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Two clinical staff

Ashford and St. Peter’s Hospitals NHS Foundation Trust maintains policies and procedures for all departments and wards to guide their operational duties.

In this section, we have reproduced the index online with links to each of the documents.

Please note that we regularly review of all our documents and shall replace those that are in need of updating as soon as is possible. Documents have been written for the purpose of informing staff and are being publicly disclosed without amendment. If you have any comments or issues with regard to the information, please contact us to remedy the situation. All materials are copyrighted by the Trust and non personal use or reproduction is not permitted without prior permission.

If you require clinical guidelines or other documentation that is not published on this website, please make an FOI request and we shall provide this material within the terms of the legislation.

Exempt Policies

Under the Freedom of Information Act, we have excluded any materials of a commercially sensitive or confidential nature (listed below).

The policies that are used in the Trust but not available for public release include:

  • Central Alert System (CAS) Policy
  • OD and Workforce Strategy
  • Business Case Guidelines
  • Fraud Managment Policy
  • Overseas Visitors Policy
  • Funding Requests Policy
  • Honorary Contracts Policy
  • Fire Policy
  • Patient's Property Policy
  • Security Policy
  • Administration of Injectable Medicines
  • Chemotherapy Protocol
  • Doctors Own Prescribing
  • Medicines Management Policy
  • Vaccines and Medicines Cold Storage Policy
  • Short Term Indwelling Urinary Catheters
  • Discharge Protocol
  • Handling Deaths at Ashford
  • Mortuary Viewing
  • Patient Identification Policy
  • Care of Patients requiring Close Observation
  • Epidural Analgesia Policy
  • Patient Controlled Analgesia Policy
  • Procedure for Nurse Checking and Issuing TTOs
  • Information Security Policy


We do not routinely publish our medical policies, clinical guidelines, competencies, or care plans. These can be requested under the FOI Act but we would restrict further publication on this site due to their sensitive nature.


Due to the security aspects of our Major Incident and emergency plans, they shall not be released to the public:

  • Business Continuity Plan
  • CBRN Plan
  • Cold Weather Plan
  • Evacuation Plan
  • Flu Pandemic Plan
  • Heatwave Plan
  • Internal Incident Plan
  • Major Incident Plan
  • Snow Plan
  • Vehicle Fuel Emergency Plan