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Protocols, policies and procedures

This page is designed to answer the following questions:

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Your organisation’s agreed ways of working, policies, procedures and protocols should relate to governance, accountability and quality care provision.

Policies and procedures should align with legislation.

For example, Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires that care professionals obtain consent from the care receiver before performing any care action or treatment. Therefore, all policies, procedures and protocols relating to the provision of care or treatment should include guidance about gaining consent.

This means that care professionals will work within the statutory framework and provide high-quality care. Good governance would utilise systems to monitor that staff are complying with policies and procedures, including requesting feedback from service users and other stakeholders (e.g. service users’ families).

If feedback or audits reveal that consent is not always being requested, it is the manager’s responsibility to investigate why this is happening and take action to ensure policies and procedures are followed. Actions could include staff retraining or performance management. The manager will also need to examine if current auditing processes are sufficient or could be improved.


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