Clinical Governance

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
  • Business continuity & emergency planning
  • CPPQ (patient satisfaction survey)
  • Complaints procedures
  • Practice leaflet requirements
  • Patient safety incident reporting
  • Raising concerns (Whistle-blowing)
  • Chaperone policy
  • Clinical governance lead
  • Confidentiality

Clinical Governance

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.

Data Security & Protection Toolkit: new PSNC guidance available for the 2021/22 toolkit, with submissions required by 30th June 2022. Find out more


Community Pharmacy Patient Questionnaire (previously CPPQ)





To conduct an annual satisfaction survey and publish the results.

See PSNC webpage for more information and guidance.




For 2021/22: Read the changes to patient satisfaction survey requirements (November 2021)

Please Note:  since the changes above, contractors will now not be required to complete the Community Pharmacy Patient Questionnaire for 2021/2022. Find out more

For 22/23: Read the announcement for this years patient satisfaction survey.

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

*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.


  • The requirement for pharmacy teams to complete a national audit (intended to be on valproate) in 2021/22 will be waived; and 
  • The requirement for pharmacy teams to complete a contractor-chosen clinical audit in 2021/22 will be waived.  Find out more




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. COIVD-19 update: NHSE&I has announced a system wide “pause” of the NHS complaints process


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