Care Quality Commission
Care Quality Commission
The Care Quality Commission (CQC) makes sure hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high-quality care, and encourages them to make improvements where possible.
They do this by inspecting services and publishing the results on their website: www.cqc.org.uk
You can use the results to help you make better decisions about the care you, or someone you care for, receives.
Our CQC Inspection
Our practice is inspected by the Care Quality Commission (CQC) to ensure we are meeting essential standards of quality and safety.
This widget provides a summary of the results of the latest checks carried out by the CQC.
If you feel you would like a chaperone present at your consultation please inform your doctor/nurse who will be happy to arrange this for you.
The practice prides itself in maintaining professional standards. For certain examinations during consultations an impartial observer (a ‘chaperone’) will be required.
This impartial observer will be a practice nurse or health care assistant who is familiar with the procedure and be available to reassure and raise any concerns on your behalf. If a nurse in unavailable at the time of your consultation then your examination may be re-scheduled for another time.
You are free to decline any examination or chose an alternative examiner or chaperone. You may also request a chaperone for any examination or consultation if one is not offered to you. The GP may not undertake an examination if a chaperone is declined.
The role of a Chaperone
A chaperone is there to:
- Maintain professional boundaries during intimate examinations
- Acknowledge a patient’s vulnerability
- Provide emotional comfort and reassurance
- Assist in the examination
- Assist with undressing patients, if required
Clinical Commissioning Group
NHS Salford Clinical Commissioning Group (CCG) is the organisation that decides how to spend the NHS budget on the majority of health services for 270,000 people registered with a GP in Salford. This includes the care and treatment you receive in hospital, maternity services, community and mental health services.
COVID-19 and Your Information
The ICO recognises the unprecedented challenges the NHS and other health professionals are facing during the Coronavirus (COVID-19) pandemic.
The ICO also recognise that ‘Public bodies may require additional collection and sharing of personal data to protect against serious threats to public health.’
The Government have also taken action in respect of this and on 20th March 2020 the Secretary of State for Health and Social Care issued a Notice under Regulation 3(4) of The Health Service (Control of Patient Information) Regulations 2002 requiring organisations such as GP Practices to use your information to help GP Practices and other healthcare organisations to respond to and deal with the COVID-19 pandemic.
In order to look after your healthcare needs during this difficult time, we may urgently need to share your personal information, including medical records, with clinical and non clinical staff who belong to organisations that are permitted to use your information and need to use it to help deal with the Covid-19 pandemic. This could (amongst other measures) consist of either treating you or a member of your family and enable us and other healthcare organisations to monitor the disease, assess risk and manage the spread of the disease.
Please be assured that we will only share information and health data that is necessary to meet yours and public healthcare needs.
The Secretary of State for Health and Social Care has also stated that these measures are temporary and will expire 30 September 2020 unless a further extension is required. Any further extension will be will be provided in writing and we will communicate the same to you.
Please also note that the data protection and electronic communication laws do not stop us from sending public health messages to you, either by phone, text or email as these messages are not direct marketing.
It may also be necessary, where the latest technology allows us to do so, to use your information and health data to facilitate digital consultations and diagnoses and we will always do this with your security in mind.
Freedom of Information
The Freedom of Information Act creates a right of access to recorded information and obliges a public authority to:
- Have a publication scheme in place
- Allow public access to information held by public authorities.
The Act covers any recorded organisational information such as reports, policies or strategies, that is held by a public authority in England, Wales and Northern Ireland, and by UK-wide public authorities based in Scotland. However, it does not cover personal information such as patient records, which are covered by the Data Protection Act.
Public authorities include government departments, local authorities, the NHS, state schools and police forces.
The Act is enforced by the Information Commissioner who regulates both the Freedom of Information Act and the Data Protection Act.
The surgery publication scheme
A publication scheme requires an authority to make information available to the public as part of its normal business activities. The scheme lists information under seven broad classes, which are:
- who we are and what we do
- what we spend and how we spend it
- what our priorities are and how we are doing it
- how we make decisions
- our policies and procedures
- lists and registers
- the services we offer
You can request our publication scheme leaflet at the surgery.
Who can request information?
Under the Act, any individual, anywhere in the world, is able to make a request to a practice for information. An applicant is entitled to be informed in writing, by the practice, whether the practice holds information of the description specified in the request and if that is the case, have the information communicated to him/her. An individual can request information, regardless of whether he/she is the subject of the information or affected by its use.
How should requests be made?
- be made in writing (this can be electronically e.g. email/fax)
- state the name of the applicant and an address for correspondence
- describe the information requested.
What cannot be requested?
Personal data about staff and patients covered under Data Protection Act.
For more information see these websites:
GP Publication of Earnings
It is a contractual requirement for practices to publish their mean average earnings for 2019/20. Practices must;
- Publish details on their website by 31 March 2021.
- If asked this must also be available in paper copy or you can show the patient the information posted on the website.
The calculation excludes certain types of income and the rules are complex and open to interpretation.
Full time GP’s are defined in the guidance as working eight sessions or more. The number of GP’s includes salaried GP’s and locums who worked full or part time for 6 months or more.
The required disclosure for your practice is shown below. However, it should be noted that the prescribed method for calculating earnings is potentially misleading because it takes no account of how much time doctors spend working in the practice, and should not be used to form any judgement about GP earnings, nor to make any comparison with any other practice.
All GP practices are required to declare the mean earnings for GPs working to deliver NHS services to patients at each practice.
The average pay for GPs working in Silverdale Medical Practice in the last financial year was £51174 before tax and National Insurance. This is for 1 full time GP and 6 part time GPs and 2 locum GPs who worked in the practice for more than six months.
EARLY WARNING FOR 2019/20
A new contract term means that anyone earning above £150,000 will need to declare income separately. The rules and method for doing this have yet to be agreed between NHS England and the BMA so no further information is available at this stage.
Infection Control Statement
We aim to keep our surgery clean and tidy and offer a safe environment to our patients and staff. We are proud of our modern, purpose built practice and endeavour to keep it clean and well maintained at all times.
If you have any concerns about cleanliness or infection control, please report these to our reception staff.
Our GPs and nursing staff follow our Infection Control Policy to ensure the care we deliver and the equipment we use is safe.
We take additional measures to ensure we maintain the highest standards:
- Encourage staff and patients to raise any issues or report any incidents relating to cleanliness and infection control. We can discuss these and identify improvements we can make to avoid any future problems
- Carry out an annual infection control audit to make sure our infection control procedures are working
- Provide annual staff updates and training on cleanliness and infection control
- Review our policies and procedures to make sure they are adequate and meet national guidance
- Maintain the premises and equipment to a high standard within the available financial resources and ensure that all reasonable steps are taken to reduce or remove all infection risk
- Use washable or disposable materials for items such as couch rolls, modesty curtains, floor coverings, towels etc., and ensure that these are laundered, cleaned or changed frequently to minimise risk of infection
- Make alcohol hand rub gel available throughout the building
We have allocated a named accountable GP for all of our registered patients. If you do not know who your named GP is, please ask a member of our reception team. Unfortunately, we are unable to notify patients in writing of any change of GP due to the costs involved.
Your doctors and their staff and everyone else working for the NHS have a legal duty to maintain the highest level of confidentiality about patient information.
In some instances, you may be receiving care from other people as well as the NHS. We may need to share some information about you with them so that we can all work together for your benefit. Anyone who receives confidential information about you from us is also under a legal duty of confidence. Unless there are exceptional circumstances, for example, when the health or safety of others is at risk, we will not disclose your information to third parties, without your permission.
We will only give your relatives, friends and carers information if you want us to.
In certain circumstances, we are required by law to report information to the appropriate authorities. This information is only provided after formal authority has been given by a qualified health professional.
We understand how important it is to keep your personal information safe and secure and we take this very seriously. We have taken steps to make sure your personal information is looked after in the best possible way and we review this regularly.
Please read this Privacy Notice (‘Privacy Notice’) carefully, as it contains important information about how we use the personal and healthcare information we collect on your behalf.
- WHY WE ARE PROVIDING THIS PRIVACY NOTICE
We are required to provide you with this Privacy Notice by Law. It explains how we use the personal and healthcare information we collect, store and hold about you. If you are unclear about how we process or use your personal and healthcare information, or you have any questions about this Privacy Notice or any other issue regarding your personal and healthcare information, then please do contact our Data Protection Officer (details below).
The Law says:
- We must let you know why we collect personal and healthcare information about you;
- We must let you know how we use any personal and/or healthcare
information we hold on you;
- We need to inform you in respect of what we do with it;
- We need to tell you about who we share it with or pass it on to and why; and
- We need to let you know how long we can keep it for.
- THE DATA PROTECTION OFFICER
The Data Protection Officer at the Surgery is Dr Karin McCall. You can contact them on email at Silverdalemedicalpractice@nhs.net if:
- You have any questions about how your information is being held;
- If you require access to your information or if you wish to make a change to your information.
- If you wish to make a complaint about anything to do with the personal and healthcare information, we hold about you.
- Or any other query relating to this Notice and your rights as a patient.
- If you request access to your medical records, the GP has to check through your medical records to ensure there is no third-party information and also nothing which might be detrimental to your health, this takes the clinicians time, you request access to paper records, electronic records but may not be the most secure way or through your NHS app.
- ABOUT US
We, at Silverdale Medical Practice (‘the Surgery’) situated at Pendlebury Health Centre, 659 Bolton Road, Pendlebury, Manchester, M27 8HP, are a Data Controller of your information. This means we are responsible for collecting, storing and handling your personal and healthcare information when you register with us as a patient.
There may be times where we also process your information. That means we use it for a particular purpose and, therefore, on those occasions we may also be Data Processors. The purposes for which we use your information are set out in this Privacy Notice.
- INFORMATION WE COLLECT FROM YOU
The information we collect from you will include:
- Your personal contact details (such as your name, address, contact telephone numbers (landline and mobile) and email address, including place of work and work contact details);
- Details and contact numbers of your next of kin;
- Your age range, gender, ethnicity;
- Details in relation to your medical history;
- The reason for your visit to the Surgery;
- Medical notes and details of diagnosis and consultations with our GPs and other health professionals within the Surgery involved in your direct healthcare.
- INFORMATION ABOUT YOU FROM OTHERS
We also collect personal information about you when it is sent to us from the following:
- a hospital, a consultant or any other medical or healthcare professional, or any other person involved with your general healthcare.
- Immigration information, solicitors requests, insurance applications, housing information, court orders et
YOUR SUMMARY CARE RECORD
Your summary care record (‘SCR’) is an electronic record of your healthcare history (and other relevant personal information) held on a national healthcare records database provided and facilitated by NHS England.
You can ask your doctor to add further information to your SCR from your medical notes. This can include health problems such as diabetes and your treatment preferences.
This record may be shared with other healthcare professionals and additions to this record may also be made by relevant healthcare professionals and organisations involved in your direct healthcare.
You may have the right to demand that this record is not shared with anyone who is not involved in the provision of your direct healthcare. SCRs improve care, but if you do not want to have a SCR, then you are entitled to opt out. You can tell your GP or you can fill out a SCR opt out form. If you would like a form or wish to enquire further as to your rights in respect of not sharing information contained within this record then please contact our Data Protection Officer.
If you are happy with the use of this information you do not need to do anything. You may however change your mind at any time.
- NATIONAL DATA OPT-OUT
A new national data opt-out was introduced in May 2018, following recommendations from the National Data Guardian. You can opt out of having your confidential patient information shared for reasons beyond your individual care, for example for research and planning.
Your health records contain a type of data called confidential patient information. This data can be used to help with research and planning.
You can choose to stop your confidential patient information being used for research and planning. You can also make a choice for someone else like your children under the age of 13.
To help the NHS respond to coronavirus, your information may be used for coronavirus research purposes even if you have chosen not to share it. Any information used will be shared appropriately and lawfully.
Confidential patient information is when 2 types of information from your health records are joined together.
The 2 types of information are:
- something that can identify you;
- something about your health care or treatment;
For example, your name joined with what medicine you take.
Identifiable information on its own is used by health and care services to contact patients and this is not confidential patient information.
Health and care staff may use your confidential patient information to help with your treatment and care. For example, when you visit your GP they may look at your records for important information about your health.
Confidential patient information might also be used to:
- plan and improve health and care services;
- research and develop cures for serious illnesses.
You can stop your confidential patient information being used for research and planning. Find out how to make your choice at https://www.nhs.uk/your-nhs-data-matters/manage-your-choice/
If you’re happy with your confidential patient information being used for research and planning you do not need to do anything.
Any choice you make will not impact your individual care.
- WHO WE MAY PROVIDE YOUR PERSONAL INFORMATION TO AND WHY
Whenever you use a health or care service, such as attending Accident & Emergency or using Community Care Services, important information about you is collected to help ensure you get the best possible care and treatment. This information may be passed to other approved organisations where there is a lawful basis, to help with planning services, improving care, research into developing new treatments and preventing illness. All of this helps to improve services and provide better care to you and your family and future generations. However, as explained in this Privacy Notice, confidential information about your health and care is only used in this way where allowed by law and would never be used for any other purpose without your clear and explicit consent.
We may pass your personal information on to the following people or organisations, because these organisations may require your information to assist them in the provision of your direct healthcare needs. It, therefore, may be important for them to be able to access your information in order to ensure they may properly deliver their services to you:
- Hospital professionals (such as doctors, consultants, nurses, etc);
- Other GPs/Doctors;
- Nurses and other healthcare professionals;
- Any other person that is involved in providing services related to your general healthcare, including mental health professionals.
- Solicitors, insurance companies or anyone where you have consented to your information being released.
OTHER PEOPLE WHO WE PROVIDE YOUR INFORMATION TO
- Clinical Commissioning Groups;
- Local authorities;
- Community health services;
- For the purposes of complying with the Law e.g. Police, Solicitors, Insurance Companies;
- Anyone you have given your consent to, to view or receive your record, or part of your record. Please note, if you give another person or organisation consent to access your record, we will need to contact you to verify your consent before we release that record. It is important that you are clear and understand how much and what aspects of, your record you give consent to be disclosed.
Extended Access – we provide extended access services to our patients which means you can access medical services outside of our normal working hours. In order to provide you with this service, we have formal arrangements in place with the Clinical Commissioning Group and with other practices whereby certain key “hub” practices offer this service on our behalf for you as a patient to access outside of our opening hours. This means, those key “hub” practices will have to have access to your medical record to be able to offer you the service. Please note we ensure that those practices comply with the Law and protect the use of your information, we have very robust data sharing agreements and other clear arrangements in place to ensure your data is always protected and used for those purposes only.
The key Hub practices are as follows:
Swinton Primary Care Network.
- Data Extraction by the Clinical Commissioning Group – the clinical commissioning group at times extracts medical information about you, but the information we pass to them via our computer systems cannot identify you to them. This information only refers to you by way of a code that only your practice can identify (it is pseudo-anonymised). This therefore protects you from anyone who may have access to this information at the Clinical Commissioning Group from ever identifying you as a result of seeing the medical information and we will never give them the information that would enable them to do this.
There are good reasons why the Clinical commissioning Group may require this pseudo-anonymised information, these are as follows:
Swinton Primary Care Network – GP+
Covid Hot Services provided by SPCT
Research and studies where you have consented to engage.
- Primary Care Network
We are a member of Swinton Primary Care Network (PCN). This means we will be working closely with a number of other Practices and health and care organisations to provide healthcare services to you. These Practices are listed at the end of this Privacy Notice. See Schedule 1 below.
During the course of our work we may share your information with these Practices and other health care organisations/professionals. We will only share this information where it relates to your direct healthcare needs.
When we do this, we will always ensure that appropriate agreements are in place to protect your information and keep it safe and secure. This is also what the Law requires us to do.
If you would like to see the information the PCN holds about you, please contact Andrea Simpson at firstname.lastname@example.org. See also your rights listed below.
- ANONYMISED INFORMATION
Sometimes we may provide information about you in an anonymised form. If we do so, then none of the information we provide to any other party will identify you as an individual and cannot be traced back to you.
- YOUR RIGHTS AS A PATIENT
The Law gives you certain rights to your personal and healthcare information that we hold, as set out below:
- Access and Subject Access Requests
You have the right to see what information we hold about you and to request a copy of this information.
If you would like a copy of the information we hold about you, please email our Data Protection Officer. We will provide this information free of charge however, we may in some limited and exceptional circumstances have to make an administrative charge for any extra copies if the information requested is excessive, complex or repetitive.
We have one month from the date of a request to reply to you and give you the information that you require. We would ask, therefore, that any requests you make are in writing and it is made clear to us what and how much information you require.
- Online Access
- We are currently working towards offering all existing patients’ on-line access to their medical records. All new patients will automatically be given on-line access to their records.
- Please note that online access will also provide access to all relevant correspondence attached to your record. It is your responsibility to make sure that you keep your information safe and secure if you do not wish any third party to gain access.
We want to make sure that your personal information is accurate and up to date. You may ask us to correct any information you think is inaccurate. It is very important that you make sure you tell us if your contact details including your mobile phone number has changed.
You have the right to ask for your information to be removed however, if we require this information to assist us in providing you with appropriate medical services and diagnosis for your healthcare, then removal may not be possible.
We cannot share your information with anyone else for a purpose that is not directly related to your health, e.g. medical research, educational purposes, etc. We would ask you for your consent in order to do this however, you have the right to request that your personal and healthcare information is not shared by the Surgery in this way. Please note the Anonymised Information section in this Privacy Notice.
You have the right to request that your personal and/or healthcare information is transferred, in an electronic form (or other form), to another organisation, but we will require your clear consent to be able to do this.
- THIRD PARTIES MENTIONED ON YOUR MEDICAL RECORD
Sometimes we record information about third parties mentioned by you to us during any consultation. We are under an obligation to make sure we also protect that third party’s rights as an individual and to ensure that references to them which may breach their rights to confidentiality, are removed before we send any information to any other party including yourself. Third parties can include: spouses, partners, and other family members.
- HOW WE USE THE INFORMATION ABOUT YOU
We use your personal and healthcare information in the following ways:
- when we need to speak to, or contact other doctors, consultants, nurses or any other medical/healthcare professional or organisation during the course of your diagnosis or treatment or on-going healthcare;
- when we are required by Law to hand over your information to any other organisation, such as the police, by court order, solicitors, or immigration enforcement.
We will never pass on your personal information to anyone else who does not need it, or has no right to it, unless you give us clear consent to do so.
14. LAWFUL JUSTIFICATION FOR COLLECTING AND USING YOUR INFORMATION
In accordance with the retained EU law version of the General Data Protection Regulation ((EU) 2016/679) (“UK GDPR”), the Data Protection Act 2018 and any other relevant legislation, regulation, code of practice or guidance the Law says we need a lawful basis to handle your personal and healthcare information.
CONTRACT: We have a contract with NHS England to deliver healthcare services to you. This contract provides that we are under a legal obligation to ensure that we deliver medical and healthcare services to the public.
CONSENT: Sometimes we also rely on the fact that you give us consent to use your personal and healthcare information so that we can take care of your healthcare needs.
Please note that you have the right to withdraw consent at any time if you no longer wish to receive services from us.
NECESSARY CARE: Providing you with the appropriate healthcare, where necessary. The Law refers to this as ‘protecting your vital interests’ where you may be in a position not to be able to consent.
LEGAL OBLIGATION: Sometimes the Law obliges us to provide your information to an organisation (see above).
- SPECIAL CATEGORIES
The Law states that personal information about your health falls into a special category of information because it is very sensitive. Reasons that may entitle us to use and process your information may be as follows:
PUBLIC INTEREST: Where we may need to handle your personal information when it is considered to be in the public interest. For example, when there is an outbreak of a specific disease and we need to contact you for treatment, or we need to pass your information to relevant organisations to ensure you receive advice and/or treatment;
CONSENT: When you have given us consent;
VITAL INTEREST: If you are incapable of giving consent, and we have to use your information to protect your vital interests (e.g. if you have had an accident and you need emergency treatment);
DEFENDING A CLAIM: If we need your information to defend a legal claim against us by you, or by another party;
PROVIDING YOU WITH MEDICAL CARE: Where we need your information to provide you with medical and healthcare services.
- HOW LONG WE KEEP YOUR PERSONAL INFORMATION
We carefully consider any personal information that we store about you, and we will not keep your information for longer than is necessary for the purposes as set out in this Privacy Notice.
There is a separate Privacy Notice for patients under the age of 16, a copy of which may be obtained on request.
- IF ENGLISH IS NOT YOUR FIRST LANGUAGE
If English is not your first language you can request a translation of this Privacy Notice. Please contact our Data Protection Officer.
If you have a concern about the way we handle your personal data or you have a complaint about what we are doing, or how we have used or handled your personal and/or healthcare information, then please contact our Data Protection Officer.
However, you have a right to raise any concern or complaint with the UK information regulator, at the Information Commissioner’s Office: https://ico.org.uk/.
- OUR WEBSITE
The only website this Privacy Notice applies to is the Surgery’s website. If you use a link to any other website from the Surgery’s website, then you will need to read their respective Privacy Notice. We take no responsibility (legal or otherwise) for the content of other websites.
We take the security of your information very seriously and we do everything we can to ensure that your information is always protected and secure. We regularly update our processes and systems and we also ensure that our staff are properly trained. We also carry out assessments and audits of the information that we hold about you and make sure that if we provide any other services, we carry out proper assessments and security reviews.
- TEXT MESSAGING AND CONTACTING YOU
Because we are obliged to protect any confidential information, we hold about you and we take this very seriously, it is imperative that you let us know immediately if you change any of your contact details.
We may contact you using SMS texting to your mobile phone in the event that we need to notify you about appointments and other services that we provide to you involving your direct care, therefore you must ensure that we have your up-to-date details. This is to ensure we are sure we are actually contacting you and not another person.
Please note that we have installed a CCTV system inside and outside of the building for the safety of our patients/staff and in particular to record and evidence any serious incidents involving patients. We operate this system in accordance with the Law and the codes of practice issued by the Information Commissioners Office as well as other regulatory bodies. Our CCTV is monitored on an adhoc basis and only authorised NHS Estates staff will have access to it.
We will not keep images captured on CCTV for longer than is necessary.
Images are kept on a hard drive in NHS Estates reception and are only viewed if an incident occurs which requires police intervention.
If you believe your image has been captured on our CCTV you have a right to request to see it. Please contact our Data Protection Officer, who will be able to assist with your enquiry.
We will always inform you if we record or monitor any telephone call you make to us.
Telephone recordings are kept for 6 months.
Management listen to telephone calls, when a complaint is received or when reviewing the quality of our service to you. Calls are used for training purposes with our reception team.
- WHERE TO FIND OUR PRIVACY NOTICE
You may find a copy of this Privacy Notice in the Surgery’s reception, on our website, or a copy may be provided on request.
- CHANGES TO OUR PRIVACY NOTICE
We regularly review and update our Privacy Notice. This Privacy Notice was last updated on 04/05/2022.
List the Practices that are members of your PCN here
Silverdale Medical Practice
Lakes Medical Practice
Poplars Medical Practice
Sides Medical Practice
Suggestions, Comments and Complaints
We welcome all comments on the services provided by the practice.
We are continually looking to turn our patients’ feedback into real improvements in the services we provide. We use it to focus on the things that matter most to our patients, carers and their families.
We’ll let the staff involved know and share the good practice across our teams.
You may write to us or contact us by phone.
Summary Care Record
There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.
Why do I need a Summary Care Record?
Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.
This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you.
Who can see it?
Only healthcare staff involved in your care can see your Summary Care Record.
How do I know if I have one?
Over half of the population of England now have a Summary Care Record. You can find out whether Summary Care Records have come to your area by contacting the practice.
Do I have to have one?
No, it is not compulsory. If you choose to opt out of the scheme, then you will need to complete a form and bring it along to the surgery. You can opt-out by completing our Summary Care Record Opt Out form.
For further information visit the NHS Care records website.
The practice fully supports the NHS Zero Tolerance Policy. The aim of this policy is to tackle the increasing problem of violence against staff working in the NHS and ensures that doctors and their staff have a right to care for others without fear of being attacked or abused.
We understand that ill patients do not always act in a reasonable manner and will take this into consideration when trying to deal with a misunderstanding or complaint. We ask you to treat your doctors and their staff courteously and act reasonably.
All incidents will be followed up and you will be sent a formal warning after a second incident or removed from the practice list after a third incident if your behaviour has been unreasonable.
However, aggressive behaviour, be it violent or verbal abuse, will not be tolerated and may result in you being removed from the Practice list and, in extreme cases, the Police will be contacted if an incident is taking place and the patient is posing a threat to staff or other patients.