What this helps you do.
- Services with a recurring concern or an identified evidence gap.
- Managers refreshing one part of their assurance programme.
Scope of the review
- Selected themes such as medicines, infection prevention, safeguarding, consent or recruitment.
- Complaints, duty of candour, notifications, staffing, premises or records within the agreed scope.
- The relationship between policy, staff understanding, implementation and review.
How it works
- Choose the question
Define the theme, applicable requirements and the decision the audit should support.
- Set the sample
Agree proportionate records, interviews and any necessary specialist input.
- Evaluate practice
Compare the evidence with the requirement and identify supported findings.
- Define the response
Recommend actions and a repeat-check method to assess improvement.
What you receive
- A focused findings report with source and evidence references.
- An action list ordered by significance.
- A suggested follow-up sample or review method.
Explore a fictional report and action plan, or create your own non-confidential working plan.
What to prepare
- Relevant policies and the reason for the review.
- Existing audit results and associated actions.
- A defined, minimised sample of relevant records.
Use evidence references in an initial brief. Confidential records need an agreed secure handling route.
Scope and limits
- A thematic review does not establish compliance across the whole service.
- Clinical, medicines, infection-control or technical conclusions require appropriately qualified input where necessary.
Common questions
Can several themes be combined?
Related themes can be scoped together, provided coverage, sampling and specialist responsibilities remain clear.
Does the audit produce a replacement policy?
Policy recommendations can form part of the scope. A policy alone does not show that the required arrangements are working.
Sources and review
Content version: 1 November 2026. The proposed scope must be confirmed in engagement terms.
Start with a focused brief.
Describe the service and the questions you need this review to address.
Discuss your requirementsA worked example of the review
Illustrative example — not a client case. This shows a possible working method; it does not report an actual engagement or outcome.
Examining whether complaints lead to learning
Suppose a service keeps complaint responses, but managers cannot easily identify recurring themes or explain how feedback influenced practice.
- Define the complaints and learning question, the relevant requirements and a proportionate sample for the review.
- Compare the complaints procedure with recorded concerns, responses, decisions and evidence of feedback to the people involved.
- Record any gap in ownership, trend analysis or follow-through, keeping personal details out of the audit summary where they are unnecessary.
- Repeat the agreed checks after changes are introduced and examine whether managers can demonstrate learning and completed action.
This example concerns one theme. It does not establish compliance across the whole service or replace appropriate specialist input.
Related guidance and next steps
Content version: . Named expert review remains pending for public launch.