Policy

Clinical Governance, Audit & Incident Reporting Policy

The clinical governance framework, clinical audit programme, risk register and end-to-end incident and near-miss reporting that evidence safe, well-led aesthetic practice

For Aesthetic ClinicRef BS-AES-POL-010See a sample (PDF) →
£54.99
One-off purchase · no VAT · instant download
  • Instant download after checkout
  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This policy is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Policy statement and governance principles
  • 4. Definitions
  • 5. Leadership and accountability
  • 6. The clinical audit cycle
  • 7. The clinical audit programme
  • 8. Significant event analysis and learning reviews
  • 9. Incident and near-miss reporting process
  • 10. Grading the harm of an incident
  • 11. Statutory notifications and the duty of candour
  • 12. The risk register
  • 13. Outcome and complication monitoring
  • 14. Integrating complaints and patient feedback
  • 15. Clinical records and photography as governance evidence
  • 16. Governance meetings and minutes
  • 17. Evidencing the CQC Safe and Well-led key questions
  • 18. Just and learning culture
  • 19. Roles and responsibilities
  • 20. Training and awareness
  • 21. Monitoring, audit and compliance
  • 22. Related policies
  • 23. Review and version control
  • 24. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 17 (Good governance)
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 12 (Safe care and treatment)
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 20 (Duty of candour)
  • Care Quality Commission (Registration) Regulations 2009 - Regulation 18 (Notification of other incidents) and Regulation 16 (Notification of death of a service user)
  • Care Quality Commission single assessment framework (key questions Safe and Well-led, and the associated quality statements)
  • Human Medicines Regulations 2012 (as amended), including the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card scheme for reporting adverse drug reactions
  • Data Protection Act 2018 and the UK General Data Protection Regulation (UK GDPR)
  • Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)

Who it applies to

All registered managers, the nominated individual, medical director / lead clinician, prescribers, practitioners (medical, nursing, dental and non-medical injectors), clinical support staff, reception and administrative staff, locums, students and contractors of [Organisation Name]

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Adverse drug reaction
An unwanted or harmful response a patient has to a medicine that was given correctly.
Anaphylaxis
A severe, life-threatening allergic reaction needing immediate emergency treatment.
Botulinum toxin
A prescription-only injectable medicine used to relax muscles and soften lines, commonly known by brand names such as Botox.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Care Quality Commission (Registration) Regulations 2009
The rules that set out which incidents and deaths a registered provider must formally notify to the regulator.
Clinical audit
A structured check that compares what a service actually does against an agreed standard, makes changes, and then checks again to confirm improvement.
Clinical governance
The overall system a provider uses to keep its care safe and high quality and to keep improving it.
Cooling-off period
A set time between a consultation and a treatment that lets the patient reflect before deciding to go ahead.
Cosmetic Practice Standards Authority (CPSA)
The body that sets the clinical standards used to oversee non-surgical cosmetic treatments in the UK.
Contemporaneous
Written down at the time of the event or treatment, or as soon as possible afterwards, so the record is accurate.
Data Protection Act 2018
The UK law that controls how organisations collect, store and use people's personal information.
Dermal filler
An injectable gel, often based on hyaluronic acid, used to smooth lines or add volume to the face.
Disclosure and Barring Service (DBS) check
A criminal-records check showing whether a person is suitable to work with patients or vulnerable people.
Duty of candour
The legal duty to be open and honest with a patient and their family when something goes wrong with their care.
Energy-based device
A treatment device that uses energy such as laser, light, radiofrequency or ultrasound to act on the skin or tissue.
Evidence-based practice
Providing care that is supported by good-quality research and recognised professional guidance.
Fitness to practise
Whether a registered professional has the skills, knowledge, health and conduct needed to do their job safely.
Fit and Proper Persons
A legal requirement that directors and senior leaders of a service are honest, trustworthy and suitable for their role.
General Dental Council (GDC)
The body that registers and regulates dental professionals in the UK.
General Medical Council (GMC)
The body that registers and regulates doctors in the UK.
General Pharmaceutical Council (GPhC)
The body that registers and regulates pharmacists and pharmacy technicians in Great Britain.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The main set of rules a care provider must meet to deliver regulated care safely and well, enforced by the Care Quality Commission.
High-intensity focused ultrasound (HIFU)
A treatment that uses focused sound waves to heat tissue beneath the skin, used for tightening and lifting.
Hyaluronidase
An emergency medicine used to dissolve hyaluronic-acid dermal filler, for example if a blood vessel becomes blocked.
Incident
Any event that caused, or could have caused, harm to a patient, member of staff, visitor or the organisation.
Indemnity
Insurance or equivalent cover that protects a practitioner and patients if a claim is made about their care.
Infection prevention and control (IPC)
The measures used to stop infection spreading between patients, staff and visitors.
Informed consent
Agreement to treatment given freely after the risks, benefits and alternatives have been clearly explained.
Intense pulsed light (IPL)
A skin treatment that uses broad-spectrum light to target pigment, redness or hair.
Intravenous (IV)
Given directly into a vein, for example a drip delivering fluids or vitamins.
Joint Council for Cosmetic Practitioners (JCCP)
The voluntary register and standards body for practitioners who provide non-surgical cosmetic treatments in the UK.
Just and learning culture
A workplace where staff are treated fairly and supported to report mistakes so the organisation can learn, while still being accountable for reckless behaviour.
Medicines and Healthcare products Regulatory Agency (MHRA)
The UK body that regulates medicines and medical devices and monitors their safety.
Microneedling
A skin treatment that uses fine needles to make tiny punctures and encourage the skin to repair itself.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Never event
A serious, largely preventable patient safety incident that should not happen if the right safeguards are in place.
Nominated Individual
The senior person responsible to the regulator for supervising how a service is provided.
Notifiable safety incident
An incident serious enough that the law requires the provider to be open with the patient under the duty of candour.
Nursing and Midwifery Council (NMC)
The body that registers and regulates nurses and midwives in the UK.
PECR (Privacy and Electronic Communications (EC Directive) Regulations 2003)
The UK rules covering marketing by phone, email and text and the use of cookies and similar technology.
Person-centred care
Care that is shaped around the individual patient's needs, wishes and circumstances.
Platelet-rich plasma (PRP)
A treatment using a concentrated part of the patient's own blood, injected to encourage tissue repair.
Polynucleotides
Injectable substances used in aesthetic treatments to support skin repair and quality.
Prescription-only medicine (POM)
A medicine that may lawfully be supplied only on the instruction of an appropriate prescriber.
Practising privileges
An arrangement allowing an independent practitioner to work at a clinic they do not own, under agreed conditions.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013)
The law requiring certain workplace injuries, diseases and dangerous events to be reported to the Health and Safety Executive.
Risk register
A live record of the things that could go wrong, how serious each is, what is being done about them and who is responsible.
Root cause analysis (RCA)
A structured investigation that looks for the underlying system causes of an event rather than blaming one person.
Safe (key question)
One of the regulator's five key questions, asking whether people are protected from avoidable harm.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Scope of practice
The range of treatments and tasks a practitioner is trained, competent and authorised to carry out.
Significant event analysis (SEA)
A team review of a single notable event, good or bad, to understand what happened and what should change.
Single assessment framework
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
Sharps
Needles, blades and other items that can cut or puncture the skin.
SMART action
An action that is specific, measurable, achievable, relevant and time-bound, so progress can be tracked.
Statement of Purpose
A required document describing who a service is, what it does and where, shared with the regulator.
Thread lift
A treatment that inserts dissolvable threads under the skin to lift and support sagging tissue.
Triage
Quickly assessing and sorting an issue by urgency or severity so the most serious gets attention first.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.
Vascular occlusion
A blockage of a blood vessel, a serious complication that can occur if filler is injected into or compresses an artery.
Whistleblowing (speaking up)
Raising a concern about wrongdoing, risk or malpractice at work, protected by law.
Yellow Card scheme
The UK system for reporting suspected side effects of medicines and problems with medical devices to the regulator.

How it works

  1. Buy securely with Stripe - instant, no VAT, no account needed.
  2. Download your editable Word file from the link we email you straight away.
  3. Complete the placeholders for your service, then have it approved before use.
  4. Add the optional updates subscription and we keep it current as guidance changes.

Related documents

PolicyAdverse Event Management Policy£54.99
PolicySafeguarding Policy£54.99
PolicyComplaints Policy£54.99
PolicyConsent & Risk Disclosure Policy£54.99

Need the whole set?

Buy the full Aesthetic Clinic pack and save versus buying documents individually.

View the Aesthetic Clinic pack