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 or 01228 602029.

POL/002/092 Access Booking and Waiting Time Management Policy (Aug 18 - Jun 20)
POL/002/077/002 Access Control Policy (Feb 16-May 18. Extended to 31/3/19)
POL/EST/002 Accommodation Policy (Aug 18-Aug 21)
POL/001/084 Adult Risk Feed Policy (May 18-Jul 21)
POL/001/036 Advance Care Planning Policy (Apr 17-Apr 19)
POL/001/005/014 Age Appropriate Admissions Policy (Jun 18-Mar 19)
POL/001/07 Agile Working Policy (May 17-May 19)
POL/WOR/007 Alcohol & Substance Misuse Policy - Joint (Sep 18-Oct 21)
POL/002/053 Alert Policy and Procedure (Apr 17-Mar 19)
POL/004/015 Annual Leave Guidelines. Extend review date to 30/6/19
POL/004/015 Annual Leave Policy (Mar 17-Mar 20) Extended to 30/6/19
POL/002/081 Anonymisation and New Safe Haven Policy (Feb 14-May 18) Extended to 31 March 19
POL/002/077/006 Anti Malware Policy (Feb 16-May 18)
POL/004/022 Appraisal Policy (Nov 16-Nov 18. Extended to 30/6/19)
POL/WOR/001/001 Apprenticeship Guidelines for Managers (May 18-May 20)
POL/WOR/001 Apprenticeship Policy - Joint (May 18-May 20)
POL/001/066 Assessment of Adults with Incontinence and Provision of Padded/Washable Products Policy (Apr 16-Apr 18) Reviewed and Extended to Dec 18
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)
POL/CLIN/001 Being Open and Duty of Candour Policy (Aug 18-Jun 21)
POL/002/082 Bribery Policy (Jul 16-Jul 19)
POL/004/030 Business Travel Policy. Extend review date to 30/6/19
POL/WOR/010 Capability Policy - Joint (Dec 18-Nov 21)
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/002/058 Cleaning Policy (Apr 16-Apr 18)
POL/002/077/005 Clear Desk Policy (Feb 16-May 18. Extended to 31/3/19)
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 (Dec 16-Oct 18)
POL/001/052 Clinical Supervision and Peer Review Policy (Extended to 30/4/19)
POL/002/061 Closed Circuit Television Policy - CCTV (Apr 16-Apr 19)
POL/002/056 Colour Coding of Cleaning Materials and Equipment Policy (May 16-May 18)
POL-WOR-009 Competency Framework Policy Joint POL-WOR-009 (Nov18-Nov19)
POL/001/016 Complementary Therapies (Nov 17-Nov 19)
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 (Nov 17-Apr 19)
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/002/039 Control of Substances Hazardous to Health (COSHH) Policy (Oct 15-Oct 18) (Review date extended to 30/6/19)
POL/001/013/001 Controlled Drugs Policy (Dec 16-Dec 18)
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/002/010 Counter Fraud, Bribery and Corruption Policy (Mar 17-Oct 19)
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 Allied Health Professionals working with Non-Registered Clinical Support Staff
POL/001/079 Deprivation of Liberty Safeguards Policy (Oct 17-Oct 19)
POL/001/079/001 Deprivation of Liberty Safeguards Protocol
POL/004/035 Disciplinary and Capability Policy for Medical and Dental Staff. Extend review date to 30/6/19
POL/WOR/004 Disciplinary Policy - Joint (Sep 18-Aug 21)
POL/004/027 Disclosure and Barring Service Policy (Sept 17-Sept 20)
POL/002/021 Display Screen Equipment Policy (Oct 15-Dec 17)
POL/001/067 Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) (Jul 17-Jul 19)
POL/002/001 Document Development Policy (Mar 15-Nov 18)
POL/002/001/001 Document Development Resource Pack
POL/001/068 Domestic Abuse Policy (Aug 17-Aug 20)
POL/004/014 Dress Code Policy. Extend review date to 30/6/19
POL/002/032 Driving At Work Policy (Oct 15-Oct 18) (Review Date Extended to 30/6/19)
POL/001/021 Dual Diagnosis Policy (Apr 18-Sep 19)
POL/002/077/008 eHealth IT Change Management Policy (May 16-May 18. Extended to 31/3/19)
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)
POL/002/004 Email Policy (Feb 16-May 18. Extended to 31/3/19)
POL-COR-005 Emergency Preparedness Resilience Response Policy (Joint) POL-COR-005
POL/002/075 Encryption Policy (Feb 16-May 18. Extended to 31/3/19)
POL/002/100 Engagement of External Auditors Policy (May 18-May 19)
POL/001/005/008 Entry & Exit Policy for M/H and LD Wards (May 17-May 20)
POL/002/029 Environmental & Oil Storage Policy (Feb 17-Feb 20)
POL/004/004 Equality and Diversity Policy (Jun 16-Jun 19)
POL/004/021 Exit Policy (Apr 17-Apr 19)
POL/IG/002 Extended Rights of Data Subjects Policy (Joint) (May 18-May 21)
POL/COR/002 Fire Safety Policy - Joint (Aug 18-Mar 19)
POL/002/062 First Aid At Work Policy (Oct 15-Oct 18) (Review Date Extended to 30/6/19)
POL/004/029/001 Flexible Retirement Policy (Oct 17-Oct 19)
POL/004/029 Flexible Working Policy (Oct 17-Oct 19)
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/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/002/099 Governors Expenses Procedure (Nov 17-Nov 20)
POL/002/102 Governors' Council Code of Conduct (Sep 17-Nov 20)
POL/004/002 Grievance Policy (Oct 17-Oct 19)
POL/001/075 Guardianship Policy, Procedures and Guidance (Interim Joint Cumbria County Council Policy) Extended to Jun 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/002/008/012 Health Record Keeping Multidisciplinary Audit Procedure (May 17-Apr 19)
POL/002/008 Health Records Management Policy (Dec 16-Dec 18. Extended to 31/3/19)
POL/002/085 Heatwave Plan (Apr 18-Mar 19)
POL/002/006/001 Incident and Serious Incidents that Require Investigation (SIRI) Policy (May 18-May19)
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-004 Information Asset Management Policy - Joint (Jan 18-Jan 21)
POL/002/007 Information Governance Strategic Management Framework (May 17-May 19)
POL/002/068 Information Governance: Third Party Contracts and Contractors Policy (Mar 16-Feb 19. Extended to 31/3/19)
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 for Adults in Community and Inpatient Settings - Toolkit (Apr 17-Apr 19)
POL/002/040 Intellectual Property Policy (Jan 17-Jan 20)
POL/002/080 Interpreter Policy (Feb 17-Feb 20)
POL/002/077/007 IT Equipment Secure Disposal Policy (Aug 16-Aug 18. Extened to 31/3/19)
POL/004/041 Job Matching and Job Evaluation Procedure (Agenda For Change) (Feb 17-Feb 20)
POL/004/042 Job Planning Policy (Interim) Apr 17-Aug 18. Extended to 30/6/19
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/002/057 Lone Worker Policy (Apr 16-Apr 19)
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 (May 15-Apr 18) Extended to 30/6/19
POL/002/097 Managing Official Visits Procedure (Oct 17-Oct 20)
POL/004/031 Managing Personal Relationships Policy
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/004/038 Maternity, Paternity, Shared Parental, Adoption Pay and Leave Policy (Mar 17-Mar 20)
POL/002/011 Media Relations Protocol (Oct 15-Oct 17. Extended to 30/6/19)
POL/004/040 Medical Appraisal Policy (Apr 17-Apr 20)
POL/002/050 Medical Gas Cylinder Policy (Sep 16-Sep 19)
POL/001/014 Medication in Prison Policy (Dec 16-Dec 19)
POL/001/013 - Formulary Statement Medicines Policy - Formulary Statement incl. Cumbria HIV Formulary Statement (Jul 16)
POL/001/013 Medicines Policy (Dec 16-Dec 19)
POL/001/005/019 Mental Capacity Act Multi-Agency Policy (Apr 16-Apr 19)
POL/001/071 Mental Health Act Delegation Protocol (Oct 17-Oct 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)
POL/001/005/004 Mental Health Act Guidelines on Section 5 (4) 6 Hour Nurses Holding Power (Oct 17-Oct 19)
POL/001/005/013 Mental Health Act Guidelines Part IV - Consent to Treatment (Apr 16-Apr 19) Extended to 30/3/19
POL/001/005/010 Mental Health Act Guidelines: Section 17A Use of Supervised Community Treatment (Apr 16-Apr 19) (extended to Apr 19)
POL/001/005/006 Mental Health Act Guidlines on Section 17 Leave of Absence (Dec 16-Dec 19)
POL/001/005/003 Mental Health Act Guidlines on Section 5 (2) 72 Hour Holding Power (Oct 17-Oct 19)
POL/001/005/015 Mental Health Act Policy and Guidance on Section 132, 132A & 133 Patients Rights (May 18-May 19)
POL/001/005/009 Mental Health Act Policy for the Exercise of Powers to Withhold Outgoing Mail
POL/001/005/012 Mental Health Act Procedure on the exclusion of visitors to detained patients
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/002/077/004 Mobile Computing and Remote Access Policy (Feb 16-May 18. Extended to 31/3/19)
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)
POL/001/054 Multi-Professional Mentorship and Assessment in the Learning Environment (Jan 16-Jan 18. Extended to 30/6/19)
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/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 (Jun 17-Jun 18)
POL/002/098 On Call (Gold, Silver, Bronze) Policy (Dec 17-Dec 18)
POL/WOR/003 Organisational Change Policy - Joint (Apr 18-Apr 20)
POL/001/081 Paediatric Dysphagia Policy (Oct 17-Jul 19)
POL/004/009 Pay Protection Policy (Apr 18-Apr 20)
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/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/002/070 Preparing for a Serious Security Occurrence (Lockdown) Policy (Oct 15-Oct 18) (Review Date Extended to 3/6/19)
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 (PMVA) Policy (Aug 15-Dec 17)
POL/002/103 Printing Policy (Oct 17-Apr 19)
POL/002/043 Procurement Policy (Oct 17-Oct 18)
POL/WOR/005 Professional Registration Policy - Joint (Sep 18-Sep 21)
POL/002/034 Protected Mealtimes Policy (Oct 17-Oct 19)
POL/001/035 Provision of Forensic Outreach Clinics (Dec 16-Jan 18) (extended to Aug 2019)
POL/004/007 Raising Concerns Policy (May 18-Mar 21)
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/004/003 Recruitment and Selection Policy (Jan 16-Jan 18. Extended to 30/6/19)
POL/002/066 Registration Authority Smartcard Policy (Feb 18-Nov 19)
POL/002/074 Regulation of Performance Indicators Policy (Aug 17-May 18) (Extended to Feb 19)
POL/004/023 Relocation Policy (July 2018 - February 2019)
POL/002/077/010 Remote Support of End Users Device Policy (May 16-May 18. Extended to 31/3/19)
POL/004/039 Responding to concerns about Medical and Dental Staff. Extend review date to 30/6/19
POL/001/002 Resuscitation Policy (May 16-May 18)
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/002/012 Risk Management Policy and Process (Apr 16-Sept 19)
POL/002/012/01 Risk Management Strategy (Jan 17-Jan 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)
POL/001/006 Safeguarding Policy (Oct 16-Oct 19)
POL/001/003 Searching of Service Users Person, Room and Personal Belongings Policy (May 18-May 19)
POL/001/004 Seclusion and Long Term Segregation Policy (Sep 18-Sep 19)
POL-004-032 Secondment Policy (Jun 16-Jun 18. Extended to 30/6/19)
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 Management Policy (Dec 15-Dec 18)
POL/002/035 Service User and Carer Payment and Expenses Policy (Sept 17-Sept 18)
POL-COR-004 Sharps Safety Policy Joint POL-COR-004 (Nov18-Nov21)
POl/004/005/001 Sickness Absence Policy Medical and Dental Staff ONLY (Dec 13-Dec 16. Extended to 30/6/19)
POL/002/044 Smoke Free Policy (Jun 16-Dec 17)
POL/004/016 Special Leave Policy (Jun 16-May 18. Extended to 30/6/19)
POL-WOR-002 Standards of Business Conduct Policy (Joint) (Jun 18-Nov 19)
POL/003/001 Standing Orders, Reservations and Delgation of Powers and Standing Financial Instructions (Oct 17-Oct 18)
POL/001/039 Supporting Patients Choices To Avoid Long Hospital Stays - NORTH (Dec 17-Dec 20)
POL/001/007 Supportive Observations and Enhanced Engagement Policy (Mar 18-Mar 20)
POL/004/036 Time off in Lieu Policy. Extend review date to 30/6/19
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/003/005 Treasury Management Policy
POL/003/005 Treasury Management Policy (Mar 17-Mar 19)
POL/001/013/006 Vaccine Storage and Administration Procedures - Appendix 5
POL/001/013/006 Vaccine Storage and Administration Procedures (Jan 17-Feb 19)
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. Extend review date to 30/6/19
POL/004/025 Volunteer Policy. Extend review date to 30/6/19
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)