All Trust policies are listed below.  If you have any questions regarding our policies, or would like to access one for which there is no electronic version below, please email policy.governance@shsc.nhs.uk

All policies on this page are deemed to be current until replaced irrespective of their individual review date.

Please note all policies relating to the Mental Health Act are now located under “M”.


Electroconvulsive Therapy Policy (MD 008 V6 July 2021) - Interim Review

Eligibility Criteria for NHS Funded Patient Transport Policy (EST 003 V2 July 2019)

Emergency Preparedness Resilience and Response (EPRR) Policy (OPS 005 v6 March 2019)

Employee Expenses Reimbursement Policy (October 2019)

Employment Break Policy [Formerly Career Break Scheme Policy] (HR 041 v4 Nov 2019)

Engagement and Deployment of Short-Term Staffing Policy (HR 014 V2 November 2021)

Equal Opportunities and Dignity at Work Policy (HR 031 V5.1 Sept 2019)

Establishing and Maintaining Therapeutic Relationships with Service Users/Patients/Carers (NP 025 v2 2019)

Evacuation Plan


Major and Critical Incidents Plan (OPS 004 v6 March 2019)

Management of Asbestos Policy (EST 006 - v3 November 2020)

Management of Individuals at Risk of Using Ligatures to Self-Harm or Complete Suicide Policy (NP 038 V1 August 2021)

Managing Access and Exit Policy (OPS 014 v4 May 2020)

Managing Conflicts of Interest in the NHS Policy (CG 001 v2 Oct 2020)

Managing and Supporting Employees Experiencing Domestic Abuse (HR 033 v4.1 Sept 2019)

Managing Substance Misuse and Harmful Substance in Bed Based Services Policy (MD 020 v4 April 2020)

Mandatory Training Policy (October 2019)

Marsipan Protocol (for management of seriously ill people with anorexia nervosa) (September 2014)

Media Policy (CG 002 v3.1 Dec 2020)

Medical and Therapeutic Devices Policy (MD 021 v5 April 2020)

Medicines Optimisation Policy Risks and Processes (September 2019)

Mental Capacity Act – Deprivation of Liberty Safeguards Policy (NPCS 003 V8 October 2021)

Mental Health Act – Allocation of a Responsible Clinician Mental Health Act 1983 (NP 021 v5 2019)

Mental Health Act – Associate Mental Health Act Managers AMHAMs Policy (NPCS 012 V2 Dec 2018) - Extension to Review Date Dec 2021

Mental Health Act - Conveyance Policy (NPCS 002 V4 June 2021)

Mental Health Act - Equality and Human Rights Policy (NPCS v3 Nov 2020)

Mental Health Act – Nominated Deputy Section 5(2) MHA 1983 Policy (NPCS 011 V5 June 2021)

Mental Health Act – The Role of the Second Professional Mental Health Act 1983 (NCPS 013 v4 Mar 2019)

Mental Health Act – SHSC Scheme of Delegation

Mental Health Act - Section 23 – Hospital Managers Review of Detention or Community Treatment Order Under Section 23 Mental Health Act 1983 (NP 022 v4 2019)

Mental Health Act – Section 17 1983 – Authorisation of Leave (Detained Patients) Policy (NP 029 v4.1 Oct 2019)

Mental Health Act – Section 19 Policy – Transfer of Detained Patients to Another Hospital-Unit (NP 032 v1 June 2020)

Mental Health Act – Duty to Give Information Under Section 132, 132A and 133 Mental Health Act 1983 (NCPS 014 v4 Mar 2019)

Mental Health Act – Supervised Community Treatment Community Treatment Orders Guidance

Mental Health Act – Section 136 Policy and SOP for Places of Safety – v17 June 2020

Missing Absent Without Leave and Missing Patients Policy Final Review Date OPS 002 V3 Feb 2019

Mobile Phone Policy (Service Users) (OPS 015 v2 May 2020)


Parenting Leave Policy (HR 010 V3 March 2021)

Password Policy (IMST 001 Password Policy V3 June 2021)

PDR Policy (HR 049 V6 Sept 2020)

Personal Relationships at Work Policy (HR 012 V3 April 2021)

Personal Search Policy (OPS 013 V3 April 2020)

Pest Control Policy (EST 001 V2 July 2020)

Physical Health Policy (NP 020 V6 April 2021)

Policy Framework (Formerly Policy on Policies) CG 006 V8 September 2020

Preceptorship Policy (NP 028 V3 2019)

Prescribing and Administration of Emergency Oxygen in Adults in Hospital Policy (September 2019)

Prevent Policy (HR 041 V2.2 October 2021)

Procurement Policy (FIN 004 V4 July 2021) - Extension to Review Date

Promoting Attendance Policy (HR 042 V7 June 2021) - Interim Review (wellbeing link updated)

Protection of Pay and Conditions of Service Policy (HR 011 V4 March 2021)


Rapid Tranquillisation Policy and Guidelines for Inpatient Wards (MD 011 V6.1 April 2021)

Recording Policy (IMST 010 v1.2 Jan 2020)

Records Management Policy (IMST 008 V3.1 November 2019) - Review date amended

Recruitment and Selection Policy (HR 019 V5 February 2021)

Redeployment Policy (HR 049 V3.2 June 2021) - Interim Review

Redundancy Policy (HR 002 V3 August 2017) - Extension to Review Date October 2021

Registration Authority (Smartcard) Policy (HR 045 v2 April 2020)

Reimbursement of Expenses and Involvement Payments Policy: For Service Users, Carers & the Public Working with SHSC (MD 022 v1 April 2020)

Relocation and Alternatives Policy (HR 037 V3 Sept 2019)

Responding to National Confidential Inquiries and Other National Inquiries and Reviews Policy (MD 017 v3 Nov 2019)

Responding to Tenders Policy (FIN 006 V2 March 2021) - Extension to Review Date

Resuscitation Policy (NPCS 007 v2.1 2018)

Retention and Disposal Policy (February 2011)

Retirement Policy (HR 005 V5 November 2021)

Rostering Policy (HR 013 v4 Feb 2020)


Safeguarding Adults Policy (HR 040 V2.5 October 2021)

Safeguarding Children Policy (NP 017 V5 June 2019)

Safeguarding Supervision Policy (HR 039 V1.5 October 2021)

Secondment Policy (HR 045 V2 May 2020)

Security Policy (FIN 008 V8 October 2021)

Security: Aggression and Violence: protocol for tackling violence and anti-social behaviour within in-patient areas

Sexual Safety Policy (CG 008 V1 November 2019)

Smoke Free Policy (MD 005 V3 March 2021)

Social Media Policy (CG 007 V4 April 2021)

Speaking up – Freedom To Speak Up Raising Concerns Whistleblowing Policy (HR 015 v5.1 October 2018)

Staff Leaving The Trust Policy (HR 030 V2 October 2019)

Stress Management at Work Policy (HR 006 V6 December 2021)

Study and Study Leave Policy (HR 007 V5 October 2021) - Extension to Review Date October 2021

Supervision Policy (Formerly Clinical Professional Supervision and Reflective Practice Policy) (NP 019 V3 May 2020)

Sustainable Development Management Plan (June 2015)

Sustainable Procurement Policy (FIN 009 V2 Dec 2018) - Extension to Review Date Dec 2021