Policy Documents: Clinical

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/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/002/053 Alert Policy and Procedure (Apr 17-Mar 19)
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/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/001/001 Care Coordination Policy (Aug 18-Aug 21)
POL/001/080 Chaperone Policy (Oct 17-Oct 20)
POL/002/069 Clinical Audit Policy (Aug 18-Aug 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/001/016 Complementary Therapies (Nov 17-Nov 19)
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/001/013/001 Controlled Drugs Policy (Dec 16-Dec 18)
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/001/067 Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) (Jul 17-Jul 19)
POL/001/068 Domestic Abuse Policy (Aug 17-Aug 20)
POL/001/021 Dual Diagnosis Policy (Apr 18-Sep 19)
POL/001/055 Eliminating Mixed Sex Accommodation (May 17-May 19)
POL/001/005/008 Entry & Exit Policy for M/H and LD Wards (May 17-May 20)
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/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/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/002/080 Interpreter Policy (Feb 17-Feb 20)
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/001/078 Learning from Deaths Policy (Oct 17-Oct 20)
POL/001/005/020 MAPPA Multi Agency Risk Evaluation Pathway Policy (Jan 17-Jan 20)
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/002/030 Moving and Handling Policy (May 18-May 20)
POL/001/054 Multi-Professional Mentorship and Assessment in the Learning Environment (Jan 16-Jan 18. Extended to 30/6/19)
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/001/081 Paediatric Dysphagia Policy (Oct 17-Jul 19)
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/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/001/035 Provision of Forensic Outreach Clinics (Dec 16-Jan 18) (extended to Aug 2019)
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/001/002 Resuscitation Policy (May 16-May 18)
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/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/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/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/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/001/083 Whole System Discharge Policy (Dec 17-Dec 20)