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 e-mail policies

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 now located under “M”.


Absent Without Leave and Missing Patients Policy (September 2016)

Accessing Legal Advice Policy (March 2018)

Admission of 16 and 17 year olds to an Adult Mental Health Ward Policy (May 2018)

Advance Decisions to Refuse Treatment/Advance Statements (v2 2019)

Adverse Weather and Other Emergency Conditions Plan (OPS O10 v7 2019)

Aggression and Violence Policy: Respectful Response and Reduction (November 2016)

Aggression and Violence: protocol for tackling violence and anti-social behaviour within in-patient areas

Alcohol and Substance Misuse in the Workplace Policy (Jan 2019)

Appraisal Policy For Medical Staff (MD 012 v4 2019)


Back Care and Manual Handling Policy (October 2016)

Blanket Restrictions Policy (May 2018)

Bullying and Harassment Policy (v5 2019)

Bullying and Harassment Managers Guide

Bullying and Harassment Complaint Report

Business Continuity Policy (OPS 003 v1 March 2019)


Capability Policy (HR 025 v4 2019)

Improvement Plan Objectives Form (Word)

Capacity and Consent to Treatment Policy (November 2016)

Capital Programme Management Policy (January 2019) 

Career Break Scheme Policy (v3 2019)

Career Break Application Form (Word)

Catering and Food Safety Policy (HR 022 v2 June 2019)

Central Alert System (CAS) Policy (September 2016)

Chemical, Biological Radiological or Nuclear (CBRNe) Emergencies on SHSC Sites Plan (OPS 008 v3 2019)

Claims Policy (September 2016)

Clinical Audit Policy (MD 009 v4 June 2019)

Clinical Professional Registration Verification Policy (November 2016)

Clinical/Professional Supervision and Reflective Practice Policy (NP 019 v2 2019)

Appendix A – Supervision Contract

Appendix B – Template Record of Clinical Professional Supervision

Appendix C – Supervision Passport for Clinical Staff

Professional Registration Update Form

Complaints Policy (October 2016)

Confidentiality Code of Conduct (September 2016)

Control of Substances Hazardous to Health Policy (HR 016 v3 2018)

Conveyance and Assistance Policy (October 2017)

Criminal Records Checking Disclosure and Barring Service Policy Procedure (CG 004 v3 March 2018)


Decontamination Policy (October 2016)

Delegation of Budgetary Authority (April 2019)

ASD User Form Guidance

ASD User Registration Form (Word)

Authorised Signatory Limits Guidance

Authorised Signatory Limits Form (Word)

Dementia Protocol – Learning Disabilities Directorate

Development, Management and Review of Policies (May 2018)

Difficult to Engage Service Users (November 2017)

Disciplinary, Capability, Ill Health and Appeals for Medical Practitioners Policy (MD 001 November 2018)

Disciplinary policy (HR 001 September 2017)

Display Screen Equipment Policy (October 2016)

Eyesight Test Request Form (Word)

Domestic Abuse Policy (NP 015 v5 June 2019)

Dress Code, Uniform and Appearance Policy (HR 024 v3 June 2019)

Dual Diagnosis Policy (OPS 007 v5 June 2019)

Duty of Candour and Being Open Policy (MD 010 v4 June 2019)


ECT (Electroconvulsive Therapy) (MD 008 v5 March 2019)

ECT Booklet

ECT Consent Form

Information Leaflet for Patients Receiving Out-Patient ECT

Mini Mental State Examination

Eligibility Criteria for NHS Funded Patient Transport (April 2014)

Frequently Asked Questions (June 2014)

Emergency Preparedness Resilience and Response (EPRR) Policy (OPS 005 v6 March 2019)

Fuel Shortage Contingency (OPS O11 v7 2019)

Heatwave Plan (OPS 009 v3 2019)

Lockdown Plan

Major and Critical Incidents Plan (OPS 004 v6 March 2019)

Pandemic Flu Plan (OPS 006 v2 April 2019)

Plan for Chemical Biological Radiological or Nuclear (CBRN) Emergencies on Trust Sites

Plan for a Total Evacuation of an SHSC Inpatient Site

Team Business Continuity Plan Guide

Team Business Continuing Plan Template

Team Business Continuity Plan Template (Word Version)

Employee Expenses Reimbursement Policy v1 March 2015

Equal Opportunities and Dignity at Work Policy (October 2016)


Falls (in-patient and residential areas) (MD 007 v2 Jan 2019)

Fire Safety Policy (July 2017)

Flexible Working Policy (May 2019)

Appendix A: Flexible Working Arrangements Application Form

Appendix B: Flexible Working Arrangements Acceptance Form

Appendix C: Flexible Working Arrangements Rejection Form



Gender Reassignment Workplace Policy (October 2016)

Grievance Policy (HR 027 v3 2019)

Dignity at Work Joint Statement


Handling Lost Property Policy (February 2019)

Hardship Salary Advance Policy (April 2019)

Health and Safety Policy (July 2017)


Implementing NICE Guidance (including Quality Standards) Policy (November 2016)

Incident Management Policy and Procedure (including Serious Incidents) (September 2016)

Incident Categories

Incident Report Form (Word)

Income Collection Policy (April 2019)

Induction Policy (December 2017)

Infection Prevention and Control (NPCS 005 v7 July 2018)

Infection Prevention and Control Standard Precautions – Prevention of Sharps Injuries and Prevention of Exposure to Blood and Body Fluids (March 2018)

Inpatient Discharge Policy (November 2016)

Inpatient Escort Policy (November 2016)

Intellectual Property Management Policy (December 2017)

Interagency Information Sharing Protocol (June 2017)


Job Share Scheme Policy (November 2016)

Joint Working Mental Health and Learning Disability (December 2006)


Latex Sensitisation Policy (August 2017)

Learning from Deaths policy (MD 002 v3 June 2019)

Leave Policy (HR 028 v3 2019)

Leave Document – Annual Leave Record

Leave Document – Jury Service

Leave Document -Special Circumstances

Additional Annual Leave Scheme Application Form – April 2017 to March 2018

Additional Annual Leave Scheme FAQs – April 2017 to March 2018

Ligature Risk Reduction Policy and Procedure (November 2017)

Safety Assessment in Patient accessible areas (includes Assessment of Ligature Points)

Local Clinical Excellence Awards Policy (HR 018 v2.1 January 2019) 

Long Service Awards Policy (February 2019)

Lone Worker Policy (June 2014)

Losses & Special Payments Policy (March 2018)

Low Voltage Electrical Safety Policy (April 2017)


Major and Critical Incidents Plan (OPS 004 v6 March 2019)

Management of Asbestos Policy (September 2015)

Management of Dysphagia for Adults with a Learning Disability Policy (November 2016)

Managing Access and Exit Policy (July 2016)

Managing and Supporting Employees Experiencing Domestic Abuse (October 2016)

Managing Substance Misuse and Harmful Substances on Inpatient Wards Policy (November 2016)

Mandatory Training Policy (October 2016)

Marsipan Protocol (for management of seriously ill people with anorexia nervosa) (September 2014)

Media Policy (December 2017)

Medical Devices Policy (November 2016)

Medicines Management Policy (October 2018)

Mental Capacity Act – Deprivation of Liberty Safeguards Policy (November 2017)

Mental Health Act – Allocation of a Responsible Clinician Mental Health Act 1983 (NP 021 v5 2019)

Mental Health Act – Associate Mental Health Act Managers AMHAM (NPCS 012 v3 January 2019)

Mental Health Act – Code of Practice Equality and Human Rights Policy (NPCS 010 v2 July 2018)

Mental Health Act – Nominated Deputy: Section 5 (2) of the Mental Health Act 1983 (NPCS 011 v4 July 2018 amended November 2018)

Mental Health Act – The Role of the Second Professional Mental Health Act 1983 (NCPS 013 v4 Mar 2019)

Mental Health Act – SHSC Scheme of Delegation

Mental Health Act Section 23 – Hospital Managers Review of Detention or Community Treatment Order Under Section 23 Mental Health Act 1983 (NP 022 v4 2019)

Mental Health Act – Section 17 Authorisation of Leave Policy (November 2016)

Mental Health Act – Duty to Give Information Under Section 132, 132A and 133 Mental Health Act 1983 (NCPS 014 v4 Mar 2019)

Mental Health Act – Supervised Community Treatment Community Treatment Orders Guidance

Mobile Phones, Communication Devices and Internet Access for Service Users Policy (October 2016)


Non NHS Income Policy (December 2017)


Organisational Change Policy (v2.1 October 2018)

Overpayments Policy (HR 029 v1 2019)


Parenting Leave Policy  (December 2017)

PDR Policy (April 2017)

Personal Files Policy (October 2016)

Personal Search Policy (June 2017)

Preceptorship Policy (October 2016)

Prescribing and Administration of Emergency Oxygen in Adults in Hospital Policy (November 2016)

PREVENT Strategy Policy (February 2016)

Promoting Attendance and Managing Sickness Absence Policy (April 2017)

Protection of Pay and Conditions of Service Policy (December 2017)


Rapid Tranquilisation Policy (v5 November 2016)

Records Management (IMST 008 v3 August 2018)

Records Management Policy – Information Governance Alliance Code of Practice 2016

Recruitment and Selection Policy (HR 019 v4 February 2019) 

Redeployment Policy (May 2017)

Redundancy Policy (September 2017)

Registration Authority (Smartcard) Policy (v1.1 May 2019)

Relationships Between Service Users And Staff Policy (November 2009)

Relocation and its Alternatives Policy (October 2016)

Responding to National Confidential Inquiries Policy (November 2016)

Resuscitation Policy (NPCS 007 v2.1 2018) 

Retention and Disposal Policy (February 2011)

Retirement Policy (November 2017)

Appendix G – Retirement Memo 

Appendix H – Gift Buffet Procedure

Pre-Retirement Course Details


Safeguarding Adults and PREVENT Policy (NP 016 v1 June 2019)

Link to the South Yorkshire Safeguarding Adults Board Procedures Manual

Safeguarding Children Policy (NP 017 v5 June 2019)

Link to the South Yorkshire Child Protection Procedures

Link to the Sheffield Safeguarding Children Protocols

Seclusion Policy (NPCS 009 v6 May 2018)

Secondment Policy v1 March 2016

Secondment Policy Appendices

Security Policy (FIN 008 v7 December 2018)

Security: Aggression and Violence: protocol for tackling violence and anti-social behaviour within in-patient areas

Slips, Trips and Falls Policy (Staff and the Public) (October 2016)

Smoke Free and Nicotine Management Policy (April 2018)

Social Media for Staff Policy (August 2016)

Speaking up – Freedom To Speak Up Raising Concerns Whistleblowing Policy (HR 015 v2 October 2018)

Stress management at work policy (HR 006 October 2017)

Study and study leave policy (HR 007 October 2017)

Sustainable Development Management Plan (June 2015)

Sustainable Procurement Policy (FIN 009 v2 December 2018)


Transfer of Clinical Care Duties Policy (November 2016)

Transition of Young People from CAMHS to Adult Mental Health Services (April 2015)

Transport Policy (September 2015)

Eligibility Criteria for NHS Funded Patient Transport (April 2014)

Frequently Asked Questions (June 2014)

Treasury Management Policy (FIN 007 v2 December 2018)


Victims Rights Policy (November 2016)

Visitors Policy (NP 018 v1.1 June 2019)

Visits By Children Policy (November 2016)

Visits Inspections and Accreditations by External Agencies Policy  (September 2016)

Volunteers Policy (March 2018)


Water Quality Policy (September 2015)

Work Experience (Widening Participation) Policy (HR 017 v1 February 2019)

Working in Uganda Policy (May 2016)

Working Time Regulations Policy (HR 023 v4 June 2019)

WTR Worker Assessment

WTR Opt Out Form


Zero Tolerance of Harassment Policy (September 2016)

Terms and Conditions

Guest WiFi Terms and Conditions