| Document Reference: | POL-006 |
| Version: | 2.0 |
| Pharmacy: | SynovaMed (trading name of Nihaal Limited) |
| Registered Address: | 11 Blaby Road, South Wigston, Wigston, LE18 4PA |
| GPhC Pharmacy Reg. | 9012552 |
| Superintendent Pharmacist | Chirag Desai (GPhC: 2079415) |
| Effective Date | 19 April 2026 |
| Next Review Date: | April 2028 |
| Approved By: | Chirag Desai, Superintendent Pharmacist & Director |
1.
Purpose
This policy describes the clinical governance framework at SynovaMed. Clinical governance is the system through which we continuously improve the quality of our service and safeguard high standards of care.
2.
Governance Structure
Responsibility is held as follows:
| Role | Held By | Responsibilities |
| Superintendent Pharmacist | Chirag Desai (GPhC: 2079415) | Overall clinical governance, SOPs, regulatory compliance, audit, complaints, safeguarding lead, data protection lead. |
| Responsible Pharmacist (RP) | Named daily per rota | Day-to-day safe and effective running of the pharmacy, dispensing accuracy, supply compliance. |
| Contracted Prescribing PIPs | Multiple GPhC-registered IPs | Individual prescribing decisions, clinical follow-up, Yellow Card reporting, CPD in scope. |
| Director/Owner | Nihaal Limited board | Commercial oversight, ensures the Superintendent Pharmacist has the resources and authority to discharge their duties. |
3.
Seven Pillars of Clinical Governance
- Clinical effectiveness: Prescribing across every service follows current SmPC, NICE guidance, and published evidence. SOPs reviewed every 2 years or sooner if guidance changes.
- Risk management: Service-specific risk assessments maintained for each clinical area we prescribe in. Serious incidents reported and investigated. Near-miss logging.
- Patient & public involvement: Patient feedback via surveys and complaints. Anonymised annual summary published.
- Audit: 10% random monthly audit of consultations by the Superintendent across every service. Quarterly governance meetings review findings. Independent peer audit annually.
- Staffing & management: Role descriptions documented. Competency sign-off at induction and annual refresher. CPD encouraged and supported.
- Education & training: Mandatory training: safeguarding, GDPR, accessible information, IPC. Prescribers maintain specialist CPD in every clinical area they prescribe in.
- Information management: Secure electronic records. UK-hosted infrastructure. Encrypted at rest and in transit. Access logged and auditable.
4.
Governance Meetings
The Superintendent Pharmacist chairs a quarterly clinical governance meeting. Attendees include contracted prescribers (virtually), the Responsible Pharmacist, and the Director where appropriate. Standing agenda items:
- Incident and near-miss log review
- Complaints summary and learning
- Audit findings and actions
- Adverse drug reaction trends
- Regulatory and guidance updates
- Patient feedback themes
- Training and CPD
- Risk assessment review
Minutes are retained for a minimum of 7 years.
5.
Audit Programme
Our audit programme covers:
- Prescribing audits (monthly): random sample of consultations, reviewed against SOPs
- Dispensing accuracy audits (monthly): sample of completed orders
- Near-miss and error audits (continuous)
- Refrigeration / cold-chain audits (monthly)
- Complaints audit (quarterly)
- Data access audit (quarterly)
- Policy and SOP currency audit (annually)
6.
Incident Reporting
All patient safety incidents and near-misses are reported to the Superintendent Pharmacist. Serious incidents are investigated using root cause analysis. Learning is shared across the team. Serious incidents are reported to the GPhC where required.
7.
Continuous Professional Development (CPD)
All pharmacists maintain CPD in line with GPhC requirements. Prescribers maintain evidence of obesity medicine CPD specifically. CPD records are reviewed as part of the annual performance process.
8.
Accountability to Regulators
We are accountable to:
- GPhC (General Pharmaceutical Council) for pharmacy standards and professional conduct
- MHRA (Medicines and Healthcare products Regulatory Agency) - for medicines safety and Yellow Card reporting
- ICO (Information Commissioner's Office) for data protection
9.
Policy Review
Reviewed every 2 years. Next review: April 2028.
SynovaMed (trading name of Nihaal Limited) | 11 Blaby Road, South Wigston, Wigston, LE18 4PA | GPhC: 9012552 | 07822 002914 | info@synovamed.co.uk Document Ref: POL-006 | Version 2.0 Effective: 19 April 2026 | Next Review: April 2028 Superintendent Pharmacist: Chirag Desai (GPhC: 2079415)