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Policies and Procedures

The following policies and procedures are in Adobe PDF document formats. If you do not have the Adobe PDF software installed on your computer, you can download the Adobe PDF Reader from the Adobe website.

To skip to a specific section of policies or procedures, please click on one of the links below:

  1. Clinical
  2. General
  3. Human Resources
  4. Health & Safety
  5. Finance
  6. Medicines Management
  7. Professional Affairs

Please note:  NHS Greater Manchester policies and procedures are available on a separate page - please click here.     

Infection Control guidelines and policies are available here.                        




Consent to Examination or Treatment Policy

Apr  2010

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Title Date
Best Clinical Practice

Jan 2008

Complaints* Nov 2009
Data Protection and Confidentiality Policy 2010
Domestic Abuse - Staff Guidelines Sept 2010
Equity and Choice Policy - Adults March 2011
Freedom of Information August 2011

Incident Management inc Management of Serious Untoward Incidents (SUI)

Sept 2009

Individual Funding Requests Policy June 2011
Information Governance Policy December 2011
Information Security Policy March 2012
Intellectual Property Policy Nov 2006
Media Policy* Sep 2007
Patient Information Policy* Jul 2007
Policy Development Policy July 2009
Procurement Strategy Jan 2010
Procurement Operational Policy Jan 2010
Procurement Contestability Guidance Jan 2010

Raising concerns under the Public Interest Disclosure Act 1998 (Whistleblowing) Policy

July 2009
Records Archiving Procedure May 2011
Records Disposal and Destruction Procedure December 2010

Records Management Policy
Records Management Strategy
Records Management Procedure

Oct 2010
Oct 2010

Records Retention Schedules Policy
Health records retention schedules (PDF, 555K)
Business and corporate (non-health) records retention schedule  (PDF, 430K)

December 2010
Research Governance Policy July 2008
Research Misconduct & Fraud Policy Dec 2005
Risk Management Policy July 2010
Risk Management Strategy  March 2009
Sponsorship policy * July 2007
Standards of Business Conduct and Commercial Sponsorship policy NHS GM policy
Volunteer Policy*

Sept 2008

Serious Incident Commissioning Policy March 2011

* These policies are due for review but will continue to apply until harmonisation of policies within the Greater Manchester Cluster.

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Human Resources

Title Date
Capability Policy* May 2008
Career Break Policy September 2010
Charter for Staff Specialists*

Sep 2006

Christmas Eve Arrangements* Dec 2006
Dignity and Respect at Work Policy* June 2009
Disagreement Policy* Mar 2008
Disciplinary Policy* July 2009
Doctors & Dentist Disciplinary Framework March 2010
Domestic Abuse Employee Policy January 2011
Equal Opportunities Policy* July 2008
Flexible Working Policy* Dec 2007
KSF Performance and Development Review Policy* March 2011

Job Share Policy*

Dec 2007

Managing Allegations Against Staff Working with Children & Young People.

June 2010

Managing Allegations Against Staff Working with Children & Young People (Guidance for Safer Working Practices)

June 2010

Managing Attendance Policy*

May 2008
Mandatory Training and Induction Policy* July 2010
Maternity Policy* July 2008
Organisational Change, Redundancy, Redeployment and Protection of Pay and Conditions of Service*

July 2009

Redeployment Policy September 2010
Retirement Policy Jan 2008
Social Networking Websites, Personal Websites and Weblogs Policy September 2010
Special Leave Policy*

Dec 2007

Term Time & Annualised Hours Policy* Mar 2008
TOIL / Flexitime Policy* May 2008

* These policies are due for review but will continue to apply until harmonisation of HR policies within the Greater Manchester Cluster.

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Health and Safety



Asbestos Management Policy

May 2011

Asbestos Management Plan

May 2011

Display Screen Equipment Policy

Mar 2010

Health & Safety Policy

July 2010

Lone Worker Policy

Jul 2008

Management of Contractors Policy

July 2011

Security Policy

June 2009

Tackling Stress at Work

July 2009

Waste Management Policy

July 2011

Manual Handling Policy Sept 2010
Pest Policy June 2011

Laundry Policy

June 2011

Fire Precautions Policy March 2009
First Aid at Work March 2010
Driving for Work March 2010
Spillage of Blood and other Bodily Fluids Policy June 2011
Food Policy May 2011

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Title Date
Counter Fraud Jun 2009
NHS Manchester Scheme of Delegation August 2011
Scheme of Delegation - NHS GM procedure  
Standing Orders - NHS GM procedure  
Standing Financial Instructions - NHS GM procedure  

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Medicines Management



Medicines Policy 2011
Security of Prescriptions - Appendix B June 2011
Do Not Prescribe List Aug 2011
Medicines Transcribing Guidelines 2011

Antibiotic Guidelines


Asthma Guidelines 2010
COPD Guidelines (Currently under review)


Diabetes Guidelines 2010
Hypertension Guidelines Nov 2011
Hyperlipidaemia Guidelines 2010
Red/Amber/Green Drug List  
Secondary Prevention of CHD 2008
Non-Medical Prescribing Policy Jan 2009

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Professional Affairs



Procedure for Identifying and Managing Concerns in relation to Primary Care Contractors

October 2011

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