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 8th January 2020

Acute Paediatrics

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

Clinical

• Classic Safety Thermometer SOP.pdf [pdf] 931KB
• Overcrowding in the Emergency Department SOP.pdf [pdf] 423KB
• Use of Red Flags within Safe Care SOP.pdf [pdf] 301KB
• Radiological confirmation of correct placement of nasogastric tubes in Adults, Children and neonates for feeding.pdf [pdf] 199KB
• 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] 76KB
• Operation of the Pneumatic Air Tube Transport System - Appendix 3 - Pharmacy laminate.pdf [pdf] 166KB
• Operation of the Pneumatic Air Tube Transport System.pdf [pdf] 359KB
• Venous Thromboembolism (VTE) Prevention SOP.pdf [pdf] 441KB
• Investigation and Management of Venous Thromboembolism (VTE) SOP.pdf [pdf] 161KB
• Breast Screening SOP.pdf [pdf] 166KB
• End of Life Care in Hospital.pdf[pdf] 2MB
• Specimen Transport SOP.pdf [pdf] 373KB
• Disclosure of Invasive Cancer Reviews - NHS Cervical Screening Programme.pdf [pdf] 248KB

Clinical Administration

• Clinic Cancellation Escalation SOP.pdf [pdf] 367KB

Corporate Governance

• Management of External Assessments.pdf [pdf] 313KB

Facilities & Estates

• Labelling, Allocation and Management of Global Location Numbers.pdf [pdf] 577KB
• Theatre Ceiling Void Access SOP.pdf [pdf] 169KB
• Water Flushing SOP.pdf [pdf] 675KB

Finance

• Labelling, Allocation and Management of Functional GLN.pdf [pdf] 383KB
• Losses and Special Payments.pdf [pdf] 240KB

Fire Safety

• Workplace Fire Safety Checklist.pdf [pdf] 731KB
• Record of Fire Evacuation Drills and Incidents.pdf [pdf] 198KB
• Developing an Evacuation Plan.pdf [pdf] 266KB
• Trust Employees Working in Non Trust Buildings Workplace Fire Safety Checklist.pdf [pdf] 539KB
• Personal Emergency Evacuation Plan.pdf [pdf] 249KB
• Procedure for Concourse Closures.pdf [pdf] 58KB
• DSEAR Risk Assessment.pdf [pdf] 131KB

Health & Safety

• Ionising Radiation Safety Policy - Managerial Responsibilities For Radiation Safety Procedure.pdf[pdf] 211KB
• Ionising Radiation Safety Policy: Procedure for Control of Radioactive Substances.pdf[pdf] 301KB
• Management of Classified Persons under the Ionising Radiations Regulations 2017.pdf [pdf] 467KB
• First Aid at Work SOP.pdf [pdf] 474KB
• Cooperation of Employers.pdf [pdf] 367KB
• SOP for Medical Exposures.pdf [pdf] 249KB
• Ionising Radiation Safety Policy: SOP for Occupational and Environmental Monitoring.pdf [pdf] 192KB
• Ionising Radiation Safety Policy: Procedure for Incidents Involving Ionising Radiations.pdf [pdf] 617KB
• Ionising Radiation Safety Policy: Responsibilities of Radiation Protection Supervisors.pdf [pdf] 808KB
• SOP for Radiation Risk Assessment.pdf [pdf] 299KB
• Preventing Slips Trips & Falls.pdf [pdf] 732KB
• COSHH Risk Assessment SOP.pdf [pdf] 696KB
• Workplace Safe Environment Safety Inspection SOP.pdf [pdf] 425KB

Healthcare Governance

• Incident Management Procedures.pdf [pdf] 541KB
• Managing Safety Incidents Within the NHS Cervical Screening Programme.pdf [pdf] 934KB

Human Resources

• Severe Weather Procedure.pdf [pdf] 191KB
• Local Clinical Excellence Awards Procedure.pdf [pdf] 693KB
• Appeals Procedure.pdf [pdf] 315KB
• Acting Down Procedure for Consultant & SAS Doctors.pdf [pdf] 121KB
• Medical and Surgical Matron of the Day SOP.pdf [pdf] 137KB
• Verification of Registration of Clinical Staff.pdf [pdf] 389KB
• Locum Consultant Appointment SOP.pdf [pdf] 227KB
• Substantive Consultant Appointment SOP.pdf [pdf] 245KB
• Substantive Consultant Recruitment Form.pdf [pdf] 676KB
• Criminal Records Disclosure SOP.pdf [pdf] 309KB
• Safe Recruitment SOP.pdf [pdf] 822KB
• Nursing Safer Staffing Escalation SOP.pdf [pdf] 139KB
• Dealing with Bullying and Harassment SOP.pdf [pdf] 447KB

Infection Control

• Infection Control Hot Spot Strategy.pdf [pdf] 769KB
• Infection Prevention and Control Framework.pdf [pdf] 610KB
• Guidelines for Identification of Roles and Responsibilities in relation to Infection Prevention and Control.pdf [pdf] 1MB
• Guidelines for the Reporting of Healthcare-Associated Infections.pdf [pdf] 376KB
• IC Manual Contents - November 2019.pdf [pdf] 196KB
• Exclusion of Healthcare Workers with Conditions and.or Infectious Diseases.pdf [pdf] 327KB
• Decontamination of Reuseable Intercavity probes.pdf [pdf] 129KB
• Decontamination of Laryngoscopes.pdf [pdf] 184KB
• Preliminary Cleaning of Flexible and Intubating Endoscopes.pdf [pdf] 141KB
• The use of Surgical instruments for neurosurgical patients born after 1st January 1997.pdf [pdf] 139KB
• Decontamination of Reuseable sentinel pobes.pdf [pdf] 127KB

Information Governance

• Disclosure of Personal Information by Email SOP.pdf [pdf] 150KB
• Disposal of Paper Confidential Waste SOP.pdf [pdf] 125KB
• Management of Records on IT Network Shares.pdf [pdf] 240KB
• Confidential Information SOP - Appendix A.pdf [pdf] 297KB
• Confidential Information SOP.pdf [pdf] 239KB
• Data Protection Impact Assessment SOP.pdf [pdf] 307KB
• Disclosure of Person Identifiable Information by Post.pdf [pdf] 132KB
• Disclosure of Personal Information by Telephone SOP.pdf [pdf] 427KB
• Information Governance Incident Handling SOP.pdf [pdf] 406KB
• Management of Freedom of Information (FOI) Requests SOP.pdf [pdf] 527KB

Manual Handling

• Major Trauma clothes off sequence Emergency Department.pdf [pdf] 818KB
• 30 Turning an ICU Patient Prone.pdf [pdf] 344KB
• Bariatric Manual Handling SOP.pdf [pdf] 497KB
• 01 Front Sheet for Operating Procedure for Safe Manual Handling Techniques.pdf [pdf] 135KB

Occupational Health

• Immunisation and Screening of Healthcare Workers SOP.pdf [pdf] 580KB
• Display Screen Equipment (DSE) SOP.pdf [pdf] 1MB
• Prevention and Management of Dermatitis Latex Allergy SOP.pdf [pdf] 945KB
• Management of Stress SOP.pdf [pdf] 328KB
• Management of Contamination Incidents SOP.pdf [pdf] 2MB
• Prevention of Contamination Incidents.pdf [pdf] 780KB
• Mediation SOP.pdf [pdf] 320KB
• Substance Misuse at Work SOP.pdf [pdf] 469KB

Operational Management

• Nurse in Charge - Rules and Responsibilities.pdf [pdf] 322KB
• Postbridge Day Unit Area as Escalation Area.pdf [pdf] 467KB
• Tamar Ward.pdf [pdf] 321KB
• Non-elective care of cardiology patients, and care of inpatients on Bickleigh, Braunton and Torcross (CCU) wards.pdf [pdf] 469KB
• Non-elective care of Elderly Care patients, and care of inpatients on Hartor, Hembury, Monkswell and Shipley wards.pdf [pdf] 268KB
• Non-elective care of renal patients, and care of inpatients on Mayflower ward.pdf [pdf] 260KB
• Non-elective care of General Medical patients, and care of inpatients on who are admitted outside of the Medicine bed.pdf [pdf] 407KB
• Non-elective care of Haematology patients, and care of inpatients on Bracken Unit.pdf [pdf] 333KB
• Non-elective Care of Oncology Patients, and care of Inpatients on Brent Ward.pdf [pdf] 310KB
• Simple Discharge SOP.pdf [pdf] 289KB

Procurement

• Supply Chain Product Recalls and Returns (SC04).pdf [pdf] 886KB
• Tendering and Contracting SOP.pdf [pdf] 245KB
• Supply Chain New Product Introduction.pdf [pdf] 287KB
• Supply Chain Product Ordering.pdf [pdf] 216KB
• Supply Chain Inventory Control.pdf [pdf] 219KB
• Supply Chain Product Receipting.pdf [pdf] 235KB
• Supply Chain Stock Issue.pdf [pdf] 228KB
• Supply Chain Cage Management.pdf [pdf] 211KB
• Supply Chain Fork Lift Truck Operation.pdf [pdf] 227KB
• Invoicing & Payments SOP.pdf [pdf] 864KB
• Requisitioning, Ordering, Receipting SOP.pdf [pdf] 2MB

Safeguarding

• Unidentified and Hospital Trauma Patients.pdf [pdf] 387KB
• Management of Patients with Female Genital Mutilation (FGM).pdf [pdf] 568KB
• Bruising in Immobile babies and Children.pdf [pdf] 420KB
• Child Protection Information Service (CP-IS).pdf [pdf] 385KB
• Managing the care needs of people with a learning disability in the Acute Hospital setting.pdf [pdf] 2MB

Maternity

• Infant-Neonate Abduction SOP.pdf [pdf] 341KB
• Maternity Theatre Recovery SOP.pdf [pdf] 349KB
• Caesarean Section Wound Dressings.pdf [pdf] 319KB
• Labelling of Neonatal Screening Blood Spot Cards.pdf [pdf] 353KB
• Registration, Identification and Security of Newborn Infants SOP.pdf [pdf] 294KB
• Guideline Development within Maternity Services.pdf [pdf] 191KB
• Carriage and storage of Entonox by Midwives.pdf [pdf] 570KB
• Lodging Mothers on Transitional Care Ward SOP.pdf [pdf] 191KB
• Co - Sleeping Between with Mother and Infant.pdf [pdf] 158KB
• Maternity Triage SOP.pdf [pdf] 395KB
• Placental Histology SOP.pdf [pdf] 486KB
• Elective Caesarean Section SOP.pdf [pdf] 437KB

Medical Devices

• Medical Equipment Users Guide.pdf [pdf] 463KB

Medicine Management

• Management of Drug Errors.pdf [pdf] 1017KB
• SOP for Clinical Service Continuity in the Event of ARIA e-Prescribing System Unavailability.pdf [pdf] 269KB
• Administering IV drugs and fluids SOP.pdf [pdf] 571KB
• Safe Handling and Administration of Injectable Cytotoxic Drugs.pdf [pdf] 174KB
• Managing Extravastion SOP.pdf [pdf] 199KB
• Setting up variable rate IV insulin infusion SOP.pdf [pdf] 246KB

• Unidentified and Hospital Trauma Patients.pdf [pdf] 387KB
• Management of Patients with Female Genital Mutilation (FGM).pdf [pdf] 568KB
• Bruising in Immobile babies and Children.pdf [pdf] 420KB
• Child Protection Information Service (CP-IS).pdf [pdf] 385KB
• Managing the care needs of people with a learning disability in the Acute Hospital setting.pdf [pdf] 2MB

Security

• SOP for Individuals who are Violent or Aggressive.pdf [pdf] 319KB
• SOP for Individuals who are Violent or Aggressive Form.pdf [pdf] 368KB
• Appendix 1 - Acceptable Behaviour Agreement.pdf [pdf] 49KB

Theatres

• Monitoring of patients undergoing procedures requiring Local anaesthesia.pdf [pdf] 155KB
• Management and use of Soltran during kidney perfusion.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] 316KB
• Management of patients with body piercing on peri-operative pathways SOP.pdf [pdf] 289KB
• Throat Pack Use in Theatre SOP.pdf [pdf] 176KB
• Throat Pack Flow Chart.pdf [pdf] 23KB
• Cardiac Telephone Pre-Assessment MRSA Sreening SOP.pdf [pdf] 602KB
• Electrosurgery SOP.pdf [pdf] 175KB

Vascular Access

• Selection of Patient Groups Where 3M Tegaderm CHG IV Securement Dressing for Central Venous Access Device (CVAD) and .pdf [pdf] 187KB
• Acute Care Team Lower Limb Cannulation and Venepuncture SOP.pdf [pdf] 281KB
• Competency Ultrasound guided cannula.pdf [pdf] 482KB
• Ultrasound Guided Peripheral Intravenous Cannulation in Adult Patients.pdf [pdf] 251KB
• Peripheral Venepuncture - Appendix 1 - Combined Labs Request Form.pdf [pdf] 843KB
• Peripheral Venepuncture - Appendix 1 - Microbiology Request Form.pdf [pdf] 109KB
• Peripheral Venepuncture - iCM poster.pdf [pdf] 32KB
• Peripheral Venepuncture.pdf [pdf] 627KB
• SOP for the removal of Central Venous Catheter (Short term lines), Peripherally Inserted Central Catheters (PICC) and .pdf [pdf] 254KB
• SOP for the Administration of medication through a central venous catheter or midline using a Surgical Aseptic Non T.pdf [pdf] 200KB
• Taking a Blood sample (other than blood cultures) from a Central Venous Catheter.pdf [pdf] 201KB
• Management of Peripheral Cannulae SOP.pdf [pdf] 594KB
• Management of EZIO Intraosseous Catheter.pdf [pdf] 828KB