Good Governance Under the Spotlight: Why ‘Tick-Box’ Audits Could Be Failing Your Service
Date: 8 July 2025
When the Care Quality Commission (CQC) inspects a service under Regulation 17 – Good Governance, one of the most frequent findings is this:
Audits were completed — but they didn’t identify the issues found at inspection. Or if they did, no action was taken.
It’s a red flag that audits and quality assurance have become tick-box exercises — a paper trail, rather than a genuine driver of improvement. And it’s a major risk to your compliance.
🔍 What’s Going Wrong?
Many services carry out audits monthly, weekly, even daily — but CQC still finds breaches in practice. Why?
📋 Audits are completed by staff who aren’t trained in what they’re reviewing (e.g. meds audits done by someone who doesn’t administer medication)
🔄 Audits are delegated without checks on accuracy or understanding
🧩 No one questions the audit outcomes or cross-references them with incidents, complaints or other indicators
🚫 Action plans aren’t created — or not followed through
📉 The Governance Breach CQC Is Looking For
The CQC routinely includes phrases in inspection reports such as:
“Audits had not identified the concerns we found on inspection.”
“Although an audit had been completed, it did not result in action or improvement.”
“The provider was not aware of the issues until we raised them.”
This is how Regulation 17 breaches are identified. It’s not that audits weren’t done — it’s that they weren’t effective.
✅ What Good Governance Looks Like
Real governance isn’t about ticking boxes. It’s about:
🌟 Being curious and reflective about how your service operates
📈 Using audits as a learning and improvement tool
👥 Involving the right people — those who understand the standards, the practice, and what good looks like
📊 Linking audits to action — clear, dated, and accountable plans
If a care plan audit shows gaps — who’s responsible for updating it? When will it be reviewed? Who checks it was done?
🚨 Delegation ≠ Abdication
It’s common for Registered Managers to delegate audits. That’s fine — but the responsibility for oversight stays with you.
If you delegate to someone who doesn’t know the subject matter (e.g., audits medication but isn’t trained or experienced in meds administration), the audit may be superficial at best — and dangerously misleading at worst.
🧠 “Do They Know What Good Looks Like?”
This is a key question for every audit. Ask yourself:
Has this person been trained in the area they’re auditing?
Do they know what best practice looks like?
Would they spot something subtle — or only the obvious?
Don’t assume. Train and support your team to become confident auditors — or keep key audits at senior level.
🤝 Effective Delegation: A Core Leadership Skill
Delegation is vital — but it must be done with care. As a Registered Manager, your role isn’t to do everything yourself — but to ensure everything is done to a high standard.
That means delegating with intention. Don’t just hand over a task — hand over the responsibility with support.
Here’s how to delegate audits or governance tasks effectively:
✅ Only delegate to people who are competent and trained in that specific area (e.g. someone auditing medicines should be trained and experienced in meds handling)
📝 Give a clear scope — what to check, how to record it, and how to raise any concerns
📅 Set deadlines and expectations — don’t assume it will get done
📞 Check in before and after — offer support, clarify doubts, and review the outcome
🔍 Sample completed audits to check consistency, accuracy and whether any learning points were missed
Delegation done well empowers your team and strengthens your oversight. Done poorly, it’s a fast track to compliance risks.
📝 Tools to Strengthen Governance
If you’re struggling to make audits meaningful, start with how you capture and act on findings. Our Editable Action Plan Template is designed to help you:
