Procedure re-written. (i.e. All staff with responsibility for the creation, use and management of organisational responsibility)

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1 Standard Operating Procedure Title of Standard Operation Procedure: Corporate Records Management Procedure Reference Number: ECT Version No: 2.0 Supersedes Versions No: 0.1 Amendments Made: Procedure re-written Issue Date: October 2017 Review Date: October 2019 Purpose and Background This document sets out a framework for staff creating and using the Trust s corporate records to follow in order to ensure that records are managed and controlled effectively, and meet legal, operational and information needs. Scope (i.e. All staff with responsibility for the creation, use and management of organisational responsibility) corporate records Vital functions affected by this procedure: Monitoring Compliance Requirement to be monitored. Must include all requirements within NHS LA Standards Process to be used for e.g. audit Responsibl e individual/ committee for carrying out Frequency of Responsibl e individual/ committee for reviewing the results Responsib le individual/ committee for developing action plan Responsibl e individual / committee for action plan Comprehensive evidence held to demonstrate compliance against all requirements Regular audits to be undertaken Governance Manager/IGR MG According to the Corporate Records Audit Plan Governance & Records Management Group Governance Manager Governance & Records Management Group Escalations (if you require any further clarification regarding this procedure please contact): Committees / Group Consultation: Health Records Management Group August 2017 Date Approval Committee Governance & Records Management Group September 2017

2 Guidance The Trust s records are its corporate memory, providing evidence of actions and decisions and supporting daily functions and operations. Corporate records support policy formation and managerial decision-making, protect the interests of the Trust and the rights of patients, staff and members of the public. They support consistency, continuity, efficiency and productivity and help deliver services consistently. Corporate records held or created by the Trust form part of the organisation s information resource, and may comprise records in any format, (including hard copy as well as electronic and digital formats on magnetic, digital, photographic and optical media) by staff of the Trust in the course of carrying out the functions of the Trust. This procedure relates to corporate records. Corporate information relates to information generated and received by an organisation other than clinical, care or service user information. The records are those generated by the organisation s business activities, which includes, but is not limited to the following areas of the Trust:- Estates/Facilities Financial Management & Technology (IM&T) Personnel/Human Resources Purchasing/Supplies Trust Board This procedure does not apply to copies of documents published by other organisations that are kept for reference purposes only. Records Maintenance and Storage Records must be easily retrievable at any time, and there must be an auditable trail of record transactions in the event that they may be tracked and retrieved for business need or other purposes, such as requests under the Freedom of Act Records must be retained for as long as they are required, and until their scheduled disposal, subject to operational, legal, administrative and historical evaluation. Archiving and disposal of records must be managed in accordance with the Records Management Code of Practice for Health and Social Care 2016 published by the Governance Alliance (IGA) for the Department of Health (DH). Irrespective of their format, records must remain accessible up to the point of disposal. Electronic records must be retained on media that permit reliable access and data migration and/or system modifications. Guidelines for Naming Electronic Documents Held on Network Drives Filing Structure: Records should be stored in a structure of folders with meaningful titles, which is easily interpreted, and makes it straightforward for users to save records in the correct locations.

3 Ideally, a functional filing structure will have three levels of folders and idiosyncratic, locally defined, sub-folder structures should not be created which do not conform to the corporate rules The structure set out below represents a clear hierarchy using three levels of folder. The structure below represents an unclear hierarchy which would cause confusion as to where information should be stored: File Naming: File names should be short and simple File names should not be personal to the creator as this may render them unclear to other users Do not use words such as draft or memo at the beginning of a file name as it will be more difficult to find if searching for a specific document Where possible, avoid adding words which increase the length of the file name but do not add to its meaning eg and or the Do not use abbreviations which may not be familiar to all users. Common abbreviations such as NHS are acceptable Put acronyms in capital letters eg CQUIN Avoid underscores and use initial capital letters to separate titles if it is anticipated that any software being used may not recognise the file name eg RequestTracking

4 Using numbers in file names: o o If it is necessary to use two digit numbers ie 01 unless referring to a year To maintain numeric order of files names including numbers and ensure that they display in that order, include zero for numbers 1 9 ie Document01 When including names in file name, give the surname first followed by the first name or initials. Each draft of a document should have its own number. If a version number is applicable, it should always appear in the file name so that the most recent version and status of the document can be readily identified. Version numbers in documents should be shown as follows: o v1.0 followed by the word draft or final as appropriate o a major change to the document requires an increase before the point, ie v2.0 o a minor change means an increase in the number after the point ie v2.1 Include a footer which clearly displays the file path structure to enable the record to be identified and retrieved. Training All staff need to be aware of:- the need to keep information according to the Records Management Code of Practice for Health and Social Care Management-Code-of-Practice-for-Health-and-Social-Care-2016 the process for archiving and send records to Deepstore (see Appendix One) Audit The Governance Toolkit provides that there must be adequate assurance arrangements in place to ensure compliance with current information quality and records management obligations. To ensure this is maintained, the Governance department will carry out annual audits. Relevant Policies Please use the following link: Lifecycle & Records Management Policy Policy on Procedural Documents

5 Appendix One Guide to Sending and Retrieving Documents & Boxes from DeepStore Contact information:- Contact Telephone: Governance, 2nd Floor, New Alderley House, Macclesfield District General Hospital, Macclesfield, SK10 3BL ( Governance) The DeepStore address should be used for sending copies of your forms and any other queries you may have in relation to DeepStore, Retention Periods etc.

6 Title: Using the Off-Site Storage Facility for Documents and Records Reference Number: IG/CRM Version No: 0.1 Supersedes (to be read in conjunction with the Records Management Code of Practice for Health and Social Care 2016 has been published by the Governance Alliance (IGA) for the Department of Health (DH). Not Applicable New Procedure Amendments Made: Not applicable new procedure Issue Date: November 2016 Review Date: November 2019 Purpose and Background The records management function is a corporate responsibility. This procedure provides a managerial focus for corporate records (as distinct from Clinical Records which are the subject of a separate policy) of all types, in all formats, throughout their life cycle. It provides clearly defined responsibilities and objectives with regard to the Trust s corporate records. Scope (i.e. organisational responsibility) Vital functions affected by this procedure: All staff with responsibility for the creation, use and management of corporate records Monitoring Compliance Requirement to be monitored. Must include all requirements within NHS LA Standards Process to be used for e.g. audit Responsible individual/ committee for carrying out Frequency of Responsible individual/ committee for reviewing the results Responsible individual/ committee for developing action plan Responsible individual / committee for action plan Comprehensive evidence held to demonstrate compliance against all requirements Regular audits to be undertaken Governance Officer/ IGRMG According to the Corporate Records Audit Plan Governance & Records Management Group Governance Officer Governance & Records Management Group Escalations (if you require any further clarification regarding this procedure Governance Team ecn-tr.infogov@nhs.net

7 Committees / Group Date Consultation: Governance & Records November 2016 Management Group Approval Committee Governance & Records November 2016 Management Group Ratified by Committee: Governance & Records November 2016 Management Group Received for information: Internet/Intranet November 2016 Background Records Management Code of Practice for Health and Social Care 2016 requires the Trust to keep its records and documents for certain periods of time prior to disposal. The Trust also has an obligation under the Data Protection 1998 and Freedom of 2000 Acts, demanding records are properly maintained and destroyed in a timely fashion. The efficient management of physical records is necessary to comply with these legal and statutory obligations. All documents and records (held on any media) are held in the off-site storage facility (currently DeepStore) after having reached the end of their current working life or when onsite storage is at a premium. At present DeepStore is utilised for records/documents from the below departments who use their own process for managing these items :- Radiology Pathology Accident and Emergency Medical Health Records All other facilitative records from areas such as :- Estates Finance Facilities Manager/Technology Human Resources Purchasing, Supplies and Trust HQ are managed by local members of staff with the assistance from the Governance Officer. There is a dedicated DeepStore address for sending your forms and for any further queries you may have - ecn-tr.deepstore@nhs.net DeepStore Instructions 1. All boxes being sent to DeepStore must have a barcode sticker attached and a box number clearly written on the box

8 1(a) Use only a DeepStore box Attach a DeepStore barcode available from ecn-tr.deepstore@nhs.net Always use a permanent marker to label the boxes in the grid provided Do not write anything on the lid or sides of the box as it cannot be seen when stacked on shelves in DeepStore Ensure that the box reference number is unique & does not exceed 15 characters eg IG2010Box3SAR. o IG is Governance o 2010 is the year the records have been created o Box 3 is the number of boxes sent to DeepStore this year o SAR stands for Subject Access Requests 2. When filling a box ensure that each box contains the same types of documents that have the same destruction year. This will ensure that the contents are all destroyed at the same time thus saving time and money. 3. Contents should NOT contain harmful, noxious or flammable material (except paper). Glass and other sharp objects should NOT be archived unless previously agreed by the Governance Department. 4. The box should be full but not too heavy to lift (15kgs is the weight limit). 5. The contents should be in chronological order, e.g. date, alphabetical, numerical or by file reference number to facilitate retrieval. Creating a List of Contents for Each Box 6. Complete the Box Contents Form (DeepStore Form 01) listing all the documents contained in the box. This must be a comprehensive list. Keep a copy of the list and send a copy to the ecn-tr.deepstore@nhs.net mailbox. 7. A content list must be completed for all items in the box and to ensure records required in the future are easy to locate and retrieve. 8. When completing Form 01 sufficient information must be given to enable anyone to be able to retrieve documents in the future. Files may be kept for many years. Records are owned by the Trust and fall under the Data Protection Act and Public Records Act and Trust is legally responsible for them and must know their location at all times. 9. All departments must keep a comprehensive list of records stored together with retention periods. Use the link shown below for a comprehensive guide on retention periods in the NHS. The Records Management Code of Practice for Health and Social Care 2016 is a guide to the required standards of practice in the management of records for those who work within or under contract to NHS organisations in England. It is based on current legal requirements and professional best practice. 10. The retention periods for records and documents can be found at page 9 in the linked document - Whilst in this document you can search for the type of document you need to find the retention period for.

9 . To do this hold down the Ctrl key and press the F key and a Find box will appear Type in the word relating to the document, for example, Minutes, press next and you will be taken to the first instance of the word Minutes in the document Use the Next button to search the rest of the document for further instances 11. You will be asked for a copy of your box content forms and lists for audit purposes on a regular basis. Listing Box Contents DeepStore Form 01 is attached in Appendix A Forward a copy of each form to ecn-tr.deepstore@nhs.net Sending New Boxes to DeepStore 12. The box is now ready to be sent to DeepStore. Complete DeepStore New Intake Form (DeepStore Form 06) which provides a general overview of the whole order and should contain a list of the box contents (in summary). New Intakes DeepStore Form 06 is attached in Appendix A Forward a copy of each form to ecn-tr.deepstore@nhs.net 13. The Governance Department can provide you with an inventory list to enable you to cross reference your lists with barcodes where necessary. 14. Records cannot be sent to DeepStore without a retention/destruction date having been set and listed on the Box Content Form. The destruction date should be 31 st December of the year due for destruction, e.g. if a record was created in May 2015 and is due for destruction in ten years time then the destruction date will be When your boxes are ready to be collected, contact the Governance Department who will check your forms and arrange the collection for you. 16. You must reconcile the boxes with your own inventory and ensure that you record the box barcode on your master file. Failure to do this could cause problems in locating the boxes in the future. Retrieving Boxes from Deepstore 17. At some point you will need to retrieve box(es) from DeepStore. To do this you will need to complete Form 10.

10 18. When completing this form ensure that the Barcode reference is included on the sheet. This is the only method of retrieving boxes that DeepStore will use, so you need to ensure it is correct. Retrieving Boxes DeepStore Form 10 is attached in Appendix A Forward a copy of each form to ecn-tr.deepstore@nhs.net Returning Boxes to DeepStore 19. When you have finished with your retrieval, you must return the document to the box and return it to DeepStore. 20. To do this you will need to complete form 07 and again ensure that all relevant fields are completed, including the barcode reference. 21. You must inform the Governance Department that the box is ready to be returned Returning Boxes DeepStore Form 07 is attached in Appendix A Forward a copy of each form to ecn-tr.deepstore@nhs.net Ordering Boxes and Barcode Labels 22. As outlined in Point 1. above only DeepStore boxes and Barcodes should be used. 23. Barcodes are available from the Governance Department. 24. DeepStore boxes can be ordered by completing DeepStore Form 08. Ordering Storage Boxes DeepStore Form 08 is attached in Appendix A Forward a copy of each form to ecn-tr.deepstore@nhs.net Destruction of Box Contents 25. Governance will alert you to any records that are approaching their destruction date to enable you to confirm destruction or request further retention. 26. Actual destruction will be managed by the Governance Department.

11 Contact information:- Contact Telephone: Governance, 2nd Floor, New Alderley House, Macclesfield District General Hospital, Macclesfield, SK10 3BL ( Governance) The DeepStore address should be used for sending copies of your forms and any other queries you may have in relation to DeepStore, Retention Periods etc.

12 APPENDIX A DeepStore Forms Listing Box Contents DeepStore Form 01 CSV01 - DeepStore - Box Contents Form.pd New Intakes DeepStore Form 06 CSV06 - Deepstore - New Intake Form.xls Returning Boxes DeepStore Form 07 CSV07 - Deepstore - Boxes to be returned Ordering Storage Boxes DeepStore Form 08 CSV08 - DeepStore - Request For Flat Pack Retrieving Boxes DeepStore Form 10 CSV10 - DeepStore - Box Retrieval Reques If you cannot access these forms, please ecn-tr.deepstore@nhs.net

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