Document Control Template
DOCUMENT CONTROL PAGE
Title: Age Policy and Procedure
Title
Version:
or Supersedes
Originator
modifier
Designation:
Ratified by:
Circulation
Application
Supersedes:
Ratification
Reference Number:
Description of Amendment(s):
Originated By: Helena Gleeson
Modified by:
Designation:
Sub Committee Approval Date: [if required]
Delete as necessary
All Patients
All staff
Issue Date:
Circulated by:
Issued to:
Review
Review Date:
Responsibility of:
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 1 of 15
Document Control Template
POLICY CONTROL PAGE (2) CIRCULATION DOCUMENT
Circulation List:
For Information
Central Manchester and Manchester University Hospitals NHS Trust is committed to
promoting equality and diversity in all areas of its activities. In particular, the Trust wants
to ensure that everyone has equal access to its services. Also that there are equal
opportunities in its employment and its procedural documents and decision making
supports the promotion of equality and diversity. Refer to section 8 for more detail on
undertaking equalities impact assessment.
This document must be disseminated to all relevant staff, refer to section 10:
Dissemination and Implementation
The Policy must be posted on the intranet: Date Posted:
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 2 of 15
Document Control Template
Section
1
2
3
4
5
6
7
8
9
10
11
12
Contents
Page
Introduction
Purpose
Roles and Responsibilities
Detail of Policy and Procedure
4.1 Patients under the age of 16
4.1.1 Outpatients
4.1.2 Planned and Unplanned Admissions
4.2 Patients aged 16 and older
4.2.1 Outpatients
4.2.2 Planned and Unplanned Admissions
4.3 Patients aged between 16 and 19 under ongoing
follow up in the paediatric service
4.3.1 Outpatients
4.3.2 Planned and Unplanned Admissions
4.3.3 Delayed transition to adult services
4.4 Patients aged between 16 and 19 with severe
neurodisability
4.5 Exceptions
4.5.1 Outpatients
4.5.1.1 Circumstances of care of paediatric and adult
patients in the same clinical setting
4.5.1.2 Circumstances of care of patients aged 20 and
older in paediatric services
4.5.1.3 Circumstances of care of patients under the age
of 16 in adult services
4.5.2 Inpatients
4.5.2.1 Circumstances of care of patients aged 20 and
older in paediatric services
4.5.2.2 Circumstances of care of patients under the age
of 16 in adult services
4.6 Requirements and process for notification
4.6.1 Purpose
4.6.2 Circumstances
4.6.3 Process
4.7 Education and training
4.8 Clinical Areas for Young People
4.9 Safeguarding of Children and Vulnerable Adults
4.10 Risk Assessment
Equality Impact Assessment
Consultation, Approval and Ratification Process
Dissemination and Implementation
Review, Monitoring Compliance With and the
Effectiveness of Procedural Documents
Standards and Key Performance Indicators ‘KPIs’
References and Bibliography
Associated Trust Documents
Appendices
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 3 of 15
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 4 of 15
1
Introduction
An age policy and procedure is necessary to ensure that patients are cared for by
appropriately trained staff in the most age appropriate environment.
2
Purpose
The purpose of this age policy and procedure is to ensure that all employees of
CMFT involved in clinical care have clear guidance of the age of patients suitable for
clinical areas within the trust. This policy is most relevant for employees of CMFT that
are involved in the care of young people (aged between 10 and 24 years) and
particularly those who work in clinical areas where young people are not the main
users. The policy also provides specific guidance for: patients in the process of transition from paediatric to adult services
 patients with a neurodisability
 patients, who due to the location of clinical services, are not being cared for in
the most age appropriate environment.
3
Roles and Responsibilities
This policy applies to all employees of CMFT involved in clinical care.
4
Detail of Policy and Procedure
4.1 Patients under the age of 16
4.1.1 Outpatients
These patients must attend paediatric outpatients (see 4.6 for exceptions).
4.1.2 Planned and Unplanned Admissions
These patients must be admitted to paediatric wards (see 4.6 for exceptions).
4.2 Patients aged 16 and older
4.2.1 Outpatients
These patients must attend adult outpatient departments if they are a new referral.
4.2.2 Planned and Unplanned Admissions
These patients must be admitted to adult wards unless they are under follow up in
the paediatric service and also under the age of 20.
4.3 Patients aged between 16 and 19 under ongoing follow up in the paediatric
service
4.3.1 Outpatients
Patients between the ages of 16 and 19 who are under follow up in the paediatric
service are eligible to attend paediatric outpatients while transition to adult services is
being organised. Patients must have been transitioned to adult services and attend
adult outpatients by the age of 20.
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 5 of 15
4.3.2 Planned and Unplanned Admissions
Patients between the ages of 16 and 19 who are under follow up in the paediatric
service are eligible to be admitted to either paediatric or adult wards either as a
planned or unplanned admission The decision must consider the individual needs
and the preference of the patient which are then documented clearly in their case
notes. Patients aged 20 and older must be admitted to adult wards. If a patient who is
still under follow up in the paediatric service has a planned or unplanned admission
to the adult wards the paediatric team should be notified.
4.3.3 Delayed transition to adult services
With appropriate transition planning and development of transition arrangements
transfer from paediatric to adult services (either within CMFT, to another hospital trust
or to their GP) must occur before the age of 20. If a planned or unplanned admission
is required aged 20 and over this must be to the adult wards where the patient must
be under the adult team. The consultant in charge of the patient in the adult team
must notify the consultant in charge of the patient in the paediatric team.
4.4 Patients aged between 16 and 19 with severe neurodisability
Patients with a severe neurodisability are eligible to be seen in paediatric outpatients
and be admitted to paediatric wards as detailed in 4.3.
4.5 Exceptions
4.5.1 Outpatients
4.5.1.1 Circumstances of care of paediatric and adult patients in the same
clinical setting
In the trust there are several lifespan services which provide outpatient care in the
same clinical setting for children, adolescents and adults. These services are the
Regional Genetics Service, Royal Manchester Children’s Hospital, the Cochlear
Implant Service, Manchester Royal Infirmary and outpatient services in the Royal Eye
Hospital and the Dental Hospital.
Efforts should be made in these outpatient
services to recognise and meet the different needs of their patients through clearly
defined zones with appropriate information in the waiting area and ideally the
provision of separate clinics for paediatric patients, adolescent patients and adult
patients.
4.5.1.2 Circumstances of care of patients aged 20 and older in paediatric
services
In the trust the Regional Cleft Lip and Palate Service, Royal Manchester Children’s
Hospital provide a lifespan service in which it may be necessary for patients aged 20
and older to attend outpatients in the paediatric service. Efforts should be made to
recognise and meet the different needs of their patients through clearly defined
zones with appropriate information in the waiting area and ideally the provision of
separate clinics for paediatric patients, adolescent patients and adult patients.
4.5.1.3 Circumstances of care of patients under the age of 16 in adult services
In the trust there are several adult services which provide outpatient care for patients
under the age of 16. These services are the Manchester Centre for Sexual Health,
Manchester Royal Infirmary and Obstetric and Maternity, St Mary’s Hospital
(including inpatient care). Efforts should be made in these outpatient services to
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 6 of 15
recognise and meet the different needs of their patients through clearly defined
zones with appropriate information in the waiting area and ideally the provision of
separate clinics for adolescent patients and adult patients.
4.5.2 Inpatients
4.5.2.1 Circumstances of care of patients aged 20 and older in paediatric
services
In exceptional circumstances the Regional Cleft Lip and Palate Service may need to
have planned admissions to the Royal Manchester Children’s Hospital for patients
requiring surgery. For such an admission careful planning is required to ensure that
the patient receives care in a separate room from paediatric patients. Issues
surrounding safeguarding must be discussed.
4.5.2.2 Circumstances of care of patients under the age of 16 in adult services
The Cardiology Service in Manchester Royal Infirmary has stated that in exceptional
circumstances a patient under the age of 16 may need to be admitted as an inpatient
when there is no appropriate paediatric alternative available. In this exceptional
circumstance the following preplanning arrangements must occur and minimum
standards must be met.
4.5.2.2.1 Pre-planning for admission of patients under the age of 16 to an adult
ward
Step 0 Discussion with management
Prior to any preplanning the case must be discussed with the management to ensure
that there are no paediatric alternatives for the planned admission.
Step 1 Discussions and documentation
Prior to admission the following must be discussed with the patient and their
parents/carers and documented clearly in the case notes. In addition a contract must
also be generated detailing what has been discussed and agreed. The contract
should be signed by the patient, their parents/carers and a member of the admitting
team. The following information needs to be included:The reasons that there are no options for inpatient care in a paediatric setting
The minimum standards (see 4.5.2.2.2) that they can expect
Step 2 Identification of a key person/people
Prior to admission a key person must be identified. The role of the key person is to
execute the following steps in preplanning and to provide continuity of care and
support to the patient during routine ward activities including ward rounds and
investigations especially if the parents/carers are not present. They must also provide
support for the parents/carers.
Step 3 Inform ward manager
Prior to admission the ward manager must be informed to allow a review of staffing
arrangements on the ward for the duration of the patient’s stay and appropriate
location on the ward where the patient will be cared for. Ideally unless clinically
contraindicated this should be in a separate room from adult patients.
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 7 of 15
Step 4 Visit to ward and other departments and assessment by therapeutic play
services
The key person must offer the patient and their parents/carers a visit to the ward and
other relevant departments. During the visit situations such as hearing or seeing a
confused adult patient must be discussed. During the same visit therapeutic play
services must assess what support the patient requires, for instance, during
phlebotomy and other investigations, and what activities they would like to do during
their admission.
Step 5 Organise accommodation at Cobbett House for parents/carers if required
Step 6 Multidisciplinary team meeting
A meeting between the clinicians, ward staff, and therapeutic play services and
managers must be held to ensure that all staff involved in the patient’s care are
aware of the arrangements for the admission and of the patient’s and their
parent’s/carer’s preferences. Issues surrounding safeguarding must be discussed.
4.5.2.2.2 Minimum standards for patients under the age of 16 during an
admission to an adult ward
Named key person/people
Each patient and their parents/carer will be allocated a named key person/people.
The role of the key person/people is to provide continuity of care and support to the
patient during routine ward activities including ward rounds and investigations
especially if the parents/carers are not present. They must also provide support for
the parents/carers.
Environment
Patients will ideally be nursed in a separate room from adult patients unless clinically
indicated.
Visiting
Parents/carers of the patient must be allowed to visit at any time of the day or night
and if appropriate or desired must be allowed or encouraged to stay overnight.
Visitors would be required to be respectful to staff and other patients on the ward at
all times. If there are safeguarding concerns which may include the need for parents
to be supervised then supervision policy (MSCB 2009) needs to be followed.
4.6 Requirements and process for notification
4.6.1 Purpose
The purpose of notification is to review current paediatric and adult service
arrangements within specialties and also to ensure that individual patients are
receiving age appropriate care.
4.6.2 Circumstances
Notification is required in the following circumstances
4.6.2.1 Adult outpatient departments and wards
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 8 of 15


Patients under the age of 16 attending adult outpatient departments as a patient
unless specified in 4.5.1.3.
All patients under the age of 16 admitted to adult wards
4.6.2.2 Children’s Hospital
Outpatients
 Patients aged 16 and older attending paediatric outpatients as a new referral
unless stated in 4.4.
 Patients aged 20 and older attending paediatric outpatients unless stated in
4.5.1.2
Paediatric wards
 Patients aged 16 and older admitted to paediatric wards who are not under follow
up by the paediatric services unless stated in 4.4
 All patients aged 20 and older admitted to paediatric wards
4.7.3 Process
Outpatients
The manager must be notified if there is a failure to comply with the age policy. The
manager will contact the clinician responsible to discuss current service provision.
Wards
The manager must be notified prior to a planned or at the time of an unplanned
admission of a patient who fails to comply with the age policy. The manager will
contact the clinician responsible and will either make the necessary arrangement for
the patient to receive/continue their care in that setting or arrange transfer to a more
appropriate setting.
4.8
Education and training
The Trust will provide training in healthcare issues relating to young people to key
staff in all clinical areas in paediatric or adult services to ensure that patients between
the ages of 10 and 24 receive age appropriate care.
4.9
Clinical areas for young people
The trust recommends that if possible on an individual patient basis and maintaining
patient safety patients between the ages of 10 and 24 must be cared for in separate
clinical areas from either younger children or older adults.
4.10
Safeguarding of children and vulnerable adults
It is essential that safeguarding is considered in all children, young people and
vulnerable adults to paediatric and adult services. If there are known safeguarding
issues in individual patients these must be clearly communicated via the CMFT
safeguarding team to paediatric and adult services.
4.11
Risk Assessment
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 9 of 15
In certain circumstance when a patient is considered a risk to themselves or others a
risk assessment may be necessary and must take precedence over age policy.
5
Equality Impact Assessment
5.1. Central Manchester and Manchester University Hospitals NHS Trust is
committed to promoting equality and diversity in all areas of its activities. In particular,
the Trust wants to ensure that everyone has equal access to its services. Also that
there are equal opportunities in its employment and its procedural documents and
decision making supports the promotion of equality and diversity.
5.2. The initial Equality Impact Assessment (EqIA) – Assessment of Policy for
Relevance for Promotion of Equality – Initial EqIA is found at Appendix A. This must
be completed and submitted to the Equality and Diversity Department for ‘Service
Equality Team Sign Off’
5.3 Please contact the Equality and Diversity Department if you have any queries on
0161 276 6897 or equality@CMFT.nhs.uk.
6
Consultation, Approval and Ratification Process
6.1
Consultation and Communication with Stakeholders
6.2
Policy Approval Process
6.3
Ratification Process
7
Dissemination and Implementation
7.1. Dissemination of this policy will be via the CMFT intranet site. There will also
be hard copies distributed to key clinical areas throughout the Trust. Key clinical
areas are defined as those which organise planned and unplanned admissions. The
distribution of the document will be managed by the (xxx) and a record maintained of
areas where the document has been sent.
7.2. Notification of the revision of this document will be via the CMFT Intranet.
7.3. The following people will be notified of this policy and asked to ensure its
dissemination within their divisional areas: Clinical Heads of Division, Lead Nurses,
Managers
7.4. Each clinical area involved in the care of young people will have a named key
person who will undergo training in healthcare issues relating to young people. They
will undergo training and will be involved in implementation and monitoring.
8 Review, Monitoring Compliance With and the Effectiveness of Procedural
Documents
8.1. The age policy will be audited on a monthly basis by the audit department. The
data will be collated and presented annually.
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 10 of 15
8.2. Issues relating to compliance with the age policy will be addressed throughout
the year by managers.
9
Standards and Key Performance Indicators ‘KPIs’
9.1. The age policy and procedure will be updated every 3 years or when there are
significant changes needed to the document or following new guidance or
regulations.
9.2. The age policy and procedure is available via the CMFT intranet site.
9.3. Compliance with this policy will be reported to the Trust Board.
10
References and Bibliography
11
Associated Trust Documents
CMFT Child Protection Practice Guidelines
CMFT Policy for the protection of Vulnerable Adults.
People who pose a risk to others
12
Appendices
Appendix A: Equality Impact Assessment (EqIA) – Assessment of Policy for
Relevance for Promotion of Equality – Initial EqIA
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 11 of 15
Equality Impact Assessment (EqIA) – Assessment of Policy for Relevance for Promotion of Equality – Initial EqIA Appendix A
(Please complete electronically)
Children’s
1 Division
2 Directorate
3 Department/ Service
4 Policy
Age Policy and Procedure
Divisional Director/Head of Service
Martin Hodgson
5 Assessment Completed By
a) Name
b) Position
Norman Pickavance
Risk/Governance Manager
6 Lead Person
Position
Signature
Helena Gleeson
Contact No.
Date Completed
7 Does the Policy Benefit or have an Impact upon either Staff, the Public or Both?
Yes
Yes
No
Not Sure
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 12 of 15
Is there a Differential Impact?
8a) Is there any
information or
reason to believe
that the operation
of this policy would
or does affect
groups differently?
Answer:
Yes 20
No 0
Not Applicable 0
Not Sure 12
Staff
Public
Age
N/A
0
Disability
N/A
0
Gender/Sex
N/A
0
Race and Ethnicity N/A
0
Religion and Belief N/A
0
Sexuality
N/A
0
8b) How much
information or
evidence is there?
Answer:
None 2
Little 1
Some 3
Substantial 5
Staff
Public
N/A
1
N/A
1
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
9 The Level of
Concern?
Has there been any
concern expressed by
the public or staff about
the operation of this
policy?
Answer:
None 2
Little 1
Some 3
Substantial 5
Staff
Public
2
2
Sub Total
Total
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 13 of 15
10 Total Scores
Staff
0
0
0
0
0
0
0
6
Public
3
3
6
11 Reasons for Non-Applicability
Area
Reasons
Age
Disability
Policy not related to gender has an operational impact on patient’s gender
Gender /Sex
Policy not related to race or ethnicity has an operational impact on patient’s race or ethnicity
Race and Ethnicity
Policy not related to religion has an operational impact on patient religious belief
Religion and Belief
Policy not related to sexulaity has an operational impact on patient’s sexuality
Sexuality
12 Priority
Total Score
6
Priority
Low
13 Service Equality Team Sign Off
Name
Position
Signature
Date of Sign Off
Priority
0-9
10-29
30+
Low
Medium
High
EqIA Registration No.
IP
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 14 of 15
Document Control Policy CG001
See the Intranet for the latest version.
Version Number:- 5
Page 15 of 15