Updated policies

April 2024

The below policy was updated on 4 April 2024

• SD51 NEWS2 – Management and Recognition of the Deteriorating Patient (National Early Warning Scores) and Recognition of Sepsis

The below policy was updated on 3 April 2024

• HR33 Medical Job Planning (updated)

The below policies were updated on 2 April 2024

• F02 Standing Financial Instructions (updated)
• F03 Scheme of Reservation & Delegation of Powers (updated)

March 2024

The below policy was removed on 26 March 2024

• MH20 Mental Health Act Managers’ Policy (removed and replaced by SA57 Associate Hospital Managers’ Policy)

The below policy was updated on 26 March 2024

• SA57 Associate Hospital Managers (New)

The below policy was updated on​​​​​​​ 19 March 2024

• SD34 Venepuncture (updated)

The following policy was removed on 14 March 2024:

• MM13 FP10 Guidelines (removed as now covered in MMP10)

The following policy was added on 14 March 2024:

• MMP10 (SD12) Security & Handling of Prescription for Community Use (new)

The following policy was added on 11 March 2024:

• F10 Provider Selection Regime Procurement (new)

The following policies were updated on 6 March 2024:

• SA12 Domestic Abuse (updated) 
• IRP05  Safe Acceptance of Priority 3 Casualties (new) – Hidden from public webpage
• HR24 Travel and Subsistence (updated)

February 2024

The following policy was updated on 26 February 2024:

• IRP04 HAZMAT (updated) – Hidden from public webpage

The following policy was removed on 21 February 2024:

• MMP13 (SD12) Non-Medical Prescribing within the Anticoagulation Service (replaced by MMP13–Time Critical Medicines Procedure)

The following policy was updated on 21 February 2024:

• MMP13 (SD12) Reducing Harm from Omitted or Delayed Time Critical Medicines

The following policies were updated 15 February 2024

• SA13 Duty of Candour (updated)
• F03 Scheme of Reservation & Delegation of Powers (updated)

The following policy was removed on 9 February 2024

• HR36 Clinical Excellence Awards (removed from Trust Wide Policy Set – no longer relevant)

The following policy was updated on 8 February 2024

• HS9 (SA07) Management of Asbestos (updated)

The following policies were updated 7 February 2024

• SA56 Incident Coordination Centres Equipment, Documents and Supplies Checks (ICC) SOP (new document)
• HS13 (SA07) Violence Prevention & Reduction (updated)

The following policies were updated 6 February 2024

• SA19 Management & Decontamination of Medical Devices (updated)
• SD10 Copying Clinical Correspondence to SUs (updated)

The following policy was updated on 5 February 2024

• F01 Mersey Care Constitution (updated)

January 2024

The following policies were updated on 31 January 2024

• IRP07 Flooding Plan (Your Space only for staff – updated)
• HR28 Induction and Mandatory Training (updated)

The following policy was updated on 29 January 2024

• EP01 Emergency Preparedness, Resilience and Response (EPPR) (updated)

The following policies were updated on 22 January 

• New Standard Operating Procedure Template (new for use in teams and divisions when a SOP is required)

• F06  Anti-Fraud Bribery and Corruption (updated)

  SD61 Prevention and Management of Venous Thromboembolism (VTE) for inpatients
  within MCFT Policy (new)

  Sd61a  Prevention and Management of Venous Thromboembolism (VTE) for inpatients within MCFT SOP (new).

The following policy was updated on 24 January

• SA07  Health Safety & Welfare Policy   

December 2023

The following policy was updated on 13 December

• HR-G10 Recruitment & Selection Procedure (linked to HR21 Recruitment & Selection Policy) (New)

November 2023

The following policies were updated on 9 November 2023

• HR06b Raising Concerns/FTSU Policy (minor updates)
• IC02 Exposure to Bodily Fluids / Inoculation Injuries (updated)

The following policies were updated on 6 November 2023

• HR32 Supporting Trans, Non-Binary and Non-Gender Colleagues & People Who Use our Services (updated)
• HR34 Personal Relationships at Work (updated)
• HR39 European Working Time Directive (updated)
• HR45 Appraisal Personal Achievement Contribution Evaluation PACE (updated)

The following policy was updated on 14 November 

• F07 Fit and Proper Persons (updated)

The following policy was updated on 17 November 2023

HR29 Apprenticeship Policy (updated)

October 2023

The following policy was updated on 27 October 2023:

• SD48 - Reducing Restrictive Practice (updated)

The following policies were updated 26 October 2023:

• IRP00 Major Incident Plan (updated)
• HR42 Incorrect Payments (updated)
• HR-G2 Annual Leave (updated)

The following policies were updated on 24 October 2023:

• HR29 Occupational Health Operational Policy (updated)
• HR37 Supporting Colleagues (updated)
• HR47 Menopause (updated)
• HR13 Prevention & Management of Workplace Stressors (updated)

The following policies were removed/stood down on 20 October 2023:

• SD17a Safeguarding Adults from Abuse (easy read doc)
• SA51 Managing Allegations against Professionals 
• SD53  Safeguarding Supervision

The following policy was updated on 11 October 2023:

• HR11 Supporting Performance Improvement (updated)

The following policy was updated on 11 October 2023:

• HR06b  Freedom to Speak Up / Raising Concerns Policy (updated)

The following policy was udpdated on 2 October 2023:

• SD10 Copying Clinical Correspondence Letters to Service Users (updated)

September 2023

The following policy was updated on 29 September 2023

• SA55Central Alert System (CAS) (new)

The following documents are not available on the public facing website, however are available for staff members logged into the website.

• IRP01 Adverse Weather Plan
• IRP02 Fuel Shortage Plan
• IRP03 New and Emerging Pandemic Plan
• IRP04 Initial Management of Self Presenters from Incidents Involving Hazmats
• IRP06 Evacuation Shelter Plan
• IRP07 Flooding Plan
• IRP08 Community Mass Vaccination Plan
• EP03 Lockdown Policy and Supporting Guidance (updated)

The following policies were updated on 28 September 2023:

• EP01 Emergency Preparedness Resilience and Response (updated)
• SA13 Duty of Candour (updated)
• SD22 Children Visiting Trust Sites (updated)
• SD60 Management of Epilepsy in Children, Young People & Adults (new)

The following policy was updated on 27 September 2023:

• F03 Scheme of Reservation and Delegation of Powers (updated)

The following policy was added on 22 Sepember 2023:

• HR-G9 Management of Allegations Against People in a Position of Trust (PIPOT) Who Work with Children and Adults (new)

The following policies were updated on 7 September 2023:

• HR24 Travel and Subsistence (updated)
• HR25 Management of Alcohol & Substance Misuse by Staff (updated)

The following policy was removed on 4 September 2023:

• NWB15 Pay Progression (removed – no longer required – all staff now follow MCT policy)

August 2023

The following policies were updated on 11 August 2023:

• EP02 Business Continuity (updated)
• SA02  Risk Management Strategy (updated)
• SA02A Risk Management Policy (updated)

The following policy was updated on 1 August 2023:

• F01 MCT Constitution (updated)

July 2023

The following policies were updated on 31 July 2023:

• HR-G5 Partnership Agreement (updated)
• SD31A Safe Use of Ligature Cutters (new – hidden from public facing website)
• SA05 Reporting, Management & Investigation of Claims (updated)

The following policies were updated on 21 July 2023:

• IRP00 Major Incident Plan (updated)
• HR01 Maintaining Standards in a Just & Learning Culture (updated)

The following policies were updated 19 July 2023:

• SD13 Safeguarding Children (updated)
• SD17 Safeguarding Adults from Abuse (updated)

The following policy was updated on 17 July 2023:

• SA18 CCTV (updated)

The following policy was updated on 14 July 2023:

• SA54 Inquests (new)

The following policies were retired or removed on 3 July 2023:

• MM11 (SD12) High Dose Antipsychotic Therapy (updated to MMP26 High Dose Antipsychotic Therapy (HDAT)
• MM24 (SD12) Clozapine Prescribing and Monitoring (updated to MMP24 Safe Use of Clozapine)

The following policies were updated on 3 July 2023

• MMP01 (SD12) Safe Management of Controlled Drugs (updated)
• MMP07 (SD12) Medicines Reconciliation for Inpatients (updated)
• MMP17 (SD12) Medicines Management in Special Schools (updated)
• MMP19 (SD12) Transcribing of Medicines in Approved Services (updated)
• MMP23 (SD12) Safe Use of Valproate (new)
• MMP24 (SD12) Safe Use of Clozapine (new)
• MMP26 (SD12) High Dose Antipsychotic Therapy (HDAT) (new – to replace MM11)
• MMP33 (SD12) Ordering, Receipt and Storage of Medicines (excluding controlled drugs) and Medicine Keys (new)
• MMP45 (SD12) Administration of Medicines by Health Care Support Workers (updated)
• MMP46 (SD12) Medicines Management in the IV Therapy Team (new)
• SD12 Safe and Secure Medicines (updated)

June 2023

The following policies were updated on 29 June 2023:

• SD12 Safe and Secure Medicines (updated)
• MMP05 (SD12) Self Admin of Meds Scheme (new)
• MMP20 (SD12) Management of Buccal Midazolam for Status Epilepticus (updated)
• MMP25 (SD12) Management of Patient’s Own Drugs (updated)
• MMP29 (SD12) Initiation & Maintenance of Inpatient Anticoagulation Therapy (new)
• MMP36 (SD12) Medicines Management in GP Support Services (updated)
• MMP39 (SD12) Use of Unlicensed and Off-Label Meds (updated)
• MMP40 (SD12) Safe Use & Insertion of Naso Gastric Tube for Admin of Medication (new)
• MMP42 (SD12) Prescribing (Inpatients) (updated)
• MMP44 (SD12) Medicines Management at Wavertree Bungalow (new)

The following policy was retired / removed on 29 June 23:

• MM01 (SD12) Self Admin SOP (replaced by MMP05)

The following policy was updated on 21 June 2023:

• HR-G3 Guidelines for Referral to Relevant Regulatory Bodies (Non Medical) (updated)

The following policies were updated on 15 June 2023:

• IRP04 Plan for Initial Management of Self Presenters from Incidents Involving Hazardous Materials (new)
• SA53 Patient Safety Incident Response (updated)
• HR27  Supporting Staff with mental or Physical Disabilities (updated)
• HR51 Workforce Sharing Procedure (Mobilisation Principles) (new)

The following policy was updated on 7 June 2023:

• HR45 Appraisal Personal Achievement Contribution Evaluation PACE (updated)

The following policies were updated on 2 June 2023:

• SA52 SOP for Cheshire & Merseyside Resilience Hub (updated)
• SD04 Supportive Observations (updated)
• SD59 Uniform, Workwear and Attire (updated)

• SA45 Learning from Deaths (updated)

May 2023

The following policies were updated on 19 May 2023:

• HS1 (SA07) Risk Assessment (updated)
• HS2 (SA07) Risk Assessment Procedures New and Expectant Mothers (updated)
• HS12 (SA07) First Aid Management (updated)
• HR13 Prevention & Management of Workplace Stressors (updated)
• MMP03 (SD12) Administration of Discretionary Medicines (updated)
• MMP08 (SD12) Administration of Medicines (updated)
• MMP09 (SD12) Safe Use of Injectable Medicines (updated)
• MMP15 (SD12) Administration of COVID-19 Influenza Vaccs (updated)
• MMP18 (SD12) Safe Prescribing of Methadone/Buprenorphine (updated)
• MMP19 (SD12) Transcribing of Medicines in Approved Services (updated)
• MMP34 (SD12) Handling & Management of COVID-19 and Influenza Vaccs into and within the Trust (updated)

The following policies were removed on 12 May 2023:

• NWB02 Disciplinary Policy (retired document)
• NWB03 Disciplinary Procedure (retired document)
• NWB16 Promoting Attendance Policy (retired document)
• NWB17 Promoting Attendance Procedure (retired document)

The following policy was updated on 3 May 2023:

• HR48 Family Leave (updated email address in policy only)

April 2023

The following policies were updated on 25 April 2023:

• SD11 Rapid Tranquillisation (updated)
• MMP01 (SD12) Controlled Drugs (updated)
• MMP07 (SD12) Medicines Reconciliation for Inpatients (updated)
• MMP08  (SD12) Administration of Medicines (updated)
• MMP36 (SD12) Medicines Management in GP Support Services (new)
• MMP37 (SD12) Management of Anticipatory Medicines for End of Life Care in the Community Children’s Nursing Team (EoL CCNT) (new)
• MMP42 (SD12) Prescribing (Inpatients) (new)

The following policy was updated on 14 April 2023:

• HR41 Respect, Civility & Resolution (updated)

March 2023

The following policy was updated on 29 Mar 2023:

• SA53 Patient Safety Incident Response PSIR (updated)

The following policies were updated on 28 Mar 2023:

• MMP01 (SD12) Safe Management of Controlled Drugs (minor change)
• MMP07a (SD12) Medicines Reconciliation (Community) (minor change)
• MMP17 (SD12) Medicines Management in Special Schools (new)
• MMP19 (SD12) Transcribing in Approved Services (minor change)
• MMP28 (SD12) Management of Thickening Agents in the SALT Team (minor change)
• MMP32 (SD12) Medicines Management at Huyton CoRE & Cluster (new)
• MMP38 (SD12) Safe Use of Opioid Medicines (new)
• MMP39 (SD12) Safe Use of Unlicensed / Off-Label Medicines (new – supersedes SD36)
• SD02 Death of a Service User (minor change to include reference to SD12)
• SA50 Patient Group Directions (updated)

The following policies were retired on 28 Mar 2023:

• SD36 Unlicensed Off-Label Medicines
• 027 Management & Admin of Children’s Own Medicines in Special Schools

The following policies were updated on 17 Mar 2023:

• MC04 Deprivation of Liberty Safeguards (DoLS) (updated)
• F04 Standards of Business Conduct (updated)

The following policy was updated on 10 Mar 2023:

• SD42 Physiotherapists Administering Acupuncture (updated)

The following policy was updated on 9 Mar 2023:

• HR49 Apprenticeship (updated)

February 2023

The following policy was updated on 28 Feb 2023:

• HR23 Management & Production of Staff Rosters (updated)

The following policy was removed on 17 Feb 2023:

• MM01 (SD12) Self Administration of Medicines (removed as this now covered in MMP08)

The following policies were updated on 17 Feb 2023:

• MMP01 (SD12) Safe Management of Controlled Drugs (minor change)
• MMP04 (SD12) Overt & Covert Administration of Medicines (minor change)
• MMP07 (SD12) Medicines Reconciliation (inpatients) (minor change)
• MMP08 (SD12) Administration of Medicines (minor change)
• MMP09 (SD12) Safe Use of Injectable Medicines (minor change)
• MMP11 (SD12) Discharge Medicine Services (full review/no changes)
• MMP12 (SD12) Safe use of Buvidal (Addiction Services) (full review/no changes)
• MMP41 (SD12) Medicines Management in Knowsley Treatment Rooms (minor change)
• SD12 Safe & Secure Medicines (minor change)
• MCT08 Safe Management of Controlled Drugs SOP (updated)

The following policy was updated on 13 Feb 2023:

• SA53 Patient Safety Incident Response (New)

January 2023

The following policies were removed on 30 Jan 2023:

• SD54 Assessment of Infected Wounds (removed and now covered by SD58 Overarching Wound Assessment policy)
• HR-G6 Mentors & Practice Teachers (removed due to new MNC standards)

The following policies was updated on 30 Jan 2023:

• SA52 Cheshire & Merseyside Resilience Hub SOP (updated)

The following policy was updated on 23 Jan 2023:

• MMP07a (SD12) Medicines Reconciliation for Patients in the Community (New)
• MMP14 (SD12) Zuclopenthixo Acetate (Acuphased) Procedure (New)
• MMP20 (SD12) Management of Buccal Midazolam for Status Epilepticus (Minor Change)
• MMP25 (SD12) Management of Patient’s Own Drugs Procedure (New)

The following policies have been updated on 13 January 2023:

• MMP09 (SD12) Injectable Medicines (updated)
• MMP43 (SD12) Potassium Permanganate (new)

The following policy was updated on 9 January 2023:

• SD59 Uniform, Workwear & Attire (updated)

The following policies have been updated on 4 January 2023:

• HR01 Maintaining Standards in a Just & Learning Culture (updated)
• HR44 Hybrid Working (new)

December 2022

The following policy was updated on 16 December 2022:

• F03 Scheme of Reservation & Delegation of Powers (minor amendment)

The following policies have been updated on 6 December 2022:

• SA01 Policy Management Framework
• SA30 Slips, Trips & Falls Prevention Management

The following policy was updated on 5 December 2022:

• SA26 Use of Bedrails (updated)

November 2022

The following policies have been updated on 30 November 2022:

• SD34  Venepuncture (updated)
• SA43 Official Visitors (updated)

The following policies have been updated 28 November 2022:

• MMP01 Safe Management of Controlled Drugs (minor change)
• MMP20 Management of Buccal Midazolam (New)
• MMP45 Administration of Medicines by Health Care Support Workers (HCSWs) (New)
• HR07 Appendix A – Toolkit for Managers (Supporting Health & Wellbeing) (updated) and HR07 Appendix B – Toolkit for Managers
• EP01 Emergency Preparedness Resilience & Response (EPRR) (updated)
• IRP01 Heatwave Plan (updated)
• IRP06 Evacuation & Shelter Plan (updated)
• F03 Scheme of Reservation & Delegation (updated)

The following policy has been retired:

• MM20 Administration of Buccal Midazolam for Status Epilepticus (superseded by MMP20)

The following policy has been retired:

• 22 Nov 2022  - MM20 Administration of Buccal Midazolam for Status Epilepticus (superseded by MMP20)

The following policies have been updated:

• 22 Nov 2022

- MMP01 Safe Management of Controlled Drugs (minor change)

- MMP20 Management of Buccal Midazolam (New)

- MMP45 Administration of Medicines by Health Care Support Workers (HCSWs) (New)

• 23 Nov 2022

- HR07 Appendix A – Toolkit for Managers (Supporting Health & Wellbeing) (updated)

- HR07 Appendix B – Toolkit for Managers

• 24 Nov 2022

- EP01 Emergency Preparedness Resilience & Response (EPRR) (updated)

- IRP01 Heatwave Plan (updated)

- IRP06 Evacuation & Shelter Plan (updated)

- F03 Scheme of Reservation & Delegation (updated)

The following policies have been updated:

• 7 Nov 2022 - HS8 (SA07) Environmental Suicide Risk Assessment ESRA (appx added – this policy is not available on the public website)
• 17 Nov 2022

- MMP04 Overt and Covert Administration of Medicines in Food or Drink (Inpatients) (New)

- MMP15 Administration of COVID / Flu Vaccinations to Inpatients (updated)

- MMP09 Safe Use of Injectable Medicines (New)

- SD12a COVID-19 Vaccination handling & Management (updated)

- MMP34 Handing & Management of COVID-19 & Flu Vaccinations within the Trust (updated)

- HR37 Supporting Colleagues (updated)

The following policies have been retired:

• 17 Nov 2022

- MM10 Administration of Medicines in Food / Drink (superseded by MMP04)

- MMP27 COVID-19 Moderna Handling & Management (absorbed into MMP15)

- MMP27a COVID-19 Spikevax (absorbed into MMP15)

October 2022

The following policies have been updated:

• 13 Oct 2022 - SD04 Supportive Observations (updated)
• 18 Oct 2022 - HR19 Organisational Change (updated)
• 19 Oct 2022 - IC02 Inoculation Injuries (updated)

The following policies have been updated/removed:

• 27 Sep 2022 - SD04 Supportive Observations (minor amendment)
• 5 Oct 2022 - SD55 Speech and Language Therapies SOP (removed – national guidance on use of PPE is adequate)
• 10 Oct 2022

- MMP15 (SD12) Administration of COVID & Flu Vaccinations for Inpatients (updated)

- MMP27a (SD12) SpikeVax Bivalent COVID-19 Vaccine Handling & Management (new)

- MMP28 (SD12) Management of Thickening Agents (SALT) (new)

- MMP31 (SD12) Transfer of Inpatient Medication Records (new)

- MMP34 (SD12) Booking Out COVID-19 & Influenza Vaccinations from the Vaccination Centre (new)