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
Central Alert System (CAS) Policy Apr-20 Apr-23
Clinical Procurement and Introduction of New Products Policy Jun-24 Jun-27
Complaints, Concerns, Patient Advice and Liaison Service (PALS), Compliments and Remedy Policy Jun-24 Jun-26
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 Nov-23 Nov-26
Handling the Media Policy Sep-20 Sep-23
Induction Policy Sep-22 Oct-22
Managing Conflicts of Interest Policy Jun-21 Jun-23
National Guidance Monitoring Nov-23 Nov-26
PAT Dogs and Assistant Dogs on Hospital Premises Jun-23 Jul-26
Patient Safety Incident Response Policy (PSIRF) Apr-24 Apr-26
Policy Writing and Ratification May-18 Dec-20
Preceptorship Policy for Newly Registered Practitioners Mar-24 Apr-27
Publication and Provision of Patient Information Nov-14 Nov-16
QSIA Policy Sep-22 Sep-25
Records Management Policy Nov-22 Nov-25
Rostering Policy Apr-23 Apr-24
Safe Staffing Policy (Nursing and Midwifery) Apr-23 Apr-26
Scheme of Delegation Feb-23 Feb-24
Standing Financial Instructions Feb-23 Feb-24
Standing Orders Jun-23 Jun-24
Supplier Representatives Policy Jun-24 Jun-26
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



Title Last Review Next Review
Clinical Commissioning Policy: Individual Funding Requests Feb-24 Feb-27
Co-Payment Treatments Jun-24 Jun-27
Counter Fraud and Corruption Policy Apr-22 Apr-25
Fundraising Policy Mar-23 Mar-25
Operational Protocol for Provider to Provider Contracts Nov-23 Nov-26
Overseas Visitors Policy Apr-23 Apr-26
Private Patient Services Aug-20 Aug-22
Tender and Bid Process Guidelines Nov-23 Nov-26



Title Last Review Next Review
Acting Up and Secondment Policy Jun-24 Oct-24
Adoption Leave and Surrogacy Policy Jan-23 Jan-26
Alcohol and Drugs at Work Policy Jun-24 Oct-24
Annual Leave Policy Jun-24 Oct-24
Annual Leave Policy for Medical Staff Dec-20 Nov-23
Appeals Procedure Jun-24 Jun-27
Career Break Policy Jun-24 Oct-24
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 Jun-24 Jun-27
Partnership and Recognition Agreement Apr-21 Apr-24
Performance and Capability Policy Jun-24 Oct-24
Personal and Family Relationships Policy Jun-24 Oct-24
Recruitment and Selection Policy Aug-21 Aug-24
Retirement Policy Dec-22 Dec-25
Shared Parental Leave Policy Jul-23 Jul-26
Sickness Absence Policy Jun-24 Oct-24
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 Dec-23 Dec-26
First Aid Policy May-23 Jun-26
Management and Reduction of Stress Policy Dec-20 Dec-23
Management of Body Fluid Exposure (BFE) Policy Dec-23 Dec-26
Medication and Vaccination Policy Feb-22 Feb-25
Pre-Placement Policy Nov-23 Nov-26
Upper Limb Disorder Policy Mar-22 Mar-25


Health and Safety

Title Last Review Next Review
Control of Substances Hazardous to Health (COSHH) Jun-24 Jun-27
Display Screen Equipment Oct-19 Oct-22
Health and Safety Policy Jul-20 Jul-23
Latex Management Policy Jun-24 Jun-27
Lone Worker Policy Jul-21 Jul-24
Slips, Trips and Falls (Non Patient) Policy Oct-19 Oct-22
Smoke and Vape Free Site Policy Jun-24 May-27



Title Last Review Next Review
Fire Safety Policy Jul-20 Jul-23
Handling of Clinical Negligence Claims Jun-21 Jun-24
Learning from Deaths Policy Jul-23 Nov-24
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 Mar-24 Mar-27
Violence and Aggression Policy Aug-23 Aug-26



Title Last Review Next Review
Patient’s Property Policy Oct-18 Oct-21
Security Policy Jan-21 Jan-24



Title Last Review Next Review
Administration of Injectable Medicines Policy by Intravenous Route Aug-23 Aug-26
Administration of Naloxone in Adults Sep-22 Sep-24
Antimicrobial Prescribing Policy Nov-23 Nov-26
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 Apr-24 Apr-27
Medicines Management Policy Nov-22 Nov-23
Non-Medical Prescribing Policy Jun-23 Jun-26
Parenteral Nutrition Policy for Adults Mar-21 Mar-24
Patient Group Direction Policy Oct-21 Oct-24
Purchasing Medicines for Safety Policy Jan-24 Jan-26
Rapid Tranquilisation Policy Jan-24 Jan-26
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 Jun-23 Jun-24
Medical Devices Training for Clinical Staff Feb-20 Feb-23
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 Apr-23 Apr-26
Central Venous Catheter Care Policy Jan-21 Aug-23
Clostridioides Difficile Apr-23 Apr-26
Diarrhoea, Vomiting, Gastroenteritis, and Foodborne Infections Apr-23 Apr-26
Infection Prevention and Control In the Built Environment Dec-23 Dec-26
Meticillin Resistant Staphylococcus Aureus (MRSA) Policy Apr-23 Apr-26
Multi-Drug Resistant Organisms Apr-23 Apr-26
Outbreak Policy Dec-23 Dec-26
Peripherally Inserted Central Line (PICC) Care Guidelines Oct-20 Oct-23
Peripheral Venous Catheter Care Policy for Adults Dec-23 Dec-26
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


Patient Care

Title Last Review Next Review
Accessible Information Standard and Interpretation Policy Mar-24 Mar-26
Admission, Transfer, and Discharge of Adult Patients Policy Apr-21 Apr-24
Blood Transfusion Policy for Adult Patients Apr-23 Apr-25
Blood Transfusion Policy for Neonatal and Paediatric Patients Mar-24 Mar-27
Care of the Bereaved Oct-20 Oct-23
Chaperoning Guidelines for Clinical Staff Aug-22 Jul-25
Compassionate Communication Policy May-22 May-23
Copying patients into clinical letters Apr-18 Feb-21
Covert Administration of Medication Policy Mar-24 Mar-27
Delirium Policy Mar-24 Mar-27
Dementia Care Policy Nov-21 Nov-24
Early Release of the Deceased Patient out of Normal Working Hours Jun-22 Dec-24
Enteral Feeding Policy for Adults Apr-21 Apr-24
Handling Deaths at Ashford Hospital Dec-21 Dec-24
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
Moving and Handling Policy May-23 May-26
Nasogastric and Orogastric Feeding Tubes (Adult) Oct-23 Oct-26
Operational Pressures Escalation Level (OPEL) Plan Jan-24 Jan-25
Organ Donation Policy Jun-24 Jun-27
Oxygen Policy Aug-13 Aug-16
Patient Consent Policy Mar-24 Mar-27
Patient Identification Policy Oct-19 Sep-21
Pressure Area Management Policy Jan-24 Jun-24
Recording of Vital Signs in Adults Jan-24 Jan-27
Resuscitation Policy Apr-24 Apr-26
Safe Handover Nursing SOP Mar-24 Feb-25
Supportive Observation Policy Dec-23 Dec-26
Trauma Operational Policy Aug-23 Aug-26
Venous Thromboembolism (VTE) Prevention Policy Mar-24 Mar-26
Verification of Expected Death by Registered Healthcare Professionals Jun-24 Jun-27
Wound Care Policy May-18 May-21


Nursing Procedures

Title Last Review Next Review
Advanced Clinical Practice Policy Jun-23 Jun-25
Nurse Checking and Issuing of Discharge Medication (TTO) Policy May-18 May-21
Nurse-Led Skin Minor Procedures Policy Aug-21 Aug-24


Major Incident

Title Last Review Next Review
Adverse Weather Plan Apr-24 May-25
Business Continuity Plan / Critical Incident Plan Feb-24 Feb-25
Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) Plan Sep-23 Sep-24
Communications Incident Response Plan Sep-23 Sep-24
Counter Measures Plan May-24 May-26
Emergency Preparedness Resilience and Response (EPRR) Framework Sep-23 Sep-24
Evacuation Plan Dec-22 Dec-23
Lockdown Plan Jun-24 Jun-25
Major Incident Plan Sep-23 Sep-24
Respiratory Viruses Infection Prevention and Control Policy Dec-23 Dec-25
Vehicle Fuel Emergency Plan Mar-23 Mar-24
VIP Policy Sep-23 Sep-26


Information and Technology

Title Last Review Next Review
Acceptable Use Policy Dec-23 Jul-26
Confidentiality and Data Protection Policy Apr-22 Apr-25
Data Quality Policy Apr-23 Apr-26
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-23 Nov-24
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 Dec-23 Dec-26
Portable Computer Device Policy Sep-22 Feb-25
Print and Fax Policy Jan-22 Jan-25
Registration Authority (Smartcard) Policy Dec-23 Dec-26
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 Oct-22 Oct-25
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 Oct-23 Apr-25
Travel and Car Parking Policy Sep-19 Oct-22
Water Hygiene Policy Oct-22 Oct-25



Title Last Review Next Review
Baby / Child (Abduction) Security Policy Oct-22 Apr-24
De-Escalation, Clinical Holding, and Restraint Policy for Adults and Young People Mar-24 Mar-27
Deprivation of Liberty Safeguarding Policy Nov-21 Nov-24
Did Not Attend (DNA) for Adults at Risk Sep-23 Sep-26
Domestic Abuse Policy Dec-23 Dec-26
Domestic Abuse Policy (Workforce) Dec-23 Dec-26
Female Genital Mutilation (FGM) Policy Jun-20 Jun-23
Maternity Safeguarding Policy Sep-23 Sep-26
Mental Capacity Act Policy Apr-24 May-27
Mental Health Act Policy Jul-24 Nov-24
Safeguarding Adults at Risk Policy Sep-23 Sep-26
Safeguarding Children Policy Dec-21 Dec-24
Safeguarding Supervision Policy (Adults and Children) May-22 May-25
Was Not Brought Policy Oct-21 Oct-24


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