P_CIG_18 Management of Controlled Drugs Policy


The purpose of this document is to provide policy and operational guidance on all aspects of controlled drug management in Lincolnshire Community Health Services (LCHS). 


This document covers the management of controlled drugs in Skegness, John Coupland, Johnson, and Louth Community Hospitals, the Butterfly Hospice, Community Nursing Services, and Urgent Care Centres, together with the policy for prescribing, supply, storgage and disposal of controlled drugs.





























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P_CIG_21 Prevent Strategy Policy

            This policy describes how the Trust will meet its statutory responsibilities under the Counter Terrorism and Security Act 2015 and how the Trust, and its employees, can respond, if they are concerned that a service user of the Trust or another employee appears to be being exploited in this way.


            Contest, the Governments national counter terrorism strategy, aims to reduce the risk to the United Kingdom and its interests overseas from international terrorism, so that people can go about their lives freely and with confidence. These forms of terrorism include but are not limited to:


  • Al-Qa’ida influenced groups

  • Far Right extremists

  • Environmental extremists

  • Animal Rights extremists


    This policy addresses the potential for vulnerable people supported by or working for the Trust to become radicalised by others such that they are at risk of being drawn into terrorism. A vulnerable person may be exploited by others to become radicalised in a number of ways. This includes, for instance, right wing extremist groups as well as those who claim to be inspired by religious motivations. The Trust believes that this policy is a proportionate response and in no way seeks to limit legitimate debate and freedom of expression.

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P_HR_27 Promoting Equality Valuing Diversity Protecting Human Rights Policy

This policy sets out how Lincolnshire Community Health Services NHS Trust will use equality legislation as a lever to enable our trust to achieve two key things:

  • firstly to deliver patient-centered services that are accessible to everyone;
  • and secondly to become a model employer that attracts and retains the best employees who reflect the population that we serve.

This policy applies to all staff working within the Trust, (including temporary staff, contractors, students and those with honorary contracts) and relates to other Trust staff, contractors and staff from other organisations working on Trust premises.

It applies to all Trust premises and to all Trust staff working in other premises.

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P_CS_08 Resuscitation Policy

It is the aim of Lincolnshire Community Health Services to provide a high quality, consistent and evidence based response from appropriately skilled staff to any sudden collapse, medical emergency or cardiopulmonary arrest within their work environments.


In the context of this document the term resuscitation applies to and includes cardiopulmonary arrest, paediatric and medical emergencies involving life support actions.




LCHS recognises that an effective response to, and the management of a cardiac arrest or medical emergency is a key objective


The Trust will aim to achieve the core standards for Resuscitation,  (Quality Standards for cardiopulmonary resuscitation practice and training, Resuscitation Council, 2013, 2016) :


  • Ensuring effective communication arrangements to summon an appropriate response

  • An early warning system is in place for the recognition of patients at risk of cardiac arrest (Patient Safety First, NPSA, 2009) LCHS uses the National  Early Warning Score.

  • Ensure access to appropriate equipment, including defibrillators / Automated External Defibrillators to ensure defibrillation can be achieved in 3 minutes

  • Provide access to appropriate training and development to ensure the competencies of staff

  • Ensure all training in accordance with Resuscitation Council (UK) Resuscitation Guidelines 2015

  • Ensure staff understand decisions specific to CPR and  Do Not Attempt CPR (DNACPR) policy is in place.

  • Reporting of all Life Support actions using Datix and review of all deaths following cardiac arrest where LCHS staff are present by the Mortality Review Panel.

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P_CIG_20 Safe and Secure Handling of Medicines


This policy aims to offer practical advice and outline steps that must be taken to ensure medicines are handled safely and securely within all care environments and services and by directly employed staff.

The policy is underpinned by key legislation, for example, the Medicines Act, the Misuse of Drugs Act and associated regulations, the Health and Safety at Work Act, the Control of Substances Hazardous to Health Regulations and the regulations relating to the disposal of hazardous and other controlled wastes.

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P_F_02 Treasury Management Policy

The Policy establishes a clear control framework for managing treasury activities and mitigating risks to ensure the objectives are delivered. The Trust can only invest surplus funds solely within the Government Banking Services (GBS) and the National Loans Fund, up to a maximum investment period of three months. The Trust has put in place key controls over the treasury and investment system that include:

    • Clear definition of policies, processes and controls including description of roles and duties of the parties involved.
    • Regular review of treasury activities.
    • Separation of duties between those who set policy and monitor compliance and those who account for treasury activities and
    • The inclusion of treasury management activities within the scope of review by internal audit and external audit.

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P_CoG_19 VIP Policy

There are occasions when a VIP (Very Important Person) might visit Lincolnshire Community Health Services NHS Trust (LCHS) services or premises.This could occur during the working day or in the out of hours period.

VIPs mightincludemembersoftheRoyal family,senior politicians(e.g.SecretaryofState,Ministers),representativesfromnationalbodiessuchastheDepartmentofHealth,celebrities,sportspeopleetc.

Additionallythetrustprovidesurgent careserviceswhichcanbeaccessedbyeveryoneandthiscanincludeVIPsandthoseinprotectivecustody,thismaybeanemergencywithlittlewarning.

Itisimportantthatthetrustisabletocontinuenormalbusinessandthatcareprovidedtoothersis notcompromised.InadditionitisimportanttosafeguardboththeprivacyoftheVIPandthosearoundthemincludingstaff.Itisalsoimportanttosafeguardthereputationoftheorganisation.

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P_CIG_19 Choices Policy

Lincolnshire Community Health Services (LCHS) strives to provide high quality care to patients in their own home. When patients needs require them to be cared for in an alternate environment such as a community hospital or a short term community care (transitional) bed (assessment and treatment, transitional care, reablement or rehabilitation), LCHS teams manage this change but continue to aim for their patients to return to care provided in their own home as soon as possible. When ready for discharge (This means assessed by LCHS as safe and ready to be moved on from their present place of care) services remain committed to the principle of Home First which recognises the importance of discharge into patients own homes where this can be done safely.

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P_CS_44 Administration of Low Molecular Weight Heparin by a Senior Healthcare Support Worker / Allied Professional

In community settings many of the individuals receiving Low Molecular Weight (LMW)

Heparin do not have any specific nursing need requiring the intervention of a Registered Nurse; consequently an additional visit to administer treatment is required. In order to effectively utilise staff resources and reduce the number of individuals accessing a patient’s home it is proposed that Senior Health Care Support Workers and Allied Health Professionals (AHP’s) are trained to administer this treatment as part of the delivery of planned care.


This document applies to all non-registered nursing staff and Registered Allied Health Professionals, employed by Lincolnshire Community Health services NHS Trust, who have undergone training and have been deemed competent in the administration of LMW Heparin for named patients.

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P_HR_66 Employee Benefits Policy

Lincolnshire Community Health Services NHS Trust (LCHS) is committed to developing a workforce proud to be part of LCHS (strategic aim number 9) and has therefore developed a holistic total rewards package which is available to all employees.

Across the organisation there has been a drive to recruit and retain high quality employees into the organisation. It has been identified, that a holistic employee benefits package offered to all employees could make working in community services a more attractive option to prospective and current employees and support Trust-wide efforts to recruit into Lincolnshire and positively impact the retention of staff.

The rewards package also acts as a valuable income generating opportunity for the organisation and encompasses the ‘NHS Fleet Solutions Staff Benefit Car Scheme’ and ‘NHS Home Electronic Solutions Salary Sacrifice Scheme’, the LCHS ‘Cycle to Work Scheme’ and the LCHS Childcare Vouchers.

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