Procedural documents policy

1 Document summary

1.1 Purpose

This policy provides a structured framework for the creation, review, approval, and management of procedural documents within the trust. It ensures consistency, compliance with governance standards, and supports a restorative just culture. This policy covers policies, policy manuals, procedures, and emergency preparedness, resilience and response plans. Other document types (for example, strategies, patient group directors (PGDs), local working instructions) are referenced but not governed by this policy.

1.2 Document lifecycle

1. Review: triggered 6 months before expiry. Involves assessment, amendments, equality impact assessment (EIA), consultation, and submission for approval.
2. Approval: via designated approval groups. May be approved, conditionally approved, or rejected.
3. Publication: managed by Corporate Assurance; authors verify accuracy.
4. Amendments:
   • major: follow full review process.
   • minor: contact head of corporate assurance
5. Extension or removal: requires approval group decision and documented rationale.

1.3 New document development

• Initiated by accountable directors.
• Requires justification, consultation, and use of approved templates.
• Requires approval by executive directors via head of corporate assurance.

1.4 Consultation

• Mandatory for all procedural documents.
• Includes subject-matter experts, internal stakeholders, and patient voice.
• Recorded in the tracking document.

1.5 Responsibilities

• All staff: must access, understand, and comply with relevant documents.
• Authors: ensure quality, consultation, and timely review.
• Corporate Assurance and Clinical Effectiveness teams: oversee process, provide support, and maintain systems.
• Approval groups: validate consultation, approve documents, and set review timelines.

1.6 Monitoring and compliance

• Regular audits and reviews by the head of corporate assurance.
• Non-compliance escalated through reminders and line management.

2 Introduction and aim

The trust’s suite of policies, procedures, and business continuity plans provide colleagues with consistent guidance to carry out their roles safely, effectively, and in line with best practice. These documents clarify expectations, authority, and responsibilities, supporting smooth service delivery and compliance with governance standards.

The procedural document policy has been developed to:

• provide an approved framework and templates for the creation, review, and management of procedural documents
• set out the arrangements for the control of procedural documents essential for compliance with governance standards
• promote standardisation in the provision of safe and effective care and the management of risk

The procedural document policy establishes a hierarchy and categories of trust procedural documents with supporting documentation and sets out the requirements and the standards for each step of the development, deployment, monitoring and revision of these documents.

2.1 Types of procedural documents

2.1.1 Strategy

A long-term plan of action (3 to 5 years) outlining how the trust will achieve strategic goals and reach the intended outcome.

These documents are published on the website.

2.1.2 Policy

Policies are concise, formal statements of principles that indicate how the trust will act in a specific area of operation.

Policies regulate and direct actions and conduct. In the absence of a trust-defined policy, any existing legislation, regulation, standards, statutes or rules, constitute the policy.

These procedural documents are accessed through the trust’s quality assurance system under the document section policies and procedures.

2.1.3 Policy manual

A collection of policies and procedures combined to reduce duplication and aid access. Used where multiple linked processes are best managed together.

Development of manuals are to be undertaken with support from the Corporate Assurance team and or the clinical effectiveness support officer as appropriate.

2.1.4 Procedure

Procedures describe step-by-step instructions for implementing a policy.

It focuses on process rather than the result.

They are accessed through the trust’s quality assurance system under the document section policies and procedures.

2.1.5 Emergency preparedness, resilience and response plans

Emergency preparedness, resilience and response plans provide a structure to ensure the resilience of an organisation to any eventuality, to help ensure continuity of service to key users, patients or service users.

These procedural documents are accessed through the trust’s quality assurance system under the document section policies and procedures.

2.1.6 Patient group directions

Authorises supply of prescription only medicines (POMs) to groups of patients, without individual prescriptions. Registered colleagues using patient group directions (PGDs) should be sufficiently trained to supply and administer POMs.

Approved and or adopted at the trust medicines optimisation group.

These procedural documents are accessed through the trust’s quality assurance system under the document section patient group directives.

2.1.7 Local working instructions

Department or service specific documents outlining local processes.

Best practice is to follow the procedure template, labelled clearly as local working instruction.

These documents are held locally and should be made available on the intranet under the relevant department.

Please note, for the purposes of this policy, the terms procedural documents will refer only to policies, policy manuals, procedures, and business continuity plans.

3 Procedure

3.1 Review of a procedural document

Six months prior to the procedural document review date the author will be reminded via the quality assurance system that the document is coming up for review. A weekly email from the quality assurance system will be received reminding the author of all tasks that are coming up or due for action.

Please note: all reviews (including where no changes are required) must be submitted to and approved by the relevant approval group.

3.1.1 Step 1 initial review by author

The author must assess whether the document:

• remains required, or should be withdrawn from circulation
• could be merged into another existing policy
• is in an accessible format (see appendix B writing style guidance)
• requires specialist support:
  • clinical effectiveness lead for clinical documents
  • Corporate Assurance team for all other procedural documents

3.1.2 Step 2 document amendments

Apply all changes using track changes, coloured font, or equivalent tools to ensure visibility during consultation.

3.1.3 Step 3 equality impact assessment (policies only)

• Review and update the equality impact assessment conducted at the last review or during development, support is available from equality and diversity lead.
• Please refer to equality impact assessment template and guidance.

3.1.4 Step 4 tracking document

Complete the relevant sections of the tracking document up to consultation journey section, please refer to appendix G tracking document template and guidance.

3.1.5 Step 5 consultation

Circulate the revised procedural document (with visible changes), and revised equality impact assessment and tracking document out (if applicable) for consultation, setting a deadline for responses (generally 2 weeks). Please refer to section 3.6 below.

3.1.6 Step 6 update after consultation

• Amend the master copy of the document as required.
• Update the consultation Journey section of the tracking document with:
  • comments received
  • author’s responses
• Ensure sufficient, robust consultation has taken place before proceeding (see section 3.6).

3.1.7 Step 7 submission to Corporate Assurance team

• Send the final draft, updated tracking document, and equality impact assessment (EIA) to: rdash.corporate-assurance@nhs.net.
• Corporate Assurance team will:
  • check compliance with process
  • forward paperwork (see appendix H cover sheet guidance) to the approval group administrator
  • request inclusion on the agenda

3.1.8 Step 8 approval group meeting

The author must attend the meeting to:

• outline the procedural document
• summarise changes made
• respond to questions

The approval group will assess the presented procedural document and ensure that:

• appropriate consultation has taken place
• the monitoring arrangements are robust and appropriate

Outcome from approval group:

• approved: Corporate Assurance team processes the procedural document, tracking document and the equality impact assessment (or Clinical Effectiveness team where applicable)
• approved subject to changes: author must resubmit amendments to the procedural document and resubmit to Corporate Assurance team within two weeks for publication along with updated tracking document and equality impact assessment
• not approved: make changes requested and re-submit to the next meeting of the approval group, support will be provided by the Corporate Assurance team and or the Clinical Effectiveness team as appropriate

Please note: should the approval group not be quorate at the time of the meeting then approval can be sought virtually and can be approved via this method if sufficient responses are received that meet the quoracy level.

As part of the ratification, the approving group will set the timescale for the next review for three years unless otherwise stated, with a maximum period of five years.

3.1.9 Step 9 post approval actions

The Corporate Assurance team will process the approved document within one week:

• file in the document library
• upload and record monitoring details in the quality assurance system
• notify the author of publication and advise that the document should be checked for accuracy and legibility

The author must then:

• check that the document is published accurately and legibly
• confirm that appendices (forms, letters, templates) are usable
• provide feedback to the Corporate Assurance team where necessary rdash.corporate-assurance@nhs.net

Please note:

• all procedural documents remain in force until formally superseded and ratified by the relevant approval group
• early reviews may be required due to:
  • internal service redesign or practice change
  • updated national and or regional guidance or legislation changes

In such cases, the full review process (steps 1 to 9) must be followed.

3.2 Extension requests

An extension may be requested if a procedural document cannot be reviewed before its expiry date.

Step 1: complete sections 1 and 2 of the tracking document, please refer to appendix G tracking document template and guidance.

Step 2: send the tracking document to the Corporate Assurance team who will check that the correct process has been followed and send appropriate paperwork (see appendix H, approval group cover sheet guidance) to the administrator of the approval group and request it is an agenda item.

Step 3: attend the relevant approval group meeting and provide an outline of the reason for extension and answer any questions the group may have.

The approval group will assess the extension request taking into account any previous extensions and will make one of the following decisions:

• approved: tracking document to be processed by corporate assurance team (via clinical effectiveness team for documents approved by the clinical effectiveness meeting)
• not approved: undertake any recommendations made by the approval group, support will be provided by the corporate assurance officer or clinical effectiveness lead or support officer as appropriate.

Please note: should the approval group not be quorate at the time of the meeting then approval can be sought virtually and can be approved via this method if sufficient responses are received that meet the quoracy level.

Step 4: if approved, corporate assurance team will process within one week (on receipt for those documents approved by the clinical effectiveness meeting):

• file in the document library
• upload and complete the monitoring details on the document section of the quality assurance system
• advise the author that the extension has been processed

3.3 Amendments

There are two categories of amendments.

Major amendment: defined as a significant change in roles, responsibilities, scope or process that is required to be undertaken.

For all major changes the author should also check the procedural document to ensure that all the content remains appropriate and current. Where there is a change in role or responsibility the policy author check that the individual or team inheriting the responsibility is aware and in agreement.

Major amendments are classed a document review and should therefore follow the process outlined above in section 3.1, review of procedural documents.

Minor amendment: defined as no significant change made to the process. Such as (this is not a definitive list):

• a correction of a spelling mistake
• expanding an acronym
• amendment to contact person or details
• rewording of a sentence for clarity
• inserting a link outlined in the procedural document

Guidance to be sought from the head of corporate assurance to confirm the change is minor.

3.3.1 Minor amendments

The author should take the following steps for the minor changes to be made:

Step 1: ensure any changes are visible using track changes, change in font colour or a similar function.

Step 2: complete the sections 1 of the tracking document, please refer to appendix G tracking document template and guidance.

Step 3: send to corporate assurance team to agree changes are minor and can be made without approval by an approval group. The Corporate Assurance team will then:

• file in the document library
• upload and complete the monitoring details on the quality assurance systems
• advise the author that the changes have been made and that the document has been published

Please note: for all minor amendments there will be no change to the review date.

3.4 Removal of a procedural document

A procedural document may be withdrawn from circulation if the author considers it’s no longer required. This needs to be discussed with the accountable director who has been allocated the procedural document and explore:

• why is it no longer needed?
• is the content covered elsewhere?
• are there any associated risks if the document was to be removed?

If removal is supported by the accountable director, the following steps should be taken:

Step 1: complete the sections 1 and 2 of the tracking document, please refer to appendix G tracking document template and guidance.

Step 2: send tracking document to the Corporate Assurance team rdash.corporate-assurance@nhs.net who will check that correct process has been followed and send the appropriate paperwork (see appendix H approval group cover sheet guidance) to the administrator of the approval group and request it is an agenda item.

Step 3: attend the relevant approval group meeting and provide an outline of the reason for removal request and answer any questions the group may have.

The approval group will assess the removal request and will make one of the following decisions:

• approved: Corporate Assurance team will process within 1 week, (on receipt for those documents approved by the clinical effectiveness meeting)
• not approved: undertake any recommendations made by the approval group

Please note: should the approval group not be quorate at the time of the meeting then approval can be sought virtually and can be approved via this method if sufficient responses are received that meet the quoracy level.

Step 4: if approved the Corporate Assurance team will process within one week (on receipt for those documents approved by the clinical effectiveness meeting):

• file in the document library and archive
• archive the on the quality assurance system
• advise the author that the document has been removed

3.5 New subject not covered by existing procedural document

The decision to develop a new procedural document initially rests with the relevant accountable director, before being presented to the appropriate approval group.

If an individual identifies the need for a new procedural document, they should follow the steps below:

Step 1: check for existing documentation. Before proceeding, ensure that no existing document already covers the subject. Check the following sources:

• the Royal Marsden suite of policies (clinical nursing procedures referred to by the trust)
• any collaborative, multi-agency, or regional policy the trust has adopted
• contact the Corporate Assurance team to check the trust’s procedural library
• for clinical documents, speak to the clinical effectiveness lead for advice

Step 2: discuss with the accountable director. Gain support from the relevant accountable board director (if unsure please query with either the head of corporate assurance of clinical effectiveness lead) by discussing:

• the justification for the new document
• how it aligns with service priorities
• whether it could be extended to cover other services or the wider trust
• whether implementation is feasible within current resources
• if the document is recommended by an external body (for example, Care Quality Commission)

Step 3: submit a request. If supported, complete the new procedural document request form (see appendix D) and send it to the head of corporate assurance.

Step 4: review and decision. The head of corporate assurance will:

• review the form for completeness
• confirm that checks in step 1 have been completed
• meet with at least two members of the executive group (including the director of corporate assurance) to make a decision

If the decision is not to proceed, feedback will be provided to the requester and the accountable director.

3.5.1 Approval to develop a new procedural document

If approved, the accountable director for the newly proposed document will identify an author to develop using the appropriate template:

• appendix E policy and procedure template and guidance
• appendix F procedure template and guidance

The author must ensure the document:

• is written clearly and concisely, using unambiguous language
• is in an accessible format for colleagues
• considers relevant legislation and guidance, where legal uncertainty exists, consult the accountable director, who may seek advice from trust solicitors
• does not infringe copyright permissions
• assesses risks and potential adverse consequences, with guidance on mitigation
• identifies training implications and discusses with the head of learning and development
• considers fraud risks and consults the local counter fraud specialist
• for policies, outlines monitoring mechanisms, such as:
  • incident reporting (consult the incident reporting system manager)
  • clinical audit (consult the clinical effectiveness lead)

Refer to appendix B writing style guidance for further support. Clinical effectiveness support officer (for clinical documents) and Corporate Assurance team (for all documents).

3.5.2 Drafting and consultation process

Once the initial draft is complete, follow these steps:

3.5.2.1 Step 1: equality impact assessment

Complete the equality impact assessment using the template and guidance. Contact the equality and diversity lead for further support.

3.5.2.2 Step 2: tracking document

Complete sections 1 to 3 of the tracking document (see appendix G).

3.5.2.3 Step 3: consultation

Send the draft document and equality impact assessment out for consultation, setting a deadline (typically 2 weeks). Refer to section 3.6 and appendix C.

3.5.2.4 Step 4: update document

Incorporate feedback received during consultation. Update the master copy and section 3 of the tracking document with comments and responses. Ensure robust consultation before proceeding.

3.5.2.5 Step 5: submit for approval

Send the final draft, updated tracking document, and completed equality impact assessment to the head of corporate assurance, who will:

• verify the process has been followed correctly
• submit the paperwork (see appendix H cover sheet guidance) to the approval group administrator for inclusion on the agenda

3.5.2.6 Step 6: attend approval group

Attend the meeting (or nominate a deputy) to present the document, explain its purpose, and respond to questions.

The approval group will assess:

• whether the document meets required standards
• whether appropriate monitoring and consultation have occurred

Outcomes:

• approved: Corporate Assurance team processes the document (via Clinical Effectiveness team if applicable)
• approved with changes: amend and return within 2 weeks
• not approved: make requested changes and re-submit, support will be provided as needed

Please note: if the group is not quorate, virtual approval may be sought if sufficient responses meet quoracy requirements.

The group will also set a review timescale (typically 18 to 24 months for new documents).

3.5.2.7 Step 7: publication

If approved, the Corporate Assurance team will:

• file the document in the document library
• upload and complete monitoring details in the quality assessment system
• notify the author of publication and remind of the authors responsibility to review the document in line with process (3 yearly review, change in legislation)

The author should verify that:

• the document is published correctly
• it is legible and accessible
• appendices (for example, forms, letters, templates) are usable

Feedback should be sent to rdash.corporate-assurance@nhs.net.

3.6 Consultation

3.6.1 Why consultation matters

Consulting with colleagues, trade unions, committees, relevant groups and external stakeholders is essential when developing or reviewing procedural documents. Effective consultation helps ensure documents are accurate, practical and successfully implemented.

3.6.2 Who to involve

The document author should decide which stakeholders to involve, in consultation with the responsible director or senior manager. This decision depends on the nature and scope of the document being developed or reviewed.

Important: a procedural document will not be approved unless appropriate consultation has taken place and responses have been received.

3.6.3 Consultation stages

Consultation should be carried out in two stages. Depending on the complexity of the document and the extent of changes made:

• it may be appropriate to undertake both stages at the same time
• it may need to be circulated more than once at either stage.

Therefore, sufficient time should be allowed for consultation before submitting the document for approval, considering the renewal or launch date when planning timelines.

3.6.3.1 Stage 1: subject-matter experts and working groups

This stage ensures the document is accurate, legally compliant and operationally sound. Consult with subject-matter experts and working groups. See appendix C for further examples.

3.6.3.2 Stage 2: internal colleagues and mandatory specialists

This stage ensures the document is understandable, and practical to implement. Consult with colleagues who will use the document in practice. Also include any departments or services affected by its implementation. The following mandatory specialists should also be included in this stage:

• counter fraud specialist, to ensure fraud risks are addressed
• Mental Capacity Act lead, to ensure capacity-related content is accurate
• head of learning and development, to confirm training requirements and availability
• head of safeguarding to ensure safeguarding legislation and guidance has been taken into consideration
• clinical effectiveness lead, (for clinical procedural documents), to ensure consistency and correct use of templates
• Corporate Assurance team, (for all other procedural documents), to ensure consistency and correct use of templates
• digital accessibility developer, to ensure the document meets accessibility standards

3.6.3.2.1 How to circulate for consultation

At both stages outlined above, on circulation to appropriate internal stakeholders the author should include:

• a clear deadline for responses (usually two weeks)
• a named contact for responses
• a request for a response, even if it is “no comment”
• a short explanation of the consultation type
• new document: include background and purpose
• scheduled review: highlight key changes
• early review: explain why it is being reviewed early and outline key changes

Example emails are available in appendix C.

3.6.3.3 Stage 3 patient voice

The patient voice is to be included in the review and development of all procedural documents and will be facilitated by the author through the corporate assurance team. The author is responsible for providing an outline of the procedural document around (template available at appendix I):

• why it is needed,
• what it is aiming to cover
• the audience it is for

This will be issued to the patient stakeholder group for identifying interested parties and facilitating a discussion group. This group will be attended by the corporate assurance team with the policy author.

3.6.4 Recording

All consultation undertaken is to be recorded in consultation journey section of the tracking document including:

• who has been included in the process
• all responses received and the author’s response to each comment including any changes made
• if suggested changes are not actioned, then the rationale is to be recorded as to why it is not appropriate

3.7 Awareness raising

Once a procedural document has been approved, the Corporate Assurance team will issue communication via the staff app update.

Where there has been a significant change in process or a new process has been established additional communication should be arranged by the author to the relevant colleagues in order to support the successful implementation. If training is impacted, the author should liaise with the Communications team and learning and development to ensure appropriate actions are taken.

4 Responsibilities

4.1 All colleagues

All colleagues have a responsibility to work in line with the trust’s ratified procedural documents and should:

• be aware of how to access them
• be aware of those which are relevant to their area of work
• act in accordance with them
• attend any training which is offered in relation to them
• report to their manager any issues affecting compliance with them, in order that these can be taken account of

Assignment and notification: colleagues will be notified via the quality assurance system of their designated cohort of procedural documents (and will, from time to time, receive updates or notifications when policies are updated or refreshed). These are procedural documents that are most pertinent to their respective roles.

Confirmation of readership: colleagues will be required to confirm through the notification system that they have read and understood the designated cohort of procedural documents.

Monitoring and compliance: the head of corporate assurance will monitor compliance with this requirement. Non-compliance will, in the first instance be via reminders from the quality assurance system, but will escalate to line managers and responsible directors, but the emphasis for compliance is with colleagues own personal responsibility.

4.2 Management of procedural documents

While the trust governance arrangements aim to provide a co-ordinated approach to the development of procedural documents throughout the organisation, there are individuals who have specific responsibilities and duties in relation to the management of procedural documents as detailed below.

4.2.1 Procedural document authors

Procedural document authors are responsible for:

• ensuring the document does not duplicate any existing document within the procedural document library
• are in line with any national subject-matter documents
• writing the document in the approved style and format, ensuring it is legible and appendices are usable (for example, editable forms)
• identifying any implementation needs
• liaising with the head of learning and development to assess how best to address learning needs
• taking remedial action where monitoring highlights failures in implementation or compliance
• initiating early reviews in response to:
  • internal feedback (for example, changes to practice, service redesign)
  • national or regional guidance or legislative changes
• ensuring appropriate consultation is undertaken
• reviewing and ratifying documents in line with agreed review dates, allowing time for consultation
• for documents that have had significant change or key process changes the author should ensure clear communication has been issued to colleagues affected following publication of an approved document

Please note that transfer of authorship will only be completed with the agreement of the proposed new author.

4.2.2 Head of learning and development

Head of learning and development is responsible for:

• considering training implications identified by authors
• planning appropriate training programmes in close liaison with managers
• reviewing procedural documents during consultation to ensure inclusive language is used and that documents align with this policy

4.2.3 Equality and diversity lead

Equality and diversity lead is responsible for:

• advising authors on completing equality impact assessments (EIAs).
• approving equality impact assessments before final document approval
• reviewing procedural documents during consultation to ensure equality impacts have been addressed

4.2.4 Corporate Assurance team

Corporate Assurance team is responsible for:

• coordinating reviews of corporate procedural documents through to approval under clinical leadership executive (CLE) sub-groups, this includes checking mandatory consultation has taken place and formatting requirements are met
• reviewing procedural documents during consultation to ensure compliance with this policy
• monitoring the approval process to ensure it aligns with this policy, liaising with approval group chairs as required
• maintaining an effective system for procedural document control
• providing advice and guidance to colleagues, particularly corporate policy authors and leads on document development and review

4.2.5 Clinical effectiveness lead

Clinical effectiveness lead is responsible for:

• providing support, advice and guidance to clinical policy authors, leads, and clinical colleagues during document development and review
• reviewing clinical procedural documents during consultation to ensure compliance with this policy

4.2.6 Clinical effectiveness support officer

Clinical effectiveness support officer is responsible for:

• coordinating reviews of clinical documents through to approval under the clinical effectiveness meeting (CEM), this includes ensuring consultation and formatting requirements are met before forwarding for publication
• providing support, advice and guidance to clinical policy authors, leads, and colleagues as required
• reviewing clinical procedural documents under the remit of clinical effectiveness meeting to ensure compliance with this policy

4.2.7 Accountable directors

Accountable directors are responsible for:

• upholding the requirements of this policy
• identifying an author for the development or review of procedural documents
• ensuring all trust procedural documents within their remit remain current

4.2.8 Approval groups

Approval groups are responsible for:

• ensuring all procedural documents within their remit are reviewed, approved, and reported in line with this policy
• confirming appropriate consultation has taken place prior to approval
• ensuring monitoring arrangements are identified within policies before approval
• making further recommendations as appropriate
• considering and approving extensions to review dates
• approving the removal of procedural documents within their remit

5 Training implications

There are no specific training needs in relation to this policy. However, colleagues must be familiar with its contents, as well as any individual or group responsibilities identified for implementing it.

6 Monitoring arrangements

6.1 Monitoring compliance: sample check

Monitor compliance with style and format, explanation of any terms used, consultation process, approval process, associated documents, supporting references.

• How: sample check of register database of documents.
• Who by: head of corporate assurance.
• Reported to: director of corporate assurance.
• Frequency: annually.

6.2 Monitoring compliance: review of all documents

Monitor compliance with style and format, explanation of any terms used, consultation process, approval process, associated documents, supporting references.

• How: review of all procedural documents as part of the consultation process.
• Who by: Corporate Assurance team.
• Reported to: procedural document authors.
• Frequency: as part of consultation process.

6.3 Monitoring compliance: control of documents

Control of documents, including archiving arrangements.

• How: sample check of register database of documents.
• Who by: head of corporate assurance.
• Reported to: director of corporate assurance.
• Frequency: annually.

6.4 Monitoring compliance: review arrangement

• How: report on the management of procedural documents detailing; documents reviewed and approved; scheduled for review; exception report on policies exceeded their review date.
• Who by: head of corporate assurance.
• Reported to: applicable approval groups.
• Frequency: 3 times a year.

7 Appendices

7.1 Appendix A approval groups

The responsibility for approval of procedural documents is the board of directors, however the majority have been delegated to the clinical leadership executive, with the exception of the following:

• reservation of powers and scheme of delegation (including standing orders)
• standing financial instructions
• risk management framework
• risk appetite framework

The clinical leadership executive (CLE) retains the authority for the approval of all other procedural documents and from time to time will receive and approve procedural documents. However, in the main, CLE delegates to its subgroups the responsibility for the review and approval of the procedural documents within its remit.

The clinical leadership executive subgroups are:

• Risk Management Group
• Operational Management Group
• Digital Group
• People and Teams Group
• Estates and Sustainability Group
• Finance Group
• Research and Innovation Group
• Equity and Inclusion Group
• Education and Learning Group
• Quality and Safety Group, due to the high volume of documents under the remit of safety and quality, approval will be supported by its feeder groups

7.2 Appendix B writing style guidance

Content should follow the style guidance of NHS digital style guide. For any further style guidance not listed within the guide please use the GOV.UK style guidance as this is the basis of the NHS digital style guidance.

7.2.1 Layout

7.2.1.1 Fonts, spacing and paragraphs

• Arial 12pt text (point) font is generally accepted in the NHS.
• Left justify writing.
• Single line spacing, only use 1.5 line spacing for leaflets.
• The daily email is single line spacing.
• Use only one space after a full stop, not two.
• Use one space after a comma, colon and semi-colon.
• Paragraph indentation and spacing should be set at 0pt.

7.2.1.2 Headings

Headings are important to all users for reading content. However, headings are especially important for users who rely on screen readers as they convey the structure and importance of the content.

Heading 1 should be used for the title page. Ensure that all headings follow the correct nesting order and do not skip levels for example:

Heading 2

• Heading 3

• Heading 3

Heading 2

• Heading 3

  • Heading 4

7.2.1.3 Tables and text boxes

• For accessibility reasons, tables and text boxes should only contain numerical data and statistical information
• They need to have headings for columns and rows as appropriate for this very reason as they are tabular data.
• Never merge cells in tables, this makes navigation very confusing for screen readers as rows and columns have inconsistent numbers of cells so will not line up with headings.
• They should not be used to highlight key sections of text or to list the names of people, committees, teams or organisations, bullet points are more appropriate.

7.2.2 Grammar

7.2.2.1 Apostrophes

7.2.2.2 Singular and plural: ‘s or s’?

The apostrophe s is used to indicate possession. It goes after the thing doing the possessing. Use it before the s when the thing doing the possessing is singular and after the s if the thing doing the possessing is plural, for example: one week’s notice; two weeks’ notice; the patient’s care (one patient); the patients’ care (more than one patient).

Exceptions: if the thing doing the possessing is already pluralised, for example: people and women, put the apostrophe before the s, for example: The men’s toilet; children’s services.

7.2.2.3 Colons and semi-colons and lists

Our preferred style of list is to use a list with a lead-in sentence. This should be introduced with a colon and in British English unless a proper noun, all items on the list after the colon should begin with a lowercase and have no full stops, for example: the recipe needs three things:

• flour
• sugar
• butter

List without a lead-in should be sentence case, therefore should start with a capital letter and end with a full stop.

Reported speech: use a colon when introducing a complete quote, for example: The spokesman said: “We were delighted to help.”

7.2.2.4 Hyphens

• Hyphenate two words that when used together have a different meaning than when used separately, for example. patient-led; carer-focused.
• Use to avoid clashes of letter, for example. blue-eyed is hyphenated; redeye is not.
• Do not hyphenate words with the prefix re, except to avoid a clashing “e” for example.
  re-elect is hyphenated; refurbish is not.
• Do not hyphenate inpatient or wellbeing.
• Hyphenate ages, for example. A seven-year-old child; a 100-year-old coin.

7.2.3 Style

7.2.3.1 Inclusive language guidance

Language is powerful and it can help to shift attitudes and behaviours. Inclusive language can help to promote and embed equality, diversity and inclusion. We need to practice empathy and consider the impact of the words and phrases we use on the experience of others. Everyone has different individual personal preferences about language and identity. Language is always evolving and changing. This means there are no definitive rules but understanding some key principles will help you adopt an inclusive approach on a day-to-day basis.

7.2.3.2 What if I get it wrong?

For some of us communicating in a more inclusive way is about changing deeply embedded habits and it will take time. It is okay to make mistakes. Apologise, correct what you have said, learn from the mistake and work to communicate more inclusively next time. Repeated mistakes indicate a lack of respect and can be very distressing.

7.2.3.3 Use of Plain English

All NHS written communications should be clear, concise, honest and open. Due to the complex subjects we deal with, the words we use need to be as simple and accessible as possible. This means they need to be:

• free of jargon
• as far as possible, free of acronyms, acceptable acronyms include:
  • NHS
  • RDaSH
  • GP
• avoid all acronyms unless the reader needs to know the acronym
• free of overly technical language

7.2.3.4 Common pitfalls

Use the most commonly known, plain English words, for example:

• begin or start, not commence
• help, not assist
• need, not require
• people, not individuals
• use, not utilise
• move, not mobilise
• change, not amend
• while, not whilst
• among, not amongst
• in, not within (unless it is actually inside something)

7.2.3.5 Repetition

Avoid unnecessary repetition, for example: We are here to provide help and guidance is commonly used but only help or guidance is necessary because they are much the same thing. A short summary should be a summary; a pair of twins should be twins.

7.2.3.6 Contractions

Avoid contractions such as don’t, isn’t, can’t in written work, except in direct quotes. Spell it out: Do not; is not; cannot.

7.2.3.7 English and American

Use English versions of words rather than American for example: realise not realize.

7.2.3.8 Capital letters

Minimise the use of capital letters; they are often overused.

• Always use sentence case, even in page titles, headings and service names, the exception to this are proper nouns, for example:
  • departments: the Civil Service
  • buildings: Tickhill Road Hospital, Swallownest Court
  • place names: Rotherham, Doncaster and North Lincolnshire
  • brand names: SystmOne, Radar
  • legal acts and legislation: Mental Health Act, General Data Protection Regulation
  • faculties, departments, institutes or schools: Health Research Authority, National Institute for Health and Care Excellence
  • names of groups, teams, directorates and organisations: Communications team (lowercase team), Children’s Care Group, Corporate Directorate, Ofsted, Care Quality Commission
  • names of specific, named government schemes: NHS Low Income Scheme
  • specific committees: Finance, Digital and Estates Committee
• Avoid capitals for general references for example, Our governors; each care group; the commissioners.
• Job titles have initial capitals only when the title is a specific one, for example, The Chief Executive; Chief Executive Joe Bloggs. Do not use capitals for generic job titles, for example, “the nurses on the ward”; “the doctors agreed”.
• Organisations have initial capitals only when the name is specified, for example, “a South Yorkshire Police spokesman said…”. In general references, do not use capitals, for example. We are working in partnership with the police.
• Use lower case “t” for our trust and foundation trust, unless you are giving the full name of a foundation trust, for example: Anytown NHS Foundation Trust.

7.2.3.9 Singular and plural

• Treat collective nouns: companies, governments and other bodies – as singular for example the trust is; the public expects
• Be consistent, for example, do not say “the team is running a course” (which is correct) followed by “and they are hoping that it will be useful” (which is incorrect and inconsistent with the first part of the sentence).

7.2.3.10 Numbers

• We use numerals for numbers, including1 and 2 for statistics, time, measurements, lists and steps, for example, measurements such as dosages we use “200mg” not “two-hundred milligrams”. People find numerals easier to read and they scan for them.
• The same rule works for ordinal numbers: (8th, 9th, 10th, 11th). We do not use superscript, for example “8th”.
• For numerals over 999, insert a comma for clarity, for example, they raised over £2,000.
• For phone numbers, use structure phone numbers, for example, “0XXX XXX XXX” is much easier compared to “0XXXXXXXXX”.
• Avoid using percentages if possible, avoid 50%, it is much easier to understand if you say 1 in 2 or half.

7.2.3.11 Time

Use the 12-hour clock with a colon, followed by am or pm, with no spaces, for example 8pm; 6:30am. Avoid unnecessary zeros, for example, 8:00pm. Use midnight instead of “0:00” or “12am”, and use midday instead of “12noon” or “12pm”.

7.2.3.12 Dates

• Put the day before the month, for example. Friday 12 April 2013 if you are also writing the year.
• If you don’t have a year, it’s 12 April.
• Do not include suffixes after the day, for example. 20th.
• Do not use “of”, for example The 19th of June, should be 19 June.

7.2.3.13 Decades

Do not use an apostrophe before the s, for example, 1960s, not 1960’s.

7.2.3.14 Acronyms

• Use acronyms without explaining what they stand for only when they are well known, for example NHS; UK; DVLA; US; EU; VAT; MP.
• In all other cases, the first time you use an acronym, explain it in full, followed by its initials which should be in brackets. for example, Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH). Best practice is to repeat this in each section of your document to help the reader as they not remember what the acronym stands for.
• Do not use full stops in abbreviations, UK not U.K.

7.2.3.15 Bullet points

Start each bullet point with a capital letter. An exception to this rule is a bullet point list preceded by a follow-on sentence, for example.

• A portion is:
  • 80g of fresh, canned or frozen fruit and vegetables
  • 30g of dried fruit
• Do not put “or”, “nor” or “and” after the bullets.
• Without a lead in sentence each bullet point should have a full stop. As they are separate points.

7.2.3.16 Quotation and speech marks

• Use double in all other instances, for example, the article refers to “all medicines used in the treatment of psychosis.”
• Use single quotation marks for quotes within a quote: “‘Helicopter parenting’ linked to behavioural problems in children”

7.2.3.17 Emphasis: italics, bold, capitals or underlines

• Do not underline text, it is commonly accepted that underlined text is a link and this can be confusing for all users.
• Italics should be avoided as text can be difficult to read, especially for some people with reading disabilities like dyslexia. Use bold text instead to emphasise the desired words.
• Bold text should be used to emphasise a word or words in a sentence. Use bold sparingly as too much bold text makes it difficult for users to know which parts of your content they need to pay most attention to. NHS Digital tend to use bold to highlight specific instructions to give them emphasis, for example: select More, then select Messages.
• Avoid using capitals for entire words as it can appear aggressive. Block capitals can be difficult to read for all users.

7.2.3.18 Symbols

• Use per cent instead of % unless it is in a table.
• Always use and unless the ampersand (&) is part of a recognised name or abbreviation, for example, A&E; and M&S.
• Exclamation marks (!) tend to be overused and can be seen as aggressive in tone. Only use an exclamation mark when something amusing or surprising has been expressed. Only one exclamation mark or question mark is necessary.
• The use of slashes (/) is very common and should be replaced with or, for example:
  • “and /” to “and, or”.
  • “cats/dogs” to “cats or dogs”

7.2.3.19 Images

A number of issues can be caused by images, which can sometimes be difficult to address, therefore, it is recommended that images are only used where necessary. For example, images containing information:

• cannot be read by screen readers
• can be difficult to read on mobile phones and smaller screens
• with insufficient contrast can be difficult to read for certain users
• that are poor quality can be difficult to read

Alt-text should be used to describe or give meaning to an image. However, alt-text will only address some screen reader issues. The other previously stated problems stated apply to all users and should be considered as well within an image. When using alt-text, it should only be a short description. It should be very a direct description of the image meaning. It doesn’t have to describe the visual characteristics of the image but it must convey the meaning of the image.

Here are some examples of when and how to use alt-text, based on the purpose of the image.

7.2.3.20 Logos

When assigning alt-text to logos, there is no need to write the word “logo”. Instead write the actual text contained in the logo.

For example, the RDaSH logo should have the alt-text “Rotherham Doncaster and South Humber NHS Foundation Trust”.

Alt-text can be assigned to an image in Microsoft Word by right-clicking the image, then selecting View alt-text.

7.2.3.21 Image

All non-decorative images should have alt-text that should always convey the information within the image. For example, if it is a picture of a person smiling, if you need to show the meaning that they are happy give it the alt text “Person smiling” otherwise “Person” would be more appropriate.

7.2.3.22 Diagram and flowcharts

In the case of diagrams and flowcharts this meaning is far too large to describe with just at-text, it is best practice to mark the image as decorative (see decorative image) and provide a description of the diagram or flowchart in the surrounding text.

7.2.3.23 Images containing information

Wherever possible, images should not be used to convey information. This information is intended to be read, so serve it as text, for example, flowcharts and diagrams can often be represented as a numbered list.

For example, if you have an instructional picture of how to do an exercise, it can be marked as decorative as long as it has an adjacent text description of the meaning described in the image. This ensures that people who are unable to access the image because of barriers such as, visual impairments (blindness, low vision, colour blindness), cognitive impairments, language barriers (you can easily translate text within an image) or technology barriers (the image is unable to load) can still understand the meaning contained within the image.

Some advantages to using text include:

• screen reader users will have access to all the information
• text will reflow (wrap) when users zoom in to make the content bigger, avoiding the need to scroll in 2 dimensions
• the text can be read by search engines, like Google and Bing, which makes it easier to find the content in searches, this also applies to the local search facilities of individual websites.

7.2.3.24 Decorative images

Images used for decoration do not add information to the content and therefore may not need alt-text. Because decorative images do not add any information to the content, consideration should be made whether it is necessary to keep.

An image can be assigned as decorative in Microsoft Word by right-clicking the image, then selecting View alt-text, and then clicking Mark as decorative.

7.3 Appendix C consultation

7.3.1 Stakeholder examples for guidance

It is important that we prepare our documents through consultation with the contributions of colleagues including our patients and carers. A process has been established with our community partner that will facilitate this. The central corporate assurance team will, for most documents, but especially those that have greatest involvement or impact on patients and carers, undertake this engagement process, which must be completed before approval by the respective group and therefore authors must bear this in mind as they progress through the processes outlined below.

Any procedural document that will have impact on working practices and patterns of work for colleagues, should include consultation with the Policy Forum via the deputy director of human resources and learning.

7.3.1.1 Clinical general documents

7.3.1.1.1 Stage 1

• Mental Health Act manager.
• Patient Safety team.
• Patient Experience team.

7.3.1.1.2 Stage 2

• Selection of service managers from across each clinical directorate for identifying colleagues to be part of consultation.
• Mandatory specialists.

7.3.1.2 Clinical general relating to admission and discharge documents

7.3.1.2.1 Stage 1

• Patient Flow team.
• Mental Health Act manager.
• Patient Safety team.
• Patient Experience team.

7.3.1.2.2 Stage 2

• Selection of service managers and matrons from across each clinical directorate for identifying colleagues to be part of consultation.
• Mandatory specialists.

7.3.1.3 Clinical general relating to resuscitation documents

7.3.1.3.1 Stage 1

Resuscitation Operational Group.

7.3.1.3.2 Stage 2

• Selection of service managers from across each clinical directorate for identifying colleagues to be part of consultation.
• Mandatory specialists.

7.3.1.4 Prescribing and medicines management documents

7.3.1.4.1 Stage 1

• Trust Medicines Optimisation Group members
• Non-medical prescribing (NMP) Leads Group members where appropriate

7.3.1.4.2 Stage 2

• Selection of service managers from across each clinical directorate for identifying colleagues to be part of consultation.
• Mandatory specialists.

7.3.1.5 Safeguarding documents

7.3.1.5.1 Stage 1

Safeguarding Assurance Group members.

7.3.1.5.2 Stage 2

• Selection of service managers from across each clinical directorate for identifying colleagues to be part of consultation.
• Mandatory specialists.

7.3.1.6 Mental Health Act and Mental Capacity Act documents

7.3.1.6.1 Stage 1

Mental Health Operational Group members.

7.3.1.6.2 Stage 2

• Selection of service managers from across each clinical directorate for identifying colleagues to be part of consultation.
• Mandatory specialists.

7.3.1.7 Patient experience documents

7.3.1.7.1 Stage 1

• Patient Safety team.
• Patient Safety Operational Group members.

7.3.1.7.2 Stage 2

• Selection of service managers from across each clinical directorate for identifying colleagues to be part of consultation.
• Mandatory specialists.

7.3.1.8 Infection prevention and control documents

7.3.1.8.1 Stage 1

Infection Prevention And Control Committee members.

7.3.1.8.2 Stage 2

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• mandatory specialists

7.3.1.9 Finance documents

7.3.1.9.1 Stage 1

Finance team.

7.3.1.9.2 Stage 2

• Information Governance team.
• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Mandatory specialists.

7.3.1.10 Emergency planning documents

7.3.1.10.1 Stage 1

• Estates team.
• Emergency Preparedness, resilience and Response (EPRR) Group members.

7.3.1.10.2 Stage 2

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Human Resources and Organisational Development team where appropriate.
• Mandatory specialists.

7.3.1.11 Estates and facilities documents

7.3.1.11.1 Stage 1

• Health and Safety team.
• Health and Safety Forum members.
• Patient Safety members.

7.3.1.11.2 Stage 2

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Human resources and organisational development team where appropriate.
• Mandatory specialists.

7.3.1.12 Health safety and security documents

7.3.1.12.1 Stage 1

• Health and Safety team.
• Security team.
• Health and Safety Forum members.
• Patient Experience team.
• Patient safety members.

7.3.1.12.2 Stage 2

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Human Resources And Organisational Development team where appropriate.
• Mandatory specialists.

7.3.1.13 Human resources documents

7.3.1.13.1 Stage 1

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Mandatory specialists.

7.3.1.13.2 Stage 2

Human Resources Policy Forum members.

7.3.1.14 Information governance and record management documents

7.3.1.14.1 Stage 1

Information Governance and Cyber Group members

7.3.1.14.2 Stage 2

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Mandatory specialists.

7.3.1.15 Information management documents

7.3.1.15.1 Stage 1

Data Quality Group members.

7.3.1.15.2 Stage 2

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Mandatory specialists.

7.3.1.16 Learning and development documents

7.3.1.16.1 Stage 1

• Learning and Development team.
• Health and Safety Forum members.

7.3.1.16.2 Stage 2

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Mandatory specialists.

7.3.1.17 Patient safety documents

7.3.1.17.1 Stage 1

• Health and Safety Forum members.
• Subject specific:
  • Patient Safety Operational Group members where appropriate
  • Medical Devices Advisory Group members where appropriate

7.3.1.17.2 Stage 2

• Selection of:
  • service managers from across each clinical directorate for identifying colleagues to be part of consultation
  • heads of and team managers from backbone directorates
• Mandatory specialists.

7.3.1.18 Research governance documents

7.3.1.18.1 Stage 1

• Research panel members.
• Information Governance team.
• Corporate Assurance team where appropriate.

7.3.1.18.2 Stage 2

Mandatory specialists.

Please note: policies that affect specific groups of external stakeholders should be discussed with those groups during the consultation process.

The mandatory specialists for inclusion in consultation of all procedural documents are:

• Matt Treharne-Clarke, Counter Fraud Specialist (360 Assurance)
• Yvonne Taylor, Mental Capacity Act lead
• Kim Shilomboleni, interim head of learning, development and education
• Shirley Kirkland, head of equality, diversity, inclusion and participation
• Kay Kharvat, clinical effectiveness lead (clinical policies only)
• Lousie Bertman, head of safeguarding
• Susan Black, corporate assurance officer or corporate assurance team?
• Ben Allison, digital accessibility developer

7.3.2 Email examples

7.3.2.1 Example 1

Dear colleagues,

You have been selected to take part in the consultation process following the development of the attached new contributions policy and procedure. This new policy has been created to outline the process on making additional contributions to charities direct from your salary for which there have been numerous enquiries.

Can you please take the time to read through and return any comments or queries you have with the content or flow to “John Smith, Contributions Manager at john.smith1005@nhs.net” by close of play on the “15 December 2022”. If you have no comments, can you still respond to confirm that you have no comments to make.

7.3.2.2 Example 2

You have been selected to take part in the consultation process following the review of the attached contributions policy and procedure. The review was due as part of the review cycle and has been updated to reflect the following key changes:

• “streamline of form A”
• “update of contact numbers”

Can you please take the time to read through and return any comments or queries you have with the content or flow to “John Smith, Contributions Manager at john.smith5@nhs.net” by close of play on the “15 December 2022”. If you have no comments, can you still respond to confirm that you have no comments to make.

7.3.2.3 Example 3

You have been selected to take part in the consultation process following the review of the attached contributions policy and procedure. This is an early review due to there being a change in national guidance and includes the following key changes:

• “revised section 5.3 in line with minimum and maximum values of contributions”
• “update of references”

Can you please take the time to read through and return any comments or queries you have with the content or flow to “John Smith, Contributions manager at john.smith5@nhs.net by close of play on the “15 December 2022”. If you have no comments, can you still respond to confirm that you have no comments to make.

Please note: that the comments and responses received from stage 1 of the consultation are to be noted within section 3 of the attached tracking document.

7.4 Appendix D new procedural document request form

Refer to appendix D: new procedural document request form (staff access only).

7.5 Appendix E policy and procedure template and guidance

Refer to appendix E: policy and procedure template and guidance (staff access only).

7.6 Appendix F procedure template and guidance

Refer to appendix F: procedure template and guidance (staff access only).

7.7 Appendix G tracking document template and guidance

Refer to appendix G: tracking document template and guidance (staff access only).

7.8 Appendix H approval group cover guidance

Refer to appendix H: approval group cover guidance (staff access only).

7.9 Appendix I patient voice consultation template

Refer to appendix I: patient voice consultation template (staff access only).

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Document control

• Version: 10.
• Unique reference number: 270.
• Ratified by: clinical leadership executive.
• Date ratified: 18 November 2025.
• Name of originator or author: head of corporate assurance.
• Name of responsible individual: director of corporate assurance.
• Date issued: 2 December 2025.
• Review date: November 2028.

Page last reviewed: December 02, 2025
Next review due: December 02, 2026

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