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Class 5: Our policies and procedures

Class five includes information on: 
  • Policies and procedures relating to the conduct of business and the provision of services
  • Policies and Procedures relating to Health and Safety
  • Policies and procedures relating to Human Resources, including recruitment and employment
  • Policies and procedures relating to Equality and Diversity, Equality Scheme and Equality Impact Assessments 
  • Welsh Language Scheme
  • Complaints
  • Information Governance
  • Estate Management
  • Charging Regimes

For an organisation of the Health Board’s size and complexity, it is essential that it has in place policies, procedures and protocols that all staff must abide by to ensure proper performance and to reduce adverse incidents. 
 
The Health Board has numerous policies and procedures in place across all areas of health board business including corporate, clinical care, and employment. These are used to provide guidance and standards for our staff.   
 
The Health Board's approved corporate policies and procedures, can be found in the Policies and Procedures part of the website.  Policies and procedures for handling requests for information will also be found under this section. 
 
The Health Board's Standing Orders and Standing Financial Instructions are available to download from the Key Documents section of our website.

The Health Board's Health and Safety Policy can be found in the Policies and Procedures part of our website following the link for Corporate Policies.

The Health Board's employment policies can be found under the Policies and Procedures part of the Health Board's website.  
 
All current job vacancies within Aneurin Bevan University Health Board are advertised on the NHS Jobs website.

As required by equality legislation, Equality Impact Assessments (EqIA) are undertaken for all policies and procedures before they can be approved.  The process of EqIA enables the organisation to consider the effects of its decisions, policies or services on different communities, individuals or groups.  It is a crucial tool in helping us to improve the quality of local services and to meeting the needs of those who use them as well as our employees by taking into consideration the needs of people on the basis of their gender, race, disability, sexual orientation, religion or belief, age, language of choice and human rights. 
 
The Health Board's policies on Equality and Diversity can be found under the Policies and Procedures part of the Health Board's website.  
 
The Health Board's Equality Plan outlines how we aim to improve patient/staff experience and outcome and add value. We are working today to make sure that Aneurin Bevan University Health Board is best placed to provide safe, high quality services that everyone can be proud of.  A copy of the Strategic Equality Plan and Objectives, along with other useful information, can be found in the Equality, Diversity and Human Rights Section part of our website.

Under the Welsh Language Act 1993, the NHS in Wales has a statutory duty to deliver their services to the public in both Welsh and English in accordance with the requirements placed on the Health Board under the Welsh Language Standards, Section 26 of the Welsh Language (Wales) Measure 2011.
 
This legislation gives the Welsh language official status in Wales, and reinforces the principle that the Welsh language should not be treated less favourably than the English language in Wales.
 
The Measure states that individuals in Wales should be able to conduct their lives through the medium of Welsh if they choose to do so.
 
Since the official implementation of the standards on 30th May 2019, as a Health Board, we are committed to treating the Welsh and English languages on the basis of equality. 
 
We are working towards offering services wherever possible in the language of choice, without the need for the patient to make a specific request for it. This is called making an ‘active offer’ of Welsh and is a key component of the Welsh Government Strategic Framework: More than just words.
 
 
 

The regulations for the management of concerns in Wales were introduced in April 2011. The regulations require health bodies to investigate once, investigate well.  The Aneurin Bevan University Health Board Putting Things Right Team aims to support all staff and patients in the management of patient concerns (complaints, patient safety incidents and claims).  A key aim of the Health Board is to ensure that it is well placed to learn from adverse events. 
 
The team supports the investigation of concerns using a common process and facilitates action planning to improve services for patients. The team are always happy to provide advice and support during the investigation and resolution of a concern.  
 
For further information please visit the Putting Things Right website pages.  If you have any queries, please contact: 
Jane Rowlands-Mellor             
Assistant Director
Putting Things Right
Aneurin Bevan University Health Board
Tel: 01633 431674

Information Governance is a framework that brings together legal, ethical and quality standards that apply to the handling of information; it applies to sensitive and personal information, of both employees and patients.  In the Health Board this is overseen by the Information Governance Committee (IGC) and is managed on a day to day basis by the Information Governance Unit.  The Information Governance Committee reports directly to The Board. 
 
A senior person, usually a health professional is nominated in each health organisation to act as a Caldicott Guardian, responsible for safeguarding the confidentiality of patient information. The person appointed for Aneurin Bevan Health Board is Dr Paul Buss, Medical Director. 
 
Information Governance sits alongside clinical and corporate governance and focuses on ensuring that information is handled in a confidential and secure manner. 
 
NHS Wales has produced a leaflet entitled 'Your Information Your Rights'. It explains why the NHS collects information about patients and how the information is used.  It gives details on the patients' right to see their health record and how to gain access to them. 
Information Governance includes the following standards and requirements:
  • General Data Protection Regulations
  • Data Protection Act 
  • Caldicott Report
  • Common Law Duty of Confidentiality 
  • Data accreditation and data quality 
  • Freedom of Information Act Information Sharing Protocols - Wales Accord on the Sharing of Personal Information
  • Information Security assurance - ISO 27001/2
  • Records Management
The Health Board's approved Information Governance policies and procedures, can be found in the Policies and Procedures part of the website. 
The NHS Governance e-manual provides advice and guidance on all aspects of governance in the NHS in Wales. 
The Information Commissioner’s Office (ICO) is the UK’s independent authority set up to uphold information rights in the public interest, promoting openness by public bodies and data privacy for individuals.

A great deal of work has been done within NHS Wales to implement the recommendations and principles of the review of Patient Identifiable Information published in 1997 by a committee chaired by Dame Fiona Caldicott. 

Caldicott is a key element of the Information Governance agenda in Wales, providing organisations working in Health and Social Care with a set of recommendations and principles to help ensure that person identifiable information (including that of patients, staff and service users) is adequately protected.  Completion of the Caldicott (C-PIP) assessment provides Information Governance and Caldicott Leads with a comprehensive tool to highlight areas where improvements are required, and a benchmark for evaluating progress. 

However, since 1997 there have been significant changes in both the legal framework and codes of practice which govern access to and the use of patient identifiable information.  Further information on the review and the code of practice is available via the following links: -

An independent report on the Caldicot Review written March 2013 - Information Governance in the Health Care System - Information to Share or not to Share is now available for review.

The Freedom of Information Act 2000 provides public access to information held by public authorities.  It does this in two ways:
  • public authorities are obliged to publish certain information about their activities; and
  • members of the public are entitled to request information from public authorities.
The Act covers any recorded information that is held by a public authority in England, Wales and Northern Ireland, and by UK-wide public authorities based in Scotland. Information held by Scottish public authorities is covered by Scotland’s own Freedom of Information (Scotland) Act 2002. 
Public authorities include government departments, local authorities, the NHS, state schools and police forces.
 
Recorded information includes printed documents, computer files, letters, emails, photographs, and sound or video recordings. 
The Act does not give people access to their own personal data (information about themselves) such as their health records or credit reference file.

If a member of the public wishes to see information that a public authority holds about them, they should make a Subject Access Request under the Data Protection Act 1998.
 
 
For further information relating to Caldicott, please contact:
 
Medical Director
Aneurin Bevan University Health Board
Headquarters
St Cadoc's Hospital
Lodge Road
Caerleon
Newport
NP18 3XQ
Telephone: 01633 4365971
 
For further information relating to Information Governance, please contact:
 
Head of Information Governance
Aneurin Bevan University Health Board
Mamhilad Park Estate
Mamhilad
Pontypool
NP4 0YP
Telephone: 01495 765324
 
For further information relating to Freedom of Information, please contact:
 
Director of Corporate Governance
Aneurin Bevan University Health Board
Headquarters
St Cadoc's Hospital
Lodge Road
Caerleon
Newport
NP18 3XQ
Telephone: 01633 435959

Aneurin Bevan University Health Board has responsibility for a range of estates facilities and buildings.  If you require information regarding these, please contact: 
 
Chief Operating Officer
Aneurin Bevan University Health Board
Headquarters
St Cadoc's Hospital
Lodge Road
Caerleon
Newport
NP18 3XQ
Telephone: 01633 435940

The majority of information can be downloaded free of charge from our website.  Please see our Charges for Information pages for further details. For those without internet access, a hard copy will be made available by post, free of charge, by contacting us. Information will be provided in alternative formats on request in order to comply with the Disability Discrimination Act 1995. 
 
However, requests for multiple printouts, for archived copies of documents which are no longer accessible or available on the website or for documents in other mediums (e.g. CD Rom) may attract a charge to cover the production and postage.  The UHB will advise you of the cost and charges to be paid in advance.