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:

  • do not discriminate
  • promote equality
  • address the diverse needs of individuals
  • ensure human rights are upheld
  • ensure fair treatment
  • protect dignity

Policy templates and guidance document (only available to staff)

This document includes:

  • policy templates
  • guidance on how to use the policy template
  • details of policy approval routes
  • policy approval flowchart
  • top Tips for Policy Authors
  • FAQs

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:

Patient Experience Team by emailing interpreters@ncic.nhs.uk

Search files

Title
Adult Conscious Sedation Policy Details

Description

This policy applies to all clinical staff involved in the conscious sedation of patients.
Adult Organ Tissue Donation Policy Details

Description

This policy outlines the process of organ and tissue donation.
Adult Orthopaedic Elective Ward Ring Fence Policy Details

Description

This policy is to provide a safe, protected ward environment conducive to a modern arthroplasty service as laid out by the Getting it Right First Time
Adult Urinary Catheterisation and Catheter Care Policy Details

Description

This policy will set out standards and guidance for NCIC Foundation Trust relating to urinary catheterisation and catheter care in adult patients.
Bed Rails - Safe and Effective Use Of Bed Rails Policy Details

Description

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
Blood Transfusion Policy Details

Description

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).
Bowel Management Policy Details

Description

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.
Cancer Access Policy Details

Description

This policy sets out the rules and principles under which the North Cumbria Integrated Care NHS Foundation Trust (NCIC) manages cancer pathways.
Chaperone Policy Details

Description

The purpose of this policy is to raise staff awareness of the use of chaperones and provides the procedure to follow for the protection of both patient and healthcare professional.
Consent to Examination and Treatment Policy Details

Description

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.
Policy for Continence Assessment and Provision of Containment Products for Children and Young People Details

Description

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.
Do Not Attempt Cardio Pulmonary Resuscitation Policy (DNACPR) Details

Description

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision should improve patient care by preventing futile resuscitation attempts on patients unlikely to benefit.
Emergency Department CIC Operational Policy Details

Description

This policy outlines the service, procedures and model of care utilised within the Emergency Department in providing safe and efficient patient care.
End of Life and Bereavement Policy Details

Description

This policy has been developed to inform best practice on bereavement and End of Life care/ management.
Feed at Risk Adults Policy Details

Description

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.
Fetal Remains Policy for Respectful Disposal of Non-Viable Fetuses Under 18 Weeks Gestation Details

Description

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.
Handling of Complaints, Concerns, Comments & Compliments Details

Description

This policy is to inform all Trust staff regarding the handling of complaints, concerns, comments and compliments.
High Risk Acute Care Transfer Policy Details

Description

This policy standardises the approach to inter-hospital transfer of patients between hospitals and organisations.
Hospital Post Mortem Examination Policy Details

Description

This policy explains the process for requesting a hospital (Non-Coroners) post mortem examination.
Identification of the Named Consultant – Cumberland Infirmary Carlisle (CIC) & West Cumberland Hospital (WCH) Details

Description

The purpose of this policy is to provide clear information to ALL staff regarding the identification of the named hospital consultant.
Immunisation of Patients (Hospitals) Policy Details

Description

This policy ensures the Trust has information for patients about vaccinations which they understand to enable informed decisions about immunisation.
Incident and Serious Incident (SI) Policy Details

Description

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.
Infant Feeding Network Details

Description

NCIC are following the Lancashire & South Cumbria Maternity and Newborn Alliance Policy and Procedures, providing NCIC responsibilities & monitoring process.
Interim Discharge Policy Statement Details

Description

This document temporarily replaces the 'Whole System Discharge' Policy which is currently being updated.
Introducing New Clinical Interventional Procedures Details

Description

This policy outlines processes regarding new interventional procedures or techniques.
Learning from Deaths Policy Details

Description

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
Management of Results from Pathology and Radiology Examinations Policy Details

Description

This Policy describes the standardised approach for the management of diagnostic results in order to ensure we provide the best care for patients.
Managing Allegations Against Staff Working with Vulnerable People Details

Description

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.
Massive Haemorrhage Policy Details

Description

The aim of this policy is to give written instruction to staff in managing patients undergoing the treatment for massive blood loss.
Mental Capacity Act / Deprivation of Liberty Safeguards (DoLS) Policy Details

Description

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.
Nasogastric Nasojejunal Tube Policy Details

Description

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.
National Early Warning Score (NEWS2) Details

Description

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.
NHSi Delivering Same Sex Accommodation Details

Description

NHSi Delivering Same Sex Accommodation / Eliminating Mixed Sex Accommodation Policy Details

Description

Nutrition and Hydration Policy Details

Description

The policy also aims to improve the nutrition and hydration of patients for whom care is provided in inpatient, outpatient, domiciliary or residential/nursing home and Mental Health settings.
Outpatient Clinic Template Management Details

Description

This Policy mandates use of a consistent Trust-wide approach for the administration and management of outpatient clinic templates and appointment bookings.
Paediatric Dysphagia Policy Details

Description

This policy aims to inform and guide those working with children in the community presenting with dysphagia needs.
Patient Elective Access Policy Details

Description

The purpose of this policy is to ensure all processes are applied in the same equitable way on all elements of the patient’s pathway.
Patient Identification Policy Details

Description

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.
Patients Detained Under the Mental Health Act (MHA 1983) Details

Description

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.
Photography Video Recording Policy Details

Description

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.
Point of Care Testing (PoCT) Policy Details

Description

This policy aims to ensure that Point of Care Testing (PoCT) is used appropriately within the Trust to improve patient care.
Private Patient Policy Details

Description

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.
Reducing the Risk of DVTs or PE in Adults Policy Details

Description

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
Removal of Samples from Deceased Children in Cases of Sudden Unexpected Death Policy Details

Description

This policy provides an integrated approach to ensuring samples are taken from deceased children in accordance with the Human Tissue Act (2004).
Resuscitation Policy Details

Description

This Policy provides guidelines and standards for attempts of resuscitation throughout the Trust.
Royal Marsden Manual of Clinical Nursing Procedures (9th Edition) Policy.pdf Details

Description

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.
Safe Practice for Accounting of Swabs, Needles and Instrument during Invasive Procedures Policy Details

Description

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.
Self-Harm Policy and Care Guidance Details

Description

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.
Smoke Free Policy Details

Description

This policy underpins the trust’s commitment to a smoke free environment, for the benefit of all patients, staff and visitors.
Supporting People with Learning Disabilities to Access Acute Services Policy (Review date extended to 31/08/2022) Details

Description

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.
Supporting Access to Maternal Breastmilk for Children Looked After Details

Description

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.
Supporting People to Make Choices to Avoid Long Hospital Stays Policy Details

Description

Transfusion Management of Patients who Refuse Blood/Blood Component/Product Details

Description

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
Transition Out of Children and Families Health Services Details

Description

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.
Verification of Expected Death in an Adult Patient by a Registered Practitioner Details

Description

The policy sets out the legal requirements and prohibitions to support practitioners verifying expected adult patient deaths.
Whole System Discharge Policy Details

Description

This Policy is currently being reviewed to reflect the changes to discharge requirements as a result of the Covid-19 Hospital discharge policy and will become the Transfer of Care policy. An interim position statement sets out the current operating arrangements for Cumbria Infirmary Carlisle (CIC), West Cumberland Hospital (WCH) and the community hospitals with links to associated systems and process whilst this policy is being updated. Staff are instructed to use the ‘Interim Position on Transfer of Care Policy’ until the updated document is available.