Governance Audit Framework
CQC-mapped audit modules covering all 22 CQC regulations (3–20A + Registration Reg 13) — from daily temperature checks to annual Fit & Proper Person declarations. Every audit is timestamped, signed, and inspector-ready.
Flip through the Governance Rooms — one patient journey and the whole clinic, shown regulation by regulation, with live proof from a real UK clinic.
Reg 12
Temperature Log
Safe Care & Treatment
Daily fridge temperature monitoring for all refrigerated injectables — botulinum toxin, skinboosters, and biologics. Records min, max, and current readings with named staff sign-off and thermometer reset confirmation.
- Daily min / max / current readings
- Named staff sign-off
- Thermometer reset confirmation
- Out-of-range alert flags
- Monthly trend summary
CQC inspectors routinely request temperature logs as primary evidence of safe medicines management. Gaps or unsigned entries result in immediate required action.
Reg 12
Prescription Log
Safe Care & Treatment
Tracks every prescription-only medicine ordered, received, stored, and administered. Captures serial numbers, batch references, quantities, ordering clinician, storage sign-off, and weekly reconciliation.
- Serial number & batch tracking
- Ordered by / received by / stored by
- Quantity ordered vs quantity received
- Storage location & temperature confirmation
- Weekly stock reconciliation
HMRC and CQC both require a fully documented POM audit trail. This log also forms part of the three-document VAT exemption evidence chain for qualifying treatments.
Reg 12
PPE Audit
Safe Care & Treatment
Monthly stock check and compliance review of all personal protective equipment — gloves, aprons, masks, eye protection, and face shields. Verifies correct usage, disposal compliance, and reorder thresholds.
- PPE stock levels by type
- Usage compliance observation
- Disposal compliance check
- Reorder triggers logged
- Staff training on correct use
CQC inspectors give PPE compliance heightened scrutiny. Monthly documented audits with stock levels and disposal records are now expected as standard for all clinical environments.
Reg 12
Infection Control Audit
Safe Care & Treatment
Full infection prevention and control audit covering hand hygiene facilities, PPE availability, clinical waste disposal procedures, decontamination protocols, and treatment room cleanliness standards.
- Hand hygiene compliance check
- PPE availability & usage audit
- Clinical waste segregation & disposal
- Decontamination procedure review
- Treatment room cleanliness score
IPC is one of the first areas a CQC inspector examines on arrival. Timestamped monthly audits with named sign-off provide contemporaneous evidence of active infection control governance.
Reg 15
Environmental Audit
Premises & Equipment
Monthly review of the clinical environment — room condition, equipment state, cleaning schedules, clinical waste management, and general premises standards. Supports photographic evidence capture.
- Treatment room condition assessment
- Equipment visual inspection
- Cleaning schedule sign-off
- Clinical waste compliance check
- Maintenance issues logged & actioned
Inspectors physically walk your premises. An evidenced monthly environmental log demonstrates ongoing oversight — not last-minute pre-inspection preparation.
Reg 12
Emergency Drug & Equipment Audit
Safe Care & Treatment
Monthly check of all emergency medications and equipment — adrenaline auto-injectors, oxygen, resuscitation equipment, hyaluronidase stock, and AED. Verifies expiry dates, quantities, and readiness.
- Adrenaline auto-injector (expiry + quantity)
- Oxygen supply & delivery equipment
- Hyaluronidase stock check
- AED battery & pad expiry dates
- Resuscitation bag & airway kit inspection
An out-of-date or incomplete emergency kit is an automatic CQC required action. Monthly documented checks with named sign-off are the minimum expected standard.
Reg 12
IPC & Integral Safety Review
Safe Care & Treatment
Deep-dive IPC review covering sterilisation equipment validation, autoclave cycle logs, needle stick injury protocol, sharps disposal compliance, and single-use item governance — beyond routine IPC checks.
- Autoclave / sterilisation cycle validation
- Needle stick injury protocol review
- Sharps disposal contractor compliance
- Single-use item segregation
- IPC training currency confirmation
This audit distinguishes active clinical safety governance from basic compliance. Outstanding-rated clinics complete this systematically alongside, not instead of, routine IPC.
Reg 12
Medicines Management Audit
Safe Care & Treatment
Comprehensive review of all medicines management practices — storage conditions, expiry checks, stock reconciliation, prescriber oversight, Patient Group Directions compliance, and controlled drug register.
- Stock count & expiry date audit
- Storage condition verification
- Prescriber oversight documentation
- PGD compliance check
- Controlled drug register review
Medicines mismanagement is one of the most common causes of Requires Improvement ratings in aesthetic clinics. Monthly structured audits demonstrate active rather than reactive governance.
Reg 15
Fire Safety Audit
Premises & Equipment
Covers all four fire safety obligations across their correct frequencies: weekly alarm test logging, monthly emergency lighting check, quarterly extinguisher visual inspection, and annual fire drill with full evacuation record.
- Weekly fire alarm test log
- Monthly emergency lighting test
- Quarterly extinguisher visual inspection
- Annual fire drill record & staff attendance list
- Observer name & director sign-off
Fire safety spans four distinct frequency obligations under Reg 15. Missing any single tier creates a compliance gap that inspectors will find and document.
Reg 17
Record Keeping Audit
Good Governance
Audits the quality, completeness, and retrievability of clinical records — consent form completion rates, medical history documentation, treatment note quality, record accuracy, and GDPR compliance spot-check.
- Consent form completion rate
- Medical history documentation review
- Treatment note quality assessment
- Record retrievability test
- GDPR compliance spot-check
Reg 17 requires accurate, contemporaneous records. A quarterly audit proves you actively monitor documentation quality — not just collect forms and file them.
Reg 15
Health & Safety Audit
Premises & Equipment
Full operational health and safety review — risk assessment status, equipment maintenance logs, sharps management compliance, COSHH substance inventory, manual handling training, and workplace accident log review.
- Risk assessment review & date stamp
- Equipment maintenance records
- Sharps management compliance check
- COSHH substance inventory
- Accident & near-miss log review
H&S audits demonstrate the Well-Led behaviours CQC look for — proactive identification and systematic management of operational risks, not just reactive responses to incidents.
Reg 17
Patient Feedback Audit
Good Governance
Structured review of patient satisfaction data, complaints, compliments, and actions taken. Demonstrates the complete feedback loop — received, reviewed, acted upon — that CQC inspectors specifically look for.
- Satisfaction survey response summary
- Complaints received & resolved log
- Compliments recorded
- Actions taken from feedback
- Improvement initiatives linked to feedback
CQC looks for evidence that feedback drives service improvement. An audit showing the full loop — received → reviewed → acted on — satisfies both Reg 17 and the Caring domain criteria simultaneously.
Reg 12
Antibiotic Prescribing Audit
Safe Care & Treatment
Reviews all antibiotic prescribing decisions against NICE clinical guidelines, confirms appropriate clinical indications, documents allergy screening, and checks antimicrobial stewardship compliance.
- Prescribing decisions reviewed vs NICE guidelines
- Allergy screening documentation
- Indication & dose appropriateness
- Patient information provided
- Antimicrobial stewardship compliance
NICE antimicrobial stewardship guidance applies to any clinic prescribing antibiotics for infection prophylaxis. CQC expects evidence of guideline-adherent prescribing decision-making.
Reg 12
Skills & Emergency Drills
Safe Care & Treatment
Documents emergency simulation drills — anaphylaxis response, medical emergency management, resuscitation equipment checks, and hyaluronidase emergency protocol practice. Records all attending staff.
- Anaphylaxis drill record & staff attendance
- Resuscitation equipment function check
- Emergency drug kit confirmation
- Hyaluronidase protocol review
- Observer notes & improvement actions
Reg 12 requires clinics to be prepared for medical emergencies. Skills drill records prove staff can execute protocols — not just that they’ve read them on a policy document.
Reg 20
Incident & Adverse Event Audit
Duty of Candour
Logs and reviews all adverse events, complications, near-misses, and complaints. Each incident records severity, immediate actions, patient communication under Duty of Candour, root cause analysis, and learning outcomes.
- Incident type & severity classification
- Immediate actions taken & by whom
- Patient notification record (Reg 20)
- Root cause analysis
- Learning outcomes & service improvements
Reg 20 Duty of Candour requires openness when things go wrong. An active incident log with documented learning outcomes is direct evidence of a candour-compliant safety culture.
Reg 9
Accessibility Audit
Person-Centred Care
Annual review of premises and service accessibility — physical access, communication formats, reasonable adjustments, disability access provisions, sensory impairment considerations, and Equality Act compliance.
- Physical access assessment (ramps, doors, bathrooms)
- Communication format availability (large print, digital)
- Reasonable adjustments record
- Staff disability awareness training check
- Equality Act compliance review
The Responsive CQC domain specifically assesses accessibility. An annual audit with documented adjustments and reasonable provisions demonstrates genuine person-centred care.
Reg 5
Fit & Proper Person Check
Fit & Proper Persons
Annual verification that all registered managers and directors meet Fit and Proper Person requirements — enhanced DBS checks, professional registration currency, relevant qualifications, references, and disqualification screening.
- Enhanced DBS certificate check & renewal date
- Professional registration verification (NMC/GMC)
- Relevant qualifications & CPD records
- Director disqualification check
- Annual declaration with signatures
Reg 5 is non-negotiable. CQC will not register or re-register a service where Fit & Proper Person requirements cannot be evidenced with timestamps and signed declarations.
Reg 17
Audit Schedule & Annual Programme
Good Governance
The master governance calendar — maps all 18 audit types to their scheduled frequencies, assigns named owners, tracks completion rates, generates overdue alerts, and produces the annual governance programme document.
- Annual audit calendar with all 19 types (including Mock CQC Inspection)
- Named owner assignment per audit
- Completion rate tracking dashboard
- Overdue alert notifications
- Annual governance programme export
CQC inspectors ask to see your audit programme — not just individual completed audits. A documented, scheduled forward programme demonstrates governance planning, not reactive compliance.
All KLOEs
Mock CQC Inspection Score
Regs 5 · 9 · 10 · 12 · 15 · 17 · 18 · 19 · 20
Run a full simulated CQC inspection across all five Key Lines of Enquiry — Safe, Effective, Caring, Responsive, and Well-Led. Produces a RAG-rated score per domain, an overall inspection rating, and a prioritised action plan. Evidence is auto-linked from your live platform data.
- RAG score per KLOE domain (Safe, Effective, Caring, Responsive, Well-Led)
- Overall rating: Inadequate / Requires Improvement / Good / Outstanding
- Auto-linked evidence from audits, consent, training & risk register
- Named inspector attribution and timestamped sign-off
- Gap & action flagging — every partial/no answer generates an action item
- Trend comparison across quarterly inspection runs
- Downloadable inspection-ready PDF/Word report
CQC inspectors expect providers to demonstrate continuous quality improvement. A documented mock inspection history is direct evidence for Reg 17 (Good Governance) and shows a Well-Led culture. Running quarterly ensures no domain falls below Good undetected.
Every audit. Every regulation. One platform.
See the full Governance Audit Framework in a live demo — including real-time dashboard, completion tracking, and inspector-ready evidence export.