Policies A to Z - Doncaster and Bassetlaw Teaching Hospitals

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Health and Safety

CORP/HSFS 1 – Health and Safety Policy plus H&SRAF -Health and Safety Risk Assessment Form 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 – Ionising and 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 35 – Evacuation and Shelter 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 4 – Fair Treatment for All
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 60 – Substance Misuse Policy
CORP EMP 61 – DBTH Study Leave & associated funding policy
CORP EMP 62 – Carer’s Policy

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

Finance

CORP/FIN 1 (A) – Standing Orders – Board of Directors – July 2023
CORP/FIN 1 (B) – Standing Financial Instructions – July 2023
CORP/FIN 1 (C) – Reservation of Powers to the Board and Delegation of Powers – July 2023
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 Strategy and Policy
CORP/RISK 14 – Being Open, Saying Sorry and Duty of Candour Policy
CORP/RISK 15 – Serious Incident (SI) 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
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 27 – Severe Weather Plan
CORP/RISK 30 – Risk Identification, Assessment and Management Policy
CORP/RISK 31 – Pandemic Influenza Plan
CORP/RISK 33 (amended 22 May 2018) – 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 13 – Capital Process, Procedure & Quality Policy (Estates & Facilities)
CORP/FAC 12 – Laundry Policy Bagging Procedure for Linen
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 plus APD Checklist – must be completed by authors/reviewers of APDs/policies
CORP/COMM 2 – Smoke Free Policy
CORP/COMM 4 – Complaints, Concerns, Comments and Compliments Resolution and Learning
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 18 – Eliminating Mixed Sex Accommodation (EMSA) Operational Policy
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

Infection, Prevention and Control

PAT/IC 2 – Asplenic Patients Policy – Management of Patients with Absent or Dysfunctional Spleen
PAT/IC 4 – Variant Creutzfeldt-Jakob Disease (vCJD) and Transmissible Spongiform Encephalopathy Agents (TSE): Minimising the Risks of Transmission
PAT/IC 5 – Hand Hygiene
PAT/IC 6 – MRSA Screening and Management of Patients with MRSA
PAT/IC 7 – Scabies – Guidance on Management
PAT/IC 8 – Sharps Policy – Safe Use and Disposal
PAT/IC 10 – Management of Respiratory Type Viruses
PAT/IC 11 – Pathology Specimens – Collection and Handling of Pathology Specimens
PAT/IC 12 – Meningococcal Infections – Management of Cases and Contacts
PAT/IC 14 – Management of Sharps Injuries and Blood and Body Fluid Exposure Incidents
PAT/IC 15 – Chickenpox/Shingles Management Policy
PAT/IC 16 – Isolation Policy
PAT/IC 17 – Management of Patients with Glycopeptide Resistant Enterococci
PAT/IC 18 – Spillage of Blood and Other Body Fluids
PAT/IC 19 – Standard Infection Prevention and Control Precautions Policy
PAT/IC 20 – Management and Control of Incident/Outbreak of Infection
PAT/IC 22 – Kitchen Hygiene and Refrigerator Monitoring Policy for Wards and Clinical Areas
PAT/IC 23 – Tuberculosis – Care of the Patient with Pulmonary or Laryngeal Tuberculosis in Hospital
PAT/IC 24 – Cleaning and Disinfection of Ward-based Equipment
PAT/IC 26 – Clostridioides difficile Infection (CDI) Policy
PAT/IC 27 – Gastroenteritis Minor Outbreak Policy (Diarrhoea and Vomiting)
PAT/IC 28 – Multi-Resistant Gram-Negative Bacteria (in particular CPE) Prevention and Control Policy
PAT/IC 31 – Surveillance Policy
PAT/IC 32 – Hazard Group 4 Viral Haemorrhagic Fevers
PAT/IC 33 – Animals on Trust Premises (Including Pets As Therapy)
PAT/IC 34 – Faecal Microbiota Transplantation Policy – Use of Faecal Microbiota Transplantation (FMT) in the management of Clostridioides difficile infection
To access the Trust Antibiotic Formulary please click here

Treatments and investigations

PAT/T 1 – Trust Policy for the Referral of Imaging Examinations by Qualified Non-Medical Healthcare Professional
PAT/T 3 – Pressure Ulcer Policy – Tissue Viability Top Ten
PAT/T 8 – Specimen and Request Form Labelling Policy
PAT/T 16 – Percutaneous Endoscopic Gastrostomy (PEG)/Enteral Tube Care Policy
PAT/T 17 – Nasogastric Tube Management and Care
PAT/T 20 – Tracheostomy Adult Care Policy (Guidelines for Best Practice)
PAT/T 21 – Drug Misuse Management in the Acute Hospital Setting – Guidelines
PAT/T 25 – Alcohol Issues in the Acute General Hospital Setting (Guidelines and Management)
PAT/T 29 – Chest Drains – Guidelines for the Insertion and Management in Adults
PAT/T 33 – Physiological Observations and prevention of deterioration in the acutely ill adult
PAT/T 37 – Non Obstetric Emergency Care for Pregnant and Postpartum Women
PAT/T 38 – Failsafe Alert for Radiological Findings (Communication Protocol)
PAT/T 43 – Nutrition and Hydration Policy for Adults in Hospital
PAT/T 44 – Clinical Guideline for Venous Thromboembolism (VTE) in over 16’s:
Reducing the risk of hospital-acquired deep
PAT/T 47 – Adjustable Gastric Band Management Practice Guidelines
PAT/T 48 – Prevention of Contrast Induced Acute Kidney Injury Guidelines in Adults (CI-AKI)
PAT/T 49 – In Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus
PAT/T 55 – Deactivation of Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronisation Therapy Defibrillator (CRT-D) Devices – Procedure (adults and young people aged 16 years and over)
PAT/T 56 – Paracentesis for Malignant Ascites Procedure [Withdrawn until further review is complete]
PAT/T 57 – Diabetes Care at the End of Life
PAT/T 60 – Care after Death and Bereavement Policy: Operational policy for staff to follow in the event of a patient death
PAT/T 61 – Telephoned Pathology Results
PAT/T 62 – Child Death Review Policy
PAT/T 64 – Female Genital Mutilation: Identification, Reporting and Management
PAT/T 65 – End of Life: Guidelines for the Management of Patients in last hours/days of life
PAT/T 66 – Parenteral Nutrition Policy
PAT/T 69 – Nasal Retention Device Policy
PAT/T 70 – Peri-operative Management of Diabetes In Adults
PAT/T 71 – High Output Stoma Policy
PAT/T 73 – Vascular Access Device Policy – (combines PAT/T 23 v.5 – Central Venous Access Devices (CVADs) Care and Management and PAT/T 45 v.3 – Peripheral Venous Cannula (PVC) Management Guidelines)
PAT/T 75 – Urinary Catheter Care Policy
PAT/T 76 – Variable Rate Intravenous Insulin Infusion Guidelines for Adults
PAT/T 77 – Doncaster Wound Care Formulary
PAT/T 78 – Newly Diagnosed Diabetes for Young Adults
PAT/T 80 – Blood Transfusion Policy: Pre-Administration
PAT/T 81 – Blood Transfusion Policy: Blood Components, Blood Products and Transfusion Reactions
PAT/T 82 – Blood Transfusion Policy: Massive Haemorrhage Protocol
PAT/T 83 – Blood Transfusion Policy: Transfusion of Neonates, Infants and Children
PAT/T 84 – Blood Transfusion Policy: Jehovah’s Witnesses and Refusal of Transfusion
PAT/T 85 – The Assessment of Sub-conjunctival Haemorrhage (SCH) in Infants

Emergency Care

PAT/EC 1 – Resuscitation Policy
PAT/EC 3 – Emergency Treatment of Anaphylaxis Policy and Guidelines
PAT/EC 4 – Patient Electronic Alert to Key worker System (PEAKS) Guidelines for Oncology and Specialist Palliative Care Patients
PAT/EC 5 – Febrile Neutropenic Patients – Management Guidelines
PAT/EC 6 – Emergency Embolisation for Bleeding Protocol
PAT/EC 8 – Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) Policy

Medicines Management

PAT/MM 1 A – Safe and Secure Handling of MEDICINES POLICY Part A
PAT/MM 1 B – Safe and Secure Handling of MEDICINES POLICY – Part B – Controlled Drugs
PAT/MM 4 – Unlicensed Medicines Policy
PAT/MM 5 – Injectable Medicines Policy
PAT/MM 6 – Paediatric Acute Pain Policy – Assessment and management of pain in children and young people
PAT/MM 7 – Patient Controlled Analgesia (PCA)
PAT/MM 9 – Self-Administration of Medicines Policy
PAT/MM 10 – Policy for the Management of Adult Patients with a Continuous Local Anaesthetic Wound and Perineural Infusion
PAT/MM 11 – Non-Medical Prescribing Policy
PAT/MM 12 – Administration of epidural analgesia (for use in adult areas excluding Maternity obstetrics)
PAT/MM 13 – Nicotine Replacement Therapy QUIT Programme Policy

Patient Safety

PAT/PS 1 – Missing Patient Policy
PAT/PS 2 – Use of Chaperones – Guidance and Framework for Clinical and Support Staff
PAT/PS 7 – Patient Identification Policy
PAT/PS 8 – Safeguarding Adults Policy
PAT/PS 10 – Safeguarding Children Policy
PAT/PS 11 – Patient Falls – Prevention and Management Policy
PAT/PS 12 – Domestic Abuse Policy
PAT/PS 13 – Safeguarding Supervision Policy
PAT/PS 15 – De-escalation: Principles and Guidance including restraint
PAT/PS 18 – Safe Staffing Guideline for Wards and Departments (Nursing, Midwifery & Theatre’s)
PAT/PS 19 – Abduction or Suspected Abduction of an Infant/Child Policy
PAT/PS 20 – Enhanced Patient Supervision and Engagement Policy
PAT/PS 22 – Employer’s Procedures under IR[ME]R 201
PAT/PS23 – Ligature 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’.)
PAT/PS 24 – Safety Standards for Invasive Procedures (SSIPs)
PAT/PS 25 – Use of Force Policy

Patient Administration

PAT/PA 1 (amended June 2019) – Referral to Hospital Access Policy
PAT/PA 2 – Consent to Examination or Treatment Policy
PAT/PA 3 – Discharge of Patients from Hospital Policy
PAT/PA 5 – Communicating Delays in Trust Outpatient Areas
PAT/PA 6 – Arrangements for the Provision of Care to Individuals who are Violent or Abusive (Age 18 or Over)
PAT/PA 8 – Adult Organ Donation Policy – Departments of Critical Care
PAT/PA 9 – Children and Young People – Guidance for Care in Hospital
PAT/PA 10 – Concordat for the Care of Prisoners Admitted to DBTH
PAT/PA 12 – Patient Property and Valuables
PAT/PA 14 – Photography and Video Policy: to Govern Clinical and Non-clinical Recordings
PAT/PA 15 – Cancer Services – ‘Key Worker’ Policy
PAT/PA 19 – Mental Capacity Act 2005 Policy and Guidance, including Deprivation of Liberty Safeguards (DoLS)
PAT/PA 24 – Transfer of Patients and their Records
PAT/PA 27 – Advance Decision to Refuse Treatment (ADRT) Policy
PAT/PA 28 – Eliminating Mixed Sex Accommodation, whilst Maintaining Privacy and Dignity Policy
PAT/PA 31 – Handover Policy
PAT/PA 33 – Clinical Site Management Team Operational Policy
PAT/PA 34 – Interpretation and Translation Services Policy
PAT/PA 37 – Bassetlaw@ Operational Policy

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