Standard Operating Procedures

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 3rd April 2024

Acute Paediatrics

• Prevention and management of patient falls (children) ....pdf [pdf] 302KB

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] 216KB

• 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] 228KB

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] 566KB

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

Information Governance

• Data Protection Impact Assessment SOP.pdf [pdf] 281KB

• 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] 352KB

• Disclosure of Personal Information by Email SOP.pdf[pdf] 512KB

• Disposal of Paper Confidential Waste SOP.pdf[pdf] 179KB

• 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

• Incidents Involving ionising Radiations.pdf[pdf] 361KB

• Responsibilities of Radiation Protection Supervisors.pdf [pdf] 754KB

• 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

Manual Handling

• 02 Inanimate Load Handling.pdf [pdf] 639KB

• 03 Moving and Transporting a Bed or Trolley.pdf [pdf] 284KB

• 05 Sit to Stand with 2 Using Key Points.pdf[pdf] 245KB

• 06 Sit to Stand Transfer with 1 Using Key Points.pdf[pdf] 332KB

• 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] 522KB

• 09 Turning the Plus Size patient using the Repo Sheet in conjunction with the overhead gantry hoist system.pdf[pdf] 578KB

• 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] 927KB

• 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 (Patients Under 150kg).pdf[pdf] 575KB

• 16 Lowering a Patient from Chair to Floor following a Cardiac Arrest.pdf[pdf] 469KB

• 17 Rota Stand Assisted Transfer from one Position to Another.pdf[pdf] 357KB

• 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 one seated position to another.pdf[pdf] 328KB

• 27 Use of the Pro Loop Patient Specific Sling in the amputee mode .pdf[pdf] 266KB

• 29 Retrieving the Patient from the floor using Evacuation Hover Jack/Lateral Transfer.pdf[pdf] 352KB

• 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

• Management and Use of Scott Duraflow Powered Air Purifying Respirator (PAPR) and Hood.pdf [pdf] 383KB

• Management and Use of CleanAir personal Respiratory Protection System (PRPS) with Dispoable Hood.pdf [pdf] 1MB

• Medical Equipment Users Guide.pdf [pdf] 495KB

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

• Programming Patients Own Drugs Locker.pdf [pdf] 288KB

Neurosurgery

• Electronic Referral System (Urgent and Emergency) in Neurosurgery.pdf [pdf] 1MB

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

• 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

• Full Capacity SOP.pdf [pdf] 309KB

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

Risk Management

• Serious & Moderate Risk Review and Approval.pdf[pdf] 247KB

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