INTRODUCTION 1. This is short guide to explain how staff should use the new templates for policies introduced across Mersey Care. This short guide should eb read in conjunction with SA01 Policy on Policies. 2. In addition some information is provided on the do s and don ts when preparing documents for Mersey Care, although further guidance is provided in the Brand Guidance document. WHY DO I NEED TO USE THIS TEMPLATE? 3. The Policy Template has been redesigned to: a) reflect our new divisional structure; b) ensure documentation looks consistent across the organisation; c) make our documents more easily cross-referenced (i.e. introducing paragraph numbering) so they can be used for a range of governance / compliance / assurance purposes. WILL ADVICE AND SUPPORT BE AVAILABLE? 4. As with the introduction of all new systems and processes, this short guide will be supported by provision of advice on the use of these templates which is available from the Corporate Governance Team at V7 if required. 5. However, all the templates have been developed for use with Ms-Word. Given that this software has been in use in Mersey Care for a number of years, the templates have been designed to allow users with even a basic knowledge to use them. Should you need further MS-Words skills, you will need to approach your line manager about obtaining further training, funded by your team. COMPLIANCE WITH THESE TEMPLATES 6. Although the effectiveness and usability of these templates will be kept under review with comments always welcome compliance with them will also be monitored through the Trust-wide Policy Group. Version 1 (March 2015) Page 1
STRUCTURE AND FORMATTING 7. The policy document will be split into 3 sections: a) Front Cover / Inside Cover the first two pages of any policy document, the front cover and inside cover, contains a number a pre-defined boxes to be completed. It must not exceed two pages; b) Main Body ideally the length of the policy should be kept to a minimum to ensure it is comprehensive and accessible to all. The template includes a series of heading which should be completed. c) Appendices given that the front cover and main body should ideally be kept to a minimum, it may be necessary to provide appendices containing a copy of any forms or supporting documents. Two of these appendices will be the Equality and Human Rights Analysis and Implementation Plan. 8. Further details about each of these 3 sections can be found in this guide. USING PLAIN ENGLISH 9. When writing policy document every effort should be made to use plain English particularly avoiding acronyms, abbreviations and NHS terminology which isn t explained. 10. Whilst all policy documents are intended for intended for internal use, these are publically available and often provided to external stakeholders as evidence SOME BASIC RULES 11. Please use these rules when preparing policy documents: a) in a sentence, only use one space after a full stop; b) only use one space after a comma, except when writing out numbers, e.g., 12,500; For a full range please refer to the Brand Guidelines. 12. The basic layout for the Report template is as follows: Margins Main Policy Document Heading Section Headings Sub Paragraph Headings Text in the body 2.54 cm all around Font: Arial 14pt, bold, centre-justified Font: Arial 12pt, bold, left-justified, upper case Section headings aren t numbered Font: Arial 11pt, bold, left-justified, lower case These sub-headings aren t numbered Font: Arial 11pt, left-justified Each paragraph sequentially numbered Version 1 (March 2015) Page 2
FRONT COVER PAGE 1 13. It is intended to provide key information relating to the policy document in a standard format. Author(s) need to ensure they: a) complete all the sections; b) keep it on page one only. 14. Two of the sections to be completed are the Recommending Committee and the Approving Committee sections. High level details are below. Please contact Sarah Jennings for further detail. Version 1 (March 2015) Page 3
INSIDE COVER PAGE 2 14. Again, author(s) will need to complete all sections of page 2 (inside cover) in line with the instructions shown below. This need to be one-page only. MAIN BODY 15. Page 3 of the template contains two supporting statements in respect of safeguarding and equality and human s rights. These statements must not be removed and are a requirement of all policy documents. 16. All policy documents must including the following in the main body: Section Contents page Purpose and rationale Outcomes focused aims and objectives Scope Definitions Duties Process Consultation Training and support Monitoring References Glossary of terms Description List the section numbers, section titles and corresponding page numbers. Purpose outline the overarching aim the policy was developed i.e. to explain the roles, responsibility and process for.. Rationale explain briefly why this policy is necessary. List to intended outcomes of the policy, ideally measurable outcomes. Outline who the policy document applies to, for example, all staff employed by the trust (whether on a temporary or permanent contract). Insert a table to outline any key terms and their definitions. A brief description of duties of the Lead Executive Director, any relevant Groups/ Committees and any key staff members (job titles) / groups. The duties of any staff / staff group s referenced anywhere within the policy should be included in this section. Outline any processes here ensuring they are descried step by step with a supporting flow-chart where appropriate. list those staff (job titles) or groups consulted with in the development of the review of the policy document i.e. committees; staff side; clinicians. Outline any training requirements necessary for staff in adhering to the policy document. You should consider whether such training needs are, or should be included in existing statutory / mandatory training and if not how this will be funded. Outline the process to be undertaken to monitor adherence to the policy document including how this will be monitored, how often, who will lead this process and where the outcomes will be reported. List any references used throughout your document. List any key terms used and an explanation of these in a table format Version 1 (March 2015) Page 4
SECTION HEADERS AND SUB HEADERS Section Headers 17. Section headers should be numbered and should be: a) Arial 12 pt font; b) in CAPITALS; and c) in bold. 20. The policy document template contains all the appropriate section headings for completion in addition to some explanation as to what to include in each section (shown in red in the template). COLOURS USED 21. The colors to be used in policy documents are included in the policy template and should not be changed. Sub Headers 18. Although not shown in the Policy Template, sub headers can be used in policy document. Sub headers shouldn t be numbered, but should be: a) Arial 11 pt font (i.e., the same size as in the rest of the main body); b) in lowercase; and c) in bold. PARAGRAPH NUMBERING 19. In order to improve navigation around the policy document for readers every paragraph of the report needs to be numbered. Version 1 (March 2015) Page 5
SUPPORTING DOCUMENTS Equality and Human Rights Analysis 22. All policy documents require an Equality and Human Rights Analysis. 23. This tool (illustrated below) should be completed to determine any direct or indirect discrimination arising from the policy document. Training on the use of this tool is available via the Equality and Human Rights Team. Implementation Plan 24. All policy documents will need an implementation plan which identifies how the document will be effectively cascaded and implemented including: a) The tasks to be completed; b) The dates these task will be completed by; c) The person(s) responsible for completing the task(s) APPENDICES 25. Appendices containing forms to be completed by staff, additional procedures or supporting information can also be included. Please ensure appendices support the main body of the policy document and a re referenced in the contents page. Version 1 (March 2015) Page 6
APPROVAL PROCESS & FINAL CHECKS 26. The full review and approval process is outlined in the Policy on Policies (SA01) and is outlined here: 27. In short, for existing policies undergoing minor changes (changes to job titles for example); the document should be signed off by the lead Executive Director and forward to Sarah Jennings. 28. For policies subject to major (full) review, the following steps must be taken. a) Circulate the working document to stakeholders for consultation b) Send the document to the lead Executive Director for agreement. c) When finalised, the document should be sent by the lead author to the appropriate Committee/ Group (see page 3 of this guide) who will recommend the document for approval. d) For compliance checking, the policy should be sent to Sarah Jennings for scheduling on the agenda of the next Policy Group meeting (trust-wide documents only). For division/service/ward based policy document this compliance checking should be undertaken by the Divisional Policy Lead. e) A report will then be prepared for the relevant Board/ Committee meeting to seek final approval. This will be completed by the Lead Executive (for Board approved documents) or the Trust Secretary for all other organisation-wide documents. f) The document will then be loaded onto the Trust Website/ Intranet and can be implemented. Version 1 (March 2015) Page 7