Clinical Governance


This policy sets out our Practice’s approach to Clinical Governance.

Implementing Clinical Governance applies throughout the Practice and is designed to ensure the safety and well-being of our patients and improve the service that they receive from us.


Summary Statement.

The Practice will always do its utmost to provide the highest quality treatment and care it can to its patients, ensuring always that it works with the most up-to-date clinical information and current best practice guidelines.

1.   Patient involvement. 

We will encourage and actively seek patient participation, ensuring there is a system in place which enables patients to provide feedback and make suggestions and be actively involved in deciding how the health services they use should develop.

This system will be supported and promoted through open dialogue, in person and / or in writing, and also through the use of the Practice’s Patient Participation Group, whose aim is to give patients an opportunity to meet, exchange ideas and information to improve the running of the Practice and ensure we are listening and responding to the needs and concerns of our patients.

2.   Patient experience. 

We will discuss feedback received from patients and publicise both suggestions and the practice response. Whenever an identifiable patient suggests, the Practice will ensure s/he will receive a personal response.

We will view the practice from the patient perspective (from formal patient survey results) and actively seek to try and implement feasible and beneficial ideas.


3.   Health & Safety and Risk Control.

The Practice implements a robust framework for ensuring it adheres to Health and Safety legislation, both for staff working within the Practice premises and environment, as well as preventing harm to patients when they attend the surgery. The Practice considers the guidelines in the revised version of the GMC document “Raising and acting on concerns about patient safety”, effective 12 March 2012, a copy of which can be downloaded here:

Dr Bapu Sathyajith is the Practice Health & Safety Lead who has overall responsibility for ensuring the Practice Premises are a safe environment for staff and patients using the service.

We operate an open system of Significant Event Reporting which ensures we review, obtain and provide feedback and learn from such incidents. Each Significant Event is discussed in detail and agreed action documented in a Significant Event Review / Clinical Policy Review Meeting.

4.   Clinical Audit. 

The Practice undertakes regular clinical audits, carefully and accurately recording the results and taking appropriate action so that we can effectively plan for the implementation of changes / improvements for the benefit of our Patients.

Our administrative procedures are also audited on a regular basis to ensure they are operating effectively.

5.   Evidence-based medical treatment. 

The Practice will develop, refine and maintain an awareness of the latest developments, research results and advances in medical treatment and assess the impact of this information on our established and proven methods of working.

To encourage discussion and learning, we will ensure that expertise and opinion is shared both within the Practice and between clinicians.

6.   Information and its use.

The Practice is committed to making maximum use of both electronic and paper-based information in clinical and non-clinical decision making and will share best practice with others both internally and externally.

We will aim to continuously improve data quality and encourage patients to participate in their own clinical treatment and be involved in making the decisions which affect them.

7.   Staff and staff management.

To encourage team working throughout the Practice, we will operate “no-blame” learning culture which will provide all Staff with an open and equal working relationship.

We aim to work towards the “Investor in People” standard, by encouraging staff training and development whilst also supporting devolution of control and empowerment.

8.   Education, Training and Continuing Professional Development (CPD). 

All Practice Staff, Clinical and Non-clinical take part in an annual appraisal system which links into their personal development programme.

GPs and nurses are obliged professionally to maintain their CPD to ensure their clinical skills are as up to date as possible and they can continue to practise. All their CPD activity will be documented as an integral part of their learning portfolio (GPs a minimum of 50 learning credits per year and Nurses a minimum of 35 hours of learning activity relevant to their practice every three years).

We ensure all Doctors benefit from CPD by undertaking revalidation, attending a variety of clinical treatment updates, GP registrar training sessions, and resuscitation training days and organising regular in-house clinical seminars from specialist consultants and in-house trainers.

Our Nurses attend training in clinical areas such as the new trends in treatment and care of patients undergoing the menopause, a diploma in chronic obstructive pulmonary disease, up dates in travel and childhood immunisation, and care of the diabetic patient.

All Non-clinical staff are encouraged to attend events related to their own specialism or professional development need, as identified by the appraisal system.

The Practice closes for Four hours each month to allow all staff to take part in protected learning sessions, including updates on basic life support, health and safety, appraisal skills, team building and information governance.

These sessions also provide the opportunity to review departmental policies and procedures, to examine any critical incidents that have occurred and to review the feedback from the annual patient survey in order to implement any changes that may be necessary as a result of its findings and recommendations.

9.  Strategic approach. 

We will operate a 5-year strategic plan based on projected patient needs, being mindful of both the current and projected National and Local healthcare situation.

We will actively participate in the Clinical Commissioning Group and focus on activity which creates resources to help achieve both immediate and longer-term patient clinical needs.



Dr Bapu Sathyajith is the Clinical Governance Lead(s) for the Practice, having responsibility for:

  • Overseeing the management of the key provisions of this Policy.
  • Provision of clinical governance leadership and advice.
  • Promotion of quality care within the practice.
  • Acting as an expert resource and advisor in the examination and review of significant events.
  • Initiating and reviewing clinical audits.
  • Keeping up to date with research and governance recommendations and communicating these accordingly.