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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 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-10 Jun-13
Education, Learning, and Development Policy Mar-20 Apr-23
Freedom to Speak Up: Raising Concerns (Whistleblowing) Policy Mar-21 Mar-24
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 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
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
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 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 Dec-20 Nov-23
Appeals Procedure Oct-17 Oct-20
Appraisal Policy Oct-20 Oct-22
Apprenticeship Policy Mar-21 Mar-22
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) 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
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 Dec-20 Dec-23
New Parent Leave Policy May-19 May-22
Organisational Change Policy Mar-18 Mar-21
Partnership and Recognition Agreement May-21 May-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 Nov-14 Nov-16
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
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 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



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
Learning from Deaths Policy Oct-17 Oct-20
Non-Clinical Claims Nov-13 Nov-16
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



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



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
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-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 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 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
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 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
Admissions Policy, Procedure and Guidelines May-18 May-21
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 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 Oct-20 Oct-23
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 Feb-20 Feb-22
Discharge Policy for Adults (and Referral Guidelines) Jul-13 Jul-16
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 Jan-21 Jan-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 Feb-17 Feb-20
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
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
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