Clinical Governance Policy / Guidance

1. Purpose 

This Clinical Governance Policy sets out the framework by which the organisation ensures high standards of quality, safety, and compliance in the recruitment, placement, and ongoing management of healthcare professionals supplied to health and social care services. The policy aligns with the Care Quality Commission (CQC) Fundamental Standards and supports the delivery of safe, effective, caring, responsive, and well-led services. 

2. Scope 

This policy applies to all directors, employees, recruiters, compliance staff, and temporary workers engaged by the organisation. It covers all recruitment, vetting, placement, monitoring, and quality assurance activities related to the supply of healthcare professionals to CQC-regulated services. 

3. Regulatory Framework 

This policy is informed by and aligned with: 

• Care Quality Commission (CQC) Fundamental Standards 
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
• CQC Key Lines of Enquiry (KLOEs) 
• NHS Employers and Skills for Care guidance (where applicable) 
• Relevant professional body standards (e.g. NMC, GMC, HCPC) 
• Safer Recruitment principles 

4. Definition of Clinical Governance (Recruitment Context) 

Clinical governance within a healthcare recruitment organisation refers to the systems, processes, and accountability arrangements that ensure only safe, competent, suitably qualified, and compliant healthcare professionals are recruited, supplied, and supported to deliver care. 

5. Principles of Clinical Governance 

The organisation’s clinical governance framework is underpinned by the following principles: 

• Safety of people who use services 
• Robust safer recruitment and compliance processes 
• Transparency, accountability, and ethical practice 
• Continuous monitoring and improvement of quality 
• Learning from incidents, concerns, and feedback 
• Strong leadership and effective oversight 

6. Governance Structure and Responsibilities 

6.1 Directors / Board 

The Board holds overall accountability for clinical governance and CQC compliance. Responsibilities include: 

• Setting strategic direction for quality and safety 
• Ensuring adequate resources for safe recruitment practices 
• Reviewing governance reports, risks, and audit findings 
• Promoting a culture of openness, learning, and continuous improvement 

6.2 Registered Manager / Nominated Individual (where

applicable) 

The Registered Manager or Nominated Individual is responsible for: 

• Day-to-day oversight of quality and safety systems 
• Ensuring compliance with CQC regulations 
• Acting as the main point of contact with the CQC 
• Ensuring effective governance arrangements are embedded 

6.3 Clinical Governance Lead 

The Clinical Governance Lead is responsible for: 

• Maintaining the clinical governance framework 
• Oversight of compliance, audit, and quality monitoring 
• Reviewing incidents, concerns, and safeguarding matters 
• Reporting quality issues and trends to senior leadership 

6.4 Recruitment and Compliance Team 

Recruitment and compliance staff are responsible for: 

• Ensuring all candidates meet safer recruitment standards 
• Completing and maintaining compliance files 
• Verifying identity, right to work, qualifications, and registrations 
• Monitoring DBS status, training, and revalidation 

6.5 All Staff 

All staff are responsible for: 

• Adhering to organisational policies and procedures 
• Raising concerns, incidents, or risks promptly 
• Acting in accordance with the organisation’s values and code of conduct

7. Key Components of Clinical Governance 

7.1 Safer Recruitment and Pre-Employment Checks 

The organisation ensures that all healthcare professionals supplied are safe and suitable by completing: 

• Enhanced DBS checks (including barred list where required) 
• Right to work in the UK verification 
• Verification of qualifications and professional registration 
• Employment history and reference checks 
• Occupational health and fitness-to-work assessments  

7.2 Training, Competence, and Ongoing Suitability

The organisation ensures ongoing competence through: 

• Mandatory training aligned to role and placement 
• Monitoring of professional registration and revalidation 
• Annual file reviews and updates 
• Engagement with clients regarding performance feedback 

7.3 Risk Management and Patient Safety 

Systems are in place to identify and manage risks, including: 

• Risk assessments for roles and placements 
• Incident and near-miss reporting processes 
• Escalation of concerns related to unsafe practice 
• Safeguarding adults and children procedures 

7.4 Incident Management and Safeguarding 

The organisation:

• Encourages prompt reporting of incidents, concerns, and allegations 
• Investigates incidents proportionately and fairly 
• Works collaboratively with clients, local authorities, and regulators 
• Refers professionals to regulatory bodies where required 

7.5 Quality Monitoring and Audit 

Quality is monitored through: 

• Regular compliance and file audits
• KPI monitoring (e.g. training compliance, DBS status) 
• Client feedback and service reviews 
• Internal governance meetings and action plans 

7.6 Information Governance 

The organisation maintains accurate and confidential records by: 

• Complying with UK GDPR and Data Protection Act 2018 
• Secure storage and controlled access to records 
• Timely and accurate documentation 

8. Openness, Transparency, and Duty of Candour 

The organisation is committed to openness and transparency and supports CQC’s Duty of Candour by: 

• Being honest when things go wrong 
• Supporting clients and stakeholders with timely information 
• Learning from errors to improve systems and processes 

9. Complaints and Feedback 

The organisation has systems to: 

• Receive and respond to complaints promptly and fairly 
• Use feedback from clients, candidates, and stakeholders to improve services 
• Record, investigate, and learn from complaints 

10. Monitoring, Assurance, and Reporting 

The effectiveness of this policy is monitored through: 

• Governance reports to senior leadership 
• Audit outcomes and compliance dashboards 
• Review of incidents, complaints, and safeguarding concerns 

11. Review and Continuous Improvement 

This policy will be reviewed annually, or sooner if required due to changes in legislation, CQC guidance, or organisational structure. 

12. Related Policies and Documents 

• Safer Recruitment Policy 
• DBS and Right to Work Policy 
• Safeguarding Adults and Children Policy 
• Incident and Allegations Management Policy 
• Complaints Policy 
• Information Governance Policy 

Date written: 27/2/2026
To be reviewed: 27/02/2027