Clinical Governance Policy

Haus of Ästhetik Ltd

Category: Governance & Quality Assurance

Effective Date: 6th October 2025

Review Date: 6th October 2026

Approved by: Managing Director & Governance & Assurance Officer

Responsible Persons:

• Owen Dickinson – Managing Director (MD), Nominated Individual (NI), Registered Manager (RM)

• Rachael Divers – Governance & Assurance Officer (GAO)

• Michelle Caudren – Safeguarding Lead (DSL, Adults & Children, Level 3)

  Version: 2.2

  Previous Versions: 2.1 (1st October 2025), 2.0 (11 May 2025), 1.0 (11 May 2024)

 

1. Purpose

This policy establishes a transparent and accountable framework for clinical governance at Haus of Ästhetik Ltd. It ensures that care is safe, effective, and continuously improved, in line with:

• CQC Regulation 17 – Good Governance

• CQC Regulation 12 – Safe Care & Treatment

• CQC Regulation 16 – Receiving and Acting on Complaints

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

• NICE Guidelines

• Save Face Accreditation Standards

• Professional Codes (GMC, NMC, GDC, HCPC)

 

2. Scope

This policy applies to:

• All clinical and administrative staff (permanent, freelance, agency).

• Oversight roles: MD/NI/RM, GAO, DSL.

• All activities involving patient safety, complaints, risk management, safeguarding, audits, and quality assurance.

 

3. Governance Principles & Structure

3.1 Leadership & Role Allocation

• MD / NI / RM – Overall accountability.

• GAO – Independent lead for governance, audits, complaints, quality assurance of NI/RM.

• DSL – Safeguarding oversight (Adults & Children).

• External Oversight – Save Face reviewer annually (reviewing quarterly minutes, audits, and compliance report).

3.2 Principles

• Separation of roles ensures no single person controls all governance functions.

• External review provides impartial validation of governance arrangements.

• Clinical governance is integrated into daily practice, not a separate or retrospective activity.

 

4. Risk & Patient Safety

• Risk Register – A live governance risk register is maintained, updated after every audit, incident, or complaint.

• Incident Reporting – All incidents (clinical, non-clinical, safeguarding) logged within 24 hours.

• Escalation:

  • If NI/RM is subject of concern → GAO or DSL escalates externally (Save Face, CQC, LADO).

  • Serious risks → reported immediately to CQC via statutory notifications.

   

• Root Cause Analysis (RCA-lite) is conducted for all serious events.

 

5. Audit & Monitoring Framework

Audit Schedule

Audit Type	Frequency	Lead	Oversight
Patient Safety Audits	Quarterly	GAO	MD / External
Infection Prevention & Control	Monthly	DSL	GAO
Treatment Outcomes	Bi-Annual	MD	GAO cross-check
Training & CPD	Annual	GAO	MD
Complaints & Incidents	Quarterly	GAO	Governance Meeting

 

• Audit findings feed into Corrective Action Plans (CAPs) with deadlines and responsible owners.

• All audits and CAPs are logged in the governance register.

 

6. Governance Meetings

• Quarterly Clinical Governance Meetings attended by MD, GAO, DSL, and external reviewer as required.

• Meetings are minuted with action logs, responsibilities, and completion deadlines.

• All four sets of minutes are to be submitted annually to Save Face for external review.

 

7. Complaints & Patient Voice

• Complaints handled under the Complaints & Feedback Policy (CQC Regulation 16).

• Independence safeguarded: GAO leads complaints; NI/RM steps aside if subject.

• Escalation routes: CQC, Save Face, GMC, NMC, ASA, ICO.

• The Annual Complaints Summary is published online.

• Patient satisfaction surveys are conducted quarterly; trends are analysed and actions agreed.

 

8. Staff Training & Competence

• All staff must complete mandatory training: BLS, anaphylaxis, safeguarding, IPC, GDPR.

• 40 hours CPD annually for clinical staff.

• Training compliance is logged and reviewed annually by GAO.

• Policy Updates: All staff are briefed on governance policy changes within 14 days; acknowledgement is recorded in the training log.

 

9. Documentation & Evidence

Each governance cycle must maintain:

• Risk register.

• Audit reports & CAPs.

• Incident & complaints logs.

• Safeguarding register.

• Governance meeting minutes.

• Annual Compliance Report (submitted to CQC and Save Face).

 

10. Escalation & External Reporting

• If unresolved governance risks persist after CAP → immediate escalation to an external reviewer and CQC.

• GAO/DSL hold the authority to escalate without MD approval if the risk is significant.

• All regulatory notifications completed in line with CQC statutory guidance.

 

11. Review & Continuous Improvement

• Policy reviewed annually, or sooner if CQC guidance, NICE standards, or MHRA alerts change.

• Governance is iterative: every audit, complaint, or incident triggers learning and potential policy updates.

• External feedback (Save Face, CQC, patient groups) is incorporated into service improvement plans.

 

12. Conclusion

Haus of Ästhetik has implemented a robust, independent, and transparent clinical governance system. With separation of roles, a live risk register, structured audits, independent external oversight, staff accountability, and clear escalation to regulators, this policy demonstrates compliance with CQC Regulations 12, 16, and 17, embedding safety, quality, and accountability into everyday practice.