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MAT-AIMS-HC-001 v1.0
ISO 42001 × CQC Well-Led
Healthcare Edition
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ISO 42001 × CQC Well-Led: Gap Severity Matrix

Two files are included in your purchase. Download both below. Print the PDF at A3 for committee use. Use the high-res PNG for digital presentations and intranet display.

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Getting Value From the Matrix

Five Ways to Use the Gap Severity Matrix

01
Governance committee agenda — standing AI governance item

Print the matrix and use it as the standing reference document for your AI governance committee agenda item. Each quarter, mark which gaps are remediated (✓), in progress (~), or open (✗). Over time this produces a documented, dated governance committee record showing systematic AI governance improvement — exactly the evidence CQC Well-Led inspectors look for.

02
Internal audit scope document

Use the matrix as the scope document for your internal AI governance audit. The nine gaps define the audit scope. The CQC KLoE column links each audit finding to the inspection framework. The severity column provides the risk-based audit prioritisation. Present the completed audit against the matrix at your next governance committee.

03
CQC inspection preparation — evidence linkage

When preparing your Well-Led evidence portfolio for a CQC inspection, use the matrix to structure your evidence mapping. For each gap, the CQC KLoE column identifies the specific inspection question your evidence must answer. Annotate the printed matrix with your evidence references — it becomes the inspection-ready evidence map the CQC inspector can see at a glance.

04
Remediation roadmap — severity-based prioritisation

Use the severity column (Critical / High / Medium) to build your remediation roadmap. Address all Critical gaps before High, all High before Medium. Assign an owner and target date to each gap using the ITIL 4 practice column to identify the correct practice owner. Present the roadmap to the board with the matrix as the supporting reference.

05
Supplier assurance — EU AI Act column

Use the EU AI Act article cross-reference column when assessing AI suppliers. For each gap, the EU AI Act article identifies the regulatory obligation that your supplier assessment should address. This gives your AI vendor evaluation framework a regulatory anchor — relevant for providers procuring AI tools from EU-connected suppliers or operating under NHS contractual requirements that reference the EU AI Act.

Quick Reference — All 9 Gaps at a Glance

The full matrix is in your downloaded files. This summary confirms all nine gaps and their severity ratings for your records.

MAT-AIMS-HC-001 v1.0 · ISO 42001 × CQC Well-Led Gap Severity Matrix · Healthcare Edition

Nine-Gap Summary Reference

#
Gap
Severity
CQC KLoE
G1
AI Policy
Cl. 5.2
Critical
Well-Led: Vision & Strategy
G2
Internal Organisation
Cl. 5.3
High
Well-Led: Governance Structures
G3
AI System Register
Cl. 6.1.2
High
Well-Led: Information & Intelligence
G4
Risk Assessment
Cl. 6.1
Critical
Safe: Risk Management
G5
AI Lifecycle Management
Cl. 6.1.3
Medium
Well-Led: Learning & Improvement
G6
Data Governance
Cl. 6.2
High
Well-Led: Information Governance
G7
AI Disclosure
Cl. 6.3
Medium
Caring: Involvement & Transparency
G8
Human Oversight
Cl. 8
Critical
Effective: Clinical Accountability
G9
Supply Chain Governance
Cl. 6.6
High
Well-Led: Third-Party Assurance

Summary only. Full CQC question text, EU AI Act articles, and ITIL 4 practices are in your downloaded matrix files.

ISO 42001 × CQC Well-Led Framework — Healthcare Series

The Matrix Identifies the Gaps. The Series Closes Them.

You now have the complete picture of where your AI governance gaps are and how they map to CQC. The next step is the Human Oversight Pocket Guide — the £47 deep-dive on the gap that carries the highest patient safety risk.

Free ✓ 5 CQC AI Governance Gaps — you have this
£19 ✓ Gap Severity Matrix — you have this
£47 Human Oversight Pocket Guide — ISO 42001 Clause 8 in depth, EU AI Act Article 14 alignment, evidence checklist for Clinical Directors and CNOs. 20–25pp.
£167 Integration Guide — Complete ISO 42001 × CQC Well-Led dual-framework mapping. 8 intersection chapters. 12-month Unified Governance Calendar. 50–70pp. For Directors of Quality.
Get the Human Oversight Pocket Guide — £47 → Or explore the full series at the Governance Academy — £97/month · 7-day free trial
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Questions or Access Issues?

Using the Matrix

Questions about the content or how to use it

For questions about interpreting severity ratings, applying the CQC mapping, or using the matrix in a governance committee context, post in the Governance Academy community.

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