Corporate Governance

P_CoG_19 VIP Policy

There are occasions when a VIP (Very Important Person) might visit Lincolnshire Community Health Services NHS Trust (LCHS) services or premises.This could occur during the working day or in the out of hours period.

VIPs mightincludemembersoftheRoyal family,senior politicians(e.g.SecretaryofState,Ministers),representativesfromnationalbodiessuchastheDepartmentofHealth,celebrities,sportspeopleetc.

Additionallythetrustprovidesurgent careserviceswhichcanbeaccessedbyeveryoneandthiscanincludeVIPsandthoseinprotectivecustody,thismaybeanemergencywithlittlewarning.

Itisimportantthatthetrustisabletocontinuenormalbusinessandthatcareprovidedtoothersis notcompromised.InadditionitisimportanttosafeguardboththeprivacyoftheVIPandthosearoundthemincludingstaff.Itisalsoimportanttosafeguardthereputationoftheorganisation.

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P_COG_17 Business Continuity Management System Business Continuity Policy

The purpose of the Business Continuity Management System is to provide a Business Continuity Management Framework for Lincolnshire Community Health Services NHS Trust. To ensure the resilience of the Trust to any eventuality and its ability to address business disruptions to critical services or functions, at an agreed level and within a time frame that minimises the impact to the organisation, staffing and the wider health and social care community, protecting also the brand and reputation.

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G_CoG_02 On Call Director SOP

The Standard Operating Procedure (SOP) provides a guide for dealing with the majority of incidents that the Director/ Manager on-call may be asked to respond to.  Lincolnshire Community Health Services NHS Trust (LCHS) operates a 24hr on call rota.  A Director on call rota is supported by the LCHS Manager on-call rota.  These Directors/Managers will be responsible for maintaining the effective and efficient provision of services to the County of Lincolnshire. The on call Director/Manager will be the responsible officers, whilst on call "in and out of hours" (24/7 for the period of their on call).

Each NHS organisation is responsible for ensuring appropriate leadership during emergencies and other times of pressure.  Incidents, emergencies and peaks in demand can occur at any time of day or night, so each organisation must have an appropriate out-of-hours on-call system.

In the first instance for the requirement of a senior management response the Manager On Call will be the initial point of contact. The Director On Call will only be contacted by either the Manager On Call or Director to Director from a partner organisation (all requests will be directed via Louth switchboard).

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P_CoG_11 Emergency Preparedness Portfolio

This portfolio contains a number of emergency preparedness plans which will support LCHS in meeting the duties set out in legislation and associated statutory guidelines as well as any other issues identified by way of risk assessments and identified capabilities. Plans contained within the portfolio are based on worst case scenarios.

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P_CoG_14 Anti Bribery Policy

All staff have a personal responsibility to make sure that they are not placed in a position which risks, or appears to risk, a conflict between their private interests and their NHS duties or allegations of their official position.

This policy provides all staff and non-executive directors with a framework to enable them to fully comply with the Bribery Act 2010 and to support them to act honestly and with integrity at all times. It is also intended to contribute to maintaining the highest standards of business conduct and ensure compliance with the 7 principles of public life drawn up by the Nolan Committee.

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P_CoG_13 Communications

It is recognised that effective and efficient communications strategies can significantly enhance both the reputation and delivery of services in any organisation. Lincolnshire Community Health Services Trust is committed to providing a framework through which the organisation can disseminate effective communications, capitalise on positive publicity and minimise the effects of negative media.

Lincolnshire Community Health Services NHS Trust is committed to providing an open and honest approach to communicating with the local community, members of the media, patients, carers and other stakeholders.

 

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P_CoG_09 Emergency Preparedness Policy

LCHS has statutory duties, under the Civil Contingencies Act, 2004 (CCA) to assess local risks and put in place emergency plans, co-operating with other local responders to enhance co-ordination and efficiency. LCHS is also required to have in place contingency plans that allow it to continue to provide services during a major incident, so far as is practicable and to recover from the additional pressure that an incident would place on it as an organisation.

This policy is not intended to be used for the response to a Major Incident, in those circumstances staff should refer to the trusts MAJOR INCIDENT/ EMERGENCY RESPONSE PLAN which details the Trusts operational response to a Major Incident / Emergencies.

LCHS must be capable of responding to major incidents of any scale in a way that delivers optimum care and assistance to the victims, that minimises the consequential disruption to healthcare services and that brings about a speedy return to normal levels of functioning.

 

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P_CoG_07 Management of External Agency Visits, Inspections and Accreditations Policy

 This policy has been developed to ensure a process that provides good co-ordination and evaluation of the work of external agency visits, inspections and accreditations to bring increased benefits to both the organisation and the review bodies. The policy will help to minimise the burden on the organisation by reducing overlap and allow for potential gaps in assurance to be identified and addressed. This policy forms part of LCHS's internal control system and provides assurance to the LCHS Trust Board, who will, wherever possible, make use of the work of the many external reviewers and ensure the whole process is efficient and meaningful to the organisation.

This policy sets out the processes to ensure that all recommendations arising from external agency visits, inspections and accreditations are implemented within specified timescales. LCHS will ensure that there is a centrally held, internally audited, record of all external agency visits, inspections and accreditations together with their reports, which is kept up-to-date and monitored within specified timescales.

The policy applies to all managers and health professionals who are identified leads and contacts for the professional and regulatory bodies for both internal and external scrutiny.

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P_CoG_06 Protocol and Procedure for Accessing External Legal Advice

 When considering the use of external solicitors for legal advice/services, it is important to strike a balance between the sensible use of public funds and the need to minimise risk to the organisation.

The aim of this protocol is to ensure staff have guidance on the likely circumstances where access to legal advice would be required and also the appropriate procedures to follow.

This protocol relates to all legal or potential issues other than Clinical Negligence matters. Any Clinical Negligence allegations, claims or potential claims are the subject of separate procedures and should be directed to the Corporate Assurance Manager

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P_CoG_04 Development & Management of Policies & Procedural Documents

This guidance applies to all policies and other procedural documents that are developed by Lincolnshire Community Health Services for implementation.

Policies and procedural documents should address:

  • What must be done to reduce, manage or eliminate risk
  • The organisation's approach to strategic, operational or clinical management issues
  • Guidelines, protocols and procedures that set out a process to enable staff to comply with a procedural document.

The purpose of this guidance is to implement a co-ordinated and uniform approach to procedural document development and management; and to provide clarity and consistency to the process of document production, approval, implementation and review.

LCHS will develop procedural documents to fulfil all statutory and organisational requirements. These will be comprehensive, formally approved and ratified, disseminated through approved channels, and implemented. Procedural documents are designed to cover key issues relating to the spectrum of the organisation's business.

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