POLICIES UNDER REVIEW

Please download a policy, make any changes and email to Sultan

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Business continuity and incident management plan  - replaced Business continuity policy  
The Business continuity and incident management plan has been developed in collaboration with NHS Surrey heartlands and partners. This will now replace our Business continuity policy.

Hardcopies will be held by off site by Dr M Mohamed and Nine Taylor.

business-continuity-policy-v5.docx business-continuity-policy-v5.docx
Size : 184.411 Kb
Type : docx
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Triage 
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CQC Staff Handbook 
Please mark any changes on policy and email to Sultan by  30 June 2025 
CQC Staff Handbook (Tempate 1.0)-draft.docx CQC Staff Handbook (Tempate 1.0)-draft.docx
Size : 1270.275 Kb
Type : docx
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Raising concerns, freedom to speak up & whistleblowing policy and procedure   
Please mark any changes on policy and email to Sultan b 28 February 2025 
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Patient immunisation guidance document -v1.15 draft 
Please mark any changes on policy and email to Sultan by  28 February 2025 
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Safe water policy 
Please mark any changes on policy and email to Sultan by  28 February 2025 
Safe water policy-v1.4.1.docx Safe water policy-v1.4.1.docx
Size : 687.297 Kb
Type : docx
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Fire policies 
Please mark any changes on policy and email to Sultan by  28 May 2025 
Fire-safety-policy- v1.4.1.docx Fire-safety-policy- v1.4.1.docx
Size : 319.484 Kb
Type : docx
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HR policies from Peninsula  
Hybrid working policy April 2024 (11).docx Hybrid working policy April 2024 (11).docx
Size : 51.817 Kb
Type : docx
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New patient registration and health check policy -v1.15 
Please mark any changes on policy and email to Sultan by  31 December 2024 
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Practice security and risk assessment policy -v1.4  
Please mark any changes on policy and email to Sultan b15 November 2024 
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Access to medical records policy  
Please mark any changes on policy and email to Sultan by  31 December 2024 
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UK GDPR policy -v1.3 
Please mark any changes on policy and email to Sultan by 07 December 2024 
UK GDPR policy -v1.3.docx UK GDPR policy -v1.3.docx
Size : 99.309 Kb
Type : docx
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Model primary care safeguarding Adults Children policy -v1.2 August 2024 
Policy updated by Dr Tara Jones. 

Please email any comments to Sultan by 15 September 2024.

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Cold chain policy -v1.10  
Please mark any changes on policies and email to Sultan by 20 October 2024 
Cold chain policy -v1.10.docx Cold chain policy -v1.10.docx
Size : 131.443 Kb
Type : docx
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Identification of carers - new policy replacing the current one  
The current policy "Carer identification protocol -v3" is being replaced by "Identification of carers policy v1.5" (from PI).

Please mark any changes on policy and email to Sultan by 30 May 2024. 

carers-identification-protocol--v3.doc carers-identification-protocol--v3.doc
Size : 53 Kb
Type : doc
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Clear desk and clear screen policy 
Please mark any changes on policies and email to Sultan by 31 July 2024 
Clear desk and clear screen policy-v1.1.docx Clear desk and clear screen policy-v1.1.docx
Size : 49.039 Kb
Type : docx
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Patient specific directions policy & Patient group directions  
Please mark any changes on policies and email to Sultan by 30 May 2024 
Patient group directions -v1.2 -draft.docx Patient group directions -v1.2 -draft.docx
Size : 706.938 Kb
Type : docx
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Staff immunisation policy 
Please mark any changes on policy and email to Sultan by 28 February 2024 
Staff immunisation policy -v1.13 DRAFT--.docx Staff immunisation policy -v1.13 DRAFT--.docx
Size : 134.41 Kb
Type : docx
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Cleaning standards and schedule policy  
Please mark any changes on policy and email to Sultan by 28 February 2024 

Please note - retention of IPC audit and cleaning records for a period of 5 years to align with all other clinical audits

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Correspondence management policy   
Please mark any changes on policy and email to Sultan by 30 May 2024 

Louise - Any changes needed to appendix B & C?

Correspondence management policy -v1.5-.docx Correspondence management policy -v1.5-.docx
Size : 80.582 Kb
Type : docx
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Bring your own device policy   
Please mark any changes on policy and email to Sultan by 15 March 2024 
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DMARD monitoring guidance document v1.1  
Please mark any changes on policy and email to Sultan by 15 March 2024 
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Death of patient policy & bereavement guidance (England & Wales) v1.15  
Please mark any changes on policy and email to Sultan by 15 April 2024 
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Accessible information standard policy 
Please mark any changes on policy and email to Sultan by 30 April  2024 
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Mobile phone policy - Staff  
Please mark any changes on policy and email to Sultan 
Mobile Phone Policy Staff -v4.doc Mobile Phone Policy Staff -v4.doc
Size : 42 Kb
Type : doc
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Compliments policy  
Please mark any changes on policy and email to Sultan by 15 April 2024 
Compliments Policy -v1.0.docx Compliments Policy -v1.0.docx
Size : 47.465 Kb
Type : docx
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First aid policy  -v1.2 
Please mark any changes on policy and email to Sultan by 30 April  2024 
First aid policy -v1.2.docx First aid policy -v1.2.docx
Size : 61.999 Kb
Type : docx
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Moving and handling policy  -v1.2 
Please mark any changes on policy and email to Sultan by 30 April  2024 
Moving and handling policy -v1.2 draft.docx Moving and handling policy -v1.2 draft.docx
Size : 643.206 Kb
Type : docx
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Risk assessment guidance document -v1 
Please mark any changes on policy and email to Sultan by xxxx xxxx 2024 
risk-assessment-guidance-document-v1.docx risk-assessment-guidance-document-v1.docx
Size : 334.348 Kb
Type : docx
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Please mark any changes on policy and email to Sultan by xxxx xxxx 2024 
Protocol for reasonable adjustments -v1 
Protocol for Reasonable adjustments-v1.docx Protocol for Reasonable adjustments-v1.docx
Size : 29.598 Kb
Type : docx
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Patient text messaging (SMS) policy -v1.1  
Please mark any changes on policy and email to Sultan by 5 April 2024 
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Privacy policies 
Please mark any changes on policy and email to Sultan by xxxx xxxx 2024 
privacy-notice -v2.docx privacy-notice -v2.docx
Size : 19.034 Kb
Type : docx
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Allergies, intolerances and sensitivities guidance document -v1.4 
Please mark any changes on policy and email to Sultan by xxxx xxxx 2024 
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Home visits protocol -v2--draft 
Please mark any changes on policy and email to Sultan by xxxx xxxx 2024 
home-visits-protocol-v2--draft.doc home-visits-protocol-v2--draft.doc
Size : 154 Kb
Type : doc
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Medicines and medical gases storage protocol -v1.4 
Please mark any changes on policy and email to Sultan by xxxx xxxx 2024 
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Patient registration and new health check policy -v1.3 
Please mark any changes on policy and email to Sultan by xxxx xxxx 2024 
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Audio, visual and photogrraphy policy 
Please mark any changes on policy and email to Sultan by xxxx xxxx 2024 
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Fire   
What needs to be done by 30 October 2023: 

- complete Fire Safety Checklist in Annex A of the Fire safety policy document

-Review Personal and emergency evacuation plan policy

-complete personal emergency evacuation plan (PEEK) - Annex A

-complete general emergency evacuation plan (GEEK) - Annex B

-review fire system test procedure

-discuss at a practice meeting

Fire-safety-policy-v1.4------.docx Fire-safety-policy-v1.4------.docx
Size : 319.122 Kb
Type : docx
fire-system-test-procedure---v2.doc fire-system-test-procedure---v2.doc
Size : 359 Kb
Type : doc
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Clinical guidance document- Sepsis  
What needs to be done by 30 October 2023:

- mark any changes on policy and email to Sultan. 

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Did not attend (DNA)   
What needs to be done by 30 October 2023:

- mark any changes on policy and email to Sultan. 

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Disclosure & Barring Service (DBS) Policy -v1.7  
Please mark any changes on policy and email to Sultan by 30 November 2023. 
DBS policy -v1.7-.docx DBS policy -v1.7-.docx
Size : 229.916 Kb
Type : docx
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Duty of candour Policy -v1.5  

Please mark any changes on policy and email to Sultan by 30 November 2023.

Duty-of-candour-policy-v1.5.docx Duty-of-candour-policy-v1.5.docx
Size : 559.502 Kb
Type : docx
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Translation & interpreter policy  
The current policy has been updated and references to KLOE have been removed.

Please mark any changes on policy and email to Sultan by 31 December 2023.

Translator-and-interpreter-policy-v1.2.docx Translator-and-interpreter-policy-v1.2.docx
Size : 42.335 Kb
Type : docx
Translator-and-interpreter-policy-v1.docx Translator-and-interpreter-policy-v1.docx
Size : 1302.373 Kb
Type : docx
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Prescribing policy 
The current policy v1.16 has been updated v1.18 and references to KLOE have been removed.

Please mark any changes on policy and email to Sultan by 31 December 2023. Comments have been received from Neha Patel (Surrey Heartlands) 18 Jan24

Policy now issued as Prescribing policy-v1.18-revised

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Prescribing-policy-v1.18-revised.docx Prescribing-policy-v1.18-revised.docx
Size : 357.566 Kb
Type : docx
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Prescribing-policy-v1.18----.docx Prescribing-policy-v1.18----.docx
Size : 355.682 Kb
Type : docx
Prescribing-policy-v1.18.docx Prescribing-policy-v1.18.docx
Size : 355.944 Kb
Type : docx
Prescribing policy -v1.16-.docx Prescribing policy -v1.16-.docx
Size : 355.519 Kb
Type : docx
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NHS services whilst abroad protocol  
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Phlebotomy guidance document 
Phlebotomy-guidance-document -v1.3.docx Phlebotomy-guidance-document -v1.3.docx
Size : 75.029 Kb
Type : docx
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Business development plan  
practice-list-size.docx practice-list-size.docx
Size : 65.239 Kb
Type : docx
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Safe water policy - Legionnaires  
Safe water policy-v1.4--.docx Safe water policy-v1.4--.docx
Size : 59.122 Kb
Type : docx
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CCTV monitoring policy  & other documents 
CCTV-monitoring-policy-v1.3.docx CCTV-monitoring-policy-v1.3.docx
Size : 247.064 Kb
Type : docx
DPIA CCTV- SHC.docx DPIA CCTV- SHC.docx
Size : 40.218 Kb
Type : docx
CCTV-audit.docx CCTV-audit.docx
Size : 31.946 Kb
Type : docx
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Information asset register 
Information Asset Register -v1.0--.xlsx Information Asset Register -v1.0--.xlsx
Size : 71.617 Kb
Type : xlsx
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COSHH risk assessment guidance document -v1.0  
Please send comments to Sultan by 15.06.2023 

The new policy will replace existing policy.

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Gender Dysphoria 
Please send comments to Sultan by 31.07.2023 

The clinical guidance document on Gender Dysphoria will replace the existing policy on the same topic.

gender-dysphoria-policy--v2.docx gender-dysphoria-policy--v2.docx
Size : 47.556 Kb
Type : docx
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The Governance Handbook  

The Governance Handbook details the governance requirements that must be considered within any primary care setting.

The handbook covers: (1) 
Clinical governance (2) Corporate governance (3) Financial governance (4) Information governance 

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Infection control prevention policy -v1.16  
Please send comments to Sultan by 25.01.2023 

The new policy will replace existing policy.

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Clinical guidance document- medical emergencies to replace Medical emergencies policy 
The clinical guidance document on medical emergencies will replace the medical emergencies policy .

Please send comments to Sultan by 30.07.2023 

medical-emergencies-policy-v1.docx medical-emergencies-policy-v1.docx
Size : 4314.378 Kb
Type : docx
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DNACPR policy (England)-v1.3 
Please send comments to Sultan by 15.01.2023 
DNACPR policy (England)-v1.3.docx DNACPR policy (England)-v1.3.docx
Size : 75.992 Kb
Type : docx
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Central alerting system policy 
Please send comments to Sultan by 31.12.2022 
Central-alerting-system-policy-v1.6.docx Central-alerting-system-policy-v1.6.docx
Size : 435.719 Kb
Type : docx
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Clinical guidance document - six-to-eight week baby check policy 
Please send comments to Sultan by 31.12.2022 
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Clinical guidance document - patient immunisation 
Current policy updated -24.11.22 - please send comments to Sultan by 31.12.2022 
patient-immunisation-policy-v1- (3).docx patient-immunisation-policy-v1- (3).docx
Size : 52.48 Kb
Type : docx
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Chaperone policy 
Current policy (v2) retired and replaced by policy adapted from Practice Index (see v1.9) - 22.11.22 -please send comments to Sultan by 31.12.2022
chaperone-policy-v2.doc chaperone-policy-v2.doc
Size : 35 Kb
Type : doc
Chaperone-policy-v1.9.docx Chaperone-policy-v1.9.docx
Size : 249.707 Kb
Type : docx
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Access to medical records policy 
please send comments to Sultan by 31.12.2022 -reviewed
Access-to-medical-records-policy-v1.13--.docx Access-to-medical-records-policy-v1.13--.docx
Size : 358.144 Kb
Type : docx
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Mental capacity act policy 
please send comments to Sultan by 29.02.2023
Mental capacity act policy-v1.3-.docx Mental capacity act policy-v1.3-.docx
Size : 55.597 Kb
Type : docx
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Managing incoming pathology results 
Management of test results protocol is to be replaced by Managing of incoming pathology results.

Please send comments to Sultan by 31.01.2023

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Clinical guidance document -learning disability 
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Complaints policy 
Complaints procedure - England -v1.15.docx Complaints procedure - England -v1.15.docx
Size : 619.618 Kb
Type : docx
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Fire  - policies reviewed 
Fire-safety-policy-v1.4.docx Fire-safety-policy-v1.4.docx
Size : 523.239 Kb
Type : docx
fire-marshal-warden-guidance-v1.docx fire-marshal-warden-guidance-v1.docx
Size : 155.898 Kb
Type : docx
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UK GDPR policy
UK GDPR policy -v1.2.docx UK GDPR policy -v1.2.docx
Size : 344.568 Kb
Type : docx
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National Data Opt-out Guidance 
National-data-opt-out-guidance-v1.4.docx National-data-opt-out-guidance-v1.4.docx
Size : 253.442 Kb
Type : docx
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Dealing with unreasonable, violent and abusive patients policy 
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New joining clinicians handbook
New-joining-clinicians-handbook-v1.docx New-joining-clinicians-handbook-v1.docx
Size : 108.683 Kb
Type : docx
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Clinical supervision policy 
clinical-supervision-policy-v1.3.docx clinical-supervision-policy-v1.3.docx
Size : 84.283 Kb
Type : docx
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Removal of patients policy 
removal of patients policy-v1.6.docx removal of patients policy-v1.6.docx
Size : 72.398 Kb
Type : docx
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Cleaning standards and schedule policy 
Cleaning-standards-and-schedule-policy-v1.3.docx Cleaning-standards-and-schedule-policy-v1.3.docx
Size : 1053.354 Kb
Type : docx
GP mythbuster 99.docx GP mythbuster 99.docx
Size : 19.548 Kb
Type : docx
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Emergency incident procedure 
Nine please comment on the updated  procedure. Thanks
emergency_incident_procedure--v2.doc emergency_incident_procedure--v2.doc
Size : 60 Kb
Type : doc
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Needlestick injuries protocol 
Wendy please comment on the updated needlestick injury protocol. Thanks
needlestick-injuries-protocol--v2.doc needlestick-injuries-protocol--v2.doc
Size : 131.5 Kb
Type : doc
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Quality assurance policy
quality-assurance-policy--v2--.docx quality-assurance-policy--v2--.docx
Size : 56.111 Kb
Type : docx
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Maternity leave and pay policy and procedure 
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Staff immunisation policy 
Staff-immunisation-policy-v1.11-draft.docx Staff-immunisation-policy-v1.11-draft.docx
Size : 308.948 Kb
Type : docx
Letter to staff about Covid-19 vaccination as a condition of employment- no longer valid 
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Locum policy
locum-policy -v2.docx locum-policy -v2.docx
Size : 80.13 Kb
Type : docx
locum-manager-agreement-v1.docx locum-manager-agreement-v1.docx
Size : 46.17 Kb
Type : docx
Locum manager agreement is now incorporated in the revised version of locum policy v2, above

All comments to Sultan

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Whistleblowing policy 
Replaced current policy (now retired) by Practice Index version which is updated regularly
whistleblowing-policy-and-procedure-v1.docx whistleblowing-policy-and-procedure-v1.docx
Size : 53.843 Kb
Type : docx
whistleblowing-policy--v1.doc whistleblowing-policy--v1.doc
Size : 44 Kb
Type : doc
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Fire policy 
fire-safety-policy-v1.docx fire-safety-policy-v1.docx
Size : 39.942 Kb
Type : docx
fire-marshal-warden-guidance-v1.docx fire-marshal-warden-guidance-v1.docx
Size : 154.962 Kb
Type : docx
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Prescribing policy 
Aim to replace current policy with revised version from Practice Index (prescribing policy). The policy also includes a section on high risk medicines and appropriate monitoring.
Prescribing policy -v1.16.docx Prescribing policy -v1.16.docx
Size : 355.091 Kb
Type : docx
repeat-prescribing-policy--v2.doc repeat-prescribing-policy--v2.doc
Size : 63 Kb
Type : doc
Cervical screening - current policy and new draft policy
cervical-screening-protocol-v3-.doc cervical-screening-protocol-v3-.doc
Size : 115 Kb
Type : doc
Cervical screening policy - v3.docx Cervical screening policy - v3.docx
Size : 72.638 Kb
Type : docx
cervical-screening-policy-v2--.docx cervical-screening-policy-v2--.docx
Size : 68.974 Kb
Type : docx
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Pandemic management policy  
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Caldicott policy 
Replaced current policy (now retired) by Practice Index version which is updated regularly
Caldicott-and-confidentiality-policy-v1.docx Caldicott-and-confidentiality-policy-v1.docx
Size : 300.311 Kb
Type : docx
caldicott-protocol--v1.doc caldicott-protocol--v1.doc
Size : 96.5 Kb
Type : doc
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Patient participation group policy 
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Communication policy 
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Correspondence management policy 

Annex1 Docman process & Annex 2 Out of hours reports transfer added

See document under Practice policies

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Mental capacity act policy 
Current policy - now retired & replaced by alternative version - from Practice Index with regular updates
mental-capacity-act-policy-v2.docx mental-capacity-act-policy-v2.docx
Size : 53.404 Kb
Type : docx
Emergency drugs policy and risk assessment 
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Infection prevention control policy 
The Practice Index policy is more comprehensive and is updated frequently by them. The PI policy will be used henceforth in preference to our current policies.
Our current policies - to be retired
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Business risk assessment guidance document
COSHH risk assessment guidance document
COSHH-risk-assessment-guidance-document-v1.docx COSHH-risk-assessment-guidance-document-v1.docx
Size : 452.122 Kb
Type : docx
Risk and issues guidance document
risk-and-issues-guidance-document--v1.docx risk-and-issues-guidance-document--v1.docx
Size : 68.593 Kb
Type : docx
Risk assessment guidance document
risk-assessment-guidance-document-v1.docx risk-assessment-guidance-document-v1.docx
Size : 333.895 Kb
Type : docx
Medical emergencies policy 
medical-emergencies-policy-v1-under review.docx medical-emergencies-policy-v1-under review.docx
Size : 4091.135 Kb
Type : docx
Pandemic staffing policy
Performance appraisal documentation 
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Summarising policy 
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Clinical guidance document - FGM
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Managing incoming pathology results 
Aim to replace current policy with revised version from Practice Index
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policy 
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Appointment punctuality policy 
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Emergency equipment Defibrillator checklist 
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Emergency equipment Oxygen checklist 
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portable-device-policy -v1.docx portable-device-policy -v1.docx
Size : 64.221 Kb
Type : docx
remote-access-to-IT-systems-policy-v1.docx remote-access-to-IT-systems-policy-v1.docx
Size : 85.112 Kb
Type : docx
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accident-reporting-policy-v1-under review.docx accident-reporting-policy-v1-under review.docx
Size : 42.129 Kb
Type : docx
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social-media-notice-for-patients.docx social-media-notice-for-patients.docx
Size : 535.424 Kb
Type : docx
Homeworking policy and procedures.docx Homeworking policy and procedures.docx
Size : 97.62 Kb
Type : docx
Audio visual recording policy 1.1 .docx Audio visual recording policy 1.1 .docx
Size : 113.518 Kb
Type : docx

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