Our policies and procedures

Shortcut: To view the full A to Z of Trust policies, click here.

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:

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

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 – Extended to February 2026
  • CORP/EMP 10 – Removal and Associated Expenses – Extended to February 2026
  • 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 – Extended to March 2026
  • 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 – Job Evaluation Policy (previously – 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 – Extended – awaiting national documentation
  • 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)
  • CORP EMP 64 – Leavers Policy
  • CORP EMP 65 – Job Planning for Consultants and SAS Doctors

DBTH Colleagues please be aware that  PAT/PS 26 – Sexual Safety Policy is available on the Hive

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 (for those who are responsible for any information systems please see Information Asset Owners Handbook)
  • 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
  • CORP/ICT 32 – Artificial Intelligence (AI) Policy

Finance

  • CORP/FIN 1 (A) – Standing Orders – Board of Directors – See CORP/FIN 1 (E)
  • CORP/FIN 1 (B) – Standing Financial Instructions
  • CORP/FIN 1 (C) – Reservation of Powers to the Board and Delegation of Powers
  • 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 now includes Standing Orders – Board of Directors
  • 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 Visitors/Patients Policy
  • CORP/FIN 8 – Charitable Funds Policy

Risk Management

  • CORP/RISK 3 – Introducing New Clinical Procedures or Practices
  • CORP/RISK 5 – Claims Handling Policy – Extended to April 2026
  • 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 19 – Clinical Audit Strategy and Policy
  • CORP/RISK 21 – Recruitment and Management of Volunteers Policy plus Volunteers Handbook
  • CORP/RISK 22 – Inquest Policy – Operational policy for staff to follow in the event of an involvement with an Inquest  plus Statement template – Extended to April 2026
  • CORP/RISK 25 – Prevent Policy – Protecting those who are vulnerable to exploitation and radicalisation through a multi-agency approach
  • CORP/RISK 30 – Risk Management Policy
  • CORP/RISK 33 –  Incident Management Policy
  • CORP/RISK 35 – Mortality Governance Policy
  • CORP/RISK 36 – Patient Safety Incident Response Policy (PSIRF)
  • CORP/RISK 37 – Emergency Preparedness, Resilience and Response (EPRR) Policy
  • CORP/RISK 38 – HAZMAT and CBRN 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’.)

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 – Extended to May 2026

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 – Extended to April 2026
  • 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

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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