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Policy Index
Trust Documentation by Category
Written by FOI Lead   

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).


Organisational
 

Title Last Review Next Review
Access Policy Aug-11 Aug-12
Being Open Policy Jan-11 Jan-14
Central Alert System (CAS) Policy Sep-11 Aug-14
Clinical Effectiveness and Audit Strategy 2010-2012 Nov-10 Nov-12
Committee and Group Policy Jan-12 Jan-14
Communication and Engagement Strategy 2010-2013 Feb-10 Feb-13
Complaints Procedure Jan-13 Feb-16
Confidentiality Policy Mar-10 Feb-13
Dealing with the police and other public bodies Jun-10 Jun-13
Gifts and Hospitality Policy Jan-12 Jan-15
Handling difficult or unreasonable complainants Apr-12 Mar-14
Handling the Media Policy Jan-10 Jan-13
Independent Mental Capacity Advocate (IMCA) Service Aug-11 Aug-13
Induction Policy Dec-10 Aug-13
Learning, Education and Development Policy Jun-11 Aug-12
Management of Complaint Files Apr-12 Apr-14
National Guidance Monitoring Framework Nov-10 Nov-12
Organisational Development and Workforce Strategy 2010-2014 Jan-10 Jan-14
PALS Policy Jan-13 Dec-15
Policy Writing and Ratification Dec-10 Dec-13
Publication and Provision of Patient Information Dec-10 Dec-13
Quality Safety and Risk Management Strategy Oct-12 Sep-17
Recognition Agreement Oct-10 Oct-12
Records Management Policy Dec-10 Dec-13
Register of Interests Policy Jun-12 Jun-14
Reimbursement of Expenses Mar-10 Mar-13
Remedy Policy Aug-11 Aug-13
Retention of radiology transitory record Mar-10 Mar-13
Scheme of Delegation Aug-12 Aug-13
Standing Financial Instructions Aug-12 Aug-13
Standing Orders Nov-11 Nov-12
Witnessing documents for patients policy Aug-09 Aug-12



Finance
 

Title Last Review Next Review
Business Case Financial Template Apr-11 Jun-12
Business Case Guidelines Apr-11 Jun-12
Co-Payment Treatments Jun-12 Jun-14
Fraud Management Policy & Response Plan 2012/13 May-13 May-14
Policy and operating procedures for dealing with individual funding requests Apr-11 Oct-11



Employment
 

Title Last Review Next Review
Annual Leave Policy May-10 May-13
Appeals Procedure Mar-10 Mar-13
Appraisal Policy Oct-12 Sep-13
Conduct, capability, Ill health and appeals policies and procedures for practitioners (doctors and dentists) May-05 Apr-13
Criminal Records Bureau (CRB) Policy Jun-10 Jun-13
Dignity at Work Oct-10 Oct-12
Disciplinary Policy Dec-11 Dec-14
Dress Code Policy Dec-12 Oct-14
Gender Reassignment Policy May-10 May-13
Grievance Policy Jul-11 Aug-14
Honorary Contracts Policy Mar-10 Mar-13
Management of Violence and Aggression Oct-12 Oct-15
Maternity, Adoption, Paternity, Parental and Fertility Treatment Leave Policy Nov-10 Apr-13
Organisational Change Policy Jul-10 Jul-13
Pay Policy for Non-Medical Staff Jan-11 Jan-13
Performance and Capability Policy Mar-09 Mar-12
Professional Registration Policy Sep-12 Sep-14
Recruitment and Selection Policy Aug-12 Aug-15
Retirement Policy Dec-12 Oct-14
Sickness Absence Policy Dec-10 Nov-13
Single Equality Scheme Jan-12 Jan-13
Temporary Staffing Policy Jun-12 Sep-13
Use of volunteers Sep-11 Sep-14
Whistle Blowing Policy May-11 Mar-13
Work Experience, Work Shadowing and Work Placement Policy May-10 May-13
Work Life Balance Policy Dec-12 Sep-15



Occupational Health
 

Title Last Review Next Review
First Aid Policy Nov-10 Nov-12
Health Surveillance Policy Jan-13 Jan-16
Hepatitis B Infected Health Care Workers May-11 May-14
Hepatitis C Infected Health Care Workers May-11 May-14
Management and Reduction of Stress Policy Jan-13 Oct-14
Inoculation Injury Policy Oct-11 Oct-13
Management of AIDS / HIV infected Health Care Workers May-11 May-14
Medication and Vaccination Policy Nov-11 Nov-13
Pre Employment Policy Jul-10 Jul-13
Upper limb disorder Oct-10 Oct-13



Risk Management
 

Title Last Review Next Review
Control of Substances Hazardous to Health Oct-12 Oct-15
Display Screen Equipment Oct-12 Oct-15
Health and Safety Policy Oct-12 Oct-15
Latex Policy Jul-12 Jul-14
Lone Worker Policy Jul-12 Jul-15
Smoke Free Site Policy Dec-10 Dec-13
Slips, Trips and Falls (Non Patient) Policy Dec-10 Oct-12



Risk
 

Title Last Review Next Review
Fire Policy Oct-12 Oct-14
Handling of Clinical Negligence Claims Oct-10 Oct-12
Incident Reporting Policy Dec-10 Nov-12
Non-Clinical Claims Dec-10 Oct-12
Patient Falls Policy Jan-12 Jan-13
Risk Assessment Policy Jun-12 Jun-14



Security
 

Title Last Review Next Review
Patient’s Property Policy Jan-10 Jan-12
Security Policy Dec-10 Oct-12



Waste Disposal
 

Title Last Review Next Review
Management of Healthcare Waste Mar-11 Dec-13



Medicines
 

Title Last Review Next Review
Administration of Injectable Medicines Policy Apr-10 Apr-13
Chemotherapy Protocol 2011 2012
Medicines Management Policy Dec-10 Nov-12
Policy for Self-Medication by Doctors Jan-08 Apr-13
Vaccines and Medicines Cold Storage Policy Feb-13 Feb-15



Medical Devices
 

Title Last Review Next Review
Interventional Procedures Policy Oct 10 Oct 12
Management, use and disposal of medical devices Dec 10 Oct 13
Mattress Audit Policy Jan 13 Jan 15
Medical Devices Training for Clinical Staff Jan 11 Dec 14
Point of Care Testing Policy Jan 09 Jan 10
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 of Infected Patient Policy Aig-12 Aug-14
Aseptic Technique Policy Mar-12 Mar-14
Blood Culture Policy for Adults Jul-12 Jul-14
Care of Centrally Placed Vascular Access Devices in Adults Dec-11 Jun-13
CJD Mar-12 Mar-14
Cleaning and Disinfection Policy Aug-12 Aug-14
Clostridium Difficile Diarrhoea Mar-12 Mar-14
Control of Tuberculosis in Hospital Aug-11 Aug-13
Glove Policy Mar-12 Mar-14
Glycopeptide Resistant Enterococci Mar-12 Mar-14
Hand Hygiene Policy for Healthcare Workers Feb-13 Feb-15
IC input into design construction and renovation projects Mar-12 Mar-14
Introduction to Infection Prevention Control Jun-12 Jun-14
Infestation Policy Jul-12 Jul-14
Isolation Policy Jul-12 Jul-14
Last Offices for the Infectious Adult Patient Mar-12 Mar-14
Linen Policy Mar-12 Mar-14
Management of Diarrhoea and Vomiting Mar-12 Mar-14
Meningococcal Disease Mar-12 Mar-14
MRSA Policy Jun-12 Jun-14
Multi Resistant Gram Negative Bacilli Mar-12 Mar-14
Outbreak Policy Jul-12 Jul-14
Peripheral Venous Catheter Care Policy for Adults Mar-12 Mar-14
Safe Handling and Disposal of Sharps Mar-12 Mar-14
Screening Policy for MRSA Aug-12 Aug-14
Short Term Indwelling Urinary Catheters Mar-12 Mar-14
Spillage of Blood and Body Fluids Mar-12 Mar-14
Standard Precautions Policy Mar-12 Mar-14
Surgical Site Infection Prevention Treatment Mar-12 Mar-14
Viral Haemorrhagic Fevers Jul-12 Jul-14



Patient Care
 

Title Last Review Next Review
Administration of blood and blood products Oct-12 May-14
Admissions Policy, Procedure and Guidelines Jun-05 Jun-07
Adult Parental Nutrition Policy Nov-11 Nov-12
Advance decision to refuse treatment - Guidance for staff Nov-10 Nov-13
Assessing a Patient's Mental Capacity to make Decisions Nov-10 Nov-13
Bedrails Policy Aug-11 Aug-13
Bereavement Office Operational Policy Apr-11 Apr-13
Care of the Bereaved Dec-10 Nov-12
Chaperoning Guidelines for Clinical Staff Jan-12 Dec-12
Cleaning and dressing a tracheostomy stoma site for adults May-06 May-07
Communicating Significant News Mar-10 Mar-13
Consent Policy May-10 Aug-13
Contacting a Hospital Chaplain or Religious Leader May-06 May-08
Copying patients into clinical letters Mar-09 Apr-11
CT scans out of hours Jul-02 Jul-04
Discharge Policy for Adults (and Referral Guidelines) Jan-11 Jan-12
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy Oct-12 Oct-16
Early Release of the Deceased Patient out of Normal Working Hours Sep-11 Nov-13
Guidelines for Parkinson's Disease Apr-11 Jan-13
Handling deaths at Ashford Hospital Apr-11 Apr-13
HIV Testing for Inpatients Jan-05 Jan-06
Interpreting Service Jan-07 Jan-09
Key Worker Protocol for Cancer and Palliative Care Services Dec-09 Sep-11
Missing Patient policy Jun-12 Jun-14
Mortuary Viewing Nov-07 Nov-08
Moving and Handling Policy Oct-12 Aug-15
Neck Breathers Jul-00 Jul-02
Oxygen Policy Nov-09 Dec-12
Patient identification policy Jan-11 Dec-12
Photographing patients Mar-06 Mar-07
Post Mortems Examinations: Guidance for Doctors Sep-11 Sep-13
Pressure Ulcer Policy Jul-10 Jul-13
Purchasing Medicines for Safety Policy Aug-10 Aug-12
Recognition of and Response to Acutely Ill Adult Patients in Ward Environments Apr-12 Apr-14
Resuscitation Policy May-12 May-16
Safeguarding Adults in the Trust Oct-12 Oct-15
Safeguarding Children Policy Nov-11 Mar-14
Supporting people with learning disabilities Dec-10 Dec-12
Tissue Donation Policy Jul-00 Jul-02
Transfer of Adult Patients (excluding Maternity) Jan-11 Dec-13



Nursing Procedures
 

Title Last Review Next Review
Back Pain Guidelines and Algorithm Nov-10 Oct-12
Care of Patients requiring Close Observation Jun-12 Jun-15
Conservative Sharp Debridement of Wounds Jan-12 Jan-14
Epidural Analgesia Policy Aug-11 Jul-13
Local Anaesthetic Guidelines Nov-11 Nov-13
Nurse-led Diagnostic Biopsies Policy Mar-10 Mar-13
Patient Controlled Analgesia (PCA) Policy May-12 Apr-14
Patient tracheostomy tubes who are in respiratory distress May-06 May-07
Procedure for nurse checking and issuing of TTOs Mar-06 Mar-08
Removal and cleaning of tracheostomy inner cannula for adults May-06 May-07
Syringe Driver Policy Jul-11 Jul-13
Tracheal bronchial suctioning in adults May-06 May-07
Transcutaneous Electrical Nerve Stimulation (TENS) Jan-10 May-12
Verification of Expected Death by Registered Healthcare Professionals Apr-12 Apr-15
Visual Acuity Mar-11 Apr-13



Major Incident
 

Title Last Review Next Review
CBRN Plan Nov 10 May 12
Flu Pandemic Plan Dec 12 Dec 13
Heatwave Plan Dec 10 Dec 11
Internal Incident Plan May 13 May 14
Major Incident Plan Mar 12 Mar 13
Snow Plan Dec 12 Apr 13
Vehicle Fuel Emergency Plan Jul 11 Jul 13



Information and Technology
 

Title Last Review Next Review
Data Quality Policy Jan 11 Sep 13
Email Policy Sep 10 Sep 13
Fax Policy Jul 10 Jul 13
Freedom of Information (FOI) Policy Sep 10 Sep 13
Freedom of Information (FOI) Procedure Sep 10 Sep 13
Information Governance Policy Sep 10 Sep 13
Information Governance Strategy Mar 11 Mar 12
Information Security Policy Sep 10 Aug 13
Internet Usage and Security Policy Dec 12 Dec 15
IT Projects Policy Mar 11 Mar 14
Portable computer device policy Dec 12 Dec 15
Remote access policy Dec 12 Dec 15



Facilities and Estates
 

Title Last Review Next Review
Decontamination Policy Dec-12 Dec-15
Operational Cleaning Plan Nov-12 Aug-15
Strategic Cleaning Plan Nov-12 Aug-15
Telecommunications Policy Nov-12 Nov-14
Travel and Car Parking Policy Jul-11 Jul-14

Last Updated on Monday, 13 May 2013 10:49