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 and Mental Capacity Act are now located under “M”.

Please note all policies relating to Medication are now attached to the Medicines Management Policy located under “M”.

Absent Without Leave and Missing Patients Policy (September 2016)

Acupuncture Policy (November 2016)

Admission of 16 and 17 year olds to an Adult Mental Health Ward Policy (December 2009)

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)

Asbestos Policy (September 2015)

Back Care and Manual Handling Policy (October 2016)

Blanket Restrictions Policy (September 2016)

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)

Capital Programme Management Policy (March 2017)

Care Programme Approach (CPA) Standard Care Pathway (October 2006)

Career Break Policy (November 2016)

Career Break Application Form (Word)

Central Alert System (CAS) Policy (September 2016)

Claims Policy (September 2016)

Clinical Audit Policy (February 2016)

Clinical Disputes Policy (resolving differences of opinion between practitioners guidance) (October 2006)

Clinical Professional Registration Verification Policy (November 2016)

Professional Registration Update Form

Complaints Policy (October 2016)

Confidentiality Code of Conduct (September 2016)

Copy Letters to Service Users (July 2005)

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

Criminal Records Checking, Disclosure and Barring (DBS) Service Policy and Procedure (October 2016)

Declaration of Interests and Standards of Business Conduct including potential Conflicts of Interest, Ethical Standards, Hospitality, Gifts, Research and Commercial Sponsorship Policy (March 2014)

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

Difficult to Engage Service Users (May 2009)

Discharge Policy (In-patient) (November 2016)

Disciplinary Policy (July 2016)

Disciplinary Policy – Managers Guidance (October 2013)

Display Screen Equipment Policy (October 2016)

Eyesight Test Request Form (Word)

Doctors Disciplinary Policy (November 2012)

Domestic Abuse Policy (Service Users) (November 2015)

Domestic Abuse Policy (Staff) (October 2016)

Dress Code Policy (October 2016)

Dual Diagnosis Policy (March 2013)

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

Dysphagia Policy (November 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)

Email Policy (April 2014)

Emergency Preparedness, Resilience and Recovery Policy (November 2016)

Fuel Shortage Contingency Plan

Heat Wave Policy (November 2016)

Lockdown Plan

Major Incident Plan

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)

Employment Checks Policy (November 2010)

Engaging Individual Self-Employed Contractors (Procurement Policy) (September 2016)

Equal Opportunities and Dignity at Work Policy (October 2016)

Escort Policy (In-patient) (November 2016)

Extension of Victims Rights Policy (November 2016)

Falls Policy (March 2013)

Fire Policy (October 2014)

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)

Fraud Policy (February 2011)

Gender Reassignment Workplace Policy (October 2016)

Grievance Policy (September 2014)

Dignity at Work Joint Statement

Handing Over Control of a Ward, Department or Hostel (June 2004)

Hardship Salary Advance Policy (September 2016)

Health and Safety Policy (February 2014)

Health and Safety Inspection Checklist

Holidays and Outings Procedure (February 2007)

Incident Management Policy (September 2016)

Incident Categories

Incident Report Form (Word)

Income Collection Policy (September 2016)

Induction Policy (November 2016)

Infection Prevention and Control Policy (June 2015)

Management of Occupational Blood and Body Fluid Exposure Incidents and Administration of Post Exposure Prophylaxis (March 2013)

Blood and Body Fluid Exposure Incident Management Pack (November 2011)

Information Governance Policy (April 2014)

Information Quality Assurance Policy (April 2014)

Information Security Policy (April 2014)

Information Sharing Protocol – Interagency Information Sharing Protocol (April 2016)

Intellectual Property Management Policy (April 2014)

Internet Acceptable Use Policy (April 2014)

Interpreting and Translation Policy (April 2009)

Interpreting and Translation Procedures and Guidance

 Requesting Information in a Different Language

Issue of Stamps (November 2008)

Job Description Disputes Resolution (October 2005)

Job Share Scheme (September 2005)

Joint Working Mental Health and Learning Disability (December 2006)

Latex Sensitisation Policy (June 2001)

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)

Legal Advice Policy (April 2014)

Ligature Risk Reduction Policy and Procedure (November 2016)

Location Flexibility Allowance Policy (December 2006)

Losses & Special Payments Policy (May 2015)

Lone Worker Policy (June 2014)

Low Voltage Electrical Safety Policy (April 2017)

Major Outbreak Plan (July 1999)

Management of Medicines Local Guidance – Learning Disability Service (June 2012)

Appendix 1 – Responsibilities/Duties of Staff Handling Medicines

Appendix 2 – Medication Training Pathway

Appendix 3 – Local Guidelines for Administration of Medication

Appendix 4 – Competency Assessment Tool

Appendix 5 – Competency Tracker Forms

Appendix 6 – Administration of Minor Ailments Homely Remedies

Appendix 7 – Standard Operating Procedure Controlled Drugs Supported Living

Appendix 8 – Standard Operating Procedure Controlled Drugs Residential

Appendix 9 – Buccal Midazolam Guidance

Appendix 10 – Medication Administration Form

Appendix 11 – Additional Monitoring Form for Checking Medication

Managing Access and Exit Policy (July 2016)

Mandatory Training Policy (October 2016)

The Training Needs Analysis (TNA) is a live document and is available from the Education, Training and Development (ETD) Department (contact them) or via the ETD page on the staff intranet.

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

Media Policy (January 2006)

Medical Devices Policy (November 2016)

Medicines Management Policy (November 2016)

Antibiotic Policy for In-patient Wards and Departments (April 2014)

Rapid Tranquilisation Policy (November 2016)

Self Administration of Medicines Local Policy (July 2013)

Mental Capacity Act – Deprivation of Liberty Safeguards Policy (November 2016)

Mental Capacity Act – Guidance for Implementation (January 2009)

Mental Health Act – Allocation of Responsible Clinician (May 2009)

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

Mental Health Act – Section 5(2) Designation of Deputy Policy (May 2016)

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

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

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

Mental Health Act – Capacity and Consent to Treatment Policy (November 2016)

Mental Health Act – Equality and Human Rights Policy (November 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 136 Joint Policy for the Implementation of Section 136 (July 2016)

Mental Health Act – Role of Second Professional in the Renewal of Detention Guidance (October 2008)

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

Mobile Communication Devices Policy (including Photographics Devices) (December 2008)

National Confidential Inquiries Policy (November 2016)

Network and Wireless Security Policy (April 2014)

Nicotine Management and Smoke Free Policy (May 2016)

Non NHS Income Policy (October 2016)

NICE – Implementation of NICE Guidance Policy (November 2016)

Observation of In-patients Policy (March 2013)

Organisational Change Policy (November 2016)

Oxygen Policy (November 2016)

Pandemic Flu Plan (February 2015)

Parenting Leave Policy (July 2015)

PDR Policy (April 2017)

Performance Development Review (Appraisal) Policy (February 2014)

Personal Files Policy (October 2016)

Personal Relationships At Work Policy (September 2014)

Appendix 2 – Relationship Risk Matrix

Personal Search Policy (November 2006)

Physical Health Policy (March 2013)

Policy on Policies (August 2016)

Policy Template (Word)

Preceptorship Policy (October 2016)

PREVENT Strategy Policy (February 2016)

Prevention and Management of the use of Restraint: Framework for Good Practice (Sheffield Adult Safeguarding Board) (August 2015)

Procurement Manual (May 2016)

Procurement Policy (May 2016)

Procurement Sustainability Policy (May 2016)

Promoting- Attendance and Managing Sickness Absence Policy (April 2017)

Protection of Pay and Conditions of Service Policy (November 2016)

Records Management Policy (February 2013)

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 Register Policy (January 2011)

Redundancy Policy (November 2016)

Registration Authority (Smartcard) Policy (February 2011)

Relationships Between Service Users And Staff Policy (November 2009)

Relocation and its Alternatives Policy (October 2016)

Remote Working and Mobile Devices Policy (April 2014)

Resolving Differences of Opinion between Practitioners (Clinical Disputes) (October 2006)

Restraints Operational Guidance Policy (August 2016)

Resuscitation Policy (March 2011)

Retention and Disposal Policy (February 2011)

Retirement Policy (October 2016)

Appendix G – Retirement Memo  (October 2016)

Appendix H – Gift Buffet Procedure (October 2016)

Pre-Retirement Course Details (February 2012)

Rostering Policy (June 2016)

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

Secondment Policy (March 2016)

Secondment Policy Appendices

Seclusion Policy (March 2017)

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)

Sexual Safety Standards (April 2011)

Sickness Absence Process – Managers Guide (August 2012)

Sleep-in Policy Agreement (March 2015)

Slips, Trips and Falls Policy (October 2016)

Social Media Policy (August 2016)

Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions (September 2016)

Stress Management Policy (June 2012)

Study Leave Policy (July 2009)

Substance Misuse And Harmful Substances On In-patient Wards Policy (November 2016)

Supervision Policy (February 2016)

Form Supervision Contract

Form Template Record

Sustainable Development Management Plan (June 2015)

Training Policy (Mandatory) (January 2011)

Appendix 1 – Training Needs Analysis

Appendix 2 – Implementation Plan

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)

Tuberculosis (Control of) in Sheffield Integrated (September 2001)

Visitors Policy (May 2016)

Visits By Children Policy (November 2016)

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

Volunteers Policy (November 2016)

Waste Management Policy (October 2014)

Water Quality Policy (September 2015)

Whistleblowing Policy (Speaking Up) (November 2016)

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)