Policies and Procedures

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  • General inquiries 0151 473 0303 (Switchboard for Trust Offices and Ashworth Hospital)
  • Rathbone Hospital Switchboard 0151 250 3000 (for Mossley Hill and Liverpool Services)
  • Hesketh Centre, Southport 01704 383100 (for North Sefton Services) 

Mersey Care operates from locations in and around Liverpool, Sefton, Kirkby, and neigbouring St Helens. View our Trust locations page

                     Need help to write /review a policy, procedure or guideline?  click here 

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             Click the policy reference number to view the policy  
                     All attachments are in Word or PDF format

            Please note: some policies have 'Impact Assessments'
           at the end of the policy, some are separate documents

Service Administration

SA01:  Development, ratification, distribution and review of policies and procedures 
SA02:  Risk management policy & strategy impact assessment
SA03:  Reporting, management and review of adverse incidents 
SA04:  Management/use of payments to Trust staff  for their involvement in commercially funded projects 
SA05:  Reporting, management and investigation of claims incl property expenses & impact assessment 
SA06:  Service user complaints & impact assessment
SA07:  Health, safety and welfare 
SA08:  Fire safety & impact assessment 
SA09:  Participation of Service Users and Carers
SA10:  Clinical risk assessment tools (to be applied in conjunction with  portfolio of risk assessment tools)
SA11:  Manual handling 
SA12:  Domestic abuse
SA13:  Being open & impact assessment
SA15:  Food hygiene  
  Cleaning Standards
SA19:  Management of medical devices 
SA20:  Smoke free 
SA21:  Identification, management and exploitation of intellectual property 
SA22:  Waste Management   
SA24 Development and review of information for service users and carers & impact assessment 
SA26:  Use of bed rails 
SA27:  Dealing with External Recommendations Specific to the Organisation & impact assessment 
SA28:  Management and control of legionella bacteria in water services 
SA29:  Management of Security Systems 
SA30:  Slips Trips and Falls & impact assessment 
SA31:  Major Incident Plan
SA32:  Systematic Approach to the Analysis & Learning from Incidents, Complaints and Claims
SA33:  Reviewing and Implementing the Recommendations of National Confidential Enquiries/Inquiries
SA34:  Corporate Environment Policy & impact assessment
:  Use of Taxis to Conduct Official Business Undertaken on Behalf of the Trust & impact assessment
SA36:  Identification of Service Users & impact assessment
SA37:  Assistance Dog Procedure
SA38: Service Provision to Young People Aged Under 18
SA39: Clinical Audit Policy 
SA40:  Equality Monitoring with implimentation plan

Guidance Document of Support / Information Available for Staff Following Involvement in Complaints, Claims, Incidents and Inquests

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Human Resources

HR01:  Disciplinary procedures 
HR02:  Grievance procedures & impact assessment
HR03:  Flexible working &  impact assessment 
HR04:  Leave for personal & family reasons & impact assessment 
HR05:  Learning & development for staff within Mersey Care 
HR06:  Concerns at work about patient care/business misconduct (whistleblowing) & impact assessment 
HR07:  Management of attendance 
HR08:  Verification of statutory registration of temporary and permanent staff 
HR09:  Zero tolerance
HR10:  Equality
HR11:  Capability  & impact assessment
HR12Handling concerns about the conduct, performance and health of medical staff 
HR13:  Stress prevention and management in the workplace & impact assessment
HR14:  Dignity and respect at work - prevention of harassment & bullying at work & impact assessment
HR15:  Lease car  
HR16:  Disclosure and Barring Service Checks (CRB) 
HR19:  Organisational change  & procedure 
HR20:  Career break  
HR21:  Recruitment and selection
HR23:  Management and production of staff rosters
HR24:  Travel and subsistence & impact assessment 
HR25:  Management of Alcohol and Substance Misuse by Staff
HR26:  Volunteers  (to be read in conjunction with the Volunteer Handbook)
HR27:  Supporting Disabled Employees
HR28: Induction and Mandatory Training & training needs analysis document
HR29: Occupational Health
HR30: Revalidation, Medical Appraisal and Job Planning 

Maternity Paternity Guidelines 
Night Worker Health Assessment Form 
Personal Responsibiity Framework
Guidelines for Tape Recording Interviews
Annual Leave Procedure & Impact Assessment
NMC Referral Guidance

Retirement Process

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FO1:  Standing orders 
FO2:  Standing financial instructions
FO3:  Scheme of reservations and delegations 
FO4:  Standards of Business Conduct 
FO6:  Anti-Fraud and Corruption Policy   

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Information Management, Technology & Governance

IT01:  Registration authority  
  IM&T Security (including links to security standards) 
IT03:  Use of mobile phones by service users in in-patient areas
IT04:  Record management  
IT06:  Health records 
IT10:  Confidentiality and information sharing  
IT11:  Data Quality & impact assessment
  Information Governance 
IT13:  Freedom of Information
IT14: Data Protection Act Policy
IT15: Clinical Coding  

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Service Delivery

SD01:  Leave for an informal inpatient
SD02:  Death of a service user 
SD03:  Lone working 
SD04:  Management of clinical risk through supportive observation 
Service users missing from an inpatient area & impact assessment
SD06:  Consent to examination or treatment (to be read/applied in conunction with Department of Health Reference Guide to Consent to Examination or Treatment)
SD07:  Resuscitation
SD08:  Managing community access; including DNA's/cancellation/booking/waiting times/ choose & book  
SD10:  Copying clinical correspondence to service users 
SD11:  Use of Rapid Tranquillisation 
SD12:  Handling of medicines 
SD13:  Safeguarding and protection of children
              (for the CQC easy read Safeguarding Children document please click the link below)
SD15:  Health & risk assessment management (H-RAMM) multi-agency public protection (MAPPA)  
             & impact assessment
SD16:  Introducton of all new interventions 
SD17:  Safeguarding Vulnerable Adults from Abuse (plus easy-read policy in appendices)
              & impact assessment
             (to be read/applied in conjunction with: Sefton Safeguarding Adults Policy & Procedural Framework 2011 the Liverpool City Council Procedural Framework for Safeguarding Adults 2013 and Safeguarding Adults Procedure Knowlsey 
SD18:  Recognition, prevention and therapeutic management of aggression and violence
SD19:  Advance statements & advance decisions 
SD20:  Searching of service users, their rooms, possessions, personal property and ward area
SD21: Care Programme Approach & impact assessment 
SD22: Children Visiting MCT Site 
SD23:  Young carer's assessment & care planning 
SD25:  Management of service users with a dual diagnosis of mental health needs & learning disability   
SD28:  Seclusion 
SD29:  Physical health care of service users & impact assessment 
SD30:  Management of Dysphagia  
SD31:  Removal of ligatures 
SD32:  Staff action following concerns regarding weapons in the community 
SD33:  Supervision
SD34:  Venepuncture Policy    
SD36:  Use of unlicensed medicines
SD37:  Dual Diagnosis related to mental illness/illicit substance misuse/alcohol use
SD38:  Suicide Prevention 
SD39:  Carers 
SD40:  Discharge/Transfer Policy
SD41: Transfer of Care
SD42: Administration of Acupuncture 
SD43: Prevent  

Situation / Exception Report Template
Enteral Feeding 2012 Guidance
Section 117 - Aftercare under the Mental Health Act 1983 & Equality Impact Assessment

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Infection Control

IC01: Infection prevention and control 
IC02: Inoculation Injuries & impact assessment & BBV Injury and Management Form

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Mental Health Act

MH01:  MHA 1983 Overarching Policy 
MH16:  Inter-agency policy and procedure for Section 136   

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Mental Capacity Act

MC01:  Mental Capacity Act Overarching Policy
MC04:  Implementation and Management of the Deprivation of Liberty Safeguards within the Meaning
             of the Mental Capacity Act 2005 & impact assessment    

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Need help to write/review a corporate procedural document? (policy, procedure or guideline)

If you are developing or reviewing a corporate procedural document (policy, procedure or guideline) and require guidance or support please click here to email Sarah Jennings, Compliance Analyst or telephone 0151 473 2778.

All corporate procedural documents should be written in line with the Corporate Policy and Procedure for the Development, Ratification, Implementation, Review and Archive of Mersey Care NHS Trust Procedural Documents.
Please find a link to this policy and other useful links below:

click here to be taken to the top of the policies page to view SA01:  Policy for the Development, Ratification, Distribution and review of policies and procedures. 

Procedural Document Proposal Form
Procedural Document Structure and Format Guidance
Implementation Plan Template

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                                                                                                                                                  Last updated 5/6/14