Policy Index by Category

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).



Title Last Review Next Review
Being Open Policy May-18 May-20
Central Alert System (CAS) Policy Oct-14 Oct-17
Clinical Effectiveness and Audit Strategy 2017-2022 Apr-18 Jul-22
Clinical Procurement and Introduction of New Products Policy Aug-17 Aug-20
Committee and Group Policy Feb-14 Feb-17
Concerns and Complaints Policy May-15 May-18
Dealing with the police and other public bodies Jun-10 Jun-13
Education, Learning, and Development Policy May-15 May-18
Freedom to Speak Up: Raising Concerns (Whistleblowing) Policy Mar-17 Mar-20
Gifts and Hospitality Policy Mar-16 Mar-19
Handling difficult or unreasonable complainants Oct-14 Oct-16
Handling the Media Policy Nov-14 Nov-16
Induction Policy May-18 Feb-21
Management of Complaint Files Oct-14 Sep-17
Managing and Responding to External Agency Visits May-18 Mar-20
National Guidance Monitoring Framework Oct-16 Oct-19
Organisational Development and Workforce Strategy 2010-2014 Jan-10 Jan-14
PALS Policy Jan-13 Dec-15
Policy Writing and Ratification May-18 Dec-20
Publication and Provision of Patient Information Nov-14 Nov-16
QSIA Policy Nov-16 Jun-18
Quality Safety and Risk Management Strategy Oct-12 Sep-17
Records Management Policy Nov-17 Nov-20
Register of Interests Policy Sep-14 Sep-16
Reimbursement of Expenses Dec-13 Dec-15
Remedy Policy Nov-13 Nov-16
Retention of radiology transitory record Jul-17 Jul-20
Safe Staffing Escalation for In-patient Areas Policy Nov-15 Nov-18
Scheme of Delegation May-18 Mar-19
Self Assessment against CQC Standards Jun-13 Jun-16
Standing Financial Instructions May-18 Mar-19
Standing Orders May-19 May-20
Supplier Representatives Policy Sep-18 Aug-20
Transformation and Improvement Strategy 2015/2016 Nov-15 Nov-18
Use of Social Media Policy Dec-16 Nov-19
Witnessing documents for patients policy Nov-14 Nov-17



Title Last Review Next Review
Business Case Financial Template    
Business Case Guidelines    
Co-Payment Treatments May-17 May-19
Counter Fraud and Corruption Policy Jan-18 Jan-19
Operating policy for dealing with individual funding requests (IFRs) Jul-17 Jun-18
Operational Protocol for Provider to Provider Contracts Mar-17 Mar-20
Overseas Visitor Policy Apr-18 Apr-21
Private Patient Services May-17 May-19
Tender and Bid Process Guideliness Apr-17 Apr-20



Title Last Review Next Review
Adoption and Surrogacy Policy May-19 May-22
Alcohol and Drugs at Work Policy Jan-17 May-20
Annual Leave Policy Jun-17 Jun-20
Annual Leave Policy for Medical Staff Oct-14 Oct-17
Appeals Procedure Oct-17 Oct-20
Appraisal Policy Jun-18 May-20
Apprenticeship Policy Jun-16 Jun-18
Buying and Selling Annual Leave Scheme Feb-19 Jan-20
Career Break Policy May-19 May-22
Conduct, capability, Ill health and appeals policies and procedures for practitioners (doctors and dentists) Nov-17 Sep-20
Dignity at Work Oct-17 Oct-20
Disciplinary Policy Jan-17 May-20
Disclosure and Barring Services (DBS) Policy Nov-14 Nov-17
Dress Code Policy (incl. Personal Hygiene) May-18 May-21
Flexible Working Policy May-19 May-22
Gender Reassignment Policy Nov-17 May-21
Grievance Policy Oct-17 Oct-20
Honorary Contracts Policy Nov-14 Nov-17
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 Mar-17 Mar-20
New Parent Leave Policy May-19 May-22
Organisational Change Policy Mar-18 Mar-21
Partnership and Recognition Agreement Sep-17 Sep-20
Pay Policy for Non-Medical Staff Oct-14 Oct-17
Performance and Capability Policy Oct-18 Oct-21
Professional Registration Policy Nov-14 Nov-17
Recruitment and Selection Policy Nov-14 Nov-16
Retirement Policy Feb-19 Feb-22
Sickness Absence Policy Jan-17 Jan-19
Special Leave Policy May-19 May-22
Temporary Staffing Policy Oct-18 Oct-21
Use of Volunteers Nov-14 Nov-16
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 Dec-16 Dec-19
Health Surveillance Policy Apr-16 Apr-19
Inoculation Injury Policy Mar-16 Mar-19
Management and Reduction of Stress Policy Oct-16 Oct-18
Medication and Vaccination Policy Jun-17 Jan-20
Pre-Placement Policy Nov-16 Nov-19
Upper Limb Disorder Policy Mar-19 Mar-22


Health and Safety

Title Last Review Next Review
Control of Substances Hazardous to Health Jun-16 Oct-18
Display Screen Equipment Oct-15 Oct-18
Health and Safety Policy Oct-15 Oct-18
Latex Policy Jun-17 Jun-19
Lone Worker Policy Jul-15 Jul-18
Slips, Trips and Falls (Non Patient) Policy Oct-15 Oct-18
Smoke Free Site Policy Feb-14 Feb-17



Title Last Review Next Review
Fire Policy Mar-17 Mar-19
Handling of Clinical Negligence Claims Feb-14 Feb-17
Incident Reporting Policy Mar-14 Mar-17
Inpatient Falls Policy Jul-18 Nov-19
Learning from Deaths Policy Oct-17 Oct-20
Non-Clinical Claims Nov-13 Nov-16
Risk Assessment Policy Oct-16 Oct-18



Title Last Review Next Review
Patient’s Property Policy Oct-18 Oct-21
Security Policy Oct-16 Oct-18



Title Last Review Next Review
Administration of Injectable Medicines Policy Mar-17 Dec-20
Administration of Naloxone in Adults Mar-19 Mar-22
Antimicrobial Prescribing Policy Mar-19 Mar-21
Homecare Medicine Service Aug-17 Aug-19
Immunoglobulin Policy Sep-16 Sep-18
Lower Limb Immobilisation Venous Thromboembolism (VTE) Prevention Policy Oct-17 Oct-18
Medicines and Vaccines Cold Storage Policy May-17 May-19
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
Management, use and disposal of medical devices Jan 17 Jan 20
Mattress Audit Policy Feb 19 Feb 22
Medical Devices Training for Clinical Staff Feb-17 Feb-20
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 Apr 18 May 20


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 Jun-16 Jun-19
Carbapenemase Producing Enterobacteriaceae (CPE) Aug-19 May-21
Central Venous Catheter Care Policy Mar-18 Mar-20
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
Elective Joint Replacement Urinalysis Pre-operative Assessment Policy May-18 Aug-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 Policy Apr-18 Apr-20
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 Treatment Apr-18 Mar-20
Tunnelled Central Venous Access Devices (HICC) Apr-18 Mar-20
Viral Haemorrhagic Fevers Apr-17 Dec-19


Patient Care

Title Last Review Next Review
Admissions Policy, Procedure and Guidelines May-18 May-21
Anticipatory Prescribing Guidelines Mar-17 Mar-19
Bedrails Policy May-18 May-21
Bereavement Office Operational Policy Nov-16 Nov-19
Blood Transfusion Policy for Adult Patients Jul-17 Jul-20
Blood Transfusion Policy for Neonatal and Paediatric Patients Jul-17 Jul-20
Cancer Operational and Escalation Policy for Monitoring of Cancer Standards Apr-16 Apr-19
Care of Patients requiring Close Observation Apr-14 Apr-17
Care of the Bereaved Aug 13 Mar 16
Chaperoning Guidelines for Clinical Staff Aug-17 Mar-20
Communicating Significant News Aug-13 Mar-16
Consent Policy Dec-16 Dec-19
Copying patients into clinical letters Apr-18 Feb-21
Covert Administration of Medication Policy Aug-19 Aug-22
CT scans out of hours Jan-17 Dec-20
Dementia Care Policy Aug-19 Aug-21
Discharge Lounge: Standard Operating Procedure Jun-19 Jun-21
Discharge Policy for Adults (and Referral Guidelines) Jul-13 Jul-16
Early Release of the Deceased Patient out of Normal Working Hours Mar-17 Mar-20
End of Life Care - Guidelines for the discharge of adult patients dying in hours and days Mar-18 Mar-21
Enteral Feeding Policy for Adults Feb-15 Jan-18
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 May-18 May-21
Interpreting Service Oct-13 Oct-15
Joint Access Policy Aug-19 Aug-20
Learning Disability Policy Nov-18 Nov-21
Missing Patient policy Jun-12 Jun-14
Mittens Policy Mar-17 Mar-20
Mortuary Viewing Jan-14 Jan-17
Moving and Handling Policy Oct-18 Jun-21
Nasal Bridle Policy Nov-16 Nov-18
Operational Pressures Escalation Plan (OPEL) Jun-18 Jun-21
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-13 Oct-15
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
Recognition of and Response to Acutely Ill Adult Patients in Ward Environments Oct-14 Apr-15
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) Jun-18 Jun-21
Transfer of Mental Health Inpatients Jan-19 Jan-22
Trauma Operational Policy Jun-17 Jun-20
Venous Thromboembolism (VTE) Prevention Policy Oct-16 Oct-18
Verification of Expected Death by Registered Healthcare Professionals Nov-16 Nov-19
VitalPAC Operational Policy Sep-16 Aug-18
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 Feb-19 May-22
Conservative Sharp Debridement of Wounds Feb-17 Feb-20
Management of the McKinley T34 Subcutaneous Ambulatory Syringe Driver Nov-16 Nov-19
Nurse-led Diagnostic Biopsies Policy Nov-14 Nov-17
Procedure for nurse checking and issuing of TTOs May-18 May-21
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-19 Jun-20
Business Continuity Plan Nov-17 Dec-19
Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) Plan Jan-19 Jan-21
Communications Incident Response Plan Sep-19 Mar-20
Emergency Preparedness Resilience and Response (EPRR) Framework Aug-18 Aug-19
Evacuation Plan Jun-18 Jun-20
Flu Plan Dec-18 Dec-19
Internal Incident Plan Jun-19 Jun-20
Lockdown Plan Jul-17 Jul-20
Major Incident Plan Nov-18 Nov-19
Vehicle Fuel Emergency Plan Mar-18 Mar-20
VIP Policy Jul-19 Jul-20


Information and Technology

Title Last Review Next Review
Confidentiality Policy Feb-19 Mar-22
Data Quality Policy Mar-18 Mar-20
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 Nov-17 Nov-18
Information Security Policy Feb-19 Feb-21
Internet Usage and Security Policy Jan-19 Jan-22
IT Projects Policy Jul 17 Jul 20
Portable Computer Device Policy Feb-19 Feb-22
Print and Fax Policy Oct 17 Oct 20
Registration Authority (Smartcard) Policy Feb 18 Feb 21
Remote Access Policy Jan-19 Jan-22


Facilities and Estates

Title Last Review Next Review
Catering Ward Provisions and Hospitality Services Policy Mar-18 Jan-20
Decontamination Policy Dec-16 Oct-19
Estates Operational Policy Nov-18 Nov-19
Management of Healthcare Waste Dec-17 Dec-19
Operational Cleaning Plan Aug-17 Aug-19
Operational Policy Medical Gas ASPH Dec-17 Nov-19
Strategic Cleaning Plan Sep-17 Sep-19
Telecommunications Policy Oct-14 Oct-16
Travel and Car Parking Policy Mar-17 Mar-19



Title Last Review Next Review
Deprivation of Liberty Safeguarding Policy Aug-18 Mar-21
Domestic Abuse Policy (Patients and Visitors) May-19 May-22
Domestic Abuse Policy (Workforce) Sep-19 Sep-22
Female Genital Mutilation (FGM) Policy Jul-16 Jul-19
Mental Capacity Policy Mar-18 Nov-20
Restraint Policy for Adults and Young People Jun-16 May-19
Safeguarding Adults at Risk Policy May-17 May-20
Safeguarding Children Policy Apr-18 Apr-21
Safeguarding Children Supervision Policy Jul-18 Jul-21
Was Not Brought Policy Jan-19 Jan-22