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) – Extension to Review Date April 2022

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

Emergency Preparedness, Resilience and Response (EPRR) Policy (OPS 005 V7 March 2022)

Employee Expenses Reimbursement Policy (October 2019)

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

End of Life Care, Policy and Procedure (NP 044 V1 February 2022)

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 V7 February 2022)

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 V2 April 2022)

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

Managing Allegations Against Staff Policy (NP 037 V2 May 2022)

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 – Role of the Second Professional Mental Health Act 1983 (NPCS 013 V5 March 2022)

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 (NPCS 014 V4 March 2019) - Extension March 2022

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)


Safeguarding Adults Policy (HR 040 V3 April 2022)

Safeguarding Children Policy (NP 017 V6 April 2022)

Safeguarding Supervision Policy (HR 039 V2 April 2022)

Searching of Persons, their Property and Environments Policy (OPS 013 V4 April 2022)

Seclusion and Segregation Policy (NPCS 009 V9 February 2022)

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 V2 April 2022)

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 Oct 2018) Extension to Review Date Feb 22

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) - Second Extension to Review Date February 2022

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