Audit template
Governance / Quality Assurance
The Regulation 17 overview audit: is the quality assurance system working and acted on? This template runs monthly in MyCareCompliance and carries 8 mapped checks across 6 CQC quality statements.
Last reviewed: September 2026. This guidance reflects CQC information available at the date above — always refer to cqc.org.uk for current regulatory requirements.
What the audit covers
Every question in the Governance / Quality Assurance is mapped to a CQC quality statement and the underlying regulation, so a failed check tells you exactly which part of the single assessment framework is at risk. This is one of the core templates we recommend for every provider.
- Runs monthly — core template
- Part of the Safety & governance audit category
- Maps to 5 regulations: Regulation 12 — Safe care and treatment, Regulation 13 — Safeguarding service users from abuse and improper treatment, Regulation 16 — Receiving and acting on complaints, Regulation 17 — Good governance, Notifications (Registration Regulation 18) — Notification of other incidents
- Failed checks become tracked improvement actions with an owner, due date and evidence
The 8 checks
Learning culture
Safe — 1 check- Regulation 12 — Safe care and treatmentGovernance / Quality Assurance
Are incidents, accidents, and near misses systematically analyzed for patterns and trends to prevent recurrence across the service?
What we look for: Look for evidence that management reviews incidents collectively, not just individually. Good looks like monthly trend analysis identifying risks (e.g., missed visits on specific routes). Fail if incidents are filed without wider service analysis.
Evidence: Incident reporting matrix, Monthly trend analysis reports, Post-incident reviews
Safeguarding
Safe — 1 check- Regulation 13 — Safeguarding service users from abuse and improper treatmentGovernance / Quality Assurance
Does the management team maintain robust oversight of all safeguarding alerts, tracking them through investigation to formal closure with local authorities?
What we look for: Review the central safeguarding log. It should show the status of all alerts, dates of submission, and outcomes. Fail if the provider cannot demonstrate the current status of open investigations or lacks evidence of final closure.
Evidence: Safeguarding tracker, Local Authority correspondence, Case review notes
Listening to and involving people
Responsive — 1 check- Regulation 16 — Receiving and acting on complaintsGovernance / Quality Assurance
Are complaints logged, acknowledged within policy timeframes, fully investigated, and used to drive improvements in care delivery?
What we look for: Sample recent complaints. Good looks like empathetic, timely responses with clear investigations and lessons learned. Fail if complaints are dismissed, responses are delayed beyond policy timelines, or no learning is recorded.
Evidence: Complaints log, Investigation reports, Written responses to complainants, Changes in care plans following complaints
Governance, management and sustainability
Well-led — 3 checks- Regulation 17 — Good governanceGovernance / Quality Assurance
Are routine audits (e.g., medication, daily care logs, care plans) completed according to the provider's monthly schedule, with clear action plans for identified shortfalls?
What we look for: Review a sample of internal audits from the last month. Good practice shows not just tick-boxes, but detailed analysis of shortfalls with assigned responsibilities and deadlines. Fail if audits are missing, generic, or lack action plans.
Evidence: Completed audit tools, Monthly audit planner, Action plans, Sign-off sheets
- Notifications (Registration Regulation 18) — Notification of other incidentsGovernance / Quality Assurance
Are statutory CQC notifications (e.g., serious injuries, safeguarding, police involvement) submitted without delay and documented in the provider's central log?
What we look for: Cross-reference the incident and safeguarding logs against the CQC notification log. Good practice means all reportable events are notified within required timeframes. Fail if reportable incidents occurred but no notification was made.
Evidence: CQC notification log, Copies of submitted notification forms, Cross-reference with incident and safeguarding logs
- Regulation 17 — Good governanceGovernance / Quality Assurance
Are essential policies and procedures reviewed regularly, aligned with current legislation, and effectively communicated to all care staff?
What we look for: Check the policy index for review dates and sample recent updates (e.g., infection control, safeguarding). Good looks like staff signing to acknowledge reading new versions. Fail if policies reference outdated legislation or staff are unaware of changes.
Evidence: Policy review schedule, Policy index, Staff newsletter, Memo sign-off sheets for policy updates
Learning, improvement and innovation
Well-led — 1 check- Regulation 17 — Good governanceGovernance / Quality Assurance
Is there an active Continuous Quality Improvement Plan (CQIP) or Service Improvement Plan that drives changes based on audit findings, incidents, and feedback?
What we look for: Examine the current improvement plan. It should be a living document, actively updated with closed actions and new objectives. Fail if the plan is static, out of date, or lacks input from recent audits or CQC inspections.
Evidence: Continuous Improvement Plan, Service Improvement Plan, Meeting minutes discussing the plan
Shared direction and culture
Well-led — 1 check- Regulation 17 — Good governanceGovernance / Quality Assurance
Is structured feedback routinely gathered from people drawing on care, their relatives, and professionals, and synthesized into the quality assurance framework?
What we look for: Look for evidence of proactive feedback collection (e.g., QA calls, surveys). Good practice includes closing the loop by informing people of changes made based on their feedback. Fail if feedback is collected but ignored in QA processes.
Evidence: Annual/quarterly surveys, Spot check feedback forms, Professional feedback emails, 'You said, We did' reports
See it running for your service
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