Mental Health Policy

South Central Ambulance Service NHS Foundation Trust

Unit 7 & 8, Talisman Business Centre, Talisman Road, Bicester, Oxfordshire, OX26 6HR

DOCUMENT INFORMATION

Author: Terry Simpson

Clinical Lead, Mental Health & Learning Disability

Ratifying committee/group: Patient Safety Group

Date of ratification: TBC

Date of Issue: May 2021

Review due by: Three years from date above

Version: 2

  

 
 
Contents 
 
DOCUMENT INFORMATION ............................................................................................... 2 
 Introduction ..................................................................................................................... 4 
Abbreviations .................................................................................................................... 4 
Scope ................................................................................................................................ 4 
Aim .................................................................................................................................... 4 
Roles and Responsibilities ................................................................................................ 5 
Definitions ......................................................................................................................... 5 
Key Elements .................................................................................................................... 6 
Decision making and key legal framework ........................................................................ 9 
Training ........................................................................................................................... 12 
Equality and Diversity .................................................................................................... 12 
Monitoring ..................................................................................................................... 12 
Consultation and Review .............................................................................................. 13 
Implementation (including raising awareness) .............................................................. 13 
References .................................................................................................................... 13 
Associated documentation ............................................................................................ 13 
Appendix 1: Review Table ............................................................................................ 14 
Appendix 2: Responsibility Matrix – Policies, Procedures and Strategies ..................... 14 
Appendix 3: Equality Impact Assessment Form Section One – Screening ................... 14 
Appendix 4: Ratification Checklist ................................................................................. 14 
 
  
   

1. Introduction

South Central Ambulance Service NHS Foundation Trust (the Trust) is committed to

delivering an excellent standard of care to patients with Mental health conditions. As a

Trust we recognise the increasing important role the ambulance service have in both

medical and with mental health care and will treat both equally, compassionately, and

holistically.

The principles underlying this policy are in accordance with the Mental Health Act 1983

(MHA) Code of Practice: (Department of Health [DH] 2015); Mental Capacity Act 2005

(MCA) Code of Practice (DH, 2007), Human Rights Act (1998) and the Equality Act 2010.

Also attached to the policy as appendices are the learning disability strategy and

dementia strategy. These often overlap and are interlinked so are directly referenced

within the policy. The delivery, monitoring and evaluation of all aspects of mental health,

dementia and learning disabilities will be encompassed within the Trust overarching

strategy linked to the NHS long term plan priorities for the ambulance sector.

Accountability and upward reporting will be through mental health projects group for new

initiatives and mental health steering group for existing initiatives, therefore linkiung this

policy to the transformation plans.

It is the underlying aim of this policy, and associated strategy, to ensure that patients’

safety, rights to dignity and privacy are balanced and maintained at all times.

2. Abbreviations

Mental Health Act 1983 (Amended 2007) (MHA).

Mental Capacity Act 2005 (MCA).

Department of Health NHS long term plan (LTP) Mental

health investment standards (MHIS)

Approved mental health professionals (AMHP’s)

3. Scope

This guidance is for all staff working within South Central Ambulance Service NHS Trust

who are involved in the care, treatment and support of people who are experiencing a

mental health crisis, relevant to role.

All NHS Trusts and Local Authorities who care for people who have been detained

under the MHA are required to ensure that practices and procedures are compliant with

the associated codes of practice, and that all staff receive training relevant to their role

within the organisation.

All ambulance clinicians have a duty to be aware of, and act in accordance with, the relevant

Codes of Practice specific to their clinical roles.

4. Aim

The purpose of this policy is to help ensure that health professionals are able to

understand and comply with the law and guidelines relating to the care, welfare, safety,

treatment and transportation of patients with mental health conditions.

This policy must be read and followed by all staff who are working for, or on behalf of, the

Trust (on a paid or voluntary basis).

5. Roles and Responsibilities

5.1 Trust Board

The Trust Board has responsibility and accountability for ensuring the provision of the

appropriate resources required to implement this policy. The Board, Committee and

Meeting structure is at Appendix 1.

5.2 Chief Executive

The Chief Executive has overall responsibility for ensuring that systems for the safe and

appropriate use of the MHA and MCA are followed.

5.3 Executive Director

The Executive Director of Patient Care is the board member responsible for the MCA.

5.4 Managers and Supervisors

The Clinical Lead for Mental Health and Learning Disability is responsible for managing the

processes and training for the safe and appropriate use of both the MHA and MCA specific

to ambulance service areas of responsibility within the Trust. This will be developed in

partnership with education leads and reported through the Executive Director of Patient

Care to the Trust Board for this purpose.

The Operations Directors and Heads of Operations, including PTS managers and 111

leads are responsible and accountable for the day to day safe and appropriate use of the

MCA and MHA aspects and must ensure that copies of the Mental Capacity Act 2005 code

of practice along with all guidance and training materials are available to their staff.

5.5 All Trust Staff

All staff have a responsibility to ensure they are familiar with and understand the policy and

any associated procedures, ensuring their application and compliance with legislation

when caring for patients in crisis.

Clinical staff have a responsibility to maintain their competency and to ensure their

familiarity with changes to legislation/therapeutic guidelines as they are adopted by the

Trust.

6. Definitions

The MHA defines Mental illness as “any disorder or disability of the mind”. This includes

functional mental illness (such as depression), organic mental illness (such as dementia)

and learning disability.

Patients with a learning disability will only be treated as suffering from a mental disorder

for certain purposes of the Act, if it is associated with abnormally aggressive or seriously

irresponsible conduct or co-existing with acute mental illness.

Apart from learning disability the Act does not distinguish between different forms of mental

illness and therefore applies to all mental illness, including all types of personality disorder.

Dependence on alcohol or drugs is not considered to be a disorder or disability of the mind

(MHA). The Trust does however recognise that addictions and dependance are often

closely linked with mental health conditions.

The Mental Capacity Act 2005 (MCA) defines Mental Capacity as “the ability of an individual

to make decisions regarding specific elements of their life”.

• This includes the ability to make a decision that affects daily life – such as when

to get up, what to wear or whether to go to the doctor when feeling ill – as well as

more serious or significant decisions.

• It also refers to a person’s ability to make a decision that may have legal

consequences – for them or others. Examples include agreeing to have medical

treatment, buying goods or making a will.

7. Key Elements

7.1 Developing Mental Health Care Provision

The Trust will work with other agencies in order to improve safe, integrated, high quality

care for patients with a mental illness.

The Trust will continue to collaborate with providers and commissioners to establish

effective patient pathways related to mental health care consistent with MHIS and the NHS

LTP. This includes but is not limited to mental health provider Trusts, Acutes, Police,

AMHP’s, commissioners, ICS’s and the third sector.

The Trust will continue to collaborate with providers and commissioners to establish highly

effective feedback from patients experience and learn from any untoward incidents.

7.2 Information sharing.

It is recognised that information sharing plays a key role in safe working practice and there

is evidence that patients, public or staff have come to harm when services do not openly

share the information they have.

The need to distinguish between the principles of confidentiality and the need to share

information must be in accordance with legislation and the guidance provided by the Trust

under latest information governance polices and processes.

For all new initiatives related to partnership collaboration with key providers new service

specification, memorandums of understanding and standard operating procedures will be

developed in collaboration. These will go through the Trust governance process through

patient safety group. Existing examples of these include but are not limited to telephone

triage, operational response, MHA transport, frequent caller system plans and joint

simulated education plans.

All staff will adhere to the Trust Confidentiality policy at all times, seeking advice if needed.

7.3 The Mental Health Act 1983 (MHA).

The Mental Health Act 1983 (as amended by the Mental Health Act 2007) is the law under

which a person can be admitted, detained and treated in hospital against their wishes. The

Act covers the rights of people while they are detained, how they can be discharged from

hospital and what aftercare they can expect to receive. The Act applies in England and

Wales.

7.4 Roles and responsibilities under the Mental Health Act.

7.4.1 Approved Mental Health Professional (AMHP).

Local Social Service Authorities (LSSAs) are allowed under legislation to approve a range

of registered and professionally qualified mental health professionals to act as

an Approved Mental Health Professional (AMHP). Individuals who can act as an AMHP

are:

• Registered social workers.

• First level nurses whose field of practice is mental health or learning disabilities.

• Registered occupational therapists.

• Registered psychologists.

AMHPs are responsible for:

• Making the application for a patient to be detained.

• Organising the safest least restrictive method of transport of the patient when a

place has been found.

• Completing an initial risk assessment.

A range of other professional roles are outlined in the Act however, as they do not

usually have a direct relationship with the ambulance service, they have not been

described here.

7.4.2 The Ambulance Service.

The MHA Code of Practice clearly defines the responsibilities of the ambulance service in

the conveyance of patients detained under the MHA. The Code of Practice aims to ensure

the individual’s right to the maintenance of their dignity and privacy by all health care

providers involved in the delivery of care.

The main role for the ambulance service under the MHA is to provide transport (and

immediate care of any physical/medical needs) for patients who have been detained (i.e.

“sectioned”); this permits restraint if required. The Trust recognise that frontline operational

staff are not currently trained in any restraint techniques. This should be explained to the

AMHP at the point of booking transport within relevant SOP’s. In rare circumstances where

there is an active risk of abscondence AMHP’s should explore alternative options of

dedicated or secure transport.

Patients should always be transported in a compassion focused manner which is most

likely to preserve their dignity and privacy and is consistent with managing any risk to their

health and safety or to other people.

This applies in all cases where patients are compulsorily transported under the Act,

including:

• Taking patients to hospital to be detained for assessment or treatment.

• Transferring patients between hospitals.

• Returning patients to hospital if they are absent without leave.

• Taking community patients or patients who have been conditionally discharged

to hospital on recall.

7.4.3 Detention under the Mental Health Act.

The MHA allows for the detention of patients that have been formally assessed or for the

purposes of the assessment and treatment of the patient’s mental health. A brief overview

of sections is outlined below. Detailed resources and practical advise has been developed

through a blended learning approach to all staff who may be involved in decision making

and or transport under both the MHA and MCA.

Ambulance clinicians have no powers to detain (ie “section”) patients under any

circumstances under the mental health act.

Section 2 (admission for assessment) – for up to 28 days.

Application is required by an Approved Mental Health Practitioner (AMHP) or nearest

relative, and two medical recommendations are needed. At least one doctor must be

approved under “section 12” of the Act and the other should know the patient in his or her

professional capacity.

Section 3 (admission for treatment) – For 6 months initially, can be reviewed and

extended.

Application and two medical recommendations are required as for section 2. This is

undertaken when the patient is already detained under section 2 or the nature and degree

of the patient’s illness is already known and therefore doesn’t require admission for

assessment.

Section 4 (admission for assessment in an emergency) – for up to 72 hours.

Application is made by the AMHP and one doctor who has examined the patient for the

purpose of the act within the last 24 hours. The person must fit the criteria for detention

under section 2 of the Act. Section 4 should only be used in a situation where to delay the

detention due to the unavailability of the second doctor presents a significant risk to the

patient or others.

Section 135(1) (magistrates powers)

This is a Magistrates order. It can be applied for by an AMHP in the best interests of a

person who is thought to be mentally disordered, but who is refusing to allow mental health

professionals into their residence for the purposes of a Mental Health Act assessment.

Section 135 magistrates' orders give police officers the right to enter the property for the

person to be taken to a locally defined “place of safety”.

Section 135(2) (magistrates powers)

A Police Officer may use powers of entry under section 135(2) of the Act when it is necessary

to gain access to premises to retake a person into custody who is already liable to detention,

or recall, under the Act.

Section 136 (police authorised powers)

This authorises a police officer to take a person from a “place to which the public have

access to” to a place of safety, usually a hospital, if it appears to a police officer that they

are suffering from “mental disorder” and “in immediate need of care or control”. The

Mental Health Act Code of Practice states that a police station should be used as a place

of safety only on an “exceptional basis”. A person detained under section 136 must be

released if they are not detained in a hospital, under the Act, within 24 hours. The purpose

of the “holding powers” is to allow an AMHP and doctors to assess if the patient needs

detention.

7.5 The Mental Capacity Act 2005 (MCA).

The MCA applies to everyone involved in the care, treatment and support of people aged

16 and over living in England and Wales who are unable to make all or some decisions for

themselves. The Trust is required to adhere to legislation and associated guidance which

relates to a patient’s mental capacity. The MCA ensures that, as far as possible, all adults

can take decisions about their own lives. Other people, (e.g. a family member, or a staff

member), must help the individual to make decisions for themselves as required.

“Mental capacity” refers to the ability of an individual to make a decision at the time that

decision needs to be made. A person is said to lack capacity, if at that point in time he/she

is unable to make a decision for him/herself because of an impairment or disturbance in

the functioning of the brain or mind.

Capacity can fluctuate; some individuals may be able to make decisions about their daily

lives but may not be able to make decisions about other things. Every effort should be

made to assist an individual in making his or her own decisions by using effective

communication. Detailed resources have been developed to support key aspects of the

MCA relevant to the ambulance sector including scenarios and decision making. All of

these have had legal input and are consistent with the MCA code of pactice which can be

found online.

On attendance at any incident where a patient is deemed to lack capacity it is important to

remember that this is not an automatic trigger to call for police attendance. Police

attendance should only be requested when a patient is presenting with actual

aggressive/violent behaviour, and after all attempts to persuade the patient to travel have

failed. Please refer to detailed practical scenarios and flowcharts in supporting blended

learning materials such as “pocket guide” A1 poster and mental health workbooks.

8. Decision making and key legal framework

8.1 Interface between the Mental Capacity Act and the Mental Health Act.

The Mental Capacity Act may be used to treat people for an immediate mental or physical

illness when they cannot consent to the treatment because they lack capacity, and where

the treatment is in their best interests. The threshold for intervening to restrict liberty should

be high (serious or life-threatening condition) following the two stage functional test and

being proportionate to the presenting risks.

The Mental Capacity Act cannot be used to detain anyone who needs treatment for a

mental illness. If a person is detained under the Mental Health Act, the Mental Capacity

Act does not apply to treatment for the person’s mental disorder - which can be given

without consent under the Mental Health Act. It also means that attorneys (and deputies)

cannot consent to, or refuse, such treatment on the patient’s behalf. For the same reason,

an advance decision to refuse treatment for mental illness can be over-ridden where

necessary.

For most other purposes, the Mental Capacity Act will continue to apply to a patient

detained under the Mental Health Act. This means, for example, that an advance decision

to refuse treatment for any illness or condition - other than mental disorder - is not affected;

nor is any power an attorney has to consent to such treatment. It also means that where a

detained patient lacks capacity to consent to treatment (other than treatment for mental

disorder) the decision-maker will need to act in accordance with the Mental Capacity Act.

For more detail on the interface between the Mental Capacity Act and the Mental Health

Act 1983 refer to the Codes of Practice.

Professionals may need to consider using the MHA to detain and treat a person who lacks

the capacity to consent to treatment, instead of the MCA, if:

• It is not possible to give the care or treatment needed without deprivations of

liberty.

• The person needs treatment that cannot be given under the MCA (for

example the person has made an advanced decision to refuse essential

treatment for the mental illness).

• The person may need to be restrained in a way not allowed under the MCA.

• The person lacks capacity to decide on some elements of the treatment but

has capacity to refuse parts of it and they have done so or:

• There is some other reason the person might not get treatment and they, or

someone else, might suffer as a result.

8.2 Conveyance.

The Mental Health Act Code of Practice (2015) 17.3 states that patients detained under

the Mental Health Act: “should always be conveyed in a manner which is most likely to

preserve their dignity and privacy consistent with managing any risk to their health and

safety or to other people.”

The Mental Health Act Code of Practice requires Local Social Services Authorities (defined

in S.145 (1) Mental Health Act), the NHS and the local Police Authority to establish a clear

policy for the use of the powers to convey a person to hospital under S.6 (1) Mental Health

Act.

The Trust will exercise its authority to convey under the Mental Health Act, using the most

clinically appropriate vehicle for the presenting circumstances.

The Trust will work with its commissioners, partner agencies and health and social care

providers to develop coordinated, multi-agency solutions for the transport of mental health

patients. This will be consistent with the NHS LTP related dedicated mental health

ambulance response vehicles.

On attendance at any incident where a patient detained under the MHA is resistive to being

transported, it is important to remember that this is not an automatic trigger to call for police

attendance. Police attendance should only be requested when a patient is presenting with

actual aggressive/violent behaviour. If required, further advice and assistance should be

requested from the responsible officer (i.e. the AMHP, following initial detention, or ward

staff if Absent Without Leave [AWOL]).

8.3 Section 136 transport.

The transport of people detained under s136 is governed by a National Ambulance

Service s136 guidance and referenced in the SCAS training materials. A brief outline of

key points to note:

Patients should be promptly screened for any underlying medical conditions before being

taken to the most appropriate place of safety.

Emergency Departments (ED) are often not the most appropriate places of safety under

the MHA. However, if a patient who has been detained under s136 MHA requires medical

treatment - for any reason - they may be taken to the ED and moved to the health-based

place of safety once treated when available. The Police Officer should stay with the patient

in ED or ensure that the ED has appropriate levels of security to monitor and manage the

patient.

8.4 Other MHA Transport.

For all detentions, the transport and conveying processes should be followed as outlined

in the relevant Joint Working Protocols (for example Surrey Sussex NEPTS, Thames Valley

and Hampshire protocols).

Guidance on processes to follow when transporting patients who have been detained under

the MHA can be found in Appendix 5.

Within Hampshire, Southampton and Portsmouth, all secure mental health transport is

commissioned via a separate commissioning contract with a private provider and this includes

ad-hoc requests from the Isle of Wight. Therefore, SCAS will only be involved on an

exceptional basis where secure mental health transport is not required. The principles of

National s136 response times are therefore monitored locally by commissioners.

8.5 Restraint (restrictive interventions).

“Restrictive interventions” are defined as ‘deliberate acts on the part of other person(s)

that restrict an individual’s movement, liberty and/or freedom to act independently’.

(Positive and Proactive Care: reducing the need for restrictive interventions. DH 2014).

Restraint can include physical, chemical and or mechanical interventions to restrict

movement. The Trust do not support the use of mechanical or chemical restraint. There is

currently a national review of acute behavioral disturbance (ABD) which is a serious

medical condition that can occur from restraint.

Ambulance staff in SCAS do not currently have training in physical restraint or safe holding.

Minimal guided assistance or support could be used in cases where the action is in the

patients best interest and a dynamic risk assessment has concluded that performing the

action would not cause harm to the ambulance crew or patient in scenarios where a patient

lacks capacity or is detained under the MHA. If the behaviour of the patient exceeds what

the crew can safely manage then assistance must be requested (this does not necessarily

have to be police. For example mental health provider or ED security). Patients should

never be held by Trust staff in a face down or face up position on the floor. Any restrictive

physical intervention should be recorded and a Datix generated. The Trust recognise the

need to consider restraint, safe holding and where it may be appropriate to explore training.

A separate policy and working group will be considered specific to physical intervention

and the legal framework behind this.

When attending a patient and restraint is used by staff it can only be used in accordance

with the legal guidance of the Mental Health Act (1983), Mental Capacity Act (2005),

Human Rights Act (1998) and actions taken under common law.

Under common law, restraint can be used to prevent harm or injury to others. Actions taken

under common law are ones that any reasonable member of the public would also take for

self-preservation of themselves and others.

When restraint is used staff must use the least restrictive form of restraint for the least

amount of time possible. Staff must also be able to demonstrate what reasonable steps

they took when reaching the decision to use restraint, completing a dynamic risk

assessment, recording decisions and actions in the patient’s clinical record. Staff should

aim to protect the patient’s dignity throughout any type of restraint, however it is recognised

that this is not always possible.

Whenever any form of forcible restraint has been used this must be recorded in the patient’s

clinical record and details handed over to staff at the receiving unit.

Ambulance staff should always monitor the physical well-being of a patient who is being

forcibly restrained by the Trust or others and should be familiar with the signs and

symptoms - and management – of Acute Behavioural Disturbance (sometimes referred to

as “Excited Delirium”), which may result after prolonged forcible restraint. In circumstances

where clinicians are on scene and a patient is being restrained (e.g. by police) clinical staff

should ensure they clearly advise others as an advocate for the patients care and where

possible medically assess the patient if there may be any evidence to suggest the patient

is compromised medically whilst under restraint.

9. Training

South Central Ambulance Service NHS Foundation Trust follows the current JRCALC UK

Ambulance Services Clinical Practice Guidelines for the management of Mental Health issues

and is committed to improving the education, training and development of all staff.

The Trust will provide access to a variety of mental health learning and educational resources,

which can be accessed by different means including e-learning, digital, technologies,

education centre and physical resources. All staff having direct contact with patients will

receive training related to compassion focused approaches to mental health. As a minimum

this will also cover an overview of mental health legislation, mental health conditions (including

dementia, learning disability and autism awareness) and the Mental Capacity Act 2005

[MCA]). This will also include providing care in partnership with other organisations including

but not limited to Mental health crisis teams, AMHP’s police and acutes. This will be delivered

via the Trust Training strategy in close collaboration with the education team.

The Trust will ensure that teaching staff are suitably qualified to deliver mental health

education. These will be supported by the Mental Health clinical lead. The Trust, working with

University partners, Police, Mental Health service providers, relevant association of

ambulance chief executives (AACE) subgroups and the Trust Subject Matter Expert, will

continue to improve the learning experience of students in relation to the wider Mental Health

within the ambulance service. This will include joint training programmes whenever possible.

10. Equality and Diversity

An Equality Impact Assessment has been undertaken on this policy. A copy of the

assessment can be found in Appendix 3.

11. Monitoring

This policy will be monitored through the mental health projects and mental health steering

groups. Upward reporting will be provided to the patient safety group. Effectiveness will also

be monitored by review of training records patient experience, system key performance

indicators and staff engagement. Accountability on system deliverables will be through to

external groups including but not limited to CCG mental health boards, ICS mental health

boards and any other relevant system reporting mechanisms. An overarching strategy and

transformation plan will be developed with ongoing project management support.

  
13 
 
12. Consultation and Review 
This Policy will be reviewed every three years. However, should national guidance or 
legislation change then the policy may be reviewed earlier. 
 
13. Implementation (including raising awareness)  
Education on this policy will be provided by the Education Department, in line with the 
training programmes. This will be done through a broad range of training and development 
methods. These include but are not limited to E-learning, technologies based training, 
simulated scenarios, videos, digital resources, physical resources, CPD sessions and 
mentorship in practice (eg SCAS clinicians collaborating with telephone triage in clinical 
contact centres and mental health operational response vehicles). Awareness of this will be 
through various communications methods as outlined in communications strategy. 
Appraisals and staff surveys provide opportunities for evaluation and continual 
development.   
  
14. References  
  
The following external sources either referenced or relevant to this policy are listed below:  
•  Mental Health Act 1983    https://www.legislation.gov.uk/ukpga/1983/20/contents  
•  Mental Capacity Act https://www.legislation.gov.uk/ukpga/2005/9/contents  
•  Policing and Crime Act 
http://www.legislation.gov.uk/ukpga/2017/3/contents/enacted  
•  Crisis Care Concordat 
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/2812
42/36353_Me ntal_Health_Crisis_accessible.pdf  
•  Five Year Forward View for Mental Health 
https://www.england.nhs.uk/wpcontent/uploads/2016/02/Mental-Health-Taskforce-
FYFV-final.pdf  
•  NHS Long Term Plan https://www.longtermplan.nhs.uk/wp-
content/uploads/2019/01/nhs-longterm-plan-june-2019.pdf  
•  Thriving at Work: The Stevenson Farmer review of mental health and employers 
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attac
hment_data/file /658145/thriving-at-work-stevenson-farmer-review.pdf  
•  Cater Report (2018): Operational productivity and performance in English NHS 
acute hospitals:  Unwarranted variations 
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attac
hment_data/file /499229/Operational_productivity_A.pdf  
•  Skills for Health: Mental Health Core skills Competency Framework 
https://www.skillsforhealth.org.uk/services/item/525-mental-health-download  
  
15. Associated documentation  
  
•  SCAS Consent Policy and Procedure.  
•  SCAS Frequent caller policy  
•  SCAS Safeguarding Vulnerable Persons Policy and Procedure.  
•  SCAS Patient Information and Confidentiality Policy.  
•  SCAS Duty of Candour Policy.  
•  SCAS Adverse Incident Reporting policy.  
•  All  joint  Working  Protocols  and  service  specifciations  (Hampshire/Thames 
Valley).  
•  National Institute for Health and Care Excellence (NICE) guidelines for Mental 
Health and behavioural conditions  

16. Appendix 1: Review Table

A full review table has been carried out on this policy and is available to the public on

request.

17. Appendix 2: Responsibility Matrix – Policies, Procedures and Strategies

A full responsibilities matrix has been carried out on this policy and is available on request

18. Appendix 3: Equality Impact Assessment Form Section One – Screening

A full Equality Impact Assessment has been carried out on this policy and is available on

request to the public and internally via our Staff Intranet.  

19. Appendix 4: Ratification Checklist

A Ratification Checklist for this policy is available on request.