All Trust policies are listed below. If you have any questions regarding our policies, or would like to access one for which there is no electronic version below, please email policy.governance@shsc.nhs.uk
All policies on this page are deemed to be current until replaced irrespective of their individual review date.
Please note all policies relating to the Mental Health Act are located under “M”.
Accessible Information and Communication Policy (NP 036 V1 June 2021) Extension to review March 2025
Accessing Legal Advice Policy (CG 003 V8 May 2022)
Affirming Gender Identity in The Workplace (HR032 V4 February 2024)
Agile Working Policy (HR053 V2 Feb 23)
Alcohol and Substance Misuse in the Workplace Policy (HR 004 V4 January 2024)
Antibiotic Policy for Inpatient Wards (MD 014 V8 December 2023)
Appraisal Policy for Medical Staff (MD 012 V6 December 2022)
Assessment of 16 and 17 year olds in the emergency department protocol
Capacity and Consent to Treatment Policy (November 2016)
Capacity and Consent to Care Support and Treatment Policy (NP 023 V7 November 2022)
Catering and Food Safety Policy (HR 022 V2 2019) - Extension to Review Dec 2022
Capital Programme Management Policy (FIN 011 v6 October 2024)
CCTV Policy (OPS 018 v1.4 January 2024)
Chaperone Policy (OPS 017 V1 March 2021) ext to September 2024
Chemical, Biological, Radiological, or Nuclear Emergencies (CBRNe) on SHSC sites Plan (V4 May 2022)
Clinical Audit Policy (MD 009 V5 November 2022)
Clinical Risk and Management of Harm Policy (NP 035 V2 October 2024)
Complaints Policy (CG010 V17 April 23)
Complex Case Management Policy (NP 042 V1.3 Dec 2021)
Confidentiality Code of Conduct Policy (IMST 011 V5 Feb 2023)
Counter Fraud, Bribery and Corruption Policy (FIN 010 V3 Dec 2021)
Data and Information Acceptable Use Policy (IMST 004 V1.3 Nov 2022)
Data and Information Asset Management Policy (IMST 005 V1.1 July 23) - Review date amended
Data and Information Governance Policy (IMST 002 V1.2 Nov 2022)
Data and Information Security Policy (IMST 003 V2 March 2022)
DBS Policy (CG 004 V6 September 2024
Decontamination Policy (FIN 017 V4 August 2024)
Delegation of Budgetary Authority Policy (FIN 018) Extension to Review August 2024
Dementia Protocol – Learning Disabilities Directorate
Dermatitis Policy (NP 033 V3 October 2024)
Deprivation of Liberty Safeguards Policy (NPCS 003 V8 October 2021) Extension to Review January 2025
Deteriorating Patient Identification and Management Policy (NP 045 v2 November 2023)
Diabetes Management Policy (V1 September 2023)
Disabled Staff Policy (HR 008 V3 October 2023)
Disciplinary Policy (HR 001 V6 December 2022)
Domestic Abuse Policy (NP 015 V8 September 2024)
Dress Code, Uniform and Appearance Policy (HR 024 V7 September 2023)
Dual Diagnosis Policy - Interim Review (OPS 007 V7 May 2024)
Duty of Candour and Being Open Policy (MD 010 V5 Dec 2021)
Dysphagia Management for Adults within SHSC Policy (MD 015 V1 March 2021)
Eligibility for NHS Funded Patient Transport Policy (EST 003 V3 July 2022)
Emergency Preparedness Resilience and Response (EPRR) Policy (OPS 005 V7.1 January 2024)
Employee Expenses Reimbursement Policy (HR 030 V4 April 2024)
End of Life Care, Policy and Procedure (NP 044 V2 June 23)
Equal Opportunities and Dignity at Work Policy (HR 031 V6 March 2024)
Establishing and Maintaining Therapeutic Relationships (NP 025 V2 2019)
Falls (Staff and Public) (HR 040 V9 Oct 2022)
Falls Inpatient Policy (OPS 016a V4 November 2023)
Freedom To Speak Up Raising Concerns (Whistleblowing) Policy ( HR 015 V7 February 2024)
Fire Safety Policy (EST 009 V8 April 23)
First Aid at Work Policy (DCE 002 V4 April 2024)
Fit and Proper Persons Policy (HR 047) Extension to Review September 2024
Implementation of NICE Guidance (Including Quality Standards) Policy (MD 019 v5 April 2020)
Income Collection Policy (FIN 015 V4 August 2023)
Induction Policy (HR09 V8.1 April 23) Extension to review December 2024
Inpatient Discharge Policy (OPS 016 V6.1 November 2023)
In-patient/Service User Escort Policy (v3 Nov 2016) - Second review date extension
Learning from Deaths Policy (MD 002 V5 April 2024)
Leave Policy (HR 028) Extension to Review November 2024
Local Clinical Excellence Awards Policy (HR 018 V3.1 June 2023) - Extended until April 2025
Lockdown Policy (OPS 013 V1.1 January 2024)
Long Service Awards Policy (February 2019) - Extension to review date April 23 2023
Lone Worker Policy (HR 052 V6 September 2024)
Losses and Special Payments Policy (FIN 013 V4 October 2023)
Low Voltage Electrical Safety Policy (EST 008 V4 April 2023)
Major and Critical Incidents Plan (OPS 004 V7 February 2022)
Management of Asbestos (EST 006 V4 July 2024)
Management of Contractors Policy (EST 005 V3 Oct 2022)
Management of Lifts Policy (EST 004 V2 Oct 2022)
Managing Access and Exit Policy 24 hour- bedded areas (OPS 14 V5 July 23)
Managing Allegations Against Staff Policy (NP 037 V3 April 2024)
Managing Conflicts of Interest in the NHS Policy (CG 001 V3 May 2024)
Managing and Supporting Employees Experiencing Domestic Abuse (HR 033 V5October 2023)
Managing Substance Misuse (MD 020 V4 October 2023)
Mandatory Training Policy (HR 036 V4 July 2022)
Marsipan Protocol (for management of seriously ill people with anorexia nervosa) (September 2014)
Media Policy (CG 002 V5 December 2023)
Medical and Therapeutic Devices Policy (MD 021 V6 June 2024)
Medicines Optimisation Policy (MD 013 V11 Feb 23)
Mental Capacity Act – Deprivation of Liberty Safeguards Policy (NPCS 003 V8 October 2021)
Mental Health Act – Allocation of a Responsible Clinician Policy (NP 021 V6 July 2022)
Mental Health Act – Associate Mental Health Act Managers (AMHAMs) Policy (NPCS 012 V3 July 2022)
Mental Health Act - Conveyance Policy (NPCS 002 V5 September 2024)
Mental Health Act, Equality and Human Rights Policy (NPCS 010 V4 June 2024)
Mental Health Act – Nominated Deputy Section 5(2) MHA 1983 Policy (NPCS 011 V6 September 2024)
Mental Health Act – Role of the Second Professional Mental Health Act 1983 (NPCS 013 V5 March 2022)
Mental Health Act – SHSC Scheme of Delegation
Mental Health Act – 1983 Section 17 Authorisation of Leave (Detained Patients) (NP 029 V5 Oct 2022)
Mental Health Act – Duty to Give Information Policy (NPCS 014 V5 July 2022)
Mental Health Act – Supervised Community Treatment Community Treatment Orders Guidance
Mental Health Act - Section 136 (NPCS 004 V1 July 2024)
Missing Absent Without Leave and Missing Patients Policy Final Review Date OPS 002 V3 Feb 2019
Pandemic Plan (OPS 006 V3 October 2022)
Parenting Leave Policy (HR 010 V3 March 2021) - extension to review November 2024
Patient Safety Incident Response Policy (MD023 v6 October 2023)
Password Policy (IMST 001 V4.2 March 23)
PDR Policy (HR 049 V6 Sept 2020)
Performance and Capability Policy (HR 025 V5.1 March 23)
Performance Development Review (Appraisal) Policy (HR 055 v8 March 2024)
Personal Relationships at Work Policy (HR 012 V4 April 2024)
Pest Control Policy (EST 001 V2 July 20)- extension to review date Jan 24
Physical Health Policy (NP 020 V8 April 2024)
Policy Framework (CG 006 V9 May 2024)
Preceptorship Policy (NP 028 V4 August 2023)
Prescribing and Administration of Emergency Oxygen in Adults in Hospital (MD 016 V4 Feb 2023)
Prevent Policy (NP 041 V3.1 April 2022)
Rapid Tranquillisation Policy and Guidelines for Inpatient Wards (MD 011 V7 July 2023)
Recording Policy (IMST 010 V1.3 Feb 2023)
Records Management Policy (IMST 008 V 3.2 May 2024)
Redeployment Policy (HR 049 V4 Nov 2023)
Redundancy Policy (HR 002 V4 February 2022)
Registration Authority (Smartcards) Policy (HR 045 V3 September 2023)
Relocation and Alternatives Policy (HR 037 V4 October 2023)
Remote Working & Mobile Devices (IMST 009 V2 May 2024)
Responding to Tenders Policy (FIN 006 V2 March 2021) Extension to review March 2024
Resuscitation Policy (NPCS 007 V5 February 2024)
Retention and Disposal Policy (February 2011)
Safeguarding Adults Policy (NP 40 V4 July 2023)
Safeguarding Children Policy (NP 017 V6 April 2022)
Safeguarding Supervision Policy (HR 039 V2 April 2022)
Searching of Persons, their Property and Environments Policy (OPS 013 V5 December 2022
Seclusion and Segregation Policy (NPCS 009 V9.2 March 2024)
Secondment Policy Review (HR 045 V3 May 2024)
Security Policy (FIN 009 V8 August 2023)
Service User Property and Money Policy (FIN 016 V3 August 2024)
Sexual Safety Policy (CG 008 V2 April 2022)
Smoke Free Policy (MD 005 V3 March 2021)- extension to review to March 2025
Social Media Policy (CG 007 V5 April 2024)
Speaking Up - Freedom To Speak Up Raising Concerns (Whistleblowing) Policy ( HR 015 V6 April 23)
Staff Leaving The Trust Policy (HR 035 V2 2024)
Stress Management at Work Policy (HR 006 V6 December 2021)
Study Leave Policy (HR 007 V6 July 2022)
Supervision Policy (NP 019 V4 July 23)
Supporting Attendance Policy (HR 042 V8 March 2023)
Unacceptable behaviours policy (HR48 V7 October 2023)
Use of Force Policy(NP 030 V6.1 April 2024)
Information for Victims Rights Policy (NP 024 v3 2019)
Ventilation Safety Policy (MD 024 V1 October 2023)
Visitors Policy (NP 081 V3 August 2023)
Visits by Children to Inpatient or Residential Care Settings Policy (NP 026 V5 December 2023)
Volunteer Policy (MD 004 V9 September 2023)