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DESIGNATED BODYLIMITED AUDIT
LIMITED AUDIT GUIDANCEAs part of The Medical Profession (Responsible Officers) Regulations 2010, yourResponsible Officer has to be assured that you are complying with theregulations and that this can be evidenced if necessary to the Higher LevelResponsible Officer. To ensure that you are meeting the obligations as laid out in the Regulationsand also required by the NHS / Office of the HLRO / HEIW, your ResponsibleOfficer requires us to complete an annual audit on you and produce a reportwith recommendations as appropriate. This should be considered by your board and an action plan to address anyrecommendations be put in place.
LIMITEDAUDITThe audit will be held remotely in most cases,however if you would like a site visit we arealways happy to come out and visit you, soplease ask. Sometimes we may require a sitevisit. The audit has two parts. A declaration of complianceA limited audit carried out on apercentage of your prescribedconnections, up to a total of 10 filesWe will then produce a report withrecommendations that should be sharedwith your board. Any significant findings willbe shared with your Responsible Officer. Youmay be requested to provide an action planto address any recommendations. If you do not provide all the requireddocuments including copies of policies andprocedures, Governance Tool Kit andGovernance Organogram, we will be unableto pass the audit and you will be given afurther date to provide the requiredinformation by.
DECLARATION OFCOMPLIANCEThrough it's Responsible Officer Networkmeetings, the NHS provide updated Guidanceand have introduced a number of documentsrecently, they have indicated they will want tosee at any HLRO audit. These have been addedto the declaration of compliance. They will also expect to see your policies andprocedures relating to Governance, Appraisaland Revalidation.The annual declaration of Compliance, will helpus assess what documentation you have andany gaps there may be. Please remember thatas part of the service, we provide all policesand procedures that are required. We are alsohappy to help with your Designated BodyGovernance Organogram and Self Assessmenttool kit. If you need any assistance our QualityDepartment are happy to help, so please get intouch using the following email address -doctors@acitrainingandconsultancy.co.ukUnfortunately, without the fully completeddeclaration, we are unable to pass the audit.
PRESCRIBED CONNECTIONAUDITWe will carry out an audit of your current prescribed connections. A randomselection of your connected doctors, up to a maximum of 10 files, will beselected for audit. We will provide a secure link for you to upload the documents to. On the dayadvised, our team will complete a framework level audit on the files provided.Please note that not all criteria will be applicable for every organisation. Forexample framework requires monthly DBS checks. We recommend this as goldstandard good practice, but monthly checks are not mandatory for NHSEmployer checks. If you feel there is a criteria you feel it is not appropriate foryour organisation, please let us know and we will take this in to account if weare able to, when carrying out the audit and completing the final report. All of the requirements of the NHS Employer checks are mandatory so pleaseensure you provide evidence to cover all of these. These cover Identity Checks,Criminal Records Checks, Work Health Assessments, Professional Registrationand Qualifications, Right to Work Checks and Employment History andReferencing. You can find out more about these on the NHS Employers website.
THEREPORTOnce completed, a report withrecommendations will be provided and acopy will be shared with your ResponsibleOfficer. Mandatory Recommendations relate to areaswhere you have not provided evidence thatyou are complying with the Regulations andmust be addresses immediately. You will berequired to provide an action plan for yourResponsible Officer and timelines for actionsto be completed. We may decide to hold are-audit. Good Practice Recommendations representthe gold standard so you may feel these arenot appropriate for your organisation. Should you wish to have an MS Teamsmeeting to discuss the report further, pleaselet us know. The Audit Report will also bediscussed in the Governance Meetingbetween your RO and the appropriateDirectors / Clinical Leads in your organisation. In the event there is significant informationmissing, we may be able to give a final datefor the missing items to be provided by,before issuing the report.
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