Policy Index by Category

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. security or staff safety issues).



Title Last Review Next Review
Being Open Policy Nov-14 May-15
Central Alert System (CAS) Policy Oct-14 Oct-17
Clinical Effectiveness and Audit Strategy 2012-2017 Apr-14 Mar-17
Clinical Procurement and Introduction of New Products Policy Aug-17 Aug-20
Committee and Group Policy Feb-14 Feb-17
Communication and Engagement Strategy 2013 - 2016 Jun-13 Jun-16
Concerns and Complaints Policy May-15 May-18
Dealing with the police and other public bodies Jun-10 Jun-13
Education, Learning, and Development Policy May-15 May-18
Freedom to Speak Up: Raising Concerns (Whistleblowing) Policy Mar-17 Mar-20
Gifts and Hospitality Policy Mar-16 Mar-19
Handling difficult or unreasonable complainants Oct-14 Oct-16
Handling the Media Policy Nov-14 Nov-16
Induction Policy Dec-10 Aug-13
Management of Complaint Files Oct-14 Sep-17
Managing and Responding to External Agency Visits Mar-13 Mar-16
National Guidance Monitoring Framework Oct-16 Oct-19
Organisational Development and Workforce Strategy 2010-2014 Jan-10 Jan-14
PALS Policy Jan-13 Dec-15
Policy Writing and Ratification Dec-13 Dec-16
Publication and Provision of Patient Information Nov-14 Nov-16
QSIA Policy Nov-16 Jun-18
Quality Safety and Risk Management Strategy Oct-12 Sep-17
Records Management Policy Nov-14 Dec-16
Register of Interests Policy Sep-14 Sep-16
Reimbursement of Expenses Dec-13 Dec-15
Remedy Policy Nov-13 Nov-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 Oct-16 Oct-17
Self Assessment against CQC Standards Jun-13 Jun-16
Standing Financial Instructions Oct-16 Oct-17
Standing Orders Mar-17 Mar-18
Supplier Representatives Policy Sep-15 Sep-17
Use of Social Media Policy Dec-16 Nov-19
Witnessing documents for patients policy Nov-14 Nov-17



Title Last Review Next Review
Business Case Financial Template Mar-16 Mar-18
Business Case Guidelines Mar-16 Mar-18
Co-Payment Treatments May-17 May-19
Counter Fraud and Corruption Policy Jan-17 Jan-18
Operating policy for dealing with individual funding requests (IFRs) Dec-15 Dec-18
Operational Protocol for Provider to Provider Contracts Mar-17 Mar-20
Overseas Visitor Policy Oct-15 Oct-17
Private Patient Services May-17 Nov-17
Tender and Bid Process Guideliness Apr-17 Apr-20



Title Last Review Next Review
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 Nov-14 Nov-17
Appraisal Policy Jul-14 Jul-17
Apprenticeship Policy Jun-16 Jun-18
Conduct, capability, Ill health and appeals policies and procedures for practitioners (doctors and dentists) Nov-17 Sep-20
Dignity at Work Nov-14 Nov-17
Disciplinary Policy Jan-17 May-20
Disclosure and Barring Services (DBS) Policy Nov-14 Nov-17
Dress Code Policy Nov-14 Nov-17
Gender Reassignment Policy Oct-14 Oct-17
Grievance Policy Oct-14 Oct-17
Honorary Contracts Policy Nov-14 Nov-17
Management of Violence and Aggression Mar-16 Oct-18
Maternity, Adoption, Paternity, Parental and Fertility Treatment Leave Policy Oct-15 May-17
Medical Appraisal and Revalidation Policy Mar-17 Mar-20
Organisational Change Policy Nov-14 Nov-17
Partnership and Recognition Agreement Sep-17 Sep-20
Pay Policy for Non-Medical Staff Oct-14 Oct-17
Performance and Capability Policy Nov-14 Nov-17
Professional Registration Policy Nov-14 Nov-17
Recruitment and Selection Policy Nov-14 Nov-16
Retirement Policy Nov-14 Nov-17
Sickness Absence Policy Jan-17 Jan-19
Temporary Staffing Policy Jun-12 Sep-13
Use of volunteers Nov-14 Nov-16
Whistle Blowing Policy Apr-14 Apr-17
Work Experience, Work Shadowing and Work Placement Policy Jan-18 Nov-20
Work Life Balance Policy Dec-12 Sep-15


Occupational Health

Title Last Review Next Review
First Aid Policy Dec-16 Dec-19
Health Surveillance Policy Apr-16 Apr-19
Inoculation Injury Policy Mar-16 Mar-19
Management and Reduction of Stress Policy Oct-16 Oct-18
Management of Infected Health Care Workers with BBV EPP Oct-14 Oct-17
Medication and Vaccination Policy Jun-17 Jan-20
Pre-Placement Policy Nov-16 Nov-19
Upper Limb Disorder Policy Apr-16 Mar-19


Health and Safety

Title Last Review Next Review
Control of Substances Hazardous to Health Jun-16 Oct-18
Display Screen Equipment Oct-15 Oct-18
Health and Safety Policy Oct-15 Oct-18
Latex Policy Jul-14 Nov-16
Lone Worker Policy Jul-15 Jul-18
Smoke Free Site Policy Feb-14 Feb-17
Slips, Trips and Falls (Non Patient) Policy Oct-15 Oct-18



Title Last Review Next Review
Fire Policy Mar-17 Mar-19
Handling of Clinical Negligence Claims Feb-14 Feb-17
Incident Reporting Policy Mar-14 Mar-17
Inpatient Falls Policy Jun-16 Nov-17
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 Aug-14 Oct-16
Security Policy Oct-16 Oct-18



Title Last Review Next Review
Administration of Injectable Medicines Policy Mar-17 Dec-20
Administration of Naloxone in Adults Mar-17 Mar-19
Homecare Medicine Service Aug-17 Aug-19
Immunoglobulin Policy Sep-16 Sep-18
Lower Limb Immobilisation Venous Thromboembolism (VTE) Prevention Policy Oct-17 Oct-18
Medicines Management Policy Mar-17 Mar-19
Non Medical Prescribing Policy Aug-16 Jan-18
Parental Nutrition Policy for Adults Jun-16 Jun-18
Self-Prescribing and Prescribing for Family Members and Colleagues Dec-16 Dec-18
Vaccines and Medicines Cold Storage Policy May-17 May-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 16 Feb 19
Medical Devices Training for Clinical Staff Feb-17 Feb-20
Point of Care Testing Policy Apr 15 Apr 18
Single use, single patient use and limited use medical devices policy Oct 12 Aug 15


Control of Infection

Title Last Review Next Review
Admission, Transfer and Discharge Policy for the Infected Patient Oct-17 Oct-19
Aseptic Technique Policy Jul-16 Jul-18
Blood Culture Policy for Adults Jun-16 Jun-18
Carbapenemase Producing Enterobacteriaceae (CPE) May-16 May-18
Care of tunnelled central venous access devices (HICC) May-16 May-18
Central Venous Catheter Care Policy Aug-15 Aug-17
CJD Aug-17 Mar-19
Cleaning and Disinfection Policy Aug-17 Aug-19
Clostridium Difficile Diarrhoea May-17 Nov-19
Control of Tuberculosis in Hospital Aug-15 Aug-17
Elective Joint Replacement Urinalysis Pre-operative Assessment Policy Aug-16 Aug-17
Glove Policy Apr-16 Apr-18
Glycopeptide Resistant Enterococci Jan-17 Jan-19
Hand Hygiene Policy for Healthcare Workers Aug-17 May-19
Infection Contol input into design construction and renovation projects Apr-16 Apr-18
Infestation Policy Sep-16 Sep-19
Introduction to Infection Prevention Control Apr-16 Apr-18
Isolation Policy Dec-16 Sep-18
Last Offices for the Infectious Adult Patient Apr-16 Apr-18
Linen Policy Apr-16 Apr-18
Management of Diarrhoea and Vomiting Apr-16 Apr-18
Meningococcal Disease Jul-17 Jul-19
MRSA Policy Aug-17 Aug-19
Multi Resistant Gram Negative Bacilli Mar-17 Mar-19
Notification of Infectious Diseases Policy May-17 May-19
Outbreak Policy Dec-16 Dec-18
Peripherally Inserted Central Line (PICC) Care Policy Apr-16 Apr-18
Peripheral Venous Catheter Care Policy for Adults Apr-16 Apr-18
Respiratory Viruses Policy Nov-15 Nov-17
Safe Handling and Disposal of Sharps Apr-16 Apr-18
Short Term Indwelling Urinary Catheters Apr-16 Apr-18
Spillage of Blood and Body Fluids Apr-16 Apr-18
Standard Precautions Policy Apr-16 Apr-18
Surgical Site Infection Prevention Treatment Apr-16 Apr-18
Viral Haemorrhagic Fevers Apr-17 Dec-18


Patient Care

Title Last Review Next Review
Admissions Policy, Procedure and Guidelines Nov-14 Nov-16
Advance Decisions Policy Mar-14 Nov-16
Anticipatory Prescribing Guidelines Mar-17 Mar-19
Back Pain Guidelines and Algorithm Jan-14 Dec-16
Bedrails Policy Apr-16 Nov-17
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 Co-ordination and Key Worker Guidelines Jun-12 Apr-14
Care of Patients requiring Close Observation Apr-14 Apr-17
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 Dec-16 Dec-19
Copying patients into clinical letters Feb-14 Feb-17
CT scans out of hours Jan-17 Dec-20
Decisions relating to Cardiopulmonary Resuscitation Policy Jan-15 Dec-17
Deprivation of Liberty Safeguarding Policy Feb-14 Feb-17
Discharge Policy for Adults (and Referral Guidelines) Jul-13 Jul-16
Discharge Protocol Nov-13 Jul-16
Early Release of the Deceased Patient out of Normal Working Hours Mar-17 Mar-20
Enteral Feeding Policy for Adults Feb-15 Jan-18
Epidural Analgesia Policy Nov-17 Nov-20
Expected Date of Discharge Sep-13 Sep-16
Guidance for Doctors on Post Mortems Mar-17 Mar-19
Guidelines for Parkinson's Disease Nov-14 Nov-17
Handling Deaths at Ashford Hospital Jul-17 Jul-20
IMCA Service Policy Nov-13 Nov-16
Intermittent Boluses and Continuous Infusions of Local Anaesthetics for Acute Pain Management in Adults Mar-16 Mar-18
Interpreting Service Oct-13 Oct-15
Joint Access Policy May-17 Apr-18
Mental Capacity Policy Nov-13 Nov-16
Missing Patient policy Jun-12 Jun-14
Mittens Policy Mar-17 Mar-20
Mortuary Viewing Jan-14 Jan-17
Moving and Handling Policy Jan-17 Aug-18
Nasal Bridle Policy Nov-16 Nov-18
Organ Donation Policy Oct-16 Oct-19
Oxygen Policy Aug-13 Aug-16
Patient Controlled Analgesia (PCA) Policy Mar-17 Mar-19
Patient Flow and Escalation Plan Nov-14 Jul-17
Patient Identification Policy Oct-13 Oct-15
Photographing patients Aug-17 Aug-20
Pressure Ulcer Policy Jul-13 Jul-16
Protected Mealtimes Policy Mar-14 Mar-17
Purchasing Medicines for Safety Policy Nov-14 Mar-16
Recognition of and Response to Acutely Ill Adult Patients in Ward Environments Oct-14 Apr-15
Resuscitation Policy Jul-16 Jul-18
Safeguarding Adults at Risk Policy May-17 May-20
Safeguarding Children Policy Oct-14 Oct-17
Sampling of an arterial blood gas Jan-14 Jan-17
Supporting people with learning disabilities Oct-13 Oct-16
Tissue Donation Policy Jul-13 Jul-16
Transfer of Adult Patients (excluding Maternity) Dec-14 Nov-17
Transfer of Mental Health Inpatients Jan-14 Jan-17
Trauma Operational Policy Jun-17 Jun-20
Venous Thromboembolism (VTE) Prevention Policy Oct-16 Oct-18
Verification of Expected Death by Registered Healthcare Professionals Nov-16 Nov-19
VitalPAC Operational Policy Sep-16 Aug-18
X-Ray Request Policy Jun-17 Jun-20


Nursing Procedures

Title Last Review Next Review
Advanced / Specialist Nurse Prescribing of Blood Components Jun-16 Jun-19
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 Aug-14 Aug-17
Transcutaneous Electrical Nerve Stimulation (TENS) Dec-17 Nov-20
Visual Acuity Mar-16 Mar-19


Major Incident

Title Last Review Next Review
Adverse Weather Plan Dec-17 Dec-18
Business Continuity Plan Nov-16 Nov-17
Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) Plan Jan-18 Jan-20
Emergency Preparedness Resilience and Response (EPRR) Framework Nov-17 Nov-18
Evacuation Plan Mar-16 Mar-17
Flu Pandemic Plan Dec-17 Dec-18
Internal Incident Plan Nov-16 Nov-17
Lockdown Plan Mar-16 Mar-17
Major Incident Communication Plan Dec-16 Dec-17
Major Incident Plan Nov-17 Nov-18
Vehicle Fuel Emergency Plan Feb-16 Feb-18
VIP Policy Mar-17 Mar-19


Information and Technology

Title Last Review Next Review
Confidentiality Policy Jan-14 Jan-17
Data Quality Policy Mar-16 Mar-18
Dictate IT Transcription Service Policy Oct 15 Dec 16
Email Policy Jul-17 Jul-20
Freedom of Information (FOI) Policy Feb-17 Feb-20
Information Governance Policy Nov-17 Nov-18
Information Security Policy Nov 14 Nov 17
Internet Usage and Security Policy Dec 15 Dec 18
IT Projects Policy Jul 17 Jul 20
Portable computer device policy Dec 15 Dec 18
Print and Fax Policy Oct 17 Oct 20
Registration Authority (Smartcard) Policy Feb 15 Feb 18
Remote Access Policy Dec 15 Dec 18


Facilities and Estates

Title Last Review Next Review
Catering Ward Provisions and Hospitality Services Policy Mar-16 Mar-18
Decontamination Policy Dec-16 Oct-19
Estates Operational Policy May-16 May-17
Management of Healthcare Waste Dec-17 Dec-19
Operational Cleaning Plan Aug-17 Aug-19
Operational Policy Medical Gas Ashford Apr-16 Apr-18
Operational Policy Medical Gas St Peter's Apr-16 Apr-18
Strategic Cleaning Plan Sep-17 Sep-19
Telecommunications Policy Oct-14 Oct-16
Travel and Car Parking Policy Mar-17 Mar-19