Document Control Policy

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 Document Title: Document Control Policy
Version No: 7.0
Latest version issued: 22 April 2020
Supersedes: v6.0
Name of Author (s): Laura Whitton
Consultation: EQIA Panel
Approved by: Leadership Team (formal)
Approval date: January 2019
Review date: January 2022
Equality Impact Assessment Date: November 2018
Target Audience: All North East Lincolnshire CCG Staff
Dissemination: NELCCG Intranet
CCG Global newsletter

Version Description of Amendments Date

1.0 New CCG policy October 2015
2.0 Policy reviewed and update as a result of compliance April 2016
3.0 Additional paragraph 3.7.3 June 2016
4.0 Clarification update regarding draft for consultation July 2017
5.0 Appendices/templates updated May 2017
6.0 Full policy review November 2018
7.0 Minor amendments to comply with accessibility legislation – re- April 2020
ratification not required
8.0 Review date amended by 1 year due to Covid – re-ratification November 2020
not required

The on-line version is the only version that is maintained and valid. If this document
has been printed or saved to another location, the reader must check that the version
number matches that of the on-line version.

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CONTENTS

1.0 INTRODUCTION........................................................................................................4

2.0 SCOPE........................................................................................................................ 4

3.0 PURPOSE................................................................................................................... 4

4.0 IMPACT ANALYSES...................................................................................................4

5.0 NHS CONSTITUTION.................................................................................................5

6.0 ROLE AND RESPONSIBILITIES.................................................................................5

7.0 DEFINITIONS..............................................................................................................6

8.0 DEVELOPMENT OF NEW, AND REVIEWS OF EXISTING POLICIES,

PROCEDURES AND GUIDELINES............................................................................7

9.0 CONSULTATION.........................................................................................................8

10.0 APPROVAL................................................................................................................. 9

11.0 REVIEW AND REVISION ARRANGEMENTS...........................................................10

12.0 IMPLEMENTATION...................................................................................................12

13.0 DISSEMINATION, ACCESS & TRAINING.................................................................12

14.0 REVIEW, MONITORING AND COMPLIANCE..........................................................12

15.0 REFERENCES AND LINKS TO OTHER DOCUMENTS (for this policy)...................12

16.0 APPENDIX A – Process for Policy Initiation...............................................................13

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1.0 INTRODUCTION

1.1 Organisational documentation is an essential tool of governance, which helps to achieve

the strategic objectives, operational requirements and brings consistency to everyday
activity. A standard format and approved structure for such documents helps to ensure
that policies and procedures are up to date to a professional and consistent standard,
and reflect the organisational approach.

1.2 All documents must undergo a rigorous process of development and be approved and
monitored by the appropriate committee, who in turn provide assurance to the CCG
Governing Body on relevant legal and statutory requirements, Health & Social Care
policies and guidance.

2.0 SCOPE

2.1 This policy applies to all directly and indirectly employed staff and other persons working
for and on behalf of the CCG

2.2 It is important that any members of staff who find it difficult or impossible to comply with a
particular policy or any aspect of it inform their manager at the earliest opportunity so
that it can be revised or action taken locally to make compliance possible.

3.0 PURPOSE

The purpose of this document is to create a standardised approach to the development and
structuring of CCG documentation (policies/procedures/protocols/service specifications). It
sets out standards and processes which should be met and ensures that documents are
suitably ratified, updated and implemented.

4.0 IMPACT ANALYSES

4.1 Equality & Quality Impact Assessment *

In accordance with the CCG’s commitment to Equality and Diversity, we aim to eliminate
discrimination, harassment and victimisation, advance equality of opportunity, and promote
good relations between groups. We need to do this for the nine protected characteristics:
age, disability, gender reassignment, marriage and civil partnership, pregnancy and
maternity, race, religion or belief, sex and sexual orientation.

As a result of preforming the screening analysis, the policy does not appear to have any
adverse effects on people who share Protected Characteristics and no further actions are
recommended at this stage. The equality impact assessment for this policy can be
accessed here.

* New Equality & Quality Impact Assessment to be used during 2019.

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4.2 Bribery Act 2010

The relevance of the Bribery Act 2010 must be considered in respect of every policy.

The CCG follows good NHS business practice as outlined in the Business Conduct Policy
and the Conflicts of Interest Policy and has robust controls in place to prevent fraud, bribery
and corruption. Due consideration has been given to the Bribery Act 2010 in the
development (or review, as appropriate) of this policy document and no specific risks were
identified

Anyone with concerns or reasonably held suspicions about potentially fraudulent activity or
practice should refer to the Local Anti-Fraud and Corruption Policy and contact the Local
Counter Fraud Specialist. http://www.northeastlincolnshireccg.nhs.uk/countering-fraud-in-
the-nhs

5.0 NHS CONSTITUTION

5.1 The aim of the Constitution is to safeguard the principles and values of the NHS. The
CCG is required by law to take account of the Constitution in its decisions and actions.
The CCG must, in the exercise of its functions, act with a view to securing health
services that are provided in a way which promotes the Constitution, and promotes
awareness of it.

5.2 This Policy supports the NHS Constitution as follows:

 The NHS aspires to the highest standards of excellence and professionalism in

the provision of high-quality care that is safe, effective and focused on patient
experience; in the planning and delivery of the clinical and other services it provides;
in the people it employs and the education, training and development they receive; in
the leadership and management of its organisations; and through its commitment to
innovation and to the promotion and conduct of research to improve the current and
future health and care of the population.

6.0 ROLE AND RESPONSIBILITIES

 Clinical Chief Officer - has overall accountability for the strategic and
operational management of the organisation, including ensuring all documents
(e.g. policies, standard operating procedures, guidance, and protocols) comply
with all legal and statutory requirements and are adhered too.

 Governing Body – is responsible for settings the strategic context in which

organisational documents are developed and for the approval of any changes to
the organisations strategic direction or the way in which it operates and
compliance/changes of statutory requirements. The Governing Body will also
delegates approval authority to its committees or sub-committees.

 Approving committees –the committees that have been given delegated

responsibility by the CCG’s Governing Body for the approval of new and revised
documents, and that they meet suitable standards for content and presentation.
This is also confirmed in appropriate committees terms of reference and section
10 of this policy

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  Line Managers – are responsible for ensuring their staff are aware of, and
adhere to all the organisation’s documents and they know how/where to access
them.

 Corporate Governance Team –is responsible for monitoring and maintaining a

central organisational document register, and ensuring notifications of review
dates are generated to document authors. Uploading all approved documents
onto the CCG intranet and/or internet and for business continuity purposes,
electronic copies of relevant documents will be kept in a central storage area.

 Document Authors - are responsible for producing documents, in accordance

with this document control policy, which are current, evidence based and reflect
best practice, while complying with all relevant legislation and organisational
documents. They must ensure records are kept of the stages of development
including discussion, and appropriate consultation has taken place.

 All Staff (including temporary or agency staff, contractors, students or

anyone working on behalf of the CCG) All staff and anyone working on
behalf of the CCG are responsible for ensuring that they adhere to this policy
when developing documents on behalf of the CCG and ensure they maintain up
to date awareness of this policy.

7.0 DEFINITIONS

The definitions adopted for the purpose of this document are set out below:-

 Policy: A high level document which sets the principals by which the CCG
operates endorsed by the Governing Body or its committees/sub-committees. It
provides a prescribed plan or course of action intended to influence
actions/decisions. A breach of a policy may have serious consequences for both
the CCG and its staff.

 Strategy: An overall plan to achieve longer-term objective.

 Standard Operating Procedures (SOPs): Documents on procedures, protocols

and guidelines as follows:-

 Service Specification: a document that describes what is required from a

service. It is a working tool to structure how the CCG will deliver a service,
and a reference document to measure the quality of the service

 Procedure: The established form of conducting or performing an activity

as a defined series of steps or actions to meet the requirements of a
policy. A document setting out the actions or steps to be followed by
individuals relevant to the subject set out in the document. Procedures
can be associated with a policy and describe how a policy is carried out.
They are precise and detailed and must be adhered to by all staff to which
they are relevant.

 Protocol: A defined set of behaviours or actions associated with a policy

or a task regularly undertaken with the CCG. Protocols are ways of
working based on expert opinion and can either be agreed within teams or

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 be applied organisational wide. They provide step-by-step guidance on
high-level activities with the CCG. They are precise and detailed and must
be adhered to by all staff to which they are relevant. They are non-
negotiable.

 Guidelines: Advisory or good practice principles put forward to set

standards or determine a course of action. Clinical guidelines do not
replace professional judgement and discretion.

 Standard: Specification of a required level of performance.

 Procedural documents: This is a collective term for policies, protocols,

procedures and guidelines.

 Code of Practice: Specification of standards which must be met within a

legal framework.

 Code of Conduct: Specification of standards which must be met by

members of that profession.

 Document Author: For the purpose of this document the term Document
Author will mean the original author and any subsequent person who is
responsible for reviewing or revising the document.

 Stakeholder: A person, group, or organisation that has direct or indirect

input in an organisation because it can affect or be affected by the
organisation’s actions, objectives and policies.

8.0 DEVELOPMENT OF NEW, AND REVIEWS OF EXISTING POLICIES,

PROCEDURES AND GUIDELINES

The requirement for any document should be identified taking into account statutory and
national requirements, this should be undertaken by the document author.

8.1 Policy Initiation

8.1.1 The intention to develop any document must be registered with the CCG Corporate
Governance Team who will maintain a central register, see appendix A

8.1.2 A short checklist has been developed to provide general support in the development
of documents and is available through this hyperlink.

8.2 Style & Format

8.2.1 All policies should be presented in accordance with the standard template which is
available through this hyperlink.

8.2.3 The font type, size and spacing is detailed in the checklist, so that all policies have
the same corporate appearance. Not every policy will require all the sections listed
in the policy template. Standing operating procedures, guidelines and protocols
should also be set out in same style and format as a policy. However, the document
control sheet in the policy template should be amended accordingly dependent on

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 the authorising Senior Manager. The final content of individual documents will vary
according to their nature and intended audience

8.2.3 Existing documents will need to be converted into the CCG’s corporate format at the
next review stage.

8.2.4 All existing document revisions should be carried out using the “Track Changes” tool
so that all changes made to the preceding version are clearly visible to the ratifying
committee

8.2.5 All documents should be written as concisely and clearly as possible. Avoid jargon
and unnecessary use of acronyms.

8.3 Special Circumstances

8.3.1 Local Authority, Local NHS, or Department of Health policies do not need to be
rewritten into the CCG format if the CCG is intending to adopt them. A separate front
sheet should be attached to the policy showing the title, CCG policy reference, details
of the consultation process, the standard document control requirements and a
nominated CCG Owner. The CCG Owner would be responsible for reviews and CCG
re-approval

9.0 CONSULTATION

9.1 It is the responsibility of the document author to agree and undertake the appropriate
consultation on all documentation. All documents that have an impact on staff should
be consulted on through the Trade Union Partnership Forum. The CCG HR Service
Provider will be responsible for this, prior to passing the document through the
appropriate ratification process.

9.2 All documents should be reviewed by and commented on by the appropriate internal
and external stakeholders. Staff should be given the opportunity to comment on any
documents which have a direct impact on them, this will be undertaken via the CCG
Employee Group on behalf of the CCG staff.

9.3 A record must be kept of the discussions, consultation and negotiation processes
undertaken together with any supporting documentation.

9.4 The author of the document is responsible for ensuring that all comments are
incorporated into the document and making any necessary amendments as required.

9.5 Any groups/individuals consulted throughout the development of the document

should be listed in the reference table on the document control sheet in the policy
template.

9.5 Draft documents can only be placed on the CCG internet during the
consultation/engagement period. This can only be completed by the Corporate
Governance Team. ([email protected]).

Please note the document will be removed from the internet at end of the
consultation period.

9.6 It is good practice to give consultation periods of at least two weeks to ensure that
individuals on leave and/or individuals with prioritising workloads are able to give the
document appropriate attention. At the end of a consultation period, where some

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 individuals have not responded, a view should be taken as to whether an appropriate
proportion of those consulted have responded (given the nature of the policy) and/or
whether particular individuals expected to have a key opinion have responded. As a
minimum the responses received need to be equal to the quorum requirements of the
approving committee.

10.0 APPROVAL

10.1 All policies whether new or revised existing policies will require formal approval as
per Section 11. The policy author is responsible for ensuring that a fully updated
policy, including an equality & quality impact assessment (an EIA proforma is
available through this hyperlink) is submitted to the CCG Corporate Governance
Team so these can be submitted to the relevant committee.

The following is provided as a guide.

Type of policy/procedural document Approving Committee

Human Resources (core) Trade Union Partnership Forum

CCG Leadership (formal)

Pecuniary effect Remuneration Committee

Human Resources (non-core) CCG Leadership (formal)

Pecuniary effect Remuneration Committee

Financial Integrated Governance & Audit Committee

Commissioning Council of Members and or Governing Body

Quality Clinical Governance Committee

Contracting & Procurement Care Contracting Committee

CCG Leadership Team (formal)
Corporate Governance
Integrated Governance & Audit Committee

Council of Members

Information Governance Integrated Governance & Audit Committee

Communication & Engagement Community Forum

Governing Body

Health & Safety NELC Health & Safety Advisor

Integrated Governance & Audit Committee

10.2 There may be some instances where Standard Operating Procedures (SOPs) require
approval and ratification depending on the content, potential risk and impact. Further
guidance can be obtained from the CCG Senior Leadership Team.

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10.3 If a document does not ‘fit’ this process, the senior member of staff responsible for
the document should determine the process by referring to the table above or by
contacting the Corporate Governance Team for guidance.

10.4 Policies will only be ratified, following approval by the delegated committee.

10.5 Policies/SOPs approved with outstanding conditions may be ratified by ‘Chairs

action’ dependent on the type of condition. This request should be made of the Chair
at the time of approval.

10.6 There is a requirement placed on the CCG that some policies/SOPs are formally
approved by the CCG Governing Body and this may not be delegated. The CCG
Governing Body will be expected to approve policies with significant public interest or
where enactment would require a significant change in the way the CCG operates.
Policies/SOPs presented to the CCG Governing Body for approval should first have
been considered and agreed at the appropriate sub-committee.

“E.g. of how significance of public interest would be judged”

i. deviation from national requirements - NHS Mandate, NHS
constitution, NICE recommendations
ii. adverse impact on accessibility of service (e.g. location);  
iii. change to criteria for access that impacted on significant proportion of
population and/or a vulnerable population;
iv. unresolved divergence of clinical or professional view
v. significant divergence from policies of majority of other commissioners
(local and/or national)

“E.g. of how significance change in the way the CCG operates would be judge”
i. Significant alterations to range of responsibilities or accountabilities
of the organisation, the governing body or committees of the
governing body
ii. Alteration to the methods of delivery of the organisations
responsibilities and/or accountabilities, for example through
delegation of commissioning responsibilities and/or budgets to third
party organisations or joint committees

10.7 Documents can only be placed on the CCG Intranet/Internet by the Corporate
Governance Team, following approval by the delegated committee. The document
author must email the final document, with the completed Equality & Quality Impact
Assessment, to the Corporate Governance Team
([email protected]). Once received, the Corporate Governance
Team will check that all the required information has been provided and will upload
document onto the CCG intranet and/or CCG Internet.

11.0 REVIEW AND REVISION ARRANGEMENTS

11.1 Policy Review & Revising Documents

11.1.1 Documents will (usually) be current for a maximum of three years prior to review,
unless agreed otherwise. However new policies/SOP’s will be reviewed after 12
months. As an author you will be given three months’ notice, with a reminder sent out
one month prior to expiry of review date.

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11.1.2 Where a document is beyond its review date staff are expected to continue to follow
the principals contained within it and seek advice/guidance from the document
author/professional or Senior Management Team.

11.1.3 Any documents beyond their review date will be escalated to the Integrated Audit &
Governance Committee.

11.1.4 All reviews and revisions to any document must be approved in accordance with the
processes described within this policy. The review may be brought forward as and
when required in light of national developments, legislation changes or significant
events.

11.1.5 Minor policy revisions that do not significantly alter its purpose or content can be
agreed by the Senior Manager responsible – in these cases formal committee re-
ratification will not be sought.

11.1.6 All approved policies and SOPs will be available on the CCG intranet and/or CCG
internet. Attention will also be drawn to new policies via the CCG’s Global newsletter
circulated by our Communications Team to all staff. Policy authors may also want to
consider how else they want to communicate the policy e.g. staff training or briefing
sessions.

11.1.7 When a decision is taken by the CCG that materially effects an existing policy in
terms of its impact on the operation of the organisation and/or clients/service users
and patient services, that policy document should normally be revised and available
for uploading at the date of implementation of the decision. Where that is not
practicable, the old policy must be removed at the date of implementation, and a
statement put onto the CCG website clarifying why it has been removed and when
the new version will be uploaded. The maximum time that should elapse before that
new version is uploaded will be 21 working days. Any exceptions to this must be
approved by the Accountable Officer or Chief Operating Officer.

11.2 Version Control

11.2.1 It is essential that all ratified documents follow the CCG’s approved version control
process in order that they remain easily identifiable and categorised appropriately.

 New Documents

For the creation of a new document, or the amalgamation of existing documents

into one overarching document, a new document, Version 1.0, is created, and
this is indicated on the cover sheet of the document.

 Existing Documents

Documents already in existence, which are being reviewed and updated, take on
a new version number of the next number in sequence, i.e. Version 1.0 becoming
Version 2.0. All content of the front cover sheet must be deleted and completed
as the consultation, approval and ratification stages are completed so as not to
be confused with the previous process and the new version number applied.

 Draft Documents

All documents, either new or being updated, must clearly be marked as draft by
applying a watermark to the document, draft are numbered version 0.1, 0.2 etc
and indicating this on the front cover. Documents cease to be draft only after they
have been approved by the relevant committee. When a document has been

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 approved it should be numbered version 1.0 etc. At the point that the document is
disseminated via the Intranet, the ‘draft’ markings are removed from the
document.

11.2.2 Where there are only minor amendments that do not significantly alter its purpose or
content and there is no requirement to present these changes for approval, the
version number should be raised and the amendment explained in the version control
section of the cover sheet. The Corporate Governance Team should then be sent a
copy of the revised document.

11.3 Archiving

11.3.1 The archiving arrangements are the responsibility of the Corporate Governance
Team. . The old versions will be archived using the electronic archiving system.
Only approved versions will be archived, as these are the only policies by which the
CCG can be held accountable. Draft versions of a policy remain the responsibility of
the policy author and should be archived and destroyed according to the NELCCG
Records Management Policy, which is available on the CCG Intranet. The Corporate
Governance Team will maintain a register of all documents.

11.3.2 Archived documents may be requested at short notice and can be requested from the
Corporate Governance Team.

12.0 IMPLEMENTATION
12.1 The Integrated Governance & Audit Committee is responsible for formal approval of
this policy.

13.0 DISSEMINATION, ACCESS & TRAINING

13.1 This policy will be published on the CCG’s intranet and disseminated to all staff via
the CCG’s global newsletter.

13.2 There are no specific training requirements associated with this policy. Senior
Managers should ensure that authorship of a policy/procedural document is
delegated to a member of staff with appropriate seniority. Line managers should
ensure that members of staff with document development responsibilities within their
teams have the required skills to carry out these tasks. Line managers should also
brief staff of the existence of on new/updated procedural documents when
appropriate.

13.3 Any queries relating to the document control policy, should be directed to the CCG’s
Corporate Governance Team ([email protected])

14.0 REVIEW, MONITORING AND COMPLIANCE

14.1 The effectiveness of this policy will be monitored by the Corporate Assurance Officer
and reported to the Chief Finance Officer.

14.2 This policy may be reviewed at any time at the request of either staff side or
management, but will automatically be reviewed after the first twelve months and
thereafter on a 2 yearly basis from the date of approval or as and when statutory
changes are required.

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15.0 REFERENCES AND LINKS TO OTHER DOCUMENTS (for this policy)

 The NHS Litigation Authority’s Risk Management Standard for:

An Organisation-wide Policy for the Development and Management of
Procedural Documents
 Records Management code of practice for health and social care

16.0 APPENDIX A – Process for Policy Initiation

STAGE 1: Development

1. Inform Corporate Governance Team

2. Can this policy be incorporated into an existing policy (avoid duplication)

3. Completion of the Policy & SOPs Pre-Approval Checklist is highly recommended

(Appendix B)

4. Complete draft policy using standard template (Appendix C).

5. Complete Equality & Quality Impact Assessment (Appendix D)

STAGE 2: Consultation

1. Identify your stakeholders

2. Implement consultation
3. Support completion of EQIA (EQUIA Group)
4. If needs input from the Trade Union Partnership Forum, include this within the
consultation process
5. Use and include any feedback and update your policy and identify any risks

STAGE 3: Approval

1. Identify relevant decision making committee

2. Governance Team to gain approval and agree
3. Committee reviews/comments/recommendations sent back to Author of the policy
(if required)
4. Amendments made by author (if required)
5. Upload and communication policy accordingly

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 STAGE 4: Review / Monitoring

1. Monitor implementation
2. Start review process – author to be notified three months/one month in advance
prior to review date
3. Commence review and revision process
4. Repeat stages 2 & 3 if required

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