Compliance Audits

Independent MGPS HTM02-01 compliance audits to identify gaps, prioritise actions and improve patient safety by highlighting risks. We carry out a deep dive into the site compliance against HTM02-01, BCGA & PSSR 2000. We audit wards, plant rooms, supply equipment & operational management to provide a site with a compliance snap shot along with risks for the site to prioritise.  ​

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What We Review

Each audit is structured to provide a balanced view of governance, technical evidence and on-site condition. Typical review areas include:

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• Pre-audit document request and desktop review of governance, appointments, policies, drawings, logs and test records

• Operational management review including roles, competency, training/authorisations, contractor control, communication, and record keeping

• Onsite walkdowns of MGPS sources and plant including liquid supply, plant rooms, manifolds and emergency reserves

• Inspection of cylinder management including main stores, receipt, segregation and handling

• Review of distribution infrastructure including pipework condition, zoning, AVSUs/LVAs, labelling and access control

• Clinical area audit of terminal unit, alarm, AVSU provision, user safety controls, isolation arrangements and “do not use” management

• Review of alarm systems and response arrangements including escalation, fault reporting and incident learning

• Review of permit-to-work systems, interruptions, contingency planning and prevention of unauthorised work

• Risk rating of findings using a severity and likelihood matrix with prioritised actions

• Non-compliance register and summary schedule with corrective action recommendations

• Final report pack with executive summary, risk register, photographic evidence and action plan

• Close-out meeting to brief stakeholders and agree next steps, with optional re-audit to verify close-out

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How the Audit Is carried out

• Audit Type: Independent, objective MGPS compliance review

• Delivery:

  • Site visit and documentation review

  • Interviews with key personnel where appropriate

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The audit is conducted to support improvement and assurance, not to “catch people out”.

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Reporting & Outputs

Following the audit, you’ll receive a clear, structured report designed for practical use by estates teams and senior management.

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Audit Report Includes:

• Summary of current compliance position

• Identified gaps and areas of concern

• Risk-based prioritisation of findings

• Clear, actionable recommendations

• Guidance on short-, medium- and longer-term improvements

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Reports are written in plain, easy to read language and are suitable for use in internal reviews, governance meetings and inspection preparation. We produce this is a interactive sheet which is easy to view and move around with a summary sheet so the non-compliances can be actioned in a structured way.