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Copy of Trust Policy

Governance of Artificial Intelligence

Dear Freedom of Information Officer,

I am writing to make a request under the Freedom of Information Act 2000.

I am a Research Associate for a Consultant Psychiatrist in the NHS, and this request forms part of academic research looking at how NHS mental health trusts approach the governance of artificial intelligence. As advocates for mental health, we hope this research will contribute to the evidence base that helps mental health trusts secure the funding they need.

I would be grateful if you could provide copies of the following, where they are held:

1. Any current policy, procedure, standard operating procedure, framework or guidance document governing the use of artificial intelligence, including generative AI and large language models, ideally with the document reference number and version where these are readily available.

I appreciate that AI may not have its own dedicated document; if it is instead addressed within your information governance, data protection, acceptable use of IT, email and internet, or clinical safety policies, the relevant policy or policies would be very helpful, and there is no need to pinpoint the specific section if that is not straightforward.

If no such policy exists, it would be useful to know whether one is currently in draft, if that information is recorded.

2. Any register, inventory or list of artificial intelligence systems currently deployed or being piloted by the Trust. I am very happy for any security-sensitive details to be redacted.

3. The terms of reference of any group, board, committee or design authority with responsibility for artificial intelligence governance, along with the minutes of its two most recent meetings.

4. Any guidance the Trust holds on the use of artificial intelligence, including ambient voice technology or AI scribing, with patients who may lack capacity to consent.

Where any of the above is not held, a simple confirmation of that would be entirely sufficient.

Electronic copies by email would be ideal.

Thank you very much for your time and assistance.

Yours faithfully

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Clinical Ethics Support

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Dear Gloucestershire Health and Care NHS Foundation Trust,

This is a Freedom of Information request. With respect to your organisation:

1. Please provide the date when your medical device (as defined by MHRA, i.e. also including relevant software) procurement policy (or policies, if you e.g. have a separate one for medical software) was/were last updated.

2. Please state whether the policy (mentioned in point 1 above) requires that a clinical ethicist should be consulted during purchase decisions (if a clinical ethicist is only needs to be consulted under certain conditions, please list these). A clinical ethicists is defined as a member of your clinical ethics committee (under whatever name it operates in your organisation, but this does not include research ethics committees) or an academic with a dedicated post in ethics or a permanent staff members explicitly employed to provide clinical ethics support.

3. If the policy requires ethical issues to be considered during such devise purchase decisions, but not via input of a clinical ethicist as defined above, please state the mechanisms in place for fulfilling that requirement.

4. Please state whether you had clinical ethicist (as defined above) involvement in the purchase of any clinical artificial intelligence applications irrespective of whether this is mandated by your policy.

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Gloucestershire Adult Autism and ADHD Service Policies

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Under the Freedom of Information Act, I would like to request the following information:

1. All policy documents in respect of Gloucestershire Adult Autism and ADHD Service’s non-recognition of private diagnoses in respect of ADHD and autism assessments, which were relevant in the period 1 January 2021 to date.

2. All equalities and diversity assessments conducted in respect of the policy documents in point 1.

3. All supporting documents referred to in the policy documents and assessments in points 1 and 2.

4. Any internal discussion documents or minutes regarding potential changes to the policy documents and assessments in points 1 and 2.

I would like you to provide the information in electronic documents by email to the above address. If some documents will take longer to obtain, I should be grateful if you would provide an interim response with the documents that are available at that time.

Please contact me at the above email address if you need to clarify.

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Hypertension (High Blood Pressure) Resources

I am making a Freedom of Information Request to your NHS Trust, requesting the following:

• A copy of all educational literature resources (e.g. Word documents, powerpoints, Patient Information Leaflets, written Advice and Guidance documents etc.) that are distributed, or presented, to patients within your Trust relating to the management of Hypertension (High Blood Pressure), either in community-based or hospital-based settings.

I am disclosing a disability under the Equality Act, and have attached a picture of my Blue Badge, along with my Photo Identification and Proof of Address (Council Tax Exemption Letter), to confirm this.

I request under the Equality Act that I am provided with any correspondence regarding my Freedom of Information Request, including acknowledgements and the data itself, to be provided in hard-copy to my address below:

Joseph Dixon
17 Brandenburg Road
Corby
Northamptonshire
NN18 9BU

This is owing to the fact that I am unable to comprehend complex data off of a screen. I therefore request that all responses and data are provided to me in hard-copy, and where possible in Large Print and/or Easy Read format (e.g. Ariel Size 16). Where conversion into large print is not easily possible for certain documents, please send what you have in hard-copy so I can use physical devices such as a magnifier to comprehend them.

Yours sincerely,

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Policies, Procedure and Guidance Documents – Information Requests

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Dear Freedom of Information Team,

Please treat this email as a request under the Freedom of Information Act 2000.

I request copies of any current policies, procedures, guidance documents, protocols, frameworks or standard operating procedures used by Gloucestershire Health and Care NHS Foundation Trust relating to:

• the handling, assessment and processing of Police DP1 requests
• disclosure of personal data to police or law enforcement agencies
• proportionality and necessity assessments relating to disclosures to law enforcement bodies
• governance or approval processes for disclosures to police forces in relation to misconduct or disciplinary matters
• Caldicott Guardian involvement in external disclosures
• information governance procedures relating to law-enforcement requests
• complaints procedures relating to information governance or data-sharing concerns
• staff conduct on social media platforms
• online professionalism and online communications involving members of the public
• bullying, harassment, dignity at work, or inappropriate staff conduct
• and communications or reputational guidance applicable to staff use of social media.

Please also provide copies of any guidance, templates, checklists or decision-making frameworks used by staff when assessing requests for disclosure from police forces.

If the Trust does not maintain any local policy in respect of the above, please identify any national NHS guidance, NHS England standards, codes of conduct or external frameworks relied upon when assessing complaints relating to staff conduct on social media platforms or online interactions involving members of the public.

If any of the requested information is already publicly available, please provide links to the relevant documents.

If any part of this request is considered exempt from disclosure, please identify the specific exemption relied upon and provide any disclosable material in redacted form where appropriate.

Kind regards,

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Therapeutic Observations

Hi,

I am undertaking a project looking at therapeutic observations, and comparing policies from different mental health trusts/providers.
Please could I ask you to send me a copy of your observation policy?
Thanks in advance.

Kind regards,

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Seclusion Practices

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To whomever this concerns,

I’m an MSc student studying Clinical and Health Psychology at the University of Manchester.

I’m currently conducting a research project as part of my degree, where I am exploring seclusion practices in the NHS.

The data from this request would be used as part of my analysis, and, therefore, would be greatly appreciated.

Please could you send me all the trust policies related to seclusion practices?

For example: in what circumstances these practices should be used; how they should be used; staff training; any guidance on ensuring practice is trauma-informed; and how the process is monitored or reviewed.

I would like to make it clear that this request is not for any individualised patient data.

Please be assured that your Trust’s name will be anonymised as part of my analysis.

Kind regards,

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Seclusion Practices

To whomever this concerns,

My name is Eleanor Anderson, and I’m an MSc student studying Clinical and Health Psychology at the University of Manchester. I’m currently conducting a research project as part of my degree, where I am exploring seclusion practices in the NHS.

The data from this request would be used as part of my analysis, and, therefore, would be greatly appreciated.

Please could you send me all the trust policies related to seclusion practices? For example: in what circumstances these practices should be used; how they should be used; staff training; any guidance on ensuring practice is trauma-informed; and how the process is monitored or reviewed.

I would like to make it clear that this request is not for any individualised patient data.

Please be assured that your Trust’s name will be anonymised as part of my analysis.

Kind regards,

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Clinical Risk Assessment & Management and or Suicide Prevention

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Hello Gloucestershire Health and Care NHS Trust FOI team,

I am writing to you under the Freedom of Information Act 2000 to request the following information from Gloucestershire Health and Care NHS Trust’s freedom of information department. Please may you provide me with:

1. A copy of your Policie(s)/ procedures, strategies and or any clinical guidance relevant to mental health care pertaining to clinical risk assessment and management and or suicide prevention.
2. Do you use any triage tools, rag rating or scales to stratify clinical risk?
2.1. If Yes, do they inform care in any way including different tiers.
2.2. If Yes please provide a copy.

Please provide the information in the form of word documents or if not possible pdf files.

If it is not possible to provide the information requested due to the information exceeding the cost of compliance limits identified in Section 12, please provide advice and assistance, under the Section 16 obligations of the Act, as to how I can refine my request.

If you can identify any ways that my request could be refined, I would be grateful for any further advice and assistance.

If you have any queries please don’t hesitate to contact me via email and I will be very happy to clarify what I am asking for and discuss the request, my details are outlined below.

Thank you for your time and I look forward to your response.

Best wishes,

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Discharge of Patients who have not Engaged and/or have not Attended Appointments

Dear Sir,

FOI Discharge of patients who have not engaged and/or have not attended appointments

1) Please disclose all versions of your policies on the management and discharge of patients who do not attend appointments (DNAs) and/or who disengage from care for the period 2022-2026 YTD

2) The trust previously disclosed to another FOI requestor that it discharged a total of 27,497 patients in the period 2019 to 2024 because they did not attend appointments or did not engage with care.

This is a link to the previous FOI request and trust response:

https://www.whatdotheyknow.com/request/discharges_from_mental_health_se_20

Please disclose:

a) Whether the trust audits if such discharges for non-attendance/non-engagement to check if they are safe and in compliance with trust policies

If so, please disclose a copy of the clinical audit protocol and the results of any clinical audits undertaken in the last two years

b) Whether the trust reviews whether such discharges for non-attendance/non-engagement are ever followed by near misses or serious incidents?

If so, please disclose the policy or procedures governing this work, and the results of any such reviews undertaken in the last two years

c) If the data is held centrally and can be provided within FOIA limits, has inappropriate discharge of destabilising and disengaging patients been identified as a factor in serious incidents (completed suicide and homicide) in the last two years?

Yours,

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SAR / Information Sharing Policy

Dear FOI team,

Under the FOI Act, please can you provide the following:

1. A copy of your Trusts SAR Policy and Information Sharing Policy
2. Copies of SOPs or documents used for training and guidance to your SAR staff (or the staff that processes SARs on behalf of the Trust) e.g. reviewing for third party material, recognising a SAR etc.
3. The number of WTE employed in your SAR teams, including A4C banding
4. The structure for SAR team
5. Compliance rate for the following calendar years: 22, 23, 24, 25(thus far)

Thank you

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Paternity Leave Policies and Data

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Dear Gloucestershire Health and Care NHS Foundation Trust,

I would please like to know:

1) Your parental leave policies, including paternity leave and pay and maternity leave and pay. If you have different policies for medical and non-medical staff, please include all different policies.

2) In the last three years for which you have data, how many staff members were eligible for paternity leave?

3) In the last three years for which you have data, how many staff members took paternity leave, and for how many weeks on average?

4) In the last three years for which you have data, what was the average salary for staff who were eligible for paternity leave? (If it is not possible to provide this, please provide the average salary for all the trust’s staff instead)

For queries 2 – 4, please provide separate data for medical and non-medical staff, but if this is not possible, please provide combined data for both instead.
If you are unable to answer all of these questions, please prioritise answering them in order.

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Advanced Decision to Refuse Treatment / Lasting Power of Attorney

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Freedom of Information Request

1. Do you have a policy (or policies) which outlines the responsibilities of health and care professionals and the Trust towards a patient who has an Advance Decision to Refuse Treatment (ADRT) or Lasting Power of Attorney (LPA) for Health and Welfare?

This document might include:

– how an ADRT/LPA should be used in decisions about a person’s treatment,

– what to do if there are doubts about the validity and/or applicability of the document,

– how to involve Health and Welfare Attorneys when making treatment decisions

– how or when decisions will be referred to the Court of Protection

If yes, please share a copy with us in any available format.

2. In the event that a patient or family member, or someone using the Trust’s services has a concern about the implementation of an Advance Decision to Refuse Treatment (ADRT) or a Lasting Power of Attorney (LPA) for Health and Welfare, does the Trust/Health Board have a documented process or course of action that would be provided to the person to allow them to resolve their concerns?

If yes, please share a copy with us.

If this information is covered within a policy you have included in the response above, please leave blank.

3. Do you have a named individual who is responsible for overseeing the Trust’s compliance with the Mental Capacity Act 2005?

If yes, please share their contact details.

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NHS Uniform Policy

We are a law firm and act for Health Workers 4 Palestine (“HW4P”), a private company limited by guarantee (Company number: 15544250). HW4P advocates for the rights of Palestinian health workers, and its aims include ensuring that healthcare workers are protected and supported globally during humanitarian crises and armed conflict.

The purpose of this letter is to submit a FOIA request on HW4P’s behalf, expeditious compliance with which is necessary for its vital work.

Request for Information

1. Please disclose any correspondence received by your organisation (including by your chief executive) in the last 6 months from NHSE regarding (i) uniform policy, (ii) use of political symbols by NHS staff.

2. Please disclose any new uniform policy for your organisation from the last 6 months, including policies which are in draft and not yet published or implemented.

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Policy Alignment with Supreme Court Ruling on Biological Sex

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The recent Supreme Court ruling in ‘For Women Scotland vs The Scottish Ministers’, clarified the meaning of ‘sex’ in the Equality Act 2010 as ‘biological sex’. The Equality and Human Rights Commission states:

‘This means that, under the Act:
A ‘woman’ is a biological woman or girl (a person born female) A ‘man’ is a biological man or boy (a person born male) If somebody identifies as trans, they do not change sex for the purposes of the Act, even if they have a Gender Recognition Certificate (GRC).
A trans woman is a biological man
A trans man is a biological woman’

Please set out what action(s) you have taken in your NHS Trust to ensure that each of the following aligns with the Supreme Court ruling and, in consequence, with the Equality Act 2010:

1) Gender reassignment and/or transgender guidance and policies relating to staff
2) Gender reassignment and/or transgender guidance and policies relating to patients
3) Policies on same sex accommodation
4) Related Equality Impact Assessments

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Policy Compliance

In accordance with the Freedom of Information Act, please could you answer the following questions –

Who holds trust wide responsibility for the maintenance of procedures and policies?

What is their name and email address?

What digital tools does the Trust use for the staff to reference these procedures and policies? – i.e. – intranet.

How does the Trust record that staff have read and comply with the procedures and policies?

Which tools are used for on-boarding new staff in relation to reading procedures and policies?

How do the heads of department monitor that clinical and non clinical staff have read/understood mandatory procedural updates?

How many staff have accessed your NHS Intranet in the past year?

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Policies

I write to make a formal request under the Freedom of Information Act 2000 for access to the following information held by Gloucestershire Health & Care NHS Foundation Trust:

I. Care of the Deteriorating Patient Policy
II. Digital Call Recording Policy
III. CLP247 Assessment and Care Management Policy
IV. CLP005 Health Records and Clinical Record Keeping Policy
V. Mental Health Intermediate Care Team (MHICT) Operational Policy v10
VI. Supporting Attendance Policy and Procedures
VII. Home Working Policy (Final)
VIII. Improving Performance Policy and Procedure v4
IX. Disciplinary Policy and Procedure v3
X. Core Assessment Form(s) within RiO
XI. Maxwell Centre/Suite Checklist Form
XII. Improving Access to Psychological Therapies (Let’s Talk) Operational Policy – including assessment and treatment guidance/policy for therapeutic approaches such as Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), and Eye Movement Desensitisation and Reprocessing (EMDR).

Note: Please provide any policies, guidance, or procedures that were introduced, in use, or updated between April 2023 and September 2023. If specific documents from that period are unavailable, please provide the closest available version, and specify the time frame during which it was in use, as well as the date it was withdrawn, if known. Additionally if a policy has since been entirely replaced, updated, or changed, kindly provide the most recent version of that policy. And:
XIII. Multi-Agency Section 136 Policy, Procedure, and Guidance (only if it has been reviewed or updated as part of the Right Care, Right Person approach).

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IG and IT Policies, NHS Policies for Email Storage at the Trust

1. What is the email retention policy at your trust for official NHS clinical staff emails related to patient care. Also, what is the retention policy for deleted clinical emails, deleted by staff from their mailbox?

1a) Does your trust require that clinical emails related to patient care be placed in the patient’s record?

2. What is the back-up policy at your trust for backing up clinical staff/doctor’s emails related to patient care? How often are the clinical emails backed-up and how long are the back-ups kept? Are the back-ups automated?

3. Are deleted clinical emails (deleted by staff) recoverable on the email system at your trust, either from onsite or offsite storage? How long after the emails are deleted by staff, can the emails be recovered from the different locations they are stored?

4. Your trust uses nhs.uk email so NHSMail helpdesk cannot assist with forensic discovery of emails. Hence, does your trust perform a forensic discovery equivalent to the forensic discovery provided by NHSmail help desk to retrieve deleted NHSmail (dot net) emails up to 2 years after they were created/sent even if deleted prior to 2 years by staff?

ie Can your trust retrieve deleted nhs.uk emails up to 2 years after they were created/received?

5. Do your doctor’s have the ability to permanently delete emails from all locations without IT system administrative privileges? Do the doctors at your trust have IT system administrative privileges?

6. When emails are deleted by clinical staff without significant knowledge and access rights, there are other possible places where the deleted emails can be recovered from: For example, local offline storage, where emails are cached on the local machine in an offline storage file (OST) which even when emails are deleted from the mailbox, can leave fully recoverable items, unless the OST file is forensically destroyed. Does your trust maintain an email OST for the staff NHS emails?

7. Are clinical staff emails archived off into different locations? If yes, what are these locations.

8. Can your trust IT team identify and create a log of emails deleted by a specified doctor working at your trust? How long after email deletion can the log still be created?

9. When emails are deleted on the local staff computer and need to be retrieved, administrators can perform a search across the entire MS 365 environment to establish the presence of any of these emails in other user mail-boxes and non-email storage locations – is this a process that your trust can perform via the IT team or other team?

10 If staff emails related to patient’s clinical care are requested under DPA 2018 SAR, what is the IT process undertaken at your trust to identify and retrieve the emails. Are offline storage searched and all locations as mentioned in this FOI or only the staff local computer/mailbox? Can you retrieve clinical emails requested under SAR DPA 2018 for up to 2 years after creation/send even if the staff have deleted them?

11) NHS’s data retention and information management policy states that “an email will be retained and available for forensic discovery in NHSMail for two years after it was sent/received or until it is deleted from the mailbox by staff, whichever is later.” Does your trust adhere to this policy with your nhs.uk email system? ie your trust must be able to retrieve a clinical email for 2 years after it was created or sent, even if it was deleted by staff prior to 2 years – NHSMail helpdesk cannot assist – so does your IT team have a process to ensure compliance with NHS’s policy highlighted above?

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Policies about Mental Health and Learning Disability

I am making this request under the Freedom of Information Act 2000.

I understand from the CQC’s registration directory, and your website, that you operate one or more ‘mental health units’, defined by the Mental Health (Use of Force) Act 2018, and that one or more of these units is either providing mental health inpatient services for people with learning disabilities, or sometimes accommodates people with learning disabilities as part of a wider adult mental health services

Request 1.

Following a previous FOI for ‘restraint policies’, please provide any adaptations of restraint-related policies, or procedures, for people with learning disabilities, e.g. easy read guidance. We are particularly interested in sourcing good practice in how people with learning disabilities are supported when they come into NHS mental health units.

Request 2.

Please could you list the ‘mental health units’ as defined above, which provide treatment to people with learning disabilities, either exclusively, or as part of wider adult services.

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Personal Carers in Trust Sites

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1. Does your hospital trust allow patients to have their Personal Assistant/paid carers assist them in hospital settings?
2. Does your trust have a protocol or policy in place regarding Personal Assistants/paid carers assisting with complex care needs in hospital settings? What is it?
3. Does this policy apply both to admissions as well appointments and treatments as a day patient?
4. How many times in the last 3 years has a patient had their care needs met by their usual PAs/paid carers whilst in hospital?

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249-2024

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1. Has the trust received written advice or guidance from NHS England setting out how to comply with the NHS sexual safety charter? Please answer yes or no.
1.1 If yes, please set out what advice or guidance NHS England provided, or provide a copy of it.

2. Point 10 of the NHS sexual safety charter states: “We will capture and share data on prevalence and staff experience transparently.” If you answered yes to question 1, has NHS England provided written advice or guidance as to how the trust should record the prevalence of unwanted, inappropriate and/or harmful sexual behaviour in order to comply with point 10 of the charter? Please answer yes or no.

2.1 If yes, please set out what advice or guidance NHS England has provided, or provide a copy of it. Specifically, please clarify whether this guidance prescribes what sexual harm data the trust should record, and how to record it? For example, does it stipulate that the trusts should record specific categories of sexual harm, such as patient-on-staff or staff-on-patient incidents? If so, please provide details.

3. If the trust has received no guidance from NHS England as to how to record the prevalence of unwanted, inappropriate and/or harmful sexual behaviour, how does the trust currently record these incidents?

3.1 Does the trust record and centrally collate all types of sexual safety incidents? Please answer yes or no.

3.2. Which of the following categories of incidents does the trust record and centrally collate. Please answer yes or no:

• Patient-on-staff incidents
• Staff-on-staff incidents
• Patient-on-patient incidents
• Staff-on-staff incidents
• Visitor-on-staff incidents
• Visitor-on-patient incidents
• Patient-on-visitor incidents
• Staff-on-visitor incidents

3.3 Does the trust record any other categories of incidents, such as incidents perpetrated by members of the public? If so, please provide details of these categories.

4. Is the trust fully compliant with all 10 points of the sexual safety charter?

4.1. If yes, when did the trust become fully compliant?

4.2 If no, what points of the charter has the trust yet to comply with; and when does the trust expect to become fully compliant with the charter?

5. Has the trust’s compliance with the charter been assessed or audited by NHS England? Please answer yes or no.

5.1 If yes, what were the findings of that assessment or audit? Was the trust deemed to be fully compliant, partially compliant or not compliant?

5.2 If yes, when was the assessment or audit carried out and when did the trust receive its findings?

6. Has the trust undertaken any internal audits or assessments of its compliance with the sexual safety charter? Please answer yes or no.

6.1 If yes, what were the findings or this assessment or audit?

6.2 If no, does the trust have plans to conduct an audit or assessment of compliance?

6.3 If you answered yes to 6.2, when does the trust plan to conduct this assessment or audit of compliance?

7. Does the trust keep centralised records of child abuse committed on the trust premises? Please answer yes or no

8. Which incident and risk reporting system does the trust use to record sexual unwanted, inappropriate and/or harmful sexual behaviour? (For example, Datix or Ulysses.)

9. Has the trust appointed a domestic abuse and sexual violence (DASV) lead? Please answer yes or no.

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