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 Policy (October 2016)

Adverse Weather Policy (November 2016)

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 (August 2014)

Appraisal Policy For Medical Staff (November 2016)

Associate Mental Health Act Managers’ (AMHAM) Policy (May 2018)


Back Care and Manual Handling Policy (October 2016)

Blanket Restrictions Policy (May 2018)

Bullying and Harassment Policy (October 2016)

Bullying and Harassment Managers Guide

Bullying and Harassment Complaint Report


Capability Policy (November 2016)

Improvement Plan Objectives Form (Word)

Capacity and Consent to Treatment Policy (November 2016)

Capital Programme Management Policy (March 2017)

Career Break Policy (November 2016)

Career Break Application Form (Word)

Central Alert System (CAS) Policy (September 2016)

Claims Policy (September 2016)

Clinical Audit Policy (May 2017)

Clinical Professional Registration Verification Policy (November 2016)

Professional Registration Update Form

Complaints Policy (October 2016)

Confidentiality Code of Conduct (September 2016)

Control of Substances Hazardous to Health (COSHH) Policy (October 2014)

Conveyance and Assistance Policy (October 2017)

Counter Fraud, Bribery and Corruption Policy (August 2015)

Criminal Records Checking Disclosure and Barring Service Policy Procedure (CG004 v3 March 2018)


Decontamination Policy (October 2016)

Delegation of Budgetary Authority (September 2016)

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 (MD001) (November 2018)

Display Screen Equipment Policy (October 2016)

Eyesight Test Request Form (Word)

Domestic Abuse Policy (November 2015)

Dress Code Policy (October 2016)

Dual Diagnosis Policy (March 2013)

Duty of Candour and Being Open Policy and Procedure (September 2016)


Electro Convulsive Therapy (ECT) Policy and Procedure (November 2016)

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 Recovery Policy (November 2016)

Fuel Shortage Contingency Plan

Heat Wave Policy (November 2016)

Lockdown Plan

Major Incident Plan

Pandemic Flu Plan (February 2015)

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 (March 2015)

Equal Opportunities and Dignity at Work Policy (October 2016)


Fire Safety Policy (July 2017)

Flexible Working Policy (October 2014)

Appendix A: Flexible Working Arrangements Application Form

Appendix B: Flexible Working Arrangements Acceptance Form

Appendix C: Flexible Working Arrangements Rejection Form

Food Safety Policy (April 2016)


Gender Reassignment Workplace Policy (October 2016)

Grievance Policy (September 2014)

Dignity at Work Joint Statement


Hardship Salary Advance Policy (September 2016)

Health and Safety Policy (July 2017)

Health and Safety Inspection Checklist


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

Incident Management Policy (September 2016)

Incident Categories

Incident Report Form (Word)

Income Collection Policy (September 2016)

Induction Policy (December 2017)

Infection Prevention and Control Policy (June 2015)

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 (April 2016)


Job Share Scheme Policy (November 2016)

Joint Working Mental Health and Learning Disability (December 2006)


Latex Sensitisation Policy (August 2017)

Learning from Deaths Policy (September 2017)

Leave Policy (incorporating the Additional Annual Leave Scheme) (November 2016)

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

Leaver Guidance (October 2015)

Ligature Risk Reduction Policy and Procedure (November 2017)

Lone Worker Policy (June 2014)

Losses & Special Payments Policy (March 2018)

Low Voltage Electrical Safety Policy (April 2017)


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 Responsible Clinician (August 2016)

Mental Health Act – Code of Practice Equality and Human Rights Policy (NPCS010 v2 July 2018)

Mental Health Act – Community Treatment Orders Policy (June 2016)

Mental Health Act – Nominated Deputy: Section 5 (2) of the Mental Health Act 1983 (NPCS011 v4 July 2018 amended November 2018)

Mental Health Act – Role of Second Professional in the Renewal of Detention Guidance (May 2016)

Mental Health Act – SHSC Scheme of Delegation

Mental Health Act – Section 23 Hospital Managers Review of Detention Policy (September 2016)

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

Mental Health Act – Section 132 Duty to Give Information Policy (June 2016)

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


Non NHS Income Policy (December 2017)


Organisational Change Policy (October 2018)


Parenting Leave Policy  (December 2017)

PDR Policy (April 2017)

Personal Files Policy (October 2016)

Personal Search Policy (June 2017)

Physical Health Policy (March 2013)

Preceptorship Policy (October 2016)

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

PREVENT Strategy Policy (February 2016)

Procurement Sustainability Policy (May 2016)

Promoting Attendance and Managing Sickness Absence Policy (April 2017)

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


Rapid Tranquilisation Policy (November 2016)

Records Management Policy – Information Governance Alliance Code of Practice 2016

Trustwide Records Audit Tool

A Protocol for using Electronic Notes in Psychological Therapies

Recruitment and Selection Policy (November 2016)

Redeployment Policy (May 2017)

Redundancy Policy (September 2017)

Registration Authority (Smartcard) Policy (March 2015)

Relationships Between Service Users And Staff Policy (November 2009)

Relocation and its Alternatives Policy (October 2016)

Remote Working and Mobile Devices Policy (April 2014)

Responding to National Confidential Inquiries Policy (November 2016)

Resuscitation Policy (May 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 Policy (October 2014)

Link to the South Yorkshire Safeguarding Adults Board Procedures Manual

Safeguarding Children Policy (January 2016)

Link to the South Yorkshire Child Protection Procedures

Link to the Sheffield Safeguarding Children Protocols

Seclusion Policy (NPCS009 v6 May 2018)

Secondment Policy (March 2016)

Secondment Policy Appendices

Security Policy (February 2016)

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

Service User Falls (In-patient and Residential) Policy (November 2016)

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

Smoke Free and Nicotine Management Policy (April 2018)

Social Media Policy (August 2016)

Speaking Up: Whistleblowing Policy (November 2016)

Supervision Policy (February 2016)

Form Supervision Contract

Form Template Record

Sustainable Development Management Plan (June 2015)


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 (September 2016)


Visitors Policy (May 2016)

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)

Working in Uganda Policy (May 2016)

Working Time Regulations Policy (February 2016)

WTR Worker Assessment

WTR Opt Out Form


Zero Tolerance of Harassment Policy (September 2016)

Terms and Conditions

Guest WiFi Terms and Conditions