SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting
Board of Directors
Date
28 September 2011
Subject
Summary of Ratified Policies
Enclosure
R
Nature of item
For information
For approval
For decision
Decision required
(if any)
The Board is asked to receive and note the following summaries of ratified
policies:
1. SWH-00485 Do Not Attempt Resuscitation (DNAR) Policy
2. SWH – 00423 Clinical Photography and Video Recording Policy
3. SWH - 00306 Development and Control of Trust Documents Procedure
4. Audit of Compliance with Development and Control of Trust Documents
Procedure (Jan-Jun 2011)
5. SWH - 00564 Essential Skills Training Policy
6. SWH - 00552 Safeguarding Vulnerable Adults Policy and Procedure
7. SWH-00025 Resuscitation Policy -Acute Hospital
8. Protection Policy Update
General
Information
Report Authors
Lead Director
Ratified/adopted
by
Meeting
Date
Resource
Implications
Revenue
Capital
Workforce
Use of Estate
Funding Source
Freedom of
Information
Confidential (Y/N)
(if yes, give
reasons)
Final/draft format
Ownership
Intended for
release to the
public

1. Julie Lyons, Resuscitation and Clinical Education
Manager
2. Margaret Russell, Acting Information Governance
Manager
3. Emma Ratley, Standards Coordinator
4. Emma Ratley, Standards Coordinator
5. Emma Ratley, Standards Coordinator
6. Kathy Wagstaff, Matron
7. Julie Lyons, Resuscitation and Clinical Education
Manager
8. Ann Pope, Director of Human Resources
Glen Burley, Chief Executive
Policy Review Group
Joint Negotiating and Consultative Committee
8 August and 12 September 2011
2 September 2011
No
Final
Trust
Yes
South Warwickshire NHS Foundation Trust
Report to Board of Directors – 28 September 2011
Summary of Ratified Policies
The following policies were ratified by the Policy Review Group on 8 August 2011:
SWH-00485 Do Not Attempt Resuscitation (DNAR) Policy
This policy replaces COR-0039 version 2 following review and incorporates new guidance
with regard to Do Not Attempt Resuscitation Orders.
The purpose of this policy is to provide clarity and definition for healthcare professionals
who are involved in decision making in relation to Do Not Attempt Resuscitation (DNAR)
orders. This policy will provide a framework for professional and clinical practice relating to
DNAR decision making and process, to ensure we comply with current legislation and
guidance.
At present this policy is specific to the Acute Trust (including Nichol Unit). It is proposed
that we work toward producing a unified policy which will encompass the acute and
community setting, with documentation common to all areas of care including the patients
home. Work has already begun on this but this may be a lengthy process due to the
number of stakeholders involved. It is hoped we will be in a position to replace this policy
within 12 months.
Relates to NHSLA Standard 4 Criterion 7
SWH-00423 Clinical Photography and Video Recording Policy
The Clinical Photography and Video Recording Policy is an existing policy that was never
formally adopted in 2006. It has been extensively reworked during 2010/2011 including
rewording to reflect current Trust policies, best practice and format. The Policy
acknowledges that clinical photography and video recordings are a valuable part of
assessing and evidencing a patient’s condition.
The Policy is applicable to all staff; managers and senior staff have particular
responsibilities for ensuring that the practice and procedures contained within the
document are maintained and acted upon.
The applicable Standard for this Policy is Care Quality Commission (CQC) Outcome 2
(Regulation 18) Consent to care and treatment.
The Clinical Photography and Video Recording Policy has been developed to ensure that
all photography and video recordings undertaken by staff conform to current legislation
and other Trust associated policies and that there is a fully justifiable purpose for carrying
out photography or video recordings.
The Clinical Photography and Video Recording Policy refers to standards, policies and
procedures as well as legal guidance which are used to develop and support proper
systems of keeping information secure and confirms that images/recordings form part of
the patient’s records and therefore come under the normal rules of confidentiality and the
Data Protection Act 1998.
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The Clinical Photography and Video Recording Policy also identifies that failure to comply
may open the organisation to criticism or legal action or both, and the confidence of the
general public in the organisation may be compromised.
The following policies were ratified by the Policy Review Group on 12 September
2011:
SWH-00306 Development and Control of Trust Documents Procedure
This procedure is an amalgamation of 3 Trust documents, combined together to reduce
duplication; (SWH-00306 Development and Control of Trust Documents Procedure v1.2,
COR 008 Development and Control of Trust Documents Policy v1.0 and COR 0034
Guidelines for Developing, Maintaining and Implementing Clinical Policies,
Protocols/Procedures, Guidelines and Care Pathways v2.0).
The main changes are as follows:
 Clarify responsibilities
 Explain more clearly the process for Development, Control and Approving/Ratifying of
Trust documents
Trust documents are a reflection of the organisation and need to be produced in a
professional, consistent approach. This procedure sets outs the Trust’s requirement when
formulating documents to achieve this, as well as ensuring that all Trust documents are
relevant, clear, communicated effectively to the appropriate staff and kept up-to-date. This
will result in a uniformity of documentation across the Trust and also promote ease of
navigation by readers. Archiving is also essential and will ensure ease of retrieval when
needing to locate a document.
Adherence to this procedure by staff of the Trust will ensure compliance with the NHSLA
Risk Management Standards and the Care Quality Commission’s Essential Standards of
Quality and Safety.
The procedure applies to all staff who are involved with the development, approval and
ratification, dissemination, review and archiving of Trust documents.
Audit of Compliance with Development and Control of Trust Documents Procedure (JanJun 2011)
Two of the fundamental areas covered by the Development and Control of Trust
Documents Procedure are the correct approval and ratification process, to include
consultation with stakeholders, and control of documents which encompasses the
following:
 Version numbers and use of catalogue numbers

Storing documents

Archiving Trust documents
A program of audits has been established to monitor whether the above procedure is
complied with and where deficiencies are identified, recommendations and actions plans
are developed to ensure improvement in practice.
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Results show that there is good compliance with some areas of the procedure but
improvement is required in other areas. It would appear that the individual roles and
responsibilities set out within the procedure were not disseminated well enough when first
ratified and have consequently not been implemented Trust-wide. This has resulted in
incorrect use of the ‘Approving Document Checklist’ and the Document Database not
being kept up to date. Archiving across the Trust is not undertaken consistently or
effectively, with some wards/areas not storing documents in shared folders for easy
access, archive or retrieval. An action plan has been generated and improvement is
already being observed in some areas.
SWH-00564 Essential Training Skills Policy
This policy replaces the previous Trust Mandatory Training Policy and Trust Training
Needs Analysis (TNA) and combines also the Trust Mandatory Training Procedure and
Community TNA.
It sets out more clearly the specific responsibilities around training and the processes
behind checking that staff attend training and follow up of those who fail to attendance
training.
Adherence to the policy will ensure compliance with statutory training as laid down by
legislation e.g. Health and Safety at Work Act 1974 and the Health and Social Care Act
2008 and Trust mandatory training requirements as set out by the NHS Litigation Authority
Risk Management Standards.
The policy applies to all staff directly employed under a contract of employment, (including
fixed term and temporary) with the organisation excluding medical staff in training.
Doctors in training are covered by the ‘Policy for Supervision of Doctors in Training (SWH00080). Bank staff are covered by the Standard Operating Procedure for Nurse Bank
Office (SWH-00505).
SWH - 00552 Safeguarding Vulnerable Adults Policy and Procedure
The above approved and ratified policy is an amalgamation of two previous documents
Safeguarding Vulnerable Adults PolicyCOR-0074 and Procedure for the Protection of
Vulnerable Adults SWH-00055. The document is in line with updated local guidance set
by both the Warwickshire Safeguarding Vulnerable Adults policy and procedure and the
Department of Health (DoH) recommendations.
Guidelines from the DoH set clear criteria for vulnerable adults regarding mental capacity
and these have been incorporated into the document.
This policy is aimed at all staff who work for SWFT, outlining the responsibilities of each
staff member group.
The policy covers the following standards:
004/R9 007/R11 016/R10 10.
Health and Social Care Act 2008 Regulation
SWH – 00025 Resuscitation Policy -Acute Hospital Version 2.0
This policy replaces SWH – 00025 Version 1.0. and is in response to Health Service
Circular SC 2000/028 (DOH 2000). This Resuscitation Policy fully supports the published
recommendations ’Clinical Practice and Training in Cardiopulmonary Resuscitation’
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produced by the Resuscitation Council (UK) (2010) and has been constructed to promote
compliance with the NHSLA Risk Management Standard 4 criterion 7 ,2011.
The aim of the policy is to provide direction and guidance for the planning and
implementation of a high-quality and robust Resuscitation Service. At present this policy is
specific to the Acute Trust to meet requirements for NHSLA Assessment in November
2011. This policy will be reviewed in 12 months to encompass the needs of patients and
staff within the community setting.
Relates to NHSLA Standard 4 Criterion 7
The following policy was adopted by the Joint Negotiating and Consultative
Committee (JNCC) on 2 September 2011:
Protection Policy Update
On 2 September 2011 the JNCC agreed to adopt the SWFT Protection Policy for the
whole organisation. The SWFT policy was reviewed and ratified last year. It now replaces
the previous NHS Warwickshire Policy which applied to staff transferring under the
Transfer of Undertakings (Protection of Employment) Regulations 2006.
Glen Burley
Chief Executive
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