Clinical guidance

We’ve produced a range of clinical guidance to support you throughout the Coronavirus pandemic.

Some of this is worst case scenario planning and we hope it won’t be needed, however we prefer to have guidance available in case it’s required.

Please note: When you click on a link a document will automatically download to your Laptop / PC.


Managing short periods of service user leave during the Covid pandemic

As Covid restrictions in England begin to reduce, we must continue to risk assess any planned periods of service user leave, both prior to the leave and on return to the Trust. In order to take steps to mitigate the risk of infection, our use of leave may still be reduced where risk assessed as appropriate. In doing so, any current Covid outbreaks on the ward and local transmission rates should be considered.

Decisions around leave for service users during this period continue to be particularly complex and need to take into account:

  • Rights of service users to have time off the ward when appropriate.
  • Rights of staff to be safe in terms of potential infection risk whilst escorting service users.
  • Rights of other service users on wards who might be physically vulnerable from Covid to be protected from exposure.

All leave should start with a planned risk assessment that considers the patient’s place of leave, any risks associated and their ability to follow the ‘Hands, Face, Space, Fresh Air’ Public Health advice. Based on the risk assessment, consideration should be given to the need to isolate and swab patients on return from leave.

Read the updated leave guidance on our website which covers the principles for decision-making, proposals for the approach across the Trust, and details on escorted/unescorted/overnight leave, unauthorised absence and assessment for the swabbing of service users on return from day leave.

If a service user has symptoms - Action Cards

If you have a suspected coronavirus case involving a service user, please use the following procedure and associated documents during work hours and out of hours.  When you click on the link the document will automatically download to your Laptop / PC.  If you are prompted for a password please refer to the Covid-19 daily emails or contact for a reminder.

Where a patient is self-isolating in the community, Care coordinators should stay in touch by phone or Skype where possible.

Please see the separate section on when to swab and to download the swab referral form.

Isolating or cohorting patients

Principles for inpatient mental health and learning disabilities staff

When to swab inpatients

Changes to testing from 1 April 2022

The UK Health Security Agency (UKHSA) wrote to all health and care providers on 30 March 2022 to advise them of new arrangements for staff and patient testing for Covid-19 from Friday 1 April 2022.

In the coming weeks they will be setting out a way forward on several areas where guidance has evolved throughout the pandemic – adapting the way that the NHS operates with COVID-19 in general circulation and with the virus likely to remain prevalent for some time to come.

The following new guidance applies at LYPFT from 1 April 2022:

Covid-19 main symptoms reminder


a high temperature – feeling hot to touch on your chest or back


a new, continuous cough – coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours


a loss or change to your sense of smell or taste – you cannot smell or taste anything, or things smell or taste different to normal

Testing for inpatients

The infection prevention and control (IPC) team will complete lateral flow tests for all asymptomatic patient admissions. The referral process will need to be completed as it was before. Until this has been completed patients would need to isolate.

Any new admission who is immune-suppressed or has been admitted from an environment where there were positive cases will require a PCR test.

Lateral flow tests on day 3, and days 5-7 of admission will be undertaken by the IPC team in addition to the test on admission. If one of these is positive, then a PCR test will be completed and the patient must isolate.

Any patient with a plan of discharge to a care home setting will need a referral to IPC for a PCR test to be completed.

Anyone returning from a period of planned overnight leave should complete a lateral flow test and does not require a PCR.

ECT patients will be asked to complete a lateral flow test either on the ward or in the community prior to treatment.

All weekly swabs and surveillance swabs will now stop. However, if there is an outbreak then the rest of the ward will need to receive PCR tests as before.

Pre and post discharge swabbing of inpatients

Please complete the Swab Referral Form (updated 30 November 2021) for pre and post discharge swabbing of inpatients.

Wards are asked to call an infection control colleague on 0113 85 55957 to ensure that the criteria for testing is met.

They then need to complete the form and send it to

People who are non-compliant with COVID-19 infection control protocols

There are a significant number of people who receive Learning Disability or Mental Health services who are currently not complying with government guidance in relation to both social distancing and self-Isolation.

Adult Social Care (Leeds City Council) have shared guidance for service users with learning difficulties who are struggling with social distancing in the community and who may be putting themselves or others at risk.  You can download the People with Learning Disabilities or Mental Health issues who are non-compliant with infection protocols in place due to Covid-19 guidance for more information.  If you have any concerns about one of our service users, please contact the Safeguarding team directly.

Standard operating procedures
Inpatient visiting within LYPFT sites

Updated 10 June 2022

Return of Visiting

Now that we have finally begun to see a reduction in the numbers of service users testing positive in our inpatient areas, we are pleased to share that visiting can re-start.

It is important that we follow the same principles for reducing the risk of visiting that were in place before the sudden increase in cases. Please read the latest visiting guidance.

Read more about the guidance for visitors on our visiting page.

Testing for outpatients, community patients and visitors

Unless it is deemed necessary by local care teams, visitors to hospital settings and those attending outpatient appointments will no longer be required to test on or before arrival.

COVID 19: Medicines Information and Advice

The following guidance has been produced/ updated to support the safe and effective use of medicines during the pandemic:

COVID: Training
COVID: Managing medicines in social care
COVID: Administration from original packs in Care Homes

Medicines Supply

No more than a 1 month supply of medication should be prescribed or supplied – it is essential that this advice is followed in all sectors to protect against the medicines supply chain collapsing.

Primary Care / Community pharmacy

Like the rest of the health service community pharmacy is under significant pressure. The Pharmacy MOLS team are available to help with any queries/ problems due to this

Sending Medication to Services Users Home via Taxi

Guidance has been produced to support the taxi transport of medication directly to a service users home, not usually advised but may be necessary in current situation. Further work is being done to utilise redeployed staff and / or NHS volunteers, also to adapt the guidance to include transport directly from pharmacy.


Medicines Code

Medicines prescribed on a less frequent basis e.g. weekly, should be administered on the prescribed day, ideally at the same time of day. Variation of up to 15% is permitted in exceptional circumstances without the need to contact the prescriber. In practice this means that weekly medicines can be administered within 1 day of the date due, fortnightly within 2 days and those given every 4 weeks within 4 days.

Outside these time frames the prescriber or a pharmacist must be contacted for advice and a record made in the patients notes. If the nurse/ nursing associate is advised to administer the dose the actual time (and date if applicable) of administration must be clearly recorded in the patient’s notes and where possible, on the current prescription.

Depot Antipsychotics – Dosing Intervals

Typical Antipsychotics ie flupentixol decdanoate, haloperidol decanoate, pipothiazine palmitate, zuclopenthixol decanoate. Consider increasing the dosing interval of the depot where possible, e.g. instead of weekly or two-weekly dosing, increase to four-weekly dosing. A longer dosing interval does not diminish the effectiveness of the drug as long as the overall dose remains the same.

Paliperidone Palmitate (Xeplion) monthly – patients who have been clinically stable on monthly paliperidone palmitate (Xeplion) for at least 4 months (and do not require dose adjustment) can be switched to 3-monthly paliperidone palmitate injection (Trevicta) if clinically appropriate. Contact Annabel Black/ Emma Russel in pharmacy to arrange supply via Polarspeed.

Dosing intervals for the following need to remain the same

  • Aripiprazole LAI (Abilify Maintena) – monthly
  • Risperidone LAI (Risperidal Consta) – every 2 weeks

For further information/ advice contact pharmacy medicines information.

Depot Antipsychotics – Second Check

It is considered good practice, where additional practitioners are available, for a second check to be made in order to minimise the risk of error.

This does not need to be performed by a qualified member of staff. However the second check needs to performed by someone who is competent to do so and is able to verify the following:

  • Name of the depot injection (drug name) against the depot prescribed on the prescription – both need to be the same
  • Appropriate strength to ensure the least volume of depot is administered to the service users
  • Feel confident to escalate or request advice regarding any issue related to the checking process

Missed Doses – Download guidance regarding the management of missed doses of depot medication at this time.

ClozapineDownload guidance on managing patients prescribed clozapine who are affected by the COVID-19 outbreak.

Lithium – Download guidance on monitoring patients prescribed lithium.

Patients with Coronairus

When managing acute disturbance in the context of COVID-19, suggest the NAPICU guidelines are followed in conjunction with the LYPFT guidelines.

General Symptomatic Treatment

Paracetamol is recommended first line.  Response to concerns regarding COVID-19 and NSAIDs / Ibuprofen:

Key points ‘There appears to be no evidence that NSAIDs increase the chance of acquiring Covid-19.’ A review of the evidence is being conducted ‘in the interim, for patients, who have confirmed Covid-19 or believe they have Covid-19, that they use paracetamol in preference to NSAIDs’ and ‘Those currently on NSAIDs for other medical reasons (e.g. arthritis) should not stop them.’

Administration of medicines via Nebuliser

We would recommend the mouthpiece as the preferred method rather than mask as the medication goes into the lungs and not on to the face.

What the video doesn’t say, is that you keep nebulising until the liquid starts gurgling. Then tap the nebuliser chamber pot (where you put the nebuliser solution in) and it’ll keep going for another minute or so. After this time, stop. There is always a dead volume, where you could keep the nebuliser running for hours and it won’t vapourise, so don’t worry about that.

Palliative care
Palliative Care – Subcuteneous Fluids

Download York Palliative care guidelines on subcutaneous fluids.

Yorkshire and Humber Palliative care guidance on subcutaneous fluids: For many patients, the use of clinically assisted (artificial) hydration will not be of benefit and decisions about their use should be made in a patient’s best interests. If clinically assisted artificial hydration or nutritional support is in place, review the rate/volume/route according to individual need. The possible benefits of withdrawing or reducing clinically assisted hydration/nutrition include reduced vomiting, incontinence, and reduced painful venepuncture. If indicated, fluids can be administered subcutaneously; usually 1-2L/24 hours and preferably site in the abdomen. Monitor for uncomfortable fluid accumulation at the infusion site.

Oxygen / Oxygen cylinders

All areas with Grab Bags should have two ZX oxygen cylinders (large one which is in a wheeled holder). Some areas over two floors such as Asket may also have a CD cylinder so it can be carried upstairs.

Oxygen cylinders are ordered on an exchange basis (full one delivered and empty one returned) by wards contacting British Oxygen Company (BOC), usually delivered the following working day.  All areas that have O2 cylinders should have an account with BOC.  The call centre number for orders is 0800 111333.

Oxygen masks, tubing, nasal cannula are ordered from NHS Logistics. A list of the required equipment to support the management of respiratory symptoms is being compiled.


Oxygen is a medicine and therefore must be prescribed except in except in emergencies, where oxygen should be given first and documented later.

The adoption of the guideline would be at the discretion of the clinical team, or attending medic, based upon the service users situation, situation or agreed pathway:

  • Short term awaiting transfer
  • Palliative Care provision
  • Longer care O2 provision

Additional cylinders have been requested from BOC, there is now a national system for allocation of additional cylinders.

Safe Storage – oxygen cylinders are flammable. Empty and full cylinders must be securely stored to ensure they do not fall and to prevent theft (there has been a recent increase in the theft of oxygen cylinders).

Ethical framework for staff

In response to the Covid-19 pandemic, Trusts across the country have been setting up ethical advisory groups to help support decision making during this extremely challenging time. As part of this, the following documents have been produced to support you:

To contact our ethical advisory group:

Supporting people with a learning disability or autism
Trust smoking policy

In response to staff concerns, we are now completely smoke-free across all Trust sites. This includes the use of e-cigarettes.

The Physical Health team are working alongside staff to make sure they are trained and equipped to enable this.