How to Write a Governance Policy for a Dental Practice: A CQC Guide
A dental practice governance policy explains how the provider will oversee the quality, safety and management of its services. It should identify who is responsible for making decisions, how risks are controlled, how performance is monitored and how the practice learns when something goes wrong.
For new dental providers, governance and quality assurance policies form part of the supporting evidence required when applying to register with the Care Quality Commission. Established practices also need effective governance systems to demonstrate ongoing compliance with CQC regulations.
A governance policy should not simply repeat the wording of Regulation 17 or list a collection of audits. It should accurately describe how your dental practice is managed and how information leads to action and improvement.
This guide explains how to write a dental practice governance policy that reflects CQC requirements and the practical realities of running an oral health service.
Why does a dental practice need a governance policy?
CQC’s governance and quality assurance policy guidance states that these policies help CQC determine whether a provider has effective systems for running a well-led service and delivering good-quality care.
The policy must demonstrate how the provider will meet:
the UK General Data Protection Regulation
Regulation 17 requires providers to establish and operate effective systems for:
assessing and improving service quality and safety
identifying and reducing risks
maintaining accurate and secure patient records
maintaining staff and management records
seeking and acting on feedback
improving how information is processed and used
CQC can refuse a registration application if it is not satisfied that the proposed provider can and will continue to comply with Regulation 17.
Include the correct document-control information
Every policy submitted with a new-provider application should include:
the legal name of the applicant
the name or role of the person responsible for the policy
the date the policy was created
the date it will be reviewed
the policy version
an approval record
The applicant name should match the legal entity shown in the CQC application and statement of purpose. If a limited company is applying to register, the policy should identify that company rather than only using the dental practice’s trading name.
CQC also expects policies to be complete, relevant to the proposed service, consistent with other application documents and supported by current legal and professional references.
Define the purpose and scope of the policy
Begin with a short statement explaining what the policy is intended to achieve.
For example:
This policy describes the systems through which the provider oversees the quality, safety and management of the dental service. It explains how responsibilities are allocated, performance is monitored, risks are managed and improvements are implemented.
The scope should identify who the policy applies to. This may include:
the provider
directors or partners
the nominated individual
the registered manager
dentists and dental care professionals
practice managers
reception and administrative staff
trainees, locums and temporary workers
contractors where relevant
The policy should cover every location operated by the provider, or clearly explain where location-specific governance arrangements differ.
Explain the leadership and accountability structure
CQC requires the policy to explain how governance will be achieved, which leaders and staff groups have governance responsibilities and how accountability operates within the organisation.
Identify the responsibilities of relevant roles, such as:
Provider or directors: overall accountability for regulatory compliance, resources and strategic oversight.
Nominated individual: supervision of the management of regulated activities on behalf of an organisation.
Registered manager: day-to-day management of the regulated activities and compliance with the regulations.
Practice manager: coordination of operational governance, audits, meetings, action plans and staff records.
Clinical lead or principal dentist: oversight of clinical standards, clinical audits and professional practice.
Infection prevention and control lead: monitoring decontamination, infection-control audits and related actions.
Safeguarding lead: oversight of safeguarding systems, referrals, training and local arrangements.
Radiation protection roles: responsibilities established under the relevant ionising-radiation legislation.
Team members: following policies, reporting risks and incidents and contributing to improvement.
Avoid allocating every responsibility vaguely to “management”. Named roles make it easier to demonstrate accountability.
CQC also wants an organisational structure chart that accurately reflects the business and its roles. This can be included as an appendix or submitted as a supporting document.
Describe how governance decisions are made
The policy should explain where governance information is reviewed and how decisions are recorded.
For a small dental practice, this may take place through:
monthly or quarterly governance meetings
regular team meetings
individual clinical discussions
audit-review meetings
management reviews
annual policy and risk reviews
The policy should state who attends, how frequently meetings take place, who records the minutes and how actions are monitored.
Governance arrangements should be proportionate. A single-location practice does not need to recreate the committee structure of a large corporate provider. It does, however, need a reliable way to review important information, agree actions and check that improvements have been completed.
CQC Dental Mythbuster 27 explains that clinical governance encompasses quality assurance, quality improvement and the management of risks and incidents. CQC looks at whether leadership and governance support safe, effective and person-centred care.
Set out your quality assurance systems
Your governance policy should identify the information used to assess the quality and safety of the practice.
This could include:
clinical and non-clinical audits
patient feedback and surveys
complaints and compliments
incidents, near misses and significant events
safeguarding concerns
infection-control monitoring
medicines and medical-emergency checks
equipment testing and servicing
staff training and competency assessments
recruitment and professional-registration checks
patient safety alerts
referrals and clinical outcomes
staff feedback
risks recorded on the practice risk register
The policy should explain who reviews this information, how often it is reviewed and what happens when a concern is identified.
A policy stating that “audits will be completed regularly” is too vague. Include an audit schedule or refer to a separate schedule identifying the audit topic, frequency, responsible person and expected reporting arrangements.
Include a dental audit programme
CQC Dental Mythbuster 17 explains that clinical audit and quality improvement form part of a dental service’s quality assurance and risk-management arrangements.
CQC identifies the following as essential audit areas:
Infection prevention and decontamination: HTM 01-05 states that decontamination processes should be audited at least every six months, with further review depending on the outcome.
Dental radiography: practices must establish and maintain appropriate quality-assurance audits under IRR17 and IR(ME)R.
Accessibility: providers should review their premises and services against the Equality Act 2010.
Other useful audit and improvement topics include:
clinical record keeping
antimicrobial prescribing
consent
complaints
patient satisfaction
emergency medicines and equipment
safeguarding records
referral management
failed appointments and treatment completion
staff recruitment files
The policy should describe the complete audit cycle:
Select the subject and relevant standard.
Collect and analyse the data.
Identify areas requiring improvement.
create a measurable action plan.
Implement the agreed changes.
Repeat the audit to establish whether improvement occurred.
A completed audit without an action plan or repeat measurement may identify a problem but does not demonstrate that the practice has improved.
Explain how risks and incidents are managed
The policy should link governance to the practice’s risk-management and incident-reporting arrangements.
Explain how the practice will:
identify clinical and operational risks
record risks on a risk register
assess likelihood and potential impact
introduce controls
assign actions to responsible people
set completion dates
escalate serious or increasing risks
review whether controls remain effective
learn from incidents and near misses
share relevant learning with the team
CQC expects action to be proportionate to the seriousness of the risk. A high-risk concern affecting patient safety should not remain on an action plan for several months without interim controls.
The policy should also refer to external reporting where applicable, including CQC notifications, safeguarding referrals, radiation incidents, RIDDOR reports and reporting to professional bodies.
Cover records management and data protection
CQC requires the governance policy to explain how records concerning patients, staff and management procedures will be properly maintained and stored.
Dental practices process health information, which receives additional protection under data-protection legislation. The policy should therefore cover:
accurate and contemporaneous clinical records
secure storage of paper and electronic information
authorised access controls
confidentiality
record retention and secure destruction
information sharing
backup and recovery arrangements
responding to data breaches
staff and recruitment records
audit, meeting and management records
The government’s data-protection guidance explains that personal information must be processed lawfully, fairly and transparently; collected for specified purposes; limited to what is necessary; kept accurate; retained only as long as required; and protected against unauthorised access, loss or damage.
CQC Dental Mythbuster 8 also emphasises that dental care records should be accurate, complete, legible, current and stored and shared appropriately.
Include patient and staff feedback
A governance policy must explain how the practice will seek and act on feedback.
Feedback may come from:
patient surveys
the NHS Friends and Family Test, where applicable
complaints and compliments
online reviews
verbal comments
patient participation activities
accessibility reviews
staff meetings
appraisals and staff surveys
commissioners and other professionals
The policy should explain how feedback is recorded, analysed and reported. It should also describe how the practice communicates changes made in response, such as through a “you said, we did” notice.
Collecting feedback without reviewing or acting on it does not demonstrate effective governance.
Explain how improvements are monitored
An effective policy should describe the practice’s improvement process.
Actions arising from audits, incidents, complaints, risk assessments and feedback should be entered on an action plan. Each action should have:
a clear description
a responsible person
a priority or risk level
a target date
an update or completion record
evidence that the action was effective
Completed actions should be reviewed rather than simply marked as closed. For example, if a records audit identifies poor documentation of consent, the practice might provide training, revise the record template and repeat the audit to check whether documentation improved.
Common problems with dental governance policies
Weak governance policies often:
use a generic template written for another healthcare sector
fail to identify the legal provider
contain an inaccurate management structure
assign responsibilities to people who do not work at the practice
list audits without stating their frequency
describe collecting data without explaining how it is analysed
omit risk escalation arrangements
overlook staff and management records
mention GDPR without explaining information controls
fail to connect findings with action plans and improvement
conflict with the application or statement of purpose
CQC will not assess the policy in isolation. It may compare it with the application forms, organisational structure, statement of purpose and information provided during the assessment process.
Final dental governance policy checklist
Before approving the policy, check that it:
identifies the correct provider and locations
defines its purpose and scope
assigns leadership and governance responsibilities
includes an accurate organisational structure
explains meetings and decision-making arrangements
describes quality and safety monitoring
includes a dental audit programme
covers risks, incidents and learning
addresses patient, staff and management records
reflects UK GDPR and the Data Protection Act 2018
explains how feedback leads to improvement
includes action planning and follow-up
contains current references and working links
has an owner, approval date and review date
A good governance policy should provide a clear and credible account of how the dental practice will be managed. More importantly, the systems described in it must operate in practice.
Download the Free Dental Practice Governance Policy Template
To help you put these requirements into practice, I have created a free editable Dental Practice Governance and Quality Assurance Policy Template.
The three-page template includes document-control fields, leadership responsibilities, governance meetings, quality assurance, dental audits, risk and incident management, records management, feedback arrangements and an improvement action plan.
It is designed to provide a clear starting point for new and existing dental providers. However, it must be adapted to reflect your legal entity, locations, staffing structure, services and actual governance arrangements before it is approved or submitted to CQC.
Support with dental CQC registration
Governance policies are only one part of a dental CQC registration application. The provider application, registered manager application, statement of purpose, organisational structure and supporting evidence must all describe the same service and management arrangements.
I provide specialist CQC registration support for dental practices, including application support, evidence reviews, policy checks and preparation for the registered manager assessment. Related reading: dental mock inspection.
This article provides general guidance and does not constitute legal advice. CQC requirements and professional guidance may change, so providers should check the latest official sources before submitting an application.
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