Policy

Clinical Governance Policy

A framework for assuring the safety, effectiveness and quality of clinical care across all regulated activities

For Private Healthcare ClinicRef BS-PH-POL-002See a sample (PDF) →
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  • 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
  • 4. Definitions
  • 5. The clinical governance framework
  • 6. Governance structure and committees
  • 7. Patient safety and incident management
  • 8. Duty of candour
  • 9. Clinical effectiveness, audit and outcomes
  • 10. Practising privileges and workforce assurance
  • 11. Mapping to the CQC Single Assessment Framework
  • 12. Roles and responsibilities
  • 13. Training
  • 14. Records, monitoring and audit
  • 15. Related documents
  • 16. Version control and review
  • 17. Appendix A - Clinical governance committee assurance checklist
  • 18. Appendix B - Duty of candour record form
  • 19. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - in particular Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 20 (Duty of candour)
  • Care Quality Commission (Registration) Regulations 2009 - in particular Regulations 16 to 18 and Regulation 20
  • Health and Social Care Act 2008
  • Care Quality Commission Single Assessment Framework (published 2023, in force 2026) - five key questions and quality statements
  • Health and Care Act 2022 (including the Patient Safety Incident Response Framework duty context)
  • Data Protection Act 2018 and the UK General Data Protection Regulation (UK GDPR)
  • Ionising Radiation (Medical Exposure) Regulations 2017 (where applicable)
  • Mental Capacity Act 2005 and the Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2022 (Regulation 12A, Liberty Protection Safeguards readiness)
  • Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)
  • Equality Act 2010

Who it applies to

All clinical and non-clinical staff, registered managers, the nominated individual, the registered provider, locum and agency practitioners, contractors, and any individual delivering or supporting regulated activities on behalf of [Organisation Name].

Glossary

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

After-action review
A structured team discussion held soon after an event to learn what happened, why, and how to do better next time.
Bacteraemia
The presence of bacteria in the bloodstream, which can cause a serious infection.
Caldicott principles
A set of standards that govern how people's confidential health and care information may be used and shared.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Clinical audit
A check of whether care is meeting agreed standards, followed by changes and a re-check to confirm improvement.
Clinical governance
The system of accountability, checks and behaviours through which an organisation assures and improves the quality and safety of its clinical care.
Clostridioides difficile (C. difficile)
A bacterium that can cause severe diarrhoea and bowel infection, often after antibiotic use, and is monitored as a healthcare-associated infection.
Co-production
Designing and improving services together with the patients and public who use them.
Contemporaneous record
A note made at the time of an event or very soon afterwards, so it is an accurate and reliable account.
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 person and their family when something goes wrong with their care.
Equality Act 2010
The law protecting people from discrimination based on characteristics such as age, disability, sex or race.
Freedom to Speak Up Guardian
An independent person who supports staff to raise concerns about safety or wrongdoing and reports themes to the board.
Friends and Family Test
A short feedback question asking patients whether they would recommend a service to others.
Fundamental standards
The minimum standards of safety and quality below which care must never fall.
General Medical Council (GMC)
The body that registers and regulates doctors in the United Kingdom.
Getting It Right First Time (GIRFT)
A national programme that reviews how specialties work and recommends ways to improve care and reduce unwarranted variation.
Health and Care Professions Council (HCPC)
The body that registers and regulates a range of health and care professionals, such as physiotherapists and paramedics.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting out the fundamental standards that registered care providers must meet.
Healthcare-associated infection
An infection that a patient picks up as a result of receiving healthcare rather than from their original illness.
Indemnity
Insurance or cover that pays for the costs of claims if a practitioner's care is alleged to have caused harm.
Infection prevention and control (IPC)
The measures used to stop infection spreading between patients, staff and visitors.
Information governance
The framework for handling people's personal and health information legally, securely and appropriately.
Liberty Protection Safeguards (LPS)
A legal framework, intended to replace the Deprivation of Liberty Safeguards, for authorising care arrangements that deprive a person of their liberty when they cannot consent.
Locum
A practitioner who works temporarily to cover for another, for example during absence or to meet extra demand.
Medical Advisory Committee (MAC)
A committee of senior clinicians that advises the board on clinical standards, practising privileges and professional matters.
Medicines and Healthcare products Regulatory Agency (MHRA)
The body that regulates medicines, medical devices and blood components for safety in the United Kingdom.
Mental Capacity Act 2005
The law that protects and supports people who may be unable to make particular decisions for themselves.
Meticillin-resistant Staphylococcus aureus (MRSA)
A type of bacterium resistant to several common antibiotics that can cause difficult-to-treat infections.
Morbidity
Illness, injury or complications experienced by a patient.
Mortality and morbidity review
A regular meeting where clinicians examine deaths and complications to identify learning and improve care.
National Institute for Health and Care Excellence (NICE)
The body that produces evidence-based guidance on treatments and care for use across health and social care.
National Joint Registry
A national database that records joint replacement operations to monitor how well implants and surgery perform over time.
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 never happen if the correct safeguards are followed.
Nominated Individual
The senior person responsible to the regulator for supervising how a service is provided.
Notifiable safety incident
An unexpected incident during care that results in, or could result in, death or a specified level of harm, triggering the duty of candour.
Nursing and Midwifery Council (NMC)
The body that registers and regulates nurses and midwives in the United Kingdom.
Patient Safety Incident Response Framework
A national approach to responding to and learning from patient safety incidents, focused on improvement rather than blame.
Patient-reported experience measures (PREMs)
Feedback collected from patients about their experience of care, such as communication and dignity.
Patient-reported outcome measures (PROMs)
Information collected from patients about their health and quality of life before and after treatment.
Plan-Do-Study-Act
A four-step cycle for testing and refining a change on a small scale before adopting it more widely.
Practising privileges
Permission granted to a practitioner, usually a consultant, to work in an independent hospital without being employed by it, subject to agreed conditions.
Quality account
An annual report in which a provider sets out the quality of the services it delivers and its improvement priorities.
Quality statements
The 'we statements' the regulator uses to describe what good care looks like under each key question.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)
The law requiring certain workplace injuries, diseases and dangerous events to be reported to the Health and Safety Executive.
Responsible officer
A senior doctor who oversees the appraisal and revalidation of doctors and makes recommendations about their fitness to practise.
Revalidation
The periodic process by which registered professionals demonstrate they remain up to date and fit to practise.
Risk assessment
A structured check identifying what could cause harm and what is being done to prevent it.
Risk register
A live record of the risks an organisation faces, how serious they are, and what is being done to control them.
Root cause analysis
A structured investigation that looks beyond immediate causes to find the underlying system reasons an incident happened.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Scope of practice
The range of clinical activities a practitioner is trained, competent and permitted to carry out.
Sepsis
A life-threatening reaction to infection in which the body damages its own tissues and organs, needing urgent treatment.
Single Assessment Framework (SAF)
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
Statement of Purpose
A required document describing who a service is, what it does and where, shared with the regulator.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.
Venous thromboembolism (VTE)
A blood clot that forms in a vein, such as in the leg, which can travel to the lungs and become life-threatening.
World Health Organization surgical safety checklist
A standard set of safety checks completed by the surgical team before, during and after an operation to reduce avoidable harm.
Yellow Card scheme
The UK system for reporting suspected side effects of medicines and problems with medical devices to the regulator.

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  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.

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