This policy sets out a systematic approach to managing and responding to external visits, inspections and accreditations.

The Care Quality Commission, the NHS Litigation Authority (NHSLA) and other organisations for example the Health & Safety Executive (HSE) require that Trusts demonstrate compliance with recommendations from external agencies and this will be achieved through robust implementation of this policy.

A systematic process that provides good coordination and evaluation of the work of external agency visits, inspections, accreditations and audits brings increased benefits to the organisation, helps minimise the burden on the organisation by reducing overlap and allow potential gaps in assurance to be identified and addressed. It is an integral part of the organisation’s internal control system and provides assurance to the board, who need, wherever possible, to make use of the work of the many external reviewers and ensure the whole process is efficient and meaningful to the organisation and allows continuous improvement in the quality and safety of services.



The policy sets out the processes by which the Trust provides Board Assurance that visits are properly organised, managed and communicated. It ensures a systematic approach to responding to recommendations and requirements of external bodies including the monitoring of action plans and identification of risks arising from such visits. It ensures that a central register of visits is maintained.


Policy Details

Download: n/a
Compiled by: Head of Accreditation and Regulation
Ratified by: Integrated Governance Assurance Committee
Date Ratified: May 2018
Date Issued: June 2018
Review Date: March 2020
Target Audience: All staff
Contact name: Head of Accreditation and Regulation


See also:

  • Quality, Safety and Risk Management Strategy
  • Guidance for Self-Assessment of Compliance against the Care Quality
  • Commission’s Essential Standards of Quality & Safety


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