How to evidence pharmacist supervision and governance for CQC

Written by the Virtual Pharmacist clinical team

To evidence pharmacist supervision and governance for CQC, show how the clinicians doing medicines work are supervised, how their competence is assured and how the practice oversees the results. With an outsourced service, supervision of the clinical team sits inside the provider’s governance framework, and the practice keeps the evidence of its own oversight. This article sets out what to have ready.

What does CQC look at when medicines work is shared?

CQC looks at whether medicines are managed safely and whether the people doing clinical work are competent, supported and working within their scope. Inspectors may ask how the practice knows that pharmacists and technicians are appropriately registered, how their work is reviewed and how clinical decisions are escalated to GPs. The same questions apply whether the work is done in-house or by a service. Inspectors work to CQC’s single assessment framework, which asks whether a service is safe, effective, caring, responsive and well-led.

Our resources on CQC clinical searches and medicines findings at inspection cover the searches side in more detail.

Who supervises the pharmacists in a managed service?

The provider supervises its own clinical team under its clinical governance framework. At Virtual Pharmacist, more than 100 GPhC-registered pharmacists and pharmacy technicians work under one framework, and 85% of the pharmacists are independent prescribers. Supervision, competence and training for our team are run within that framework.

The practice keeps oversight of the service it commissions. That split is what the evidence should show.

For the practice, the useful question is how that supervision works day to day: how clinical questions are escalated within the provider’s team, how work is checked and how learning from incidents is shared. Ask the provider to describe it, and keep the description on file.

What evidence should the practice hold?

The practice should hold a short file that shows how it oversees the service. A practical list:

• A written description of the service: workstreams, systems and reporting
• The provider’s clinical governance framework, or a summary of it
• The agreed escalation route to your GPs for clinical decisions
• Reports on the work delivered and the GP actions raised and closed
• Notes from service reviews with the provider
• The provider’s data security position, such as its DSPT status and certifications

Our clinical governance and data security page sets out our framework and certifications in one place, and practices can use it in this file.

Keep the file short and current. An inspector needs to see that the practice knows what the service does and reviews it, and a few well-kept pages show that clearly.

How do you evidence competence and registration?

Evidence registration through the GPhC register, which anyone can check, and evidence competence through the provider’s governance framework. Ask the provider how competence is assessed for each type of work, such as structured medication reviews or high-risk drug monitoring, and how prescribing is kept within each prescriber’s scope. Record the answer in your file. For independent prescribers, record how prescribing decisions outside a prescriber’s scope reach a GP. Ask, too, how the provider keeps skills current, for example through training, peer review or audit of completed work, and note the answer alongside the registration check.

How does the clinical record help at inspection?

The clinical record gives inspectors a direct view of the work. Our team codes every action in the practice’s own record as it happens, so an inspector can see who reviewed a patient, what was decided and what followed. Well-coded records also let the practice run its own searches to check that monitoring and reviews are up to date.

Before an inspection, practices often run the searches an inspector might, such as monitoring for high-risk drugs or patients affected by recent safety alerts. With good coding, those searches return a clean list, and any patients still to be seen can be worked before the visit.

How often should the practice review the service?

Review the service on a regular cycle agreed with the provider, and keep a short note of each review. A good review compares delivery with the plan, looks at open GP actions and sets the next priorities. The notes show an inspector that the practice oversees the service actively. Include a clinical example in the notes, such as a patient whose medicines were changed after a review and how the GP action was closed. Examples like this show oversight in practice.

What about data security?

Data security evidence should show that the provider meets NHS standards for handling patient data. Virtual Pharmacist meets the NHS Data Security and Protection Toolkit standards for 2025-26, holds Cyber Essentials certification and is registered with the ICO (ZB127110). Keep a note of these in the same file as your governance evidence. Record how access to your clinical system is set up and controlled as well. Our team works through secure, NHS-approved access arranged through your existing systems.

What we see in practice

Inspection dates focus attention on medicines work. Three practices in Northamptonshire came to us with CQC inspection dates already set. At each one, the medicines-safety searches were built, run and worked through inside two weeks. All three practices received medicines-safety support ahead of their inspections.

Read the full example in our clinical pharmacy case studies.

Preparing for CQC? Send us an enquiry and we will reply within one working day.