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 Jun-23 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 Mar-21 Mar-24
Handling the Media Policy Sep-20 Sep-23
Induction Policy Sep-22 Oct-22
Managing and Responding to External Agency Visits May-18 Mar-20
Managing Conflicts of Interest Policy Jun-21 Jun-23
National Guidance Monitoring Framework Dec-20 Oct-23
PAT Dogs and Assistant Dogs on Hospital Premises Jun-23 Jul-26
Policy Writing and Ratification May-18 Dec-20
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 May-22 May-23
Supplier Representatives Policy Jul-20 Jul-22
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 Jul-20 Jul-23
Co-Payment Treatments May-22 May-24
Counter Fraud and Corruption Policy Apr-22 Apr-25
Fundraising Policy Mar-23 Mar-25
Operational Protocol for Provider to Provider Contracts Sep-20 Sep-23
Overseas Visitors Policy Apr-23 Apr-26
Private Patient Services Aug-20 Aug-22
Tender and Bid Process Guidelines Apr-17 Apr-20



Title Last Review Next Review
Acting Up and Secondment Policy Apr-21 Apr-24
Adoption Leave and Surrogacy Policy Jan-23 Jan-26
Alcohol and Drugs at Work Policy Aug-22 Apr-24
Annual Leave Policy Apr-21 Apr-24
Annual Leave Policy for Medical Staff Dec-20 Nov-23
Appeals Procedure Apr-21 Apr-24
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 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 Mar-18 Mar-21
Partnership and Recognition Agreement Apr-21 Apr-24
Performance and Capability Policy Oct-18 Oct-21
Personal and Family Relationships Policy Aug-22 Sep-23
Recruitment and Selection Policy Aug-21 Aug-24
Retirement Policy Dec-22 Dec-25
Shared Parental Leave Policy Oct-20 Oct-23
Sickness Absence Policy May-20 May-23
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 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 Feb-22 Feb-25
Pre-Placement Policy Jul-20 Jul-23
Upper Limb Disorder Policy Mar-22 Mar-25


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-21 Jul-24
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 Safety Policy Jul-20 Jul-23
Handling of Clinical Negligence Claims Jun-21 Jun-24
Incident Reporting Policy Jul-20 Jul-23
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 Sep-20 Sep-23
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-22 Nov-23
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 Nov-22 Nov-23
Medicines Management Policy Nov-22 Nov-23
Parenteral Nutrition Policy for Adults Mar-21 Mar-24
Patient Group Direction Policy Oct-21 Oct-24
Purchasing Medicines for Safety Policy Nov-22 Nov-23
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
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 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
Carbapenemase Producing Enterobacteriaceae (CPE) Dec-21 Sep-24
Central Venous Catheter Care Policy Jan-21 Aug-23
CJD Aug-17 Mar-20
Clostridioides Difficile Apr-23 Apr-26
Control of Tuberculosis in Hospital Oct-17 Oct-20
Diarrhoea, Vomiting, Gastroenteritis, and Foodborne Infections Apr-23 Apr-26
Infection Contol input into design construction and renovation projects Apr-16 Apr-19
Infestation Policy Sep-16 Sep-19
Meningococcal Disease Jul-17 Jul-20
Meticillin Resistant Staphylococcus Aureus (MRSA) Policy Apr-23 Apr-26
Multi-Drug Resistant Organisms Apr-23 Apr-26
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
Short Term Indwelling Urinary Catheters Jul-19 Jul-22
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
Viral Haemorrhagic Fevers Apr-17 Dec-19


Patient Care

Title Last Review Next Review
Admission, Transfer, and Discharge of Adult Patients Policy Apr-21 Apr-24
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 Feb-22 Feb-25
Bereavement Office Operational Policy Dec-21 Dec-24
Blood Transfusion Policy for Adult Patients Apr-23 Apr-25
Blood Transfusion Policy for Neonatal and Paediatric Patients Jun-21 Jun-24
Care of the Bereaved Oct-20 Oct-23
Chaperoning Guidelines for Clinical Staff Aug-22 Jul-25
Compassionate Communication Policy May-22 May-23
Consent Policy Sep-20 Sep-23
Copying patients into clinical letters Apr-18 Feb-21
Covert Administration of Medication Policy Aug-19 Aug-22
CT scans out of hours Jan-17 Dec-20
Delirium Policy Jul-20 Jul-22
Dementia Care Policy Nov-21 Nov-24
Discharge Lounge: Standard Operating Procedure Sep-21 Sep-23
Early Release of the Deceased Patient out of Normal Working Hours Jun-22 Dec-24
Enhanced Care, Supportive Observation and Therapeutic Engagement Policy Dec-20 Dec-22
Enteral Feeding Policy for Adults Apr-21 Apr-24
Epidural Analgesia Policy Oct-21 Oct-24
Expected Date of Discharge May-18 May-21
Guidance for Doctors on Post Mortems Dec-21 Dec-24
Guidelines for Parkinson's Disease Jan-19 Jan-22
Handling Deaths at Ashford Hospital Dec-21 Dec-24
Imaging Request Protocol for Cardiology Specialist Nurses May-23 May-26
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 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
Mittens Policy May-21 May-24
Mortuary Viewing Sep-20 Sep-23
Moving and Handling Policy May-23 May-26
Nasal Bridle Policy Nov-16 Nov-18
Operational Pressures Escalation Level (OPEL) Plan Jul-23 Jun-24
Organ Donation Policy Oct-16 Oct-19
Oxygen Policy Aug-13 Aug-16
Patient Controlled Analgesia (PCA) Policy - Adults Aug-22 Mar-24
Patient Controlled Analgesia (PCA) Policy - Paediatrics Jun-22 Jun-24
Patient Identification Policy Oct-19 Sep-21
Photographing patients Aug-17 Aug-20
Preoperative Anaemia Pathway Apr-23 Dec-24
Pressure Area Management Policy Jan-19 Jan-22
Protected Mealtimes Policy Mar-14 Mar-17
Recording of Vital Signs in Adults May-23 May-26
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 Mental Health Inpatients Jan-19 Jan-22
Trauma Operational Policy Aug-23 Aug-26
Venous Thromboembolism (VTE) Prevention Policy Apr-21 Feb-22
Verification of Expected Death by Registered Healthcare Professionals Oct-20 Sep-23
Wound Care Policy May-18 May-21
X-Ray Request Policy Jun-17 Jun-20


Nursing Procedures

Title Last Review Next Review
Advanced Clinical Practice Policy Jun-23 Jun-25
Advanced / Specialist Nurse Prescribing of Blood Components Nov-22 Apr-24
Conservative Sharp Debridement of Wounds Aug-21 Aug-24
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 Skin Minor Procedures Policy Aug-21 Aug-24
Transcutaneous Electrical Nerve Stimulation (TENS) Dec-17 Nov-20


Major Incident

Title Last Review Next Review
Adverse Weather Plan May-23 May-24
Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) Plan Sep-23 Sep-24
Communications Incident Response Plan Sep-23 Sep-24
Corporate Business Continuity Plan Sep-23 Sep-23
Counter Measures Plan Nov-22 Nov-23
Emergency Preparedness Resilience and Response (EPRR) Framework Sep-23 Sep-24
Evacuation Plan Dec-22 Dec-23
Internal Incident Plan Sep-23 Sep-24
Lockdown Plan Jan-23 Jan-24
Major Incident Plan Sep-23 Sep-24
Respiratory Virus Plan Jun-22 Jun-23
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 Jul-20 Jul-23
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-22 Nov-23
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 Jul-21 Jul-24
Portable Computer Device Policy Sep-22 Feb-25
Print and Fax Policy Jan-22 Jan-25
Registration Authority (Smartcard) Policy Jul-21 Jul-24
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 Nov-19 Oct-22
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 Nov-22 Oct-23
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
Deprivation of Liberty Safeguarding Policy Nov-21 Nov-24
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
Mental Health Act Policy Aug-22 Nov-24
Restraint Policy for Adults and Young People Jan-20 Nov-22
Safeguarding Adults at Risk Policy Mar-20 Mar-23
Safeguarding Children Policy Dec-21 Dec-24
Safeguarding Maternity Policy Mar-20 Mar-23
Safeguarding Supervision Policy (Adults and Children) May-22 May-25
Was Not Brought Policy Oct-21 Oct-24


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