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Westleicestershireccg.nhs.uk

WEST LEICESTERSHIRE CLINICAL COMMISSIONING GROUP
BOARD MEETING
12 March 2013
Subject:
Presented to the
WLCCG Board by:

EXECUTIVE SUMMARY

1. West Leicestershire Clinical Commissioning Group (WLCCG) is required to have
in place a range of policies and procedures in preparation for statutory authorisation on the 1 April 2013. 2. WLCCG organisational policies and procedures required for authorisation have been formally adopted. There are however a number of other policies and procedures that underpin the operations of the CCG. These relate to the following areas: workforce, finance, clinical, health and safety and corporate governance. 3. Practically these policies and procedures have been in operation across the PCT and the nature of CCG operations are consistent with the PCT and therefore address the risk and regulations that apply to our functions. 4. Whilst the current situation is not without risk, the approach described in this paper offers a pragmatic approach from 1 April 2013. 5. There remains significant work to refine the volume, development, approval, implementation and monitoring of policies and procedures within the CCG.
RECOMMENDATIONS

6. The West Leicestershire Clinical Commissioning Group is requested to:
formal adoption and transfer of the operational policies and procedures identified in annexes 2-6. delegated authority to the Corporate Management Team to approve operational policies delegated authority to the sub groups of the Board to approve policies and procedures within their sphere of responsibility the approach being undertaken to update all policies and procedures INTRODUCTION
7. The purpose of this paper is to outline the proposal for the formal adoption of a
range of policies and procedures in preparation for statutory authorisation on the 1 April 2013. 8. The paper aims to provide a pragmatic approach to manage a significant body of work that spans multiple specialist work streams. BACKGROUND AND CONTEXT
9. As part of the NHSCB authorisation process the CCG has developed and
approved a range of organisational strategies and associated policies. These are therefore in place and supersede the documents that were in operation in the PCT. 10. The LLR CCGs have been working collaboratively with colleagues in the PCT cluster and GEM CSU to ensure that a pragmatic and operational viable system is in place for 1 April 2013. CURRENT POSITION
11. CCG organisational policies and procedures required for authorisation have been
formally adopted. There are however a number of other policies and procedures that underpin the operations of the CCG. These are outlined in more detail in following sections: WORKFORCE (HUMAN RESOURCES)
12. All PCT policies and procedures have been reviewed by GEM to ensure that they
are fit for purpose for transfer to CCGs. 13. GEM has confirmed that all policies have been reviewed by specialist advisors; staff side have been involved and that they have been subject to a due regard impact assessment to comply with equalities legislation. 14. It is expected as part of the GEM service offer that the development, implementation and monitoring of these will be part of their responsibilities. 15. Appendix 1 details the workforce policies FINANCE
16. The development and approval of financial policies and procedures is referenced
within the CCG constitution. The chief finance officer has responsibility to ensure the required policy and procedural framework is in place from 1 April 2013. 17. An update of the existing Standing Financial Instructions (SFI’s) will be discussed by the Corporate Management Team and circulated for comment and approval to the Finance and Performance sub group by the end of March 2013. 18. Appendix 1 details the financial policies CLINICAL
19. The CCG holds a register of all current clinical policies and procedures used and
20. A review of future applicability and content is being progressed. It is recommended that similar to the other key policy areas, these transfer and are formally adopted by CCGs for use from 1 April 2013. 21. It is recommended that Board Nurses in conjunction with clinical governance and clinical chairs take a view on LLR CCG work plan. 22. Whilst it is acknowledged that there will be benefit in sharing this workload, formal approval will be a requirement for individual CCG Governing Bodies. 23. Appendix 1 details the clinical policies HEALTH AND SAFETY
24. There are range of current policies and procedures in operation across the PCT
and CCG. There has been no formal review of these as there has been no specialist support retained by the CCG, either within our structures or through GEM CSU. 25. Practically these policies should transfer to the CCG on the 1 April 2013 as the nature of CCG operations are consistent with the PCT and therefore address the risk and regulations that apply to our functions. 26. Whilst this is acknowledged as practical step, a specialist review of the CCG health and safety needs has been commissioned by ELR CCG on behalf of all CCGs. This review will provide each organisation with an overarching health and safety risk assessment; specific risk assessments (e.g. DSE, fire lone working etc.) for applicable regulations and will therefore include a review of the required policies. 27. It will be for individual CCGs to ensure that any revision and updates to the transferring policy framework is approved and implemented at an appropriate level. 28. Appendix 1 details the health and safety policies CORPORATE GOVERNANCE
29. The risk management framework will be updated in line with changes following
completion of the review of CCG risk registers and Board Assurance Framework. 30. The suite of policy documents relating to information, records and data protection are being reviewed by the specialist information governance and records lead manager based within GEM CSU. 31. It has been confirmed that all policies will be reviewed prior to the 1 April. These will be received by the Joint information Governance Steering Group. This group has been reconvened and will support the LLR CCGs take his area of work forward. 32. For future reference the advisory and support provide by the information governance manager is transferring to GEM CSU. 33. Appendix 1 details the corporate governance policies MISCELLANEOUS
34. Whilst every effort has been made to capture all policies and procedures currently
used by the CCG during in its shadow period of operation, there is a low risk that there may have been an omission from the work plan for each of the policy areas described above, or that a standalone management policy that has not been identified. 35. In the event of such an occurrence it is proposed that any such policy be retained for use within the CCG and upon identification it is reported to CMT and included in an appropriate work stream for review. GOVERNANCE AND INTERNAL CONTROL
36. The CCG lacks a current management control framework and it is likely that the
current scheme of reservation and delegation (SoRD) is not explicit to manage this area efficiently and effectively given the volume and level of detail. 37. In order to achieve a balanced and appropriate mechanism a review of the CCG SoRD is needed to ensure appropriate levels of reservation and delegation are in place within the CCG. The Audit Committee on behalf of the Governing Body will provide mechanism to ensure that proposed scheme manages risk appropriately. CONCLUSION
38. Whilst priority has been given to the pre-requisite areas for authorisation there
remains significant work to refine the volume, development, approval, implementation and monitoring of policies and procedures within the CCG. 39. Whilst the current situation is not without risk, the approach described in this paper offers a pragmatic approach from 1 April 2013.
RECOMMENDATION
40. The West Leicestershire Clinical Commissioning Group is requested to:
formal adoption and transfer of the operational policies and procedures identified in annexes 2-6. delegated authority to the Corporate Management Team to approve operational policies delegated authority to the sub groups of the Board to approve policies and procedures within their sphere of responsibility the approach being taken to update all policies and procedures Appendix 1
Corporate Governance Policies
Freedom of Information Act 2000 Policy. Publication Scheme and Leaflet
Risk Management Framework
Risk Management Policy
Claims Management Policy
Risk Register Policy
Policy and Procedure for Reporting, Investigating and managing Incidents,
Accidents, Near Misses and Dangerous occurrences (including serious
incidents)
Incident Reporting Form
Midlands and East - Policy for the Reporting and Management of Serious
Incidents
Business Continuity Management (BCM) Policy 2012
Safeguarding Adults Policy 2011-12 Safeguarding Children and Young People Policy Safeguarding Children and Young People Training Strategy Data protection Act 1998 Policy Individual Funding Request Policy, IFR Form and IFR Leaflet Information Lifecycle Management Policy Records management Policy and Policy for Appraisal, Retention and Disposal of Records Records Management and Lifecycle Policy and NHS Code of Practice (2006), Business and Corporate (Non-Health) Records Retention Schedule Policy for Dissemination, Implementation and Monitoring of NICE Guidance Health and Safety Policies
COSHH Policy
Eye Testing and Glasses reimbursement form
Health, Safety and Welfare at Work Policy
First Aid Policy
PAT Guidelines
Working Along in Safety Policy
Terrorist Attack and Bomb threat guidance
CCTV Policy
Security Policy including Buildings and Assets
Moving and Handling Policy
Display Screen Equipment
Waste Policy
Health and Safety Inspection Process
Fire Safety Policy
Asbestos Policy
Asbestos Management Plan
Appendix 1
Workforce Policies
Recruitment, Selection and Induction Policy and Procedure
Equality, Diversity and Human Rights Managing the Balance between Work and Life Policy and Procedure Smoke-free on NHS Premises Whistle blowing in the NHS Performance Management Policy and Procedure Disciplinary Procedure Dignity at Work Policy Managing Absence due to Ill Health Management of Annual Leave and General Public Holidays Retirement Maternity, Adoption, Paternity Leave Policy Management of Change Policy Education, Learning and Development Policy and Procedure Exit Questionnaire Grievance Policy Disputes Policy Allegations that a worker may be harming a child or adult in need of safeguarding Policy Email and Internet Access Monitoring Management of Stress at Work Alcohol, Drugs and other Substance Misuse Policy Professional Registration Policy Agency and Contractor usage Policy Staff Experiencing Domestic Violence/Abuse Policy Trade Union and Professional Organisation Recognition Agreement Facilities and Time Off for accredited Trade Union or Professional Organisations Finance Policies
Corporate Finance Budget Manual
Counter Fraud Policy
Losses and Special Payments (under review)
Lease Car Policy (under review)
Policy for the Development of Finance Staff
Reimbursement of Travel and other Expenses incurred by members of the public
and their carers who have been asked to be involved in the work of the PCT
(under Review)
Appendix 1
Clinical Policies
Patient Group Direction for Paracetamol for Mild to Moderate Pain and Pyrexia
by Registered Nurses working in Walk in Centres/Minor Injury Units
Patient Group Direction For Ibuprofen For Pain Pyrexia And Inflammation By Registered Nurses Working In Walk In Centres/Minor Injury Units Patient Group Direction for Chlorphenamine For Allergic Conditions by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for Lidocaine Hydrochloride Injection for Local Anaesthesia by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for Administration of Salbutamol Solution via a Nebuliser for Acute Asthma by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Administration of Benzylpenicillin Injection by Registered Nurses in Suspected Meningococcal Disease at the Walk in Centre/MIUs Patient Group Direction for the Supply Of Phenoxymethylpenicillin (Penicillin V) for the Treatment of Acute Sore Throats by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for Administration of Activated Charcoal Oral Suspension by Nurses Working in Walk In Centres / Minor Injury Units Patient Group Direction for Administration of Aspirin Tablets for Cardiac Chest Pain by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Administration of Adrenaline (Epinephrine) 1:1000 (1mg in 1ml) Injection for the Emergency treatment of acute anaphylactic reaction by Registered Nurses at the Walk in Centre/MIUs Patient Group Direction for Combined Diphtheria, Tetanus (Adsorbed), acellular Pertussis, and Inactivated Polio Virus vaccination (dTaP/IPV) for pregnant women Patient Group Direction for the Administration of Oxybuprocaine as Local Anaesthetic for Eye Trauma by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction Immunisations and Vaccinations for Children Patient Group Direction for the Supply/ Administration of Co-Codamol 30/500 Tablets by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Supply and Administration of Cetirizine for the Relief of Allergic Reactions by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Administration of Entonox by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Supply and Administration of Co-Magaldrox by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Administration of Diclofenac Sodium injection in acute pain by Registered Nurses working in Walk in Centres/Minor Injury Units Appendix 1
Patient Group Direction for the Supply of Hydrocortisone Cream 1% for Reaction to Insect Bites by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Supply and Administration of Prednisolone for the Management of Acute Exacerbation of COPD/ Asthma by Registered Nurses working in Walk in Centres/ Minor Injury Units Patient Group Direction for the Supply of Co-Amoxiclav in Human and Animal Bites by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Administration of Oxygen by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Supply of Metronidazole in Human and Animal Bites by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Supply of Sodium Fusidate Ointment in the treatment of Impetigo by Registered Nurses working in Walk in Centres/ Minor Injury Units Patient Group Direction for the Supply of Amoxicillin for the Acute Exacerbation of COPD/Asthma by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the Administration of Water for Injections for Reconstitution of Injectable Products by Registered Nurses working in Walk in Centres/Minor Injury Units Patient Group Direction for the administration of Immunisations and Vaccines for travel and associated infections Patient Group Direction for the Administration of Seasonal Influenza Vaccine by Registered Nurses

Source: http://www.westleicestershireccg.nhs.uk/sites/default/files/paper_k_policies.pdf

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