A protocol, process or procedure describes how we will make the policies work. At this stage you need to ensure that you have worked out what the staff members have to do to make sure we meet quality standards.

Essentially these are the steps we will follow to make sure that we meet our policy objectives. Here is how policies and processes fit together:-

A policy might read something like "Our policy is to maintain strict fire safety precautions and ensure all staff are aware of how to deal with ...... etc.“

These are some of the processes required to put this in practice:-

  • Carrying out regular risk assessments
  • Daily safety checks to ensure safety is maintained, for example that fire doors are not inadvertently blocked
  • Regular fire drills
  • Testing alarms and fire systems on a regular basis


  • Written copies of risks assessments and actions taken
  • Daily checklist completed, signed, and reviewed
  • Log of fire drill activity
  • Log of alarm tests


Even if you have protocols in place, you should review the BMA guide to CQC, which includes pro-forma protocols for each of the outcomes. See the resources section for links.

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