As innovators in service delivery, we understand that exceptional clinical governance is essential to the safety of our patients. Working with a specialist developer we have created an award-winning clinical governance product that has been successfully adopted within our organisation and is improving the service we provide our patients – Clinical Guardian. Clinical Guardian and our approach to audit was commended by CQC as outstanding.

The clinical audit process is set out in our Audit Framework. This includes using Clinical Guardian in SevernSide to comprehensively audit the case records of all clinicians. In Practice Services, peer review audit and topic audits are undertaken for all clinical staff. Both approaches scrutinise standards of record keeping and clinical care including history taking, examination, diagnosis, and patient management plans.

Clinical audit helps assure us that the quality and safety of patient care is of a high standard.

To ensure non-clinical staff are also performing to a high standard, there will be an audit of work. Sampling will consist of reviewing written records and any relevant logs or checklists for accuracy and consistency, as well as listening to a sample of recorded calls in line with expectations. Methods of observing staff as well as reviewing patient feedback and staff feedback will also be utilised.

Any issues picked up during this process will be discussed directly between the employee and the line manager; any training needs will also be identified and discussed. Staff are always encouraged to discuss with their line manager any concerns they may have relating to their role.