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 (v2 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)

Antibiotic Policy (v5 September 2019)

Appraisal Policy For Medical Staff (MD 012 v4 2019)


Back Care and Manual Handling Policy (V8 October 2016)

Blanket Restrictions Policy (May 2018)

Bullying and Harassment Policy (v5 2019)

Business Continuity Policy (OPS 003 v1 March 2019)


Capability Policy (HR 025 v4 2019)

Capacity and Consent to Treatment Policy (November 2016)

Capital Programme Management Policy (January 2019) 

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

Capacity to Consent to Care, Support and Treatment Policy (NP 023 v6 2019)

Central Alert System (CAS) Policy (V2 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)

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)


Data and Information Acceptable Use Policy (IMST 004 v1.1 Nov 2019)

Data and Information Sharing Policy (IMST 007 v1.2 Nov 2019)

Decontamination Policy (FIN 017 v3 Oct 2019)

Delegation of Budgetary Authority (April 2019)

Dementia Protocol – Learning Disabilities Directorate

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 (HR 039 V4 Oct 2019)

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)

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

Employee Expenses Reimbursement Policy (October 2019)

Employment Break Policy [Formerly Career Break Scheme Policy] (HR 041 v4 Nov 2019)

Employment Break Policy – Appendix A – Application Form (Word)

Equal Opportunities and Dignity at Work Policy (October 2016)

Establishing and Maintaining Therapeutic Relationships with Service Users/Patients/Carers (NP 025 v2 2019)


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

Falls (Staff and Public) (HR 040 v8 Oct 2019)

Fire Safety Policy (July 2017)

Flexible Working Policy (May 2019)



Gender Reassignment In The Workplace Policy (HR 032 V3 Sept 2019)

Greenlight for Mental Health Policy (OPS 012 V1 2019)

Grievance Policy (HR 027 v3 2019)


Handling Lost Property Policy (February 2019)

Hardship Salary Advances (FIN 014 v1.3 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)

Income Collection Policy (FIN 015 v2 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 (October 2019)

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 July 2019)

Ligature Risk Reduction Policy and Procedure (MD 003 V4 Oct 2019)

Safety Assessment in Patient accessible areas (includes Assessment of Ligature Points)  (Oct 2019)

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

Lockdown Policy (OPS 013 V1 Oct 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 (EST 006 v2 2019)

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 (HR 033 V4 Sept 2019)

Managing Substance Misuse and Harmful Substances on Inpatient Wards Policy (September 2019)

Mandatory Training Policy (October 2019)

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

Media Policy (December 2017)

Medical Devices Policy (November 2016)

Medicines Optimisation Policy Risks and Processes (September 2019)

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 (NP 029 v4 Oct 2019)

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 Management Policy (HR – v3 2016)

Personal Search Policy (June 2017)

Policy on Policies Policy (CG 006 v7 2019)

Preceptorship Policy (NP 028 V3 2019)

Prescribing and Administration of Emergency Oxygen in Adults in Hospital Policy (September 2019)

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 v3.1 Nov 2019)

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)

Relocation and Alternatives Policy (HR 037 V3 Sept 2019)

Remote Working and Mobile Devices Policy (IMST 009 v1.8 Nov 2019)

Responding to National Confidential Inquiries and Other National Inquiries and Reviews Policy (MD 017 v3 Nov 2019)

Resuscitation Policy (NPCS 007 v2.1 2018) 

Retention and Disposal Policy (February 2011)

Retirement Policy (November 2017)


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

Safeguarding Children Policy (NP 017 v5 June 2019)

Seclusion Policy (NPCS 009 v6 May 2018)

Secondment Policy v1 March 2016

Security Policy (FIN 008 v7 December 2018)

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

Service User Property and Money Policy (FIN 016 1.2 2019)

Sexual Safety Policy (CG 008 V1 Nov 2019)

Smoke Free and Nicotine Management Policy (April 2018)

Social Media Policy (CG 007 V3 2019)

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

Staff Leaving The Trust Policy (HR 030 V2 October 2019)

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)

Treasury Management Policy (FIN 007 v2 December 2018)


Information for Victims Rights Policy (NP 024 v3 2019)

Visitors Policy (NP 018 v1.1 June 2019)

Visits by Children to In-Patient or Residential Care Settings Policy (NP 026 V4 2019)

Volunteers Policy (March 2018)


Water Quality Policy (EST 007 V2 2019)

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

Working in Uganda Policy (NP 027 V2 2019)

Working Time Regulations Policy (HR 023 v4 June 2019)


Zero Tolerance of Harassment Policy (Third Party) (September 2019)

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