This policy sets out the framework for the creation (and review) of new Trust-wide policies. It provides the corporate requirements for development of document, the procedure for ratification, and the requirements after ratification relating to dissemination, implementation, monitoring, review and archiving. The policy includes requirements set out in the risk management standards by the NHS Litigation Authority (NHSLA) and it is expected that staff comply with this policy.



This policy is relevant to all Trust staff who are developing or reviewing a policy.



This policy sets out expectations and standards for what is required when policies, are created, and how they are approved and ratified.

This policy will ensure all documentation is consistent in format, compilation and dissemination and that the trust meets all its legal responsibilities, and that the trust conforms to risk management standards, thereby ensuring a high level of safety and effectiveness for patients and staff.


Policy Details

Download: PDF version
Compiled by: George Absi, Head of Regulation and Accreditation
Ratified by: Trust Executive Committee
Date Ratified: May 2018
Date Issued: May 2018
Review Date: December 2020
Target Audience: Any trust staff developing or reviewing a trust policy
Contact name: George Absi, Head of Regulation and Accreditation


See also:

  • Branding Manual
  • Quality and Safety Strategy


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