Policies

Policies

CO01 – Access and Choice Policy
The policy has been reviewed in light of new guidance ‘Department of Health Choice Framework – 2015’.
It sets out the mechanisms that the CCG will adopt to fulfil its legal obligations in relation to choice.

CO02 – Complaints-Policy-and-Procedure
The policy is designed to outline the process for handling complaints generated by patients or their representatives and aims to set out clear guidelines for staff, managers and complainants about how complaints will be managed

CO03 – MCA and DOLS Policy
The policy has been developed, merging two previous policies into one,  in light of new guidance and should be read in conjunction with the:

The Mental Capacity Act: Code of Practice
https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice

Deprivation of Liberty Safeguards (DoLS): Code of Practice
http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085476

CO04 – Fire Safety Policy
This document sets out the CCGs’ approach to minimising the incidence of fire within its premises and the impact of fire on life safety, delivery of service, the environment and property.

CO05 – Antifraud Bribery and Corruption Policy
The policy has been reviewed to take into account new guidance.  One of the aims of the policy is to improve the knowledge and understanding of everyone in the CCG, irrespective of their position, about the risk of fraud and corruption within and against the organisation and its unacceptability.

CO06 – Health and Safety Policy
This policy sets out CCG procedures to ensure the health, safety and welfare of its employees, clients, patients, students, contractors, visitors and members of the general public.

CO07-Incident-Reporting-and-Management-Policy (4)
The policy was reviewed with no major amendments.   It sets out the CCG’s approach to the management of incidents in fulfilment of its strategic objectives and statutory obligations.

The reporting of incidents will help the CCG identify potential breaches in its core business including breaches in:

  • contractual obligations;
  • internal processes;
  • performance targets;
  • service specifications;
  • statutory duties.

This policy will enable the organisation to learn lessons from adverse events and supports implementation of action to prevent incidents reoccurring.  Reported incidents will be periodically analysed and results will be shared with directorates, departments and stakeholders where appropriate. The reporting and management process uses a root cause approach to analyse incidents.

CO08 – Intellectual Property Management Policy
This document outlines a policy for the effective management of IP and gives a brief definition of what intellectual property is.

CO09 – Mental Capacity Act Policy
The policy covers the areas outlined in the Department of Health Code of Practice and offers procedural guidance for those staff who may be required to justify any actions and interventions.

CO10 – Moving and Handling Policy
This document sets out the CCGs’ approach to minimising the incidence of manual handling injuries within its premises and the impact of manual handling on health and well-being, delivery of service, the environment and property.

Please note – CO11 – Policy and Framework for Partnership Governance is now featured within policy CO18

CO12 – Procurement Policy
This document outlines the process to ensure that procurement activity relating to clinical health services complies with relevant legislation and Department of Health guidance.  It provides guidance on when to use procurement, to outline key aspects of procurement and set out key considerations to take into account when undertaking a procurement process.

CO13 – Risk Reporting Management Policy (3)
This policy has been reviewed with no major changes and sets out the CCG’s approach to risk and the management of risk in fulfilment of its overall objectives. In addition the adoption and embedding within the organisation of an effective risk management framework and processes will ensure that the reputation of the CCG is maintained and enhanced, and its resources are used effectively to ensure business success, continuing financial strength and to ensure continuous quality improvement in its operating model.

CO14 Safeguarding Children and Looked After Children (4)
This policy outlines the responsibilities of the CCG in applying the Children’s Act Code of Practice, with regard to ensuring that as Commissioners of services, these responsibilities are also adopted by those that we commission services from.

CO15 – Safeguarding Adults Policy
The policy aims to ensure all CCG staff are aware of their specific roles and responsibilities in relation to safeguarding adults and know how and when to raise a concern.  It also outlines the role of the Named and Designated professionals. The policy is designed to take into account the principles identified within the Care Act Guidance 2014 and the “Safeguarding Vulnerable People in the Reformed NHS: Accountability and Assurance Framework 2013. As a commissioning organisation the CCG has an explicit responsibility to ensure provider compliance around adult safeguarding, this is clearly identified within the policy.

Please note that there is a separate policy for use within primary care.

CO16 – Security Policy
This document outlines the CCG’s commitment to promoting and improving the security of its premises/assets and the safety of staff, patients and visitors to the CCG.

CO17 – Serious Incidents Management Policy V3
The policy has been reviewed in light of new guidance. It outlines the process and procedures to ensure that serious incidents (SIs) and never events (NEs) are identified, investigated and learned from as set out in the Serious Incident Framework 2015/16 and Never Event Framework 2015/16. This revised Framework replaces the Serious Incident Framework and Never Event Framework published in 2013.

CO18-Standards of Business Conduct and Declaration of Interest Policy V3
The policy has been updated to take into account new guidance, “Managing Conflicts of Interest: Revised Statutory Guidance for CCGshttps://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/revsd-coi-guidance-june16.pdf

The purpose of this policy is to ensure exemplary standards of business conduct are adhered to, as public servants, by Governing Body members, Committee and Sub-committee members and employees of the CCG (as well as individuals contracted to work on behalf of the CCG or otherwise providing services or facilities to the CCG such as those within commissioning support services).   Through this Policy individuals will be aware of their own responsibilities as well as the CCG’s responsibilities as corporate bodies (including the constituent Member Practices).  The Policy also sets out the responsibilities of the CCG as an employer, especially in light of the individual and corporate obligations set out in the Bribery Act 2010.

CO19 – Violence and Aggression Policy
The aim of this policy document is to reduce the risks, so far as it is reasonably practicable, for staff. It applies to all employees of the CCG and in particular deals with the issue of violence, aggression and abuse against a member of its staff by a member of the public (i.e. patient, member of the patient’s family, member of the public etc.).

CO20 – Domestic Violence in the Workplace
This is a new policy for the CCG.  It should be read in conjunction with NDCCG Adults Policy and the Local Safeguarding Children Board’s (LSCB) Safeguarding and Looked After Children Policy which outline what staff must do where child abuse or neglect is considered, suspected or alleged and the Safeguarding Adult’s Board (SAB) inter agency policy and procedures and Managing allegations against staff Policy and Procedures (2015).

This policy ensures that both victims and perpetrators of domestic abuse are aware of the support that is available within the organisation. It will provide guidance to line managers when supporting staff who are affected by domestic abuse.

CO21-Local-policy-re-GP-professional-performance–V1.1-.
The policy has been reviewed recently and the conflicts of interest section has been made more robust.  It is a corporate policy and procedure for the management and handling of performance concerns related to general practitioners working within the CCGs.

CO22 – Expenses reimbursement policy for patient carer and public involvement in engagement activity
This is a new policy for the CCG which sets out the responsibilities for all CCG staff and any third party commissioned by the CCG to undertake patient, carer and public engagement activity on its behalf. It explains the implications for benefits, employment law and tax, enabling local people to make an informed choice about receiving expenses and what this may mean for them.

This policy has been developed in conjunction with members of patient groups within the CCG.  Input has also been sought from Durham County Council’s Welfare Rights Team in the development of this policy to ensure that all involved are fully aware of how reimbursement of expenses can impact on benefits and HM Revenue and Customs rules.

CO23 – Managing Allegations Against Staff Policy
This policy outlines how, as a commissioning organisation, North Durham CCG will effectively fulfil its legal duties and statutory responsibilities with regard to managing allegations against staff.  The policy applies to all CCG staff and anyone working on behalf of or undertaking work or volunteering for the CCG, including those staff registered as Performers on the National Performers’ List ie GPs.  Each GP practice is responsible for ensuring it has a policy in place for managing allegations against staff that they employ.

CO24 – Policy for Commissioning of Care Provision within the Continuing Health Care Pathway
This new policy has been developed to help provide a common and shared understanding of CCG commitments in relation to individual choice, resource allocation and safe commissioning.

Value Based Clinical Commissioning October 2016

Human Resources Policies 

HR02 – Absence Management Policy
The purpose of the policy is to set out the CCG’s approach to the management of absence and attendance within the workplace. The policy will also set out guidance to staff and managers about their responsibilities in relation to Absence Management.

HR03 Adoption Policy – approved EiC 170516
The Adoption Leave policy is designed to implement the statutory rights to leave following the placement of a child for adoption.

HR04 – Annual Leave Policy
The aim of the Annual Leave Policy is to ensure a uniform and equitable approach to the calculation of annual leave and general public holiday entitlements which take into account the arrangements as defined under NHS Terms and Conditions.

HR05 – Career Break Policy
The Career Break Policy has been designed to allow employees the opportunity to take an unpaid break from their employment, of up to 5 years.

HR06 – Change Management Policy
The purpose of this document is to set out the CCG’s approach to the management of organisational change and the procedures that should be followed by managers wishing to implement major change.

HR07 Disciplinary Policy – final approved EiC 170516
The policy aims to encourage employees to achieve and maintain the required standards of conduct, performance and attendance.

HR08 – Equality and Diversity Policy
This document sets out the CCG’s commitment to equality of opportunity for all employees and is committed to employment practices, policies and procedures which ensure that no employee, or potential employee, receives less favourable treatment on the grounds of gender, race, colour, ethnic or national origin, sexual orientation, marital status, religion or belief, age, trade union membership, disability, offending background, domestic circumstances, social and employment status, HIV status, gender reassignment, political affiliation or any other personal characteristic. Diversity will be viewed positively and, in recognising that everyone is different, the unique contribution that each individual’s experience, knowledge and skills can make is valued equally.

HR09 Flexible Working Policy Version 3 – approved ME 160927 
This policy sets out the flexible working arrangements that are available within the organisation and is supplemented by separate policies on different options.

HR10 – Further Education CPD Policy
This document details the procedure for staff who wish to undertake further education and training.

HR11 – Grievance Policy
The purpose of this policy is to ensure that all grievances are resolved as quickly as possible and also, wherever practicable, at the level at which they arise without the fear of recrimination.

HR12 – Harassment and Bullying at Work Policy
This policy is designed to ensure that all complaints of harassment are dealt with objectively, quickly, sensitively, and confidentially.

HR13 – Induction Policy
This policy ensures all staff are clear about the requirements of their role and have an overall understanding of the CCG.

HR14 – Job Evaluation Policy
This policy is designed to ensure that all posts within the organisation are dealt with in a fair and consistent manner.

HR16 – Managing Work Performance Policy
This document establishes the CCG’s requirements in the standards of work to be achieved by its staff, which will be realistic and clearly defined. In order to fulfil this responsibility the organisation will ensure that individual employees’ work is monitored fairly.

HR17 – Maternity Policy
This policy is designed to provide a framework across the organisation for a consistent and timely to approach to the new and expectant mother.

HR18 – Appraisal Policy
This Appraisal Policy sets out the CCG’s approach to performance review and to talent management.

HR19 Other Leave Policy V3 approved EiC 170221
This policy document sets out the CCG’s commitment to helping employees balance the demands of domestic and work responsibilities by the provision of paid and unpaid leave subject to exigencies of the service.

HR20 – Parental Leave Policy
This document sets out the parental leave entitlements provided to enable employees to take time off work to look after a child or make arrangements for a child’s welfare.

HR22 – Paternity Leave Policy
This policy details the arrangements within the Organisation in relation to paternity leave and pay.

HR24 Professional Registration Policy – approved EiC 170516
The policy aims to ensure that all staff required to be registered with a statutory regulatory organisation/body to practice their specialty/field, are fully aware of their contractual obligation to be registered. The document sets out the role and responsibilities, the monitoring arrangements and the procedure for and implications for lapsed registration.

HR25 – Recruiting Ex-Offenders
This document sets out how the CCG uses the Disclosure service provided by the Disclosure Barring Service (DBS) to assess applicants’ suitability for positions of trust.

HR26 – Recruitment & Retention Premia Policy
The aim of the Recruitment and Retention Policy is to ensure that the CCG remunerates all of its employees at a level at which recruitment and retention difficulties will not be encountered. This Policy also takes full account of the arrangements for the policy as defined under the NHS Terms and Conditions of Service.

HR27 Recruitment and Selection Policy final approved EiC 170516
The Recruitment and Selection Policy is designed to support managers in providing a fair, consistent and effective approach to the recruitment of all employees and to help managers deal with recruitment and selection effectively and consistently.

HR28 Redeployment Policy – V3 rolled over EiC 170516
This policy is designed to assist all employees who are at risk of losing their job as a result of ill health capability, performance, redundancy or end of a fixed term contract of over a year.

HR29 – Retirement Policy
This policy is designed to assist employees who are considering or have taken the decision to retire from service and outlines the options available and support that can be expected from management.

HR30 – Secondment Policy
This policy facilitates the secondment of CCG staff both internally within the organisation and externally within the wider NHS and exceptionally with other non NHS Bodies. It is also designed to encourage staff from external organisations to take up a secondment where available within the Organisation, for the mutual benefit of both organisations.

HR31 – Substance Misuse Policy
The purpose of this policy is to provide managers with guidance for managing the effects of substance misuse by employees.

HR32 – Temporary Promotion Policy
The aim of this policy is to ensure a fair and equitable approach across the CCG to situations in which an individual may be asked to temporarily work, either wholly or partly, in a higher pay band for a significant period of time.

HR33 – Training and Development Policy
The purpose of the CCG’s Training and Development Policy is to ensure that the CCG is resourced, at all times, with people who have the appropriate competence and experience to enable the CCG to achieve its purpose and meet future needs.

HR34 – Travel and Expenses Policy
The purpose of this policy is to provide a structured framework to claiming travel expenses, practical guidance to staff and managers on process and procedure and ensure that travel expenses are claimed in a consistent, accurate and timely way.

HR35 Raising Concerns (Whistleblowing) Policy V3 approved EiC 170221
This policy aims to encourage employees to feel confident in raising serious concerns regarding the practice of the organisation, provide avenues for employees to raise those concerns and receive feedback on any action taken, ensure that employees receive a response to their concerns, reassure employees that they will be protected from possible reprisals, subsequent discrimination, victimisation or disadvantage if they have a reasonable belief that they have made any disclosure in good faith.

HR36 – Working Time Directive Policy
This document sets out the European Working Time Regulations entitlements of employees to maximum working hours, rest periods, rest breaks whilst at work, annual leave and working arrangements for night workers.

HR37 Incremental Pay Progression Framework Policy approved ME 160927
This framework focuses on enhancing the effective management of annual pay progression through robust annual appraisals to ensure the personal development of the employee and the efficiency of the organisation.

HR39 Shared Parental Leave policy- V1 Final approved ME 160927
The purpose of this policy is to provide managers and employees with information and guidance about entitlements to shared parental leave relating to conditions of service, and to provide the basis for a clear understanding of the nature and period of leave, paid and unpaid, that will apply in particular circumstances.

HR40 Managing Allegations against Staff Policy – V1 final approved EiC 170516

This policy outlines how, as a commissioning organisation, North Durham CCG will effectively fulfil its legal duties and statutory responsibilities with regard to managing allegations against staff.  The policy applies to all CCG staff and anyone working on behalf of or undertaking work or volunteering for the CCG, including those staff registered as Performers on the National Performers’ List ie GPs.  Each GP practice is responsible for ensuring it has a policy in place for managing allegations against staff that they employ.

HR41 Domestic Abuse in the Workplace Policy V1 final approved EiC 170516

This policy ensures that staff who are both victims and perpetrators of domestic abuse are aware of the support that is available within the organisation. It also provides guidance to line managers when supporting staff who are affected by domestic abuse.

Information Governance

IG01-Confidentiality and Data Protection Policy
This policy relates to the processing of personal information and to the management of personal information about staff,patients/service users. The CCG is required by law to comply with the Data Protection Act 1998, which is concerned with the lawful processing of information relating to living individuals.To comply with the law staff or others who process personal information must ensure they follow the Data Protection Principles and the Caldicott Principles.The obligation to keep information confidential arises out of the common law duty of confidentiality, professional obligations and staff/third party contracts. The HS code of Practice: Confidentiality provides guidance to the NHS and related organisations. These duties  and obligations mean that all staff with access to confidential personal information must keep that information safe and secure.

IG02-Data Quality Policy
This policy is designed to ensure that the importance of data quality within the CCGs is disseminated to all staff. It will describe the meaning of data quality, who is responsible for its maintenance and how it can continue to improve in the future. Although this policy relates to patient/service user data and information, the principles included are applicable to any other data/information staff may encounter i.e. recording of minutes, etc.

IG03-Information Governance and Information Risk Policy
This policy relates to information governance and information risk management as a vital asset, both in terms of the management of health and social care for individual patients/service users and the efficient management of services and resources. It plays a key part in governance, service planning and performance management. Information risk management is an essential component of information governance and is an integral part of good management practice. The intent is to embed information risk management in a practical way into business processes and functions.

IG04- Information Access Policy
This policy relates to all information and records held by or on behalf of the CCGs whether computerised, paper or any other permanent storage media, including photographic, video and voice recordings and is supported by appropriate procedures to assist staff in complying with the CCGs statutory obligations. This policy will be available on the internet in line with the Guide to Information.

IG05 – Information Security Policy
This policy document sets out the detailed procedures, rules and standards governing information security that all users of the CCG’s information systems must comply with. This policy document states the CCG’s commitment to information security and sets out the CCG’s overall approach to managing information security.

IG06 – Records Management Policy and Strategy
This policy sets out the principles of records management for the CCG. It provides a framework for the consistent and effective management of records that is standards based and fully integrated with other information governance initiatives within the CCG. Records management is necessary to support the business of the CCG and to meet its obligations in terms of legislation and national guidelines.

IG07—Internet-and-Email-Acceptable-Use-Policy.
This policy sets out the expectations of the CCG for the proper use of its e-mail systems and compliments other information Gg use of the internet and e-mail by:

• setting out the rules governing the sending, receiving and storing of e-mail,
• establishing user rights and responsibilities for the use of systems,
• promoting adherence to current legal requirements and NHS information governance standards.

IG08 – Social Media Policy
The purpose of this policy is to provide guidance to CCG staff on social media/networking on the internet and external use of the other online tools such as blogs, discussion forums and interactive news sites. It seeks to give direction to staff in the use of these tools and help them to understand the ways they can use social media to help achieve business goals. This is a rapidly changing area and this policy is expected to be updated and amended as communication strategies evolve.