Our policies and procedures

Struggling to open one of the policies? Right-click the link and press ‘save as’ and open the document this way.

Current written policies, procedures, guidelines and protocols for delivering our functions and responsibilities, are referred to as ‘Approved Procedural Documents (APDs)’. These are mainly facilitated and managed by the Trust’s APD Process Group.

Corporate Policy Documents – are the policies which affect how we run the Trust. Select one of the links below to view the policies within a particular section:

• Health And Safety, Fire And Security
• Employment And Work Life Balance
• Information, Communication And Technology (ICT)
• Finance
• Risk Management
• Facilities
• Procurement
• Records Management
• Communication/General

To view the full A to Z of Trust corporate policies and procedures, scroll further down this page.

Always ensure that you are using the most up to date policy or procedural document.  If you are unsure, you can check that it is the most up to date version by looking at the policy within the relevant section above.

Policies

Please note: To search for a policy, press the ‘CTRL’ key and ‘F’ together. Then type in the name of the policy or keyword to find the relevant document.

Health and Safety

• CORP/HSFS 1 – Health and Safety Policy and Health and Safety Policy Statement
• CORP/HSFS 2  – Health and Safety at Work – Medical Surveillance
• CORP/HSFS 3  – Lone Workers Policy plus Reliance Protect Pulse Device Training and Reliance Protect ID Lone Worker Device Training
• CORP/HSFS 4 – Manual Handling Policy
• CORP/HSFS 5  – Violence, Prevention & Reduction Policy
• CORP/HSFS 7  – Control of Substances Hazardous to Health (COSHH) Guidance
• CORP/HSFS 8 – Non-patient Slips, Trips and Falls Guidance (refer to PAT/PS 11 for Patient Falls)
• CORP/HSFS 9  – Optical Radiation Policy
• CORP/HSFS 10 A – Asbestos Policy
• CORP/HSFS 10 B  – Asbestos Management Plan
• CORP/HSFS 10 C – Asbestos Safety Information Manual
• CORP/HSFS 12  – Safe Use of Display Screen Equipment Guidance
• CORP/HSFS 13 – Glove Use Policy (Latex)
• CORP/HSFS 14 – Fire Safety Policy (Note: to be read in conjunction with CORP/COMM 2 – Smoke Free Acute Services Policy) PLUS Protocol 0 – Fire Safety Management and Governance(AF); Protocol 1 – Fire Prevention; Protocol 2 – Fire Risk Assessment; Protocol 3 – Fire Stopping(AF); Protocol 4 – Fire Doors and Fire Door Assemblies(AF); Protocol 5 – False Alarms; Protocol 6 – Fire Strategy; Protocol 7 – Fire Safety Audits; Protocol 8 – Fire Response Plans; Protocol 9 – Information for the Fire Rescue Service
• CORP/HSFS 15  – Security Policy – incorporating Bomb Threat/Suspect Packages
• CORP/HSFS 16  – Mobile Communications Policy
• CORP/HSFS 17 A – Waste Management Policy
• CORP/HSFS 17 B  – Waste Management Manual
• CORP/HSFS 21 A – Ionising Radiations Safety Policy
• CORP/HSFS 21 B – Non-Ionising Radiations Safety Policy
• CORP/HSFS 22 – Electronic Door Access Control and System Policy
• CORP/HSFS 23 – Handling of the Larger Person Policy
• CORP/HSFS 24 – Identification Badge Policy
• CORP/HSFS 27 – Electrical Safety Policy
• CORP/HSFS 28  – Window Management Policy
• CORP/HSFS 30  – Management of Contractors Policy and Procedures
• CORP/HSFS 31  – Permit to Work Policy and Procedures
• CORP/HSFS 32  – Work at Height Policy
• CORP/HSFS 33  – First Aid at Work Policy
• CORP/HSFS 34 – Closed Circuit TV Policy
• CORP/HSFS 36A – Water Safety Plan: Governance Policy
• CORP/HSFS 36B – DBTH Water Safety Plan Operations and Procedures Manual (WSP/Tech)
• CORP/HSFS 37 – Pest Prevention Control Policy
• CORP/HSFS 38 – Heating and Ventilation Policy
• CORP/HSFS 39– Lift Management and Lifting Equipment Policy

Employment and Work Life Balance

• CORP/EMP 1 – Sickness Absence Policy
• CORP/EMP 2 – Disciplinary Procedure
• CORP/EMP 3 – Grievance and Resolution Policy
• CORP/EMP 9 – Restructure, Reorganisation, Redeployment and Redundancy Policy
• CORP/EMP 10 – Removal and Associated Expenses
• CORP/EMP 11 – Professional  Registrations Policy – Fitness to Practice
• CORP/EMP 12  – Retirement Policy
• CORP/EMP 13 – Conduct, Capability, Ill Health and Appeals Policies and Procedures for Practitioners
• CORP/EMP 14 – Freedom to Speak Up Policy ‘Speak up to make a difference’
• CORP/EMP 15 – Parenting Leave Policy
• NHS Employers – Occupational Shared Parental Leave and Pay Scenarios
• CORP/EMP 17 – Working with Vulnerable Adults & Children – Disclosure and Barring Service (DBS)
• CORP/EMP 20 – Dress Code and Uniform Policy
• CORP/EMP 22 – Pay Banding Policy
• CORP/EMP 24– Support Following the Death of a Member of Staff
• CORP/EMP 25 – Capability Procedure: Managing Poor Performance
• CORP/EMP 27 – Equality Analysis Policy
• CORP/EMP 29 – Statutory and Essential Training (SET) Policy
• CORP/EMP 31 – Health and Wellbeing Policy
• CORP/EMP 32 – Appraisal Policy
• CORP/EMP 33 – Employee Expenses and Subsistence Policy
• CORP/EMP 34 – Over and Underpayments
• CORP/EMP 35 – Doncaster and Bassetlaw Teaching Hospitals – Roster Policy
• CORP/EMP 36 – Recruitment and Selection Policy
• CORP/EMP 38 – Appraisal Policy for Medical Staff of DBTH as Designated Body
• CORP/EMP 39 – Secondment Policy
• CORP/EMP 47 – Special Leave Policy (Incorporating Carer’s and Emergency Leave)
• CORP/EMP 48 – Flexible Working Policy
• CORP/EMP 49  – DBTH Leave Policy (including Annual, Professional and Duty for all staff, including medical)
• CORP/EMP 50 – Preceptorship Policy (for new registrants)
• CORP/EMP 52 – Recruitment and Retention Premia Policy
• CORP/EMP 53 – Pension’s Contribution Alternative Reward Policy (Lifetime and Annual Allowance)
• CORP/EMP 54–  Menopause Policy
• CORP/EMP 55 – Development and Approval of Autonomous Practice for Staff, Associate Specialist and Specialty Grade (SAS) – Doctors and Dentists
• CORP/EMP 56– Pay Progression Policy
• CORP/EMP 57 – Reasonable Adjustments Policy
• CORP /EMP 58 – Civility Respect & Resolution Policy
• CORP/EMP 59 – Equality Diversity and Inclusion Policy
• CORP/EMP 60 – Substance Misuse Policy
• CORP EMP 61 – DBTH Study Leave & associated funding policy
• CORP EMP 62 – Carer’s Policy
• CORP EMP  63– DBTH Financial Wellbeing Policy (Including Salary Sacrifice)

Information, Communication and Technology

• CORP/ICT 2  – Information Management and Technology (IM&T) Security Policy (this policy is only available via the Trust’s network and by staff only. It can be accessed on the ‘B’ drive, via DBHShared within the folder marked ‘internal documents).
• CORP/ICT 3  – Information Management Systems (Registration) Policy
• CORP/ICT 7  – Data Protection Policy
• CORP/ICT 8  – Safe Haven Guidelines
• CORP/ICT 9  – Information Governance Policy
• CORP/ICT 10  – Confidentiality Code of Conduct
• CORP/ICT 11  – Digital Transformation (IT Operations) Business Continuity & Disaster Recovery (BCDR) Policy (This policy is only available via the Trust’s network and by staff only. They can be accessed on the ‘B’ drive, via DBHShared within the folder marked ‘internal documents’.)
• CORP/ICT 14  – Information Records Management – Code of Practice
• CORP/ICT 15 – Freedom of Information (FOI) Policy
• CORP/ICT 19  – Registration Authority Policy for the Management and Issue of Smartcards
• CORP/ICT 21  – Information Risk Management Policy
• CORP/ICT 22 – 3rd Party Access to the Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust’s Network and Core Patient Systems
• CORP/ICT 23 – Data Quality Policy
• CORP/ICT 27  – Email and Internal Communications Policy
• CORP/ICT 28  – Internet Usage Policy
• CORP/ICT 29 – Acceptable Use Policy
• CORP/ICT 30 – The DBTH Subject Access Request (SARs & DSARs) Policy

Finance

• CORP/FIN 1 (A) – Standing Orders – Board of Directors – September 2024
• CORP/FIN 1 (B) – Standing Financial Instructions – September 2024
• CORP/FIN 1 (C) – Reservation of Powers to the Board and Delegation of Powers – September 2024
• CORP/FIN 1 (D)  – Fraud, Bribery and Corruption Policy and Response Plan
• CORP/FIN 1 (E)  – Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust – CONSTITUTION
• CORP/FIN 4 – Standards of Business Conduct and Employees Declarations of Interest Policy.
• CORP/FIN 6 – Private Patient and Category II Procedure
• CORP/FIN 7  – Overseas Patients
• CORP/FIN 8 – Charitable Funds Policy

Risk Management

• CORP/RISK 3 – Introducing New Clinical Procedures or Practices
• CORP/RISK 5 – Claims Handling Policy
• CORP/RISK 6  – Alert Management System Policy
• CORP/RISK 8 – Point of Care Testing Policy and Guidelines
• CORP/RISK 9 – Business Continuity Management Policy
• CORP/RISK 14 – Being Open, Saying Sorry and Duty of Candour Policy
• CORP/RISK 16 – Maternity Services Risk Management Strategy
• CORP/RISK 19 – Clinical Audit Strategy and Policy
• CORP/RISK 21 – Recruitment and Management of Volunteers Policy plus Volunteers Handbook
• CORP/RISK 22 (amended April 2019) – Inquest Policy – Operational policy for staff to follow in the event of an involvement with an Inquest  plus Statement template
• CORP/RISK 23 – Corporate Business Continuity Plan for Disruption to Road Fuel Supply
• CORP/RISK 25 – Prevent Policy – Protecting those who are vulnerable to exploitation and radicalisation through a multi-agency approach
• CORP/RISK 30 – Risk Identification, Assessment and Management Policy
• CORP/RISK 33 – Incident Management Policy
• CORP/RISK 35 – Mortality Governance Policy
• CORP/RISK 36 – Patient Safety Incident Response Policy (PSIRF)

Facilities

• CORP/FAC 2 – Non-Emergency Trust Funded Transport (Internal Transportation)
• CORP/FAC 3  – Medical Gas Systems Policy
• CORP/FAC 7 – Hospital Catering Policy – Provision of Food to Patients, Staff and Visitors
• CORP/FAC 10 – Space Utilisation Policy
• CORP/FAC 11 – Use and Care of Trust Vehicles
• CORP/FAC 12 – Laundry Policy Bagging Procedure for Linen
• CORP/FAC 13 – Capital Process, Procedure & Quality Policy (Estates & Facilities)
• CORP/FAC 14 – Trust Accommodation Policy
• CORP/FAC 15 – Estates and Facilities Operational Management Policy

Procurement

• CORP/PROC 2  – Supplier and Manufacturer Representative Policy
• CORP/PROC 3 – Selection and Procurement of Medical and Surgical Products Policy
• CORP/PROC 4 – Medical Devices Management Policy
• CORP/PROC 8  – (Procurement Policy) Policy and Guidance for the Procurement of Goods, Services and Works

Records Management

• CORP/REC 1 – Order of Filing in Hospital Casenotes Policy
• CORP/REC 2  – Safeguarding Patient Records held Separately from Medical Records Libraries and in Transit Policy
• CORP/REC 3  – Processing Requests for Access to Health Records Procedure
• CORP/REC 4  – Requesting, Locating and Tracking Patients Records Policy
• CORP/REC 5 – Clinical Records Policy
• CORP/REC 6  – Record Keeping Standards
• CORP/REC 8 – Legal Retention and Destruction of Hospital Patient Medical Records

Communication and General

• CORP/COMM 1  – Approved Procedural Documents (APDs) – Development and Management Policy, Policy Template plus APD Checklist – must be completed by authors/reviewers of APDs/policies
• CORP/COMM 2  – Smoke Free Policy
• CORP/COMM 4  – Complaints Handling Policy (Including Concerns)
• CORP/COMM 5  – Developing Information for Service Users Policy and Guidelines
• CORP/COMM 10– NICE Guidance
• CORP/COMM 11 – Management of Reviews, Visits, Inspections and Accreditations Policy
• CORP/COMM 14 – Research Governance Policy
• CORP/COMM 17 – Recording of Research Information in Patient Casenotes
• CORP/COMM 20 – Clinical Outcome Review Programme Policy
• CORP/COMM 23 – Audio & Video (Social Media Apps) Usage Policy
• CORP/COMM 24  – Social Media Policy
• CORP/COMM 25  – Establishment and Administration of Committees Policy
• CORP/COMM 26  – Intellectual Property Policy
• CORP/COMM 27  – Media and Public Relations Policy
• CORP/COMM 28 – Quality Performance Impact Assessment Policy
• CORP/COMM 29 – Management of visiting dignitaries, celebrities, media representatives and other invited visitors to the Trust
• CORP/COMM 30 – Advanced Practice Policy

Complaints – Policies, procedures and contacts for complaints 

The PALS office holds:

• Information which explains how the NHS Formal Complaints Procedure works
• Information explaining external advocacy
• Information explaining the role of the Health Service Ombudsman

For information, contact: The Patient Advice & Liaison Service Manager, Doncaster Royal Infirmary, Armthorpe Road, Doncaster DN2 5LT. Telephone: 01302 366666, or e-mail: dbth.pals.dbh@nhs.net

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