Policies and Procedures in Health and Social Care: What They Are and Why CQC Cares
A policy says what your service commits to. A procedure says how staff do it. Here is the difference, real examples, and what inspectors look for when they check that both are current and followed.
In health and social care, a policy is a written statement of what an organisation commits to and expects, and a procedure is the step-by-step instruction staff follow to carry it out. Together they keep care consistent and safe, and they are core evidence that a service is well-led under CQC Regulation 17.
“Policies and procedures” is one of the most searched phrases in adult social care, and it is often used loosely. This guide gives clear definitions, examples from a care home or home care service, and the practical question that matters for registered providers: how do you show CQC that they are current and actually used?
Key takeaways
- A policy states the standard and the reason. A procedure states who does what, in what order.
- CQC does not publish a single mandatory policy list, but its regulations imply a core set every provider needs.
- Policies and procedures count as governance records under Regulation 17.
- Inspectors test them through staff answers and records, not just by reading the document.
- Generic, copied policies that do not describe your service are a common weakness.
In this guide
Policy vs Procedure: The Difference
| Policy | Procedure | |
|---|---|---|
| What it is | A statement of principles, responsibilities and expected standards | The practical steps to carry the policy out |
| Answers | What do we do, and why? | How, who and when? |
| Changes | Rarely, when law, guidance or your stance changes | More often, as practice or systems change |
| Example: safeguarding | We do not tolerate abuse and we report all concerns | Step-by-step: who to tell, how to record it, how to refer to the local authority, in what timescale |
You will also hear “protocol”, “guidance” and “standard operating procedure” used in the same space. For most care providers the working distinction is the one above: the principle, then the practice.
Examples of Policies and Procedures in a Care Setting
- Safeguarding adults: the policy sets zero tolerance and duties; the procedure covers recognising, reporting and referring concerns. See the safeguarding referral process.
- Medicines management: ordering, storage, administration, recording and error reporting. See our medication error log.
- Complaints: how people can complain, who investigates and the response timescales. See the complaints log.
- Mental capacity and DoLS: how capacity is assessed and how restrictions are authorised. See MCA and DoLS in practice.
- Whistleblowing: how staff raise concerns safely. See our whistleblowing policy guide.
- Infection prevention and control, fire safety, health and safety, data protection, recruitment and supervision.
For the set CQC-registered providers are most often expected to hold, see our required policies list.
Why Policies and Procedures Matter to CQC
CQC’s Regulation 17 requires systems and processes that assess, monitor and improve quality and safety. Its guidance lists governance records that evidence this, including “policies and procedures”, alongside audits, reviews and action plans (CQC: Regulation 17). Policies also underpin other regulations, for example safeguarding under Regulation 13 and complaints under Regulation 16.
The practical stake is consistency. If two staff would handle the same medicines error two different ways, that is a governance problem inspectors will find quickly.
What a Good Policy Looks Like
- Specific to your service. Names your roles, your local safeguarding contacts and your systems.
- Clear ownership. One named person is responsible for keeping it current.
- Dated and versioned, with a next review date. See how often to review care policies.
- Written in plain language that a new starter can follow.
- Backed by a procedure, so the “what” always has a “how”.
- Known to staff, through induction, supervision and team meetings.
Common Mistakes Inspectors Notice
- Bought or copied templates left unedited, including another provider’s name or local authority.
- Policies with no review date or an overdue one.
- Staff who cannot describe the procedure when asked.
- Practice that contradicts the policy, for example a two-signature medicines rule that daily records show is not followed.
- Missing policies for regulated activities the service actually delivers.
A useful self-check is to pick three policies and ask three staff to explain the procedure, then compare. Our mock inspection questions give you a starting script.
Managing Them in Practice
The workable approach is a single register of all policies with an owner, version and review date, checked against the list you need. CQCLogic includes a policy register that records each policy’s version, review date and owner, holds the policy file, and compares your register with a built-in list of 30 required policies to show gaps. It is not a policy-writing service, so your policies still need to reflect how your service actually works.
Track them in one place
See a sample improvement plan, view pricing or get started free.
Frequently Asked Questions
What is a policy and procedure in health and social care?
A policy states what a service commits to and expects, such as protecting people from abuse. A procedure sets out the steps staff follow to do it, such as who to tell and how to record a concern.
What is the difference between a policy and a procedure?
A policy answers “what and why”. A procedure answers “how, who and when”. Policies change rarely; procedures change as practice and systems change.
What are examples of policies and procedures in a care home?
Safeguarding adults, medicines management, complaints, mental capacity and DoLS, whistleblowing, infection prevention and control, fire safety, data protection, recruitment and staff supervision.
Why are policies and procedures important in health and social care?
They keep care consistent and safe, protect people using the service and staff, and are governance evidence under CQC Regulation 17.
Does CQC require specific policies?
CQC does not publish a single mandatory list, but its regulations require providers to have systems for areas such as safeguarding, complaints and medicines. See our required policies list.
How often should policies be updated?
CQC sets no fixed interval. At least yearly, and after any change in law, an incident or an inspection finding, is the common standard. See our review guide.
Sources: CQC: Regulation 17, Good governance