Document Control policy - Welcome to the IOW NHS

1 Page 1 of 26 Document Control policy Version No Document Control policy policy Type Non Clinical Directorate corporate policy Owner Director of Governance and Risk policy Author corporate Governance and Risk Manager Next Author Review Date 1st April 2024 Approving Body corporate Governance 10th September 2020 Version No. policy Valid from date 1st September 2020 policy Valid to date: 30th September 2024 During the COVID19 crisis, please read the policies in conjunction with any updates provided by National Guidance, which we are actively seeking to incorporate into policies through the Clinical Ethics Advisory Group and where necessary other relevant Oversight Groups NB: The policy Template contains the sections that have to be included in a policy ; any additional references or referencing are subject to requirements of the policy lead director or stakeholders. Page 2 of 26 Document Control policy Version No NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust Document HISTORY (Procedural Document version numbering convention will follow the following format.)

2 Whole numbers for approved versions, , , etc. With decimals being used to represent the current working draft version, , , , etc. For example, when writing a procedural Document for the first time the initial draft will be version ) Date of Issue Version No. Date Approved Director Responsible for Change Nature of Change Ratification / Approval Nov 15 FT Programme Director/Company Secretary policy replaces Procedural Document policy 16 Dec 15 FT Programme Director/Company Secretary Ratified at Risk Management Group 19 Jan 16 FT Programme Director/Company Secretary Ratified at policy Management Group 25 Jan 16 1 FT Programme Director/Company Secretary Approved at Trust Executive Committee 14 Jun 16 Company Secretary policy Management Group 30 Jun 16 2 30 June 16 Company Secretary Trust Executive Committee 13-12-16 3 13-12-16 Company Secretary review corporate Governance and Risk Sub-committee December 2017 Director of Quality Governance policy review and update to reflect changes but never completed July 2020 Associate Director of corporate Affairs policy review and update to reflect changes 21 Aug 2020 Associate Director of corporate Affairs policy draft approved with comments corporate

3 Governance 10 Sep 2020 10 Sep 20 Associate Director of corporate Affairs Final approved version ready to upload corporate Governance 29 Jan 2021 10 Sep 20 Associate Director of corporate Affairs 12 month blanket policy extension due to covid 19 applied with author review date 6 months prior to Valid to Date. Quality & Performance Committee 6 May 2021 10 Sep 20 Associate Director of corporate Affairs Extended policy uploaded and linked back with new cover sheet corporate Governance Page 3 of 26 Document Control policy Version No Contents 1 Executive 5 2 Introduction .. 6 3 Definitions .. 6 Consultation .. 6 Ratification and Approval .. 6 Strategy and Strategic Plans .. 6 policy .. 7 Protocol .. 7 HR policy .. 7 Standard Operating Procedure (SOP) .. 7 Patient Group Directives (PGD) .. 7 Guidelines including clinical guidelines .. 8 Form .. 8 Leaflets and Publicity Materials; including patient information leaflets.. 8 Business Continuity Plan.

4 8 Terms of Reference (TOR) .. 8 4 Scope .. 8 5 Purpose .. 8 6 Roles and 9 The Trust Board .. 9 The Chief Executive .. 9 Associate Director of corporate Affairs .. 9 Executive Directors .. 9 Trust Leadership Committee (TLC) .. 9 Executive Led Sub-Committees .. 10 Clinical Directors, Director of Operations or services (including Deputy Directors, Associate Directors) and Heads of Nursing .. 10 corporate Governance Team .. 10 Clinical Standards Group (CSG) .. 11 Finance Department .. 11 People and Organisational Development Sub-Committee .. 11 Health and Safety and Security Sub-Committee .. 11 Estates Sub-Committee .. 12 Information Governance Sub-Committee (IGSC) .. 12 Care Group(s) and Director of Operations meeting(s).. 12 Document Lead Director .. 12 The Author of the Document .. 13 Page 4 of 26 Document Control policy Version No All staff .. 13 Line Managers .. 13 7 policy Detail/Course of Action .. 13 Document development.

5 13 Document templates .. 14 Document Consultation, Ratification and approval .. 15 Identification and use of documents of external origin .. 18 Document dissemination .. 19 Document Review .. 20 8 Archiving Documents .. 20 9 Retrieving archived documents.. 21 10 Consultation .. 21 11 Training .. 21 12 Monitoring Compliance and Effectiveness of this policy .. 21 13 Links to other Trust Documents .. 21 14 References .. 21 15 Appendices .. 22 Page 5 of 26 Document Control policy Version No 1 Executive Summary The Isle of Wight NHS Trust is committed to ensuring that all documentation utilised is fit for purpose and compliant with the most up to date legislation and best practice. In order to achieve this, the Trust has adopted a robust process of Document production, ratification and dissemination. No documentation must be utilised unless it has been ratified through the appropriate channels, commensurate with the importance of the Document , and all documents, once approved must be made available to all staff via the most appropriate page of the Trust intranet.

6 The following principles must be adopted when introducing new documentation, or reviewing existing documentation across the organisation. The author/reviewer of any Document must be the most appropriate or competent person. This will be based on their role, experience and/or qualifications. The author/reviewer may be an employee of the Trust; however, there may be occasions when external or specialist support will be required to ensure documentation is robust. The ratification process must be commensurate with the significance of the Document in line with the procedure outlined below. Review periods set must be proportionate, however, reviews must be brought forward under the following circumstances:- The issue of pertinent NICE guidelines Changes in legislation and guidance Changes in Best Practice To address identified risks, or trends To address changes in service provision, or governance arrangements To incorporate advancements in technology or clinical practice as identified through relevant governing bodies.

7 In response to regulator recommendations and directives. NB this list is not exhaustive Once ratified all documentation must be stored on the Trust Intranet for ease of accessibility for staff. In the event that the intranet is not available, all policies are available from the corporate Governance Team. Hard copies of all Standard Operating Procedures, Guidelines and policy Group Directives must be made available by each respective department in the Trust. In addition certain documentation will be made available to the public via the Trust website including all policies and strategies. Page 6 of 26 Document Control policy Version No 2 Introduction The Trust recognises that it is important that it has in place a robust process for the creation, ratification, approval, dissemination, revision and review of all documentation. It is imperative that documentation has been through an appropriate ratification and approval process prior to adoption by the Trust to ensure that it complies with relevant legislation and best practice.

8 Similarly a robust Document Control process will ensure consistency of approach across the Trust. The Trust recognises that untoward (or adverse) incidents may occur because staff are unaware of what is expected of them, both individually and collectively. Therefore the purpose of this Document Control policy is to implement a co-ordinated and uniformed approach to Document management throughout the Trust and to reduce risk via a comprehensive and consistent application of a Document Control framework. 3 Definitions The Trust has adopted the following definitions:- Consultation The process of engaging with subject matter experts or those to whom a Document will apply or impact on in order to ensure their views are adequately considered and responded to within a Document . Ratification and Approval Approval of a given Document will take one of two forms:- Ratification and final approval, is where the Document has reached the end of the approval process it has reached the meeting where the final decision to adopt the Document will be taken.

9 Interim approval, is where the Document is still progressing through the approval process, and has not yet reached the forum where the final decision to adopt the Document will be taken, for example a Document may be interim approved at the Information Governance Sub- Committee, but achieve final approval at the Trust Leadership Committee. It is only when a Document has achieved final approval that it is ready for dissemination and implementation. Strategy and Strategic Plans A strategy or strategic plan is an overarching Document that focuses on the direction of travel and includes a vision of what the Trust aims to achieve. Strategy therefore will include as a minimum analysis of the following:- The current position where are we now; The vision, what is it we want to achieve. How will we get there what steps do we need to take. Page 7 of 26 Document Control policy Version No A strategy often also incorporates an action plan to be followed in order to achieve the vision.

10 The Trust utilises two forms of strategy Document , namely corporate and operational. corporate strategies span the breadth of the organisation, whereas operational strategies relate to a specific service (including corporate Services), or area of business. policy A policy is an organisational wide framework which applies in all circumstances as relevant to all staff. All staff must comply with policies at all times. Policies set out the main duties of staff and how they should be carried out. Many policies incorporate legal or statutory duties, how they apply and how staff are able to meet these duties through applying the policy . Protocol Protocols dictate what we do, and audits of protocols ensure that we are doing what we say we will. A protocol is a Document setting out the actions or steps to be followed by staff relevant to the subject set out in the Document . Protocols can be associated with a policy and describe how a policy is carried out.