Trust Policies
A selection of Trust policies 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 7th February 2024
Acute Paediatrics
- Nasogastric Policy for Children and Young People.pdf[pdf] 3MB
- Direct Observation of Practice Record.pdf[pdf] 106KB
- National Reporting and Learning Systems (NRLS) 0223 Nasogastric.pdf[pdf] 77KB
- National Reporting and Learning Systems (NRLS) 0223A Nasogastric.pdf[pdf] 49KB
- National Reporting and Learning Systems (NRLS) 0224 Nasogastric.pdf[pdf] 32KB
- National Reporting and Learning Systems (NRLS) 1253 Nasogastric.pdf[pdf] 137KB
- High Flow Nasal Cannula Therapy Paediatrics.pdf [pdf] 2MB
- Paediatric Nutrition and Mealtimes Policy.pdf[pdf] 574KB
- Paediatric Gastrostomy and Jejunostomy Policy.pdf[pdf] 1MB
Advanced Practice
Cancer
Corporate Governance
- Fraud, Bribery and Corruption Policy.pdf [pdf] 381KB
- Standing Orders.pdf[pdf] 372KB
- Standing Financial Instructions.pdf[pdf] 478KB
- Electronic Signature Policy.pdf[pdf] 535KB
- Use of external Auditors for Non-Audit Servi.pdf [pdf] 226KB
- Management of External Assessments.pdf [pdf] 255KB
Clinical
- Chaperoning Policy.pdf[pdf] 333KB
- Adult Nasogastric Tube Insertion and Procedure Managment Policy.pdf[pdf] 420KB
- Appendix A - Competency for Registered Staff in Nasogastric Tube Insertion and Management.pdf[pdf] 223KB
- Appendix B - Decision Tree for nasogastric tube placement checks in ADULTS.pdf[pdf] 144KB
- Appendix C - Adult Record of Insertion of Nasogastric Tube.pdf[pdf] 166KB
- Appendix D - Adult Nasogastric Tube Position Record.pdf[pdf] 151KB
- Prevention and Management of Pressure Ulcers Policy.pdf[pdf] 405KB
- Haematology and Oncology Service Line Clinical Chemotherapy Service Policy.pdf[pdf] 1MB
- Transition from Children to Adult Services Policy.pdf [pdf] 3MB
- Transition from Children to Adult Services - Flow chart for transition 16-17 year olds.pdf [pdf] 87KB
- Essential Adult Inpatient Observations, Reporting and Escalation Policy.pdf[pdf] 2MB
- Adult Total Parenteral Nutrition Policy.pdf[pdf] 339KB
- Adult Enteral Feeding Policy.pdf[pdf] 525KB
- Bowel Care for Adults.pdf[pdf] 1MB
- Topical Negative Pressure Wound Therapy.pdf[pdf] 672KB
- Policy for the Accommodation of Well Infants to Adult Wards.pdf[pdf] 486KB
- Clinical Department Rostering Policy.pdf [pdf] 375KB
- Syringe Driver Policy.pdf [pdf] 400KB
- Lower Limb Ulceration.pdf [pdf] 603KB
- Wound Care Policy.pdf [pdf] 516KB
Clinical Administration
Clinical Records Management
- Clinical Records Keeping Policy.pdf[pdf] 307KB
- Data Quality Policy.pdf[pdf] 378KB
- Health Records Policy.pdf[pdf] 900KB
- Patient Change of Identity Policy.pdf[pdf] 312KB
- Subject Access Request (SAR) Policy.pdf[pdf] 1MB
Communications
- Media and Filming Policy.pdf[pdf] 269KB
- Staff Social Media Policy.pdf [pdf] 565KB
- VIP and non-patient visitor policy.pdf[pdf] 257KB
Corporate Records Management
- The Development and Management of Formal Documents.pdf [pdf] 276KB
- Records Management Policy.pdf[pdf] 327KB
Digital & Innovation
- Information Security Policy.pdf [pdf] 277KB
- NHSMail Acceptable Use Policy.pdf [pdf] 156KB
- Telecommunications Policy.pdf [pdf] 304KB
- Internet Use Policy.pdf [pdf] 228KB
- Network Security Policy.pdf [pdf] 194KB
Emergency Planning
Facilities
- Linen Services Policy.pdf[pdf] 334KB
- The Safe Handling Management and Disposal of Hospital Waste.pdf[pdf] 898KB
- Estates Services Provision Policy.pdf[pdf] 438KB
- Operational Policy for Medical Gases.pdf[pdf] 384KB
- Electrical Safety Policy.pdf[pdf] 825KB
- Environmental Cleaning Policy.pdf[pdf] 322KB
- Pest Control Policy.pdf[pdf] 296KB
- Water Management Policy.pdf[pdf] 3MB
- Control of Smoking Policy (Patients and Visitors).pdf[pdf] 245KB
- Global Location Number (GLN) Policy.pdf[pdf] 540KB
- Lift Management and Maintenance Policy.pdf[pdf] 948KB
- Bed Head Service Policy.pdf[pdf] 163KB
- Operational Policy for Specialised Ventilation in Healthcare.pdf [pdf] 420KB
- Asbestos Policy.pdf [pdf] 586KB
- Music Licence Policy.pdf [pdf] 358KB
Trust Policies
Financial
- Financial Governance Policy.pdf[pdf] 345KB
- Asset Management Policy Nov 2014.pdf[pdf] 674KB
- Capital Investment Policy.pdf[pdf] 449KB
- Cash and Treasury Management Policy.pdf[pdf] 312KB
- Supplier Representative Policy.pdf[pdf] 283KB
- Overseas Visitors Policy.pdf[pdf] 325KB
- Policy for Requesting and Using Staff Taxis Charged to the Trust.pdf[pdf] 202KB
Fire Safety
Health and Safety
- Health & Safety Policy.pdf[pdf] 953KB
- Control of Substances Hazardous to Health (COSHH) Policy.pdf[pdf] 448KB
- Prevention and Management of Patient Falls in Hospital (Adults) Policy.pdf[pdf] 438KB
- Appendix 1 - Falls Risk Assessment & Care Plan.pdf[pdf] 189KB
- Appendix 2 - Safety Brief.pdf[pdf] 514KB
- Appendix 3 - Falls Prevention leaflet.pdf[pdf] 196KB
- Appendix 4 - Fall sticker.pdf[pdf] 260KB
- Appendix 5 - Post Fall Flowchart.pdf[pdf] 567KB
- Appendix 6 - Community and Offsite Outpatient areas post fall flow chart.pdf[pdf] 528KB
- Appendix 7 - Outpatients Post Fall Flowchart.pdf[pdf] 124KB
- Appendix 8 - Outpatient Falls Sticker.pdf[pdf] 3MB
- Using bedrails safely and effectively (adults).pdf[pdf] 348KB
- Operational Policy for Pressure Systems in Healthcare.pdf[pdf] 523KB
Haematology and Transfusion
- Hospital Transfusion Policy.pdf[pdf] 4MB
- Emergency Blood Management Plan.pdf[pdf] 366KB
- Policy for the Provision of Intraoperative Cell Salvage.pdf[pdf] 2MB
- Major Haemorrhage Policy.pdf[pdf] 5MB
Healthcare Governance
- Care of Deceased Patients Policy.pdf[pdf] 390KB
- Resuscitation Policy.pdf[pdf] 432KB
- Resuscitation Policy Appendix 1.pdf[pdf] 5MB
- Consent to Examination or Treatment Policy.pdf[pdf] 456KB
- The introduction of new clinical devices and procedures Policy.pdf[pdf] 231KB
- Appendix 1 The introduction of new clinical devices and procedures policy flow chart.pdf[pdf] 177KB
- Appendix 2 New clinical device or procedure proposal form[xls] 149KB
- Clinical Audit Policy.pdf[pdf] 315KB
- Management and Implementation of National Guidance and Enquiries Policy.pdf[pdf] 529KB
- Organ-Donation-Policy.pdf[pdf] 950KB
- Incident Management Policy.pdf[pdf] 937KB
- Mortality Review Policy.pdf[pdf] 982KB
- Hospital Identification Standards (GS1) Policy.pdf[pdf] 477KB
- Employer's IRMER Procedures for Use of the Mini C - Arm in the Surgery Care Group.pdf[pdf] 733KB
Trust Policies: Human Resources
Human Resources
- Secondary Employment Policy.pdf[pdf] 297KB
- Medical & Dental Appraisal Policy.pdf[pdf] 639KB
- Pastoral & Spiritual Care Departmental Policy.pdf[pdf] 275KB
- Respecting Religion at Work Policy.pdf[pdf] 237KB
- Carers Policy.pdf[pdf] 226KB
- Sickness Absence Policy.pdf[pdf] 339KB
- Maternity Leave Policy.pdf[pdf] 383KB
- Freedom to Speak Up.pdf[pdf] 739KB
- Grievance and Dispute Policy.pdf[pdf] 312KB
- Uniform and Dress Code Policy.pdf[pdf] 330KB
- Recruitment and Selection Policy.pdf[pdf] 314KB
- Organisational Change Policy.pdf[pdf] 391KB
- Redeployment Policy.pdf[pdf] 316KB
- Remuneration for Additional Clinical Work.pdf[pdf] 279KB
- Remuneration for Senior Medical & Dental Staff Covering Absent Colleagues.pdf[pdf] 375KB
- Reception and Induction of Senior Medical and Dental Staff.pdf[pdf] 329KB
- Implementation of the Working Time Regulations to Senior Medical Staff.pdf[pdf] 299KB
- Leave Policy.pdf[pdf] 341KB
- Parental Leave Policy.pdf [pdf] 247KB
- Trade Union Facility Time Policy.pdf[pdf] 260KB
- Trade Union Recognition Agreement Policy.pdf[pdf] 248KB
- Maintaining High Professional Standards.pdf[pdf] 421KB
- Maintaining High Professional Standards Flowchart.pdf[pdf] 123KB
- Volunteers and Volunteering Policy.pdf[pdf] 316KB
- Appeals in Senior Medical and Dental Doct Job Planning Pay Progression Dispute Policy.pdf[pdf] 246KB
- Mediation for Senior Medical and Dental Doctors in the Job Planning & Pay Progression Disputes.pdf[pdf] 241KB
- Honorary Contracts Policy Including the Award of Honorary Contracts for Retired Senior Medical and Dental Staff.pdf[pdf] 351KB
- Adoption and Surrogacy Policy.pdf[pdf] 232KB
- Protection of Earnings Policy.pdf[pdf] 255KB
- Employee Records Management.pdf[pdf] 281KB
- Managing Close Personal Relationships at Work Policy.pdf[pdf] 220KB
- Recruitment & Selection Procedure for Appointment of Doctors to Remunerated Management Post.pdf[pdf] 199KB
- Salary Overpayments and Underpayments Policy.pdf[pdf] 248KB
- Secondment Policy.pdf[pdf] 246KB
- Senior Medical and Dental Staff Study Leave Policy.pdf[pdf] 1MB
- Supporting Colleagues in Crisis Situations[pdf] 378KB
- Learning Development and Study Leave Policy.pdf[pdf] 1MB
- Equality, Diversity, and Human Rights Policy.pdf[pdf] 224KB
- Revalidation for Nurses and Midwives.pdf[pdf] 244KB
- My Appraisal Policy.pdf[pdf] 315KB
- Exception Reporting and Work Schedule Policy.pdf[pdf] 451KB
- Leave Policy for all Junior Doctors and Dentists including Trainees, Military Trainees and Trust Doctors.pdf[pdf] 304KB
- Rota Design & Rostering Policy.pdf[pdf] 300KB
- Fit and Proper Persons Policy.pdf[pdf] 922KB
- Conduct Policy.pdf[pdf] 314KB
- Unpaid & Sabbatical Leave Policy.pdf[pdf] 284KB
- Reservist and Cadet Force Adult Volunteer Policy.pdf[pdf] 250KB
- Retirement Policy.pdf[pdf] 261KB
- Flexible Working Policy.pdf [pdf] 251KB
- Leave Policy for Medical & Dental Consultants on the new 2003 contract & SAS Doctors.pdf [pdf] 293KB
- Constitution & Terms of Reference - Medical Staff Panel.pdf[pdf] 330KB
Trust Policies
Information Governance
- Audio and Visual Recording Policy.pdf[pdf] 621KB
- Audio and Visual Recording Policy Poster1.pdf [pdf] 374KB
- Audio and Visual Recording Policy Poster 2.pdf [pdf] 373KB
- Appropriate Policy Document.pdf [pdf] 232KB
- Information Governance Policy.pdf[pdf] 265KB
Ionising Radiation Safety
Moving and Handling
- Moving and Handling People and Objects Policy.pdf [pdf] 310KB
- Plus Size Moving and Handling Policy.pdf [pdf] 390KB
Maternity
- Infant Feeding Policy.pdf[pdf] 943KB
- Management of substance use in pregnancy and postnatal period.pdf [pdf] 486KB
- Maternity Training Needs Analysis [docx] 79KB
- Maternity Training Needs Analysis Matrix.[xls] 63KB
- Maternity Operational Staffing and Escalation Policy.pdf[pdf] 478KB
- Escalation in Maternity Policy.pdf [pdf] 334KB
- Trust Policy for Maternity in the event of lift failure within the maternity building.pdf [pdf] 296KB
- Neonatal Unit Infant Feeding Policy.pdf[pdf] 375KB
- Maternity Unit Medicine Directives (Includes Midwives Exemptions and Protocols).pdf[pdf] 750KB
- Paediatric Bed Management and Escalation Policy.pdf [pdf] 1MB
- Respectful Management of Pregnancy Remains of Less than 22 weeks gestation.pdf [pdf] 2MB
Medical Devices
- The Management and Use of Medical Devices Policy.pdf[pdf] 379KB
- Medical Device Training Policy.pdf[pdf] 326KB
- Asset numbering and labelling policy.pdf [pdf] 489KB
Medicines Management
- Non Medical Prescribing Policy.pdf[pdf] 522KB
- Medicines Management Policy.pdf [pdf] 831KB
- Medicines Reconciliation in Adults Policy.pdf[pdf] 360KB
- Policy for the Procurement,Prescribing,Supply & Admin of Unlicensed Med.pdf[pdf] 615KB
- Policy for Self-Administration of Medicines by Patients (Adult and Paediatric).pdf[pdf] 556KB
- Intrathecal Chemotherapy Policy.pdf[pdf] 269KB
- Policy for Safe Procedural Sedation in Adults.pdf[pdf] 750KB
- PHNT Anticoagulant Policy.pdf[pdf] 440KB
- Procedures for Administering Injectable Drugs.pdf[pdf] 5MB
- Policy to Support Administration of Selected Medication.pdf[pdf] 530KB
- Policy for the Administration of Melatonin to Children for sleep EEGs in the Neurophysiology Department..pdf [pdf] 588KB
- Self Prescribing by Medical Staff Policy.pdf[pdf] 315KB
- Safe Management of Controlled Drugs.pdf[pdf] 655KB
- Covert Administration of Medicines.pdf[pdf] 282KB
- Pharmacist Enabling Policy.pdf[pdf] 273KB
- Policy for Reducing Dosing Errors with Opioid Medicines in Adults.pdf[pdf] 2MB
- Administration of Medicines via a Patient Group Direction (PGD).pdf[pdf] 660KB
- New Medicine Policy.pdf[pdf] 1MB
- Using Patients Own Drugs (PODs) Policy.pdf[pdf] 426KB
Nutrition
Operational Management
Trust Policies P-Z
Patient Services
- Producing and Managing Patient Information Policy.pdf[pdf] 441KB
- Translation and interpreting Policy.pdf[pdf] 1MB
- PALS Policy.pdf[pdf] 269KB
- Managing and Responding to Formal Complaints Policy.pdf[pdf] 1MB
- Managing and Responding to Formal Complaints - Appendix 8.pdf[pdf] 119KB
- Managing and Responding to Formal Complaints - Appendix 13.pdf[pdf] 96KB
- Managing and Responding to Formal Complaints - Appendix 14.pdf[pdf] 205KB
- Management of Patient Property Policy.pdf [pdf] 596KB
Physical Interventions
- Paediatric Physical Intervention Policy.pdf[pdf] 586KB
- Best Interest Decision Tool.pdf[pdf] 219KB
- Debriefing Patients and Family Carers.pdf[pdf] 171KB
- Positive behaviour plan.pdf[pdf] 127KB
- Checklist for Self-Discharging for Young Person’s.pdf[pdf] 210KB
- Risk Assessment for planned Restrictive Physical interven.pdf[pdf] 173KB
- Therapeutic (pharmacological) management and restrictive interventions policy.pdf[pdf] 409KB
Point of Care Testing
- TRW.POC.POL.354.6 Point of Care Testing Policy.pdf[pdf] 270KB
- TRW.POC.POL.549 Point of Care Testing Training Policy.pdf[pdf] 290KB
- TRW.POC.POL.590 Point of Care Testing Audit Policy.pdf[pdf] 251KB
Preceptorship
Private Care
Procurement
- TRW.PRO.POL.1063.1 Supply Chain Inventory Management Policy.pdf[pdf] 917KB
- TRW.PRO.POL.1112.1 Purchase to Pay Policy.pdf[pdf] 287KB
Research and Development
Risk Management
- TRW.RIS.POL.86.5 Identification of Patients Policy.pdf[pdf] 563KB
- TRW.RIS.POL.102 Risk Management Policy.pdf[pdf] 931KB
- TRW.RIS.POL.230 Policy for the Management of Safety Alerts.pdf[pdf] 687KB
Safeguarding
- The Safeguarding Adults at Risk Policy (Vulnerable Adults).pdf[pdf] 513KB
- Mental Capacity Act (MCA, 2005), including Deprivations of Liberty (DoLS, 2007) Policy.pdf[pdf] 738KB
- PREVENT Policy.pdf[pdf] 406KB
- Managing the care needs of people (all ages) with a Learning Disability and/or who are Autistic in the acute hospital pdf[pdf] 1MB
- Child Protection Policy.pdf[pdf] 616KB
- Domestic Abuse Policy for Managers and Practitioners.pdf[pdf] 642KB
- Did Not Attend.Was Not Brought Policy for Children and Young People.pdf[pdf] 404KB
- Carers Policy.pdf[pdf] 537KB
- Safeguarding Supervision Policy.pdf[pdf] 282KB
Security
- Crime Prevention Policy.pdf[pdf] 272KB
- Lone Working Policy.pdf[pdf] 269KB
- Tackling Violence and Aggression Policy.pdf[pdf] 422KB
Theatres
- Correct patient, Correct procedure and Correct Site policy.pdf[pdf] 488KB
- Swab Counts in the Operating Theatre Policy.pdf[pdf] 285KB
- Skin Preparation (Surgical Site) Policy.pdf[pdf] 440KB
- Theatre Scheduling Policy.pdf[pdf] 322KB
- Policy for the application of the Surgical Safety Checklist.pdf[pdf] 990KB
- Policy for Management of Sharps in Operating Theatres and Procedural rooms.pdf[pdf] 319KB
- Instrument Count during invasive procedures.pdf[pdf] 315KB