Trust Policies & Procedures Compliance, Monitoring and Updating

Reference: 24-25567

Date response sent: 09/04/2025

Details of enquiry

1. Who holds trust wide responsibility for the maintenance of procedures and policies?
2. What is their name and email address?
3. What digital tools does the trust use for the staff to reference these procedures and policies?   – ie – intranet
4. How does the trust record that staff have read and comply with the procedures and policies?
5. Which tools are used for on-boarding new staff in relation to reading procedures and policies?
6. How do the heads of department monitor that clinical and non clinical staff have read/understood mandatory procedural updates?
7. How many staff have accessed your NHS Intranet in the past year?

Response sent

1. Who holds trust wide responsibility for the maintenance of procedures and policies?

The Corporate Governance Team holds trust-wide responsibility for managing and assuring Trust policies.

While Trust policies are centrally governed, individual directorates and teams are responsible for developing and maintaining appropriate local procedures to support policy implementation within their operational areas

1. What is their name and email address?

Not applicable.  There is no generic email address for policies

2. What digital tools does the trust use for the staff to reference these procedures and policies?   – ie – intranet

Staff access policies and procedures via the Trust Intranet, which serves as the primary digital repository. Key policies may also be made available on the Trust’s external website where appropriate.

3. How does the trust record that staff have read and comply with the procedures and policies?

Key policies are introduced as part of the mandatory Staff Induction programme. Staff are also required to complete mandatory training (on a rolling three-year basis or as required), which incorporates awareness and understanding of relevant Trust policies. Compliance with mandatory training is monitored electronically, with oversight by line managers to ensure adherence.

4. Which tools are used for on-boarding new staff in relation to reading procedures and policies?

The Trust does not use standalone digital tools for onboarding policies. Instead, new staff are oriented to Trust policies and procedures as part of the Staff Induction Training Day, which includes presentations and information on accessing policy documents.

5. How do the heads of department monitor that clinical and non clinical staff have read/understood mandatory procedural updates?

Monitoring is primarily carried out through mandatory training compliance dashboards, which alert line managers to outstanding or overdue training.  Additionally, managers are expected to  address policy changes and updates in regular supervision, team meetings, and appraisal processes.

6. How many staff have accessed your NHS Intranet in the past year?

In the past 12 months, 1,343 staff have accessed the Trust’s NHS Intranet platform