SOP: Part 1
A selection of Trust Standard Operating Procedures are available via the links below, to request in alternative formats please contact the Information Governance team via email informationgovernancePHT@nhs.net or Telephone No. 01752 431547
Last Updated 8th November 2023
Acute Paediatrics
Cancer
- Clinical Harm Review.pdf[pdf] 266KB
- Daily Cancer Tracking.pdf[pdf] 317KB
- Management of Suspected Cancer Referrals.pdf[pdf] 260KB
Clinical
- Operation of the Pneumatic Air Tube Transport System.pdf [pdf] 317KB
- Operation of the Pneumatic Air Tube Transport System - Appendix 1 - Ward laminate.pdf [pdf] 66KB
- Operation of the Pneumatic Air Tube Transport System - Appendix 2 - Laboratory Laminate.pdf [pdf] 120KB
- Operation of the Pneumatic Air Tube Transport System - Appendix 3 - Pharmacy laminate.pdf [pdf] 149KB
- Venous Thromboembolism (VTE) Prevention SOP.pdf[pdf] 2MB
- Investigation and Management of Venous Thromboembolism (VTE) SOP.pdf[pdf] 563KB
- End of Life Care in Hospital.pdf[pdf] 4MB
- Specimen Transport SOP.pdf [pdf] 511KB
- Disclosure of Invasive Cancer Reviews - NHS Cervical Screening Programme.pdf[pdf] 371KB
- Radiological confirmation of correct placement of nasogastric tubes in Adults, Children and neonates for feeding.pdf [pdf] 191KB
- Discharge Lounge SOP.pdf [pdf] 854KB
- Primary Spontaneous Pneumothorax Pathway.pdf [pdf] 214KB
- Issuing of fit notes by non-medical health care professionals.pdf [pdf] 389KB
- 16 - 17-year olds and correspondence from the Trust.pdf [pdf] 245KB
- Nursing Safer Staffing Escalation SOP.pdf[pdf] 185KB
- Transfer of Adult Patients with Mental Health Need..pdf [pdf] 441KB
- The training and support of non-medics regarding the completion of Treatment Escalation Plans (TEPs) .pdf [pdf] 305KB
- Care of last days of life patients at Mount Gould Hospital.pdf [pdf] 214KB
Clinical Administration
- Clinic Cancellation Escalation SOP.pdf[pdf] 208KB
- Delivery of Non-Face to Face Clinics.pdf[pdf] 296KB
- OPD Relet SOP.pdf [pdf] 185KB
Facilities & Estates
- Labelling, Allocation and Management of Global Location Numbers.pdf [pdf] 577KB
- Theatre Ceiling Void Access SOP.pdf [pdf] 192KB
- Ward Moves SOP.pdf [pdf] 362KB
- Drivers of Trust Vehicles.pdf [pdf] 459KB
- Water Flushing SOP.pdf [pdf] 675KB
Finance
- Losses and Special Payments.pdf[pdf] 252KB
- Labelling, Allocation and Management of Functional GLN.pdf[pdf] 619KB
Fire Safety
- Fire Incident Response and Release of Persons from Lifts.pdf[pdf] 314KB
- Workplace Fire Safety Checklist.pdf [pdf] 553KB
- Trust Employees Working in Non Trust Buildings Workplace Fire Safety Checklist.pdf [pdf] 459KB
- Personal Emergency Evacuation Plan (PEEP).pdf [pdf] 286KB
- DSEAR Risk Assessment.pdf [pdf] 357KB
Health & Safety
- First Aid at Work SOP.pdf [pdf] 471KB
- Baywatch Process.pdf [pdf] 290KB
- Baywatch Process Appendix 1 - Baywatch Process.pdf [pdf] 90KB
- Baywatch Process Appendix 2 - Baywatch Sign.pdf [pdf] 88KB
- Baywatch Process Appendix 3 - Baywatch Rota.pdf [pdf] 44KB
- Use of Yellow Wristbands.pdf [pdf] 283KB
- Preventing Slips Trips & Falls.pdf [pdf] 455KB
- Preventing Slips, Trips and Falls - Appendix 5.pdf [pdf] 195KB
- Preventing Slips, Trips and Falls - Appendix 7.pdf [pdf] 110KB
- COSHH Risk Assessment SOP.pdf [pdf] 801KB
- Workplace Safe Environment Safety Inspection SOP.pdf [pdf] 326KB
- Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR)pdf [pdf] 562KB
Healthcare Governance
- Incident Management Moderate SOP.pdf [pdf] 38KB
- Incident Management No & Minor Harm SOP.pdf [pdf] 29KB
- Incident Management SI SOP.pdf [pdf] 61KB
- Managing Safety Incidents Within the NHS Cervical Screening.pdf [pdf] 207KB
Human Resources
- Severe Weather Procedure.pdf [pdf] 207KB
- Appeals Procedure.pdf [pdf] 187KB
- Acting Down Procedure for Consultant & SAS Doctors.pdf [pdf] 160KB
- Employee Leaving SOP.pdf [pdf] 213KB
- Verification of Registration of Clinical Staff.pdf [pdf] 331KB
- Locum Consultant Appointment SOP.pdf [pdf] 154KB
- Substantive Consultant Appointment SOP.pdf [pdf] 292KB
- Dealing with Bullying and Harassment SOP.pdf [pdf] 547KB
- Supporting Our Transgender Colleagues.pdf [pdf] 283KB
SOP: Part 2
Infection Control
- Infection Control Hot Spot Strategy.pdf[pdf] 212KB
- Infection Prevention and Control Framework.pdf [pdf] 610KB
- Guidelines for the Reporting of Healthcare-Associated Infections.pdf[pdf] 169KB
- Guidelines for Identification of Roles and Responsibilities in relation to Infection Prevention and Control.pdf[pdf] 305KB
- Decontamination of Reuseable Intercavity probes.pdf [pdf] 129KB
- Decontamination of Re-Usable Laryngoscopes.pdf[pdf] 157KB
- Preliminary Cleaning of Flexible and Intubating Endoscopes.pdf[pdf] 120KB
- The use of Surgical instruments for neurosurgical patients born after 1st January 1997.pdf[pdf] 124KB
- Decontamination of Reuseable sentinel pobes.pdf [pdf] 127KB
- IC Manual Contents.pdf[pdf] 202KB
- Exclusion of Healthcare Workers with Conditions and.or Infectious Diseases.pdf[pdf] 385KB
- SOP for the Management of a Blocked or Leaking Urinary Catheter - Adult.pdf [pdf] 971KB
- Ebola virus disease Action Card.pdf [pdf] 408KB
Information Governance
- Data Protection Impact Assessment SOP.pdf[pdf] 279KB
- Disclosure of Person Identifiable Information by Post.pdf [pdf] 175KB
- Disclosure of Personal Information by Telephone SOP.pdf [pdf] 427KB
- Information Governance Incident Handling SOP.pdf[pdf] 643KB
- Management of Freedom of Information (FOI) Requests SOP.pdf [pdf] 527KB
- Disclosure of Personal Information by Email SOP.pdf[pdf] 228KB
- Disposal of Paper Confidential Waste SOP.pdf[pdf] 111KB
- Management of Records on IT Network Shares.pdf [pdf] 215KB
- Data Protection SOP.pdf [pdf] 266KB
- Confidential Information SOP.pdf[pdf] 239KB
- Confidential Information SOP - Appendix A.pdf[pdf] 114KB
- National Data Opt Out SOP.pdf [pdf] 304KB
- Data Sharing SOP.pdf [pdf] 288KB
- Document Protective Marking SOP.pdf [pdf] 211KB
- Document Protective Marking SOP - Appendix A.pdf [pdf] 102KB
Ionising Radiation Safety
- Managerial Responsibilities For Radiation Safety.pdf [pdf] 237KB
- SOP for Medical Exposures.pdf [pdf] 218KB
- SOP for Control of Radioactive Substances.pdf [pdf] 230KB
- SOP for Occupational and Environmental Monitoring.pdf [pdf] 212KB
- SOP for Incidents Involving Ionising Radiations.pdf [pdf] 403KB
- Responsibilities of Radiation Protection Supervisors.pdf [pdf] 754KB
- SOP for Radiation Risk Assessment.pdf [pdf] 188KB
- Management of Classified Persons under the Ionising Radiations Regulations 2017.pdf [pdf] 285KB
- Cooperation of Employers.pdf [pdf] 313KB
- SOP Concerning the Radiation Protection Assurance Audit Programme.pdf [pdf] 218KB
- SOP Outside Workers.pdf [pdf] 206KB
- Radiation Safety Training Procedure under the Ionising Radiations Regulations 2017 (IRR 2017).pdf [pdf] 218KB
- Radiation Safety Training Procedure under the Ionising Radiations Medical Exposures Regulations 2017 (IRMER 2017).pdf [pdf] 242KB
- The use of Clinical Imaging Board (CIB) Radiation Incident Coding Taxonomy in Datix.pdf [pdf] 660KB
Maternity
- Maternity Theatre Recovery SOP.pdf [pdf] 696KB
- Labelling of Neonatal Screening Blood Spot Cards.pdf[pdf] 165KB
- Registration, Identification and Security of Newborn Infants SOP.pdf [pdf] 163KB
- Guideline Development within Maternity Services.pdf [pdf] 191KB
- Carriage and storage of Entonox by Midwives.pdf [pdf] 451KB
- Lodging Mothers on Transitional Care Ward SOP.pdf [pdf] 191KB
- Co - Sleeping Between with Mother and Infant.pdf [pdf] 158KB
- Daily Newborn Examination Failsafe Access.pdf [pdf] 483KB
- cffDNA Testing for Fetal Rhesus Status.pdf [pdf] 474KB
- Newborn Early Warning Trigger and Track (NEWTT) Observations Recording, Reporting and Escalation Process.pdf [pdf] 294KB
- Cord blood sampling.pdf [pdf] 173KB
- Providing midwifery care for a relative or friend.pdf [pdf] 184KB
- Booking and Consent for Post-Mortems in Obstetrics and Gynaecology .pdf [pdf] 1MB
- Instrument and Swab Counts Pre and Post Birth.pdf [pdf] 190KB
- Neonatal Readmission SOP.pdf [pdf] 223KB
- Maternity Triage SOP.pdf [pdf] 254KB
- Placental Histology SOP.pdf [pdf] 179KB
- Elective Caesarean Section SOP.pdf[pdf] 253KB
- Coronavirus (COVID-19) in pregnancy – summary of RCOG guideline.pdf [pdf] 295KB
- Coronavirus (Covid-19) Patient Screening Prohramme in Maternity.pdf [pdf] 243KB
- Insertion of Cervical Ripening Balloons for induction of labour.pdf [pdf] 400KB
- Responsibility of the Consultant.pdf [pdf] 264KB
SOP: M
Manual Handling
- 02 Inanimate Load Handling.pdf [pdf] 639KB
- 03 Moving and Transporting a Bed or Trolley.pdf [pdf] 284KB
- 05 Sit to Stand Transfer with 2 Using Key points.pdf [pdf] 342KB
- 06 Sit to Stand Transfer with 1 Using Key Points.pdf [pdf] 411KB
- 07 Insertion of a Hoist Sling Whilst Patient is in a Seated Position.pdf [pdf] 683KB
- 08 Lateral Transfer of Plus Size patient Using Air Lifting Device System.pdf [pdf] 471KB
- 09 Turning the Plus Size Patient Using the Repo Sheet in Conjunction with the Overhead Gantry Hoist System.pdf [pdf] 544KB
- 10 Lateral Transfer of Patients Using XL Slide Sheet and Transfer Board.pdf [pdf] 498KB
- 11 Turning Patient onto Side using Slide Sheet.pdf [pdf] 569KB
- 13 Inserting the Tubular Slide Sheet under the Supine Patient without Rolling Them.pdf [pdf] 350KB
- 15 Manual Lifting of a Patient Using a ferno Scoop (Patinets Under 150kg).pdf [pdf] 582KB
- 16 Lowering a Patient from Chair to Floor following a cardiac Arrest.pdf [pdf] 470KB
- 17 Rota Stand Assisted Transfer from one Position to Another.pdf [pdf] 368KB
- 20 Major Trauma clothes off sequence Emergency Department.pdf [pdf] 1MB
- 21 Emergency evacuation from the Birthing Pool in the Event of a Life Threatening Situation.pdf [pdf] 806KB
- 26 ArjoHuntleigh Sara Stedy Assisted Transfer from on Seated Position to Another.pdf [pdf] 296KB
- 27 Use of the Pro Loop Patient Specific Sling in the Amputee Mode.pdf [pdf] 348KB
- 29 Retrieving the Patient from the Floor Using Evacuation Hover Jack/Lateral Transfer.pdf [pdf] 323KB
- 30 Turning an ICU Patient Prone.pdf [pdf] 479KB
- Changing ZX Oxygen Cylinder on a Lifeguard Patient Trolley.pdf [pdf] 745KB
- Handling of Gas Cylinders F; LF; VF; AV; HX and ZX.pdf [pdf] 612KB
- Handling of Gas Cylinders AK; J; and L.pdf [pdf] 703KB
- Repositioning Supine to Prone with the Prturn.pdf [pdf] 842KB
- Non-clinical Mandatory update comptency.pdf [pdf] 127KB
- Mandatory Induction Inanimate Loads Competency Statement.pdf [pdf] 121KB
- Repositioning Supine to Prone Utilising Controlled Patient Pronation Technique.pdf [pdf] 2MB
Medical Devices
SOP: M - P
Medicine Management
- Administering IV drugs and fluids SOP.pdf [pdf] 201KB
- Safe Handling and Administration of Injectable Cytotoxic Drugs.pdf[pdf] 232KB
- Managing Extravastion SOP.pdf[pdf] 944KB
- Setting up variable rate IV insulin infusion SOP.pdf [pdf] 246KB
- Management of Drug Errors.pdf [pdf] 1MB
- SOP for Clinical Service Continuity in the Event of ARIA e-Prescribing System Unavailability.pdf[pdf] 292KB
- Safe Storage of Refridgerated Medicines (Including Temperatur.pdf [pdf] 751KB
- Steroid Emergency Cards.pdf [pdf] 462KB
- Prescribing Retinoids to women of childbearing potential.pdf [pdf] 243KB
- Safe Handling of Potassium Permanganate to Minimise the Risk of Inadvertent Oral Adminisitration.pdf [pdf] 345KB
Neurosurgery
Occupational Health
- Management of Contamination Incidents SOP.pdf [pdf] 294KB
- Appendix A - Contamination Incident Poster.pdf [pdf] 709KB
- Appendix B - Contamination Incident Assessment (CIA) Form.pdf [pdf] 208KB
- Appendix C - ED Management of a High Risk Contamination Incident.pdf [pdf] 387KB
- Appendix D - PEP Patient Information Leaflet.pdf [pdf] 123KB
- Appendix E - Consent and Confidentiality – Testing for BBV.pdf [pdf] 142KB
- Appendix F - Consent Form for Source Patient Blood Testing.pdf [pdf] 156KB
- Appendix G - SHiP Referral Form for OHWB.pdf [pdf] 97KB
- Appendix H - Datix Severity Grading for Contamination Incidents.pdf [pdf] 135KB
- Prevention of Contamination Incidents.pdf [pdf] 780KB
- Appendix A - Preventing Inoculation Injuries Poster.pdf [pdf] 663KB
- Appendix B - Examples of and the order for putting on PPE.pdf [pdf] 632KB
- Appendix C - Assembling and Using a Sharps Bin Safely.pdf [pdf] 487KB
- Immunisation and pre-placement Screening of Healthcare Workers SOP.pdf [pdf] 359KB
- Display Screen Equipment (DSE) SOP.pdf [pdf] 210KB
- Prevention and Management of Dermatitis Latex Allergy SOP.pdf [pdf] 1MB
- Management of Stress SOP.pdf [pdf] 328KB
- Substance Misuse at Work SOP.pdf [pdf] 469KB
Operational Management
- Nurse in Charge - Rules and Responsibilities.pdf[pdf] 234KB
- Postbridge Day Unit Area as Escalation Area.pdf [pdf] 467KB
- Non-elective care of renal patients, and care of inpatients on Mayflower ward.pdf[pdf] 244KB
- Non-elective care of Haematology patients, and care of inpatients on Bracken Unit.pdf[pdf] 274KB
- Non-elective Care of Oncology Patients, and care of Inpatients on Brent Ward.pdf[pdf] 200KB
- Adult Ward to Ward Clinical Handover.pdf [pdf] 1MB
- Decision-making relating to moving patients between adult inpatient wards.pdf [pdf] 429KB
- SOP for Admission Assessment and Discharge of Patients referred to the Medical Assessment Unit.pdf[pdf] 351KB
- Transplant Ward Rounds.pdf [pdf] 135KB
- Non-Elective Care of Neurology Patients, and Care of Inpatients on Merrivale Ward.pdf [pdf] 316KB
Physical Intervention
- Intensive Care Unit (ICU) Safe Holding System to Manage Serious Self-Harm & Prevent Prolonged Restraint.pdf[pdf] 1MB
- UHPNT Restraint Techniques SOP.pdf[pdf] 930KB
Procurement
- Supply Chain Product Recalls and Returns (SC04).pdf[pdf] 289KB
- Supply Chain New Product Introduction.pdf [pdf] 534KB
- Supply Chain Product Ordering.pdf [pdf] 493KB
- Supply Chain Inventory Control.pdf [pdf] 475KB
- Supply Chain Product Receipting.pdf [pdf] 492KB
- Supply Chain Stock Issue.pdf [pdf] 429KB
- Supply Chain Cage Management.pdf[pdf] 206KB
- Supply Chain Fork Lift Truck Operation.pdf[pdf] 175KB
- Invoicing & Payments SOP.pdf[pdf] 864KB
- Requisitioning, Ordering, Receipting SOP.pdf[pdf] 2MB
- New Product Request Form (buyer only).pdf [pdf] 426KB
- New Product Request Form.pdf [pdf] 284KB
- Master Data & Catalogue Management SOP.pdf [pdf] 2MB
SOP: Part 3
Risk Management
Safeguarding
- Unidentified and Hospital Trauma Patients.pdf [pdf] 508KB
- Management of Patients with Female Genital Mutilation (FGM).pdf [pdf] 457KB
- Bruising in Immobile babies and Children.pdf [pdf] 274KB
- Child Protection Information Service (CP-IS).pdf [pdf] 385KB
- Discharge Information Sharing when Children are being Discharged into Care due to Safeguarding Concerns.pdf [pdf] 274KB
- Left before clinical assessment.pdf [pdf] 275KB
- Child (16 - 17 years) admitted (or Pending Admission) to Adult or Paediatric ward following Deliberate Self harm.pdf [pdf] 96KB
Security
- SOP for Individuals who are Violent or Aggressive.pdf[pdf] 319KB
- SOP for Individuals who are Violent or Aggressive Form.pdf[pdf] 8KB
- Appendix 1 - Acceptable Behaviour Agreement.pdf[pdf] 271KB
Theatres
- Management of patients with body piercing on peri-operative pathways SOP.pdf [pdf] 289KB
- Throat Pack Use in Theatre.pdf[pdf] 190KB
- Throat Pack Flow Chart.pdf [pdf] 23KB
- Cath Lab and pacing Theatre Telephone Pre-Assessment process for MRSA Screening SOP.pdf [pdf] 121KB
- Electrosurgery SOP.pdf[pdf] 183KB
- Monitoring of patients undergoing procedures requiring Local anaesthesia.pdf [pdf] 155KB
- Safe Storage, Management and Use of Kidney Perfusion Fluid During Kidney Retrieval and Transplantation.pdf [pdf] 125KB
- Main Recovery Clinical Management SOP.pdf [pdf] 1MB
- Main Recovery Operational Management.pdf [pdf] 345KB
- Supporting the team following sudden death or catastrophic event.pdf [pdf] 258KB
- Care of the Imminently Dying or Deceased Patient in the Perioperative Clinical Area.pdf [pdf] 240KB
- Sharps Handling during invasive procedures in the Operating Theatre or Procedure room.pdf [pdf] 169KB
- SOP for Management and Verification of Implants during Invasive Procedures.pdf [pdf] 185KB
- Accessing Help During an Anaesthetic Emergency.pdf [pdf] 316KB
- Recommendations for Surgical Procedures on Patients with CIEDs.pdf [pdf] 762KB
- Management of the Use of Formalin within Theatres.pdf [pdf] 348KB
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