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Policies and Procedures

The COVID-19 Strategic Coordination Group (SCG) has approved a process to make rapid changes to either divisional or trust-wide policy documents in response to the COVID-19 pressures the trust is facing. This is called the Policy Document Change Process due to COVID-19 Pressures and is supported by the COVID-19 Document Change Form.  It is intended to allow an alternative process to that outlined in the Policy Management Framework (SA01).

Given the pressure the Trust is currently under, we are suspending the routine review and update of polices at this time up to 31 May 2021.  The only exception will be where the responsible Executive Director, Chief Operating Officer (Clinical Divisions), Director of Security (Secure & SpLD) or Policy Lead (across the Corporate Division) specifically requests that a policy document is updated. 

Please note that the review dates on all policy documents are advisory, if the review date is exceeded the policy is still valid until it is replaced.

The SA01:  Policy Management Framework is your guide to writing/developing or reviewing a policy to ensure it meets with Trust standards.

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.

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, South Sefton Community Services transaction and the Liverpool Community Services NHS Trust transaction, a number of policies are specific to staff transferring from these services as indicated.

Struggling to find what you're looking for? Use our search tool.

To view all Community Services Division-specific policies, please click here:



SA01:  Policy Management Framework and COVID-19 Change Form (word format)
SA02:  Risk management Strategy
SA02A: Risk Management Policy and associated Risk Management Template
SA03:  Reporting, management and review of adverse incidents 
            Appendix 2-Incident Management
            Appendix 3-Initial Incident Review
            Appendix 4-72hr Review Process
            Appendix 5-Review Allocation and Level of Review
            Form: Serious Incident Report and Action Plan
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 word version of form
             HS4 COSHH
             HS5 Workplace Inspections 
             HS6 Central Alerting System 
             HS7 Management of Contractors
             HS9 Management of Asbestos 
             HS10 Provision and Use of Work Equipment
             HS11 Electricity at Work
             HS12 First Aid Management
             HS13 Managing Violence, Aggression and Abuse in the Community
             HS14 Lone Working
             HS15 Operational Management and the Use of Lone Working Device
             HS16 Driving Safely at Work
             HS17  Moving and Handling
             HS18  Social Distancing
             HS19: Radiation Safety 

SA08:  Fire safety
SA10:  Use of Clinical Risk Assessment (to be applied in conjunction with portfolio tools
                  attached to policy)   
SA12:  Domestic abuse
SA13:  Being open
SA15:  Food safety   
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 (Formerly Smoking Cessation)
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:  Water Safety - Legionella and other Waterborne Pathogens  
SA29:  Management of Security Systems 
SA30: Slips Trips and Falls 
SA36:  Identification of Service Users
SA37:  Assistance Dog Procedure
SA39:  Clinical Audit Policy 
SA40:  Equality Monitoring 
SA41:  Performance Indicator Kite-Marking 
SA42:  Preceptorship Policy
SA43:  Official Visitors Policy
SA45:  Learning from Deaths
SA46:  Quality Practice Alert Standard Operating Procedure and Template
Delivering Same Sex Accommodation
SA48:   Linen & Laundry
SA50:   Management of Patient Group Directions
SA51:  Managing Allegations Against Professionals who Work with Children and Adults
SA52:  Standard Operating Procedure for Cheshire & Merseyside Resilience Hub


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 procedure & impact assessment  
HR02:  Grievance procedures - Replaced by HR41 
HR03:  Flexible working, application formimpact assessment
HR04:  Leave for personal & family reasons (incorporating Maternity guidelines) 
HR05:  Learning & development
HR06a: Freedom to Speak Up Strategy
HR06b: Raising Concerns (Freedom to Speak Up) Policy
HR07:  Supporting Attendance- Toolkit for Managers and Toolkit for Colleagues
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:  Supporting Improvement (Formerly Capability Policy)  
HR12:  Handling concerns about the conduct, performance and health of medical staff 
HR13:  Prevention and management of workplace stressors & word copy of forms
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 Wellness Planning Agreement 
HR28:  Induction and Mandatory Training
HR29:  Occupational Health
HR30:  Revalidation & Medical Appraisal 
HR31:  Framework for the Participation & Volunteering Programme  (to be read in conjunction with the Volunteer Handbook)   
HR32:  Supporting Trans*, non binary and non-gender employees and people who use our                             services  
HR33:  Medical Job Planning
HR34:  Personal Relationships at Work
HR35:  Reimbursement of Expenses - Council of Governors
HR36:  Clinical Excellence Awards
HR37:  Supporting Colleagues
HR38:  Acting Down Protocol
HR39:  European Working Time Directive
HR40:  Temporary Staffing 
HR41:  Respect Civility and Resolution
HR42:  Incorrect Payments
HR43:  Pay Progression

HR-G1:  Night Worker Health Assessment Form   and form in Word format
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


F01:  Constitution
  Standing Financial Instructions
F03:  Scheme of Reservation and Delegation of Powers 
F04:  Standards of Business Conduct & Former LCH Staff Declarations of Interest Form
F05:  Governor Handbook
F06:  Anti-Fraud and Corruption Policy
F07:  Fit and Proper Persons 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
IT04:  Record management  
IT06:  Health records & Divisional Guidance Documents to be read with policy:
Local Guidance -- Community Guidance -- Specialist LD Guidance -- Secure Guidance -- Psychological Practice Guidance

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 REPLACED BY HS14 ABOVE 
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)
SD10:  Copying clinical correspondence to service users 
SD11:  Use of Rapid Tranquillisation
           RT01 Equivalent dosage chart for Haloperidol administration 2015  
SD12:  Handling of medicines
SD12A: COVID-19 Vaccine Handling and Management

          Medicines Overarching Policy
          Controlled Drugs

Related Medicines Management Procedures:

          MM RD Recorded Drugs
          MM01 Self Administration Procedure (SAM)
          MM02 Patient Group Directions *REMOVED* Now covered in SA50 PGD Trust wide policy
          MM03 How Medicines are Reconciled on Admission to the Trust
          MM05 Procedure for Non-Medical Prescribers
                   Appendix 1-Procedure and Criteria for Non-Medical Prescribers
                   Appendix 2-ID and Application for Non-Medical Prescribers
                   Appendix 3-Non-Medical Prescribing Proposal Form
                   Appendix 4-Registration for Electronic Pad Prescribing
                   Appendix 5-NMP Approval to Practice Registration Form
                   Appendix 6-To be added to staff members Job Description on completion of
                                     Non Medical Prescribing Qualification
                   Appendix 7-NMP Annual Declaration of Competence to Practice
          MM06 What we do to support Medicines Optimisation in the Scott Clinic
          MM07 Administration of Medication in Supported Accommodation
          MM08 Discretionary Medication Procedure
          MM09 Medication Errors
          MM10 Administration of Medication in Food/Drink
          MM11 High Dose Antipsychotics
          MM12 Procedure for Ordering, Receipt, Storage and Monitoring of Medicines in Community                            Teams
          MM13 FP10 Guidelines
          MM21 Cold Chain for Temperature Controlled Products (Vaccines/ Medicines/                       

Related Medicines Management Procedures for Specialist Learning Disabilities Division:

          MM20 Administration of Buccal Midazolam for Status Epilepticus     

Related Medicine Management Procedures for Addiction Services ONLY:

      MM22 Procedure & Guidance for "Take Home Naloxone" in  Addiction 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 may present with behaviours of concern (formerly recognition,              Support of service users who present with challenging behaviour)
SD19Advance statements & advance decisions 
SD21:  Care Programme Approach 
SD22:  Children Visiting MCT Sites  
SD23:  Identification of Young carers & assessment process  
SD25:  Management of service users with a dual diagnosis of mental health needs & learning                        disability   
SD28:  Seclusion 
SD29:  Physical Health Care  
SD30:  Management of Dysphagia  
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:  Physiotherapists Administering Acupuncture 
SD43:  Prevent  
SD44:  Nutrition 
SD45:  Replaced with EP03 (below)
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
SD51:  NEWS2-Management and Recognition of the Deteriorating
              Patient (National Early Warning Scores) and Recognition of Sepsis
SD52:   Assessment and Management of Choking (Adults)
SD53:   Safeguarding Supervision
SD54:   Assessment and Management of Infected Wounds
SD55:   Speech & Language Therapists SOP
SD56:   Prevention and Management of Pressure Ulcers

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 


EP01:  Emergency Preparedness, Resilience and Response (EPRR) Policy
EP02:  Business Continuity Policy
              EP02a:  Business Continuity 101
              EP02b:  Business Impact Analysis Template
              EP02c:  Business Continuity Plan Template
EP03   Lockdown Policy and Supporting Guidance
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
     IRP00:  Major Incident Plan
     IRP01:  Heatwave Plan
     IRP02:  Fuel Shortage Plan 
     IRP03:  Plan for the Management of Pandemic Influenza
     IRP04:  Plan for the initial management of self presenters from incidents involving
                  Hazardous Materials
     IRP05:  Cold Weather Plan
     IRP06:  Emergency Shelter and Accommodation Plan 

For further information, guidance, templates and tools, please visit the Emergency Planning & Business Continuity SharePoint space

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

The Trust's policy template and guidance documents are 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 Management Framework (as above).  

Documents to assist in writing/reviewing policies 

The policy template is below and includes basic formatting and helpful hints on completing the document to Trust standards.

All sections should be completed where indicated and formatting rules applied.

  •  Policy Assessment Tool (to assist you to check new and updated policy documents against Trust requirements)