Policy: Food Safety. Target audience. Policy Version and advice on document history, availability and storage

Policy: Food Safety Executive or Associate Director lead Policy author/ lead Feedback on implementation to Clive Clarke, Deputy Chief Executive Janet Mason, Hotel Services Manager Janet Mason, Hotel Services Manager Date of draft 11 September 2015 Dates of consultation period September - October 2015 Date of ratification 24 March 2016 Ratified by Executive Directors Group Date of issue April 2016 Date for review March 2019 Target audience Policy Version and advice on document history, availability and storage Version 1 This Policy is stored and available via SHSC s intranet. Policy Food Safety (Version 1) Page 1 of 21

Contents Section Page Flowchart - Hazard Analysis and Critical Control Point (HACCP) 3 1 Introduction 4 2 Scope of this Policy 4 3 Definitions 4 4 Purpose of this Policy 5 5 Duties 5-6 6 Specific Details: 6.1 Catering Standards 6 6.2 Hazard Analysis Critical Control Points (HACCP) 6-7 6.3 Contracted Catering Services 7 6.4 Nutritional Strategy 7-8 6.5 Allergens 8 6.6 Pest Control 8 6.7 Training 8-10 6.8 Compliance, Monitoring and Enforcement 10 6.9 Food Brought in to the Trust 10 7 Dissemination, Storage and Archiving 11 8 Training and Other Resource Implications 11 9 Audit, Monitoring and Review 11 10 Implementation Plan 11 11 Links to other policies, standards and legislation (associated documents) 12 12 Contact details 12 13 References: 12 Appendix A - Guidelines Regarding Food Brought in by Service Users, Relatives or Visitors 13 Appendix B - Essentials of Food Safety 14 Appendix C - Version Control and Amendment Log 15 Supplementary Sections: Section A - Equality Impact Assessment Form 16-18 Section B - Human Rights Act Assessment Form and Flowchart 19-20 Section C - Development and Consultation Process 21 Policy Food Safety (Version 1) Page 2 of 21

Flowchart - Hazard Analysis and Critical Control Point (HACCP) Delivery by Supplier Food Food Purchased Purchased from from Supplier Supplier Receipt Ambient Storage Chilled Food Storage Frozen Food Storage Food Preparation Thawing Frozen Food Cooking Food Cooling Food Display/Hot Holding Reheating Food Despatch in Food Trolleys Serving Food Food Waste Cleaning of Food Room/ Structural/Equipment/ Maintenance Policy Food Safety (Version 1) Page 3 of 21

1. Introduction Sheffield Health and Social Care Foundation Trust NHS, (SHSC), has a moral and legal responsibility to take every reasonable care in all food safety issues to ensure that food for service users is safe to eat. Everyone who deals with food as part of their role has a legal responsibility to safeguard food. Attention to high standards of management of food services and good hygiene practices are essential if current legal obligations are to be met. The Trust acknowledges its responsibility for food safety and the provision of safe, nutritious food to the service users in its care and we need to maintain appropriate standards of food hygiene and food safety, comply with the legislation on food safety to provide, as far as reasonably practical, a healthy and safe environment in all locations of the Trust where food is produced for service users. This Policy has been created to meet legal requirements under the Food Safety Act 1990 and the Food Safety and Hygiene (England) Regulations 2013 (Sections 1 and 2) set out clear minimum requirements for food safety. 2. Scope of the Policy This Policy applies to all employees of the Trust including agency and bank staff, including non-shsc employees based within SHSC premises. This Policy also covers service users who may prepare food for their own- or others consumption. In these circumstances, staff should ensure that service users are instructed or supervised, with consideration to cultural/religious requirements, and to meet high standards of food safety. 3. Definitions HACCP EHO D&V FSMS ICC CQC DH CQC Hazard MUST Food Handler Food Hazard Analysis Critical Control Points Environmental Health Officer Diarrhoea and Vomiting Food Safety Management System Infection Control Committee Care Quality Commission Department of Health Care Quality Commission A hazard is anything that may cause harm to a consumer and could include: Micro-biological eg. Salmonella, E.coli, Listeria etc. Physical eg. contamination by glass, wood, plastic, dirt or soil etc. Chemical eg. contamination by cleaning chemicals, insecticides etc. Malnutrition Universal Screening Tool any person involved in a food business or who handles or prepares food, whether open (unwrapped) or packaged Includes drinks and ice 4. Purpose Policy Food Safety (Version 1) Page 4 of 21

The purpose of this Policy is to demonstrate the Trust s commitment to comply with food legislation requirements in all areas within the Trust. The Trust will follow the Hazard Analysis Critical Control Points (HACCP) approach; - a food safety system that identifies hazards within the food chain and adopts systems of good practice to minimise operation risk. This Policy takes into account the relevant legislation and Department of Health guidelines, including SHSC guidelines. 5. Duties (Roles and Responsibilities) Board of Directors and Chief Executive The Board of Directors, via the Chief Executive, are responsible for: Ensuring there are effective and adequately resourced arrangements for food safety within the organisation. Ensuring that the role of the Hotel Services function is fulfilled by appropriate and competent persons. Ensuring that appropriate systems are in place so that the responsibility for food safety management is effectively devolved to: o All staff groups in the Trust who have a responsibility for the provision or service of food and beverages. Director of Facilities Management The Director has overall responsibility for ensuring that catering services provided by SHSC and agencies comply with this Food Safety Policy. The responsibility will extend to proposed programmes of work relating to food safety risk management for consideration as part of the annual business planning process In line with delegated authority, the day-to-day management of food safety will be devolved to the Hotel Services Manager, but the Director of Facilities Management retains accountability. Hotel Services Manager Is responsible for: Compliance with food safety for the Trust and provide suitable advice and support to food handlers/managers on food safety issues. Developing and maintaining the delivery of the Level 2 in Food Safety - Chartered Institute of Environmental Health (CIEH) to food handlers within the Trust. Compliance with legislation to include the preparation and updating of food safety policies and appropriate procedures. Dietitian Provides professional advice on dietary requirements for service users, including detailed advice on specific food allergies or food intolerances. Training staff on the use of the Malnutrition Universal Screening Tool (MUST). Analyses menus to provide service users with a well-balanced diet. Developing a weight-management pathway to oversee healthier eating and improved nutrition. Managers of Food Handlers Have a responsibility for ensuring that: Policy Food Safety (Version 1) Page 5 of 21

Food-handling staff are trained in food hygiene relevant to their work role and duties. Food service is carried out efficiently and hygienically. Co-operate with the Hotel Services Manager on issues that may impact on food safety. Safe practices from point of receipt of food to point of service are adhered to. Food Handlers Have a responsibility to: Ensure all aspects of food safety are adhered to. Adhere to personal hygiene practices. Report to their line manager any issues which they believe could result in food poisoning. Attend mandatory training to a level commensurate to their duties undertaken. All food handlers will be provided with suitable protective clothing to prevent food safe from cross contamination. All food handlers will undergo Occupational Health clearance prior to the commencement of their duties. Food handlers have access to the Essentials of Food Hygiene document which is located in the Catering Framework (SHSC). See Appendices. 6. Specific Details 6.1 Catering Standards The Trust s Catering Services Framework document is a supporting reference guide and includes appropriate written codes of practice, and identifies standards to be met for purchase, storage, preparation, cooking/regeneration and service of food. The testing and recording of food temperatures throughout the food chain, (food receipt through to point of service), is an essential part of the quality control of good, nutritious, safe food. It is a legal requirement to carry out a risk assessment of the food production in each kitchen to identify hazards that have the potential to cause harm to service users, staff and visitors, and introduce controls to remove or minimise the risks. This system is formally known as HACCP (Hazard Analysis Critical Control Points). The managers of food handlers must understand the need for such control, carry out regular monitoring and ensure clear, understandable records are kept. Procedures must be established to cover corrective action where necessary. Accurate records may afford the Trust a due diligence defence should one be needed. This system should be reviewed and revised as necessary. 6.2 Hazard Analysis Critical Control Points (HACCP) A food safety management system which identifies, evaluates and controls hazards which are significantly for food safety. HACCP is a systematic analysis of all hazards or risks involved in ordering, receiving and storage. All possible hazards are identified, the critical points to ensuring food safety are highlighted and measures are in place to control and monitor the risks or hazards associated with those critical points. The requirements of current legislation and best catering practice demand that management of food safety be based on the principles of HACCP. The Trust is committed to this approach to the management of food safety and this approach will underpin all our catering operations. See Appendices for the HACCP template and flowchart. Four-Weekly Review Document In addition to HACCP there is the four weekly review - adapted from the Food Standard Agency - Safer Food, a monitoring system that documents and identifies any persistent problems, their details and how they were dealt with. In the event of anything different happening, or if something goes wrong, this requires documenting. This is evidence to show you have taken action to make sure that food is safe to eat. Further information can be found in the guidelines of the Catering Framework SHSC. See appendices - 4 Week Review document. Policy Food Safety (Version 1) Page 6 of 21

6.3 Contracted Catering Services The Director of Facilities Management will ensure that all specifications for tendering of catering operations and catering management leases include a requirement for the successful contractor to develop, implement and maintain a robust food safety management system including hazard analysis. The Director of Facilities Management ensures the contractors systems: Comply with current food safety legislation. Comply with best practice. 6.4 Nutritional Strategy Having access to a healthy and nutritious diet is a basic human right and good nutrition and hydration is essential for mental and physical wellbeing. SHSC provides meals to service users and this five-year strategy aims to demonstrate the Trust s commitment to providing a healthy balanced diet and ensuring the nutritional needs of all service users are assessed and attended to. The Trust aims to provide the necessary information and support so that individual service users are able to consume appropriate nutrition with dignity and in an environment conducive to promote and enhance health. To meet these needs the Trust has adopted the following standards of Good Nutritional Care: Standards of Good Nutritional Care (Nutrition Alliance) Ten key characteristics: 1. Everyone using healthcare and care services is screened to identify those who are malnourished or at risk of becoming malnourished. 2. Everyone using care services has a personal care support plan and, where possible, has had personal input to identify their nutritional care and fluid needs and how they are to be met. 3. The care provider must include specific guidance on food and beverage services and nutritional care in its service delivery and accountability arrangements. 4. People using care services are involved in the planning and monitoring arrangements for food service and beverage/drinks provision. 5. An environment conducive to people enjoying their meals and being able to safely consume their food and drinks is maintained. (NB: this can be known as Protected Mealtimes ). 6. All staff/volunteers have the appropriate skills and competencies needed to ensure the nutritional and fluid needs of people using care services are met. All staff/volunteers receive regular training on nutritional care and management. 7. Facilities and services are designed to be flexible and centred on the needs of the people using them. 8. The care-providing organisation has a policy for food service and nutritional care, which is centred on the needs of people using the service. Performance in delivering that care is effectively managed in line with local governance and regulatory frameworks. 9. Food service and nutritional care are provided safely. 10. Everyone working in the organisation values the contribution of people using the service and all others in the successful delivery of nutritional care. Nutrition and Hydration Digest (The British Dietetic Association) The Digest covers a wide audience, including service users, people in care settings, recipients of community care and those in their own homes. It provides a platform for caterers, dietitians and clinicians to speak with voice, from a well-referenced evidence-base. It explicitly covers the dietitian s role within food and beverage services, with a focus on ensuring optimal consumption of appropriate and enjoyable meals, snacks and drinks throughout the day. The Trust will also consider other implications from The Hospital Food Standards Panel s report on standards for food and drink in NHS Hospitals and where appropriate plan for their implementation. Policy Food Safety (Version 1) Page 7 of 21

However these are not necessarily directly linked to food safety and are more to do with nutritional requirements and sustainability in procurement practices 6.5 Allergens It is important to consider how known allergens affect the safety of food when foods can become contaminated through cross contamination. Therefore, all providers and handlers of food shall take the necessary steps to avoid any contamination. There are 14 Allergens that must be tracked: 1. Cereals containing gluten - wheat, oats, rye, barley, spelt, kamut 2. Eggs 3. Fish 4. Peanuts 5. Soya beans 6. Milk 7. Nuts - almonds, cashews, pecan, Brazil, pistachio, Macadamia 8. Celery 9. Mustard 10. Sesame seeds 11. Sulphur Dioxide/Sulphites - (where added at 10mg/kg or 10ml/L in finished product). Used as a preservative in some dried fruits, vegetables, soft- and alcoholic drinks 12. Lupin - flour and seeds from the Lupin plant: bread and pastries 13. Molluscs - clams, oysters, scallops 14. Crustaceans - prawns, crabs, lobsters All food handling staff will be required to receive allergy awareness training and be aware of the procedures and policies for handling. An appropriate level of information will be provided for recipients of foods. See the Allergen Toolkit for Healthcare Catering for further information. 6.6 Pest Control The presence of pests cannot be tolerated in food premises. It is a legal requirement that pests be systematically eliminated. All premises in the Trust will be covered by a pest control contract. The nature, style and content of the specification for pest control services will be in accordance with the NHS Executive Model Contract. Facilities management has a responsibility for monitoring and review of the Policy and contract. A nominated person must ensure that staff are trained to: Recognise the presence of pests, or pest activity, and take appropriate action. Maintain high standards of housekeeping and cleanliness to discourage pests. Store and dispose of waste carefully. If an infestation problem occurs it should be reported to Estate Services through the Direct Link procedure (27 18181). 6.7 Training It is a legal requirement that all food handling staff will be trained to a level commensurate with their work activities and training records maintained to ensure compliance with Trust, department and statutory requirements. Staff will also be trained in the use of chemicals and with respect to personal hygiene, awareness of sickness reporting procedures and infection control good practices. The managers of food handlers employed within the Trust will ensure their staff: Undergo induction prior to commencing food handling duties. Are trained to undertake food handling tasks efficiently. Undergo the relevant hygiene awareness training. Undergo the relevant, formal food hygiene training depending on their grade. Policy Food Safety (Version 1) Page 8 of 21

Hygiene Awareness/Refresher Training It is good practice that food handling staff receive food hygiene training. All food handling staff will receive refresher training at a minimum frequency of once every three years; the training should include the following information: Overview of food safety management systems - the importance of high standards Personal hygiene, hand hygiene, wearing protective clothing/hairnets Reporting food poisoning symptoms to their supervisor Cross contamination Colour coding guidelines Food storage, ambient, chilled, frozen Importance of temperature control Food waste disposal Cleaning and disinfection Identifying food pests Formal Training The Trust will provide a one day course - accredited by the Chartered Institute of Environmental Health, (CIEH) Level 2 in Food Safety in Catering. The following subjects will be covered: Introduction The Importance of Food Safety Hazards to Food Physical and Chemical Hazards Biological Hazards Illness linked to Food High Risk Food Time and Temperature Control Personal Hygiene Premises and Equipment Cleaning and Disinfection Food Pests Production to Storage Displaying and Selling Food Food Safety Control A multi choice exam paper is taken at the end of the session (6 hours) and a minimum mark of 20 out of 30 must be achieved to receive a pass. Other formal training Intermediate and Advanced Food Hygiene or NVQ equivalent is sourced externally. Agency Training Managers who utilise agency staff will ensure they undergo instruction and supervision and/or training to commensurate with their work activity. Managers who seek agency staff should also seek evidence that they have received the appropriate level of food hygiene training. Training Needs Analysis Policy Food Safety (Version 1) Page 9 of 21

Staff Grade Training Required Update Hotel Services Manager Catering Supervisors Senior Housekeepers Site Co-ordinators (catering responsibility) CIEH Advanced Food Hygiene or NVQ equivalent CIEH Advanced Food Hygiene or NVQ equivalent CIEH Intermediate Food Hygiene or NVQ equivalent CIEH Intermediate Food Hygiene or NVQ equivalent Cook-Housekeepers Nursing/Support/Occupational Therapist staff (if supporting service users in therapeutic cooking projects Nursing/support staff not involved in cooking projects CIEH Level 2 in Food Safety CIEH Level 2 in Food Safety Hygiene Awareness/Refresher Training 6.8 Compliance, Monitoring and Enforcement The standards within food premises are also subject to inspections by local authority Environmental Health Officers (EHO). These inspections are unannounced. The inspector has a legal right to access all food areas and examine relevant documentation. Failure to comply may result in prosecution. All issues relating to food safety are reported and monitored by the Nutritional Strategy Group. An annual report on the management of food safety will be presented to the Nutritional Strategy Group and any risk issues identified and an action plan drawn up and implemented for risk mitigation. Appropriate training must be given to staff and monitored against the Trust s Mandatory Training Policy. An internal audit of the premises and the food safety management shall be conducted annually by the Control of Infection Team, or by competent person(s), and formally documented and issued to the Director of Facilities Management. This Policy will be reviewed within three years of ratification or earlier if required due to concerns identified through monitoring the Policy, changes in legislation, significant concerns raised by enforcement action or significant incidents. 6.9 Food Brought in to the Trust This Policy also applies to food brought into the Trust by service users, visitors or relatives. (See Appendix A - Guidelines Regarding Food Brought in by Service Users, Relatives or Visitors). These guidelines are to minimise the risk of food poisoning to service users. Takeaway menus Takeaway food will be managed and monitored by managers at ward level. It is recommended that any takeaway food delivered to the ward will be documented by nursing/support staff; (in case of a food poisoning outbreak). 7. Dissemination, Storage and Archiving (Control) An electronic copy of the Policy shall be accessible via the Trust s intranet and discussions and directorate awareness of the Policy via meetings and training groups. 8. Training and Other Resource Implications Policy Food Safety (Version 1) Page 10 of 21

Within the Trust, Directorate managers at all levels must ensure that food handling staff under their control are aware of this Policy. The implementation of this Policy should have no additional resource requirements. There are no other training needs for the implementation of this Policy. The introduction of this Policy should provide improved clarity on how food safety is managed within the Trust. 9. Audit, Monitoring and Review The Hotel Services Manager is responsible for monitoring the effectiveness of this Policy. Monitoring will be achieved through site inspections and compliance assessment. This Policy will be reviewed within three years of ratification or earlier if needed due to concerns identified through monitoring the Policy, changes in national guidance, legislation, significant concerns raised via enforcement action or significant incidents. 10. Implementation Plan Action/Task Responsible Person Deadline Progress update Arrange for revised Policy to be launched on to the Trust intranet and remove the old Policy. Hotel Services Manager October 2014 Inform all Trust staff of the revised Policy via a Trust-wide email, asking team managers to ensure all staff have access to the latest version of this Policy and the previous Policy to be removed and destroyed Hotel Services Manager October 2014 Inclusion into the Risk Manual via the Trust intranet. Health and Safety Advisor October 2014 11. Links to other policies, standards and legislation (associated documents) Relevant Legislation, National Guidance and Associated SHSC documents The Food Safety Act 1990 The Food Safety & Hygiene (England) Regulations 2013 Food Premises (Regulations) 1991 Food Hygiene (Amendments) Regulations 2006 COSHH Policy The Food Safety (Temperature Control) Regulations 1995 Policy Food Safety (Version 1) Page 11 of 21

Guidance for Management of Allergens (British Dietetic Association) Hazard Analysis, Critical Control Point (HACCP) - EU food hygiene legislation Food Hygiene & Pest Control in the Health Service DHSS (Amendment) Act 1986 (96)14 DH - Chilled and Frozen Guidelines on Cook Chill and Cook Freeze Catering Systems 1989 Department of Health - Food handlers - Fitness to Work Catering Services Framework SHSC folder Nutritional Strategy Policy 12. Contact Details Title Name Phone E-mail Deputy Chief Executive/ Social Care Leadership Director of Corporate Services Clive Clarke 27 18758 clive.clarke@shsc.nhs.uk Director of Facilities Management Helen Payne 27 18697 helen.payne@shsc.nhs.uk Hotel Services Manager Janet Mason 27 18350 janet.mason@shsc.nhs.uk Senior Nurse for Infection Prevention and Control? 27 16720? 13. References Food Safety Act 1990 Food Hygiene (England) Regulations 2006 Nottingham University Hospital NHS Trust Chartered Institute of Environmental Health Croner Catering Food Standards Agency Policy Food Safety (Version 1) Page 12 of 21

Appendix A - Guidelines Regarding Food Brought in by Service Users, Relatives or Visitors It is not the intention to deter any relative or visitor from bringing food in for a service user. However, as a Trust we do have food safety legislation and NHS guidelines with which to comply; all of which are intended to ensure the safety of the service user as well as offering protection for staff, and the Trust, in the event of litigation and/or prosecution. 1. The service user whose visitor(s) brought in the food should be the only one who consumes it. 2. Service users, their relatives or visitors should be advised of the need to notify a member of staff of any food which they intend to bring in, giving, if possible, details of the quantity and the nature of the food; in particular if the food needs refrigerating. 3. The food should be labelled to show to whom it belongs and the date it was brought in. 4. With the exception of stilled- and fizzy drinks plus confectionery, eg. chocolate, sweets, etc. the food will only be kept for 24-hours, after which time it will be discarded. 5. If any high-risk foods, eg. dairy products, soft cheese, pâté, cooked meats, cooked rice, egg dishes etc. are brought in, they must be stored in a refrigerator and be clearly labelled and dated. 6. Should the food require re-heating then the preferred option would be to use the microwave oven and ensure the food is re-heated to a temperature of at least 75 C, or above, using the probe thermometer. 7. Staff are empowered to discard food after 24-hours. Hotel Services Management 2014 Appendix B - Policy Food Safety (Version 1) Page 13 of 21

Essentials of Food Safety Wash your hands thoroughly and frequently throughout the day and avoid unnecessary handling of food. Hands must be washed, particularly: o o o o o o o o o On entering and re-entering the kitchen or food service area Before handling any prepared foods After handling raw meat, poultry, fish or vegetables After handling food and non-food waste or refuse After any cleaning procedure After touching ears, nose, mouth or hair After using the WC After any contact with service users or their immediate surroundings Before or during food-handling duties. Keep yourself clean and wear clean, protective clothing when working, especially when working with food. There must be sufficient reserve clothing to allow all food handlers and visitors to the food area to be dressed cleanly. The clothing should be appropriate for the work performed, and restricted to the particular work area. Cover cuts/spots with a blue waterproof dressing. Keep you hair clean and tidy, cover with head when working with food. Do not scratch your head. Do not wear earrings, rings, bracelets, wristwatches, false nails or nail varnish. Do not wear strong aftershave or perfume. Do not smoke or eat when working with food. Advise your supervisor if you have had, or are currently suffering from, symptoms such as diarrhoea, vomiting, nausea, eye-, ear- or nose discharges, septic cuts or any other skin condition or infection, or if you have been in close contact with someone with food poisoning or sickness and diarrhoea. Temperature control - remember to keep your refrigerator below 5ºC and your freezer below - 18ºC. Always keep raw- and ready-to-eat food separate. Rotate stock and check use-by dates. Food should be cooked to 75ºC or above. Use a food thermometer probe. Appendix C - Version Control and Amendment Log Policy Food Safety (Version 1) Page 14 of 21

Version No. Type of Change Date Description of change(s) 1 Draft policy creation September 2014 Previous guidance in operation updated to policy status. Policy Food Safety (Version 1) Page 15 of 21

Supplementary Section A - Stage One Equality Impact Assessment Form 1. Have you identified any areas where implementation of this Policy would impact upon any of the categories below? If so, please give details of the evidence you have for this? Grounds / Area of impact People / Issues to consider Type of impact Description of impact and reason / Negative (it could disadvantage) Positive (it could advantage evidence Race People from various racial groups (e.g. contained within the census) No No Gender Male, Female or transsexual/transgender. Also consider caring, parenting responsibilities, flexible working and equal pay concerns No No Disability The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has a substantial and longterm effect on a person s ability to carry out normal day-to-day activities. This includes sensory impairment. Disabilities may be visible or non visible No No Sexual Orientation Lesbians, gay men, people who are bisexual No No Age Children, young, old and middle aged people No No Religion or belief People who have religious belief, are atheist or agnostic or have a philosophical belief that affects their view of the world. Consider faith categories individually and collectively when considering No No possible positive and negative impacts. 2. If you have identified that there may be a negative impact for any of the groups above please complete questions 2a-2e below. 2a. The negative impact identified is intended OR 2b. The negative impact identified not intended 2c. The negative impact identified is legal OR 2d. The negative impact identified is illegal OR (see 2e) (i.e. does it breach antidiscrimination legislation either directly or indirectly?) 2e. I don t know whether the negative impact identified is legal or not (If unsure you must take legal advice to ascertain the legality of the Policy) Policy Food Safety (Version 1) Page 16 of 21

3. What is the level of impact? HIGH MEDIUM LOW - Complete a FULL Impact Assessment (see end of this form for details of how to do this) - Complete a FULL Impact Assessment (see end of this form for details of how to do this) - Consider questions 4-6 below 4. Can any low level negative impacts be removed (if so, give details of which ones and how) 5. If you have not identified any negative impacts, can any of the positive impacts be improved? (if so, give details of which ones and how) 6. If there is no evidence that the Policy promotes equality and equal opportunity or improves relations with any of the above groups, could the policy be developed or changed so that it does? No 7. Having considered the assessment, is any specific action required - Please outline this using the pro forma action plan below (The lead for the Policy is responsible for putting mechanisms in place to ensure that the proposed action is undertaken) Issue Action proposed Lead Deadline Policy Food Safety (Version 1) Page 17 of 21

8. Lead person Declaration: 8a. Stage One assessment completed by :. (name). (signature) (date) 8b. Stage One assessment form received by Patient experience and Equality Team..(date) 8c. Stage One assessment outcome agreed. (sign here).... (Head of Patient Experience and Equality) OR (date agreed) 8d. Stage One assessment outcome need review.. (sign here).... (Head of Patient Experience and Equality).. (date returned to Policy lead for amendment) (if review required please give details in text box below) If a full EQIA is required the stage 1 assessment form should be retained and a completed EQIA report submitted to the relevant governance group for agreement by the chair. The chair will forward the completed reports to the Patient Experience and Equality team for publication. Any questions relating to the completion of this form should be directed to the Head of Patient Experience and Equality. Policy Food Safety (Version 1) Page 18 of 21

Supplementary Section B - Human Rights Act Assessment Form and Flowchart You need to be confident that no aspect of this Policy breaches persons Human Rights. You can assume that if a policy is directly based on a law or national policy it will not therefore breach Human Rights. If the Policy, or any procedures in the Policy, are based on a local decision which impact on individuals you will need to make sure their human rights are not breached. To do this, you will need to refer to the more detailed guidance that is available on the SHSC web site http://www.sct.nhs.uk/humanrights-273.asp (relevant sections numbers are referenced in grey boxes on diagram) and work through the flow chart on the next page. 1. Is your policy based on and in line with the current law (including case law) or policy? Yes. No further action needed. No. Work through the flow diagram over the page and then answer questions 2 and 3 below. 2. On completion of flow diagram is further action needed? No, no further action needed. Yes, go to question 3 3. Complete the table below to provide details of the actions required Action required By what date Responsible Person Policy Food Safety (Version 1) Page 19 of 21

Human Rights Assessment Flow Chart Complete text answers in boxes 1.1 1.3 and highlight your path through the flowchart by filling the YES/NO boxes red (do this by clicking on the YES/NO text boxes and then from the Format menu on the toolbar, choose Format Text Box and choose red from the Fill colour option). Once the flowchart is completed, return to the previous page to complete the Human Rights Act Assessment Form. 1.1 What is the Policy/decision title?.. 1 1.2 What is the objective of the Policy/decision?.. 1 1.3 Who will be affected by the Policy/decision?.. 1 Will the Policy/decision engage anyone s Convention rights? YES Will the Policy/decision result in the restriction of a right? 2.2 YES 2.1 NO NO Flowchart exit There is no need to continue with this checklist. However, o Be alert to any possibility that your policy may discriminate against anyone in the exercise of a Convention right o Legal advice may still be necessary if in any doubt, contact your lawyer o Things may change, and you may need to reassess the situation Is the right an absolute right? 3.1 YES NO 4 The right is a qualified right Is the right a limited right? YES 3.2 Will the right be limited only to the extent set out in the relevant Article of the Convention? 3.3 NO YES 1) Is there a legal basis for the restriction? AND 2) Does the restriction have a legitimate aim? AND 3) Is the restriction necessary in a democratic society? AND 4) Are you sure you are not using a sledgehammer to crack a nut? YES NO Policy/decision is likely to be human rights compliant BUT Policy/decision is not likely to be human rights compliant please contact the Head of Patient Experience, Inclusion and Diversity. Get legal advice Regardless of the answers to these questions, once human rights are being interfered with in a restrictive manner you should obtain legal advice. You should always seek legal advice if your policy is likely to discriminate against anyone in the exercise of a convention right. Access to legal advice MUST be authorised by the relevant Executive Director or Associate Director for policies (this will usually be the Chief Nurse). For further advice on access to legal advice, please contact the Complaints and Litigation Lead. Policy Food Safety (Version 1) Page 20 of 21

Supplementary Section C - Development and Consultation Process Record of Consultation Name of Policy: Food Safety Name of Policy Lead: Janet Mason Date: October 2014 Contact Details: 0114 2718350 Consultation Plan: Who will be significantly affected by the Policy (or need to implement it): All food handlers List staff groups, service users and carers, other stakeholders below: Nutritional Strategy Group, Ward Managers and Building Managers Is this a big change to a current policy or a new policy? Yes If NO If YES Consultation via email and discussion at relevant governance groups is sufficient Consider a wider consultation process e.g. with focus groups, attendance at team or directorate meetings RECORD OF CONSULTATION (interactive) Group or individual consulted Date of consultation/ response received Comments on draft policy Your response (say if policy amended if not, say why not) Standard reference to Service Users. Nutritional Strategy Group 15, 16 September & 6 October 2014 Additional information regarding takeaway meals. Information updated accordingly Minor re-wording Heads of Department No comments received Senior Housekeepers and Catering Supervisor No comments received Ward/Service Managers No comments received Policy Food Safety (Version 1) Page 21 of 21