Clinical

pdf Absent Without Leave (AWOL) Policy & Procedure (674 KB)

pdf Policy on a Page - AWOL (339 KB)

THIS POLICY IS CURRENTLY UNDER REVIEW

WHILST THE POLICY IS UNDER REVIEW, THE CONTENT HAS BEEN CONFIRMED AS REMAINING CURRENT PRACTICE

When a patient subject to the Mental Health Act is absent without leave or an informal patient is missing

This policy describes the procedure to be followed when a patient subject to the Mental Health Act (MHA) is absent without leave or an informal patient is missing. This includes managing, reporting, monitoring and reviewing incidents. The aim of this policy is to ensure the safety of patients and improve joint working between Sussex Partnership NHS Foundation Trust (Sussex Partnership) and Sussex Police.

The policy covers all Sussex Partnership services and applies to all in-patient, both detained under the MHA and informal, as well as patients subject to Guardianship and Supervised Community Treatment.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Absent Without Leave (423 KB)

 

pdf Active Engagement incorporating Did Not Attend (DNA) Policy & Procedure (302 KB)

The policy sets the standards of how to promote engagement with service users and how to manage and escalate issues when service users are not engaged or do not attend appointments. Actions are based on clinical judgement relating to the level of clinical risk.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Active Engagement inc. DNA Management (459 KB)

 

pdf Care Programme Approach (CPA) Policy (Including Standard Care) (554 KB)

pdf Policy on a Page - Care Programme Approach (CPA) (80 KB)

All service user in secondary care will be allocated a lead practitioner and there are 2 levels of care - standard and CPA. Everyone receiving care will have a personal support plan  - this will be a brief record of agreed care for those on standard care, and a more comprehensive plan for those on CPA.  This plan should be co-produced with the service user and based on recovery principles.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Care Programme Approach (394 KB)

 

pdf Child Exploitation Policy (530 KB)

pdf Child Exploitation Policy on a Page (148 KB)

Sussex Partnership NHS Foundation Trust is committed to supporting children who have been subjected to, or may be at risk of any form of exploitation. This policy is intended to provide a baseline framework for practitioners to address exploitation concerns and take immediate action as appropriate.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf Child Sexual Exploitation Policy EHRIA (455 KB)

pdf Child Visiting Policy (141 KB)

The best interests and safety of children must be considered at all times. This policy sets out arrangements for children visiting hospital in different settings.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf EHRIA - Child Visiting (375 KB)

 

pdf Clinical Bed Management Standard Operating Procedure (752 KB)

The purpose of this policy is to ensure that patients have access to safe, timely and appropriate care and treatment. This policy applies to all functional inpatient services, dementia inpatient services, community and crisis teams in adult and older adults services and the early intervention for psychosis teams.

 

pdf Complementary Therapies Policy (133 KB)

pdf Complementary Therapies Policy on a Page (151 KB)

The purpose of this guidance is to ensure that a framework exists to ensure that in all areas where a complementary therapy is offered, staff will be appropriately trained and supervised, and that the therapy is performed in a safe and satisfactory manner appropriate to the needs and wishes of the client.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf EHRIA - Complementary Therapies (430 KB)

 

pdf Crisis Resolution Home Treatment Team Policy (794 KB)

This policy provides the operational guidelines under which the Crisis Resolution Home Treatment Team will provide a safe and evidence-based service. The nature of the teams is such that it is not possible to cover all eventualities within this policy. CRHTT will need to consider the principles of this policy and other Trust policy and guidance when making decisions to best meet the needs of individual service users.

pdf Domestic Abuse & Sexual Violence Policy (592 KB)

pdf Policy on a Page - Domestic Abuse & Sexual Violence (196 KB)

Domestic abuse and sexual violence is commonplace in society, and is even more prevalent among people who have experiences of mental ill-health. Domestic abuse and sexual violence are also known to have an impact on mental well-being.

This policy is designed to provide a framework for staff to identify, and respond to, domestic abuse and sexual violence in an effective and supportive way that promotes safety and empowers those who experience it, as well as enabling staff to hold perpetrators accountable for their actions. This policy applies to all Trust services.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Domestic Abuse & Sexual Violence (527 KB)

 

pdf Duty of Candour (Being Open) Policy (590 KB)

pdf Policy on a Page - Duty of Candour (Being Open) (107 KB)

The intention of this policy is to ensure that staff are clear about the requirements of Regulation 20 (Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulation 2015) - Duty of Candour. This is a statutory (legal) duty to ensure that as an organisation we are open, honest and transparent with people who use services and other ‘relevant persons’ (people acting lawfully on their behalf) in relation to care and treatment. It sets out some specific requirements that providers must follow when things go wrong with care and treatment resulting in a notifiable safety incident. This includes informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf EHRIA - Duty of Candour (Being Open) (412 KB)

 

pdf Electro-Convulsive Therapy (ECT) Policy (389 KB)

pdf Policy on a Page - Electro-Convulsive Therapy (ECT) (176 KB)

This policy is designed to ensure the safe and equitable delivery of ECT which is in line with current evidence and good practice as detailed by ECTAS.   This policy has been developed to protect the Human Rights of patients accessing the ECT service.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf EHRIA - Electro Convulsive Therapy (ECT) (563 KB)

 

pdf Female Genital Mutilation Policy (80 KB)

pdf Female Genital Mutilation Policy on a Page (175 KB)

Sussex Partnership NHS Foundation Trust is committed to supporting individuals that have been subjected to Female Genital Mutilation (FGM) or may be at risk of this.

This policy and guidance is intended to provide a baseline framework for practitioners to address these needs and take immediate action where appropriate.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf EHRIA - Female Genital Mutilation (528 KB)

 

pdf Policy on a Page - Food & Nutrition (222 KB)

pdf Food and Nutrition Policy (290 KB)

Nutritional guidelines for screening, assessment and treatment for malnutrition or obesity, as well as promoting good health through food.

If you like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Food & Nutrition (436 KB)

 

pdf Infection Prevention & Control Policy (220 KB)

Healthcare associated infections can be traumatic to the patient and costly in terms of time, resources and wellbeing. Staff are expected to comply with this policy and ensure their training is up to date. 

Appendices:

pdf IPC1 - Antibiotic Prescribing Policy (191 KB)

pdf IPC2 - Aseptic Technique & Care of Invasive Devices (309 KB)

pdf IPC3 - Collection of Microbiological Specimens (210 KB)

pdf IPC4 - Decontamination of Medical Equipment (333 KB)

pdf IPC5 - Environmental Cleaning (425 KB)

pdf IPC6 - Estates & Facilities Management (147 KB)

pdf IPC7 - Food Hygiene (162 KB)

pdf IPC8 - Hand Hygiene, Appendices 1 & 2 (579 KB)

pdf IPC8a - Hand Hygiene, Appendix 3 (410 KB)

pdf IPC8b - Hand Hygiene, Appendix 4 (439 KB)

pdf IPC8c - Hand Hygiene, Appendix 5 (219 KB)

pdf IPC9 - Infection Control Principles, Precautions & Personal Protective Equipment (275 KB)

pdf IPC9a - Infection Control Principles, Precautions & Personal Protective Equipment, Appendix 2 (314 KB)

pdf IPC10 - Last Offices (174 KB)

pdf IPC11 - Laundry Management (129 KB)

pdf IPC12 - Management of Healthcare Waste (231 KB)

pdf IPC13 - Management of Infections in Staff (103 KB)

pdf IPC14 - Pest Control (117 KB)

pdf IPC15 - Pets in The Clinical Area (163 KB)

pdf IPC16 - Recognition & Management of an Outbreak of Infection (607 KB)

pdf IPC17 - Single Use & Single Patient Use Medical Devices (192 KB)

pdf IPC17a - Single Use & Single Patient Use Medical Devices, Appendix 1 (134 KB)

pdf IPC17b - Single Use & Single Patient Use Medical Devices, Appendix 2 (164 KB)

pdf IPC18 - Spillages of Blood & Body Fluids (139 KB)

pdf IPC19 - Toy Cleaning (188 KB)

pdf IPC19.1 - Toy Cleaning, Policy on a Page in Clinical Settings (423 KB)

pdf IPC20 - Vaccination Programme for Staff & Service Users (173 KB)

pdf IPC21 - Infections with Specific Alert Organisms (475 KB)

pdf IPC21.1 - Infections with Specific Alert Organisms - Categorisation of Service User by Risk (41 KB)

pdf IPC22 - Sharps Management Protocol (386 KB)

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link

pdf EHRIA - Infection Prevention & Control (467 KB)

 

pdf Internet Access for Service Users (265 KB)

pdf Internet Access for Service Users Policy on a Page (84 KB)

The purpose of this policy is to provide staff of the Trust with an outline of their responsibilities whilst facilitating access to the Internet for service users under the care of the Trust. It also outlines the limitations and responsibilities which service users need to be aware of whilst accessing the Internet on Trust property and using Trust equipment and/or networks.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Internet Access for Service Users (755 KB)

 

pdf Lindridge Medicines Code (725 KB)

This policy is to ensure the safe and secure handling of medicines and to ensure compliance with infection and control structure.

This policy must be read and complied with by all members of staff who are involved in the assessment of a service user's care needs or who are involved in supporting the service user with their medicines.

 

pdf Mixed Sex Accommodation – Maximising Individual Dignity Policy (520 KB)

This policy sets out for all Trust staff, our roles and responsibilities in relation to mixed sex accommodation in order to maintain the safety, privacy and dignity of our patients and carers. 

Protecting the safety, privacy and dignity of our patients is paramount. Sussex Partnership NHS Foundation Trust (the Trust) has a duty to deliver services in an environment, which promotes the safety, privacy and dignity of service users. All staff are expected to treat patients, service users, relatives, carers and visitors with respect and dignity and ensure the safety and privacy of patients and service users is maintained at all times.

If you would like to see the Equality & Human Rights Impact Analysis, please click on the link

  pdf EHRIA - Mixed Sex Accommodation - Maximising Individual Dignity (541 KB)

 

pdf Moving On Policy (743 KB)

This policy supports people’s timely, effective discharge from an NHS inpatient setting, to a setting which meets their diverse needs and is their preferred choice amongst available options. It applies to all adult inpatients in Sussex Partnership Foundation Trust (SPFT) settings, and needs to be utilised before and during admission to ensure that those who are assessed as ready and safe for transfer can leave hospital in a safe and timely way.

 

pdf Policy on a Page - Moving on Policy (544 KB)

pdf Non-Medical Prescribing Policy (659 KB)

pdf Policy on a Page - Non-Medical Prescribing (499 KB)

The purpose of this procedure is to give non-medical prescribers guidance, information and advice on; good practice, training, local processes once qualified, accountability, record keeping, audit and the security and safe handling of medicines.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Non-Medical Prescribing (561 KB)

 

pdf Non-Recent (Historic) Allegations of Abuse Policy (375 KB)

pdf Non-Recent (Historic) Allegations of Abuse Policy on a Page (156 KB)

All persons working within the Trust have a responsibility to safeguard and promote the welfare of service users and any wider risk to the community. This policy sets out the action to take if you have concerns about non-recent abuse during the course of your work. The policy is applicable to all employees of the Trust, including volunteers, and any staff working within the Trust on a service level agreement or honorary contract.

pdf Open Door Policy and Ward Access (279 KB)

pdf Policy on a Page - Open Door (377 KB)

The policy clearly identifies wards where normal practice is for the ward door to be open (ie not locked)

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Open Door (522 KB)

 

pdf Physical Health Assessment & Wellbeing Policy (1.29 MB)

This policy aims to promote and champion physical health and holistic assessment for all patients as part of socially inclusive practice and as an integral element of working with a “whole person” approach.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Physical Health Assessment & Wellbeing (446 KB)

 

  pdf PMVA - Prevention & Management of Violence & Aggression (Formerly Restrictive Physical Interventions) (943 KB)

  pdf TPCL025 Policy on a Page PMVA (501 KB)

This policy reflects current national guidance relating to the de escalation and management and prevention of violence and aggression including restrictive physical interventions for people with learning disability and autistic spectrum disorder, in health, education and social care settings. The policy sets out Sussex Partnership NHS Foundation Trust’s (the Trust) approach to minimising the risks to staff, service users and carers that could potentially arise through violent or aggressive behaviour. The policy provides guidance and summarises the actions that staff are required to take in order to maintain a safe working area, their own and others safety and what to do if they find themselves in a potentially violent situation. This policy applies across all Trust care groups and services.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf TPCL025 EHRIA PMVA Policy Final 2020 (485 KB)

 

pdf Prevention and Management of Pressure Ulcers (1.76 MB)

pdf Prevention and Management of Pressure Ulcers Policy on a Page (781 KB)

The Trust is committed to both reducing the incidence of pressure ulcer development across its services and also to promoting healing following tissue damage.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Prevention & Management of Pressure Ulcers (428 KB)

 

pdf Rapid Tranquillisation Policy (Including the use of oral PRN medication) (545 KB)

pdf Rapid Tranquillisation Poster (350 KB)

The purpose of this document is to provide staff working in Sussex Partnership NHS Foundation Trust wards with guidance about the use of Rapid Tranquillisation (RT). It sets out the main provisions of appropriate use of RT, use of associated medication and the roles and responsibilities of staff.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf Rapid Tranquillisation EHRIA (534 KB)

This policy is for staff use only. To request a copy, please contact the Corporate Governance Team on:

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pdf Resuscitation and Medical Emergencies Policy (1.65 MB)

pdf Policy on a Page - Resuscitation & Medical Emergencies Policy (230 KB)

The purpose of the policy is to ensure that staff understand, and are able to provide, appropriate treatment in the event of a sudden deterioration of a patient (or other individual within trust premises) including the need for resuscitation and provide appropriate treatment during the medical emergency.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Resuscitation & Analphylaxis (404 KB)

pdf Safe and Effective Assessment & Management of Clinical Risk: Policy and Procedure (294 KB)

pdf Minimum Standards for the Recording of Risk (134 KB)

pdf Safe and Effective Assessment & Management of Clinical Risk: - Policy on a Page (150 KB)

Managing risk effectively involves the expertise of both professional and service user: the practitioner is an expert through training and the service user's expertise comes from their own experiences. Sharing this knowledge and working collaboratively maximises the chance of success and minimises negative impacts when things do not turn out as hoped. A key task for all staff working directly or indirectly with service users and their families/carers is to assess and describe presenting risks and, as far as possible, work with the individual and their family & carers to reduce the risk of harm.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf Safe and Effective Assessment & Management of Clinical Risk EHRIA (487 KB)

 

pdf Safeguarding Adults Policy (740 KB)

pdf Policy on a Page - Safeguarding Adults (176 KB)

Safeguarding is core to safe and effective care. Responsibilities for NHS organisations to discharge their statutory responsibilities to safeguard and promote the welfare of young people, children and adults are clearly defined in national legislation and guidance.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link.

pdf EHRIA - Safeguarding Adults (486 KB)

 

pdf Safeguarding Children Policy (363 KB)

pdf Policy on a Page - Safeguarding Children (307 KB)

The Trust provides mental health and learning disability services across Sussex. These services are organised into care groups; Working Age Adults, Older People, Child and Adolescent, Secure and Forensics, Assessment and Treatment, Learning Disabilities and Prison Healthcare. In Hampshire we provide Child and Adolescent Mental Health services only. All care groups have a responsibility to safeguard and promote the welfare of children and this policy is applicable to all staff working across the organisation.

The purpose of this policy is to provide clear and consistent guidelines and policy directives when safeguarding children and young people.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf EHRIA - Safeguarding Children (485 KB)

pdf Searching Patients and Their Property Policy & Procedure (403 KB)

pdf Policy on a Page - Searching Patients & Their Property (97 KB)

This policy outlines the processes and procedures for implementing a search and other considerations that need to be taken into account such as capacity and consent.

The policy is based on the guidance contained with the Mental Health Act Code of Practice (2015) and NICE guidance (2015) – Violence and Aggression: Short-term management in mental health, health and community settings.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf EHRIA - Searching Patients & Their Property (580 KB)

 

All people who use Trust services are entitled to be respected, valued and worked with in a way that it is sensitive to the needs of each individual. This policy aims to provide staff with information and good practice required to achieve this aim for people using our services who are trans..

pdf Therapeutic Engagement & Observation Policy (685 KB)

pdf Policy on a Page - Therapeutic Engagement & Observation (130 KB)

This is one of the most important policies and procedures for our wards. The careful and continuous assessment of clinical risk, reflected in an up to date care plan and supported by the right level of observation keeps our patients safe. Based on national guidance, it has been written by nurses in practice, and tested with colleagues across the Trust.  We welcome your feedback. If you would like to contribute to this continuous improvement programme, you will be warmly welcomed, please contact the Nursing Directorate.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below

pdf EHRIA - Therapeutic Engagement & Observation (226 KB)

 

pdf Transfer and Management of Sussex Partnership Inpatients Requiring Care in a Local General Hospital Policy (387 KB)

pdf Transferring Patients Requiring Care in a Local General Hospital Policy on a Page (736 KB)

This policy provides guidance to staff in such circumstances ensuring that the mental health, substance misuse and/or learning disability care needs of a patient continue to be met, both appropriately and effectively, throughout their period of care in the general hospital.

If you would like to see the Equality & Human Rights Impact Analysis (EHRIA), please click on the link below:

pdf EHRIA - Transfer of Service Users (535 KB)

 

pdf Use of Clozapine in Community Teams Policy (756 KB)

pdf Use of Clozapine in Community Teams Policy on a Page (112 KB)

This policy sets out the practice criteria to be followed by all Trust healthcare professionals for the prescribing, administration, side effect management and monitoring of clozapine in the community setting. The aim of this document is to enable the safe and effective use of clozapine in the Trust in the treatment of mental illness.

 

pdf Use of Clozapine in In Patient Units Policy (724 KB)

pdf Use of Clozapine in In Patient Units Policy on a Page (112 KB)

This policy sets out the practice criteria to be followed by all Trust healthcare professionals for the prescribing, administration, side effect management and monitoring of clozapine in inpatient units. The aim of this document is to enable the safe and effective use of clozapine in the Trust in the treatment of mental illness.

 

pdf Venepuncture Policy (243 KB)

pdf Venepuncture Policy on a Page (140 KB)

Sussex Partnership NHS Foundation Trust recognises the need to provide a quality venepuncture service to patients and service users in both hospital and community settings. To ensure that the diagnosis and treatment of patients and service users is not unduly delayed, appropriate non-medical staff must be supported and facilitated to perform this necessary diagnostic procedure in line with evidence based practice

 

 

pdf Venous Thromboembolism Policy (302 KB)

This Policy is intended to ensure that all inpatients in the care of SPFT receive adequate and appropriate anti thrombotic care to prevent VTE. It also ensures that documentation of VTE risk forms a part of the overall care / assessment of the patient.