Policies

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	Nov-22	Apr-25
Freedom to Speak Up: Raising Concerns (Whistleblowing) Policy	Mar-21	Mar-24
Handling the Media Policy	Sep-20	Sep-23
Induction Policy	Sep-22	Oct-22
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	Sep-22	Sep-25
Records Management Policy	Nov-22	Nov-25
Safe Staffing Escalation for In-patient Areas Policy	Nov-15	Nov-18
Scheme of Delegation	Dec-21	Dec-22
Standing Financial Instructions	Dec-21	Dec-22
Standing Orders	May-22	May-23
Supplier Representatives Policy	Jul-20	Jul-22
Supporting Trans Patients and Service Users	Jun-22	Jun-25
Use of Social Media Policy	Dec-16	Nov-19
Witnessing Documents for Patients Policy	Jun-21	Jun-24

Finance

Title	Last Review	Next Review
Clinical Commissioning Policy: Individual Funding Requests	Jul-20	Jul-23
Co-Payment Treatments	May-22	May-24
Counter Fraud and Corruption Policy	Apr-22	Apr-25
Fundraising Policy	Sep-22	Sep-25
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 Up and Secondment Policy	Apr-21	Apr-24
Adoption Leave and Surrogacy Policy	Jan-23	Jan-26
Alcohol and Drugs at Work Policy	Aug-22	Apr-24
Annual Leave Policy	Apr-21	Apr-24
Annual Leave Policy for Medical Staff	Dec-20	Nov-23
Appeals Procedure	Apr-21	Apr-24
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	Sep-21	Sep-24
Disciplinary Policy	Sep-21	Sep-24
Disclosure and Barring Services (DBS) Policy	Aug-22	Aug-23
Dress Code Policy (incl. Personal Hygiene)	Feb-22	Feb-25
Emergency Cover (Acting Down) Policy	Sep-22	Nov-22
Flexible Working Policy	Nov-22	Nov-25
Grievance Policy	Sep-21	Sep-24
Job Matching and Evaluation Policy	Sep-21	Sep-24
Maternity Leave and Fertility Treatment Policy	Jan-23	Jan-26
Medical Appraisal and Revalidation Policy	Dec-20	Dec-23
New Parent Leave Policy	Jan-23	Jan-26
Organisational Change Policy	Mar-18	Mar-21
Partnership and Recognition Agreement	Apr-21	Apr-24
Performance and Capability Policy	Oct-18	Oct-21
Personal and Family Relationships Policy	Aug-22	Sep-23
Recruitment and Selection Policy	Aug-21	Aug-24
Retirement Policy	Dec-22	Dec-25
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

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	Feb-22	Feb-25
Pre-Placement Policy	Jul-20	Jul-23
Upper Limb Disorder Policy	Mar-22	Mar-25

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-21	Jul-24
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	Jun-21	Jun-24
Incident Reporting Policy	Jul-20	Jul-23
Learning from Deaths Policy	Oct-17	Oct-20
Management of Violence and Aggression	Mar-16	Oct-18
Non-Clinical Claims	May-21	May-24
Prevention and Management of Adult Inpatient Falls	Apr-21	Apr-24
Risk Assessment Policy	Oct-21	Oct-24
Risk Management Policy	Sep-20	Sep-23

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	Sep-22	Sep-24
Antimicrobial Prescribing Policy	Nov-22	Nov-23
Homecare Medicine Service	Nov-22	Nov-23
Intravenous and Subcutaneous Immunoglobulin Prescribing Guidance	Jul-22	Jul-24
Lower Limb Immobilisation Venous Thromboembolism (VTE) Prevention Policy	Feb-21	Jan-23
Medicines and Vaccines Cold Storage Policy	Nov-22	Nov-23
Medicines Management Policy	Nov-22	Nov-23
Parenteral Nutrition Policy for Adults	Mar-21	Mar-24
Patient Group Direction Policy	Oct-21	Oct-24
Purchasing Medicines for Safety Policy	Nov-22	Nov-23
Self Administration Policy	Nov-22	Nov-23
Self-Prescribing and Prescribing for Family Members and Colleagues	Dec-16	Dec-18

Medical Devices

Title	Last Review	Next Review
Interventional Procedures Policy	Dec-22	Nov-25
Management of Medical Devices	Mar-22	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	May-21	May-24
Single Use, Single Patient Use, and Limited Use Medical Devices Policy	Jun-21	Jun-24

Control of Infection

Title	Last Review	Next Review
Aseptic Non-Touch Technique Policy	May-18	May-21
Carbapenemase-Producing Enterobacterales (CPE) / Carbapenem Resistant Organisms (CRO)	Dec-21	Sep-24
Central Venous Catheter Care Policy	Jan-21	Aug-23
CJD	Aug-17	Mar-20
Clostridium Difficile Diarrhoea	May-17	Nov-20
Control of Tuberculosis in Hospital	Oct-17	Oct-20
Glycopeptide Resistant Enterococci	Jan-17	Jan-20
Infection Contol input into design construction and renovation projects	Apr-16	Apr-19
Infestation Policy	Sep-16	Sep-19
Management of Diarrhoea and Vomiting	Jan-19	Jan-22
Meningococcal Disease	Jul-17	Jul-20
MRSA Policy	Sep-21	Sep-24
Multi Resistant Gram Negative Bacilli	Mar-17	Mar-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
Short Term Indwelling Urinary Catheters	Jul-19	Jul-22
Standard Infection Prevention and Control Precautions Policy	Apr-22	Apr-25
Surgical Site Infection Prevention and Treatment	Mar-22	Mar-25
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	Feb-22	Feb-25
Bereavement Office Operational Policy	Dec-21	Dec-24
Blood Transfusion Policy for Adult Patients	Aug-22	Feb-23
Blood Transfusion Policy for Neonatal and Paediatric Patients	Jun-21	Jun-24
Care of the Bereaved	Oct-20	Oct-23
Chaperoning Guidelines for Clinical Staff	Aug-22	Jul-25
Compassionate Communication Policy	May-22	May-23
Consent Policy	Sep-20	Sep-23
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
Delirium Policy	Jul-20	Jul-22
Dementia Care Policy	Nov-21	Nov-24
Discharge Lounge: Standard Operating Procedure	Sep-21	Sep-23
Early Release of the Deceased Patient out of Normal Working Hours	Jun-22	Dec-24
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	Oct-21	Oct-24
Expected Date of Discharge	May-18	May-21
Guidance for Doctors on Post Mortems	Dec-21	Dec-24
Guidelines for Parkinson's Disease	Jan-19	Jan-22
Handling Deaths at Ashford Hospital	Dec-21	Dec-24
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	Jul-22	Jul-23
Learning Disability Policy	Apr-22	Apr-25
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-22	Dec-23
Organ Donation Policy	Oct-16	Oct-19
Oxygen Policy	Aug-13	Aug-16
Patient Controlled Analgesia (PCA) Policy - Adults	Aug-22	Mar-24
Patient Controlled Analgesia (PCA) Policy - Paediatrics	Jun-22	Jun-24
Patient Identification Policy	Oct-19	Sep-21
Photographing patients	Aug-17	Aug-20
Preoperative Anaemia Pathway	Feb-23	Feb-26
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 Mental Health Inpatients	Jan-19	Jan-22
Trauma Operational Policy	Nov-22	Nov-25
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	Nov-22	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 Skin Minor Procedures Policy	Aug-21	Aug-24
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	May-22	May-23
Business Continuity Plan	Sep-22	Sep-23
Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) Plan	Dec-22	Dec-23
Communications Incident Response Plan	Oct-22	Jun-23
Counter Measures Plan	Nov-22	Nov-23
Emergency Preparedness Resilience and Response (EPRR) Framework	Jan-22	Jan-23
Evacuation Plan	Dec-22	Dec-23
Internal Incident Plan	Sep-22	Sep-23
Lockdown Plan	Jan-23	Jan-24
Major Incident Plan	Aug-22	Jun-23
Respiratory Virus Plan	Jun-22	Jun-23
Vehicle Fuel Emergency Plan	Mar-23	Mar-24
VIP Policy	Nov-22	Nov-23

Information and Technology

Title	Last Review	Next Review
Acceptable Use Policy	Jul-20	Jul-23
Confidentiality and Data Protection Policy	Apr-22	Apr-25
Data Quality Policy	Nov-20	Nov-22
Digital Backup and Restore Policy	Jun-22	Jun-25
Digital Technology Projects Policy	Apr-22	Apr-25
Email Policy	Sep-22	Jun-24
Freedom of Information (FOI) Policy	Oct-22	Sep-25
Information Governance Policy	Nov-22	Nov-23
Information Security Policy	Sep-22	Jul-24
Information Technology Change Policy	Oct-22	Oct-25
Internet Usage and Security Policy	Jan-23	Jan-26
Log Retention Policy	Jun-22	Jun-25
Microsoft Office 365 Acceptable Use Policy	Jul-21	Jul-24
Portable Computer Device Policy	Sep-22	Feb-25
Print and Fax Policy	Jan-22	Jan-25
Registration Authority (Smartcard) Policy	Jul-21	Jul-24
Remote Access Policy	Sep-22	Jan-25
Transcription Service Policy	Nov-21	Nov-24

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	Oct-22
Operational Cleaning Plan	Nov-19	Oct-22
Operational Policy Medical Gas ASPH	Jan-20	Jan-22
Strategic Cleaning Plan	Nov-19	Oct-22
Telecommunications Policy	Nov-22	Oct-23
Travel and Car Parking Policy	Sep-19	Oct-22
Water Hygiene Policy	Oct-22	Oct-25

Safeguarding

Title	Last Review	Next Review
Baby / Child (Abduction) Security Policy	Oct-22	Apr-24
Deprivation of Liberty Safeguarding Policy	Nov-21	Nov-24
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
Mental Health Act Policy	Aug-22	Nov-24
Restraint Policy for Adults and Young People	Jan-20	Nov-22
Safeguarding Adults at Risk Policy	Mar-20	Mar-23
Safeguarding Children Policy	Dec-21	Dec-24
Safeguarding Maternity Policy	Mar-20	Mar-23
Safeguarding Supervision Policy (Adults and Children)	May-22	May-25
Was Not Brought Policy	Oct-21	Oct-24