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 9th May 2023
Acute Paediatrics
- NG Policy for Children and Young People.pdf[pdf] 3MB
- Direct Observation of Practice Record.pdf [pdf] 102KB
- NRLS 0223 Nasogastric.pdf [pdf] 73KB
- NRLS 0223A Nasogastric.pdf [pdf] 34KB
- NRLS 0224 Nasogastric.pdf [pdf] 28KB
- NRLS 1253 Nasogastric.pdf [pdf] 129KB
- High Flow Nasal Cannula Therapy Paediatrics.pdf [pdf] 1MB
- Paediatric Nutrition and Mealtimes Policy.pdf [pdf] 570KB
- Paediatric Gastrostomy and Jejunostomy Policy.pdf [pdf] 1MB
Cancer
Corporate Governance
- Fraud, Bribery & Corruption Policy
- Management of External Assessments.pdf [pdf] 313KB
- Standing Orders.pdf[pdf] 303KB
- Standing Financial Instructions.pdf [pdf] 404KB
- Electronic Signature Policy.pdf [pdf] 531KB
Clinical
- Chaperoning Policy.pdf[pdf] 329KB
- Adult Nasogastric Tube Insertion and Procedure Managment Policy.pdf[pdf] 416KB
- Appendix A - Competency for Registered Staff in Nasogastric Tube Insertion and Management.pdf[pdf] 218KB
- Appendix B - Decision Tree for nasogastric tube placement checks in ADULTS.pdf[pdf] 140KB
- Appendix C - Adult Record of Insertion of Nasogastric Tube.pdf[pdf] 162KB
- Appendix D - Adult Nasogastric Tube Position Record.pdf[pdf] 147KB
- Prevention and Management of Pressure Ulcers Policy.pdf[pdf] 401KB
- Syringe Driver Policy.pdf[pdf] 548KB
- Haematology and Oncology Service Line Clinical Chemotherapy Service Policy.pdf[pdf] 1MB
- Transition from Children to Adult Services Policy.pdf[pdf] 1MB
- Essential Adult Inpatient Observations, Reporting and Escalation Policy.pdf [pdf] 687KB
- Adult Total Parenteral Nutrition Policy.pdf [pdf] 335KB
- Adult Enteral Feeding Policy.pdf[pdf] 520KB
- Bowel Care for Adults.pdf [pdf] 1MB
- Topical Negative Pressure Wound Therapy.pdf [pdf] 667KB
- Policy for the Accommodation of Well Infants to Adult Wards.pdf [pdf] 482KB
Clinical Administration
Clinical Records Management
- Clinical Records Keeping Policy.pdf[pdf] 302KB
- Data Quality Policy.pdf [pdf] 373KB
- Health Records Policy.pdf [pdf] 896KB
- Change of Identity Policy for Adopted Patients.pdf[pdf] 311KB
- Subject Access Request (SAR) Policy.pdf[pdf] 1MB
Communications
Corporate Records Management
- The Development and Management of Formal Documents.pdf[pdf] 231KB
- Information Lifecycle and Records Management Policy.pdf[pdf] 322KB
Emergency Planning
Facilities
- Linen Services Policy.pdf[pdf] 330KB
- The Safe Handling Management and Disposal of Hospital Waste.pdf [pdf] 894KB
- Estates Services Provision Policy.pdf [pdf] 434KB
- Operational Policy for Medical Gases.pdf [pdf] 380KB
- Asbestos Policy.pdf [pdf] 248KB
- Electrical Safety Policy.pdf [pdf] 853KB
- Headlines Electrical Safety Policy.pdf [pdf] 255KB
- Environmental Cleaning Policy.pdf [pdf] 318KB
- Pest Control Policy.pdf [pdf] 292KB
- Water Management Policy.pdf[pdf] 3MB
- Music Licence Policy.pdf [pdf] 738KB
- Control of Smoking Policy (Patients and Visitors).pdf [pdf] 195KB
- Global Location Number (GLN) Policy.pdf[pdf] 464KB
- Lift Management and Maintenance Policy.pdf [pdf] 944KB
- Bed Head Service Policy.pdf [pdf] 159KB
- Operational Policy for Pressure Systems in Healthcare.pdf [pdf] 395KB
Trust Policies
Financial
- Financial Governance Policy.pdf[pdf] 341KB
- Asset Management Policy Nov 2014.pdf [pdf] 670KB
- Capital Investment Policy.pdf[pdf] 442KB
- Cash and Treasury Management Policy.pdf[pdf] 308KB
- Supplier Representative Policy.pdf[pdf] 278KB
- Overseas Visitors Policy.pdf[pdf] 374KB
Fire Safety
Health and Safety
- Health & Safety Policy.pdf [pdf] 949KB
- Control of Substances Hazardous to Health (COSHH) Policy.pdf [pdf] 443KB
- Ionising Radiation Safety Policy.pdf[pdf] 247KB
- Prevention and Management of Patient Falls in Hospital (Adults) Policy.pdf [pdf] 434KB
- Appendix 1 - Falls Risk Assessment & Care Plan.pdf [pdf] 233KB
- Appendix 2 - Safety Brief.pdf [pdf] 510KB
- Appendix 3 - Falls Prevention Leaflet.pdf [pdf] 192KB
- Appendix 4 - Falls Sticker.pdf [pdf] 256KB
- Appendix 5 - Post Fall Flowchart.pdf [pdf] 563KB
- Radon Management Policy.pdf [pdf] 213KB
- Using bedrails safely and effectively (adults).pdf [pdf] 335KB
- Operational Policy for Pressure Systems in Healthcare.pdf [pdf] 498KB
Healthcare Governance
- Care of Deceased Patients Policy.pdf[pdf] 374KB
- Resuscitation Policy.pdf[pdf] 471KB
- Resuscitation Policy Appendices 1 - 18d.pdf[pdf] 5MB
- Consent to Examination or Treatment Policy.pdf[pdf] 451KB
- The introduction of new clinical devices and procedures Policy.pdf [pdf] 220KB
- Appendix 1 The introduction of new clinical devices and procedures policy flow chart.pdf [pdf] 172KB
- Appendix 2 New clinical device or procedure proposal form.pdf [xls] 149KB
- Hospital Transfusion Policy.pdf [pdf] 2MB
- Emergency Blood Management Plan.pdf [pdf] 468KB
- Policy for the Provision of Intraoperative Cell Salvage.pdf [pdf] 2MB
- Clinical Audit Policy.pdf [pdf] 330KB
- Management and Implementation of National Guidance and Enquiries Policy.pdf [pdf] 576KB
- Organ Donation Policy.pdf [pdf] 946KB
- Massive Transfusion Policy.pdf[pdf] 5MB
- Incident Management Policy.pdf[pdf] 1MB
- Mortality Review Policy.pdf [pdf] 978KB
- Hospital Identification Standards (GS1) Policy.pdf [pdf] 473KB
- Employer's IRMER Procedures for Use of the Mini C - Arm in the Surgery Care Group.pdf [pdf] 729KB
Trust Policies: Human Resources
Human Resources
- Secondary Employment Policy.pdf [pdf] 292KB
- Appraisal Policy & Procedure for Consultants & SAS Doctors.pdf [pdf] 635KB
- Pastoral & Spiritual Care Departmental Policy.pdf [pdf] 271KB
- Respecting Religion at Work Policy.pdf[pdf] 232KB
- Carers Policy.pdf[pdf] 215KB
- Sickness Absence Policy.pdf [pdf] 387KB
- TRW.HUM.POL.82 11.3 Maternity Leave Policy.pdf[pdf] 389KB
- TRW.HUM.POL.83 7.3 Raising Concerns Policy.pdf[pdf] 729KB
- Grievance and Dispute Policy.pdf [pdf] 332KB
- Uniform and Dress Code Policy.pdf [pdf] 326KB
- Recruitment and Selection Policy.pdf [pdf] 309KB
- Working Policy.pdf[pdf] 240KB
- Organisational Change Policy.pdf[pdf] 377KB
- Redeployment Policy.pdf[pdf] 312KB
- Leave Policy for Medical & Dental Consultants on the new 2003 contract & SAS Doctors.pdf [pdf] 364KB
- Remuneration for Additional Clinical Work.pdf[pdf] 274KB
- Remuneration for Senior Medical & Dental Staff Covering Absent Colleagues.pdf[pdf] 370KB
- Reception and Induction of Senior Medical and Dental Staff.pdf[pdf] 324KB
- TRW.HUM.POL.184.4 Implementation of the Working Time Regulations to Senior Medical Staff.pdf[pdf] 289KB
- Leave Policy.pdf[pdf] 336KB
- Parental Leave Policy.pdf [pdf] 247KB
- Paternity Leave Policy.pdf[pdf] 210KB
- Trade Union Facility Time Policy.pdf [pdf] 255KB
- Trade Union Recognition Agreement Policy.pdf [pdf] 243KB
- Working Time Regulations Policy.pdf [pdf] 244KB
- TRW.HUM.POL.255.11 Maintaining High Professional Standards.pdf[pdf] 416KB
- TRW.HUM.POL.255.9 Maintaining High Professional Standards Flowchart.pdf[pdf] 119KB
- Volunteers and Volunteering Policy.pdf [pdf] 312KB
- TRW.HUM.POL.302.5 Appeals in Senior Medical and Dental Doct Job Planning Pay Progression Dispute Policy.pdf[pdf] 242KB
- TRW.HUM.POL.303.4 Mediation for Senior Medical and Dental Doctors in the Job Planning & Pay Progression Disputes.pdf[pdf] 236KB
- Constitution & Terms of Reference - Medical Staff Panel.pdf[pdf] 286KB
- TRW.HUM.POL.310.6 Award of Honorary Contracts for Retired Senior Medical and Dental Staff.pdf[pdf] 337KB
- Adoption and Surrogacy Policy.pdf[pdf] 227KB
- TRW.HUM.POL.313.4 Retirement Policy.pdf[pdf] 281KB
- Policy for Requesting and Using Staff Taxis Charged to the Trust.pdf [pdf] 217KB
- Protection of Earnings Policy.pdf[pdf] 243KB
- Clinical Department Rostering Policy.pdf [pdf] 433KB
- TRW.HUM.POL.375.4 Employee Records Management.pdf[pdf] 277KB
- Managing Close Personal Relationships at Work Policy.pdf[pdf] 210KB
- Recruitment & Selection Procedure for Appointment of Doctors to Remunerated Management Post.pdf[pdf] 194KB
- TRW.HUM.POL.433.3 Salary Overpayments and Underpayments Policy.pdf[pdf] 243KB
- Secondment Policy.pdf [pdf] 241KB
- Promoting Positive Practice and Supporting Transgender Staff Policy.pdf[pdf] 283KB
- Senior Medical and Dental Staff Study Leave Policy.pdf [pdf] 1MB
- Supporting Colleagues in Crisis Situations[pdf] 360KB
- Workforce Induction and Training Policy.pdf [pdf] 1MB
- Equality,Diversity, and Human Rights Policy.pdf[pdf] 223KB
- TRW.HUM.POL.1045.1 Revalidation for Nurses and Midwives.pdf[pdf] 239KB
- TRW.HUM.POL.1053.2 Appraisal and Personal Development Policy.pdf[pdf] 301KB
- Exception reporting and work schedule policy - Junior Doctors.pdf [pdf] 977KB
- Leave Policy for all Junior Doctors and Dentists including Trainees, Military Trainees and Trust Doctors.pdf[pdf] 292KB
- TRW.HUM.POL.1128 Preceptorship Policy for Registered Nurses, Operating Department.....pdf[pdf] 327KB
- Rota Design & Rostering Policy.pdf [pdf] 296KB
- Fit and Proper Persons Policy.pdf [pdf] 309KB
- Conduct Policy.pdf [pdf] 309KB
- Unpaid & Sabbatical Leave Policy.pdf [pdf] 268KB
- Reservist and Cadet Force Adult Volunteer Policy.pdf [pdf] 240KB
Trust Policies
Information Governance
- Audio and Visual Recording Policy.pdf[pdf] 621KB
- Appropriate Policy Document.pdf [pdf] 232KB
- Information Governance Policy.pdf[pdf] 265KB
Information Management and Technology
- Information Security Policy.pdf[pdf] 256KB
- NHSMail Acceptable Use Policy.pdf [pdf] 156KB
- Telecommunications Policy.pdf [pdf] 304KB
- Internet Use Policy.pdf [pdf] 313KB
- Network Security Policy.pdf [pdf] 194KB
Infection Control
- The Management and Control of MRSA.pdf[pdf] 398KB
- Policy for the Prevention of TSE.pdf[pdf] 2MB
- Control and Use of Antimicrobials.pdf[pdf] 277KB
Moving and Handling
- Moving and Handling People and Objects Policy.pdf[pdf] 877KB
- Plus Size Moving and Handling Policy.pdf [pdf] 376KB
Maternity
- Infant Feeding Policy.pdf[pdf] 943KB
- Management of substance use in pregnancy and postnatal period.pdf [pdf] 486KB
- Maternity Training Needs Analysis.pdf[docx] 79KB
- Maternity Training Needs Analysis Matrix.pdf[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] 827KB
- Medicines Reconciliation in Adults Policy.pdf[pdf] 360KB
- Policy for Reducing Dosing Errors with Opioid Medicines in Adults.pdf[pdf] 2MB
- 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
- Policy for the Safe Administration of Intrathecal Cytotoxic Drugs.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] 663KB
- Self Prescribing by Medical Staff Policy.pdf [pdf] 364KB
- Safe Mangement of Controlled Drugs.pdf [pdf] 604KB
- Pharmacist Enabling Policy.pdf [pdf] 259KB
Nutrition
Operational Management
Trust Policies P-Z
Patient Services
- Producing and Managing Patient Information Policy.pdf [pdf] 436KB
- Translation and interpreting Policy.pdf [pdf] 1MB
- PALS Policy.pdf [pdf] 257KB
- Management of Patient Property Policy.pdf [pdf] 1MB
- Managing and Responding to Formal Complaints Policy.pdf [pdf] 1MB
- Managing and Responding to Formal Complaints - Appendix 8.pdf [pdf] 115KB
- Managing and Responding to Formal Complaints - Appendix 13.pdf [pdf] 92KB
- Managing and Responding to Formal Complaints - Appendix 14.pdf [pdf] 201K
Physical Interventions
- Management of Physical (Restraint) for Adults in an Acute Hospital Setting[pdf] 590KB
- Paediatric Physical Intervention Policy.pdf[pdf] 582KB
- Best Interest Decision Tool.pdf[pdf] 227KB
- Debriefing Patients & Family Carers.pdf[pdf] 177KB
- Discharge against medical advice proforma.pdf[doc] 97KB
- Positive behaviour plan.pdf [pdf] 113KB
- Risk Assessment for planned Restrictive Physical interventions for Childre.pdf[pdf] 230KB
Point of Care Testing
- Point of Care Testing Policy.pdf[pdf] 236KB
- Point of Care Testing Training Policy.pdf[pdf] 278KB
- Point of Care Testing Audit Policy.pdf[pdf] 239KB
Private Care
Procurement
- Supply Chain Inventory Management Policy.pdf [pdf] 725KB
- Purchase to Pay Policy.pdf [pdf] 282KB
- Master Data & Catalogue Management SOP.pdf[pdf] 2MB
Research and Development
Risk Management
- Identification of Patients Policy.pdf[pdf] 559KB
- Risk Management Policy.pdf[pdf] 605KB
- Risk Management Policy Annex 5 - Risk Escalation Procedure for Corporate Departments.pdf[pdf] 138KB
- Risk Management Policy Annex 5 - Risk Escalation Procedure for Service Lines and Care Groups.pdf[pdf] 137KB
- Policy for the Management of Safety Alerts and Product Recall.pdf[pdf] 690KB
Safeguarding
- The Safeguarding Adults at Risk Policy (Vulnerable Adults).pdf[pdf] 874KB
- Child Protection Policy.pdf [pdf] 1MB
- Domestic Abuse Policy for Managers and Practitioners.pdf [pdf] 1MB
- Child 16-17 years admitted following self harm Vs 5 21 June 2016.pptx [pptx] 122KB
- Did Not Attend.Was Not Brought Policy for Children and Young People.pdf[pdf] 399KB
- Carers Policy.pdf [pdf] 826KB
- Mental Capacity Act (MCA, 2005), including Deprivations of Liberty (DoLS, 2007) Policy.pdf[pdf] 720KB
- PREVENT Policy.pdf [pdf] 401KB
- Managing the Care needs of People (all ages) with a Learning Disability and /or who are Autistic in the Acute Hospital Setting.pdf [pdf] 1MB
Security
- Crime Prevention Policy.pdf[pdf] 390KB
- Lone Working Policy.pdf [pdf] 265KB
- Tackling Violence and Aggression Policy.pdf[pdf] 418KB
Theatres
- Correct patient, Correct procedure and Correct Site policy.pdf[pdf] 484KB
- Swab Counts in the Operating Theatre Policy.pdf [pdf] 319KB
- Skin Preparation (Surgical Site) Policy.pdf[pdf] 436KB
- Theatre Scheduling Policy.pdf [pdf] 310KB
- Policy for the application of the Surgical Safety Checklist.pdf[pdf] 986KB
- Policy for management of Sharps in Operating Theatres and Procedural rooms.pdf [pdf] 354KB
- Policy for Instrument Count during invasive procedures.pdf[pdf] 449KB
Vascular Access
Page footer image
Put people first
Take ownership
Respect others
Be positive
Listen, learn, improve