Policies Based System

Simplify your policies

Most organisations have a comprehensive multi-page document to cover everything. This makes it complicated to understand especially for front line staff.


  • Policies are statements of intent i.e. "What we are aiming for"
  • They do not say HOW we will do this
  • Policies generally do not require customisation

Procedures and protocols

  • These define how we will implement the policies, i.e. the rules and methodology for people to follow
  • These may be more detailed and will vary with every organisation as each works slightly differently to others

Customisation affects management side more than staff side. e.g. staff usually pass over complaints to managers, job done, whereas Managers will have to define who will handle the investigation and who will have the final say

How to simplify policies

  1. Don't complicate it for staff.
  2. The only person who really needs to know the detailed process or protocol is the line manager.
  3. For staff, differentiate between MUST know Vs USEFUL to know

CQC says they're not interested

Is it about policies?

"Absolutely not. We are much less interested in policies and protocols than in knowing what care is like for your patients, whether staff know what to do about things like child protection, and so on. Good practices shouldn’t need to do anything they aren’t already doing."

Professor David Haslam, National Clinical Adviser to the Care Quality Commission

"We won’t normally spend a great deal of time reading policy or procedure documents, unless we need to look at them to substantiate other evidence or what staff or patients have told us about their experiences."

This is where the CQC focus their inspections:-

  • Experiences people have when they receive care and the impact the care has on their health and wellbeing.
  • Talking to patients, their families and their carers.
  • Looking at records or speaking with staff and how they reach their judgements.

British Medical Association says don'r bother

Question: Is 'CQC' all about policies and protocols?

What the BMA says:

"We believe that most providers will already be compliant with the essential standards" and "CQC registration should not involve the development of large numbers of new policies and protocols."

Extracts from the BMA CQC Registration guidance for GPs.

How many policies do you need

This depends on the size of your organisation and the purpose of your policies.
This is what you should aim to have for a typical organisation with less that 50 staff:-

CQC Policies 20 to 30
 HR 5 to 10
 Health & Safety 5 to 10
 Admin 5 to 10

For larger organisations, the numbers might go up by say 20% due to the complexities of dealing with stricter and more centralised systems.

Minimise the number of policies

  1. Focus on key policies and get them right
  2. A common sense approach to safety will cover most unusual situations
  3. It is better to invest time in developing staff and instilling a common sense
  4. Do not overwhelm staff with paperwork to cover every eventuality.

Make your policies more efficient

Separate and differentiate the functions:-

Separate policies for CQC compliance Vs admin and HR  CQC don't need to see your holidays policy
Differentiate Staff-side polices Vs Management-side policies Simplifying staff policies saves their time and makes it easier to understand and retain knowledge
Policy statements Vs Procedures and protocols to follow Make it easier to explain and understand what we are aiming for Vs how to do things

Restructure your policies:-

  1. Common practice is to insert the name of a responsible person in each policy. DON'T DO THIS.
  2. Enter just the job title of the person e.g. "Fire Marshall"
  3. Then, create a Responsible Persons chart and pin it on every notice board

Now you don't have to edit your policies AND you have a central chart, always accessible to staff.


  1. Review the policies
  2. Customise them ONLY where appropriate
  3. Ensure staff actually absorb and understand
  4. Test staff knowledge regularly
  5. Keep a record of staff training/reading of policies

What NOT to do

Here are some 3 simple tips to keep things under control

  1. 300 policies are great as a reference library but don't treat them all as frontline policies
  2. Unnecessary policies waste time. The hundreds of cheap policies you got would take a solid 3 months to review
  3. The more policies you have, the more stressful the job becomes, minimise to essential policies only

what suppliers won't tell you about costs

What you could buy

  1. Simple downloadable package: Typically £300 or less. Gives you over 500 policies, procedures, protocols, letters, forms and template documents
  2. Online systems with staff activity logs. Typically £1,000 - £2,000 per annum with over 1,000 pages of guidance

Typical operational costs

  • Time to read every policy: Between one and three solid months, that's why most don't bother.
  • Online systems are efficient for staff tracking, but also add in time to manage and then test knowledge
  • Time to brief all the staff and testing their knowledge typically costs around £15,000 for a small organisation

Saving time and money

  • Publishers would go out of business if they told you that you only need 50 policies and that hardly anything really changes each year.
  • You do not need a policy for every occasion, common sense application of a standard policy often does the job
  • If you are buying this as a useful reference library, be discerning in how you use the material


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