How we keep care safe at Ready Health

1. Purpose

This policy sets out how Ready Health is led, governed and held to account so that every service we provide is safe, effective, caring, responsive and well-led. It describes the structures, meetings, reporting lines and assurance processes that give the directors confidence that standards are being met and that risks are identified and managed.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health operates a clear governance framework with named accountability at director level. The Registered Manager is accountable to the CQC for the day-to-day management of regulated activities; the Clinical Directors are jointly accountable for clinical quality and safety.
• Governance is proportionate to the size of the clinic but is systematic: decisions are documented, actions are tracked to completion, and assurance is based on evidence rather than assumption.
• All policies are version-controlled, approved by the Registered Manager and a Clinical Director, published to staff and reviewed at least every two years or sooner following an incident, a change in law or guidance, or a change in service.
• Quality assurance draws on audit, incident and complaint data, patient feedback, staff feedback, risk registers and external inspection findings.

4. Roles and responsibilities

Registered Manager (Mr Shamir Patel)

Leads the governance framework, chairs the governance meeting, maintains the policy library, submits statutory notifications to the CQC and ensures actions are completed.

Clinical Director (Dr Venkata Bandaru)

Provides clinical leadership and challenge, co-approves policies, leads safeguarding and signs off clinical audit findings.

All staff and contractors

Follow policies, report concerns, incidents and near misses, and take part in audit, training and learning activity.

5. Procedure

5.1 Governance meeting

• A clinical governance and quality meeting is held at least quarterly, with a standing agenda covering incidents, complaints, safeguarding, medicines safety, audit results, risk register, training compliance, patient feedback, policy updates and external alerts (MHRA, NatPSA, CAS).
• Minutes record attendees, decisions, owners and deadlines. An action log is reviewed at every meeting until each item is closed.

5.2 Assurance dashboard

• The Registered Manager maintains a quality dashboard covering: incidents by category and harm, complaints and response times, audit programme status, mandatory training compliance, DBS and registration checks, equipment servicing, and patient satisfaction.
• Exceptions and adverse trends are escalated to the directors between meetings where required.

5.3 Policy control

• Each policy carries a unique reference, version number, effective date, review date and the approving signatures.
• Superseded versions are archived and retained. Staff confirm they have read new or revised policies, and this is recorded.

5.4 External accountability

• Statutory notifications are made to the CQC under the Care Quality Commission (Registration) Regulations 2009 without delay.
• Ready Health cooperates fully with inspection, commissioner, professional regulator and ICO enquiries.

6. Monitoring and review

• Annual review of the governance framework by the directors.
• Quarterly review of the action log and quality dashboard.
• Outcome of CQC inspection and any provider information returns.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17 (Good governance)
• Care Quality Commission (Registration) Regulations 2009
• CQC Single Assessment Framework – Well-led quality statements

8. Related policies

• Clinical Governance Policy
• Risk Management Policy
• Audit Policy
• CQC Compliance Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy describes how Ready Health continuously improves the quality of its clinical services and safeguards high standards of care. It brings together clinical effectiveness, risk management, patient experience, staff competence, information quality and learning into a single framework.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Every clinician works within their professional scope, current evidence-based guidance and Ready Health protocols.
• Clinical decisions are recorded contemporaneously in the patient record in Semble, with the rationale for prescribing and any deviation from guidance clearly documented.
• Ready Health uses NICE guidance, BNF, SPCs, relevant specialist guidance and national safety alerts to underpin its clinical protocols.
• Clinical governance is a shared responsibility; any member of staff may raise a clinical concern and will be supported to do so.

4. Roles and responsibilities

Clinical Directors

Set clinical standards, approve protocols and clinical templates, review clinical incidents, and lead peer review.

Registered Manager

Ensures governance systems operate, records are kept and actions are completed.

Clinicians (doctors, pharmacist prescribers, nurses)

Practise safely within scope, maintain registration and CPD, participate in audit, peer review and supervision.

5. Procedure

5.1 The pillars of clinical governance

• Clinical effectiveness – protocols for each service (e.g. ADHD assessment and titration, weight management, testosterone therapy, phlebotomy) are evidence-based and reviewed with this policy.
• Clinical audit – an annual audit programme is agreed (see Audit Policy).
• Risk management – clinical risks are recorded on the risk register and reviewed quarterly.
• Patient experience – feedback and complaints inform service changes.
• Staffing and competence – credentials, training and supervision are checked and recorded.
• Information – records are accurate, secure and auditable.

5.2 Safety alerts and guidance

• The Registered Manager receives MHRA Drug Safety Updates, National Patient Safety Alerts and CAS alerts, logs each alert, determines relevance and records the action taken.
• Relevant clinicians are informed within two working days and patient searches are completed where an alert affects prescribed medicines.

5.3 Peer review

• A sample of each prescriber's consultations is reviewed at least annually against the relevant protocol, with feedback recorded.
• New prescribers or new service lines receive enhanced case review during their first three months.

6. Monitoring and review

• Clinical governance standing item at the quarterly governance meeting.
• Annual peer review completion rates.
• Safety alert log reviewed quarterly.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance), HSCA 2008 (RA) Regulations 2014
• GMC Good Medical Practice; GPhC Standards for Pharmacy Professionals; NMC Code
• NICE guidance and MHRA Drug Safety Update

8. Related policies

• Governance and Quality Assurance Policy
• Audit Policy
• Prescribing Policy
• Scope of Practice Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out Ready Health's approach to continuous quality improvement (QI), so that learning from data, feedback and incidents is turned into measurable improvements for patients.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health uses a simple, recognised QI method – the Model for Improvement with Plan-Do-Study-Act (PDSA) cycles – for improvement work.
• Improvement priorities are chosen using evidence: audit results, incident trends, complaints, patient feedback, staff suggestions and external benchmarks.
• Every improvement project has an owner, a measurable aim, a timescale and a documented outcome.
• Staff at every level are encouraged to suggest improvements; suggestions are acknowledged and considered at the governance meeting.

4. Roles and responsibilities

Registered Manager

Maintains the QI log, supports project owners and reports progress to the governance meeting.

Clinical Directors

Prioritise clinical improvement projects and approve changes to clinical practice.

Staff

Identify improvement opportunities and participate in projects.

5. Procedure

5.1 Running an improvement project

• Define the problem and the aim (what we want to achieve, by how much, by when).
• Agree measures – outcome, process and balancing measures.
• Test changes on a small scale using PDSA cycles and record the results.
• Adopt, adapt or abandon each change based on the data.
• Embed successful changes into policy, templates or training and share the learning.

5.2 Sources of improvement ideas

• Patient satisfaction surveys and online reviews.
• Incident, complaint and safeguarding themes.
• Audit and re-audit findings.
• Staff meetings, appraisals and supervision.

6. Monitoring and review

• QI log reviewed at each governance meeting.
• At least two documented improvement projects completed per year.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 17 (Good governance), HSCA 2008 (RA) Regulations 2014
• NHS England – Quality, service improvement and redesign (QSIR) tools
• Institute for Healthcare Improvement – Model for Improvement

8. Related policies

• Audit Policy
• Learning from Incidents Policy
• Complaints Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy establishes how Ready Health plans, conducts and acts on clinical and non-clinical audits to provide assurance that care meets agreed standards and to drive improvement.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health maintains an annual audit programme approved at the governance meeting.
• Audits measure practice against explicit standards (NICE, national guidance or Ready Health protocols) and complete the audit cycle through re-audit.
• Audit data is handled in line with UK GDPR; patient-identifiable data is minimised and stored securely.
• Findings, actions and re-audit dates are recorded and reported to the directors.

4. Roles and responsibilities

Registered Manager

Maintains the audit programme and log, allocates audit leads and tracks actions.

Clinical Directors

Approve clinical audit topics, standards and conclusions.

Audit leads

Plan and carry out audits, present results and propose actions.

5. Procedure

5.1 Minimum annual audit programme

• Prescribing audits for each service line (e.g. ADHD monitoring, GLP-1 weight-management eligibility and follow-up, testosterone monitoring).
• Clinical record-keeping audit.
• Consent documentation audit.
• Infection prevention and control audit and hand hygiene audit.
• Medicines storage and fridge temperature audit; emergency medicines and equipment checks.
• Information governance and access audit.
• Recruitment file and DBS/registration audit.
• Complaints and incidents handling audit.

5.2 Audit cycle

• Select topic and agree standard and target.
• Collect data using a defined sample and method.
• Compare results with the standard, identify gaps and agree SMART actions.
• Implement changes and re-audit within an agreed timeframe, typically 6–12 months.

6. Monitoring and review

• Audit programme completion reported quarterly.
• Proportion of audits with completed re-audit.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 17 (Good governance), HSCA 2008 (RA) Regulations 2014
• HQIP – Best Practice in Clinical Audit
• Health and Social Care Act 2008 Code of Practice on the prevention and control of infections

8. Related policies

• Clinical Governance Policy
• Quality Improvement Policy
• Clinical Records Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health identifies, assesses, controls and monitors risks to patients, staff, visitors, information, finances and reputation.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health maintains a single risk register covering clinical, operational, premises, information, workforce and financial risks.
• Risks are scored consistently using a 5 x 5 likelihood-and-consequence matrix (score 1–25).
• Every risk has a named owner, existing controls, further actions with deadlines, and a target score.
• Risks scoring 15 or above are reported to both directors immediately and reviewed at least monthly.

4. Roles and responsibilities

Registered Manager

Owns the risk register, facilitates risk assessment and reports to the governance meeting.

Clinical Directors

Own clinical risks and agree risk appetite and escalation.

All staff

Identify and report hazards and risks and follow the control measures in place.

5. Procedure

5.1 Risk assessment

• Identify the hazard or risk and who might be harmed.
• Record existing controls and score the current risk (likelihood x consequence).
• Decide further actions, owner and deadline, and set a target score.
• Review the risk at the frequency set by its score: 1–6 annually, 8–12 quarterly, 15–25 monthly.

5.2 Specific risk assessments

• Health and safety, fire, COSHH, legionella, lone working, display screen equipment and new or expectant mothers.
• Data protection impact assessments for new systems or processing (e.g. new software or AI tools).
• Clinical risk assessments for new services or medicines.

5.3 Escalation

• Any risk that could result in serious harm, regulatory breach or service failure is escalated to a director the same day.

6. Monitoring and review

• Risk register reviewed at every governance meeting.
• Annual review of risk scoring and appetite by the directors.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Management of Health and Safety at Work Regulations 1999
• Regulation 12 and Regulation 17, HSCA 2008 (RA) Regulations 2014
• UK GDPR Article 35 (Data protection impact assessments)

8. Related policies

• Health and Safety Policy
• Incident Reporting Policy
• Emergency/Business Continuity Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy explains how staff at Ready Health report, record, investigate and escalate incidents and near misses so that harm is reduced and learning is shared.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health promotes an open, just and learning culture. Staff are encouraged to report incidents and near misses without fear of blame.
• All incidents, including near misses, are reported on the incident log as soon as possible and no later than the end of the working day.
• Incidents are graded by actual and potential harm: no harm, low, moderate, severe, death.
• Statutory and external reporting is completed where required (CQC, RIDDOR, MHRA Yellow Card, ICO, safeguarding, police, CD Accountable Officer).

4. Roles and responsibilities

Staff member involved or witnessing

Makes the area safe, seeks clinical help, informs the Registered Manager and completes the incident report.

Registered Manager

Reviews and grades incidents, decides the level of investigation, makes external notifications and records outcomes.

Clinical Directors

Lead or review clinical investigations and determine whether the Duty of Candour applies.

5. Procedure

5.1 Immediate actions

• Ensure the patient and others are safe; provide or summon clinical care and call 999 if needed.
• Preserve any evidence (equipment, medicines, records).
• Inform the Registered Manager or a director.

5.2 Reporting

• Complete the incident form: date, time, location, people involved, factual description, immediate actions and harm.
• Record factual information in the patient's clinical record where the incident involves a patient.

5.3 Investigation

• Low/no-harm incidents: brief review by the Registered Manager within 5 working days.
• Moderate harm or above, or significant near misses: structured investigation (e.g. After Action Review or root-cause analysis) completed within 20 working days, reviewed by a Clinical Director.

5.4 External notifications

• CQC: death, serious injury, abuse or allegation of abuse, police involvement and other events under the Registration Regulations 2009.
• RIDDOR: specified injuries, dangerous occurrences and reportable diseases to the HSE.
• MHRA Yellow Card: suspected adverse drug reactions and device incidents.
• ICO: reportable personal data breaches within 72 hours.
• Controlled drug incidents to the NHS England CD Accountable Officer.

6. Monitoring and review

• Incident trends reviewed quarterly at the governance meeting.
• Timeliness of investigation and closure audited annually.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Care Quality Commission (Registration) Regulations 2009, Regulations 16–18
• RIDDOR 2013
• UK GDPR Article 33
• NHS Patient Safety Incident Response Framework (principles)

8. Related policies

• Duty of Candour Policy
• Learning from Incidents Policy
• Risk Management Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health meets its statutory Duty of Candour and its wider professional duty to be open and honest with patients when things go wrong.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health is open and transparent with patients and those acting on their behalf in relation to their care and treatment.
• The statutory Duty of Candour applies to any notifiable safety incident – an unintended or unexpected incident that, in the reasonable opinion of a health professional, could result in or appears to have resulted in death, severe harm, moderate harm or prolonged psychological harm.
• An apology is not an admission of liability. Every patient affected by a notifiable incident will receive a sincere apology.
• Every registered professional also follows their own professional duty of candour, including for near misses.

4. Roles and responsibilities

Clinical Directors

Decide whether an incident is notifiable, lead or delegate the candour conversation, and approve the written notification.

Registered Manager

Ensures candour steps are recorded and completed within timescales.

All clinicians

Tell patients when something has gone wrong and escalate promptly.

5. Procedure

5.1 Steps when a notifiable safety incident occurs

• Notify the patient (or their representative) in person as soon as reasonably practicable after becoming aware – normally within 10 working days.
• Give a true account of what is known, explain what further enquiries will be carried out and offer a sincere apology.
• Offer appropriate support, including contact details for a named person.
• Follow up in writing with the information given, the apology and details of the enquiries.
• Share the outcome of any investigation in writing and offer a further meeting.
• Keep a secure written record of all communications.

5.2 Where the patient cannot be contacted or declines

• Record all attempts to contact the patient and any decision by the patient not to engage.

6. Monitoring and review

• All moderate-and-above incidents audited for candour compliance.
• Candour compliance reported at the governance meeting.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 20 (Duty of candour), HSCA 2008 (RA) Regulations 2014
• CQC guidance – Regulation 20: Duty of candour
• GMC/NMC joint guidance – Openness and honesty when things go wrong

8. Related policies

• Incident Reporting Policy
• Complaints Policy
• Learning from Incidents Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy explains how patients and others can raise a complaint with Ready Health, and how complaints are acknowledged, investigated, responded to and learned from.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health welcomes complaints and feedback as an opportunity to improve. Anyone who uses or is affected by our services may complain, as may a representative with the patient's consent.
• Complaints can be made verbally, in writing, by email or through the website, and will be handled fairly, confidentially and without discrimination.
• Making a complaint will never adversely affect a patient's care.
• Complaints should normally be made within 12 months of the event or of becoming aware of it; this may be extended where reasonable.

4. Roles and responsibilities

Registered Manager (Complaints Manager)

Receives, logs, investigates or delegates investigation, and signs the final response.

Clinical Directors

Review complaints involving clinical care and approve clinical responses.

All staff

Try to resolve concerns informally where possible and pass all complaints to the Registered Manager the same day.

5. Procedure

5.1 Timescales

• Acknowledge the complaint within 3 working days, offering a discussion and explaining the next steps.
• Provide a full written response within 20 working days, or explain the reason for any delay and agree a revised date.

5.2 Investigation and response

• Review records, speak with staff involved and consider the patient's desired outcome.
• The response explains what happened, what was found, an apology where appropriate, actions taken, and the next steps available to the complainant.
• Consider whether the Duty of Candour or safeguarding procedures apply.

5.3 If the complainant remains dissatisfied

• Offer a local resolution meeting with a director.
• Stage 2 – internal review: the complainant may ask, within 6 months of the final response, for the complaint to be reviewed by the director not involved in the original response. A written stage 2 response is sent within 20 working days. This is Ready Health's final response.
• Ready Health does not subscribe to an independent complaints adjudication scheme (such as ISCAS). The final response says this clearly and sets out the other routes available below.
• For self-funded private care, patients may seek independent advice from Citizens Advice, or legal advice about their consumer rights.
• For NHS-funded care, signpost to the Parliamentary and Health Service Ombudsman.
• Patients may share their experience with the CQC, which does not investigate individual complaints but uses the information to inform its monitoring.
• Concerns about an individual clinician may be raised with the GMC, GPhC or NMC.

5.4 Record keeping

• Complaint files are kept separately from clinical records and retained for 10 years.

6. Monitoring and review

• Complaints log reviewed at each governance meeting, including themes and timeliness.
• Annual complaints report.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 16 (Receiving and acting on complaints), HSCA 2008 (RA) Regulations 2014
• PHSO – Complaint Standards framework principles
• Consumer Rights Act 2015

8. Related policies

• Duty of Candour Policy
• Learning from Incidents Policy
• Person-Centred Care Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy describes how Ready Health turns incidents, near misses, complaints, safeguarding concerns and external reports into shared learning and sustained change.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Learning, not blame, is the purpose of review. Individual accountability is addressed separately and fairly, in line with a just culture approach.
• Learning is shared with all relevant staff and, where appropriate, with patients and partner organisations.
• Changes arising from learning are tracked until implemented and their effect is checked.

4. Roles and responsibilities

Registered Manager

Collates learning, maintains the learning log and ensures dissemination.

Clinical Directors

Lead review of clinical learning and approve changes to protocols.

All staff

Participate in reviews and apply learning to practice.

5. Procedure

5.1 Sources of learning

• Internal incidents and near misses; complaints and compliments.
• Safeguarding reviews and audits.
• National safety alerts, Prevention of Future Deaths reports and CQC publications.

5.2 Sharing learning

• Learning is summarised in a short 'Learning Bulletin' circulated after each governance meeting.
• Significant learning is discussed at team meetings and signed as read by staff.
• Protocols, templates, checklists and training are updated where needed.

5.3 Checking effectiveness

• Each learning action has a review date. Re-audit or spot-checks confirm the change has been sustained.

6. Monitoring and review

• Learning log and bulletin reviewed quarterly.
• Repeat incidents of the same type monitored as an indicator of effectiveness.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• NHS England – Patient Safety Incident Response Framework
• Regulation 17 (Good governance), HSCA 2008 (RA) Regulations 2014

8. Related policies

• Incident Reporting Policy
• Quality Improvement Policy
• Complaints Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health maintains its registration with the Care Quality Commission and continuously meets the fundamental standards.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• High Street Health Ltd (t/a Ready Health) is registered with the CQC to carry on regulated activities at 22 High Street, Standish, Wigan WN6 0HL and will carry on only the activities for which it is registered.
• Ready Health complies with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Care Quality Commission (Registration) Regulations 2009.
• The CQC rating and link to the latest report are displayed conspicuously on the premises and on the website.
• Ready Health keeps its Statement of Purpose accurate and notifies the CQC of changes.

4. Roles and responsibilities

Registered Manager (Mr Shamir Patel)

Manages the regulated activities, submits notifications, maintains evidence of compliance and liaises with the CQC.

Nominated Individual / Directors

Supervise the management of regulated activities and meet the fit and proper person requirements.

All staff

Understand the fundamental standards and how their role contributes to them.

5. Procedure

5.1 Notifications to the CQC

• Death of a person using the service; serious injury; abuse or allegations of abuse; incidents reported to or investigated by the police; events that stop the service running safely.
• Changes to the Statement of Purpose, registered manager, nominated individual, company details or premises.
• Absence of the Registered Manager for 28 days or more.

5.2 Ongoing compliance

• An evidence folder is maintained against the CQC key questions (Safe, Effective, Caring, Responsive, Well-led) and quality statements.
• A self-assessment against the Single Assessment Framework is completed annually.
• Responses to provider information requests are submitted on time.

5.3 Rating display

• The current rating is displayed at reception and on every page of the website where information about regulated activities appears, with a link to the CQC report.

6. Monitoring and review

• Annual CQC self-assessment reviewed by both directors.
• Notifications log reviewed quarterly.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
• Care Quality Commission (Registration) Regulations 2009
• Regulation 20A (Requirement as to display of performance assessments)

8. Related policies

• Governance and Quality Assurance Policy
• Fit and Proper Persons Policy
• Incident Reporting Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health delivers care that is tailored to each person's needs, preferences, values and goals, and how patients are treated with dignity and respect.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Each patient is treated as an individual. Care plans reflect what matters to the patient as well as clinical need.
• Patients receive clear information about their condition, treatment options, risks, benefits, alternatives and costs before they decide.
• Patients are involved in decisions and supported to manage their own health, including through written information and follow-up.
• Privacy and dignity are respected at all times, including in consultation rooms, during examinations and in all communication.

4. Roles and responsibilities

Clinicians

Use shared decision-making, document the patient's preferences and agree a plan with the patient.

Reception and administrative staff

Provide courteous, accurate information and respect confidentiality at the front desk and on the telephone.

Registered Manager

Monitors patient feedback and acts on themes.

5. Procedure

5.1 Before treatment

• Provide clear written information about the service, fees, what is and is not included, and how to contact the clinic.
• Establish communication needs, reasonable adjustments and preferred name and pronouns.

5.2 During consultation

• Explore the patient's ideas, concerns and expectations; agree goals.
• Offer a chaperone for intimate examinations.
• Share decisions using plain language and check understanding.

5.3 After consultation

• Provide a written summary or plan and safety-netting advice.
• With consent, share relevant information with the patient's NHS GP to support safe, joined-up care.

6. Monitoring and review

• Patient satisfaction survey results reviewed quarterly.
• Record audit for evidence of shared decision-making.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 9 (Person-centred care) and Regulation 10 (Dignity and respect), HSCA 2008 (RA) Regulations 2014
• NICE NG197 – Shared decision making

8. Related policies

• Consent Policy
• Accessible Information/Reasonable Adjustments Policy
• Chaperone Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health obtains valid consent for examination, investigation and treatment.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• No examination, investigation or treatment is carried out without valid consent, except where the law permits (for example, in the best interests of an adult lacking capacity under the Mental Capacity Act 2005).
• Valid consent is voluntary, informed and given by a person with capacity to make the decision.
• Following Montgomery v Lanarkshire (2015), clinicians discuss material risks – those a reasonable person in the patient's position would consider significant – and reasonable alternatives, including no treatment.
• Consent is a continuing process; patients may withdraw consent at any time.

4. Roles and responsibilities

Clinician providing treatment

Is responsible for ensuring valid consent is obtained and documented.

Clinical Directors

Approve consent forms and patient information for each service.

5. Procedure

5.1 Forms of consent

• Written consent is obtained for off-label or unlicensed prescribing, controlled drug treatment (e.g. ADHD stimulants), GLP-1 weight-management treatment, testosterone therapy, and any procedure with significant risk.
• Verbal or implied consent is acceptable for routine examinations and phlebotomy, and is recorded in the notes.

5.2 Information to give

• Nature and purpose of the treatment; benefits; material risks and side effects; alternatives including no treatment; monitoring requirements; costs; and what happens if the patient stops.

5.3 Children and young people

• Young people aged 16–17 are presumed to have capacity. Under-16s may consent if Gillick competent; otherwise consent is obtained from a person with parental responsibility.

5.4 Remote consultations

• Identity is verified before consent is taken, and consent is recorded in Semble with the date and method.

6. Monitoring and review

• Annual consent documentation audit.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 11 (Need for consent), HSCA 2008 (RA) Regulations 2014
• Mental Capacity Act 2005
• GMC – Decision making and consent (2020)
• Montgomery v Lanarkshire Health Board [2015] UKSC 11

8. Related policies

• Mental Capacity Policy
• Person-Centred Care Policy
• Prescribing Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy explains how Ready Health applies the Mental Capacity Act 2005 (MCA) when a person aged 16 or over may lack capacity to make a decision about their care.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Staff apply the five statutory principles: presumption of capacity; support to make decisions; the right to make unwise decisions; best interests; and the least restrictive option.
• Capacity is decision-specific and time-specific.
• Ready Health does not deprive any person of their liberty.

4. Roles and responsibilities

Clinicians

Assess capacity where there is reason to doubt it, record the assessment and, if needed, make best-interests decisions.

Clinical Directors

Provide advice on complex capacity questions.

5. Procedure

5.1 Two-stage capacity test

• Is there an impairment of, or disturbance in the functioning of, the mind or brain?
• If so, does it mean the person is unable to understand, retain, use or weigh the information, or communicate their decision?

5.2 Where a person lacks capacity

• Check for a valid Lasting Power of Attorney (health and welfare), court deputy or Advance Decision to Refuse Treatment.
• Make a best-interests decision, consulting the person's family, carers and others with an interest, and considering their past and present wishes.
• Consider whether the treatment can wait until capacity is regained. Most elective private treatments offered by Ready Health should be deferred rather than given in best interests.

5.3 Recording

• Document the decision in question, how capacity was assessed, the steps taken to support the person and the outcome.

6. Monitoring and review

• MCA training compliance.
• Audit of capacity assessments where recorded.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Mental Capacity Act 2005 and Code of Practice
• Regulation 11 (Need for consent), HSCA 2008 (RA) Regulations 2014

8. Related policies

• Consent Policy
• Safeguarding Adults Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health protects adults with care and support needs from abuse and neglect, and how staff recognise and respond to concerns.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Safeguarding is everyone's responsibility. Any concern is acted on the same day.
• Ready Health follows the Care Act 2014 and the Wigan Safeguarding Adults Board multi-agency procedures.
• Dr Venkata Bandaru is the designated Safeguarding Lead.
• The principles of empowerment, prevention, proportionality, protection, partnership and accountability, and 'Making Safeguarding Personal', underpin our approach.

4. Roles and responsibilities

Safeguarding Lead (Dr Venkata Bandaru)

Advises staff, decides on referrals, liaises with the local authority and maintains safeguarding records.

Registered Manager

Deputises for the Safeguarding Lead, ensures training compliance and notifies the CQC of abuse or allegations.

All staff

Recognise signs of abuse and report concerns immediately.

5. Procedure

5.1 Types of abuse

• Physical, sexual, psychological/emotional, financial or material, neglect and acts of omission, self-neglect, discriminatory, organisational, domestic abuse, modern slavery.

5.2 Responding to a concern

• If a person is in immediate danger, call 999.
• Listen, do not investigate or promise confidentiality, and record the person's own words.
• Report to the Safeguarding Lead the same day.
• The Safeguarding Lead decides on a referral to Wigan Council Adult Social Care, with the adult's consent where possible, unless others are at risk or it is in the public interest.

5.3 Allegations against staff

• Refer to the Registered Manager (or the other director if the manager is implicated); consider suspension, local authority referral, DBS barring referral and professional regulator referral.

5.4 Training

• All staff complete safeguarding adults training at the level appropriate to their role in line with the Adult Safeguarding Intercollegiate Document; clinicians at Level 3; refreshed at least every 3 years.

6. Monitoring and review

• Safeguarding log reviewed at each governance meeting.
• Training compliance reported quarterly.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Care Act 2014 and statutory guidance
• Regulation 13 (Safeguarding service users from abuse), HSCA 2008 (RA) Regulations 2014
• Adult Safeguarding: Roles and Competencies for Health Care Staff (Intercollegiate Document)

8. Related policies

• Safeguarding Children Policy
• Mental Capacity Policy
• Whistleblowing Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health safeguards and promotes the welfare of children and young people under 18 who use our services or who are connected to adults we see.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• The welfare of the child is paramount.
• Ready Health follows Working Together to Safeguard Children 2023 and the Wigan Safeguarding Children Partnership procedures.
• Dr Venkata Bandaru is the designated Safeguarding Lead.
• 'Think Family': staff consider the safety of children in the household when assessing adults (for example, parental mental health, substance misuse or domestic abuse).

4. Roles and responsibilities

Safeguarding Lead (Dr Venkata Bandaru)

Advises staff, makes or approves referrals to children's social care and maintains records.

Registered Manager

Deputises, maintains training records and ensures CQC notifications.

All staff

Recognise signs of abuse, neglect and exploitation and report concerns without delay.

5. Procedure

5.1 Responding to a concern

• If a child is at immediate risk, call 999.
• Record concerns factually, report to the Safeguarding Lead the same day and do not delay a referral to seek consent where this would place the child at greater risk.
• Referrals are made to Wigan Children's Social Care (Start Well) and confirmed in writing within 48 hours.

5.2 Specific risks

• Child sexual and criminal exploitation, female genital mutilation (mandatory reporting to police for regulated professionals where FGM is known in under-18s), radicalisation (Prevent), and fabricated or induced illness.

5.3 Services for young people

• Where children attend (for example, ADHD assessment), a parent or person with parental responsibility is present unless there is a clear, documented reason otherwise.

5.4 Training

• Staff complete safeguarding children training at the level required by the Intercollegiate Document; clinicians seeing children at Level 3; refreshed at least every 3 years.

6. Monitoring and review

• Safeguarding log and referral outcomes reviewed quarterly.
• Training compliance audit.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Children Act 1989 and 2004
• Working Together to Safeguard Children 2023
• Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff (Intercollegiate Document)
• Serious Crime Act 2015 (FGM mandatory reporting)

8. Related policies

• Safeguarding Adults Policy
• Chaperone Policy
• DBS Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health offers and provides chaperones to protect the dignity of patients and support clinicians during intimate or sensitive examinations.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All patients are offered a chaperone for any intimate examination (breasts, genitalia, rectum) and for any examination the patient considers intimate.
• Chaperone availability is advertised in reception, in consultation rooms and on the website.
• Family members or friends are not used as formal chaperones, although patients may bring someone for support.
• Only staff who have been trained and DBS-checked act as chaperones.

4. Roles and responsibilities

Clinician

Offers a chaperone, explains the examination and records the offer and response.

Chaperone

Stays for the whole examination, observes, supports the patient and raises any concerns.

5. Procedure

5.1 Before the examination

• Explain what the examination involves and why it is needed; obtain consent.
• Offer a chaperone. If declined and the clinician is not comfortable proceeding, rearrange the appointment.

5.2 During the examination

• Provide privacy to undress and a gown or cover; the chaperone stands where they can see the examination.

5.3 Recording

• Record that a chaperone was offered, whether accepted or declined, and the chaperone's name and role.

5.4 Children

• A parent or person with parental responsibility should be present for any examination of a child.

6. Monitoring and review

• Annual audit of chaperone documentation.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• GMC – Intimate examinations and chaperones (2024)
• Regulation 10 (Dignity and respect), HSCA 2008 (RA) Regulations 2014

8. Related policies

• Person-Centred Care Policy
• Consent Policy
• Safeguarding Adults Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out Ready Health's commitment to equality, diversity and inclusion for patients, staff, contractors and visitors.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health does not discriminate on the grounds of the nine protected characteristics under the Equality Act 2010: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.
• We make reasonable adjustments so that disabled people can use our services and work for us.
• Harassment, bullying and victimisation are not tolerated and will be dealt with through disciplinary procedures.
• Recruitment, training, promotion and pay decisions are made fairly on merit.

4. Roles and responsibilities

Directors

Lead an inclusive culture and ensure this policy is applied.

Registered Manager

Monitors complaints, feedback and workforce data for inequality and ensures EDI training.

All staff

Treat everyone with respect and challenge discriminatory behaviour.

5. Procedure

5.1 For patients

• Access to interpreters (including BSL) for consultations where needed; family members are not used as interpreters for clinical discussions except in an emergency.
• Services and eligibility criteria are designed to avoid indirect discrimination.

5.2 For staff

• Equality training at induction and refreshed every 3 years.
• Flexible working requests and reasonable adjustments are considered fairly.

5.3 Raising concerns

• Patients may use the Complaints Policy; staff may use the grievance or Whistleblowing Policy.

6. Monitoring and review

• Annual review of complaints and feedback for EDI themes.
• Training compliance.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Equality Act 2010
• Regulation 10 (Dignity and respect) and Regulation 13, HSCA 2008 (RA) Regulations 2014

8. Related policies

• Accessible Information/Reasonable Adjustments Policy
• Recruitment Policy
• Complaints Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health identifies, records, flags, shares and meets the information and communication needs of patients with a disability, impairment or sensory loss, and makes reasonable adjustments to its services.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health follows the principles of the Accessible Information Standard (DCB1605).
• Communication needs are asked about at registration and recorded in the patient record in Semble so they are visible to all staff.
• Reasonable adjustments are anticipatory as well as reactive, and are provided at no extra cost to the patient.

4. Roles and responsibilities

Reception staff

Ask about and record communication and access needs.

Clinicians

Deliver information in the format required and document adjustments.

Registered Manager

Arranges interpreters and alternative formats and reviews premises accessibility.

5. Procedure

5.1 The five steps

• Identify – ask patients about communication and information needs.
• Record – document needs clearly in the record.
• Flag – use an alert on the patient record.
• Share – with consent, include needs in referrals and letters.
• Meet – provide information in the required format (large print, easy read, email, BSL interpreter, longer appointments, a support person present).

5.2 Reasonable adjustments

• Examples include longer or quieter appointments, first or last appointment of the day, remote consultations, written summaries, and adjustments for neurodivergent patients attending ADHD services.
• Premises: ground-floor consultation facilities are used for patients with mobility needs.

6. Monitoring and review

• Annual audit of recorded communication needs.
• Patient feedback on accessibility.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Accessible Information Standard (DCB1605)
• Equality Act 2010, sections 20–21

8. Related policies

• Equality, Diversity and Inclusion Policy
• Person-Centred Care Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health protects the confidentiality of patient information and when information may be lawfully shared.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All staff and contractors have a common law duty of confidentiality and sign a confidentiality agreement at induction.
• Patient information is shared only with consent, where required by law, or where there is an overriding public interest (for example, to prevent serious harm).
• The Caldicott Principles guide all use and sharing of patient information.
• Shamir Patel is the Information Governance Lead and advises on confidentiality decisions.

4. Roles and responsibilities

Information Governance Lead (Mr Shamir Patel)

Advises on disclosure decisions and records the rationale for any disclosure without consent.

All staff

Protect patient information, verify identity before disclosing information and report breaches.

5. Procedure

5.1 Practical confidentiality

• Consultations take place in private rooms; conversations at reception are kept discreet.
• Identity is verified using at least two identifiers before discussing a patient on the telephone or online.
• Screens are locked when unattended; paper records are not left in public areas.

5.2 Sharing with the patient's GP

• With consent, clinically relevant information is shared with the patient's NHS GP. Where a patient declines GP sharing for a treatment where safe prescribing depends on it (e.g. controlled drugs or GLP-1 medicines), the clinician may decline to prescribe.

5.3 Disclosures without consent

• Permitted where required by law (e.g. court order, notifiable diseases, FGM reporting), for safeguarding, or in the public interest. Decisions are documented and approved by a director where time allows.

5.4 Requests from third parties

• Police, solicitors and insurers must provide written requests and appropriate consent or legal basis.

6. Monitoring and review

• Confidentiality breaches reviewed via incident reporting.
• Annual IG training compliance.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Common law duty of confidentiality
• UK GDPR and Data Protection Act 2018
• The Eight Caldicott Principles (2020)
• GMC – Confidentiality: good practice in handling patient information

8. Related policies

• Data Protection Policy
• Information Governance Policy
• Clinical Records Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the standards for creating, maintaining, storing, sharing and retaining clinical records at Ready Health.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Every patient contact is recorded in the electronic patient record (Semble) contemporaneously or as soon as possible afterwards and on the same day.
• Records are accurate, legible, attributable, dated and timed, and sufficient to allow another clinician to continue care safely.
• Where an approved AI scribe (Heidi) is used to draft notes, the patient is informed, and the clinician reviews, corrects and takes responsibility for the final record before it is saved.
• Records are retained in line with the NHS Records Management Code of Practice.

4. Roles and responsibilities

Clinicians

Create and maintain complete, accurate records.

Registered Manager

Manages access permissions and retention and leads the record-keeping audit.

Information Governance Lead

Oversees subject access requests and records security.

5. Procedure

5.1 Content of a clinical record

• Presenting complaint, relevant history, examination findings, investigations, diagnosis or working impression, options discussed, consent, management plan, prescriptions with rationale, safety-netting and follow-up.
• Communication needs, allergies and alerts are kept up to date.

5.2 Corrections

• Entries are never deleted. Corrections are made as an addendum with date, time and author.

5.3 Paper documents

• Incoming paper documents are scanned into Semble and the originals shredded securely once quality-checked.

5.4 Access and subject access requests

• Access is role-based. Patients may request their records under UK GDPR; requests are fulfilled within one calendar month.

5.5 Retention

• Adults: 8 years after last contact. Children: until the 25th birthday (or 26th if 17 at conclusion of treatment), or 8 years after death.

6. Monitoring and review

• Annual clinical record-keeping audit against this policy.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• NHS England – Records Management Code of Practice 2023
• UK GDPR and Data Protection Act 2018
• Regulation 17(2)(c), HSCA 2008 (RA) Regulations 2014

8. Related policies

• Patient Confidentiality Policy
• Information Governance Policy
• Data Protection Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health manages medicines safely and legally across procurement, storage, prescribing, supply, administration, monitoring and disposal.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health is a dispensing clinic. Urgent private prescriptions may be dispensed on site; otherwise prescriptions are sent to an electronic pharmacy partner (e.g. CloudRx) or issued on paper. Most prescriptions are printed, wet-signed and handed to the patient.
• Ready Health does not use Patient Group Directions (PGDs) or Patient Specific Directions (PSDs). All medicines are prescribed by an appropriately qualified prescriber.
• Medicines are obtained only from licensed wholesalers and stored securely at the correct temperature.
• Medication errors and suspected adverse reactions are reported internally and to the MHRA Yellow Card scheme as appropriate.

4. Roles and responsibilities

Clinical Directors

Hold overall accountability for medicines governance.

Registered Manager

Oversees ordering, stock control, storage checks and medicines audits.

Prescribers

Prescribe safely within scope and in line with the Prescribing Policy.

Staff dispensing or handling medicines

Follow dispensing procedures and complete accuracy checks.

5. Procedure

5.1 Procurement and receipt

• Order from MHRA-licensed wholesalers; check deliveries against the order for product, strength, quantity, expiry and integrity; refrigerated items are put away immediately.

5.2 Dispensing on site

• Each item is labelled with patient name, medicine, strength, dose and directions, date, and clinic name and address; supplied with a patient information leaflet.
• A second person accuracy check is completed where staffing allows; if not, a documented self-check is completed.
• Schedule 2 controlled drugs are not stocked or dispensed on site.

5.3 Repeat requests

• Repeat requests are received via the website, by telephone or at reception and are reviewed by a prescriber against monitoring requirements before issue.

5.4 Posting medicines

• Where medicines must be posted in an emergency, Royal Mail tracked delivery is used, with packaging suitable for the product and a record of the tracking number.

5.5 Disposal

• Expired or returned medicines are placed in licensed pharmaceutical waste containers; denaturing kits are used for any controlled drugs.

6. Monitoring and review

• Quarterly medicines storage and stock audit.
• Annual review of medication incidents and Yellow Card reports.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Human Medicines Regulations 2012
• Regulation 12(2)(g), HSCA 2008 (RA) Regulations 2014
• NICE NG5 – Medicines optimisation
• RPS – Professional guidance on the safe and secure handling of medicines

8. Related policies

• Prescribing Policy
• Controlled Drugs Policy
• Medicines Storage Policy
• Cold Chain Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the standards for safe, effective and legal prescribing by doctors and independent prescribers at Ready Health, including remote prescribing.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Only registered prescribers acting within their competence and scope of practice may prescribe.
• Prescribers follow GMC, GPhC or NMC standards, the RPS Competency Framework for all Prescribers, and Ready Health service protocols.
• Prescribers must have adequate knowledge of the patient's health, including relevant medical history, current medicines and allergies, before prescribing.
• Patients are asked for consent to share prescribing information with their NHS GP. For medicines where safe prescribing depends on GP information or ongoing monitoring (e.g. controlled drugs, GLP-1 receptor agonists, testosterone), treatment will not normally proceed without it.

4. Roles and responsibilities

Prescribers

Assess, prescribe, document and monitor; report adverse reactions.

Clinical Directors

Approve service prescribing protocols and review prescribing through peer review and audit.

5. Procedure

5.1 Before prescribing

• Verify identity (and age where relevant) and obtain an adequate history, including a medicines reconciliation.
• Obtain baseline observations or tests required by the protocol (e.g. BMI for weight management; blood pressure, pulse and weight for ADHD medicines; bloods for testosterone therapy).
• Discuss benefits, risks, alternatives and monitoring and obtain consent.

5.2 Writing the prescription

• Prescriptions include all legal requirements, are printed where possible and wet-signed, or sent electronically to the partner pharmacy.
• Schedule 2 and 3 controlled drugs are prescribed only by prescribers holding a private controlled drug prescriber code, on FP10PCD forms, and in line with the Controlled Drugs Policy.
• Unlicensed or off-label prescribing is justified, documented and the patient is informed.

5.3 Remote prescribing

• Remote prescribing follows the joint principles for remote consultations and prescribing; face-to-face review is arranged where needed for safe prescribing (e.g. examination, physical measurements).

5.4 Monitoring

• Prescribers set and record review intervals; repeat prescriptions are not issued where monitoring is overdue.

6. Monitoring and review

• Annual prescribing audit per service line.
• Peer review of prescribing decisions.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Human Medicines Regulations 2012
• GMC – Good practice in proposing, prescribing, providing and managing medicines and devices
• GPhC – Guidance for providing pharmacy services at a distance
• RPS – A Competency Framework for all Prescribers

8. Related policies

• Medicines Management Policy
• Controlled Drugs Policy
• Scope of Practice Policy
• Consent Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health safely and lawfully prescribes, stores and manages controlled drugs (CDs).

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health prescribes Schedule 2 CDs (for example, ADHD stimulant medicines) on private prescriptions but does not hold stock of Schedule 2 CDs.
• The only CDs held on site are those contained within the emergency drugs kit. These are stored securely and checked regularly.
• Ready Health does not currently maintain a CD register because no Schedule 2 stock is held. If Schedule 2 stock is ever held, a bound or compliant electronic CD register will be introduced before any stock is received.
• CD concerns and incidents are reported to the NHS England Controlled Drugs Accountable Officer for the area.

4. Roles and responsibilities

Clinical Directors

Accountable for CD governance and liaison with the CD Accountable Officer.

CD prescribers

Hold a private CD prescriber code and prescribe in accordance with this policy.

Registered Manager

Oversees emergency kit checks and CD incident reporting.

5. Procedure

5.1 Prescribing Schedule 2 and 3 CDs

• Use the pink FP10PCD private CD prescription form, including the prescriber's private CD prescriber code.
• Include the patient's name and address, the form and strength, the total quantity in words and figures, the dose, and the prescriber's signature and date.
• Prescribe no more than 30 days' supply unless clinically justified and documented.
• Prescriptions are valid for 28 days from the appropriate date.
• Check for concurrent CD prescribing and substance misuse risk before prescribing.

5.2 Security of prescription forms

• FP10PCD forms are kept locked away; serial numbers are recorded on receipt and on issue; loss or theft is reported immediately to the CD Accountable Officer and police.

5.3 Emergency kit CDs

• Stored in a locked container in a restricted area; contents and expiry checked weekly and recorded.

5.4 Destruction

• Expired CDs are denatured using an approved kit, witnessed where required, and recorded.

6. Monitoring and review

• Quarterly CD prescribing audit.
• Annual CD self-assessment and occurrence reporting to the CD Accountable Officer as requested.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Misuse of Drugs Act 1971
• Misuse of Drugs Regulations 2001
• Misuse of Drugs (Safe Custody) Regulations 1973
• Controlled Drugs (Supervision of Management and Use) Regulations 2013
• NICE NG46 – Controlled drugs: safe use and management

8. Related policies

• Prescribing Policy
• Emergency Medicines Policy
• Medicines Storage Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health prescribes antimicrobials responsibly to preserve their effectiveness and reduce antimicrobial resistance.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Antibiotics are prescribed only when clinically indicated and in line with NICE and UKHSA primary care guidance.
• Where appropriate, back-up (delayed) prescribing and self-care advice are used.
• The narrowest-spectrum effective antibiotic is chosen, at the correct dose and shortest effective duration.
• Patients receive information on why antibiotics are or are not needed and what to do if symptoms worsen.

4. Roles and responsibilities

Prescribers

Follow local and national antimicrobial guidance and document the indication and duration.

Clinical Directors

Lead antimicrobial audit and learning.

5. Procedure

5.1 When prescribing

• Record the indication, diagnosis, antibiotic, dose, route and duration.
• Check allergy status and document the nature of any allergy.
• Use the TARGET antibiotic toolkit patient leaflets for self-care and safety-netting.
• Obtain samples for culture where guidance recommends before starting treatment.

5.2 Education

• Prescribers complete antimicrobial stewardship CPD at least every 3 years.

6. Monitoring and review

• Annual antibiotic prescribing audit against NICE/UKHSA guidance.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• NICE NG15 – Antimicrobial stewardship
• UKHSA – Managing common infections: guidance for primary care
• RCGP TARGET Antibiotics Toolkit
• UK National Action Plan on AMR 2024–2029

8. Related policies

• Prescribing Policy
• Infection Prevention and Control Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health maintains the cold chain for medicines that must be stored between +2°C and +8°C, so that their safety and effectiveness are preserved.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Refrigerated medicines are stored in a dedicated pharmaceutical refrigerator, not a domestic fridge, and never with food or specimens.
• Temperatures are monitored and recorded every working day.
• Any cold chain breach is treated as an incident and stock is quarantined until advice is obtained.

4. Roles and responsibilities

Registered Manager

Designated cold chain lead; oversees checks, servicing and breach management.

Nominated deputy

Completes daily checks in the lead's absence.

Staff receiving deliveries

Place refrigerated stock in the fridge immediately on receipt.

5. Procedure

5.1 Daily monitoring

• Record current, minimum and maximum temperatures at least once each working day, reset the thermometer and sign the record.
• Use a calibrated data logger in addition to the fridge's built-in thermometer.

5.2 Fridge management

• Keep the fridge no more than 50% full to allow air circulation; do not store stock against the back wall or in door compartments.
• The fridge plug is switched-off-protected and labelled 'Do not switch off'.
• The fridge is serviced and the logger calibrated annually.

5.3 Breach procedure

• If the temperature is outside +2°C to +8°C: quarantine stock in a working fridge, label 'Do not use', record the readings and duration, and contact the manufacturer or wholesaler for advice.
• Discard stock if advised and report the incident.

5.4 Transport and posting

• Refrigerated medicines supplied to patients are packed with validated cool packaging; patients are advised how to store them at home.

6. Monitoring and review

• Monthly review of temperature records by the Registered Manager.
• Quarterly cold chain audit.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• UKHSA – Immunisation against infectious disease (Green Book), Chapter 3: Storage, distribution and disposal
• MHRA – Good Distribution Practice guidance
• Human Medicines Regulations 2012

8. Related policies

• Medicines Storage Policy
• Medicines Management Policy
• Medical Equipment Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how medicines, prescription stationery and medical gases (if any) are stored securely and appropriately at Ready Health.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All medicines are stored in locked cupboards or a locked pharmaceutical fridge in areas not accessible to the public.
• Ready Health does not hold medical oxygen or cannabis-based products.
• Room temperatures in medicine storage areas are monitored and kept below 25°C.
• Stock is rotated so that the shortest-dated items are used first, and expired stock is removed promptly.

4. Roles and responsibilities

Registered Manager

Controls key-holding, stock checks and storage audits.

All staff handling medicines

Keep medicines locked away and report concerns about storage.

5. Procedure

5.1 Security

• Keys or codes for medicine cupboards are held only by authorised staff and not left in locks.
• Blank prescription forms, including FP10PCD forms, are stored locked and logged.

5.2 Environment

• Record room temperatures daily in medicine storage areas; take action if above 25°C.
• Keep storage areas clean, dry and away from direct sunlight.

5.3 Stock checks

• Monthly expiry date check with short-dated items flagged; records kept.
• Patient-returned medicines are not reissued and are disposed of as pharmaceutical waste.

6. Monitoring and review

• Quarterly medicines storage audit.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Human Medicines Regulations 2012
• Misuse of Drugs (Safe Custody) Regulations 1973
• RPS – Professional guidance on the safe and secure handling of medicines

8. Related policies

• Cold Chain Policy
• Controlled Drugs Policy
• Physical Security Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out which emergency medicines and equipment Ready Health holds, how they are checked, and how staff respond to medical emergencies such as anaphylaxis, collapse or cardiac arrest.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health holds emergency medicines and equipment appropriate to the services provided, based on a documented risk assessment approved by the Clinical Directors.
• Ready Health does not hold medical oxygen; this decision is supported by the risk assessment and immediate access to 999 emergency services.
• All staff complete basic life support training annually, and clinicians complete anaphylaxis training.
• The location of the emergency kit and defibrillator (if held on site, or the nearest public-access defibrillator) is known to all staff.

4. Roles and responsibilities

Registered Manager

Maintains the emergency kit, weekly checks and risk assessment.

Clinicians

Recognise and manage medical emergencies within their competence.

All staff

Call 999, fetch the emergency kit and start basic life support.

5. Procedure

5.1 Emergency kit contents (minimum, subject to risk assessment)

• Adrenaline 1 mg/mL (1:1000) ampoules for intramuscular use, with appropriate needles and syringes, in line with Resuscitation Council UK anaphylaxis guidance.
• Other emergency medicines agreed in the risk assessment (for example, aspirin, glucose gel, salbutamol inhaler with spacer, benzylpenicillin where relevant).
• Pocket mask, gloves, and access to an automated external defibrillator.

5.2 Checks

• Weekly documented check of contents and expiry dates; resupply immediately after use.

5.3 Responding to an emergency

• Call for help and dial 999; follow Resuscitation Council UK algorithms.
• Record the event, medicines given and times; hand over to paramedics; complete an incident report.

6. Monitoring and review

• Weekly check records reviewed monthly.
• Annual emergency scenario drill.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Resuscitation Council UK – Emergency treatment of anaphylaxis (2021) and Quality standards: primary care
• Regulation 12(2)(d)–(e), HSCA 2008 (RA) Regulations 2014

8. Related policies

• Medicines Management Policy
• Controlled Drugs Policy
• Training and Competency Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health recruits staff safely and fairly, so that everyone working for us is suitable, competent and of good character.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Recruitment is fair, transparent and free from discrimination, in line with the Equality Act 2010.
• No one starts work until all pre-employment checks required by Schedule 3 of the Regulated Activities Regulations 2014 are complete and verified, unless a documented risk assessment approved by a director permits a supervised start pending a single outstanding item.
• Recruitment records are kept for every member of staff and contractor and are auditable.

4. Roles and responsibilities

Registered Manager

Leads recruitment, carries out and records checks, and makes appointment decisions with a director.

Directors

Approve appointments of clinical staff and risk-assessed starts.

5. Procedure

5.1 Pre-employment checks (Schedule 3)

• Proof of identity including a recent photograph.
• Right to work in the UK.
• Enhanced DBS check, including barred list checks where the role is regulated activity.
• Satisfactory evidence of conduct in previous health or social care employment and the reason employment ended.
• Two references, including the most recent employer.
• Full employment history with a written explanation of any gaps.
• Relevant qualifications and professional registration.
• Health declaration confirming the person is able to carry out the role, with reasonable adjustments.

5.2 Process

• Job description and person specification; structured interview with scoring; decision recorded.
• Conditional offer, checks completed, then unconditional offer and contract.

6. Monitoring and review

• Annual audit of all personnel files against Schedule 3.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 19 (Fit and proper persons employed) and Schedule 3, HSCA 2008 (RA) Regulations 2014
• Immigration, Asylum and Nationality Act 2006
• Equality Act 2010

8. Related policies

• DBS Policy
• Professional Registration Policy
• Staff Induction Policy
• Locum/Contractor Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health ensures that its directors and those in equivalent positions meet the Fit and Proper Person Requirement (Regulation 5), and that all staff meet Regulation 19.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Directors must be of good character, have the qualifications, competence, skills and experience necessary for the role, be able by reason of their health to perform the role, and not have been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement in carrying on a regulated activity.
• Directors must not be an undischarged bankrupt, subject to a sequestration order or disqualified as a company director, or appear on a barred list.
• Fitness is checked on appointment and reviewed annually.

4. Roles and responsibilities

Directors

Complete an annual self-declaration and notify immediately any change in circumstances.

Registered Manager

Maintains the fit and proper person file for each director.

5. Procedure

5.1 Checks on appointment and annually

• Enhanced DBS check (with barred list checks where applicable) renewed every 3 years or via the Update Service.
• Companies House disqualified directors register search and insolvency register search.
• Professional registration check.
• Self-declaration of fitness, good character and financial standing.

5.2 If concerns arise

• The other director(s) consider the concern, take advice where needed and act proportionately, including notifying the CQC.

6. Monitoring and review

• Annual review of director FPP files.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 5 (Fit and proper persons: directors) and Regulation 19, HSCA 2008 (RA) Regulations 2014
• CQC guidance for providers on Regulation 5

8. Related policies

• Recruitment Policy
• DBS Policy
• CQC Compliance Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health uses Disclosure and Barring Service (DBS) checks and handles DBS information fairly and securely.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All staff, directors and contractors engaged in regulated activity have an enhanced DBS check with the relevant barred list checks before starting work.
• DBS certificates are renewed every 3 years, or checked annually through the DBS Update Service where the individual is subscribed.
• A criminal record will not automatically bar someone from employment; decisions are risk-based and fair, in line with the Rehabilitation of Offenders Act 1974.
• Ready Health has a legal duty to refer to the DBS anyone removed from regulated activity because they harmed or posed a risk of harm.

4. Roles and responsibilities

Registered Manager

Processes checks, records certificate details and makes risk assessments with a director.

Staff

Disclose any cautions, convictions or investigations during employment immediately.

5. Procedure

5.1 Handling information

• Record the certificate number, date and level; do not retain copies of certificates beyond six months unless in exceptional circumstances.
• Store DBS information securely with access limited to those who need it.

5.2 Positive disclosures

• Discuss the disclosure with the applicant and consider relevance, seriousness, time elapsed and pattern; record the decision and rationale.

6. Monitoring and review

• Quarterly DBS status review on the staff compliance tracker.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Safeguarding Vulnerable Groups Act 2006
• Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975
• DBS Code of Practice

8. Related policies

• Recruitment Policy
• Fit and Proper Persons Policy
• Safeguarding Adults Policy
• Safeguarding Children Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the induction that every new member of staff, locum, contractor and trainee receives before and during their first weeks at Ready Health.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• No one works unsupervised until the core induction has been completed and signed off.
• Induction is tailored to the role and covers the clinic, its systems, its policies and the individual's responsibilities.
• Trainees (for example, pharmacist independent prescriber trainees) receive the trainee-specific induction in addition to this policy.

4. Roles and responsibilities

Registered Manager

Plans and records induction and signs it off.

Inductee

Completes all elements and confirms understanding.

5. Procedure

5.1 Day one

• Welcome, tour of the premises, fire procedure (evacuate via the ground-floor rear exit and assemble on the left side of the building by the shed), first aid arrangements, emergency kit location and security.
• IT accounts, Semble access, confidentiality agreement and IT acceptable use sign-off.
• Introduction to key policies: safeguarding, incident reporting, whistleblowing, IPC, health and safety, data protection.

5.2 First four weeks

• Role-specific training and competency assessment.
• Review of mandatory training status.
• Shadowing and supervised practice as appropriate.

5.3 Probation

• Review meetings at 1, 3 and 6 months, recorded in the staff file.

5.4 Practical expectations

• The clinic opens at 9am; staff are ready for the first appointment at 9am.
• Staff follow the Staff Dress Code and treat the premises and colleagues with respect.

6. Monitoring and review

• Audit of induction records for all starters in the year.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 18 (Staffing), HSCA 2008 (RA) Regulations 2014
• Skills for Health – Core Skills Training Framework

8. Related policies

• Training and Competency Policy
• Recruitment Policy
• Staff Dress Code

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the mandatory and role-specific training requirements for Ready Health staff and how competence is assessed and recorded.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All staff complete mandatory training aligned to the Core Skills Training Framework at the frequencies set out below.
• Clinical staff demonstrate competence before undertaking any clinical task independently, with competence re-assessed periodically.
• Training records are kept on the staff compliance tracker.

4. Roles and responsibilities

Registered Manager

Maintains the training matrix and flags overdue training.

Clinical Directors

Sign off clinical competencies.

Staff

Complete training on time and maintain their own CPD.

5. Procedure

5.1 Mandatory training and frequency

• Basic life support – annually; anaphylaxis (clinical staff) – annually.
• Safeguarding adults and children – every 3 years at the appropriate level.
• Information governance and data security – annually.
• Fire safety – annually.
• Infection prevention and control – annually for clinical staff, every 3 years for non-clinical staff.
• Health, safety and welfare; equality and diversity; conflict resolution; moving and handling – every 3 years.
• Mental Capacity Act and Prevent – every 3 years.

5.2 Clinical competencies

• Examples: phlebotomy, ECG recording, blood pressure measurement, dispensing, ADHD monitoring, injection technique teaching for GLP-1 and testosterone therapies.
• Competency is assessed by direct observation and recorded with the assessor's name and date.

6. Monitoring and review

• Training compliance reported at each governance meeting (target 95%).

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 18 (Staffing), HSCA 2008 (RA) Regulations 2014
• Skills for Health – Core Skills Training Framework

8. Related policies

• Staff Induction Policy
• Clinical Supervision Policy
• Appraisal and Performance Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health provides clinical supervision to support safe practice, reflection and professional development.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All clinicians have access to clinical supervision appropriate to their role and experience.
• Supervision is a supportive, confidential and reflective process; it is separate from line management and disciplinary processes, except where patient safety concerns arise.
• Trainee prescribers are supervised by their designated prescribing practitioner in line with the requirements of their training programme.

4. Roles and responsibilities

Clinical Directors

Provide or arrange supervision and ensure it is recorded.

Supervisees

Prepare for sessions, reflect on practice and act on agreed learning.

5. Procedure

5.1 Frequency

• At least quarterly for experienced clinicians; monthly for new clinicians during their first six months or when starting a new service line.
• Ad hoc supervision is available at any time for urgent clinical questions.

5.2 Content and recording

• Case discussion, reflective practice, incidents and complaints, wellbeing and development needs.
• A brief record (date, attendees, themes, actions) is kept; case details are anonymised.

6. Monitoring and review

• Annual audit of supervision records.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 18 (Staffing), HSCA 2008 (RA) Regulations 2014
• GPhC and NMC revalidation requirements for reflective discussion

8. Related policies

• Training and Competency Policy
• Appraisal and Performance Policy
• Scope of Practice Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health appraises staff annually and manages performance fairly and supportively.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All staff receive an annual appraisal covering performance, objectives, training needs and wellbeing.
• Doctors undergo annual whole-practice appraisal for GMC revalidation through their designated body; pharmacists and nurses meet GPhC and NMC revalidation requirements.
• Concerns about performance are addressed early, informally where possible, and formally where necessary.

4. Roles and responsibilities

Registered Manager / Directors

Conduct appraisals, agree objectives and manage performance concerns.

Staff

Prepare for appraisal and take ownership of their development.

5. Procedure

5.1 Annual appraisal

• Review of the previous year's objectives, feedback (patient and colleague where available), audit and incident involvement, and training.
• Agree SMART objectives and a personal development plan.

5.2 Managing performance concerns

• Informal stage: discuss concerns, agree support and a review date.
• Formal stage: a written improvement plan, with support and review, in line with the capability procedure.
• Clinical performance concerns that may affect patient safety are escalated to a Clinical Director and, where required, to the professional regulator.

6. Monitoring and review

• Appraisal completion rate reported annually (target 100%).

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 18 (Staffing), HSCA 2008 (RA) Regulations 2014
• GMC – Guidance on supporting information for appraisal and revalidation
• Acas Code of Practice on disciplinary and grievance procedures

8. Related policies

• Training and Competency Policy
• Clinical Supervision Policy
• Professional Registration Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health confirms and monitors the professional registration, revalidation and indemnity of its registered healthcare professionals.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All healthcare professionals must hold current registration with the appropriate regulator (GMC, GPhC, NMC or HCPC), with any required annotations (e.g. independent prescriber).
• Registration and indemnity are checked on appointment and at least annually, and conditions or restrictions are acted on immediately.
• Professionals must inform Ready Health straight away of any change to their registration, conditions, investigations or indemnity.

4. Roles and responsibilities

Registered Manager

Checks registers, records evidence and maintains the compliance tracker.

Registered professionals

Maintain registration, revalidation and indemnity.

5. Procedure

5.1 Checks

• Online register check (screenshot or reference retained), including prescriber annotation where relevant.
• For doctors: GMC licence to practise, specialist or GP register where relevant, and designated body and responsible officer.
• Evidence of appropriate indemnity cover for the work undertaken at Ready Health.
• Private controlled drug prescriber code where CD prescribing is undertaken.

5.2 If registration lapses

• The professional must stop practising in that capacity immediately until registration is restored.

6. Monitoring and review

• Quarterly register checks recorded on the compliance tracker.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Medical Act 1983; Pharmacy Order 2010; Nursing and Midwifery Order 2001
• Regulation 19, HSCA 2008 (RA) Regulations 2014

8. Related policies

• Recruitment Policy
• Scope of Practice Policy
• Locum/Contractor Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health engages, checks, inducts and oversees locum and self-employed clinical contractors.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Locums and clinical contractors meet the same pre-engagement standards as employed staff.
• A written agreement sets out the scope of work, responsibilities, confidentiality, data protection obligations and indemnity.
• Locums and contractors follow Ready Health policies and protocols.

4. Roles and responsibilities

Registered Manager

Completes checks and induction and keeps the contractor file.

Clinical Directors

Agree scope of practice and provide clinical oversight.

5. Procedure

5.1 Before the first session

• Identity, right to work, enhanced DBS, professional registration, indemnity, references, CV and training certificates.
• Signed contractor agreement and confidentiality agreement.

5.2 Induction

• Local induction (premises, fire, emergency kit, systems, key protocols) before seeing patients.

5.3 Oversight

• Sample case review during the first month and then as part of normal peer review.

6. Monitoring and review

• Annual audit of locum and contractor files.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 18 and Regulation 19, HSCA 2008 (RA) Regulations 2014
• NHS Employers – Employment check standards

8. Related policies

• Recruitment Policy
• Staff Induction Policy
• Contractors Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health defines, agrees and monitors the scope of practice of each clinician so that everyone works within their competence.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Each clinician has a written scope of practice agreed with a Clinical Director, setting out the services, conditions, medicines and age groups they may assess and treat.
• Clinicians must not work outside their agreed scope and must seek advice or refer where a case is outside their competence.
• Ready Health's Inclusion and Exclusion Criteria define which conditions the clinic will and will not treat; individual scopes operate within these criteria.

4. Roles and responsibilities

Clinical Directors

Agree and review scopes of practice and approve extensions.

Clinicians

Work within scope, maintain competence and declare limitations.

5. Procedure

5.1 Agreeing a scope of practice

• Review of qualifications, registration annotations, experience, training and evidence of competence.
• Written scope signed by the clinician and a Clinical Director.

5.2 Extending scope

• Identify the new area, complete training, undertake supervised practice and competence assessment, then update the written scope.

5.3 Review

• Scopes are reviewed annually at appraisal and whenever services change.

6. Monitoring and review

• Annual audit to confirm every clinician has a current signed scope.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• GMC Good Medical Practice; GPhC Standards for Pharmacy Professionals; NMC Code
• RPS – A Competency Framework for all Prescribers

8. Related policies

• Prescribing Policy
• Professional Registration Policy
• Clinical Governance Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This is Ready Health's statement of general policy on health and safety. It sets out our commitment to protecting the health, safety and welfare of staff, patients, visitors and contractors at 22 High Street, Standish.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health will, so far as is reasonably practicable, provide safe premises, equipment and systems of work, adequate information, instruction, training and supervision, and a healthy working environment.
• Suitable and sufficient risk assessments are carried out, recorded and reviewed.
• Staff are consulted on health and safety matters.
• The Health and Safety Law poster is displayed and employers' liability insurance is maintained and displayed.

4. Roles and responsibilities

Directors

Overall responsibility for health and safety and provision of resources.

Registered Manager

Day-to-day health and safety lead; arranges risk assessments, inspections and training.

All staff

Take reasonable care of themselves and others, follow safe systems of work and report hazards, accidents and near misses.

5. Procedure

5.1 Arrangements

• General workplace, display screen equipment, manual handling, slips and trips, and new and expectant mothers risk assessments.
• Quarterly premises safety inspection with actions recorded.
• First aid: at least one trained first aider on duty and a stocked first aid kit.
• Accident book completed for all injuries; RIDDOR reports made where required.
• Portable appliance testing and fixed electrical installation testing at the required intervals.

5.2 Stress and wellbeing

• Work-related stress is assessed using the HSE Management Standards approach, and support is available.

6. Monitoring and review

• Annual health and safety review.
• Accident and incident trends reviewed quarterly.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Safety at Work etc. Act 1974
• Management of Health and Safety at Work Regulations 1999
• Workplace (Health, Safety and Welfare) Regulations 1992
• RIDDOR 2013
• Regulation 15 (Premises and equipment), HSCA 2008 (RA) Regulations 2014

8. Related policies

• Risk Management Policy
• Fire Safety Policy
• COSHH Policy
• Lone Working Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health prevents and controls infection to protect patients, staff and visitors.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health complies with the Code of Practice on the prevention and control of infections and follows the National Infection Prevention and Control Manual for England.
• Standard infection control precautions are applied to every patient, every time.
• The Registered Manager is the IPC Lead.
• The premises are cleaned to a documented schedule to the National Standards of Healthcare Cleanliness 2021.

4. Roles and responsibilities

IPC Lead (Registered Manager)

Leads IPC audits, training and outbreak management; maintains the IPC annual statement.

Clinicians

Apply standard and transmission-based precautions.

All staff

Follow hand hygiene and cleaning procedures.

5. Procedure

5.1 Standard infection control precautions

• Hand hygiene using the WHO 5 Moments; bare below the elbows for clinical activity.
• Appropriate personal protective equipment based on risk.
• Safe management of the care environment, equipment, blood and body fluid spills, linen and waste.
• Respiratory and cough hygiene.
• Sharps safety and management of occupational exposure.

5.2 Clinical procedures

• Phlebotomy and injections follow aseptic non-touch technique.
• Single-use items are never reused; reusable equipment is decontaminated between patients.

5.3 Staff health

• Clinical staff are offered hepatitis B vaccination and serology results are recorded; staff with infectious illness do not attend work.

6. Monitoring and review

• Annual IPC audit and quarterly hand hygiene audit.
• Annual IPC statement.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Social Care Act 2008: Code of Practice on the prevention and control of infections
• National Infection Prevention and Control Manual for England
• National Standards of Healthcare Cleanliness 2021
• Regulation 12(2)(h), HSCA 2008 (RA) Regulations 2014

8. Related policies

• Sharps Management Policy
• Waste Management Policy
• Legionella Policy
• Staff Dress Code

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health prevents fire and protects people in the event of a fire at 22 High Street, Standish.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• A suitable and sufficient fire risk assessment is carried out by a competent person and reviewed annually or following significant change.
• Fire detection, alarms, emergency lighting and extinguishers are maintained and tested.
• All staff receive fire safety training at induction and annually.

4. Roles and responsibilities

Registered Manager (Responsible Person)

Ensures the fire risk assessment, testing and training are completed.

Fire marshal(s)

Lead evacuation and check that all areas are clear.

All staff

Know the evacuation route and assembly point and keep escape routes clear.

5. Procedure

5.1 Evacuation procedure

• On discovering a fire, raise the alarm and call 999.
• Evacuate the building via the ground-floor rear exit.
• Assemble on the left side of the building by the shed.
• Staff assist patients and visitors to leave; do not use lifts or stop to collect belongings.
• The fire marshal takes a roll call using the staff rota and appointment list.
• Do not re-enter the building until authorised by the Fire and Rescue Service.

5.2 Testing and checks

• Weekly fire alarm test; monthly emergency lighting function test; annual full-duration test and servicing.
• Annual servicing of extinguishers; daily check that escape routes and fire doors are clear.
• At least one fire drill per year, recorded.

5.3 Personal Emergency Evacuation Plans

• PEEPs are completed for staff who need assistance; patients with mobility needs are assisted by staff.

6. Monitoring and review

• Fire log reviewed monthly.
• Annual fire risk assessment review.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulatory Reform (Fire Safety) Order 2005
• Fire Safety (England) Regulations 2022
• HM Government – Fire safety risk assessment: healthcare premises

8. Related policies

• Health and Safety Policy
• Emergency/Business Continuity Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health controls the risk from Legionella bacteria in the water systems at its premises.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• A legionella risk assessment of the water system is carried out by a competent person and reviewed at least every 2 years or after significant change.
• A written control scheme is implemented and records are kept for at least 5 years.

4. Roles and responsibilities

Registered Manager (Responsible Person)

Ensures the risk assessment and control scheme are in place and records are kept.

Nominated staff

Carry out routine flushing and temperature checks.

5. Procedure

5.1 Control measures

• Hot water stored at 60°C or above and distributed at 50°C or above at outlets within one minute; cold water below 20°C within two minutes.
• Monthly temperature checks at sentinel outlets, recorded.
• Weekly flushing of little-used outlets for several minutes.
• Descaling and disinfection of showerheads (if any) quarterly.
• Remove dead legs and redundant pipework where identified.

5.2 If results are out of range

• Record, investigate and take corrective action; seek specialist advice if temperatures cannot be maintained.

6. Monitoring and review

• Monthly review of water temperature records.
• Risk assessment review at least every 2 years.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• HSE ACOP L8 – Legionnaires' disease: the control of legionella bacteria in water systems
• HSG274 Part 2
• HTM 04-01 – Safe water in healthcare premises

8. Related policies

• Health and Safety Policy
• Infection Prevention and Control Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health protects people from hazardous substances used or produced at work, including cleaning chemicals, disinfectants and biological agents.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• A COSHH inventory and risk assessment are held for every hazardous substance used at the premises.
• Safety data sheets are obtained and kept accessible for every hazardous product.
• Exposure is prevented or, where this is not possible, adequately controlled.

4. Roles and responsibilities

Registered Manager

Maintains the COSHH file, assessments and training records.

All staff

Use substances only as instructed, wear the PPE specified and report spills and exposures.

5. Procedure

5.1 Assessment

• Identify the hazard, route of exposure, who may be exposed, control measures, PPE, storage, first aid and spill arrangements.

5.2 Controls

• Substitute with less hazardous products where possible.
• Store chemicals in original labelled containers in a locked cupboard, away from medicines.
• Never mix cleaning products; follow dilution instructions.

5.3 Biological agents

• Blood and body fluids are managed through standard infection control precautions and the Sharps Management Policy.

6. Monitoring and review

• Annual review of the COSHH inventory and assessments.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Control of Substances Hazardous to Health Regulations 2002 (as amended)
• HSE – COSHH essentials

8. Related policies

• Health and Safety Policy
• Infection Prevention and Control Policy
• Waste Management Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health selects, maintains, calibrates, cleans and records medical devices and equipment.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All medical devices are UKCA or CE marked, used in accordance with manufacturers' instructions and only by trained staff.
• An equipment register lists every item with serial number, location, service and calibration dates.
• Faulty equipment is withdrawn immediately, labelled 'Do not use' and reported.

4. Roles and responsibilities

Registered Manager

Maintains the equipment register and arranges servicing, calibration and PAT testing.

Users

Carry out pre-use checks, clean equipment between patients and report faults.

5. Procedure

5.1 Examples of equipment

• Blood pressure monitors, weighing scales and height measures, ECG machine, centrifuge, pulse oximeter, thermometers, pharmaceutical refrigerator and data logger, defibrillator (where held).

5.2 Maintenance

• Service and calibrate at the frequency recommended by the manufacturer, and at least annually for measuring devices.
• Retain service certificates.

5.3 Adverse incidents

• Report device-related incidents to the MHRA via the Yellow Card scheme and act on MHRA field safety notices.

6. Monitoring and review

• Quarterly check of the equipment register for overdue servicing.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Medical Devices Regulations 2002
• MHRA – Managing medical devices (2021)
• Provision and Use of Work Equipment Regulations 1998
• Regulation 15, HSCA 2008 (RA) Regulations 2014

8. Related policies

• Cold Chain Policy
• Infection Prevention and Control Policy
• Health and Safety Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health segregates, stores, transports and disposes of waste safely and lawfully.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health complies with its waste duty of care and uses licensed waste contractors.
• Waste is segregated at source using the colour-coded system in HTM 07-01.
• Waste transfer notes and hazardous waste consignment notes are retained for at least 3 years.

4. Roles and responsibilities

Registered Manager

Manages contracts, storage and documentation, and completes pre-acceptance audits.

All staff

Segregate waste correctly and report incorrect disposal.

5. Procedure

5.1 Segregation

• Orange – infectious waste suitable for alternative treatment.
• Yellow – infectious waste for incineration.
• Yellow/black ('tiger') – offensive/hygiene waste.
• Sharps containers: orange lid for sharps not contaminated with medicines; yellow lid for sharps contaminated with medicines; purple lid for cytotoxic/cytostatic contaminated sharps.
• Blue-lidded containers – waste medicines; denatured controlled drugs as per the Controlled Drugs Policy.
• Black/clear – domestic waste; confidential waste – secure shredding.

5.2 Storage

• Clinical waste bags are no more than three-quarters full, tagged and stored in a locked area until collection.

6. Monitoring and review

• Annual waste audit.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Environmental Protection Act 1990 – Duty of Care
• Hazardous Waste (England and Wales) Regulations 2005
• HTM 07-01 – Safe and sustainable management of healthcare waste

8. Related policies

• Sharps Management Policy
• Infection Prevention and Control Policy
• Medicines Management Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health prevents sharps injuries and manages exposure to blood-borne viruses.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Safer sharps devices are used where reasonably practicable.
• Needles are never re-sheathed.
• Sharps containers are assembled correctly, labelled, used at the point of use and closed when filled to the line.
• Patients using injectable treatments at home (for example, GLP-1 or testosterone) are advised on safe sharps disposal.

4. Roles and responsibilities

Registered Manager

Provides safer sharps, containers and training; records and investigates injuries.

Clinicians

Dispose of sharps immediately at the point of use.

5. Procedure

5.1 Needlestick or splash injury – immediate action

• Encourage bleeding under running water; do not suck or scrub. Wash with soap and water. For splashes to eyes or mouth, irrigate with water.
• Report to the Registered Manager immediately and complete an incident report.
• Attend the local Emergency Department or occupational health promptly (post-exposure prophylaxis for HIV is most effective within 1 hour and should be started within 72 hours).
• Risk-assess the source patient and seek consent for blood-borne virus testing.

5.2 Reporting

• Report to the HSE under RIDDOR where the source is known to be positive for a blood-borne virus, or where the injury results in infection or over seven days' absence.

6. Monitoring and review

• Sharps injury reports reviewed quarterly.
• Sharps container audit as part of the IPC audit.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Safety (Sharp Instruments in Healthcare) Regulations 2013
• UKHSA – Eye of the Needle; BHIVA PEP guidance

8. Related policies

• Infection Prevention and Control Policy
• Waste Management Policy
• Incident Reporting Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health protects staff who work alone, including when opening or closing the clinic, working out of hours or conducting home visits.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Lone working is risk-assessed and minimised.
• Staff working alone have a means of summoning help and a check-in arrangement.
• Staff are not expected to put themselves at risk and may leave any situation where they feel unsafe.

4. Roles and responsibilities

Registered Manager

Completes lone working risk assessments and maintains check-in arrangements.

Lone workers

Follow the procedure, keep a charged mobile phone and report incidents.

5. Procedure

5.1 In the clinic

• Avoid seeing new or unknown patients alone at the end of the day where possible; keep the front door secured when the clinic is closed.
• Inform a colleague or director when opening or closing alone.

5.2 Off site

• Record the visit address, expected arrival and departure times before leaving.
• Check in on arrival and on completion; if no contact within 30 minutes of the expected time, the named contact attempts to call and then escalates, including calling the police if needed.
• Use an agreed code phrase to signal danger during a call.

6. Monitoring and review

• Annual review of lone working risk assessments and incidents.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Safety at Work etc. Act 1974
• Management of Health and Safety at Work Regulations 1999
• HSE INDG73 – Protecting lone workers

8. Related policies

• Home Visit Policy
• Health and Safety Policy
• Physical Security Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health prepares for, responds to and recovers from incidents that disrupt normal services, so that patients continue to receive safe care.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health maintains a business continuity plan covering loss of premises, utilities, IT and clinical systems, key staff, suppliers and telephony.
• Critical services are prioritised: continuity of prescriptions for patients on ongoing treatment (especially controlled drugs and time-critical medicines), safeguarding, and communication with patients.
• The plan is tested at least annually.

4. Roles and responsibilities

Registered Manager

Owns and tests the plan and leads the response.

Clinical Directors

Make clinical prioritisation decisions during an incident.

All staff

Know how to access the plan and their role within it.

5. Procedure

5.1 Scenarios and responses

• Loss of premises: relocate to remote consultations; arrange prescriptions via the electronic pharmacy partner; divert telephones.
• Loss of Semble or IT: use the offline contact list and paper downtime forms; back-enter records when restored.
• Power or utility failure: protect the medicines fridge, move stock to an alternative fridge if the outage exceeds safe limits, and follow the Cold Chain Policy.
• Staff absence: redistribute clinics and prioritise urgent and time-critical patients.
• Pandemic or severe weather: follow national guidance and switch to remote care where safe.

5.2 Communication

• Update the website and voicemail message; contact affected patients; notify the CQC if the service cannot run safely.

5.3 Key contacts

• The plan contains contact details for utilities, IT support, Semble, the landlord, insurers, suppliers and all staff, and is kept both electronically off site and in paper form.

6. Monitoring and review

• Annual test or tabletop exercise.
• Plan reviewed after any activation.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Civil Contingencies Act 2004 (principles)
• ISO 22301 – Business continuity management (principles)
• Care Quality Commission (Registration) Regulations 2009, Regulation 18

8. Related policies

• Fire Safety Policy
• Cybersecurity Policy
• Cold Chain Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health complies with UK data protection law when processing personal data about patients, staff and others.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• High Street Health Ltd (t/a Ready Health) is the data controller for the personal data it processes and is registered with the Information Commissioner's Office.
• Personal data is processed lawfully, fairly and transparently; for specified purposes; adequately and limited to what is necessary; accurately; kept no longer than necessary; securely; and with accountability.
• Health data is special category data. Ready Health relies on UK GDPR Article 6(1)(b) or (c) and Article 9(2)(h) for providing care, and on explicit consent or other appropriate conditions where required.
• Mr Shamir Patel is the Information Governance Lead and acts as the Data Protection Officer point of contact.

4. Roles and responsibilities

Information Governance Lead (Mr Shamir Patel)

Oversees compliance, the privacy notice, records of processing, DPIAs, data subject requests and breach management.

All staff

Handle personal data in line with this policy and report breaches immediately.

5. Procedure

5.1 Transparency

• A privacy notice is available on the website and at reception.

5.2 Individuals' rights

• Requests for access, rectification, erasure, restriction, objection and portability are logged and answered within one calendar month (extendable by two months for complex requests).
• Identity is verified before disclosure.

5.3 Processors and third-party software

• Written data processing agreements are in place with processors (e.g. Semble, the electronic pharmacy partner, laboratory and diagnostic providers, and approved AI tools such as Heidi).
• A register of approved third-party and AI software is maintained; new tools require a DPIA and director approval before use.

5.4 Personal data breaches

• Report to the IG Lead immediately; contain and assess; notify the ICO within 72 hours if there is a risk to individuals, and inform affected individuals without undue delay if the risk is high.

6. Monitoring and review

• Annual data protection audit and DSPT-aligned self-assessment.
• Breach and request logs reviewed quarterly.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• UK GDPR
• Data Protection Act 2018
• Data (Use and Access) Act 2025
• ICO guidance for the health sector

8. Related policies

• Information Governance Policy
• Patient Confidentiality Policy
• Cybersecurity Policy
• CCTV Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out Ready Health's framework for managing information – including confidentiality, data protection, information security, records management and information quality.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Information governance is led by the Information Governance Lead, Mr Shamir Patel, with oversight from both directors.
• Ready Health aligns its IG arrangements with the NHS Data Security and Protection Toolkit (DSPT) standards and completes the toolkit where required.
• All staff complete data security awareness training annually.

4. Roles and responsibilities

Information Governance Lead

Leads the IG framework, maintains the information asset register and advises on IG matters.

Directors

Provide senior accountability for information risk.

All staff

Comply with IG policies and complete training.

5. Procedure

5.1 Core components

• Information asset register listing systems, owners, data held, legal basis, retention and security controls.
• Record of processing activities.
• Data flow mapping, including transfers to GPs, laboratories, pharmacies and diagnostic providers.
• Data protection impact assessments for new systems or processing.

5.2 Information quality

• Patient demographics are checked at each contact; data is accurate and complete.

5.3 Information sharing

• Share information using secure methods (e.g. secure NHS mail or encrypted email, secure portals) and only the minimum necessary.

6. Monitoring and review

• Annual IG review and DSPT-aligned assessment.
• IG incidents reviewed at each governance meeting.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• UK GDPR and Data Protection Act 2018
• NHS Data Security and Protection Toolkit
• National Data Guardian – 10 data security standards
• Caldicott Principles

8. Related policies

• Data Protection Policy
• Cybersecurity Policy
• Clinical Records Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the technical and organisational measures Ready Health uses to protect its systems and data from cyber threats.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health aims to meet the technical controls of Cyber Essentials as a minimum standard.
• Access to systems is based on least privilege and removed promptly when no longer needed.
• Multi-factor authentication is enabled on all systems that support it, including Semble, email and cloud storage.

4. Roles and responsibilities

Information Governance Lead

Oversees cybersecurity controls, suppliers and incident response.

IT support provider

Maintains devices, patching and backups.

All staff

Follow secure practices and report suspicious activity immediately.

5. Procedure

5.1 Technical controls

• Firewalls and secure router configuration; default passwords changed.
• Operating systems and applications patched within 14 days of critical updates; unsupported software removed.
• Anti-malware on all devices; full-disk encryption on laptops.
• Automatic screen locking; individual user accounts – no shared logins.
• Regular backups, tested for recovery, with at least one copy held separately.

5.2 Phishing and social engineering

• Do not click unexpected links or open attachments; verify requests to change bank details or share data by telephone using a known number.

5.3 Incident response

• Disconnect the affected device from the network, report to the IG Lead, preserve evidence and follow the business continuity plan.
• Report to Action Fraud/NCSC and the ICO where required.

6. Monitoring and review

• Annual cybersecurity review against Cyber Essentials controls.
• Access rights review every 6 months.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• NCSC – Cyber Essentials requirements
• NHS DSPT
• Computer Misuse Act 1990
• UK GDPR Article 32

8. Related policies

• IT Acceptable Use Policy
• Information Governance Policy
• Emergency/Business Continuity Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the acceptable use of Ready Health's IT equipment, systems, email, internet and personal devices used for work.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• IT systems are provided for Ready Health business. Limited personal use is permitted if it does not interfere with work or breach this policy.
• Users must sign this policy before being given system access.
• Use of systems may be monitored lawfully and proportionately for security and compliance.

4. Roles and responsibilities

Registered Manager

Grants and removes access and records user agreements.

All users

Use systems responsibly and securely.

5. Procedure

5.1 Users must

• Keep passwords confidential and use strong, unique passwords with multi-factor authentication.
• Lock screens when leaving a device unattended.
• Access patient records only when needed for their role.
• Store work data only on approved systems – not on personal devices, USB sticks or personal cloud storage.
• Use only approved software and AI tools listed on the approved software register.

5.2 Users must not

• Share accounts, install unapproved software or disable security controls.
• Send patient-identifiable data by unsecured email, text or messaging apps.
• Access, create or share offensive, illegal or discriminatory material.
• Enter patient-identifiable data into unapproved AI tools.

5.3 Personal devices

• Personal devices may be used for work only with approval, a screen lock and no local storage of patient data.

6. Monitoring and review

• Annual confirmation of signed agreements for all users.
• Breaches managed through incident reporting and disciplinary procedures.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• UK GDPR and Data Protection Act 2018
• Computer Misuse Act 1990
• Investigatory Powers (Interception by Businesses etc.) Regulations 2018

8. Related policies

• Cybersecurity Policy
• Social Media Policy
• Data Protection Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health operates any closed-circuit television (CCTV) system lawfully, proportionately and transparently.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• CCTV is used only for the prevention and detection of crime and for the safety and security of staff, patients and premises.
• CCTV is never installed in consultation or treatment rooms, toilets or changing areas.
• Signs are displayed informing people that CCTV is in operation, why, and who to contact.
• A data protection impact assessment is completed before installation or significant change.

4. Roles and responsibilities

Information Governance Lead

Responsible for CCTV compliance, access and disclosure decisions.

Authorised staff

Access recordings only when necessary and record the reason.

5. Procedure

5.1 Retention and security

• Recordings are retained for no longer than 31 days unless required for an investigation, then securely overwritten.
• The recorder is kept in a secure location with password protection.

5.2 Access and disclosure

• Individuals may request footage of themselves as a subject access request; third parties are obscured where necessary.
• Disclosure to the police is on written request and logged.

6. Monitoring and review

• Annual CCTV review including DPIA and signage check.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• UK GDPR and Data Protection Act 2018
• ICO – Video surveillance guidance
• Surveillance Camera Code of Practice

8. Related policies

• Data Protection Policy
• Physical Security Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health protects its premises, people, medicines, equipment and information from unauthorised access, theft and damage.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Clinical and staff-only areas are restricted and kept secure.
• Medicines, prescription stationery and records are locked away when not in use.
• The premises are secured and alarmed when unoccupied.

4. Roles and responsibilities

Registered Manager

Oversees security arrangements, key holding and alarm maintenance.

All staff

Follow security procedures and challenge or report unknown persons.

5. Procedure

5.1 Opening and closing

• Opening and closing checklists are followed, including checking windows and doors, setting the alarm, securing medicines and switching off equipment except the medicines fridge.

5.2 During opening hours

• Reception is staffed whenever the front door is open; visitors are signed in.
• Staff-only doors are kept closed; unattended rooms are locked.

5.3 Security incidents

• Report theft, break-in or suspicious behaviour to the Registered Manager and the police (999 in an emergency, 101 otherwise), and complete an incident report.

6. Monitoring and review

• Annual security risk assessment.
• Security incidents reviewed quarterly.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Regulation 15 (Premises and equipment), HSCA 2008 (RA) Regulations 2014
• Misuse of Drugs (Safe Custody) Regulations 1973

8. Related policies

• Key/Access Control Policy
• Visitors Policy
• CCTV Policy
• Medicines Storage Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health manages visitors (other than patients and their companions) to maintain safety, security and confidentiality.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• All non-patient visitors sign in and out, wear a visitor badge where issued, and are accompanied in non-public areas.
• Visitors must not access patient information and are asked to respect confidentiality.
• Children accompanying patients remain under the supervision of their parent or carer.

4. Roles and responsibilities

Reception staff

Sign visitors in and out and inform the host.

Host

Accompanies the visitor and ensures they follow safety procedures.

5. Procedure

5.1 Arrival

• Verify identity and purpose of visit (e.g. representatives, inspectors, auditors, trainees).
• Record name, organisation, host, time in and time out.
• Brief the visitor on fire evacuation (ground-floor rear exit; assembly on the left side of the building by the shed).

5.2 Pharmaceutical and commercial representatives

• Seen by appointment only; interactions follow the Conflict of Interest and Gifts and Hospitality policies.

5.3 Inspectors

• CQC and other authorised inspectors are given access in line with their powers; identity is checked.

6. Monitoring and review

• Visitor log reviewed as part of the annual security review.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Safety at Work etc. Act 1974 (duty to non-employees)
• UK GDPR

8. Related policies

• Physical Security Policy
• Contractors Policy
• Conflict of Interest Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health manages non-clinical contractors working at or for the premises (for example, maintenance, IT, cleaning and waste contractors).

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Contractors are competent, insured and, where they may have unsupervised access to patients or patient information, appropriately vetted.
• Contractors comply with Ready Health's health and safety, infection control, security and confidentiality requirements.
• Work that may create risks (e.g. hot works, work at height, electrical work) is risk-assessed and scheduled to avoid patient areas during clinics.

4. Roles and responsibilities

Registered Manager

Selects and approves contractors, checks documentation and briefs them.

Contractors

Work safely, follow instructions and report incidents.

5. Procedure

5.1 Before work starts

• Obtain public liability insurance, relevant accreditation (e.g. Gas Safe, NICEIC) and risk assessment/method statement.
• For contractors with access to personal data (e.g. IT support, shredding), a confidentiality or data processing agreement is signed.

5.2 On site

• Sign in, receive a safety and fire briefing, and be supervised in clinical and restricted areas.

6. Monitoring and review

• Approved contractor list reviewed annually.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Safety at Work etc. Act 1974
• Construction (Design and Management) Regulations 2015 where applicable
• UK GDPR Article 28

8. Related policies

• Visitors Policy
• Locum/Contractor Policy
• Health and Safety Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health controls keys, alarm codes, access fobs and system access to protect the premises, medicines and information.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Keys and codes are issued only to authorised people and recorded in the key register.
• Keys to medicine cupboards and the controlled drugs container are held by authorised clinical staff only.
• Access is removed on the day a person leaves or no longer needs it.

4. Roles and responsibilities

Registered Manager

Maintains the key register and changes codes when required.

Key holders

Keep keys secure, never lend them and report loss immediately.

5. Procedure

5.1 Key register

• Record the key or code issued, the holder, date issued and date returned.

5.2 Loss or compromise

• Report immediately; change alarm codes and locks as risk dictates; complete an incident report.

5.3 Leavers

• Collect keys and fobs, change shared codes and disable all system accounts on the last working day.

5.4 Periodic review

• Alarm and door codes changed at least annually and whenever a key holder leaves.

6. Monitoring and review

• Six-monthly key register and system access review.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Misuse of Drugs (Safe Custody) Regulations 1973
• UK GDPR Article 32

8. Related policies

• Physical Security Policy
• Medicines Storage Policy
• Cybersecurity Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the standard of dress and appearance expected of everyone working at Ready Health, supporting infection prevention, safety, professionalism and patient confidence.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Staff present a clean, smart and professional appearance appropriate to a healthcare setting.
• Clinical staff are 'bare below the elbows' during direct patient care and clinical procedures.
• Identification badges showing name and role are worn at all times.
• The dress code is applied fairly and accommodates religious, cultural and disability needs, provided infection control and safety are maintained.

4. Roles and responsibilities

Registered Manager

Ensures the dress code is followed and considers adjustment requests.

All staff

Comply with the dress code.

5. Procedure

5.1 Clinical staff

• Short sleeves or sleeves rolled above the elbow for clinical activity; disposable over-sleeves may be used for religious reasons, discarded after each patient.
• No wrist watches, bracelets or rings with stones during clinical care (a plain band is acceptable); nails short and clean with no false nails or nail varnish.
• Long hair tied back; closed-toe footwear.
• Uniform or tunic changed daily and washed at 60°C where possible.

5.2 All staff

• Smart business or clinic attire; no clothing with offensive slogans; minimal jewellery.
• Trainees and observers follow the same standards as clinical staff.

6. Monitoring and review

• Informal monitoring by the Registered Manager; dress code included in the IPC audit.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Equality Act 2010
• National Infection Prevention and Control Manual for England
• NHS England – Uniforms and workwear guidance (principles)

8. Related policies

• Infection Prevention and Control Policy
• Staff Induction Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the requirements for anyone who drives on Ready Health business, including for home visits, deliveries of medicines or specimens, and travel between sites.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Only authorised staff with a valid licence, appropriate insurance and a roadworthy vehicle may drive on Ready Health business.
• Drivers comply with the Highway Code and road traffic law at all times.
• Mobile phones must not be held or used while driving; hands-free use is discouraged.

4. Roles and responsibilities

Registered Manager

Authorises drivers and checks documentation annually.

Drivers

Maintain their vehicle, licence and insurance and report changes.

5. Procedure

5.1 Documentation checks (on authorisation and annually)

• Valid driving licence (with a DVLA licence check code where needed).
• Insurance covering business use.
• Current MOT (where applicable) and vehicle tax.

5.2 Transporting medicines and specimens

• Medicines and specimens are carried in secure, labelled containers out of sight, at the correct temperature, and never left unattended in a vehicle.
• Controlled drugs are transported only where necessary and are kept on the person or in a locked container.

5.3 Fitness to drive

• Staff must not drive if impaired by fatigue, illness, alcohol, drugs or medication, and must inform the DVLA and Ready Health of relevant medical conditions.

5.4 Accidents and fines

• Report accidents immediately; fines and penalties are the driver's responsibility.

6. Monitoring and review

• Annual audit of driver documentation.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Road Traffic Act 1988
• The Highway Code
• HSE INDG382 – Driving at work

8. Related policies

• Home Visit Policy
• Lone Working Policy
• Medicines Management Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out when and how Ready Health clinicians undertake home visits safely and to the same clinical standard as clinic appointments.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Home visits are offered only where clinically appropriate and within the clinician's scope, for example for patients unable to attend the clinic.
• Every home visit is risk-assessed in advance for clinical and personal safety.
• Clinicians follow the Lone Working and Drivers policies.

4. Roles and responsibilities

Clinical Directors

Approve which services may be delivered by home visit.

Visiting clinician

Completes the risk assessment, carries appropriate equipment and records the consultation.

Registered Manager

Operates the check-in arrangements.

5. Procedure

5.1 Before the visit

• Confirm the patient's identity, address, reason for visit and any known risks (e.g. aggression, animals, access).
• Record the visit details and expected times with the named contact.
• Take the equipment, PPE, sharps container and documentation required.

5.2 During the visit

• Maintain infection control and confidentiality; offer a chaperone where needed (by arranging a second staff member).
• Leave if you feel unsafe.

5.3 After the visit

• Check in with the named contact; complete records in Semble on the same day; dispose of clinical waste appropriately.

6. Monitoring and review

• Annual review of home visits and associated incidents.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Health and Safety at Work etc. Act 1974
• Regulation 12, HSCA 2008 (RA) Regulations 2014

8. Related policies

• Lone Working Policy
• Drivers Policy
• Chaperone Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health and its staff use social media responsibly, protecting patient confidentiality, professional standards and the clinic's reputation.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Only authorised staff post on Ready Health's official accounts.
• Patient information, images or identifiable details are never shared on social media without explicit written consent.
• All advertising and promotional content complies with the ASA/CAP Code and medicines advertising law; prescription-only medicines are never advertised to the public.
• Staff follow their professional regulator's guidance on social media in their personal use.

4. Roles and responsibilities

Directors

Approve the social media strategy and sensitive posts.

Authorised staff

Create and moderate content in line with this policy.

All staff

Use personal social media responsibly.

5. Procedure

5.1 Official accounts

• Content is clinically accurate, evidence-based and reviewed by a clinician before publishing.
• Do not offer individual clinical advice on public channels; direct enquiries to private channels or appointments.
• Respond to reviews without confirming whether someone is a patient or disclosing any information.

5.2 Personal use

• Do not post about patients, colleagues or confidential clinic matters; make clear that personal views are your own.
• Do not accept friend requests from patients on personal accounts.

6. Monitoring and review

• Quarterly review of official accounts for compliance.
• Breaches managed through incident and disciplinary procedures.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Human Medicines Regulations 2012, Part 14 (Advertising)
• CAP Code (UK Code of Non-broadcast Advertising)
• GMC – Using social media as a medical professional; GPhC and NMC social media guidance
• UK GDPR

8. Related policies

• IT Acceptable Use Policy
• Patient Confidentiality Policy
• Conflict of Interest Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy encourages and enables staff to raise concerns about wrongdoing, risk or malpractice at work, and explains how they will be protected and supported.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health wants staff to speak up. Concerns about patient safety, malpractice, fraud, abuse, legal breaches or cover-ups will be taken seriously.
• Staff who raise concerns in good faith will not suffer detriment. Victimisation of anyone who speaks up is a disciplinary matter.
• Concerns may be raised in confidence, and anonymously if preferred, although this may make investigation harder.

4. Roles and responsibilities

Directors

Receive and investigate concerns fairly and feed back to the person raising the concern.

All staff

Raise concerns promptly and support colleagues who speak up.

5. Procedure

5.1 How to raise a concern

• Speak to the Registered Manager or either director. If the concern involves one director, raise it with the other.
• Concerns may be raised verbally or in writing; a record is kept.

5.2 What happens next

• The concern is acknowledged within 5 working days and investigated proportionately; the person is kept informed and told the outcome where possible.

5.3 Raising concerns externally

• Staff may contact prescribed persons, including the Care Quality Commission, the GMC, GPhC or NMC, the HSE or the ICO; and may seek independent advice from Protect (the whistleblowing charity).

6. Monitoring and review

• Concerns (anonymised) reviewed annually by the directors.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Public Interest Disclosure Act 1998
• Employment Rights Act 1996 (Part IVA)
• National Guardian's Office – Freedom to Speak Up principles

8. Related policies

• Safeguarding Adults Policy
• Anti-Fraud Policy
• Incident Reporting Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health identifies, declares and manages conflicts of interest so that clinical and business decisions are made in patients' best interests.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Staff and directors must declare any interest that could influence, or be perceived to influence, their judgement – including financial interests, outside employment, directorships, shareholdings, relationships with suppliers, pharmacies or pharmaceutical companies.
• Prescribing decisions are based solely on clinical need. Where a patient's prescription can be dispensed by Ready Health or a partner pharmacy, patients are told they may choose where to have it dispensed.
• The register of interests is maintained and reviewed annually.

4. Roles and responsibilities

Directors

Declare their own interests and decide how conflicts are managed.

Registered Manager

Maintains the register of interests.

All staff

Declare interests on appointment, annually and when circumstances change.

5. Procedure

5.1 Declaring and managing interests

• Complete a declaration form; the directors decide whether action is needed (e.g. excluding the person from a decision, disclosure to patients, or ending the interest).
• Directors' other roles (for example, roles with other pharmacy or healthcare businesses) are declared and recorded.

5.2 Procurement

• Suppliers are chosen on value, quality and safety; anyone with an interest in a supplier does not take part in the decision.

6. Monitoring and review

• Annual review of the register of interests.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Bribery Act 2010
• GMC – Financial and commercial arrangements and conflicts of interest
• GPhC Standards for Pharmacy Professionals, Standard 6
• ABPI Code of Practice

8. Related policies

• Gifts and Hospitality Policy
• Anti-Fraud Policy
• Financial Controls Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out how Ready Health staff handle offers of gifts, hospitality and sponsorship so that no one's judgement is compromised.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Staff must not accept any gift, hospitality or benefit that could be seen to influence their professional judgement or decisions.
• Gifts from suppliers, pharmaceutical companies or anyone seeking to do business with Ready Health are declined, other than items of low value (under £10) related to clinical practice.
• Small gifts of low value from grateful patients (e.g. chocolates) may be accepted and shared. Cash or cash equivalents are never accepted.
• All gifts and hospitality over £25 offered or received are recorded in the register, whether accepted or declined.

4. Roles and responsibilities

Registered Manager

Maintains the gifts and hospitality register.

All staff

Declare offers and seek advice if unsure.

5. Procedure

5.1 Hospitality

• Modest hospitality at educational meetings is acceptable if proportionate and secondary to the educational purpose.

5.2 Sponsorship

• Commercial sponsorship of events or training is approved in advance by a director and declared.

5.3 Gifts in wills

• Any bequest to a member of staff is reported to the directors.

6. Monitoring and review

• Annual review of the gifts and hospitality register.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Bribery Act 2010
• Human Medicines Regulations 2012, regulation 300 (inducements and hospitality)
• GMC and GPhC professional standards

8. Related policies

• Conflict of Interest Policy
• Anti-Fraud Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out Ready Health's zero-tolerance approach to fraud, bribery and corruption, and how suspected fraud is reported and investigated.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Ready Health does not tolerate fraud, bribery or corruption by staff, contractors, patients or suppliers.
• Proportionate procedures are in place to prevent bribery, including the Conflict of Interest and Gifts and Hospitality policies.
• Suspected fraud is reported promptly and investigated; where appropriate, it is reported to the police or Action Fraud and to professional regulators.

4. Roles and responsibilities

Directors

Lead fraud prevention and decide on investigation and reporting.

All staff

Remain alert to fraud and report suspicions.

5. Procedure

5.1 Examples of fraud risks

• Prescription fraud (including forged or altered prescriptions, false identity or false information given to obtain medicines).
• False invoices, payment diversion and bank detail change scams.
• Misuse of Ready Health funds, time or property.

5.2 Prevention in clinical services

• Identity verification for patients, and additional checks for controlled drugs and medicines at risk of misuse, including GLP-1 weight-management medicines (e.g. verified weight and BMI).

5.3 Reporting

• Report concerns to a director immediately; do not investigate yourself or alert the suspect.

6. Monitoring and review

• Annual fraud risk assessment and review of incidents.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Fraud Act 2006
• Bribery Act 2010
• Economic Crime and Corporate Transparency Act 2023 (failure to prevent fraud offence)

8. Related policies

• Financial Controls Policy
• Whistleblowing Policy
• Conflict of Interest Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.

1. Purpose

This policy sets out the financial controls that protect Ready Health's income, assets and financial sustainability, supporting the delivery of safe services.

2. Scope

This policy applies to all directors, employees, locums, contractors, trainees and volunteers working at or on behalf of Ready Health (High Street Health Ltd), 22 High Street, Standish, Wigan WN6 0HL, including when consulting with patients remotely.

3. Policy statement

• Financial processes include segregation of duties and director authorisation proportionate to the size of the business.
• Accounts are maintained in the accounting system and reconciled regularly.
• Patient fees are transparent and published; patients receive clear information on costs before treatment.

4. Roles and responsibilities

Directors

Approve budgets, authorise payments above agreed limits and review management accounts.

Registered Manager / administrative staff

Process income and expenditure in line with this policy.

5. Procedure

5.1 Income

• Payments are taken through approved payment systems; receipts and invoices are issued; cash handling is minimised and recorded.
• Refunds are authorised by a director and recorded.

5.2 Expenditure

• Purchases are approved in advance; invoices are checked against orders and deliveries before payment.
• Changes to supplier bank details are verified by telephone using a known number.

5.3 Reconciliation and reporting

• Bank reconciliations monthly; management accounts reviewed by the directors; annual accounts filed at Companies House.

5.4 Financial sustainability

• The directors review financial risks that could affect service continuity as part of the risk register.

6. Monitoring and review

• Monthly review of management accounts.
• Annual accounts and external accountant review.

This policy will be reviewed by 1 October 2028, or sooner if legislation, national guidance, CQC requirements or our services change.

7. Legislation and guidance

• Companies Act 2006
• Regulation 17 (Good governance), HSCA 2008 (RA) Regulations 2014
• Consumer Rights Act 2015 (price transparency)

8. Related policies

• Anti-Fraud Policy
• Conflict of Interest Policy
• Governance and Quality Assurance Policy

Approved by Mr Shamir Patel, Registered Manager, and Dr Venkata Bandaru, Clinical Director. The signed copy is held by Ready Health and is available on request.