In this section, we have a listing of all our corporate policies. Please note that some are not published due to their nature (e.g. potential security or staff safety issues).

 

Organisational

Title	Last Review	Next Review
Being Open Policy	May-18	May-20
Central Alert System (CAS) Policy	Apr-20	Apr-23
Clinical Procurement and Introduction of New Products Policy	Jun-21	Jun-24
Committee and Group Policy	Feb-14	Feb-17
Complaints, Concerns, Patient Advice and Liaison Service (PALS), Compliments and Remedy Policy	Feb-20	Feb-23
Dealing with the Police and Other Public Bodies	Jun-21	Jun-24
Education, Learning, and Development Policy	Mar-20	Apr-23
Freedom to Speak Up: Raising Concerns (Whistleblowing) Policy	Mar-21	Mar-24
Handling the Media Policy	Sep-20	Sep-23
Induction Policy	May-18	Feb-21
Managing and Responding to External Agency Visits	May-18	Mar-20
Managing Conflicts of Interest Policy	Jun-21	Jun-23
National Guidance Monitoring Framework	Dec-20	Oct-23
Policy Writing and Ratification	May-18	Dec-20
Publication and Provision of Patient Information	Nov-14	Nov-16
QSIA Policy	Nov-16	Jun-18
Records Management Policy	Nov-17	Nov-20
Retention of radiology transitory record	Jul-17	Jul-20
Safe Staffing Escalation for In-patient Areas Policy	Nov-15	Nov-18
Scheme of Delegation	Jul-20	Jul-21
Standing Financial Instructions	Jul-20	Jul-21
Standing Orders	May-20	May-21
Supplier Representatives Policy	Jul-20	Jul-22
Use of Social Media Policy	Dec-16	Nov-19
Witnessing documents for patients policy	Nov-14	Nov-17

 

Finance

Title	Last Review	Next Review
Clinical Commissioning Policy: Individual Funding Requests	Jul-20	Jul-23
Co-Payment Treatments	Mar-20	Mar-22
Counter Fraud and Corruption Policy	Apr-20	Apr-21
Operational Protocol for Provider to Provider Contracts	Sep-20	Sep-23
Overseas Visitor Policy	Apr-18	Apr-22
Private Patient Services	Aug-20	Aug-22
Tender and Bid Process Guidelines	Apr-17	Apr-20

 

Employment

Title	Last Review	Next Review
Acting Down (Emergency Cover) Policy	Nov-19	Nov-22
Acting Up and Secondment Policy	Apr-21	Apr-24
Adoption and Surrogacy Policy	May-19	May-22
Alcohol and Drugs at Work Policy	Jan-17	May-20
Annual Leave Policy	Apr-21	Apr-24
Annual Leave Policy for Medical Staff	Dec-20	Nov-23
Appeals Procedure	Apr-21	Apr-24
Appraisal Policy	Oct-20	Oct-22
Apprenticeship Policy	Mar-21	Mar-22
Buying and Selling Annual Leave Scheme	Feb-21	Jan-22
Career Break Policy	May-19	May-22
Conduct, capability, Ill health and appeals policies and procedures for practitioners (doctors and dentists)	Dec-20	Nov-23
Dignity at Work	Oct-17	Oct-20
Disciplinary Policy	Jan-17	May-20
Disclosure and Barring Services (DBS) Policy	Mar-20	Mar-21
Dress Code Policy (incl. Personal Hygiene)	May-18	May-21
Flexible Working Policy	May-19	May-22
Grievance Policy	Oct-17	Oct-20
Honorary Contracts Policy	Mar-20	Mar-21
Job Matching and Evaluation Policy	Sep-17	Sep-21
Management of Safeguarding Allegations Made Against Staff and Volunteers Working in the Trust	Jul-18	Jul-21
Management of Violence and Aggression	Mar-16	Oct-18
Maternity Leave and Fertility Treatment Policy	May-19	May-22
Medical Appraisal and Revalidation Policy	Dec-20	Dec-23
New Parent Leave Policy	May-19	May-22
Organisational Change Policy	Mar-18	Mar-21
Partnership and Recognition Agreement	Apr-21	Apr-24
Pay Policy for Non-Medical Staff	Oct-14	Oct-17
Performance and Capability Policy	Oct-18	Oct-21
Personal and Family Relationships Policy	Sep-19	Sep-22
Professional Registration Policy	Mar-20	Mar-21
Recruitment and Selection Policy	Aug-21	Aug-24
Retirement Policy	Feb-19	Feb-22
Shared Parental Leave Policy	Oct-20	Oct-23
Sickness Absence Policy	May-20	May-23
Special Leave Policy	May-19	May-22
Staff Allocation Policy for Accommodation	Aug-21	Aug-24
Temporary Staffing Policy	Oct-18	Oct-21
Transitioning at Work Policy	Sep-21	Aug-24
Volunteers Policy	Jul-20	Jul-23
Work Experience, Work Shadowing and Work Placement Policy	Jan-18	Nov-20

 

Occupational Health

Title	Last Review	Next Review
Exposure Prone Procedures (EPPs) and Bloodborne Viruses (BBVs) - Management of Healthcare Workers (HCW) with a BBV	May-19	Jul-22
First Aid Policy	Jul-20	Jul-23
Health Surveillance Policy	Jan-21	Jan-24
Management and Reduction of Stress Policy	Dec-20	Dec-23
Management of Bodily Fluid Exposure and Innoculation Injuries Policy	Aug-20	Aug-23
Medication and Vaccination Policy	Jun-17	Jan-20
Pre-Placement Policy	Jul-20	Jul-23
Upper Limb Disorder Policy	Mar-19	Mar-22

 

Health and Safety

Title	Last Review	Next Review
Control of Substances Hazardous to Health	Mar 20	Apr 22
Display Screen Equipment	Oct-19	Oct-22
Health and Safety Policy	Jul-20	Jul-23
Latex Policy	Oct-20	Jun-23
Lone Worker Policy	Jul-15	Jul-18
Slips, Trips and Falls (Non Patient) Policy	Oct-19	Oct-22
Smoke Free Site Policy	Feb-14	Feb-17

 

Risk

Title	Last Review	Next Review
Fire Safety Policy	Jul-20	Jul-23
Handling of Clinical Negligence Claims	Feb-14	Feb-17
Incident Reporting Policy	Jul-20	Jul-23
Learning from Deaths Policy	Oct-17	Oct-20
Non-Clinical Claims	May-21	May-24
Prevention and Management of Adult Inpatient Falls	Apr-21	Apr-24
Risk Assessment Policy	Oct-16	Oct-18
Risk Management Policy	Sep-19	Aug-21

 

Security

Title	Last Review	Next Review
Patient’s Property Policy	Oct-18	Oct-21
Security Policy	Jan-21	Jul-22

 

Medicines

Title	Last Review	Next Review
Administration of Injectable Medicines Policy by Intravenous Route	Dec-20	Dec-23
Administration of Naloxone in Adults	Mar-19	Mar-22
Antimicrobial Prescribing Policy	Mar-19	Mar-21
Homecare Medicine Service	Mar-20	Mar-22
Immunoglobulin Policy	Sep-16	Sep-18
Lower Limb Immobilisation Venous Thromboembolism (VTE) Prevention Policy	Feb-21	Jan-23
Medicines and Vaccines Cold Storage Policy	Feb-20	Feb-22
Medicines Management Policy	Feb-19	Feb-22
Parental Nutrition Policy for Adults	Aug-18	Jun-20
Patient Group Direction Policy	Nov-17	Nov-20
Purchasing Medicines for Safety Policy	May-18	May-21
Self Administration Policy	Mar-18	Mar-20
Self-Prescribing and Prescribing for Family Members and Colleagues	Dec-16	Dec-18
Tranquilisation Policy	Sep-17	Sep-19

 

Medical Devices

Title	Last Review	Next Review
Interventional Procedures Policy	Dec-16	Nov-19
Managemen of Medical Devices	Jun-21	Jun-24
Mattress Audit Policy	Feb-19	Feb-22
Medical Devices Training for Clinical Staff	Feb-20	Feb-23
Point of Care Testing Policy	Jun-15	Apr-18
Radiation Protection Policy	Jul-18	Jul-21
Single Use, Single Patient Use, and Limited Use Medical Devices Policy	Jun-21	Jun-24

 

Control of Infection

Title	Last Review	Next Review
Admission, Transfer and Discharge Policy for the Infected Patient	Oct-17	Oct-20
Aseptic Non-Touch Technique Policy	May-18	May-21
Blood Culture Policy for Adults	Oct-19	Oct-22
Carbapenemase Producing Enterobacteriaceae (CPE)	Aug-19	May-21
Central Venous Catheter Care Policy	Jan-21	Aug-23
CJD	Aug-17	Mar-20
Cleaning and Disinfection Policy	Aug-17	Aug-19
Clostridium Difficile Diarrhoea	May-17	Nov-20
Control of Tuberculosis in Hospital	Oct-17	Oct-20
Glove Policy	May-19	May-22
Glycopeptide Resistant Enterococci	Jan-17	Jan-20
Hand Hygiene Policy for Healthcare Workers	Aug-17	May-20
Infection Contol input into design construction and renovation projects	Apr-16	Apr-19
Infestation Policy	Sep-16	Sep-19
Introduction to Infection Prevention Control	Apr-16	Apr-19
Isolation Policy	Oct-18	Oct-21
Last Offices for the Infectious Adult Patient	Apr-16	Apr-19
Linen Policy	Apr-18	Apr-20
Management of Diarrhoea and Vomiting	Jan-19	Jan-22
Meningococcal Disease	Jul-17	Jul-20
MRSA Policy	Jul-19	Jul-22
Multi Resistant Gram Negative Bacilli	Mar-17	Mar-20
Notification of Infectious Diseases Policy	May-17	May-20
Outbreak Policy	Jan-19	Jan-22
Peripherally Inserted Central Line (PICC) Care Guidelines	Oct-20	Oct-23
Peripheral Venous Catheter Care Policy for Adults	Jun-19	May-21
Respiratory Viruses Policy	Apr-18	Apr-21
Safe Handling and Disposal of Sharps	Apr-18	Apr-20
Short Term Indwelling Urinary Catheters	Jul-19	Jul-22
Spillage of Blood and Body Fluids	Apr-18	Mar-20
Standard Precautions Policy	Apr-18	Apr-20
Surgical Site Infection Prevention and Treatment	Apr-21	Apr-23
Tunnelled Central Venous Access Devices (HICC)	Apr-18	Mar-20
Viral Haemorrhagic Fevers	Apr-17	Dec-19

 

Patient Care

Title	Last Review	Next Review
Admission, Transfer, and Discharge of Adult Patients Policy	Apr-21	Apr-24
Anticipatory Prescribing Guidelines	Mar-20	Mar-23
Arterial Blood Gas (ABG) sampling via needle puncture for Specialist Nurses and Allied Health Professionals	Apr-21	Apr-23
Autonomic Dysreflexia - Guidance on Safe Management of Bladder and Bowel Care Procedure	Jan-20	Jan-22
Bereavement Office Operational Policy	Nov-16	Nov-19
Blood Transfusion Policy for Adult Patients	Oct-19	Oct-22
Blood Transfusion Policy for Neonatal and Paediatric Patients	Jun-21	Jun-24
Cancer Operational and Escalation Policy for Monitoring of Cancer Standards	Apr-16	Apr-19
Care of the Bereaved	Oct-20	Oct-23
Chaperoning Guidelines for Clinical Staff	Aug-17	Mar-20
Consent Policy	Sep-20	Sep-23
Copying patients into clinical letters	Apr-18	Feb-21
Covert Administration of Medication Policy	Aug-19	Aug-22
COVID-19 Operational Policy	Jul-20	Jul-22
CT scans out of hours	Jan-17	Dec-20
Delirium Policy	Jul-20	Jul-22
Dementia Care Policy	Aug-19	Aug-21
Discharge Lounge: Standard Operating Procedure	Sep-21	Sep-23
Early Release of the Deceased Patient out of Normal Working Hours	Dec-20	Jan-22
End of Life Care - Guidelines for the discharge of adult patients dying in hours and days	Mar-18	Mar-21
Enhanced Care, Supportive Observation and Therapeutic Engagement Policy	Dec-20	Dec-22
Enteral Feeding Policy for Adults	Apr-21	Apr-24
Epidural Analgesia Policy	Nov-17	Nov-20
Expected Date of Discharge	May-18	May-21
Guidance for Doctors on Post Mortems	Mar-17	Mar-19
Guidelines for Parkinson's Disease	Jan-19	Jan-22
Handling Deaths at Ashford Hospital	Jul-17	Jul-20
Intermittent Boluses and Continuous Infusions of Local Anaesthetics for Acute Pain Management in Adults	Apr-21	Jun-23
Interpreting Service	Oct-13	Oct-15
Joint Access Policy	Mar-20	Apr-21
Learning Disability Policy	Nov-18	Nov-21
Management of the Deteriorating Adult Inpatient	Nov-19	Nov-22
Missing Patient Policy - Local Arrangements	Apr-21	Apr-24
Mittens Policy	May-21	May-24
Mortuary Viewing	Sep-20	Sep-23
Moving and Handling Policy	Jun-20	Jun-23
Nasal Bridle Policy	Nov-16	Nov-18
Operational Pressures Escalation Level (OPEL) Plan	Dec-20	Dec-22
Organ Donation Policy	Oct-16	Oct-19
Oxygen Policy	Aug-13	Aug-16
Patient Controlled Analgesia (PCA) Policy	Mar-19	Mar-22
Patient Identification Policy	Oct-19	Sep-21
Photographing patients	Aug-17	Aug-20
Preoperative Anaemia Pathway	Sep-18	Dec-19
Pressure Area Management Policy	Jan-19	Jan-22
Protected Mealtimes Policy	Mar-14	Mar-17
Resuscitation and ReSPECT Policy	Sep-18	Aug-21
Sampling of an arterial blood gas	May-18	May-21
Serious Communicable Disease Information	Apr-19	Apr-22
Transfer of Adult Patients (excluding Maternity)	Dec-20	Jun-21
Transfer of Mental Health Inpatients	Jan-19	Jan-22
Trauma Operational Policy	Jun-17	Jun-20
Venous Thromboembolism (VTE) Prevention Policy	Apr-21	Feb-22
Verification of Expected Death by Registered Healthcare Professionals	Oct-20	Sep-23
VitalPAC Operational Policy	Aug-19	Aug-22
Wound Care Policy	May-18	May-21
X-Ray Request Policy	Jun-17	Jun-20

 

Nursing Procedures

Title	Last Review	Next Review
Advanced / Specialist Nurse Prescribing of Blood Components	Jun-21	Apr-24
Conservative Sharp Debridement of Wounds	Aug-21	Aug-24
Guidelines for the Use of the CME T34 McKinley Subcutaneous Ambulatory Syringe Pump in Palliative Care	Nov-20	Feb-24
Nurse Checking and Issuing of Discharge Medication (TTO) Policy	May-18	May-21
Nurse-led Diagnostic Biopsies Policy	Nov-14	Nov-17
Transcutaneous Electrical Nerve Stimulation (TENS)	Dec-17	Nov-20
Visual Acuity	Apr-19	Apr-22

 

Major Incident

Title	Last Review	Next Review
Adverse Weather Plan	Jun-21	Dec-21
Business Continuity Plan	Dec-19	Dec-20
Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) Plan	Jan-21	Jan-23
Communications Incident Response Plan	Apr-21	Apr-22
Emergency Preparedness Resilience and Response (EPRR) Framework	Jan-21	Jan-22
Evacuation Plan	Oct-20	Sep-22
Flu Plan	Oct-20	Oct-21
Internal Incident Plan	Oct-20	Oct-21
Lockdown Plan	Oct-20	Oct-21
Major Incident Plan	May-21	May-22
Vehicle Fuel Emergency Plan	Jul-20	Jul-21
VIP Policy	Jul-20	Jul-21

 

Information and Technology

Title	Last Review	Next Review
Acceptable Use Policy	Jul-20	Jul-23
Confidentiality Policy	Feb-19	Mar-22
Data Quality Policy	Nov-20	Nov-22
Dictate IT Transcription Service Policy	Mar-18	Mar-21
Email Policy	May-19	May-22
Freedom of Information (FOI) Policy	Feb-17	Feb-20
Information Governance Policy	Sep-20	Sep-21
Information Security Policy	Feb-19	Feb-21
Internet Usage and Security Policy	Jan-19	Jan-22
IT Projects Policy	Jul 17	Jul 20
Microsoft Office 365 Acceptable Use Policy	Jul-21	Jul-24
Portable Computer Device Policy	Feb-19	Feb-22
Print and Fax Policy	Oct-17	Oct-20
Registration Authority (Smartcard) Policy	Jul-21	Jul-24
Remote Access Policy	Jan-19	Jan-22

 

Facilities and Estates

Title	Last Review	Next Review
Catering Ward Provisions and Hospitality Services Policy	Jun-20	Jun-23
Decontamination Policy	Jan-20	Oct-22
Estates Operational Policy	Jan-20	Jan-23
Management of Healthcare Waste	Nov-19	Apr-21
Operational Cleaning Plan	Nov-19	Apr-21
Operational Policy Medical Gas ASPH	Jan-20	Jan-22
Strategic Cleaning Plan	Nov-19	Apr-21
Telecommunications Policy	Oct-14	Oct-16
Travel and Car Parking Policy	Sep-19	Sep-21

 

Safeguarding

Title	Last Review	Next Review
Baby / Child (Abduction) Security Policy	Apr-21	Apr-24
Deprivation of Liberty Safeguarding Policy	Apr-20	Mar-21
Did Not Attend (DNA) for Adults at Risk	Nov-19	Nov-22
Domestic Abuse Policy (Patients and Visitors)	May-19	May-22
Domestic Abuse Policy (Workforce)	Sep-19	Sep-22
Female Genital Mutilation (FGM) Policy	Jun-20	Jun-23
Mental Capacity Act Policy	Nov-20	Nov-23
Restraint Policy for Adults and Young People	Jun-16	May-19
Safeguarding Adults at Risk Policy	Mar-20	Mar-23
Safeguarding Children Policy	Jun-20	Apr-21
Safeguarding Maternity Policy	Mar-20	Mar-23
Safeguarding Children Supervision Policy	Jul-18	Jul-21
Was Not Brought Policy	Jan-19	Jan-22