Clinical policies
Clinical general
- Admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures
- Animals in healthcare settings policy
- Assessment and care of children and young people with mental health needs who are placed in an acute general hospital ward policy
- Assessment and screening of drug and alcohol issues in combination with a mental health diagnosis policy
- Bariatric policy (care of the bariatric patient)
- Blanket restrictions policy
- Blood transfusion policy
- Breastfeeding support groups SOP
- Care and treatment of children under the age of 18 on adult acute mental health inpatient areas policy
- Care of the adult patient following death (last offices) SOP
- Care programme approach (CPA) policy
- Chaperoning policy
- Children and young peoples MHS for children and young people that are placed in tier 4 establishments SOP
- Children visiting inpatient and residential units within the trust policy
- Children with special educational needs and disability in Doncaster health contribution (SEND) policy
- Clinical audit policy
- Clinical risk assessment and management policy
- Consent to care and treatment policy
- Continence manual
- Controlled access and egress for inpatient wards policy
- Disengagement policy
- Disengaging with services (C or YP and CAMHS) policy
- Drug misuse on trust premises policy
- Dysphagia management policy
- Electro-convulsive therapy (ECT) clinical guidelines policy
- Electronic handover by medical staff SOP
- Eliminating mixed sex accommodation and maintaining privacy, dignity and respect policy
- Enteral tube feeding adults policy
- Forensic services manual
- Healthcare record keeping policy
- Infant feeding policy Doncaster community
- Infant feeding policy joint or North Lincolnshire
- Interpreters policy (provision, access and use of, for patients, service users and carers)
- Learning from deaths policy the right thing to do
- Mobile devices, social media, the internet and digital content, appropriate and acceptable use
- Nutrition and hydration policy (promoting good nutrition for patients for patients, adults)
- Paro Seal as a therapeutic activity in older people’s MHS SOP
- Patient falls manual (prevention and management)
- Patient identification policy
- Patients missing or absent without leave (AWOL) policy
- Patients trans equality policy
- Patients with a mental health problem and learning disability management policy
- Physical health policy
- Port-a-Cath™ policy (TIVAD) management (children)
- Prevention of scalding and drowning policy
- Primary care mental health service policy
- Requesting a change of lead clinician
- Requesting a second opinion policy
- Resuscitation manual
- Royal Marsden clinical procedures
- Searching of a person or their property policy
- Secluded or segregated policy management of a secluded or segregated patient
- Self harm in primary and specialist care services policy
- Supportive therapeutic observation policy
- Taser or irritant spray on inpatient guidelines
- Tendable SOP
- Transfer of deceased patients policy
- Transition children and young people’s mental health to AMHS and LD services
- Venepuncture with RRI for people who lack capacity to consent SOP
- Venous thromboembolism (VTE) policy
- Verification of expected death policy
- VIP visiting trust services and facilities (VIP, celebrity or governor) policy
- Vision based patient monitoring system (VBPMS) (non-contact technology) policy
- Visiting patients on inpatient areas policy
- Wound care and tissue viability manual
- Wound care formulary Doncaster
Infection prevention and control
Mental Capacity Act
Mental health legislation
- Advance statements and advance decisions to refuse treatment policy
- Approved clinician policy
- Community treatment order policy
- Discharge of a patient by their nearest relative procedure
- Guardianship Doncaster policy
- Guardianship North Lincolnshire policy
- Guardianship Rotherham policy
- Hospital managers protocol
- Leave for inpatients policy and guidance including section 17
- Police assistance and conveyance for the admission of patients detained under MHA 1983 to hospital
- Receipt and scrutiny of detention papers policy (MHA 1983)
- Section 117 MHA 1983 policy
- Section 132 (MHA 1983) explaining to patients their legal rights SOP
- Section 132 informing detained patients of their legal rights procedure
- Section 135 mental health act 1983 policy
- Section 136 of the mental health act 1983 policy
- Section 19 transfer of patients detained under the MHA 1983 to another hospital or unit procedure
- Section 29 displacement of nearest relative Doncaster policy
- Section 29 displacement of nearest relative North Lincolnshire policy
- Section 29 displacement of nearest relative Rotherham policy
- Section 5(2) procedure
- Section 5(4)
- Section 62 procedure for clinical staff
- Section 86 warrant, guidance and procedure (removal of alien patient)
- When a second opinion appointed doctor attends policy
Patient group direction
- Atropine supply and administration by CaSH nurses (PGD)
- Diphtheria, tetanus, acellular pertussis and inactivated poliomyelitis vaccine PGD
- Heparin sodium to line lock a vascular access device administration (PGD)
- Hepatitis A and B vaccine PGD
- Hepatitis A vaccine (UKHSA) PGD
- Hepatitis B vaccine (UKHSA) PGD
- Human papillomavirus vaccine (HPV) PGD
- Inactivated influenza vaccine PGD
- Live attenuated influenza vaccine nasal spray suspension (LAIV) PGD
- Measles, mumps and rubella (MMR) administration of vaccine PGD
- Meningococcal (groups A,C,W and Y) administration of national routine vaccination programme PGD
- REVAXIS low dose diphtheria, tetanus and inactivated poliomyelitis vaccine (Td/IPV) PGD
- Sexual health azithromycin for the treatment of uncomplicated chlamydia trachomatis, uncomplicated mycoplasma genitalium and non-gonococcal and non-specific urethritis PGD
- Sexual health ceftriaxone intramuscular injection for Neisseria gonorrhoeae infection PGD
- Sexual health clotrimazole 1% cream for symptomatic relief of vulvovaginal candidiasis PGD
- Sexual health clotrimazole 500mg pessary for treatment of vulvovaginal candidiasis PGD
- Sexual health combined hormonal contraceptive transdermal patch PGD
- Sexual health combined oral hormonal contraceptive (COC) PGD
- Sexual health doxycycline for uncomplicated chlamydia trachomatis, epididymo-orchitis uncomplicated mycoplasma genitalium and non-gonococcal and non-specific urethritis PGD
- Sexual health etonogestrel (eg Nexplanon®) 68mg subdermal implant for contraception PGD
- Sexual health fluconazole 150mg capsule for vulvovaginal candidiasis PGD
- Sexual Health Imiquimod 5% weight in weight cream for the treatment of external anogenital warts PGD
- Sexual health intramuscular medroxyprogesterone (DMPA) acetate injection PGD
- Sexual health levonorgestrel 1500 mcg tablet(s) for emergency contraception PGD
- Sexual health lidocaine 10mg/ml spray to facilitate intrauterine contraception (IUC) insertion or removal
- Sexual health lidocaine 2.5% plus prilocaine 2.5% cream (EMLA Cream 5%, Nulbia 5% cream) to facilitate intrauterine contraception (IUC) insertion or removal
- Sexual health lidocaine hydrochloride 1% Injection to facilitate insertion and removal of subdermal etonogestrel implant PGD
- Sexual health oral acyclovir for the treatment of genital herpes simplex virus (HSV) infections PGD
- Sexual health oral metronidazole for bacterial vaginosis (BV) or Trichomonas vaginalis (TV) PGD
- Sexual health PGD equality impact assessment
- Sexual health podophyllotoxin 0.15% weight in weight cream or 0.5% weight per volume solution for the treatment of external anogenital warts PGD
- Sexual health progestogen only contraceptive pill (POP) PGD
- Sexual health progestogen-only intra-uterine device (IUD) PGD
- Sexual health subcutaneous medroxyprogesterone acetate (SC-DMPA) injection PGD
- Sexual health ulipristal acetate 30mg table for emergency contraception PGD
- Sodium chloride 0.9% injection as a flush administration PGD
- Template protocol for the insertion of copper intrauterine devices (Cu-IUDs)
Prescribing and medicines management
- Admin of injectable medications by healthcare assistants SOP
- Alcohol detoxification policy Doncaster inpatients
- Antidepressant medication management within children and young people’s mental health service SOP
- Clozapine clinic protocols
- Controlled drug prescribing (Aspire drug and alcohol service Doncaster) SOP
- Controlled drugs (RDaSH care groups, community physical health services) SOP
- Controlled drugs (St Johns hospice) SOP
- Controlled drugs (with the exception of St John’s Hospice and RDaSH physical health community services) SOP
- Covid 19 testing machine Abbott ID now SOP
- Destruction of controlled drugs and unknown substances by pharmacy services staff SOP
- Glucometer Abbott FreeStyle Optium Neo H SOP
- Glucometer nova StatStrip Xpress 2 SOP
- High dose intra muscular vitamin supplements for patients undergoing alcohol detoxification SOP
- Influenza vaccine administered to staff working for RDaSH written instruction
- Lithium monitoring via nurse led clinic policy
- Management of medicines on hazel, hawthorn and magnolia wards SOP
- Medicines reconciliation
- Non-medical prescribing policy
- Pre-emptive prescribing for the last days of life
- Rapid tranquillisation policy and guidelines (pharmacological management of violence)
- Roche Cobas point of care device SOP
- Safe and secure handling of medicines in trust day care facilities (MH services and LD day services) SOP
- Safe and secure handling of medicines manual
- Syringe driver administration of drugs via the CME medical T34 syringe driver SOP
- Transcription of medicines at new beginnings SOP
Safeguarding
- Domestic abuse policy
- Female genital mutilation (FGM), identification, reporting and management
- Multi agency risk assessment conference (MARAC) SOP
- Perplexing presentation and fabricated or induced illness in children procedure
- Prevent strategy policy
- Procedure for managing allegations against people in positions of trust (PIPOT)
- Safeguarding adults policy
- Safeguarding children policy
- Sexual safety policy