Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

Adults’ Health and Care Department Procedure: 14/14 v2

Developing, writing and reviewing: Departmental policies, procedures and guidance

Date: 14 November 2017

Effective Date: 1 December 2017

Summary: This document provides a step by step guide to the development and review of all Adult Services policy, procedural, and guidance documents

Issued By: Ed Walton, Rob Vernon

Contact: ahc.policy@hants.gov.uk

Sponsor: Care Governance Board

Authority to Vary: Departmental Management Team, Care Governance Board

Procedures cancelled or amended:

Developing Writing and Reviewing Departmental Policies and Procedures 04/14 v1

Version Control:Amendment: Date:

YOU SHOULD ENSURE THAT:-

You read, understand and, where appropriate, act on this information

All people in your workplace who need to know see this procedure

This document is properly filed in a place to which all staff members in your workplace have access

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 1 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

“Developing, writing and reviewing departmental policies, procedures and guidance”

Purpose

The purpose of this document is to set out how Adults’ Health and Care departmental documentation - in the form of policies, procedures, protocols, guidance and practice manuals – is to be developed and presented in order to have a positive impact on practice.

Scope

This procedure applies to all staff developing or amending any policies, procedures, protocols or guidance for Adults’ Health and Care in any setting.

References

Healthcare Quality Improvement Partnership – Social Care Audit In Practice

Developing Policies, Procedures and Protocols

Stakeholder Consultation

Safeguarding, Quality and Governance Team

Care Governance Working Group

Care Governance Board

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 2 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

Contents:

Front Sheet Page 1

Purpose Page 2

Scope Page 2

References Page 2

Stakeholder Consultation Page 2

Contents Page 3

Introduction, Background and Exceptions Page 4

Principles and Definitions Page 5

Roles, Responsibilities and Expectations Page 6

Policy Statement Page 7

Policy Framework

a. Agreeing the need

Page 8

Page 8

b. Gathering evidence and insight Page 9

c. Drafting, Sign Off and Publication Page 10

d. Monitoring and Review Page 11

Implementation Plan Page 11

Performance Monitoring Page 11

Impact Assessments Page 11

Appendices

a. version control front-sheet

b. policy document template

c. process guidance

Page 12

Page 12

Page 13

Page 16

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 3 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

1) Introduction, Background and Exceptions

Good policy development is essential for the delivery of care services that are safe, consistent and effective. In turn, this enables the Department to meet statutory obligations, and supports staff to implement departmental strategy and transformation objectives.

This document requires authors to follow a number of specific stages in order to ensure new policies, procedures and guidance have the desired impact: changing practice to deliver the best possible outcome for service users, carers and communities.

This document encourages authors to consider how changes will be defined, implemented and monitored, alongside identifying how any transitions will be managed.

Developing policy and procedure is a collective activity. Best practice guidelines recommend engaging with stakeholders early on in the process. This can help authors to reflect on current practice, to identify areas for improvement, and to discuss the most effective way to manage change.

“Evidence-based practice tells us that quality is best achieved by teams reflecting in a structured way on the service they currently provide and then on how it could be developed.”

Social care governance: a workbook based on practice in England SCIE Guide 38 (SCIE, 2011)

Exceptions:

Multi-agency documents

Multi-agency documents are not subject to the standards in this procedure. Where the author of a multi-agency document is an HCC employee and the document covers HCC services the use of HCC templates and logos will be encouraged.

Integrated Services

HCC has formal partnership arrangements in place with other agencies to jointly provide services. If partner organisations manage services on behalf of HCC Adults’ Health and Care, jointly agreed policies and procedures can be agreed. Where the responsibility of the local authority is not delegated to a partner organisation, the responsibilities of Adults’ Health and Care staff should be set out in Adults’ Health and Care policies and procedures following this guidance. The appropriate meeting or committee may be a Joint Partnership Board and the sponsor may be employed by another agency. But Adults’ Health and Care governance and accountability outlined in this document must still be followed.

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 4 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 5 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

2) Principles and Definitions:

Policy Statement:

Policy statements clearly define what it is that the policy is intended to achieve. They should be less than 100 words and should focus on general outcomes rather than specific situations.

For example, “Adults’ Health and Care Department will ensure care and support services in Hampshire are reviewed and monitored with the Quality Outcomes Contract Monitoring Framework”.

Process or Procedure:

Process or Procedure documents define how the policy outcomes are intended to be achieved. They may include step-by-step instructions for simple processes or flowcharts that guide decision making in complex scenarios.

For example, a step-by-step process may be useful to define the stages in arranging a Direct Payment. A decision making flowchart may detail different courses of action, if, for example, a service user may or may not be deemed to have capacity to manage a Direct Payment.

Guidance Notes:

Guidance notes provide additional explanatory information as to why certain circumstances may require flexibility in process or procedure. Guidance notes should help inform decision making where there is room to exercise professional judgement within a set process.

For example, safeguarding policy may suggest using the “least restrictive option”, guidance notes may provide further detail on the options available and how to decide which option may be the most appropriate in the context.

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 6 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

3) ROLES, RESPONSIBILITIES & EXPECTATIONS:

Care Governance Board – The board that formally approves all Adults’ Health and Care Department specific policy. In exceptional cases requiring urgent sign-off only the Departmental Management Team has the authority to approve Adults’ Health and Care Department policy.

Design Authority - The Design Authority's purpose is to maintain a consistent, coherent and overall perspective of departmental processes, providing effective change control for business and technology process change and initiatives.

Care Governance Working Group – This working group brings together expertise from across the department. The group can advise on policy development and signpost to sources of evidence, insight and best practice.

Document Sponsor – The Departmental Management Team or Senior Management Team member who has agreed the need for a policy or procedure to be created, reviewed, or updated. The sponsor can also be a board or committee with the relevant authority.

Document Author – The member of staff nominated by the policy sponsor to lead the creation, review, or update of the policy.

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 7 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

4) Policy Statement:

“Adults’ Health and Care Department will seek to develop and maintain social care policy, procedure and guidance in such a way that:

is sufficient to meet the agreed needs of the department and is aligned with overarching strategy and transformation objectives

takes account of the most up-to-date legislation, evidence and insight

is accessible, with clearly defined expectations in order to be of practical use for the target audience

has a positive impact on social care practice, enhancing quality, safety and efficiency”

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 8 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

5) Policy Development Framework:

To support the four aims in the policy statement, there are four defined stages: agreeing the need; gathering evidence and insight; drafting sign off and publishing; monitoring and review.

5a) Agreeing the need:

Policy should be developed or updated to meet an agreed departmental need. The need may arise in response to changes in legislation, gaps in policy coverage, or as a result of evidence that an existing policy leads to undesirable outcomes.

In all cases it will be necessary to identify the policy sponsor. The policy sponsor could be a DMT or SMT member, or a formal board or committee.

In cases where process changes are needed, contact with the Design Authority must take place before work is started. This will enable the author to become aware of links to other relevant development and project work across the department.

The policy sponsor will nominate a lead officer to update existing policy or develop new policy. A timescale for development should be agreed at this stage. Contact should be made with the Safeguarding, Quality and Governance Team in order to align timescales with Care Governance Board and Working Group meetings.

In most cases policy will change in light of existing evidence. In some cases it may be necessary to gather evidence or insight in order to agree the need to develop new policy.

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 9 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

5b) Gathering Evidence and Insight:

Policy should take account of the most up-to-date legislation, best practice and evidence in order to have a positive impact on practice.

The evidence and insight gathered will ultimately inform policy, process and guidance and how change is implemented. An Equality Impact Assessment (EIA) must be completed for all policies and procedures. Other assessments, such as a Privacy Impact Assessment (PIA) may be required depending on the nature of the change. Further information on relevant impact assessments can be found on the links below:

Privacy Impact Assessments Equality Impact Assessments

If a decision is to be taken by an Executive Member, or Cabinet, it will be necessary to seek advice around timetabling from the Director’s Office Business Manager.Further information on Democratic Services and Impact Assessments is available here.

In most cases it is prudent to gather hard evidence, facts, figures, access or outcome data to develop a picture of what is happening. This information can then be shared with stakeholders who can provide context and perspectives on the information. This can aid in developing clear policy statements, process documents, guidance notes, implementation plans and details of how policy implementation will be monitored.

The scope and breadth of stakeholder engagement will be dependent on the nature of the policy and this should be agreed with the policy sponsor. Target groups may include:

Staff with specialist insight (such as Medicines Management Group) Impact assessment specialists Service users, carers, and communities and other relevant external stakeholders Advocacy groups or interested parties such as care associations Elected Members

The Care Governance Working Group can advise on gathering evidence and insight, including incident reports and case reviews, to inform policy and guidance. Additionally, there are further sources of evidence and insight across the County Council, further details of which can be found on the below links:

Adults’ Health and Care Business Management Information Team Adults’ Health and Care Information and Complaints Team Adults’ Health and Care Research, Learning and Development Research & Intelligence Customer Engagement Service

5c) Drafting, Sign Off and Publishing

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 10 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

Drafting:

In general, all documentation should be developed in line with the Corporate Style Guide, including Plain English guidance. There are a number of further specific standards for Adults’ Health and Care Policy and Procedures:

All documents must remain watermarked as DRAFT until they have been approved by Care Governance Board.

All documents will have a review date and page number in the footer. The review date will vary dependent on the nature of the policy and should be agreed with the policy sponsor.

All documents should have the title in the header In order to help readers navigate quickly to the most relevant information,

separate documents should be used for the following elements, templates or examples are available as appendices to this document:

o version control front-sheeto policy document templateo example process guidance notes.

Sign Off:

Quality checking at the Care Governance Working Group followed by formal sign off at the Care Governance Board is required. In some cases where another board or committee has sponsored the policy this will also be necessary.

The Safeguarding, Quality and Governance Team will advise on the most effective way to do this, alongside providing the appropriate policy numbers to aid cataloguing and version control.

Publishing:

All documentation should be stored in Hantsfile / SharePoint with the appropriate settings for publication. More information is available on the Hantsfile Publishing webpage.

Policy documents and procedures are published on the public facing Hantsweb AH&C Procedures Page with further procedural information and guidance for staff available in the internal facing social care practice manual.

All newly published policy is to be advertised in the Team Brief, which is communicated to all Adults’ Health and Care staff. This can be arranged by contacting the Corporate Communications Team along with any further publicity arrangements. Further implementation and communication needs will depend on the nature of the policy and the agreed implementation plan, details of which, including the timing of the release of any sensitive information should be agreed in advance with the project sponsor.

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 11 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

5d) Monitoring and Reviewing:

Best practice policy will define the measures through which outputs and outcomes will be monitored. In most cases it will be possible to develop measurements based on the evidence used to inform policy direction. These could be hard facts and figures as part of management information updates, or softer measures such as staff or service user feedback. Adults’ Health and Care Business Management Information Team can advise on the measures it will be possible to use to monitor implementation.

All policies should have a defined review date. This will vary dependent on the nature of the policy and should be agreed with the policy sponsor.

In order to ensure that policy is kept up-to-date and takes account of other changes and interdependencies, the Safeguarding, Quality and Governance Team will:

review policy documentation to ensure quality standards are met annually review and update policy front-sheets with policy authors issue reminders, one year, six months and three months before review dates to

understand which documents need to be republished, revised or rewritten audit policy and procedure around 12 months after implementation and report

findings to the Care Governance Board, document authors and sponsors.

6) Implementation plan

There are no specific training needs identified. This policy will be communicated via: Team Brief Hantsnet Care Governance Board & Working Group Procedures webpage & Social Care Practice Manual

7) Performance monitoring

There are no set specific performance measures. Compliance with this policy will be monitored via the Safeguarding, Quality and Governance Team, Care Governance Working Group, Design Authority, and Care Governance Board.

8) Impact assessment statements

Equality impacts associated with this policy relate primarily to the presentation and formatting of policy documents to ensure accessibility. These accessibility standards are described in the corporate style guide and referenced in this document. This policy also recommends that insight and evidence gathered through engagement with equality impact specialists and relevant communities is used to inform specific guidance for each policy.

A privacy impact assessment is not required for this procedure.

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 12 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

Policy and Procedure Version Control Front-sheet

Adults’ Health and Care Department Procedure: ##/## v#

Title

Date:

Effective Date:

Summary:

Issued By:

Contact:

Sponsor:

Authority to Vary:

Procedures cancelled or amended:

Title ##/## v#

Version Control:Amendment: Date:

YOU SHOULD ENSURE THAT:-

You read, understand and, where appropriate, act on this information

All people in your workplace who need to know see this procedure

This document is properly filed in a place to which all staff members in your workplace have access

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 13 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

Policy and Procedure Template

“Title”

Purpose

This section should be succinct statement that clearly describes the purpose of the policy document.

Scope

This section should clearly define the range of functions, teams or staff to which the policy applies. Many policies apply to all staff – for example, data protection policy – while others may apply to a more specific group – for example – medication management in residential homes.

References

This section should be used to provide a list of documents that have been referenced within the wider document.

Authority to Vary (this should be recorded on the front-sheet)

In most cases:

The Design Authority should be referenced in relation to operational and IT processes.

Care Governance Board should be referenced here in relation to operational policy.

In exceptional cases:

The Departmental Management Team has authority to amend policy and business process

Member approval must be sought if significant levels of resource will be required to implement policy changes

Stakeholder Consultation

This section should be used to succinctly describe the key stakeholders that have been involved in the development of the policy.

Contents

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 14 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

In order to ensure policy documentation is developed in a clear and accessible way, it is recommended that all policies include at least the following elements:

Introduction, Background and Exceptions

This section should expand on the Purpose and provide information to briefly explain why this policy is being introduced at the current time. The background should include references to changing legislation, best practice examples, or other factors that have resulted in the need to change policy. This section should also highlight any areas where the policy does not apply. For example, data sharing legislation is intended in part to ensure personally identifiable details are not shared unnecessarily between, agencies although this may not apply in certain safeguarding situations.

Principles and Definitions:

This section should be used to define any key principles or terms that will be used throughout the policy document. This can be an important step in translating broad subjective statements into manageable practical guidance, particularly where there is scope for the application of local variation. For example, the Care Act 2014 defined a “wellbeing principle” which may need further clarification and context in order to be practically applied.

Roles, Responsibilities and Expectations:

This section should expand on the Scope and provide further information as to which functions, teams, or members of staff the policy applies to alongside outlining any key responsibilities and expectations. For example, all members of Hampshire County Council staff are responsible for raising safeguarding issues if they have concerns, all staff are expected to follow the safeguarding referral process in order to fulfil their responsibilities.

In some cases, there are specific roles ascribed to staff through legislation, for example: data protection legislation describes “data controllers” and “data handlers” and these roles will need to be referenced clearly.

Policy Statement:

Policy statements should clearly define what it is that the policy is intended to achieve. This should ideally be a statement of less than 100 words. Most policy statements are intended to apply to a diverse range of situations and should focus on general outcomes rather than specific situations.

For example, “Adults’ Health and Care Department will ensure care and support services in Hampshire are reviewed and monitored with the Quality Outcomes Contract Monitoring Framework”.

Policy Framework:

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 15 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

This is the main content of the policy document. This section should be used to describe the processes in place to support the delivery of the policy statement.

Where possible there should be links to sources of further information on the relevant processes.

For example, the Positive Risk Taking policy makes reference to three pre-existing processes: Safeguarding, Mental Capacity Assessment, and Best Interests Assessment and describes each of these within the context of positive risk taking.

Implementation Plan:

This section is used to describe how the policy is to be implemented. This section should provide a summary of any actions agreed with Workforce Development and Communications staff.

Performance Monitoring:

This section should be used to define the specific measures that will be used to monitor implementation of the specific policy. This section should summarise any actions that have been agreed with Management Information teams and any other monitoring arrangements.

Impact Assessments:

This section should be used to summarise how the various duties on local authorities to pay due regard to the impact of specific decisions and policies have been fulfilled.

Templates:

These are specific documents that are used to standardise the format of each policy, below is a brief description of each of these and their relevance to developing, implementing and monitoring policy:

version control front-sheet: this information is used by the Safeguarding, Quality and Governance team to aid with version control, cataloguing, and reviewing policy in order to ensure documentation is up to date

policy document: this main policy document will be published on the public-facing Hampshire County Council website, Hantsweb

process or procedure instructions or diagrams: this information is collected and collated as the Social Care Practice Manual which is published on the internal-facing Hampshire County Council website, Hantsnet. There is no standard template for this guidance at present.

Process Guidance: Developing Policy, Procedure or Guidance

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 16 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

Agree the need:

Identify the drivers for change: Legislative, Best Practice, Evidence, Resources

Identify any existing mechanisms in place to manage this issue

Check the policy and procedure webpage

Check the social care practice manual webpages

Check the AIS guidance pages

Contact Safeguarding, Quality and Governance shared inbox & design authority for further information.

Identify the relevant policy sponsor and agree the need to update existing or develop new policy, procedure, or guidance.

As a general rule:

Policy is used to clarify expectations and the outcomes aimed for Procedure is used to define the way in which the outcomes will be achieved Guidance is used to guide best practice in specific circumstances

Confirm timescales and scope of engagement with the Safeguarding, Quality and Governance team

Gather Evidence and Insight

The following sources of evidence and insight may be useful:

Evidence: Insight:

Legislation Customer Engagement Service

Best Practice Service Users, Carers and Communities

Research and Intelligence Elected Members

Management Information Learning and Development

Concerns and Complaints Staff and Specialist Teams

Incident Reports Equality Impact

Enquiries Privacy Impact

Drafting:

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 17 of 18

Developing, Writing and Reviewing: Departmental Policies, Procedures and Guidance

To ensure consistency, the following templates are to be used:

Policy and Procedure Front Sheet Policy Document Template

There is a section in the policy and procedure template to summarise implementation plans, performance monitoring arrangements and impact assessments that will be considered in more detail at Care Governance Working Group

NB – formal Impact Assessments will need to be completed so that the anticipated impacts can be considered when the policy, procedure or guidance is approved.

For further information please see the following links:

Privacy Impact Assessments Democratic Services Impact Assessment Guidance Equality Impact Assessments

Sign Off:

Care Governance Working Group receives a draft for discussion, consideration of implementation plans and impact assessments, quality checking and formatting in order to prepare the final draft

Care Governance Board and Design Authority will approve the final draft

Once the final draft is approved procedure numbers are assigned and version control information is catalogued

Publication:

The Safeguarding, Quality and Governance team will arrange publication to the relevant webpages

Contact Corporate Communications Team to publicise via Team Brief, Hantsnet and other publicity

Monitoring and Review:

All policies and documentation must have a review date.

The Safeguarding, Quality and Governance Team will make contact prior to this date to offer audit support

The Safeguarding, Quality and Governance Team will annually issue reminders to review policy, procedure or guidance

ahc.policy@hants.gov.uk 14/14v 2 – Review date: 31/03/2019 Page 18 of 18