Clinical Governance Policy

Clinical Governance Policy

HAUS OF ÄSTHETIK

Safe (Preventing Harm & Protecting Patients)

Effective Date: 11th May 2025
Review Date: 11th May 2026
Approved by: Managing Director

1. Purpose

HAUS OF ÄSTHETIK is committed to upholding the highest standards of clinical governance to ensure patient safety, risk management, incident reporting, and continuous quality improvement. This policy establishes a structured framework to promote safe, effective, and high-quality care in line with regulatory and best practice standards set out by:

• Care Quality Commission (CQC) Key Lines of Enquiry (KLOEs)

• National Institute for Health and Care Excellence (NICE) Guidelines

• Save Face Accreditation Standards

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

• General Medical Council (GMC) and Nursing & Midwifery Council (NMC) Codes of Conduct

This policy ensures that HAUS OF ÄSTHETIK maintains a culture of continuous learning, accountability, and high ethical standards to protect patients and improve outcomes.

 

2. Scope

This policy applies to:

• All clinical and administrative staff.

• Agency, temporary, and subcontracted personnel.

• Senior Leadership Team (SLT) and Governance Committees.

 

3. Key Principles of Clinical Governance

3.1 Patient Safety & Risk Management

• Comprehensive incident reporting framework to log, investigate, and act on near misses and adverse events.

• Clinical risk assessments conducted quarterly to identify, mitigate, and prevent risks.

• Root Cause Analysis (RCA) for serious incidents, ensuring lessons learned are incorporated into Training and practice.

• Infection Prevention & Control Audits carried out in compliance with NICE and CQC standards.

3.2 Evidence-Based Practice

• All treatments and procedures must comply with NICE clinical guidelines and evidence-based best practices.

• Ongoing review of treatment protocols to reflect advancements in aesthetic medicine.

• Clinical audit cycles conducted every six months to assess effectiveness and compliance with guidelines.

3.3 Continuous Professional Development (CPD) & Training

• Minimum of 40 hours of CPD annually for all clinical staff in line with GMC/NMC requirements.

• Mandatory annual Training in:

o Basic Life Support (BLS) & Anaphylaxis Management.

o Safeguarding Adults & Children (Level 2/3, depending on role).

o Infection Prevention & Control.

o Data Protection (GDPR) & Confidentiality.

• Quarterly clinical governance meetings to discuss patient safety, compliance, and learning outcomes.

3.4 Patient Experience & Engagement

• Transparent patient complaints process, ensuring all concerns are logged, reviewed, and responded to within 20 working days.

• Patient satisfaction surveys are conducted quarterly, and data is analysed to inform service improvements.

• Consent process to align with GMC and NMC ethical guidelines, ensuring informed decision-making.

3.5 Leadership, Accountability & Compliance

• The CQC Registered Manager is responsible for ensuring compliance with clinical governance standards.

• Senior Leadership Team (SLT) oversees:

o The development and implementation of governance policies.

Internal audits and regulatory readiness assessments.

• All staff are accountable for adherence to governance policies and must report any breaches immediately.

 

4. Incident Reporting & Investigation

4.1 Incident Categories

• Clinical incidents – adverse reactions, procedural complications.

• Non-clinical incidents – health & safety breaches, security concerns.

• Safeguarding concerns – suspected abuse, patient vulnerability.

4.2 Reporting Process

• All incidents must be reported within 24 hours via the internal reporting system.

• Investigations will follow a Root Cause Analysis (RCA) methodology.

• Lessons learned will be disseminated through staff training sessions.

• Quarterly governance meetings will review trends and implement preventive measures.

 

5. Compliance Monitoring & Audit Framework

5.1 Audit Schedule

Audit Type	Frequency	Lead Responsibility
Patient Safety Audits	Quarterly	Governance Lead
Infection Control Audits	Monthly	Clinical Lead
Treatment Outcome Audits	Bi-Annually	Clinical Governance Committee
CPD & Training Compliance	Annually	HR & Compliance Team
Incident & Complaints Review	Quarterly	Risk & Compliance Lead

5.2 Governance Review & Reporting

• Findings from audits will be reviewed at Quarterly Clinical Governance Meetings.

• Annual compliance reports will be submitted to the CQC Registered Manager and Save Face Assessor.

• Corrective Action Plans (CAPs) will be implemented where deficiencies are identified.

 

6. Review & Continuous Improvement

• This policy will be reviewed annually or earlier in response to regulatory changes.

• Governance findings will inform quality improvement initiatives.

• Staff feedback will be incorporated to enhance policy effectiveness.

 

7. Conclusion

• HAUS OF ÄSTHETIK is committed to delivering safe, ethical, and high-quality patient care through robust clinical governance structures. By ensuring comprehensive risk management, ongoing professional development, and patient-centred care, we uphold the highest CQC, NICE, and Save Face compliance standards.

• This policy reinforces our commitment to transparency, accountability, and continuous quality improvement.