Clinical Governance

What is clinical governance?

Clinical governance is a system through which healthcare providers are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which excellence in clinical care will flourish.

Why is clinical governance important?

  • It’s about being accountable, taking professional responsibility, having the right systems and processes in place and about continuously improving what we do.
  • It is a fundamental element of healthcare practice. It is a continuing process not an event.
  • It is relevant to everyone – from counter assistants to technicians, pharmacists and pharmacy contractors.

Visit CPE for more info on the following:

  • Guidance for pharmacy contractors
  • Related resources
  • 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

For contacts at the ICB around Governance, Patient Satisfaction, Claims Report etc.. please click here to view the Pharmacy Contact List.

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.

New PSNC guidance is available for the toolkit, with submissions required by 30th June 2024. Find out more


Community Pharmacy Patient Satisfaction Survey (previously CPPQ)

Patient Satisfaction Survey replaced by workforce survey from 1st Oct 2022




On 2nd September 2022, Regulations were laid in Parliament which will remove the requirement for pharmacy contractors to undertake an annual patient satisfaction survey from 1st October 2022.

Read more about this change in the regulations

This means the contractual requirement to undertake an annual patient satisfaction survey will no longer apply to contractors in 2022/23 and going forward.

See PSNC webpage for more information.

From 2022 – Contractors are now to complete the Mandatory workforce survey instead.


Get ready for the 2023 Workforce Survey: Find out more




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.

National audit 2022/23 – valproate – Find out more


As the reduced PQS contains a clinical audit, DHSC and NHSE have agreed to PSNC’s request to remove the clinical governance requirement for contractors to undertake two clinical audits in 2023/24.







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 reasonably practical after the 31st march each year.