Quality Policies

The quality related Strategies, Policies, Procedures and Guidance below are categorised by Trust Directorate so it is easier for you to find which document you are looking for.

To provide the Trust with assurances that the organisation is delivering a high quality and safe service to the public and its employees, the Quality Directorate is made up of the following eight key functions;

  • Quality Compliance
  • Patient Experience
  • Risk, Safety and Security
  • Clinical Quality
  • Clinical Safety
  • Informatics
  • Performance Improvement
  • Legal Services


Quality CompliancePatient ExperienceRisk, Safety & SecurityClinical QualityClinical SafetyInformaticsPerformance Improvement

Legal Services

Quality Improvement Strategy

Making Experiences Count Policy

Risk Management Policy

Capacity to Consent Policy

Communicable Diseases Policy

Department of Health Sharing Guidance

Data Quality Policy

Claims Policy



Quality Impact Assessment - Approval & Review Procedure

Making Experiences Count Procedure

Risk Management Procedure

Clinical Audit Policy

Infection Prevention Control Procedure

Information Governance Strategy

Quality Impact Assessment Template

4 C's Report 12/13

4 C's Report 11/12

4 C's Report 10/11

Safety Improvement Plan

Medicine Management Policy

Latex Sensitivity Policy Information Governance Policy  
'Being Open' Duty of Candour Procedure   Quality Improvement Strategy

Medicine Management Procedure Toolkit

Safeguarding Vulnerable Persons Policy  Information Sharing Agreement  
Duty of Candour Responsibilities - Staff Information    

North West Regional Policy and Guidance for Conveying Mental Health Patients

Domestic Abuse Procedure Records Management Strategy  
Quality Account 2015/16    

North West Regional Mental Capacity Act Joint Protocol

Sudden Unexpected Death in Childhood Procedure Records Management and Life Cycle Policy  

ELMS Pilot Visiting GP Services Operational Procedure

Linen Policy

Patient Information Confidentiality Policy






Research and Development Governance Framework

Safeguarding Vulnerable Persons Procedure

Clinical Records Management Policy & Procedure


Diagnosis of Death Procedure

  Patient Report Forms: Quality Management Procedure 2015  

Community Care Pathways Operational Procedure

  IM&T Security Policy  




Healthcare Governance Alert & Guidance Review Procedure





Pilot Visiting GP Referral Services Procedure including BARDoC, Mastercall, Go To Doc and FCMS Operational Procedure