Regulation 17: Good governance
Requires you to assess, monitor, and improve the quality of services and maintain accurate records. SOPs are the documented evidence that your systems exist and work.
GP Practice SOP Generator
Generate GP practice SOPs in minutes.
Your primary care practice needs dozens of standard operating procedures. Writing them from scratch takes 2–4 hours each. Generate tailored, CQC-ready SOPs in under two minutes instead.
Free to start No credit card required NHS DSPT verified
19
core SOPs every practice needs
< 2 min
per SOP
2–4 hrs
saved per SOP vs manual
Why SOPs Matter
CQC expects documented procedures. SOPs are the evidence.
A standard operating procedure describes how to carry out a specific task, step by step. Good SOPs reduce variation, protect patients, and give your practice a defensible position if something goes wrong.
Regulation 12: Safe care and treatment
Requires that care is provided safely and that risks are assessed. SOPs for clinical procedures, medicines management, and infection control directly support this regulation.
The inspection test
Inspectors ask staff how they handle specific tasks. If they describe a consistent process that matches a documented SOP, that is strong evidence of good governance. If they give different answers and no SOP exists, that is a concern.
The difference between policies, procedures, and SOPs
| Document | Purpose | Example |
|---|---|---|
| Policy | States your practice's position — the “what” and “why” | “This practice will manage controlled drugs in accordance with the Misuse of Drugs Regulations 2001” |
| Procedure | Describes the general process for an activity | “Controlled drugs are received, stored, prescribed, dispensed, and destroyed following a defined process” |
| SOP | Step-by-step instructions for a specific task — what staff follow day to day | “When a CD delivery arrives: 1. Check against the order. 2. Count each item. 3. Record in the CD register…” |
Your practice needs all three levels. The SOP is the most operational — it is what staff actually follow.
SOP Checklist
The 19 SOPs every GP practice needs
Not every practice needs every one, but this is a comprehensive starting point. How many does your practice have documented?
Reception and patient-facing
Appointment booking
on-the-day triage, routine bookings, telephone consultations
Patient registration and deduction
new patient registration, records transfer, patient removal
Repeat prescription requests
receiving, processing, authorising, and collecting
Telephone triage and signposting
handling urgent calls, directing to appropriate service
Patient complaints handling
receiving, acknowledging, investigating, and responding
Clinical room procedures
Specimen handling and transport
labelling, storage, packaging, courier collection
Cold chain management
vaccine storage, temperature monitoring, breach response
Emergency drugs and equipment checks
weekly and monthly checks, restocking, anaphylaxis kit
Infection prevention and control
cleaning schedules, hand hygiene, sharps disposal
Medicines management
- Controlled drugs management
receipt, storage, prescribing, dispensing, destruction
Repeat prescribing safety
medication reviews, high-risk drug monitoring
Drug recalls and safety alerts
responding to MHRA alerts, identifying affected patients
Administrative and back-office
- Significant event analysis
identifying, reporting, investigating, LFPSE reporting
Subject access requests
handling patient requests under UK GDPR within 30 days
Staff induction
IT access, mandatory training, fire safety, safeguarding
Health and safety
- Fire safety procedures
evacuation routes, fire warden duties, assembly points
Legionella management
weekly flushing, monthly temperature checks
COSHH
storage, handling, spill response for hazardous substances
Lone working
risk assessment, communication protocols, escalation
Plus additional SOPs
Depending on your practice, you may also need SOPs for safeguarding (children and adults), duty of candour, and clinical governance processes.
Dispensing practices will need additional medicines management SOPs beyond the three listed above.
How It Works
From prompt to SOP in under two minutes
Describe the procedure you need in plain English. Get a complete, structured SOP with purpose, scope, responsibilities, step-by-step instructions, and regulatory references.
1
Choose SOP
Open the AI tools section and select “SOP” as your document type.
2
Describe the procedure
Tell it what you need: “appointment booking for our 6-GP practice with telephone triage.”
3
Review and adjust
Your SOP is ready in under two minutes. Review it and adjust any details specific to your practice.
4
Save and distribute
Save to your compliance library for staff access, annual review tracking, and CQC evidence.
Writing SOPs manually vs generating with AI
| Writing manually | AI generation with My Practice Manager | |
|---|---|---|
| Time per SOP | 2–4 hours researching and writing | Under 2 minutes |
| For all 19 core SOPs | 40–80 hours of practice manager time | Under 40 minutes |
| Regulatory references | Manual cross-referencing required | Automatically included from compliance library |
| Structure and consistency | Varies between authors | Consistent structure across all SOPs |
| Cost | Your time, or £300+ for template packs | Free to start, paid from £12/month |
Worked Example
Reception appointment booking SOP
Generated from a brief prompt describing a six-GP practice with morning telephone triage and online booking. This is real output from the AI tool.
AI-generated example
Standard Operating Procedure: Appointment Booking
Ref: SOP-REC-001Version: 1.0Effective: March 2026Review: March 2027
1. Purpose
To ensure consistent, safe, and efficient appointment booking across all reception staff, supporting timely patient access in line with NHS England's access standards and CQC Regulation 12 (Safe care and treatment).
2. Scope
Applies to all reception staff handling appointment bookings via telephone, online, and in-person requests. Covers on-the-day urgent slots, routine bookings, telephone triage appointments, and home visit requests.
3. Responsibilities
| Role | Responsibility |
|---|---|
| Reception staff | Process bookings following this SOP; escalate where required |
| Reception lead | Monitor appointment utilisation; report capacity concerns |
| Duty GP / triage clinician | Available for telephone triage during morning window |
| Practice manager | Review SOP annually; update following configuration changes |
4. Procedure (highlights)
4.1 On-the-day urgent requests
- 1.Answer within five rings. Confirm identity (full name, date of birth, first line of address). Check record for communication needs or reasonable adjustments.
- 2.Ask patient to describe the reason using open questions: “How can we help you today?”
- 3.If symptoms may be urgent (chest pain, breathing difficulty, signs of stroke, severe bleeding), advise 999 immediately. Document the call.
- 4.For other same-day requests, offer next available telephone triage slot with duty clinician (08:00–10:30).
- 5.Record in clinical system with reason for encounter.
- 6.If no slots available, escalate to reception lead. Do not turn patient away without offering an alternative (extended hours, pharmacy, NHS 111).
4.2 Routine bookings
- 1.Verify patient identity (full name, date of birth).
- 2.Identify appointment type needed (GP, nurse, HCA, phlebotomy).
- 3.Offer next available with preferred clinician. If unavailable within two weeks, offer alternative and note preference.
- 4.For chronic disease reviews, check if patient is due a specific template (asthma, diabetes, COPD).
- 5.Confirm date, time, and clinician. Send text confirmation.
4.3 Online booking requests
- 1.Bookings via NHS App or practice website are automatically recorded.
- 2.Reception staff review online bookings at 08:00, 12:00, and 16:00 daily.
- 3.If booking appears clinically inappropriate, contact patient by telephone to rearrange.
4.4 Home visit requests
- 1.Take patient details, address, contact number, and reason for visit.
- 2.Record request in clinical system home visit module.
- 3.Pass to duty GP before 10:30 for assessment and prioritisation.
- 4.Duty GP confirms whether home visit, telephone consultation, or alternative is appropriate.
5. Related documents
Practice Access PolicyTelephone Triage ProtocolCQC Regulation 12NHS England GP Access Standards 2025/26
This SOP was generated in under two minutes. A practice manager would review it, adjust details specific to their practice, and save it to their compliance library.
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Worked Example
Controlled drugs: receipt, storage, and dispensing SOP
A more clinically detailed SOP — the kind that takes 3–4 hours to research and write from scratch. Generated from a prompt describing a dispensing practice with a part-time dispenser.
AI-generated example
Standard Operating Procedure: Controlled Drugs — Receipt, Storage, and Dispensing
Ref: SOP-MED-003Version: 1.0Effective: March 2026Review: March 2027
1. Purpose
To ensure the safe, legal, and auditable management of controlled drugs within the practice, in compliance with the Misuse of Drugs Regulations 2001, the Controlled Drugs (Supervision of Management and Use) Regulations 2013, and CQC Regulation 12 (Safe care and treatment).
2. Responsibilities
| Role | Responsibility |
|---|---|
| Medicines Lead (GP) | Clinical oversight; authorises stock orders; signs CD register |
| Dispenser | Day-to-day receipt, storage, dispensing, and register maintenance |
| Practice manager | SOP review; liaison with CD Accountable Officer; LFPSE reporting |
| All clinical staff | Report CD concerns or discrepancies immediately |
3. Procedure (highlights)
3.1 Receiving controlled drugs
- 1.When a CD delivery arrives, check against the original order immediately. Do not leave CDs unattended in an unsecured area.
- 2.Count each item and verify quantity matches the delivery note. Check expiry dates.
- 3.If any discrepancy (wrong item, wrong quantity, damaged packaging), do not sign. Contact supplier and record in CD incident log.
- 4.Record each item in CD register: date, quantity, form, strength, supplier name, signature of person receiving.
- 5.Store immediately in the controlled drugs cabinet.
3.2 Storage
- 1.All Schedule 2 and 3 CDs in a locked, wall-mounted cabinet meeting Safe Custody Regulations 1973.
- 2.Cabinet fixed to solid wall or floor with rag bolts. Keys must not be left in cabinet or stored in accessible location.
- 3.Access restricted to Medicines Lead and authorised dispensary staff.
- 4.Conduct weekly stock check with two staff present. Record running balance for each drug.
3.3 Dispensing
- 1.Verify prescription: prescriber signature, date (28-day rule for Sch 2/3), patient details, drug name, form, strength, dose, total quantity in words and figures.
- 2.Select correct drug from cabinet. Check name, form, and strength against prescription before removing.
- 3.Second check before medication leaves dispensary: dispenser and second authorised person verify drug, dose, quantity, and patient details.
- 4.Record in CD register: date, patient name, prescriber, quantity dispensed, updated running balance.
- 5.On collection, check patient ID. Representative signs the back of the prescription.
3.4 Destruction and disposal
- 1.Expired or unwanted CDs must not be disposed of in general pharmaceutical waste.
- 2.Contact CD Accountable Officer to arrange witnessed destruction.
- 3.Independent authorised witness (pharmacist, police officer, or CD Accountable Officer) must be present.
- 4.Record in CD register: date, drug name, quantity destroyed, method, signatures of both destroyer and witness.
- 5.Retain destruction records for minimum seven years.
3.5 Incident reporting
- 1. Report any discrepancy, loss, or theft to the Medicines Lead immediately
- 2. Notify CD Accountable Officer at the ICB within 24 hours
- 3. Report through Learn from Patient Safety Events (LFPSE)
- 4. Conduct significant event analysis within 72 hours
4. Related documents
CD PolicyMisuse of Drugs Regulations 2001CD Supervision Regulations 2013CQC Regulation 12CQC Regulation 17NICE CD GuidelineSEA SOP
This controlled drugs SOP would typically take 3–4 hours to research and write from scratch. The AI tool generated it in under two minutes. For a full guide to controlled drugs governance, see our controlled drugs management article.
Stay Current
An SOP with a review date of 2023 raises questions
CQC inspectors specifically look for evidence that documents are reviewed and updated. Storing SOPs in a searchable digital system with review date tracking beats a lever arch file.
Annual review
Review all SOPs at least annually. Many practices align SOP reviews with their annual compliance calendar.
Immediate review
After a significant event, a regulatory change, a CQC inspection finding, or a change in practice processes or staffing.
Triggered review
When staff report that an SOP no longer reflects what actually happens. If staff are not following the SOP, either the SOP needs updating or the staff need retraining.
My Practice Manager's compliance library stores all your SOPs with built-in review date tracking, version history, and team distribution.
Pricing
Start free. Upgrade when you are ready.
No credit card required. Generate your first SOP free to see how it works.
Free
£0
Try the AI tools, no strings attached.
- 3 lifetime AI document generations
- 1 compliance library domain (your choice)
- 5 active tasks
- 1 user
- 4 AI templates (Policy, Risk Assessment, SOP, General Assistant)
Starter
£12/month+ VAT
For practice managers getting started with AI compliance tools.
- Unlimited AI document generations
- Full compliance library (all 11 domains)
- 15 active tasks
- 1 user
- 4 AI templates (Policy, Risk Assessment, SOP, General Assistant)
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Essentials
£20/month+ VAT
Everything your practice needs for complete CQC compliance.
- Unlimited AI document generations
- Full compliance library (all 11 domains)
- All 12 AI templates
- Unlimited active tasks
- Multi-user access
- Rota management
- Email support
Pro
£45/month+ VAT
Full platform access with document distribution and CQC readiness tools.
- Everything in Essentials, plus:
- Document Manager
- Read receipts and acknowledgements
- CQC compliance check
- Priority email support
Prices shown for a 9,001–12,000 patients practice. Starter is a flat rate. See pricing for your practice size
Want someone to do it for you? See our Policy Review Service — from £25 per policy area.
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Cyber Essentials
Independently verified cybersecurity controls
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Published and verified
UK GDPR
UK-hosted infrastructure, DPA available
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FAQ
Frequently asked questions
What SOPs does a GP practice need?
There is no definitive list, because practice size, services, and dispensing status all affect what is needed. Most GP practices need SOPs covering appointment booking, repeat prescriptions, telephone triage, specimen handling, cold chain management, controlled drugs (if dispensing), infection prevention, fire safety, significant event reporting, subject access requests, and staff induction. The checklist above covers 19 essential SOPs as a starting point.
Does CQC inspect SOPs directly?
CQC does not have a checklist of required SOPs. Inspectors assess whether your practice has effective governance systems under Regulation 17 and safe care processes under Regulation 12. SOPs are the evidence that these systems exist. In practice, inspectors ask staff how they handle specific tasks — if their answers are consistent and match documented procedures, that demonstrates good governance.
How often should SOPs be reviewed?
At minimum, annually. You should also review SOPs immediately after a significant event, a regulatory change, a CQC inspection finding, or when staff report that the documented procedure no longer matches what actually happens. Recording the review date on each SOP is important — an expired review date is a visible governance gap.
What is the difference between a policy and an SOP?
A policy states your practice’s position on a topic (the “what” and “why”). An SOP provides the step-by-step instructions for carrying out a specific task (the “how”). For example, your controlled drugs policy states that the practice will comply with the Misuse of Drugs Regulations 2001. Your controlled drugs SOP describes how to receive a delivery, record it in the register, store it in the cabinet, and dispense it to a patient. Both are needed.
Can I use AI to write SOPs for my GP practice?
Yes. My Practice Manager’s AI SOP generator creates tailored standard operating procedures based on your practice’s context. You describe the procedure and the tool generates a complete SOP with purpose, scope, responsibilities, step-by-step instructions, regulatory references, and review dates. The AI handles the structure and regulatory context; you review the output and adjust details specific to your practice. Try the SOP generator free.
Are AI-generated SOPs accepted by CQC?
CQC assesses whether your procedures are documented, current, and followed by staff — not how they were written. An AI-generated SOP that has been reviewed by the practice manager, approved by the appropriate lead, and is actively used by staff meets CQC expectations in the same way as a manually written one.
Stop writing SOPs from scratch
Your practice needs dozens of standard operating procedures. Writing them manually takes 40–80 hours. Generate all 19 core SOPs in under 40 minutes and get back to managing your practice.
No credit card required. No sales calls. Generate your first SOP free.
This page describes the features and capabilities of My Practice Manager software as of March 2026. Generated SOPs are starting points for professional review and should be checked against your practice's specific requirements and current regulatory guidance. Always refer to the latest guidance from CQC, NHS England, and the Home Office (for controlled drugs legislation).