involvement with the Trust and demonstrate our commitment to working with the local community. All consultation will be led by the author and must be completed before the strategy, policy or procedure begins the approval process. 6.4. Approval Process The general approval process has been included in Appendix D and should be used for guidance when submitting strategies, policies and procedures for approval. For all committees, the policy submission form in Appendix H must be used. Guidelines can be approved by the local management of the area(s) affected. Strategies, policies and procedures that have undergone a major review must go through the full approval process, whereas those with minor amendments or updates may be sent directly to the final review group (as identified at the time of initial approval). Certain groups and committees within the Trust have specific areas of responsibility and therefore should receive strategies, policies and procedures for information and agreement. These are: Joint Staff Consultative Committee – this committee aims to actively seek and take account

of the views of employees before making decisions. Policies and procedures affecting staff working practices should be submitted for information.

Joint Negotiating Committee – this committee is the main forum for negotiation of issues affecting the whole or a major part of the Trust’s workforce, including certain employment policies and practice

Clinical Governance Committee – where a policy affects the clinical side of the organisation, it should be submitted to this committee for agreement. This will include, but is not limited to, clinical policies and procedures

Risk Management Committee – where a policy is developed to assist in the mitigation of an identified risk, it should be submitted to this committee

IM&T Steering Group – where a policy or procedure is related to information management or information technology it should be submitted to this group for agreement

Audit Committee – agrees accounting policies and procedures


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Where necessary policy authors should contact the Committee Chairperson or administrator for advice and assistance. The Committee Chairperson and administrator must ensure the policy submission form in Appendix H is used. Strategies, policies and procedures relating to professional practice should be approved by the relevant professional group, e.g. Professional Nursing Forum. Following consultation and validation, strategies and policies that have Trust-wide or cross Directorate/Department implications will be submitted for formal approval and adoption to the Management Board via the appropriate Management Board member. Such strategies and policies may be submitted to the Trust Board for approval. The decision about which strategies, policies and procedures are sent to the Trust Board will be made on a case by case basis by the relevant Executive Director. They will take into consideration the breadth of impact, associated risk and profile of the document, along with any associated requirements of the Welsh Risk Management Standards when making this decision. Departmental or Directorate policies, procedures and guidelines should be approved by the relevant Departmental or Directorate meetings. Such documents must be consistent with Trust strategies, policies, aims and objectives. 6.5. Dissemination Process All strategies, policies and procedures that have been ratified appropriately will be placed on the Trust’s Intranet site and when approved should be forwarded to the Corporate Services Officer for this to be actioned. The intranet site will be the primary location for all strategies, policies and procedures. Relevant strategies, policies and procedures will also be published on the Trust’s Internet site. Information on new and revised policies will be included in Hysbysrwydd and Team Brief on a regular basis and where appropriate other communication channels, e.g. payslips may be used to inform staff of policy development. Where appropriate, training programmes will be undertaken to support the implementation and ongoing compliance with policies. Once revised strategies, policies and procedures are approved, the Corporate Services Officer will e-mail relevant Directorate Managers to inform them. Once issued, managers will be responsible for ensuring that staff are aware of the revisions and that any out of date versions are taken out of circulation. Each Directorate or Department will put in place a robust controlled documentation system to ensure that records of distribution of strategies, policies and procedures are maintained. It is the responsibility of the author of a strategy, policy or procedure to ensure that when a document is revised, a copy of the original is forwarded to the Corporate Services Officer, as contemporaneous documents may be required at a future date. A definitive list of all strategies, policies and procedures will be maintained by the Corporate Services Officer and reported annually to the Management Board. 6.6 Review Process Strategies, policies, procedures and guidelines will be reviewed when required, e.g. as a result of changes in structures, legislation or evidence that they are no longer effective. All policies and


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procedures will be reviewed at three year intervals as a maximum. A flowchart of the review process can be found in appendix E. The following documents will be reviewed annually: Risk Management Policy and Strategy Directorate Risk Management Policies and Strategies Health and Safety Policy Major Incident Plan Fire Safety Policy Environmental Policy

This list is a minimum; there may be other documents that require annual review because of factors such as the topic they cover or the Welsh Risk Pool requirements. It is the responsibility of the policy author to ensure policies and procedures are reviewed in line with their review dates. The reviewing Committee or Board is determined at the development stage of the original document and is stated on the front of each strategy, policy and procedure. This Committee or Board can therefore agree that reviewed document. In the event of a strategy, policy or procedure passing its review date without a replacement document being provided or a review being completed, the Chairperson of the reviewing Committee may take the decision to extend the review timescale for that document (and therefore provide a new review date). In doing so, they should ensure that the strategy, policy or procedure is still up to date and fit for purpose. Where such a decision is taken, the policy author must inform the Corporate Services Officer of the new review date. 7. Equality The Trust recognises the diversity of the local community and those in its employ. Our aim is therefore to provide a safe environment free from discrimination and a place where all individuals are treated fairly, with dignity and appropriately to their need. The Trust recognises that equality impacts on all aspects of its day to day operations and has produced an Equality Policy Statement to reflect this. All strategies, policies and procedures are assessed in accordance with the Equality initial screening toolkit, the results for which are monitored centrally. This policy has undergone the initial screening process in line with the Trust’s Race Equality Scheme and has shown a high level of impact. 8. Training and awareness Ad hoc training will be available via the Corporate Services Officer as required. An explanatory session will be provided via the Managers Personnel Information Pack meeting. A training session will be arranged by Human Resources to cover the full impact assessment process for equality. 9. Dissemination This policy will be made available via the Trust’s intranet and internet sites. The policy template and equality questionnaires will be available in a format that can be completed electronically. Awareness of the policy will be raised through Hysbysrwydd and Team Brief. A copy of the approved policy will be sent to the current policy authors for their information.


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10. Freedom of Information Act 2000 Any information that belongs to the Trust may be subject to disclosure under the Freedom of Information Act 2000. This Act allows anyone, anywhere to ask for information held by the Trust to be disclosed (subject to limited exemptions). Further information is available in the Freedom of Information Act 2000 Policy. 11. Records Management Records are created or received in the conduct of the business activities of the Trust and provide evidence and information about these activities. All records are also corporate assets as they hold the corporate knowledge about the Trust. The Trust has a Records Management Strategic Framework and a Records Management Policy for dealing with records management that are consistent with: a) WHC (2000) 71 – For the Record: Managing records in NHS Trusts and Health Authorities b) The Lord Chancellor’s Code of Practice on the Management of Records under Section 46 of

the Freedom of Information Act 2000 (November 2002) Compliance with and the application of this policy will ensure that the Trust’s records are complete, accurate and provide evidence of and information about the Trust’s activities for as long as is required. 12. Review This policy will be reviewed in 3 years time. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation or guidance. 13. Monitoring Monitoring of compliance with this policy will be the responsibility of the Risk Management Committee. 14. Discipline Breaches of this policy will be investigated and may result in the matter being treated as a disciplinary offence under the Trust’s disciplinary procedure.


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Equality Assessment Process

Appendix A

Complete initial screening using questionnaire provided

Prioritisation of impact high, medium, low or none

If high, medium or low

If none

Develop policy/procedure without further reference to

equality guidance Full impact assessment to be

carried out in line with Equality toolkit as provided

Policy to progress through consultation and ratification process with policy summary

submission sheet attached

Once agreed the initial screening questionnaire and full impact assessment (if completed) must be forwarded to the Corporate Services Officer for publication on the

Trust’s websites


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Appendix B

Equality Initial Screening Impact Assessment Questionnaire Function Name of Assessor

Name of strategy/policy/procedure to be assessed

Date

Outcome of assessment

This form has been designed to be completed when carrying out an equality impact assessment. It has been written in conjunction with the tool to enable you to focus your response upon the eight stages of impact assessment. It is not intended to provide a definitive account of the content and outcome of the impact assessment process but to offer a summary of information to inform production of the impact assessment report and support effective decision-making. It is essential, that when conducting an equality impact assessment, due consideration is given to the importance of meeting each arm of the public duties outlined on pages 6-7 of the toolkit. Unless the published report evidenced consideration of each arm of the public duties when progressing through the first seven stages of the impact assessment report, the process may be deemed not to have complied with the statutory requirements of the Race Relations Amendment Act and the Disability Equality Act. In these circumstances the policy will not be considered lawful and any attempt to implement it may be challenged and could result in judicial review. In the interests of promoting an inclusive equality agenda, it is important to apply the same rigorous standards in meeting the requirements of the Race General and Disability Equality Duties to all the equality dimensions identified within the tool. Finally, where it is evident that an adverse impact may occur or that insufficient information has been obtained to provide the necessary evidence based assessment programme, remedial action will need to be identified as suggested in the guiding principles on page 5 of the toolkit.

Please use the Toolkit for Carrying out Equality Impact Assessment when working through the questions below. This is available via the Intranet site or from the Corporate Services Officer.


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Stage 1: IDENTIFYING THE AIMS OF THE STRATEGY/POLICY/PROCEDURE (Please refer to pages 11-12 of the toolkit for supplementary information and guidance)

1.1 What is the aim(s) of the document?

1.2 What is the reason for the document?

1.3. What are its objectives?

1.4. Is it a new or existing document?

1.5 Are there other strategies/ policies/procedures contributing to the same aim? If so, please list

1.6 What outcomes is the document designed to achieve?

1.7 Who is responsible for implementing it?

1.8 Who are the main document Stakeholders?

1.9 Are they represented in the document development process?

1.10 How will the documents compliment or compromise other documents?

1.11 How do you intend to measure progress against your outcomes?


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Stage 2: COLLECTING RELEVANT DATA AND INFORMATION (Please refer to pages 13-15 of the toolkit for supplementary information and guidance)

Yes / No 2.1 Has relevant, reliable and up to date, research information been collected to adequately assess the impact of the document in relation to each limb/part of the Equality Public Duty?

2.2 Does the data/information in 2.1 extend to those covered by the Public Duty as identified in Appendix C

Yes / No 2.3 Are there any data/information gaps? If yes, what action do you intend to take to address these deficits?

CONSIDERING THE EVIDENCE (Please refer to pages 15-17 of the toolkit for supplementary information and guidance)

The following questions will enable you to determine the level of relevance

Yes / No 2.4 Will the proposed document involve or have consequences for the people your organisation serves, employs or conducts business in the context of their race, gender, sexual orientation, age, religion, disability or language? If yes, please explain, identifying those likely to be affected

Yes / No 2.5 Is there any reason to believe that people from the different equality strands, taking account of interaction between strands, could be affected differently, by the proposed document? If yes, please state reason and those likely to be affected

Yes / No 2.6 Is there evidence to suggest that any part of the proposed document could discriminate unlawfully, directly or indirectly? If yes, please specify If no, please explain

2.7 Having considered all the information is the document relevant to promoting the Race Equality General Duty? Specify the arm to which it is relevant and why?

Yes / No

a. Eliminating discrimination between people of different racial groups

b. Promoting equality of opportunity between people of different racial.

c. Promoting good relations between people of different racial groups

2.8 Having considered all the information is the document relevant to promoting the Disability Equality Duty. Specify the limb to which it is relevant and why?

a. Eliminate discrimination b. Eliminate harassment of disabled people c. Promote equality of opportunity between disabled persons

and other persons


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d. Treat disabled persons more favourably, if required following reasonable adjustment

e. Promote positive attitudes towards disabled persons; and

f. Encourage participation by disabled person 2.9 Having considered all the information is the document

relevant to promoting the Universal Public Duty in relations to gender, sexual orientation, religion, language and age. Specify the arm to which it is relevant and why?

a. Eliminate discrimination b. Promote equality of opportunity

Yes / No 2.10 Are there any questions relating to the way the document will impact upon different groups and individuals that it has not been able to answer because of lack of information?

If no, why? If yes, what do you propose to do to address the

information gap? Is this a proportionate response to the document in

terms of its importance? Is the response detailed within an action plan? Please

specify

Yes / No 2.11 Does the evidence suggest the document will have a positive impact on the promotion of equality? If yes, which group(s) in particular?

2.12 What are the reasons for deciding the document is relevant or not relevant?

2.13 What is the degree of relevance and why? High Medium Low None

If the relevance is high, the full impact assessment must be completed prior to submission for approval. Also if this is a new document, the full impact assessment is to be completed before submission for approval. If this is a reviewed of an existing document and the relevance is medium or low, the full impact assessment must be completed in accordance with the timescale detailed in the Race Equality Scheme. For medium or low relevance reviewed documents, please indicate when the full impact assessment will be carried out.

Accountability Chair of Assessing Team/Assessing Individual:

Date:

Next Steps:


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FULL IMPACT ASSESSMENT Stage 3. ASSESSING THE IMPACT OF THE DOCUMENT

(Please refer to pages 17-20 of the toolkit for supplementary information and guidance)

Yes/No 3.1 Having undertaking a comparative analysis of the research information for the proposed document, is there a difference in the conclusions reached using the quantitative and qualitative methods? If yes, why and how can the differences be reconciled?

3.2 Does the comparative analysis indicate possible differential impact in either or both the quantitative and qualitative data on any racial groups Explain the nature of the adverse impact.

3.3a If yes to 3.3, please provide detailed response to each arm of the Race Equality Duty in relation to each identified racial group Thus, a. Eliminate race discrimination between persons of

different racial groups b. Promote equality of opportunity between persons of

different racial groups c. Promote good relations between different groups

3.3b If yes to 3.3, please provide a detailed response to each limb of the Disability Equality Duty in relation to each type of disability identified. Thus, a. Eliminate discrimination b. Eliminate harassment of disabled people c. Promote equality of opportunity between disabled

persons and other persons d. Treat disabled persons more favourably, if required

following reasonable adjustment e. Promote positive attitudes towards disabled persons;

and f. Encourage participation by disabled persons

3.3c If yes to 3.3, please provide a detailed response to each limb of the Universal Equality Duty, in relation to the sub-categories in gender, sexual orientation, religion, language and age. Thus, a. Eliminating unlawful discrimination b. Promoting equality of opportunity

3.4 Could the document lead to direct discrimination? If no, why? If yes, explain and provide evidence of consequent

decision made

3.5 Is the document intended to increase equality of opportunity by permitting or requiring positive action(s) to redress disadvantages?

Is it lawful?


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3.6 Are there any steps that need to be taken to counter any resentment the document might cause among other groups who consider the document to be unfair?

If yes, are these detailed within an action plan? Please specify (see page 5 of the toolkit)

3.7 Will the document contravene any aspect of the Human Rights Act 1998?

If yes, under which Articles is this likely to occur and on what grounds?

Can the contravention be mitigated? If yes, how?

3.8 Would further research be useful? If no, why? If yes, would this be a proportionate response to the

document in terms of its importance? Is the response detailed within an action plan? Please

specify (see page 5 of toolkit)


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Stage 4. CONSIDERING ALTERNATIVES (Please refer to pages 20-21 of the toolkit for supplementary information and guidance)

4.1 Are you confident that having considered all the available information that there will be no adverse impact on the grounds of race, gender, disability, sexuality, age, language, religion as a consequence of this document?

If yes, please provide evidence? If no, what is the nature and those affected by the

adverse impact? (Please link to responses in questions 3.3-3.3c above)

4.2 Are there one or more alternative measures that would achieve the desired document aim(s) whilst eliminating or mitigating the adverse impact?

If yes, what might they be?

4.3 Are there aspects of the document that could be changed and/or additional measures that could be taken, that would reduce or remove identified adverse impact(s) without compromising the document’s overall aim(s)?

If yes, what are they? If no, why?

4.4 Have you considered changing the document or designing an alternative to mitigate the effects of the adverse impact?

If no, provide details of your justification for this? The justification evidence must show that the adverse impact is:

1) not related to the grounds of race, disability, sexual orientation, age, gender and religion?

2) a proportionate and reasonable means for achieving the document purpose and aim?

3) there is no alternative measure that would secure the desired aim and purpose; and

4) your arguments are supported by legal advice?

4.5 If yes to 4.4, what are they?

4.6 If yes to 4.3 & 4.4 above, how does each option further or hinder each arm of the public duties of race, disability and other equality strands?

4.7 Will these mitigate the adverse impact?

4.8 If you intend to make amendments to the document are you confident these changes will not render the document unlawful?


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Stage 5. UNDERTAKING FORMAL CONSULTATION (Please refer to pages 22-23 of the toolkit for supplementary information and guidance)

5.1 Did informal consultation/engagement permeate all your activities from stage one of impact assessing this document?

5.2 Did the informal consultation reflect the views of those directly or indirectly affected by the document according to their different racial groups in the context of their sexual orientation, age, gender, disability, religion and language?

If yes, please provide details If no, why?

5.3 Was the output of the informal consultation used to inform and enhance participation during the formal consultation exercise?

If yes, please provide details If no, why and how would it be addressed in future.

Is your response detailed within an action plan? Please specify (see page 5 of toolkit)

5.4 What are the aims of the formal consultation?

5.5 Have the three requirements of effective consultation as detailed under stage five of the impact assessment tool been met?

5.6 Who did you consult with to ensure that the interests of different equality groups were identified during this process?

5.7 Representative organisations truly reflect the voices of the groups and individual within each equality sub-category?

If yes, please explain If no, why and how can it be improved?

5.8 Were the formal consultation responses disaggregated into the different racial groups of respondents?

If yes, please provide details of this If no, why and how can it be improved in the future Is your response detailed within an action plan?

Please specify (see page 5 of toolkit)

5.9 Did the responses of the formal consultation address each limb/part of the Equality Public Duty set out on pages 6-7 of the toolkit?

If no, why? If yes, please identify those limbs/part addressed


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5.10 Did the comparative analysis of the disaggregated consultation responses indicate adverse impact bearing in mind the document aim(s)?

If no, why? If yes, provide details of the nature and extent of

impact as well as those affected

5.11 Also, if yes to 5.10, what steps do you intend to take to mitigate this effect?

5.12 Have you obtained feedback from stakeholders engaged in the consultation process to demonstrate its effectiveness?

5.13 Are there ways in which you might seek to improve the consultation process in the future?

If yes, what are they?


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Stage 6. DECIDING WHETHER TO ADOPT A DOCUMENT (Please refer to pages 24-25 of the toolkit for supplementary information and guidance)

6.1 Has all the available evidence gathered during the course of the impact assessment enabled a robust, evidence-based decision to be made?

6.2 If yes to 6.1, who was involved in making the decision?

6.3 Was the decision made presented as recommendations to the Board supported with accompanying evidence?

If yes, did the evidence include the monitoring and publication arrangements of the impact assessment undertaken?

If no, why not?

6.4 Are the reasons for making the decision, transparent and accountable?

If yes, Please state what they are? If no, why and how can it be

improved in the future Is the response detailed within an

action plan? Please specify (see page 5 of toolkit)

6.5 Are there any additional actions that need to be taken as a consequence of making the decision to approve the document?

If yes, what are they?


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Stage 7. DEVELOPING ARRANGEMENTS TO MONITOR THE EFFECTS OF THE DOCUMENT

(Please refer to pages 25-26 of the toolkit for supplementary information and guidance)

7.1 How will the document be monitored when it becomes operational?

7.2 Do the arrangements include the collection and analysis of data that can be disaggregated in relation to each equality strand in appendix 1(of the toolkit)?

If no, explain?

7.3 Will the document be piloted to see how it actually affects those of different equality sub-categories in appendix C?

7.4 What criteria will be used to assess the effect of the document of the different equality groups?

7.5 Is the organisation confident that the information it intends to collect is sufficient to provide an evidence base to demonstrate the impact of the document upon different equality groups?

Please explain your response.

7.6 Would the decided arrangements be reflected in a formal monitoring programme/action plan presented for approval to the Board?

If no, why? If yes, provide details


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8. PUBLISHING THE RESULTS OF THE ASSESSMENT (Please refer to pages 27-28 of the toolkit for supplementary information and guidance)

8.1 How does the organisation intend to publish the impact assessment undertaken?

8.2 Does the proposed content of the report take account of the guidance and comprise of: a. the background b. methodology and sources of data c. assessment of impact d. consideration of alternatives e. formal consultation f. weight giving to the evidence to

reach a decision; and g. the decision made, as well as the

monitoring arrangements?

8.3 What arrangements have been made to publish the report?

8.4 Is the report available and accessible to all individuals and groups?

Please use the action plan below to detail any actions that are deemed necessary following the completion of the impact assessment. This should include any remedial changes to ensure the effects of identified adverse impact either reduce or eliminated and requirement to conduct further research and information gathering. The contents of this impact assessment form may be used to develop a summarised report for publication. Name of individual / assessment team responsible for conducting the impact assessment: Date Any further comments:


Equality Impact Assessment Action Plan Policy title :

Date :

Action to be undertaken

Lead officer

Date of completion

Expected outcome


The Dimensions of Social Difference

Christianity Buddhism Hinduism

Islam Judaism Sikhism

Other belief/faith No belief/faith

RELIGION

Gypsies and Travellers Jews Sikhs

White: Welsh, English, Scottish, Irish, British

European

Mixed: White and Black Caribbean

White and Black African White and Asian

Asian: Indian

Pakistani Bangladeshi

Black: Caribbean

African Chinese

Other Racial Group

RACE Under 16 16 – 24 25 – 34 35 – 44 45 – 54 56 – 64 65 – 74 75 – 84

85 & over

AGE

Physical Impairment Sensory Impairment

Mental Ill Health Learning Disability

Other disability

DISABILITY

Male Female

Transgendered Individuals

GENDER

Heterosexual Homosexual

Bi-sexual Intersexual

SEXUALITY

English Welsh

Other Language

LANGUAGE

Diagram taken from ‘A Toolkit for Carrying Out Equality Impact Assessment’ produced by the NHS Centre for Equality and Human Rights

Appendix C


Policy Approval Process

Policy development Inform the Corporate Services Officer

Specialist sub-groups e.g., PNAF, IM&T Steering, Risk Management, Health and Safety,

Infection Control

Clinical Governance Committee

Management Board

Trust Board

Equality Forum for information (discuss with Director of HR)

Head of Corporate Services to check approvals to date (prior to acceptance for Board agenda)

Appendix D

Ensure equality assessment process is completed

Relevant Staff-side Committee(s) i.e. JNC, LNC

or JSCC

Policy to be sent to Corporate Services Officer

for recording and publication


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Strategy/Policy/Procedure Review Process Does document need reviewing in terms of Equality

review schedule? (High – 2005/6, medium – 2006/7, low – 2007/8)

No Yes

Policy must be reviewed ensuring equality assessment is completed in line

with Policy on Policies. Should also consider business need as appropriate

Does the document need reviewing in terms of Welsh Risk Pool Standards?

(some documents are reviewed annually and the maximum interval is 3 years)

No Yes

Policy must be reviewed –author should give

consideration to equality requirements

Does the document need reviewing in terms of the Trust’s business need?

(this may be for various reasons e.g. changes in practice, guidance or legislation)

No Yes

No review required Policy must be reviewed –author should give

consideration to equality requirements

Submit to review committee

Upon approval send to Corporate Services Officer

Appendix E


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YMDDIRIEDOLAETH GIG CEREDIGION A CHANOLBARTH CYMRU CEREDIGION AND MID WALES NHS TRUST

TITLE OF STRATEGY/POLICY/PROCEDURE

Author <<Post title>> Equality impact <<level>>(H,M,L) Original Date <<Date of original policy>> This Revision <<Date of current policy>>

Equality assessment done

Initial screening<<yes or no>>

Full Impact Assessment<<yes or no>>

Next Review Date <<Date next review due>> Review Body <<Review committee>> Approved by <<Approval committee>> Policy Number <Provided by corporate services> Date of Approval <<Month and year of

approval>> Classification <Provided by corporate services>

Appendix F


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Title Contents page – optional: dependent on the length and complexity of the document. Introduction – mandatory: introduces the topic and includes reference and applicability of relevant legislation, definitions and context. This section should also include detail of the purpose and objectives of the strategy, policy or procedure. Scope – mandatory: the target audience for the policy or procedure must be clearly stated. An example of wording is: ‘This policy applies to all employees of the Trust in all locations including the Non-Executive Directors, temporary employees, locums and contracted staff.’ Roles and responsibilities – mandatory: expectations of staff as a whole and any specific roles and responsibilities associated with particular posts BODY OF POLICY OR PROCEDURE Training and awareness – mandatory: this section must detail how staff will be made aware of the policy and what training will be provided to ensure compliance. Training may be included in the Trust’s training programme or may be provided by specialists in the area concerned. This section should include details of the availability of the policy document. Equality – mandatory: it is important that the Trust recognises the need for equality in all aspects of its work. This must be reflected in its policy and procedure development. As a result, equality must be included in policies and procedures, with suggested text as follows: ‘The Trust recognises the diversity of the local community and those in its employ. Our aim is therefore to provide a safe environment free from discrimination and a place where all individuals are treated fairly, with dignity and appropriately to their need. The Trust recognises that equality impacts on all aspects of its day to day operations and has produced an Equality Policy Statement to reflect this. All policies and procedures are assessed in accordance with the Equality initial screening toolkit, the results for which are monitored centrally.’ Data Protection Act 1998 – optional: for use where a policy or procedure concerns the management of personal data. Suggested text: ‘The Data Protection Act 1998 protects personal data (for a definition and more information see the Data Protection Policy), which includes information about staff, patients and carers. The NHS relies on maintaining the confidentiality and integrity of its data to maintain the trust of the community. Unlawful of unfair processing of personal data may result in the Trust being in breach of its Data Protection obligations.’ Freedom of Information Act 2000 – optional: suggested text: ‘Any information that belongs to the Trust may be subject to disclosure under the Freedom of Information Act 2000. From the 1 January 2005, the Freedom of Information Act 2000 allows anyone, anywhere to ask for information held by the Trust to be disclosed (subject to limited exemptions). Further information is available in the Freedom of Information Act 2000 Policy.’


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Records Management – optional: should be considered where a policy related to the use and retention of records. Suggested text: ‘Records are created or received in the conduct of the business activities of the Trust and provide evidence and information about these activities. All records are also corporate assets as they hold the corporate knowledge about the Trust. The Trust has a Records Management Strategic Framework and a Records Management Policy for dealing with records management that are consistent with: c) WHC (2000) 71 – For the Record: Managing records in NHS Trusts and Health Authorities d) The Lord Chancellor’s Code of Practice on the Management of Records under Section 46 of

the Freedom of Information Act 2000 (November 2002) Compliance with and the application of this policy will ensure that the Trust’s records are complete, accurate and provide evidence of and information about the Trust’s activities for as long as is required.’ Review – mandatory: This policy will be reviewed in X years time. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation or guidance. Monitoring – mandatory: details how the implementation and application of the policy will be monitored and may include details on how compliance will be audited Discipline – optional Breaches of this policy will be investigated and may result in the matter being treated as a disciplinary offence under the Trust’s disciplinary procedure. References – mandatory where information is cited using the Harvard style as per Appendix G


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Harvard style bibliographies and references When providing a bibliography of documents referenced in the text, the following format is to be used: Book Family name, first initial(s). (year) Title. City of publication: Publisher. Page

number of your quotation

Standard Author of standard. (year). Standard Number : Year. Title of standard. Place of publication : Name of publisher

Chapter in an edited book

Family name, first initial(s). (year) Chapter title. In: Initial(s) Family name of editor(s), (eds). Title of book. City of publication: Publisher. Page number of your quotation

Website with no author

Title of website (year as appearing on site) [Online]. [Date accessed]. Available from World Wide Web : <url of site>

Website with author

Family name, first initial(s) (year) Title [Online]. [Date accessed]. Available from World Wide Web : <url of site>

Thesis Family name, first inital(s). (year) Title. Type of qualification, academic institution

Illustration Originator, (year) Title. Material type, location Online image Author (Year) Title of image [Online image]. [Date accessed]. Available from

World Wide Web: <url of site>

Conference paper

Family name, first initial(s). (year) Title of paper. In: Editor(s) of conference proceedings if known. Title of conference, date of conference, location of conference. Place of publication: publisher. Page number(s)

Electronic journal article

Family name, first initial(s). (year) Title of article. Journal title. [Online]. Volume (issue number) [Date accessed], page number of your quotation. Available from World Wide Web: <url of site>

Journal article Family name, first initial(s). (Year) Title of article. Journal title. Volume (issue number), page number of your quotation

CD-ROM Title (year). [CD-ROM]. City of publication: Publisher

Appendix G


POLICY SUBMISSION FORM To be completed by the Author prior to policy approval process

Title of Document: Reference Number (if known): Author: Title: Are there any National Guidelines, Policies, Legislation or Standards on this subject? Yes / No If YES please include references within document to be developed. If no, what evidence or expert body of opinion is your policy based on? …………………………………………………………………………………………………………………………………………………………………………………………………………………… Are there any existing Trust policies, procedures or guidelines that will impact or affect this document? Please list: …………………………………………………………………………………………………………………………………………………………………………………………………………………… What consultation process has the policy/guideline been through? Please list: …………………………………………………………………………………………………………………………………………………………………………………………………………………… What training will be required to implement this policy? …………………………………………………………………………………………………………………………………………………………………………………………………………………… What resource implications are associated with implementing this policy? …………………………………………………………………………………………………………………………………………………………………………………………………………………… What system is in place to audit the policy/guideline and when will it be done? …………………………………………………………………………………………………………………………………………………………………………………………………………………… Has this document been initially screened for equality impact? Yes / No If YES, what was the outcome? High / Medium / Low / None If NO, this policy cannot be submitted for approval until this screening is complete. If initial screening resulted in a HIGH impact, has the document undergone a full equality impact assessment? Yes / No If NO, this policy cannot be submitted for approval until this full assessment is completed If initial screening resulted in MEDIUM or LOW, full assessment must be completed in accordance with the Race Equality Scheme Action Plan. Please note the time for assessment below: ……………………………………………………………………………………………………………………………………………………………………………………………………………………

Appendix H

policy for development, authorisation, dissemination and ... · policy for development,...

Documents