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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 Apr-20 Apr-23
Clinical Procurement and Introduction of New Products Policy Aug-17 Aug-20
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-10 Jun-13
Education, Learning, and Development Policy Mar-20 Apr-23
Freedom to Speak Up: Raising Concerns (Whistleblowing) Policy Mar-17 Mar-20
Gifts and Hospitality Policy Mar-16 Mar-19
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
National Guidance Monitoring Framework Oct-16 Oct-19
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
Register of Interests Policy Sep-14 Sep-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 Jul-20 Jul-21
Self Assessment against CQC Standards Jun-13 Jun-16
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



Title Last Review Next Review
Co-Payment Treatments Mar-20 Mar-22
Counter Fraud and Corruption Policy Apr-20 Apr-21
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 Aug-20 Aug-22
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 Oct-20 Oct-22
Apprenticeship Policy Mar-20 Mar-21
Buying and Selling Annual Leave Scheme Jan-20 Jan-21
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 Mar-20 Mar-21
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 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 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
Personal and Family Relationships Policy Sep-19 Sep-22
Professional Registration Policy Mar-20 Mar-21
Recruitment and Selection Policy Nov-14 Nov-16
Retirement Policy Feb-19 Feb-22
Sickness Absence Policy May-20 May-23
Special Leave Policy May-19 May-22
Temporary Staffing Policy Oct-18 Oct-21
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 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 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



Title Last Review Next Review
Fire Policy Jul-20 Jul-23
Handling of Clinical Negligence Claims Feb-14 Feb-17
Incident Reporting Policy Jul-20 Jul-23
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 Jul-20 Jul-22



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 Mar-20 Mar-22
Immunoglobulin Policy Sep-16 Sep-18
Lower Limb Immobilisation Venous Thromboembolism (VTE) Prevention Policy Oct-17 Oct-18
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
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 Oct-19 Oct-22
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-20 Mar-23
Autonomic Dysreflexia - Guidance on Safe Management of Bladder and Bowel Care Procedure Jan-20 Jan-22
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 the Bereaved Aug 13 Mar 16
Chaperoning Guidelines for Clinical Staff Aug-17 Mar-20
Communicating Significant News Aug-13 Mar-16
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 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
Enhanced Care, Supportive Observation and Therapeutic Engagement Policy Feb-20 Feb-23
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 Jun-20 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 Jun-12 Jun-14
Mittens Policy Mar-17 Mar-20
Mortuary Viewing Sep-20 Sep-23
Moving and Handling Policy Jun-20 Jun-23
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-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) 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-20 Feb-22
Verification of Expected Death by Registered Healthcare Professionals Oct-20 Sep-23
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 Oct-20 Oct-21
Business Continuity Plan Dec-19 Dec-20
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 Sep-20 Sep-21
Evacuation Plan Jun-18 Jun-20
Flu Plan Dec-18 Dec-19
Internal Incident Plan Oct-20 Oct-21
Lockdown Plan Oct-20 Oct-21
Major Incident Plan Nov-19 Nov-20
Vehicle Fuel Emergency Plan Jul-20 Jul-21
VIP Policy Jul-20 Jul-21


Information and Technology

Title Last Review Next Review
Confidentiality Policy Feb-19 Mar-22
Data Quality Policy Mar-20 Mar-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 Jul-23
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 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



Title Last Review Next Review
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 Policy Mar-18 Nov-20
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