Policy Documents: All

The Trust's policies and procedures relate to its operation, staff, facilities, health and safety, risk management and services provided to patients.

The policies for Cumbria Partnership and North Cumbria University Hospitals are being reviewed to align them during 2018/Spring 2019.  For some of these, it has been agreed to extend their formal review date, as they have been assessed as still safe and legal for staff to follow until their alignment.  

Policy Help!

If you have a policy query please contact the Policy Helpdesk on PolicyHelpDesk@cumbria.nhs.uk 

POL/002/092 Access Booking and Waiting Time Management Policy (Aug 18 - Jun 20)
POL/EST/002 Accommodation Policy (Aug 18-Aug 21)
POL/001/036 Advance Care Planning Policy (Apr 17-Apr 19) Review date extended to 1st Oct 2019
POL/001/005/014 Age Appropriate Admissions Policy (Jun 18-Mar 19) Review date extended to 1st Oct 19
POL/WOR/007 Alcohol & Substance Misuse Policy - Joint (Sep 18-Oct 21)
POL/002/053 Alerts Policy and Procedure (Feb19-Feb22)
POL/WOR/029 Annual Leave Policy Joint (May 19 - May 22)
POL/004/022 Appraisal Policy (Please refer to Quarterly TALKS Joint Policy POL/WOR/025)
POL/WOR/001/001 Apprenticeship Guidelines for Managers (May 18-May 20)
POL/WOR/001 Apprenticeship Policy - Joint (May 18-May 20)
POL/CLIN/005 Aspergillosis Policy (Aug 19 to Aug 22)
POL/001/066 Assessment of Adults with Incontinence and Provision of Padded/Washable Products Policy (Apr 16-Apr 18) Reviewed and Extended to Dec 19
POL/WOR/008 Attendance Management Policy Joint POL-WOR-008 (Nov18-Nov19)
POL/001/009 AWOL - Policy for Management of Service Users Missing or Absent without official leave of Absence (May 11-Jun 19) Extend review date to 1st Oct 19
POL/CLIN/001 Being Open and Duty of Candour Policy (Aug 18-Jun 21)
POL/001/085 Blanket Restrictions Policy (Aug 19 - Aug 22)
POL/004/030 Business Travel Policy. Extend review date to 30/6/19
POL/WOR/010 Capability Policy-Joint (Dec18-Nov21)
POL/001/001 Care Coordination Policy (Aug 18-Aug 21)
POL/001/080 Chaperone Policy (Oct 17-Oct 20)
POL/003/004 Charitable Funds Policy (Oct 17-Oct 20)
POL/002/017 Claims Policy and Management Procedure
POL-002-058 Cleaning Manual (Apr 16)
POL/EST/003 Cleaning Policy (Apr 19 - Apr 21)
POL/002/069 Clinical Audit Policy (Aug 18-Aug 19)
POL/002/093 Clinical Coding Policy (Sep 18-Dec 19)
POL/001/017 Clinical Risk Policy (Feb19-Feb22)
POL/001/052 Clinical Supervision and Peer Review Policy (Extended to 31/10/19)
POL/002/061 Closed Circuit Television Policy - CCTV (Apr 16-Apr 19)
POL/WOR/009 Competency Framework Policy Joint POL-WOR-009 (Nov18-Nov19)
POL/001/016 Complementary Therapies (Nov 17-Nov 19)
POL/WOR/042 Conduct, Capability and Appeals Policy and Procedures for Medical & Dental Practitioners (Aug 19 to Aug 22)
POL/IG/005 Confidentiality Policy - Joint (Oct 18-Sep 21)
POL/001/010 Consent Policy (Jun 18-May 19)
POL/001/066/001 Continence Assessment and Provision of Containment Products for Children and Young People (May 19 - Dec 22)
POL/002/047 Control and Maintenance of Fixed Installation Pressure Vessels
POL/002/052 Control of Asbestos Policy (Aug 16-Sep 19)
POL/002/036 Control of Contractors Engaged in Construction & Engineering Works (Aug 16-Jul 19)
POL/COR/006 Control of Substances Hazardous to Health Policy (COSHH) (May 19 - May 22)
POL/001/013/001 Controlled Drugs Policy CPFT (Feb19-Feb22)
POL/004/028 Corporate and Local Induction Policy (Mar 17-Mar 19. Extended to 30/6/19)
POL/COR/001 Corporate Records Policy and Procedure - Joint (Aug 18-Sep 21)
POL/FIN/002 Counter Fraud, Bribery and Corruption Policy - Joint (Dec 18-Dec 21)
POL/IG/013 Cyber Security Encryption policy (Mar19-Mar22)
POL/IG/001 Data Protection Act Policy - Joint (May 18-Apr 21)
POL/002/064 Data Quality Policy (Nov 16-Oct 19)
POL/001/062 Delegation Guidelines for Registered Nurses and AHPs working with Non-Registered Clinical Support Staff (Feb 19 - Feb 22)
POL/001/079 Deprivation of Liberty Safeguards Policy (Oct 17-Oct 19)
POL/001/079/001 Deprivation of Liberty Safeguards Protocol
POL/WOR/020 Dignity at Work Policy and Procedure (Feb19-Feb22)
POL/WOR/004 Disciplinary Policy - Joint (Sep 18-Aug 21)
POL/WOR/024 Disclosure and Barring Service (Apr 19 - Apr 22)
POL/COR/010 Display Screen Equipment (DSE) Policy (Jun 19 to Jun 21)
POL/001/067 Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) (Jul 17-Jul 19)
POL/001/068 Domestic Abuse Policy (Aug 17-Aug 20)
POL/004/014 Dress Code Policy. Extend review date to 30/6/19
POL/COR/015 Driving at Work Policy (Jul 19 to Jul 22)
POL/001/021 Dual Diagnosis Policy (Apr 18-Sep 19) Review date extended to 1st Oct 2019
POL/002/046 Electrical (PAT) Safety Testing Policy (Dec 18-Aug 21)
POL/002/045 Electrical Safety (Fixed Installations) Policy (Dec 18-Oct 21)
POL/001/055 Eliminating Mixed Sex Accommodation (May 17-May 19) Extend review date to 1st Oct 19
POL/IG/011 Email Policy (Mar19-Mar22)
POL/COR/005 Emergency Preparedness Resilience Response Policy (Joint) POL-COR-005
POL/COR/011 Engagement of External Auditors
POL/001/007 Enhanced Engagement and Supportive Observations Policy (Oct18-Mar20)
POL/001/005/008 Entry & Exit Policy for M/H and LD Wards (May 17-May 19 Extended review date to 01 Oct 19)
POL/002/029 Environmental & Oil Storage Policy (Feb 17-Feb 20)
POL/004/004 Equality and Diversity Policy (Jun 16-Jun 19)
POL/WOR/017 Exit Policy - Joint (Feb19-Feb22)
POL/IG/002 Extended Rights of Data Subjects Policy (Joint) (May 18-May 21)
POL/COR/002 Fire Safety Policy - Joint (Apr 19 - Apr 20)
POL/COR/017 First Aid At Work Policy (Aug 19 - Aug 22)
POL/WOR/028 Flexible Retirement Policy (Apr 19 - Apr 21)
POL/WOR/043 Flexible Working Policy (Aug 19 to Aug 22)
POL/002/041 Food Safety Manual - Conventional Catering (Nov 17)
POL/002/041 Food Safety Manual - Food Regeneration (Nov 17)
POL/002/041 Food Safety Policy (Nov 17-Nov 19)
POL/IG/009 Forensic Readiness Policy (Mar19-Mar22)
POL/IG/006 Freedom of Information Act 2000 - Joint (Oct 18-Oct 21)
POL/002/042 Gas Safety Policy for Fixed Gas Installations (Dec 18-Oct 21)
POL/WOR/014 Gender Diversity and Inclusion Policy Joint (Sep18-Sep21)
POL/002/099 Governors Expenses Procedure (Nov 17-Nov 20)
POL/WOR/021 Grievance Policy (Feb19-Feb22)
POL/001/075 Guardianship Policy, Procedures and Guidance (Interim Joint Cumbria County Council Policy) Extended to 1st Oct 19
POL/002/002 Handling of Complaints, Comments, Concerns & Compliments Policy (Aug 18-Aug 20)
POL/COR/003 Health and Safety Policy - Joint (Aug 18-Aug 21)
POL/002/008 Health Records Policy (Nov18-Dec21)
POL/002/085 Heatwave Plan (Apr 18-Mar 19)
POL/CLIN/004 Immunisation of Service Users (Hospitals) Policy (Mar19-Mar22)
POL/002/006/001 Incident and Serious Incidents that Require Investigation (SIRI) Policy (May 18-May19. Extended to 31/10/19)
POL/001/073 Infant Feeding Policy (Jan 16- Nov 19)
POL/001/042 Infection Prevention and Control Policy (Aug 17-Aug 19)
POL/001/042/001 Infection Prevention and Control Policy Hyperlink to Chapters and Appendices
POL/IG/007 Information & Cyber Security Acceptable Use Policy - Joint (Oct 18-Oct 21)
POL/IG/008 Information and Cyber Security Policy - Joint (Oct 18-Oct 21)
POL/IG/015 Information Governance Strategic Framework 2019 - 2020 (Joint) (May 19 - May 20)
POL/IG/014 Information Risk Policy Joint (May 19 - May 22)
POL/IG/003 Information Sharing (Disclosure) Policy - Joint (May 18-May 21)
POL/001/013/005 Injectable Medicines Policy (May 18-May 21)
POL/001/042/027 Insertion and Maintenance of Urinary and Supra Pubic Catheter Policy (May 17-May 20)
POL/001/013/007b Insulin - Assistant Practitioners and HCA Administration of Insulin via Pen Device, by Delegation - Traiing and Competency Toolkit (May 17-May 18)
POL/001/013/007 Insulin-Safe and Effective Use of Insulin in Adults in Community & Inpatient Toolkit (Apr17-Apr19. Extended review date to Oct 19)
POL/002/040 Intellectual Property Policy (Jan 17-Jan 20)
POL/002/080 Interpreter Policy (Feb 17-Feb 20)
POL/WOR/023 Job Matching and Job Evaluation Policy (Mar19-Mar22)
POL/004/042 Job Planning Policy (Interim) Apr 17-Aug 18. Extended to 01 Oct 19
POL/CLIN/003 Joint Care Policy for Patients with Physical, Mental or Learning Disability Needs
POL/001/005/002 Joint Operational Protocol for Interagency Assistance - Appendix E (NWAS)
POL/001/005/002 Joint Operational Protocol for Interagency Assistance - Mental Health (Aug 18-Aug 21)
POL/004/037 Learning and Development Policy (Nov 17-Nov 19)
POL/001/078 Learning from Deaths Policy (Oct 17-Oct 20)
POL/COR/016 Lockdown Policy (Jul 19 to Jul 22)
POL/COR/009 Lone Working (Jun 19 - Jun 22)
POL/002/051 Maintenance and Management of Passenger and Goods Lifts (Aug 16-Aug 19)
POL/002/049 Maintenance and Management of Ventilation Systems Policy (Oct 16-Oct 19)
POL/004/010 Management Supervision Policy (Please refer to QUARTERLY Talks policy POL/WOR/025)
POL/002/097 Managing Official Visits Procedure (Oct 17-Oct 20)
POL/WOR/011 Managing Personal Relationships in the Workplace - Joint Policy (Dec 18-Nov 21)
POL/WOR/006 Managing Stress At Work - Joint (Sep 18-Sep 21)
POL/001/005/020 MAPPA Multi Agency Risk Evaluation Pathway Policy (Jan 17-Jan 20)
POL/WOR/022 Maternity/Paternity/Shared Parental/Adoption Pay and Leave Policy (Mar19-Mar22)
POL/COR/007 Media Management Policy (May 19 - Mar 22)
POL/004/040 Medical Appraisal Policy (Apr 17-Apr 20)
POL/002/050 Medical Gas Cylinder Policy (Sep 16-Sep 19)
POL/MM/001 Medicines Patient Group Directions (Jul 19 to Jul 22)
POL/001/013 - Formulary Statement Medicines Policy - Formulary Statement incl. Cumbria HIV Formulary Statement (Jul 16)
POL/001/013 Medicines Policy(Mar19-Mar21)
POL/WOR/027 Menopause Policy (Jun 19 - Jun 20)
POL/001/005/019 Mental Capacity Act Multi-Agency Policy (Apr 16-Apr 19) - Review date extended to 30/11/2019
POL/001/071 Mental Health Act Delegation Protocol (Oct 17-Oct 19) - Review date extended to 30/11/19
POL/001/005/007 - Appendix Mental Health Act Guidelines on Receipt and Scrutiny of Detention Papers - Appendix Form H3
POL/001/005/007 Mental Health Act Guidelines On Receipt and Scrutiny of Detention Papers (May 18-May 19)- Review date extended to 30/11/2019
POL/001/005/004 Mental Health Act Guidelines on Section 5 (4) 6 Hour Nurses Holding Power (Oct 17-Oct 19)- Review date extended to 30/11/2019
POL/001/005/013 Mental Health Act Guidelines Part IV - Consent to Treatment (Apr 16-Apr 19) - Review date extended to 30/11/2019
POL/001/005/010 Mental Health Act Guidelines: Section 17A Use of Supervised Community Treatment (Apr 16-Apr 19)- Review date extended to 30/11/2019
POL/001/005/006 Mental Health Act Guidlines on Section 17 Leave of Absence (Dec 16-Dec 19)- Review date extended to 30/11/2019
POL/001/005/003 Mental Health Act Guidlines on Section 5 (2) 72 Hour Holding Power (Oct 17-Oct 19) - Review date extended to 30/11/2019
POL/001/005/015 Mental Health Act Policy and Guidance on Section 132, 132A & 133 Patients Rights (May 18-May 19)- Review date extended to 30/11/2019
POL/001/005/009 Mental Health Act Policy for the Exercise of Powers to Withhold Outgoing Mail - Review date extended to 30/11/2019
POL/001/005/012 Mental Health Act Procedure on the exclusion of visitors to detained patients - Review date extended to 30/11/2019
POL/001/005/011 Mental Health Act Section 117 After Care Policy (May 18-Dec 20)
POL/001/074 Mental Health Treatment Requirements Protocol (Dec 16-Dec 19)
POL/001/005/021 Mentally Disordered Offenders Joint Protocol (Apr 17-Apr 18) (extended to Apr 19)
POL/IG/012 Mobile Computing and Remote Access Policy (Mar19-Mar22)
POL/002/030 Moving and Handling Policy (May 18-May 20)
POL/001/005/001 Multi-Agency Section 136 Mental Health Act 1983 Protocol (Mentally Disordered Persons Found in Public Places) (Jun 18-Jun 21)- Review date extended to 30/11/2019
POL/001/054 Multi-Professional Mentorship and Assessment in the Learning Environment (Jan 16-Jan 18. Extended to 31/09/19)
POL/WOR/013 Multi-Professional Preceptorship Policy V1.0 (Jan17-Jan20)
POL/002/104 Music Licence Policy (Oct 17-Oct 20)
POL/NCUH/NG11-01 Nasogastric Tube Insertion Guide NCUH
POL/NCUH/CG11-02 Nasogastric Tube pathway and guidelines CPFT
POL/NCUH/CG11 Nasogastric Tube Policy for NCUH
POL/IG/010 Network Cyber Security Policy (Mar19-Mar22)
POL/001/082 NEWS 2 (National Early Warning Score) Policy (Apr 18-Sep 19)
POL/001/030 NICE (Clinical Effectiveness) Policy (Aug 18-Aug 19)
POL/001/026 Non-Medical Prescribing Policy (Jun 17-Jun 19)
POL/001/044 Nutrition and Hydration for Adults Policy (Jan 19 - Aug 22)
POL/002/098 On Call (Gold, Silver, Bronze) Policy (Dec 17-Dec 18. Review date extended to Nov 19)
POL/WOR/003 Organisational Change Policy - Joint (Apr 18-Apr 20)
POL/001/081 Paediatric Dysphagia Policy (Oct 17-Jul 19)
POL/WOR/003/018 Pay Protection Policy-Joint (Mar19-Mar20)
POL-EF-001 Pest Control Policy and Procedures (Aug 18-Aug 20)
POL/CLIN/002 Photography and Video Recording Policy (Joint) (Sep 18-Sep 21)
POL/001/012 Physical Examination and Wellbeing of Service Users within MH and LD Services (Jun 18-Jun 20)
POL/COR/012 Policy Management Policy (Jun 19 - Jun 22)
POL/001/043 Policy to Promote Privacy, Dignity & Respect (May 17-May 20)
POL/001/018 Appendix 1 Preceptorship Appendix 1 for Band 5
POL/001/018 Appendix 2 Preceptorship Appendix 2 for Band 6
POL/001/018 Appendix 3 Preceptorship Appendix 3 for Band 7
POL/001/018 Preceptorship Policy (Feb 17-Jan 20)
POL/001/069 Pressure Ulcer Policy (Sep 17-Jul 20)
POL/001/048 Prevention and Management of Slips, Trips and Falls (Nov 16-Nov 19)
POL/001/008 Prevention and Management of Violence and Aggression (Feb19-Feb22)
POL/COR/013 Print Policy (Jul 19 to Jul 22)
POL/001/014 Prison Healthcare Medication In Possession Policy (Apr 19-Mar 21)
POL/002/043 Procurement Policy (May 19 - May 20)
POL/WOR/005 Professional Registration Policy - Joint (Sep 18-Sep 21)
POL/002/034 Protected Mealtimes Policy (Oct 17-Oct 19)
POL/001/057 Protocol for the Management of Informal Patient’s Leave from Adult Acute Mental Health In-patient Wards (Jun 17 to Aug 19) Review date extended to 1st Oct 2019
POL/001/035 Provision of Forensic Outreach Clinics (Dec 16-Jan 18) (extended to Aug 2019)
POL/WOR/025 Quarterly TALKS Policy (formerly Appraisal) Oct 18 - Oct 22
POL/WOR041 Raising Concerns Policy (Jul 19 to Jul 23)
POL/001/020/001 Rapid Tranquilisation Protocol - (B) Oral Medication (Jul 17-Jun 20)
POL/001/020/002 Rapid Tranquilisation Protocol - (C) IM Medication (Jul 17-Jun 20)
POL/001/020/003 Rapid Tranquilisation Protocol - (D) Medication Senior Clinician Authorisation (Jul 17-Jun 20)
POL/001/020 Rapid Tranquilisation Protocol (A) (Jul 17-Jun 20)
POL/WOR/012 Recruitment and Selection Policy - Joint (Nov 18-Nov 20)
POL/002/066 Registration Authority Smartcard Policy (Feb 18-Nov 19)
POL/COR/014 Regulation of Performance Indicators (Jul 19 to Jul 22)
POL/004/023 Relocation Expenses Policy (July 2018 - February 2019) Extended to October 2019
POL/003/001 Reservation and Delegation of Powers and Standing Financial Instructions v.2 (Feb19-Feb22)
POL/004/039 Responding to concerns about Medical and Dental Staff. Extend review date to 01 Oct 19
POL/001/002 Resuscitation Policy (Jan 19-Sep 20)
POL/002/013 Risk Assessment of New and Expectant Mothers At Work Policy (Oct 15-Oct 18. Extended to 30/6/19)
POL/002/014 Risk Assessment of Young Persons At Work (Oct 15-Oct 18) (Review Date Extended to 30/6/19)
POL/CLIN/006 Risk Feed - Adults Policy (Aug 19 - Aug 22)
POL/002/012 Risk Management Policy and Process (Apr 16-Sept 19)
POL/002/012/01 Risk Management Strategy (Oct 18)
POL/004/043 Rostering Policy (Jan 17 -Jun 20)
POL/001/058 Royal Marsden Hospital Manual Clinical Procedures Approved for use by CPFT Policy (Dec 18-Sep 19)
POL/001/047 Safe and Effective Use of Bedrails (Feb 17-Feb 19) Extended to October 2019
POL/002/081 Safe Haven and Effective Anonymisation Policy (May 19 - May 22)
POL/001/006 Safeguarding Policy (Oct 16-Oct 19)
POL/001/003 Searching of Service Users Person, Room and Personal Belongings Policy (May 18 to May 19) Extend review date to 1st Oct 19
POL/001/004 Seclusion and Long Term Segregation Policy (Sep 18-Sep 19) Review date extended to 1st Oct 2019
POL/WOR/026 Secondment and Acting Up Policy (Apr 19 - Apr 22)
POL/002/015 Security Policy (Oct 15-Oct 18) (Review Date Extended to 30/6/19)
POL/002/015/001 Security Strategy (Oct-15-Oct 18) (Review Date Extended to 30/6/19)
POL/001/015 Self Harm Policy (Feb 19 -Dec 22)
POL/002/035 Service User and Payment Policy
POL/COR/004 Sharps Safety Policy Joint POL-COR-004 (Nov18-Nov21)
POL/002/044 Smoke Free Policy (Jun 16-Dec 17)
POL/COR/008 Social Media Policy (May 19 - Mar 22)
POL/WOR/016 Special Leave Policy (Feb19-Feb22)
POL/WOR/002 Standards of Business Conduct Policy - Joint (Jan 19-Nov 19)
POL/WOR/030 Statutory and Mandatory Training Policy (May 19 to May 20)
POL/001/039 Supporting Patients Choices To Avoid Long Hospital Stays - NORTH (Dec 17-Dec 20)
POL/WOR/015 Time Off In Lieu (TOIL) Joint (Jan19-Jan22)
POL/001/033 Transfer and Discharge of Patients within Mental Health and Learning Disabilities Services (Aug 18-May 21)
POL/001/011 Transition out of Children and Families Health Services Policy (Oct 16-Oct 19)
POL/FIN/003 Treasury Management Policy (Apr 19 - Apr 22)
POL/001/013/006 Vaccine Storage and Administration Procedures - Appendix 5
POL/001/013/006 Vaccine Storage and Administration Procedures (May 19 - Feb 21)
POL/001/065 Venous Thromboprophylaxis (VTE) Policy (May 18-Sep 21)
POL/001/063 Verification of Expected Death (Jul 16-Jul 19)
POL/004/025 Volunteer Handbook. Extended review date to 31/10/2019
POL/004/025 Volunteer Policy. Extended review date to 31/10/2019
POL/002/055 Waste Management Policy (Aug 16-Aug 19)
POL/002/054 Water Safety and Control of Legionella Policy (Oct 16-Aug 19)
POL/001/083 Whole System Discharge Policy (Dec 17-Dec 20)