Policies and Procedures

Below is a list of Trust-wide Policies and Procedures.  Please click on  the policy reference number to open the document. If you are unable to open any PDF documents, you can download Adobe Reader by clicking here

The date for review detailed on the front of all Mersey Care NHS Trust Policies does not mean that the document becomes invalid from this date. The review date is advisory and the organisation reserves the right to review a policy at any time due to organisation/ legal changes.  

Staff are advised to always check that they are using the correct version of any policies rather than referring to locally held copies. The most up to date version of all Trust policies can be  found on this webpage.  

Please note that due to organisational changes, some references to organisational structures or roles within policies and procedures have now been superseded. Where this is the case, a covering page has been provided which includes a list of old terminology used within the policy cross referenced against the new terminology to be used when reading this document.

Please click here if you need help to write/review a corporate policy or procedure   

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          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 
SA06:  Service user complaints 
SA07:  Health, safety and welfare 
             HS1 Risk Assessment
             HS2 New Expectant Mothers
             HS3 Display Screen Equipment
             HS5 Workplace Inspections
             HS6 Central Alerting System
             HS7 Management of Contractors
             HS8 Environmental Suicide Risk Assessment
             HS9 Management of Asbestos
SA08:  Fire safety
SA10:  Clinical risk assessment tools (to be applied in conjunction with portffolio tools attached to policy) 
SA11:  Manual handling 
SA12:  Domestic abuse
SA13:  Being open
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 
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
SA31:  Major Incident Plan
SA32:  Systematic Approach to the Analysis & Learning from Incidents, Complaints and Claims 
SA34:  Corporate Environment Policy 
SA35:  Use of Taxis to Conduct Official Business Undertaken on Behalf of the Trust
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
SA41: Performance Indicator Kite-Marking 

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 
HR03:  Flexible working
HR04:  Leave for personal & family reasons (incorporating Maternity guidelines) 
HR05:  Learning & development for staff within Mersey Care 
HR06:  Raising Concerns at Work V2 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
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 & appendices in relation to HR24
  Management of Alcohol and Substance Misuse by Staff
HR27:  Supporting Disabled Employees
HR28: Induction and Mandatory Training including Training Needs Analysis
HR29: Occupational Health
HR30: Revalidation, Medical Appraisal and Job Planning 
HR31: People Participation Framework (to be read in conjunction with the Volunteer Handbook)   
HR32: Gender Realignment Support 

Night Worker Health Assessment Form 
Annual Leave ProcedureImpact Assessment
NMC Referral Guidance
Retirement Process

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Finance & Corporate Governance

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:  Corporate 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:  Corporate Data Quality
IT12:  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
SD06:  Consent to examination or treatment (to be read/applied in conunction with Department of Health Reference Guide to Consent to Examination or Treatment) all in relation to SD06
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
SD15: Multi Agency Public Protection Arrangements (MAPPA) & Health & Risk Assessment
              Management Meetings (H-RAMM) & impact assessment  in relation to SD15
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 all in relation to SD17
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 
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:  Management of Service Users who have coexisting problems, illicit substance/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 

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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 30/01/15