Policies and procedures

NHS South Gloucestershire’s policies and procedures are broken down into the following sections:

Human resources
Information governance – guidance on handling information
Health and safety
Clinical
Non-clinical
Infection control

The following templates must be used in the development and review of all procedural documents:

Equalities Impact Assessment
Front page, version control sheet and example contents page
Coversheet

No link will be available for policies that are currently under review. If you require a copy of a policy, please contact Lindsay Sayers at: Lindsay.Sayers@sglos-pct.nhs.uk .

Human resources

Please note that with effect from 1st April 2011 different policies and forms may apply to staff employed by NHS South Gloucestershire and North Bristol Trust. In the first instance please view the HR homepage to identify which policy/procedure applies

Health & Safety (including Security and COSHH files)

Asbestos - Policy for the management of Asbestos
COSHH guidelines
Display Screen Equipment
Fire Safety
First aid policy
Latex
Legionella - Control of Legionella (L8) Policy
Health & Safety
Manual Handling
Modifying Patient Care: Policy and Procedure for Modifying Patient/Client Care Plan Following The Identification of Specific Risks to Staff
PAT Testing - Electricity at Work Portable Appliance Testing (PAT) Policy
Personal Safety at Work policy
Procedure for Managing the Health & Safety of New & Expectant Mothers
Safeguarging Adults
Security Policy
Stress: Management of work related stress
Telephone policy
Transporting patients in staff cars policy and appendix for staff in the learning difficulties service
Waste management policy
Young People - guidance on risk assessment for "young people" in the workplace

Non-Clinical Policies and Procedures

Business Continuity - Policy for the development and management of Business Continuity Plans
Development and Management of Business Continuity Plans
Cas Alerts: Procedure for Managing CAS alerts
Claims Handling
Compliments, PALS Enquiries and Complaints and PALS information leaflet
Condemnation & Disposal
Controlled Drugs: BNSSG CD Local Intelligence Network - Policy for Sharing and Managing Information on Controlled Drugs (and coversheet)
Copying letters to patients
Electronic Documents: Guidance for staff on creating and managing electronic documents
Emergency Preparedness Policy
Freedom of Information and FAQs
GP Appraisal Policy and Procedure
IM&T
Losses and Special Payments
National Guidance: Policy for the Implementation of National Guidance
Performance concerns - policy for the management and support of practitioners whose performance may give cause for concern (including PDMG proceedures )
‘Policy on Policies’: Development and Management of Procedural Documents
Fraud
Pool Bike Policy
Privacy and Dignity Policy
Protocol for the Management of External Agency Visits, Inspections and Accreditations
Public Participation Committee Reimbursement
Records Management
Register of Interests & Hospitality
Smoking in the Workplace

Standing Orders, Reservation and Delegation of Powers & Standing Financial Instructions
board governance structure | integrated governance ToR
Audit Committee ToR | clinical commissioning group ToR | Remuneration and Terms of Service Committee Terms of Reference | Strategic Projects Committee TOR

Travel costs - Heathcare travel costs scheme policy and patient information leaflet - Are you entitled to help?
Whistleblower's Policy, and template for GP practices and NCAS leaflet

Information Governance - Guidance on Handling Information
Email Operational Guidance
Guidance for patients who have concerns about use of their information
Handling Information on the move - Procedures on the use of mobile computers, electronic media, remote access and sending information securely
Information Governance Management System
Information Sharing Principles
Internet Use Guidance
Process for Posting Personal Data

Clinical Policies & Guidelines
Where provider services do not have an available PCT approved clinical policy, practitioners are able to use this staff only link to Royal Marsden clinical nursing procedures.

Advanced Directives Leaflet for Public
Antimicrobial Prescribing Guidelines for BNSSG Health Community and Frontsheet (full version)
Anaphylaxis - Policy for the Management of Anaphylaxis
Antimicrobial Prescribing Guidelines for BNSSG Health Community 2010/12
Blood Transfusion - Additional Guidance for Henderson Ward, Thornbury Community Hospital
Break time snacks - Guidelines on the Consumption of Break Time Snacks for Early Years (0 - 6)
Breastfeeding Policy
Catheterisation - Clinical Guidelines for Adult Urethral Catheterisation and Supra-pubic re catheterisation
Chaperoning Guidelines for Intimate Examination, Procedure and Care
Clinical Supervision Guidelines for Nursing and Allied Health Professionals (AHP's)
Community Equipment Prescribing Guidelines
Consent Policy and consent forms:
Consent form 1 (Word version) (PDF version)
Consent form 2 (Word version) (PDF version)
Consent form 3 (Word version) (PDF version)
Consent form 4 (Word version) (PDF version)
Consent form 5 (Word version) (PDF version)
Continence - Entitlement of clients to receive incontinence pads and Continence Care Pathway
Controlled Drugs Policy - The safe handling of Controlled Drugs (CDs) by Healthcare Professionals in the community
Depression - Local Implementation of NICE Guidelines for the Management of Depression in Primary Care
Dermatology Treatment Guidelines
Did Not Attend (DNA) Policy
Digital Rectal Examination and Manual Removal of Faeces
Domestic Violence Policy & Standards
Ear Irrigation Guidelines
Family Health Needs Assessment
Family Disengagement - Policy for Did Not Attend (DNA), No Access Visits (NAV) Family disengagement in relation to children
Graseby Syringe Drivers in Adult Palliative Care
Identification - Policy for the correct identification of Service Users
Immunisations and vaccinations - Policy for the Administration of Immunisations & Vaccinations
Incident reporting - Clinical and Non-clinical Incident Reporting Policy and Procedure
Interventions Not Normally Funded List -(more information is on our Exceptional funding page)
Intimate/Personal Care guidance for children and young people
Intravenous Therapy - Policy and Procedure for the management of Intravenous Therapies
Leg Ulcer Guidelines
Maternal and Child Nutrition Guidelines (full dicument) or in sections
1: Introduction | 2: Preconception & pregnancy | 3: Infant Feeding (birth to 12 months) | 4: Toddlers & preschool | 5: Appendix
Medical devices and equipment - Policy for the Management of Medical Devices and Equipment
Medicines Management - Core Medicines Management Policy
Mental Capacity Act 2005 Practice Guidance
Methotrexate Injection - policy for the administration of Methotrexate by injection to adults diagnosed with rheumatological or dermatological conditions
Minor Injury Service - Policy and Procedure for Requesting of X-Rays by Non-Medical Practitioners
Money and valuables - Guidance on Handling Service Users Money / Valuables / Pension Books
Nutrition - Guidelines for malnutrition screening and the appropriate use of commercial sip feeds in NHS South Gloucestershire
Nutrition - Ideas for a healthy diet leaflet - appendix to guidelines for malnutrition screening
‘Policy on Policies’ - Policy & Procedure for the Development and Management of Procedural Documents
Post Natal Depression & Puerperal Psychosis - detection, management and referral in primary care
Pre-School Core Health Visiting Guidelines, Standard - new birth visit, Standard - 8-12 months, Standard - 2 - 2.5 years, Standard - removal in visits.
Prescribing - Non-medical Prescribing Policy
Radiological investigations - Protocol for Requesting Radiological Investigations by South Gloucestershire Clinical Assessment and Treatment Service (CATS) Physiotherapists
Resuscitation Policy
Royal Marsden - Policy statement for the use of the Royal Marsden Manual of nursing clinical procedures online, current edition
Safeguarding Adults Guidance and Joint Policy and Procedures for safeguarding adults from abuse
Safeguarding Children Policy and Guidance for Safeguarding children and young people in General Practice
Spillages - procedure for removal and cleaning of body spillages in PCT premises
Subcutaneous Infusion - Clinical Guidelines for Subcutaneous Infusion (Hypodermoclysis)
Transfer of Information - Procedure for the transfer of Service User healthcare information (Including infection risks)
TB - Tuberculosis Immunisation Guidelines
Venous Thromboembolism Policy (VTE)
Verification of Death by Registered Nurses and Health Professionals policy
Weighing Babies - Protocol for the management of weighing babies safely in a child health clinic and Health and Safety Leaflet
Wound Management Guidelines