Policies and procedures

IMPORTANT NOTICE – Changes to data protection law

On 25 May 2018, UK data protection laws changed to incorporate the requirements of the European General Data Protection Regulations.

We have reviewed key policies and documents to support compliance with the new laws.

Where a document has been deemed to not require a significant review as a result of the new laws, that document has remained in its current review period, unchanged.

Please be advised that within any such Trust document, reference to the Data Protection Act (1998), should be taken to mean the new UK data protection laws.

Policies and procedures


Document File Size
Administration of Discretionary Medicines Policy V7 55 KB
Care of Next Infant Policy 144 KB
Care Programme Approach (CPA) Policy V12 147 KB
Client Focused Physical Intervention Policy 164 KB
Clinical Audit Policy V4 151 KB
Clinical Handover of care policy 172 KB
Clinical Risk Assessment Management Policy V8 102 KB
Community Treatment Order Policy V5 420 KB
Consent to Examination or Treatment Policy V7 2.53 MB
Covert Administration of Medicines Policy V7 82 KB
Death of a Patient 155 KB
Disclosure or Discovery of Assisted Suicide V4 143 KB
Electro Convulsive Therapy Policy V3 195 KB
Guidance for the Management of Pornography and Sensitive Materials on Inpatient Units V5 62 KB
Guidelines for the Assessment and Management of Self Harm V3 237 KB
Identification & Management of Obesity in Adult & Older Peoples Services Policy V5 592 KB
Identification, Management, Protection and Exploitation of Intellectual Property V2 51 KB
Infant Feeding Policy V4 280 KB
Inpatient Falls Risk Management Policy 118 KB
Isolation Policy V3 158 KB
Latex Policy 134 KB
Local Internal Alert Policy 128 KB
Management of Head Body and Pubic Lice Policy V6 83 KB
Management of Scabies Policy V6 86 KB
Mattress Maintenance Policy V4 168 KB
Medicines Policy V9 139 KB
Mental Health Inpatient Service Users Who Require Care in the Pennine Acute Hospital 129 KB
MHA Section 117 - After-Care Policy V4 489 KB
Non Medical Prescribing Policy V7 192 KB
Nutrition and Hydration Policy for Inpatient Units V4 424 KB
Patient Group Directions Policy V9 139 KB
Patient Identification Policy 159 KB
Personal Protective Equipment Policy 162 KB
Physical Health Policy for Mental Health Service Users Aged 18 Years and Over V6 398 KB
Prescribing Supply and Use of Unlicensed Medicines Policy V7 349 KB
Protocol for Mental Health Inpatient Service Users Who Require Care in the Pennine Acute Hospital V6 65 KB
Psychiatric Intensive Care Operational Policy V6 409 KB
Research and Development Policy V3 280 KB
Resuscitation Policy V7.1 187 KB
Safe Management of Controlled Drugs Policy V7 103 KB
Safe Management of Medical Gases V6 99 KB
Safeguarding Families Policy V1 161 KB
Seclusion Time Out and Other Restriction of Patients Movements (within inpatient wards) Policy V6 232 KB
Secure Management of Patient Property Policy and Procedures V4 123 KB
Secure Services Placement Assessment and Management Guidance V6 200 KB
Sharps Management and Inoculation Injuries 168 KB
Short Term Management of Acutely Distressed Patients and Rapid Tranquillisation 246 KB
Specimens 150 KB
Storage Handling Distribution and Disposal of Vaccines Policy V4 114 KB
Suicide Prevention Strategy V7 114 KB
Transition of Patients from Healthy Young Minds Services Protocol V6 149 KB
Treatment of Patients Subject to the Mental Health Act 1983 Part 4 and Part 4a Policy V4 520 KB
Unexpected Death of a Service User 141 KB
Unified DNA CPR Policy V1 843 KB
Use of Mobile Phones and Tablets Policy for Service Users and Visitors V5 142 KB
Using Bedrails Safely and Effectively Policy V4 168 KB
Victims Policy V3 162 KB


Document File Size
Management of Community Services Health Records Protocol V3 723 KB
Child Visiting and Child Contact Policy V4 93 KB
Complaints and Compliments Policy V11 190 KB
Conduct of and Liaison with Pharmaceutical Company Employees V7 147 KB
Contractors On Site Policy V6 57 KB
Core and Essential Skills (Manadatory Training) Education Policy V3 186 KB
Education, Training and Development Policy V9 132 KB
Electronic Transfer of Person Identifiable Data Policy V5 263 KB
Health & Safety Policy V7 179 KB
Information Governance Strategy V3 80 KB
Information Security Policy V5 86 KB
Violence Reduction Policy Positive and Proactive Interventions V7 192 KB
Personal Injury and Clinical Negligence Claim Policy V6 159 KB
Privacy Dignity Policy V4 151 KB
Policy for the Permitted Use of Removable Media V4 77 KB
Management of Mental Health and Specialist Services Health Records Protocol V3 450 KB
Scanning and Uploading Documents to Clinical Information Systems Procedure V2 281 KB
Transition from Paper to Electronic Records and How to Volumise Procedure V2 78 KB
Business and Corporate Records Management Protocol V3 158 KB
Risk Assessment Policy V10 280 KB
Smoke Free Policy for Staff V6 160 KB
Taxi Transport Policy V2 132 KB
Non Access/Non Attendance for Mental Health Services Policy V2 145 KB
Procedure for the Condemning and Disposal of Equipment V3 57 KB
PREVENT Policy V2 109 KB
Information Sharing Policy V6 105 KB
Nicotine Management Policy V1 70 KB
Legionella Management Policy V1 125 KB
Information Risk Management Policy V1.1 134 KB
Social Media Policy 130 KB
Placing a Risk of Violence Marker on Electronic and Paper Records Policy 151 KB
Incident Reporting, Management and Investigation Policy 705 KB
Accessible Information Standard Policy 148 KB
Learning from Deaths Policy V1 220 KB
Driver Safety Policy 164 KB
Central Alerts System 130 KB
Management of Linen and Laundry Policy 156 KB
Heavy Person Policy 157 KB
Environmental Policy 139 KB
Management of Pennine Care Policy Set 348 KB
Control of Substances Hazardous to Health (COSHH) 154 KB
First Aid Policy 159 KB
Electrical Safety Policy 140 KB
Losses and Compensations Policy 123 KB
Management of and Responses to External Agency Visits, Inspections and Accreditations Policy 134 KB


Document File Size
Reservation of Powers to the Board and Delegation of Powers V11 218 KB
Fraud Policy and Response Plan V9 80 KB


Document File Size
Induction Policy V4 646 KB
Dignity at Work (Managing Bullying & Harassment at Work) Policy V7 94 KB
Core and Essential Skills (Mandatory Training) Education Policy V3 186 KB
Professional Registration Policy V6 44 KB
Volunteering Policy V5 133 KB
Partnership Working Policy V4 65 KB
Work Experience Policy V3 370 KB
Equal Opportunities Policy and Procedure V4.1 148 KB
Implementation of the NMC Standards to Support Learning and Assessment in Practice/Mentor Policy V3 100 KB
Protection of Pay Policy V2 47 KB
Long Service and Retirement Awards 71 KB
Removal and Relocation Policy 472 KB
Dress Code Policy 130 KB
Transgender Policy V1 152 KB
Procedure for dealing with Capability issues for Doctors 162 KB
Doctors Discipline and Exclusion Procedure 150 KB
Redundancy Policy V4 146 KB
Supporting Employees with a Terminal Illness 116 KB
Freedom to Speak Up Policy 150 KB
Career Break Policy 146 KB
Managing Attendance at Work 239 KB
Special Leave 41 KB
Apprenticeship Policy 140 KB
Car Lease Scheme 173 KB
Working Time Regulations Policy 129 KB
Expenses Policy 129 KB
Annual Leave Policy 148 KB
Maternity, Adoption and Paternity Leave Policy 104 KB

Information governance

Document File Size
Data Protection & Confidentiality Policy 187 KB
Access to Health Records 388 KB
Freedom of Information Policy 157 KB
Environmental Information Regulations Policy 157 KB

Health informatics

Document File Size
Permitted Use of Removable Media 302 KB
Electronic Mail Policy 201 KB
Mobile Device Usage and Security Policy 155 KB

Mental health law

Document File Size
Patients Absent Without Leave (AWOL) 209 KB
Section 17 (Leave of Absence) Policy 169 KB
Receipt and Scrutiny of Documents Policy 183 KB
Section 132, 132A and 133 – Provision of Information to Detained Patients and Nearest Relatives 210 KB
Report Writing and Attendance at (Mental Health) Tribunals and Hospital Managers’ Hearings Policy 189 KB
Nearest Relative Policy 189 KB
Exclusion of Visitors to Detained Patients in Hospital 147 KB
Section 135 Mental Health Act 1983 Warrant to Seach and Remove Patients 272 KB

Records management

Document File Size
Records Management Policy 145 KB
Records Retention Policy 181 KB
Missing Records Policy 137 KB
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