The Trust's policies relate to its operation, staff, facilities, health and safety, risk management and services provided to patients
The Trust provides a wide range of policies to support staff in their everyday lives which set out the necessary guidance for decision making and the associated processes.
At NCIC, everyone is equal. We recognise the need to tackle discrimination and promote equality. We do everything we can to ensure all our policies:
Please note that the information in italics in the policy template is for author guidance only and should be removed once you have completed the information.
If you're unsure of the process to follow within any policy, speak to your line manager before contacting the policy author or accountable director.
If you are unsure of the arrangements for managing policies, email the policy help desk on policyhelpdesk@ncic.nhs.uk
If you require written communication e.g. appointment letters, clinic outcome letters, including any of our publications, to be translated into another language or format, such as Braille, large print or audio, contact:
The aim of this policy is to provide the guidance and information required to ensure safe and effective nutrition and hydration where there are acknowledged clinical risks for adults from the age of 18.
To provide a consistent set of professional requirements that support Advanced Clinical Practice across NNCI to deliver a sustainable and progressive approach to advanced practice.
The purpose of this policy is to provide instructions for all staff involved in the care of patients and the decision to use (or not to use) bed safety rails or bed grab handles
This policy sets the standard for the transfusion of blood components in North Cumbria Integrated Care NHS Foundation Trust based on the British Society of Haematology (BSH) Guidelines and Blood Safety and Quality Regulations (2005).
This policy outlines the standards and expectations to be followed by all staff involved in the assessment and management of adult patients with suspected or confirmed neurogenic bowel dysfunction.
The purpose of this policy is to raise staff awareness of the use of chaperones and the procedure for protection of both patient and healthcare professional. Patients have a right to a chaperone.
The purpose of this policy is to set out the Trust’s arrangements for, and approach to the provision of clinical supervision through supportive conversations.
This Policy applies to all NCIC employees and also those who are not directly employed by the Trust but who act in a professional capacity within the Trust through a Service Level Agreement, ensuring systems are in place to gain and review consent from people who use their services and who are acted upon by those services.
This policy outlines arrangements for the Entry and Exit management to Trust Inpatient wards to maintain a safe environment for both patients and staff.
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision should improve patient care by preventing attempts where resuscitation would be unlikely to succeed and result in an undignified death.
This policy outlines the service, process and model of care utilised within the Emergency Departments at Cumberland Infirmary, Carlisle and West Cumberland Hospital, Whitehaven to provide safe and efficient patient care.
The clear principle driving this policy is to ensure that North Cumbria Integrated Care NHS Foundation Trust (NCIC) disposes of fetal remains in a respectful and sensitive manner.
This policy provides the correct procedure of the hospital post mortem examination process, complying with the terms and conditions of the Human Tissue Act Licence.
This policy applies to all members of staff employed within the Trust who are involved in any aspect of incident reporting. The purpose of this document is to define how incidents and serious incidents will be reported, investigated and managed to ensure learning within the organisation.
NCIC are following the Lancashire & South Cumbria Maternity and Newborn Alliance Policy and Procedures, providing NCIC responsibilities & monitoring process.
The aim of this policy is to provide a reference guide for the Cervical Screening Provider Lead (CSPL), deputy to the CSPL, administration staff who may be involved in the invasive cancer audit and for all staff whom may be involved in providing feedback to patients diagnosed with cervical carcinoma
The Learning from Deaths Policy builds on and replaces the previous mortality framework and it describes the process by which all deaths in care are identified, reported and investigated. It aims to strengthen arrangements, where appropriate, to ensure learning is shared and acted upon. It seeks to ensure the Trust engages meaningfully and compassionately with bereaved families and carers and supports staff to find all opportunities to improve the care the Trust offers by learning from deaths
This policy sets out safe practice regards feeding tube management including assessment, insertion and related tests to confirm appropriate placement which applies to all children and neonates for the purpose of feeding or administering medication.
This Policy describes the standardised approach for the management of diagnostic pathology results in order to ensure we provide the best care for patients.
This policy outlines the principles and actions required when allegations are made which give rise to concerns about a staff member’s, or volunteers’, suitability to work with children and/or vulnerable adults.
This policy describes the process for identifying those patients within the Trust who may require an assessment under the Mental Capacity Act and/or consideration of a Deprivation of Liberty.
This policy is to facilitate and support all newly registered healthcare professionals in their progress to transition into their role as a confident and competent practitioner to deliver safe high quality care.
The Nasogastric Tube Policy provides a step by step process for the insertion of a nasogastric tube (NG) and the related tests to confirm appropriate placement.
This Policy is to provide best practice guidance for health care professionals to determine and identify patients who are at risk of acute deterioration or presenting with abnormal physiological status.
The policy also aims to improve the nutrition and hydration of patients for whom the Trust provides care within inpatient, outpatient, domiciliary or residential/nursing homes.
This Policy mandates use of a consistent Trust-wide approach for the administration and management of outpatient clinic templates and appointment bookings.
The policy aims to provide staff in all NCIC services with information on how to effectively identify all patients as individuals, through positive patient identification.
This policy details the roles and responsibilities of all staff in respect of consent to treatment under the Mental Health Act 1983 (the Act) and compliance with the Mental Health Act Code of Practice 2015.
This policy lays out the expectations of how photography and video material collected by the Trust will be managed. This policy does NOT cover the use of CCTV.
The policy has been created to address the unique needs of children and young people
who have delayed or unattained continence to ensure an equitable service offer across the county.
This policy provides information to allow clinicians to utilise Intraoperative Cell Salvage in a safe and effective manner and safely identify suitable patients undergoing elective and / or emergency surgical procedures where ICS could be used.
This policy provides clear information to ALL staff regarding the provision and management of private patients and sets out a detailed framework for how private practice should be conducted within the Trust.
This Policy is designed to ensure a systematic process is in place which ensures that every Patient / Service User being admitted within NCIC inpatient facilities has a Venous Thromboembolism (VTE) risk assessment
The purpose of this document is to ensure the effective utilisation of the workforce through efficient rostering and provides the general framework with which rosters (manual or electronic) must comply.
This policy ensures clinical staff in all disciplines and at all levels, have access to up to date procedures and guidelines in the absence of a Trust approved policy, procedure or guideline, via the Royal Marsden Manual of Clinical Nursing Procedures.
This policy aims to ensure that all swabs, needles and instruments are accounted for before, during and after an invasive surgical procedure, thus preventing unintentional foreign body retention during surgery.
The purpose of this policy is to provide guidance on the roles and responsibilities of our staff in the care of patients presenting with self-harm or risk of self-harm.
This policy applies to all families in which a child is, or will be, within the looked-after system and the plan is for the child to receive maternal breastmilk.
This policy relates to the support of people with learning disabilities of all ages when accessing health care for diagnostic investigations, treatment or emergency admission.
This policy sets out the parameters for choice in relation to hospital discharge. It supports people’s timely, discharge from an NHS inpatient setting (acute & community), to a setting which meets their diverse needs and provides a framework for the appropriate application of choice amongst available options.
The purpose of this policy is to enable good flow and support for people in the most appropriate setting to meet needs whilst maintaining a focus on the person at the centre of the process.
The aim of this policy is to provide information about the management of patients who refuse blood, blood components or blood products for religious or other reasons
This policy applies to all young people who are currently receiving input from children’s health services and who have long term conditions that are likely to persist into adulthood.
This policy confirms uniform standards and standards of dress expected of employees of the Trust, based upon the objectives of patient safety public confidence and staff comfort.