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Trust Policy & Procedure Management

Reference: 23-24376

Date response sent: 01/12/2023

Details of enquiry

  1. How many policies does your Trust have?
  2. How many procedures does your Trust have?
  3. What percentage of your policies are live and in date?
  4. Do you hold a Legal Register (or similar document) to confirm which policies you must have in place by law?
  5. Do you employ any scheme of prioritisation, business crticallity or RAG rating to your policies?
  6. How many staff (if any) does your Trust employee purely to manage policies and procedures? Please indicate this as Full Time Equivalent (FTE)
  7. What grade(s) are the staff employed to manage policies and procedures?
  8. If you do not have dedicated staff to manage your organisation’s policies and procedures, how is this governance managed and by which business function?
  9. Do you use any particular software to manage policies and procedures within your organisation?

Response sent

  1. How many policies does your Trust have?

34 plus a further 15 which are combined policies and procedures = 49

  1. How many procedures does your Trust have?

97

  1. What percentage of your policies are live and in date?

60%

  1. Do you hold a Legal Register (or similar document) to confirm which policies you must have in place by law?

Yes.  We have a Master Register, which holds details all our policies and procedures, and we hold separate master files for the actual master documents.

  1. Do you employ any scheme of prioritisation, business criticality or RAG rating to your policies?

Policy Renewals are primarily driven by prevailing expiry dates, though patient-centric policies/procedures are prioritised above others.

  1. How many staff (if any) does your Trust employee purely to manage policies and procedures? Please indicate this as Full Time Equivalent (FTE)

O FTE.  This is part of Business as Usual Activity for the Corporate Governance Team.

  1. What grade(s) are the staff employed to manage policies and procedures?

This varies from Band 5 up to Director level

  1. If you do not have dedicated staff to manage your organisation’s policies and procedures, how is this governance managed and by which business function?

See our response to Question 6. Above.

  1. Do you use any particular software to manage policies and procedures within your organisation?

No

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