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Policies and Procedures

For templates and guidance on writing/ reviewing a policy, procedure or document, please refer to the bottom of this page.

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 Foundation 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 following the acquisition of Calderstones Partnership NHS FT and South Sefton Community Services transaction, a number of policies are specific to staff transferring from these services as indicated.


SA01:  Policy on policies  
SA02:  Risk management Strategy
SA02A: Risk Management Policy and associated Risk Management Template
SA03:  Reporting, management and review of adverse incidents 
SA04:  Payments to Staff for Commercially Funded Research Projects (MIAA Approved)  
SA05:  Reporting, management and investigation of claims incl property expenses 
SA06:  Management of complaints/concerns  
SA07:  Health, safety and welfare 
             HS1 Risk Assessment
             HS2 New Expectant Mothers
             HS3 Display Screen Equipment
             HS4 COSHH
             HS5 Workplace Inspections 
             HS6 Central Alerting System 
             HS7 Management of Contractors 
             HS8 Environmental Suicide Risk Assessment
             HS9 Management of Asbestos 
             HS10 Provision and Use of Work Equipment
             HS11 Electricity at Work

SA08:  Fire safety
SA10:  Use of Clinical Risk Assessment (to be applied in conjunction with portfolio tools attached to                                       policy) 
SA11:  Manual handling 
SA12:  Domestic abuse
SA13:  Being open
SA15:  Food hygiene  
SA16:  Cleaning Standards
SA19:  Management and decontamination of medical devices: Quarter 2 (June 2017) Medical Device List and Approved A-Z Decontamination of Equipment List
SA20:  Nicotine Management  
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 
SA28:  Management and control of legionella bacteria in water services 
SA29:  Management of Security Systems 
SA30:  Slips Trips and Falls 

SA31:  Major Incident Plan  
 The whole plan (including action cards and report forms)
               is available by clicking on SA31.  In addition, separate action cards
               and forms are available below.

           Action Cards:

           Administrative Support Action Card
Communications Media Action Card
Gold Commander Action Card
Incident Response Team Action Card
           Loggist Action Card
Silver Commander Action Card
Switchboard Action Card

           Report Forms:

           Action Log Report Form
Agenda Template for Meetings Form
Critical Incident Report Form
Handover-Takeover Form
Hot Debrief Form
Media Enquiry Form
Methane Report Form
Resource Request Form
Situation Report Form

           Additional Guidance Documents:

sa31a Fuel Crisis Plan
sa31b HAZMAT Guidance
sa31c Heatwave Plan
sa31d Pandemic Influenza Policy


SA34:  Environmental Policy 
SA36 Identification of Service Users
SA37:  Assistance Dog Procedure
SA38:  Service Provision to Young People Aged Under 18
SA39:  Clinical Audit Policy 
SA40:  Equality Monitoring 
SA41:  Performance Indicator Kite-Marking 
SA42:  Preceptorship Policy
SA43:  Official Visitors Policy
SA44:  Business Continuity Policy
SA45:  Learning from Deaths
SA46:   Quality Practice Alert Standard Operating Procedure and Template

SA-G1:  Guidance Document of Support / Information Available for Staff Following      
               Involvement in Complaints, Claims, Incidents and Inquests


The following HR policies relate to all staff employed by Mersey Care NHS Foundation Trust (with the exceptions highlighted in this section of the Policies and Procedures website)

HR01:  Disciplinary procedures & impact assessment  
HR02:  Grievance procedures 
HR03:  Flexible working & impact assessment
HR04:  Leave for personal & family reasons (incorporating Maternity guidelines) 
HR05:  Learning & development
HR06:  Freedom to Speak Up - Whistleblowing 
HR07:  Management of attendance 
HR08:  Verification of statutory registration of temporary and permanent staff 
HR09:  Support of people who experience abuse, discrimination and violence 
HR10:  Equality and Human Rights
HR11:  Capability   
HR12:  Handling concerns about the conduct, performance and health of medical staff 
HR13:  Prevention and management of workplace stressors & Word Version of Forms
HR14:  Dignity and respect at work - prevention of harassment & bullying at work
HR15:  Lease vehicle   
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 
HR25:  Management of Alcohol and Substance Misuse by Staff
HR27:  Supporting Staff with mental or physical disabilities & Word Version of the Supportive Disability and Wellbeing Plan 
HR28:  Induction and Mandatory Training
HR29:  Occupational Health
HR30:  Revalidation & Medical Appraisal 
HR31:  People Participation Framework (to be read in conjunction with the Volunteer Handbook)   
HR32:  Gender Realignment Support 
HR33:  Medical Job Planning
HR34:  Personal Relationships at Work
HR35:  Reimbursement of Expenses - Council of Governors
HR36:  Clinical Excellence Awards
HR37:   Supporting Colleagues

HR-G1:  Night Worker Health Assessment Form 
HR-G2:  Annual Leave Procedure 
HR-G3:  Guidelines for Referral to Regulatory Bodies (Non-Medical) Guidance
HR-G4:  Retirement Process
HR-G5:  Partnership Agreement information
HR-G6:  Mentors and Practice Teachers Working with Nursing Students Guidance
HR-G7:  Private Practice for Consultants & Speciality Doctors - Guidance


The following HR policies relate to all staff employed by Mersey Care NHS Foundation Trust who transferred from the former Calderstones Partnership NHS Foundation Trust on 1 July 2016 (where applicable)

HR 9.6   Secondment
HR 9.14 Supporting Staff Involved in an Incident Complaint or claim
HR 9.41 Bullying and Harassment of Staff by Service Users Patients Procedure
HR 9.43 Reward in Excellence and Employee Benefits
HR 13.5 Travel Claims
HR 19.6 Flexi Time for Office Based Staff
HR 23.0 Shifts Time Owing (TOIL) and Leave
HR 23.1 Holiday Arrangements for all Social Nursing Staff
HR 27.8 Recognition and Management of Burnout and Potential for Abusive Practice within the                           Workplace
HR 9.22 Retirement Procedure

The following HR policy relates to all staff employed by Mersey Care NHS Foundation Trust who work at sites within the Specialist Learning Disabilities Division

 HR 9.34 e-Rostering Policy

The following HR policy relates to all those who were on the bank as at 30 June 2016 with the former Calderstones Partnership NHS Foundation Trust and have remained on the bank with Mersey Care NHS Foundation Trust's Specialist Learning Disability Division from 1 July 2016

HR 9.31 Bank Staffing Procedure


The following HR policies relate to all staff employed by Mersey Care NHS Foundation Trust who transferred from Liverpool Community Health NHS Trust  on 1 June 2017 (where applicable)

SSCSD001: Bullying and Harassment-Dignity at Work
SSCSD002: Disciplinary
SSCSD003: Flexible Working
SSCSD004: Grievance 
SSCSD005: Lone Worker
SSCSD006: Supporting Positive Attendance - Long Term Sickness Absence Procedure
SSCSD007: Supporting Positive Attendance - Short Term Sickness Absence Procedure



F01:  Constitution
  Standing Financial Instructions
F03:  Scheme of Reservation and Delegation of Powers 
F04:  Standards of Business Conduct
F05:  Governor Handbook
F06:  Anti-Fraud and Corruption Policy


IT01:  Corporate Registration Authority  
IT02:  IM&T Security (including links to security standards) 
          SS01-Social Networking Security Standard
          SS02-Remote Working Mobile Devices Security Standard
          SS03-Internet and Email Security Standard
          SS04-User Account Investigation Security Standard
          SS05-Service User Internet Use Security Standard
          SS06-Network Account Management Security Standard

          SS07-Service User Internet Access (Specialist Learning Disabilities Only)

IT03:  Use of mobile phones by service users in in-patient areas
IT04:  Record management  
IT06:  Health records & Appendices / Procedures (to be read with policy)
IT10:  Confidentiality and Data sharing  
IT11:  Corporate Data Quality
IT12:  Information Governance 
IT13:  Freedom of Information (incorporating Environmental Information Regulations)
IT14:  Data Protection Act Policy
IT15:  Clinical Coding  


SD01:  Leave for an informal inpatient and Equality & Human Rights Analysis 
SD02:  Death of a service user 
SD03:  Lone working 
SD04:  Supportive observation  
SD05:  Service users missing from an inpatient area
SD06:  Consent to examination or treatment (to be read/applied in conjunction with
            Department of Health Reference Guide to Consent to Examination or Treatment)
             all in relation to SD06
SD07:  Resuscitation (see also DO NOT attempt cardiopulmonary resuscitation)

SSCSD008: Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
SSCSD009: Resuscitation Incorporating Anaphylaxis and Deteriorating Patient

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
           RT01 Equivalent dosage chart for Haloperidol administration 2015  
SD12:  Handling of medicines 

SSCSD010: Medicines Overarching Policy
MMSS1: Controlled Drugs

Related Medicines Management Procedures:

          MM RD Recorded Drugs
          MM01 Self Administration Procedure (SAM)
          MM02 How Patient Group Directions (PGDs) are developed and implemented in the trust
          MM03 How Medicines are Reconciled on Admission to the Trust
          MM04 What we do to check the accuracy of prescription charts
          MM05 Procedure for Non-Medical Prescribers
          MM06 What we do to support Medicines Optimisation in the Scott Clinic
          MM07 Administration of Medication in Supported Accommodation
          MM08 Discretionary Medication Procedure
          MM09 Management of Medicines Errors
          MM10 Administration of Medication in Food/Drink
          MM11 Procedure for High Dose Anti Psychotics
          MM12 Procedure for Ordering, Receipt, Storage and Monitoring of Medicines in Community                            Teams


Related Medicines Management Procedures for Specialist Learning Disabilities Division:
          MM14 Administration of Medicines
          MM15 Requisitioning Medicines
          MM16 Out of Hours Access to Medicines 
          MM17 Transportation of Medication 
          MM18 Reporting Medicines Related Incidents 
          MM19 Safe and Effective Management of Controlled Drugs
          MM20 Administration of Buccal Midazolam for Status Epilepticus
          MM21 Storage, Ordering, Distribution and Administration of vaccines (Cold Chain) 

Related Medicine Management Procedures for Addiction Services ONLY:

  MM22  Procedure & Guidance for "Take Home Naloxone" in Ambition Services

SD13:  Safeguarding and protection of children
SD15:  Health & Risk Assessment Management Meetings (H-RAMM) 
SD16:  Introduction of all new interventions 
SD17:  Safeguarding Adults from Abuse
           Safeguarding Adults from Abuse - Easy Read
               (to be read/applied in conjunction with):
             b-Liverpool City Council Procedural Framework for Safeguarding Adults 2013    
             c-Sefton Safeguarding Adults 
             d-Safeguarding Adults Procedure Knowsley 

Members of the public can locate information on
Staff can access more detail Safeguarding information through SharePoint site 

SD18Support of service users who present with challenging behaviour (formerly recognition,                             prevention and management of aggression/violence)
SD19:  Advance statements & advance decisions 
SD21:  Care Programme Approach 
SD22:  Children Visiting MCT Sites  
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 (Local Division)  
SD30:  Management of Dysphagia  
SD31:  Removal of ligatures 
SD32:  Staff action following concerns regarding weapons in the community 
SD33:  Supervision and reflective practice
SD34:  Venepuncture Policy    
SD36:  Use of unlicensed and off-label medicines
SD37:  Management of Service Users who have coexisting problems, illicit substance/Alcohol Use
SD38:  Zero Suicide 
SD39:  Carers 
SD42:  Administration of Acupuncture 
SD43:  Prevent  
SD44:  Nutrition 
SD45:  Lockdown 

Lockdown Related Procedures & Action Cards:

sd45b: Bomb threat

sd45x1 - Bomb threat action card 1: Telephone bomb threat

sd45x2 - Bomb threat action card 2: Social media

sd45x3 - Bomb threat action card 3: Suspicious package

SD46:  Multi Agency Public Protection Arrangement (MAPPA)
SD47:  End of life
SD48:  Reducing restrictive practice
SD49:  Clinical Handover at Nurse Shift Changes
SD50:  Victim's rights

SD-G1: Food and fluid refusal guidelines
SD-G2: Enteral Feeding Guidance
SD-G3: Section 117 - Aftercare under the Mental Health Act 1983 
SD-G4: Situation / Exception Report Template 


IC01:  Infection prevention and control

SharePoint link for additional printable information materials and forms:



IC02:  Inoculation Injuries & impact assessment & BBV Injury and Management Form


MH01:  MHA 1983 Overarching Policy 
MH16:  Inter-agency policy and procedure for Section 136 
MH20:  Mental Health Act Managers' Policy  


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 

Need help to write/review a corporate procedural document? (policy, procedure or guideline)

The Trust's policy template and guidance documents are all available to download below.

If you are developing or reviewing a corporate procedural document (policy, procedure or guideline) and require further guidance please email paula.murphy@merseycare.nhs.uk or telephone 0151 472 4042.

All corporate procedural documents should be written in line with the
SA01 Policy on Policies (as above).  

Documents to assist in writing/reviewing policies 

The policy template is the same for all documents, but below are three sample templates with various levels of formatting pre-installed for ease.  

You can use any of these templates to write your policy.  All sections should be completed where indicated and formatting rules applied.

  •  Policy Template (basic word document with a cover sheet and headings)
  •  Policy Template (including some guidance [in red type] and basic formatting)
  •  Policy Template (including guidance [in red type], basic formatting and an automatic contents page)