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Content reviewed October 2026.

Clinical policy pack

Clinical policies and procedures, written for your hospital, clinic, practice or pharmacy

We write the policies your service needs, from infection control and medicines to chaperoning, consent and pharmacy SOPs, each tied to the law or guidance behind it, and send them in Word and PDF, for £999 + VAT. Or start with the free policy gap audit: check your policies against the ones your service must have, with the law or guidance behind each. For a care home or home care service, see our care policy pack.

Free or written for you

Two ways to get your clinical policies in place

Check your policies with the free gap audit, or have us write the pack for your service.

Free policy gap audit
Free

Check your policies against the ones a hospital, clinic, GP or dental practice, or pharmacy must have. For each one: the law or guidance behind it, what it should cover, and whether yours is in place, missing or out of date, with its owner and review date.

Not included

  • The policies themselves
  • Policies written for your service
  • Word and PDF policy files

A workbook you fill in yourself, by email.

Free, in your inbox within one working day.

Clinical policy pack
£999 + VAT

We write the policies a hospital, clinic, GP or dental practice, or pharmacy needs, for your service.

Included

  • The policies that apply to your setting
  • Each one written for your service
  • Each one tied to the law or guidance behind it

Word and PDF.

Our team will be in touch with follow-up questions to write the pack for your service.

Both options

What each clinical policy covers, and the law or guidance behind it

The free gap audit lists each policy below, for you to check yours against, and with the pack, we write it for your service. Regulation numbers refer to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 unless a card names another law.

Infection prevention and control policy

What it covers

  • Standard precautions, including hand hygiene and protective equipment
  • Isolating patients with an infection, and managing outbreaks
  • Cleaning, disinfecting and decontaminating premises and equipment
  • Safe handling and disposal of sharps and waste
  • Who owns the policy, and when you audit and review it

The law

The standards and guidance

Our guide: Infection control training for your staff

Pharmacy standard operating procedures (SOPs)Pharmacies

What it covers

  • Ordering, storing, preparing, selling, supplying, delivering and disposing of medicines, with records
  • When staff who are not pharmacists may give advice about medicines
  • Which staff are competent for which tasks
  • Cover when the responsible pharmacist is absent or changes
  • Complaints, incidents, and telling staff when a procedure changes
  • Kept at the pharmacy for staff to read, and reviewed regularly

The law

The standards and guidance

Our guide: GPhC inspections: what happens and how to prepare

Medication and medicines management policy

What it covers

  • Supply and ordering, storage, dispensing and preparation
  • Giving, recording and disposing of medicines
  • Training and competence for staff who handle or give medicines
  • Acting on MHRA safety alerts and recalls, and reporting side effects
  • Controlled drugs: storing, transporting, destroying and disposing of them

The law

The standards and guidance

Our guide: Medication training for your staff

Chaperone policy

What it covers

  • Offering a chaperone before the appointment, ideally at booking, and again at the examination
  • Who can act as a chaperone, and the training they need
  • What happens when a patient declines, or no chaperone is available
  • Recording the offer, the patient's decision and who chaperoned
  • Telling patients about the policy in waiting areas, consulting rooms and online

The standards and guidance

Hand hygiene policy

What it covers

  • When to clean hands, from before touching a patient to after touching their surroundings
  • When to use soap and water, and when alcohol hand rub
  • Bare below the elbows, short clean nails, and what jewellery staff may wear
  • Skin care, and products for staff with occupational dermatitis
  • Refresher training, and helping patients clean their hands

The law

The standards and guidance

Our guide: Infection control training for your staff

Information governance policy

What it covers

  • Data protection policies, where proportionate to how you use personal data
  • Accurate, complete and secure patient records, and how long you keep each
  • When and how to report a personal data breach to the Information Commission
  • Confidentiality under the eight Caldicott principles
  • A Caldicott Guardian, where you deliver care for the NHS or a council
  • The NHS Data Security and Protection Toolkit, where you have access to NHS patient data and systems

The law

The standards and guidance

Our guide: Information governance training for your staff

Duty of candour policy

What it covers

  • What counts as a notifiable safety incident
  • Telling the patient, or someone acting for them, in person and as soon as reasonably practicable
  • A true account of the facts, and an apology
  • A written follow-up with the results of any further enquiries
  • Reasonable support, and written records kept securely

The law

The standards and guidance

Our guide: The duty of candour: what regulation 20 requires

Sharps policy

What it covers

  • Avoiding medical sharps, and using safer sharps, where reasonably practicable
  • No recapping of needles, unless a risk assessment calls for it and a device controls the risk
  • Secure sharps containers and written disposal instructions near where staff use sharps
  • Information and training for staff at risk
  • After an injury: recording, investigating, medical advice and any post-exposure treatment
  • Reviewing the policy and procedures at suitable intervals

The law

The standards and guidance

Clinical governance policy

What it covers

  • Audits that assess, monitor and improve quality and safety
  • Assessing, monitoring and reducing risks to patients and others
  • An accurate, complete record for each patient, made at the time and kept securely
  • Records about staff and the running of the service
  • Seeking and acting on feedback to improve the service

The law

The standards and guidance

Our guide: Clinical governance: the 7 pillars and regulation 17

Incident reporting policy

What it covers

  • Telling CQC about deaths and other incidents the 2009 Regulations list
  • Reporting injuries, diseases and dangerous occurrences to HSE
  • Being open with the patient under the duty of candour
  • Reporting problems with medicines and medical devices through the Yellow Card scheme
  • For care under the NHS Standard Contract, a patient safety incident response policy and plan

The law

The standards and guidance

Our guides: PSIRF: what it asks of providers · Incident report form and log

Resuscitation policy

What it covers

  • Resuscitation training at induction and at least yearly, to the level of each person's role
  • Emergency equipment and drugs that staff can reach at once
  • Calling for help, and defibrillation within three minutes where appropriate
  • Decisions about CPR, following the law and national guidance
  • A staff debrief and review after any cardiorespiratory arrest

The law

The standards and guidance

Both options

What else the gap audit covers, and the law behind each area

The gap audit also lists the policies for each area below, for you to check yours against, and with the pack, we write them for your service.

The law and guidance as at 12 November 2026. General information, not legal advice.

CompliantCare · Policy Management

Or keep your policies current, with proof your staff have read them

Your pack arrives in Word and PDF. Policy Management in CompliantCare takes those files in, keeps one current version of every policy and tracks who has read and understood each one, person by person. When a regulation changes, it flags the policies affected, with a redraft ready for you to approve, and when the inspector calls, one click produces the evidence pack.

The Policy Suite plan starts at £149 a month for up to 50 staff, on an annual licence: see CompliantCare pricing.

FAQ

Clinical policies and procedures: common questions

What policies does a private clinic or hospital need?

In England, a clinic or hospital registered with CQC must meet the fundamental standards in the Regulated Activities Regulations 2014, from consent (regulation 11) and safe care and treatment (regulation 12) to good governance (regulation 17) and the duty of candour (regulation 20), and have regard to the code of practice on infection prevention and control. The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 add sharps policies and procedures for healthcare employers. Hospitals have more: NHS trusts, and independent hospitals where 10 or more people work, need standard operating procedures for controlled drugs (Controlled Drugs Regulations 2013, regulation 11), and the Resuscitation Council UK's acute care standards ask for an agreed resuscitation policy. The free policy gap audit lists the policies for each area, with the law or guidance behind each, for you to check yours against.

What policies does a GP practice need?

A GP practice registered with CQC in England must meet the same fundamental standards. NHS England's chaperoning principles ask practices to display information about their chaperone policy in waiting areas, consulting rooms and on their website, and the regulator's GP mythbuster says practices should advertise the policy clearly. A practice that provides NHS services must also handle complaints under the NHS complaints regulations, and the Data Security and Protection Toolkit says every organisation with access to NHS patient data and systems must use it. The free policy gap audit covers each, with the law or guidance behind it.

What policies does a dental practice need?

A dental practice registered with CQC in England must meet the same fundamental standards. Where it takes X-rays, it needs written procedures under the Ionising Radiation (Medical Exposure) Regulations 2017 and local rules under the Ionising Radiations Regulations 2017. NHS England's HTM 01-05 covers the decontamination of instruments, the GDC's standards for the dental team ask for valid consent before treatment, and the Resuscitation Council UK sets quality standards for primary dental care. The free policy gap audit covers each, with the law or guidance behind it.

What policies does a pharmacy need?

The GPhC regulates registered pharmacies in Great Britain, and pharmacy owners must meet its standards for registered pharmacies every day. Its inspection framework expects up-to-date SOPs for every service, and regulation 4 of the Responsible Pharmacist Regulations 2008 sets what those procedures must cover, until the GPhC's first rules for responsible pharmacists come into force. It has said it needs to publish its new rules and standards before 10 December 2026. A pharmacy registers with CQC only where it carries on a regulated activity, such as treatment by a doctor or nurse.

What's in the clinical policy pack, and what does it cost?

The policies that apply to your hospital, clinic, practice or pharmacy, each written for your service and tied to the law or guidance behind it, in Word and PDF. It costs £999 + VAT.

How do I get the clinical policy pack?

Enter your work email on the pack's card above. Our team will be in touch with follow-up questions to write the pack for your service.

What's the difference between the free gap audit and the pack?

The free policy gap audit lists the policies a hospital, clinic, GP or dental practice, or pharmacy must have, with the law or guidance behind each and what each should cover, for you to check yours against: in place, missing or out of date, with its owner and review date. It holds no policies. The pack is those policies, written for your service and tied to the law or guidance behind each, in Word and PDF, for £999 + VAT.

Which country's law does the gap audit follow?

England's, for the services CQC registers: the fundamental standards cover regulated activities in England, as does the code of practice on infection prevention and control, which you must have regard to. For pharmacies, the GPhC's standards cover Great Britain, and the Responsible Pharmacist Regulations cover the UK. Health and safety, sharps, radiation and waste law cover Great Britain; fire safety law and the Mental Capacity Act cover England and Wales; the Controlled Drugs Regulations 2013 cover England and Scotland, and the Misuse of Drugs Regulations 2001 cover Great Britain; and data protection and food safety law cover the UK. Each policy and area above names its law or guidance and where it applies.