Clinical Governance

Due to the COVID-19 pandemic, some of the arrangements below have been put on hold. Please click here for more information.

Schedule 4 of the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 set out the ‘Terms of Service of NHS pharmacists in four parts.  Part 2 are the Essential services, Part 3 are the Hours of opening provisions, and Part 4 set out the other terms of service, which includes Clinical Governance.  Adherence with the clinical governance requirements is thus a part of the terms of service.

The clinical governance requirements of the community pharmacy contractual framework (CPCF) cover a range of quality related issues detailed below, help and support for which can be found on the PSNC website: click here

  • Guidance for pharmacy contractors
  • Audit
  • Chaperone policy
  • Clinical governance lead
  • Complaints procedures
  • Confidentiality
  • CPPQ (patient satisfaction survey)
  • Patient safety incident reporting
  • Practice leaflets
  • Raising concerns (Whistle-blowing)

Clinical Governance  – Actions required by 31 March 2020

PSNC has published new guidance to assist community pharmacy contractors in completing the Data Security and Protection Toolkit for 2019/20. The Toolkit, used to make a pharmacy’s information governance (IG) declaration, must be completed by 31st March 2020 but it’s recommended to do so as soon as possible.

After a complete overhaul of the Toolkit system for 2018/19, this year’s submission should now be familiar to most contractors. PSNC has again worked closely with NHS Digital to keep the workload manageable but the data security protections appropriate. Learn more about completing the Toolkit at:

Watch the webinar at:

PSNC Briefing 009/20: Upcoming clinical governance deadlines – actions to be completed by 31st March 2020

In light of the current COVID-19 situation some of the Clinical Governance deadlines have been amended:

Topic Requirements By when?
Data Security and Protection Toolkit

To use the Data Security and Protection Toolkit to complete and submit an annual information governance (IG) return.

See PSNC Toolkit webpage for more information and guidance.

Deadline moved to 30th Sept 2020 due to COVID-19
Community Pharmacy Patient Questionnaire (CPPQ)

To conduct an annual CPPQ and publish the results.

See PSNC CPPQ webpage for more information and guidance.

NHSE&I will not take action against contractors who have not completed these by 31st March 2020
Clinical audit

To conduct two audits each year: one on a topic of your choice* and one determined nationally by NHS England and NHS Improvement (the focus of the national audit for 2019/20 focusses on antimicrobial stewardship, specifically aimed at advice provided to patients on upper respiratory tract infections).

*Please note, any audits undertaken as part of the Pharmacy Quality Scheme cannot be used as the pharmacy’s own audit.

See PSNC clinical audit webpage for more information and guidance.

Pharmacy’s own audit deadline: 31st March 2020

National audit has been Cancelled

A fourth clinical governance requirement, whilst not due by 31 March, should be completed shortly afterwards and as such it is best to begin work towards achieving this alongside the requirements listed above.

Complaints report To prepare an annual report each year and send a copy to the local NHS England team. As soon as practicable after
31st March 2020Click here to read update due to COVID-19


The LPC have put together the following Checklist, which pharmacies can print out and check off as appropriate:

Pharmacy Annual Requirements Checklist – pdf




Visit PSNC Clinical Governance page: Click Here