• Safe & Effective
  • Kind & Caring
  • Exceeding Expectation
Our Policies, Procedures and Frameworks

Our Policies, Procedures and Frameworks

The Royal Wolverhampton NHS Trust regularly reviews their policies, procedures and frameworks. 

Please see below a list of the types of written protocols, policies and procedures written by the Trust. Some of these documents are linked below. If you wish to view any of these documents that are not already linked please email: rwh-tr.FOI@nhs.net.

  • Clinical Policies, Procedures, Guidelines and Frameworks
  • Corporate Policies, Procedures, Guidelines and Frameworks
Clinical Practice Policies

CP02 Deprivation of Liberty Safeguards (DoLS) Policy (PDF, 307Kb)
CP04 Discharge Policy (PDF, 2Mb)
CP05 Transfer of Patients Between Wards, Departments, Specialist Units and Other Hospitals (PDF, 1Mb)
CP06 Consent to Treatment and Investigation Policy (PDF, 1Mb)
CP07 Breastfeeding Policy for Services Outside of Maternity (PDF, 203Kb)
CP08 Children and Young People in Care Policy (PDF, 695Kb)
CP09 Transition from Children’s to Adult Healthcare Services (PDF, 382Kb)
CP11 Resuscitation Policy (PDF, 2Mb)
CP12 Care of People with Learning Disabilities (PDF, 383Kb)
CP13 Adult Self-Harm Policy (PDF, 355Kb)
CP14 Nephrostomy Care Policy (PDF, 305Kb)
CP15 Supporting Autistic Children, young people, and Adults to Access Health Services (PDF, 1Mb)
CP17 Identification and Management of Patients at Risk of Under Nutrition (PDF, 657Kb)
CP18 Clinical Photography, Video and Audio Recordings (PDF, 2Mb)
CP24 Bone Bank Policy (PDF, 865Kb)
CP26 Blood Transfusion Policy (PDF, 1Mb)
CP36 Chaperoning of Patients and Clients (PDF, 598Kb)
CP39 Criteria Led Discharge (PDF, 516Kb)
CP41 Safeguarding Children Policy (PDF, 717Kb)
CP42 Policy for the Prevention and Management of Adult and Paediatric Inpatient Falls (PDF, 1Mb)
CP45 Management of Enteral Feeding Tubes (PDF, 267Kb)
CP50 Management of Risks Associated with Pathology and Radiology Diagnostic and Screening Tests (PDF, 657Kb)
CP51 Point of Care Testing (POCT) Policy for the Dudley Group NHS Foundation Trust, Sandwell and West Birmingham NHS Trust, The Royal Wolverhampton NHS Trust and Walsall Healthcare NHS Trust (PDF, 460Kb)
CP53 Safeguarding Adults at Risk (PDF, 468Kb)
CP54 Supervision (PDF, 554Kb)
CP56 Procedural Sedation Policy (PDF, 247Kb)
CP57 Policy for the Safe Prescription, Administration and Monitoring of Oxygen Therapy in Adults (PDF, 1Mb)
CP61 Management of the Deteriorating Patient (PDF, 1Mb)
CP62 Organ Donation (Solid Organs) (PDF, 512Kb)
CP63 Paediatric Self-Harm Policy (CAMHS and Acute Hospitals in Black Country) (PDF, 839Kb)
CP66 Policy For Care of Patients Requiring Enhanced Care (PDF, 924Kb)
CP67 Identification and Management of Female Genital Mutilation Policy (FGM) (PDF, 2Mb)
CP68 Management of Dysphagia Policy (PDF, 615Kb)
CP69 Medical Handover Policy (PDF, 202Kb)

Corporate Governance Instructions
General Policies
Human Resources Policies
Health and Safety Policies
Infection Prevention Policies
Medicines Policies
Operational Policies

OP01 Governance of Trust-wide Strategy/Policy/Procedure/Guidelines and Local Procedure and Guidelines (PDF, 2Mb)
OP02 Emergency Preparedness, Resilience and Response Policy (PDF, 384Kb)
OP05 Adult Safeguarding Supervision Policy (PDF, 504Kb)
OP07 Health Records Policy (PDF, 3Mb)
OP08 Complaints Management Policy (PDF, 1Mb)
OP09 Corporate Policy and Framework for the Governance of Partnership Agreements (PDF, 392Kb)
OP10 Risk Management and Patient Safety Reporting Policy (PDF, 2Mb)
OP15 Integrated Supplies and Procurement Department Procurement Policy (PDF, 579Kb)
OP16 Critical Care Outreach Team Operational Practice Policy (PDF, 229Kb)
OP18 Patients’ Property Policy (PDF, 483Kb)
OP29 Booking Non Urgent Patient Transport Policy (PDF, 471Kb)
OP30 Research Governance Policy (PDF, 403Kb)
OP33 Estate Maintenance Policy (PDF, 324Kb)
OP39 Patient Access Policy (PDF, 1Mb)
OP47 Interpreting and Communication Policy and Procedure (PDF, 479Kb)
OP52 Patient Identification Policy (PDF, 276Kb)
OP60 Being Open (Duty of Candour) (PDF, 234Kb)
OP62 Breaking Bad News (PDF, 294Kb)
OP65 Capacity Management Policy (PDF, 546Kb)
OP67 Patient Escort Policy (PDF, 354Kb)
OP68 Volunteer Policy (PDF, 355Kb)
OP73 Undertaking an Equality Analysis (EA) (PDF, 390Kb)
OP79 Water Safety Policy (PDF, 3Mb)
OP81 Same Sex (Gender) Accommodation (PDF, 291Kb)
OP85 Information Sharing Policy (PDF, 896Kb)
OP87 Learning from Deaths Policy (PDF, 1Mb)
OP91 Data Quality Policy (PDF, 269Kb)
OP92 Clinical Coding Policy (PDF, 191Kb)
OP94 Supportive Mealtimes Policy (PDF, 211Kb)
OP95 Introduction of New Clinical Techniques and Interventional Procedures (PDF, 335Kb)
OP96 Pressure Ulcer and Moisture Associated Skin Damage Prevention and Management for Adult & Paediatric Patients in Hospital and Community Services (PDF, 4Mb)
OP97 Confidentiality Code of Conduct for staff (PDF, 1Mb)
OP101 Children and Young People Did Not Attend/Failed to be Brought to Acute or Community Appointments or for Acute Admissions/No Access Gained at Pre-Arranged Home Appointments Policy (PDF, 955Kb)
OP102 Non-Elective Surgery Policy (PDF, 282Kb)
OP104 Business Continuity Management Policy (PDF, 484Kb)
OP105 VIP/Celebrity Visitors to the Trust (PDF, 267Kb)
OP106 Safeguarding Children Supervision Policy (PDF, 1Mb) 
OP109 Conflicts of Interest Policy (PDF, 403Kb)
OP111 De-identification and Pseudonymisation Policy (PDF, 1Mb)

Standard Operating Procedures (SOPs) and Guidelines

Attendance at Strategy Discussions (Children’s Safeguarding) (PDF, 334Kb)
Clinical Guideline for the Frequency of Neurological Observation Recording in Adults (PDF, 436Kb)
Clinical Patient Information Standing Operating Procedure (PDF, 4Mb)
Discharge Lounge Procedure (PDF, 350Kb)
Dragon Medical Workflow Manager Standard Operating Procedure (PDF, 309Kb)
Engagement of Bank or Agency Nurses/Health Care Support Workers (PDF, 164Kb)
Guidance and Statement of Intent for Transgender Inclusion (PDF, 324Kb)
Guideline for the management of direct oral anticoagulant (DOAC) associated bleeding (PDF, 730Kb)
Guideline for the management of In-patients with Parkinson's Disease (PDF, 449Kb)
Guideline Perioperative Management of Medicines in Surgical Patients (PDF, 253Kb)
Management of Inpatient Diabetes Foot (PDF, 711Kb)
Mattress and Cushion Care (PDF, 183Kb)
Non-Clinical Records Procedure (PDF, 1Mb)
Paracetamol IV Prescribing Guideline (PDF, 208Kb)
Private Patients Procedure (PDF, 384Kb)
Review and Implementation of NICE Guidance, National Guidance and National Confidential Enquiries Procedure (PDF, 526Kb)
Safe Use of Ultrasound Gel to Reduce Infection Risk (PDF, 191Kb)
Ward Huddle Standard Operating Procedure (PDF, 172Kb)
Work Schedule Reviews and Exception Reporting for Doctors and Dentists in Training (PDF, 1Mb)

Our recommendations are based on current national guidelines and relevant evidence-base. These guideline helps inform clinicians clinical judgement. However, clinicians will consider the trade-off between the benefits and harms of an intervention before making a clinical decision.

A Teaching Trust of the University of Birmingham