Clinical Governance

Clinical Governance

Schedule 4 of the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 set out the ‘Terms of Service of NHS pharmacists in four parts.  Part 2 are the Essential services, Part 3 are the Hours of opening provisions, and Part 4 set out the other terms of service, which includes Clinical Governance.  Adherence with the clinical governance requirements is thus a part of the terms of service.

The clinical governance requirements of the community pharmacy contractual framework (CPCF) cover a range of quality related issues detailed below, help and support for which can be found on the PSNC website: click here

  • Guidance for pharmacy contractors
  • Audit
  • Chaperone policy
  • Clinical governance lead
  • Complaints procedures
  • Confidentiality
  • CPPQ (patient satisfaction survey)
  • Patient safety incident reporting
  • Practice leaflets
  • Raising concerns (Whistle-blowing)

Clinical Governance  – Actions required by 31 March 2019

Replacement for IG toolkit

The Data Security and Protection (DSP) Toolkit for 2018/19 is now available for completion; this replaces the Information Governance (IG) toolkit that contractors have completed in previous years. The deadline for submitting this year’s IG return is 31st March 2019.

A key feature negotiated by PSNC is that where a contractor declares that they have completed our GDPR Workbook for Community Pharmacy, the number of questions they will be asked to respond to in the Toolkit will be significantly reduced. Further information about the new toolkit is available at:

Pharmacy Services Resources Completed by
Clinical Governance

Actions required by 31st March of each year:

· Complete and submit an annual Data Security and Protection (DSP) Toolkit.

· Conduct an annual Community Pharmacy Patient Questionnaire (CPPQ) and publish the results.

· Conduct two audits each year: one on a topic of your choice and one determined by NHS England.

Info and templates available via the LPC Website & PSNC Website


NHS England Audit

31st March each year
Annual Complaints Report Each pharmacy contractor must prepare an annual report for each year, ending 31 March and submit a copy to NHS England at:  as soon as practicable after the end of the year to which the report relates. Even if a pharmacy has not received any complaints, the contractor must prepare a complaints report confirming that they have received no complaints as part of their terms of service. Info and template available via the LPC Website & PSNC Website Just after 31st March each year
Community Pharmacy Assurance Framework (CPAF) Complete the Community Pharmacy Assurance Framework (CPAF) screening questionnaire, usually advertised by June each year. Info available via the LPC Website & PSNC Website Beginning of June each year

The LPC have put together the following Checklist, which pharmacies can print out and check off as appropriate: Pharmacy Clinical Governance Requirements Checklist