Corporate & Clinical Governance

The Trust has a Healthcare Governance Framework that supports the Board of Directors in discharging its responsibilities for ensuring that high quality and safe services are in place for patients, visitors and staff.

The responsibility of the Board of Directors is to ensure that relevant and core standards are implemented and that good progress is made towards the implementation of developmental standards.

Mortality Review policy

Mortality governance is a key priority for the Trust, to ensure that we learn from the care and treatment provided to patients who die and that care and treatment is continuously improved as part of clinical governance and quality improvement work.  The prevention of avoidable harm and death through investigation and learning is central to our plans.  For more information on this important issue, see the policy on Responding to Patient Deaths read more below.

Summary of the Responding to Deaths Policy (2017)

In December 2016 the CQC published Learning, candour, accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England. The National Quality Board has subsequently published their report National Guidance on Learning from Deaths to help initiate a standardised approach to learning and reviews of deaths.  All Trusts are required to publish a local policy and approach and this is available at Responding to Deaths policy.

The policy identifies a systematic approach to the review and investigation of the deaths of people who use our services and the reporting and monitoring requirements that will provide valuable insight into whether opportunities for preventing a death have been missed and identify improvements needed. The policy explains what is expected of all staff in their different roles.

To fulfil the standards and new reporting set out in the national guidance we must ensure governance arrangements and processes include, facilitate and give focus to the review, investigation, reporting of deaths and sharing learning, including deaths that are determined more likely than not to have resulted in problems in care.  Key points include:

  1. Having an executive director with responsibility for the learning from deaths agenda and an existing non-executive director responsible for oversight of progress.

 

  1. Paying particular attention to the care of patients with a learning disability or mental health needs, an infant or child death and a still birth or maternal death.

 

  1. Having a systematic process for the identification and evidence based methodology for the case note review of deaths overseen by the mortality lead.

 

  1. Inclusion of patients who have died within 30 days of discharge.

 

  1. Inclusion of patients where concerns have been raised by other providers, staff, patients and carers.

 

  1. Timely, compassionate and meaningful engagement with bereaved families and carers during all stages of responding to a death.

 

  1. Strengthened Trust Mortality Surveillance Committee for synthesis of information from a variety of sources, identification of themes and trends.

 

  1. Improved data collection and reporting with outcomes, learning and actions reported to the Board with a focus on quality improvement.

 

  1. Inclusion of learning from reviews and investigations in the Trust’s Quality Account.

 

  1. Engagement of staff through Clinical Governance meetings and other forums to share learning.

 

The policy ensures that we are compliant with these requirements and that we are reporting in the public domain as we should. This policy will be developed further and adapted in the light of future expected national initiatives:

 

  1. The CQC will strengthen its assessments of how providers learn from deaths and how well bereaved carers and relatives are engaged.

 

  1. NHS England will develop guidance for bereaved families and carers.

 

  1. National training packages will support case note reviewers in using the Structure Judgement Review methodology.

 

  1. NHS Digital is assessing how to facilitate the development of systems and processes so that information from reviews and investigation can be collected in a standardised way.

 

  1. The Department of Health is exploring proposals to improve the way complaints involving serious incidents are handled particular in respect to learning between providers and the wider healthcare system.

 

Reporting into the Management Board are five assurance committees and an executive performance committee.

The Caring & Patient Experience (CaPE) Sub-board – Chaired by the Director of Nursing.

Its duties are to ensure appropriate strategies are in place for action, reporting and monitoring in relation to all allocated areas which include (although not exhaustively):

  • Designated elements within the Francis report recommendations
  • Patient & public involvement in service development
  • Patient involvement in their care
  • Patient Feedback
  • Care for and involvement of carers and families
  • Patient Information
  • Patient experience including Friends & Family Test and national and local patient experience surveys
  • Patient Advice & Liaison Service
  • Privacy & dignity
  • Nutrition
  • End of life care
  • Dementia care & strategy
  • Single sex compliance
  • Equality & Diversity (patients)
  • Learning Disability & Autism
  • Discharge processes

Clinical Safety Sub-Board – Chaired by the Medical Director

Its duties are to ensure appropriate strategies are in place for action, reporting and monitoring in relation to all allocated areas which include (although not exhaustively):

  • Incident reporting, analysis, staff feedback & learning
  • Infection Prevention and Control
  • Safeguarding – Adults & Children
  • Resuscitation Policy
  • Mortality & Morbidity reviews
  • Dr Foster Information
  • Safety of handovers
  • Transfusion
  • Medicines management
  • Health record keeping
  • Slips, trips and falls (patients)
  • Patient moving & handling
  • Radiation regulations
  • Research Governance

Non-Clinical Safety Sub-Board – Chaired by the Director of Workforce

Its duties are to ensure appropriate strategies are in place for action, reporting and monitoring in relation to all allocated areas which include (although not exhaustively):

  • Health & Safety
  • Health Records Management
  • Safety & availability of equipment
  • Environment
  • Fire procedure & training
  • Lone working
  • Inoculation incidents
  • Estates Management
  • Safety, availability and suitability of medical devices
  • Violence & aggression
  • Security management
  • Information Governance
  • Caldicott and Freedom of Information requests
  • Data Quality
  • Data Assurance processes for recording, monitoring and reporting of data and performance against targets and standards

Effectiveness Sub-Board – Chaired by the Medical Director

Its duties are to ensure appropriate strategies are in place for action, reporting and monitoring in relation to all allocated areas which include (although not exhaustively):

  • Promote best practice through the ongoing development of local clinical guidelines and protocols
  • NICE compliance
  • Local and national clinical audit programme
  • Informed consent
  • Research & Development
  • Clinical Ethics
  • Clinical outcome measures
  • Diagnostic Testing and Screening
  • Maternity clinical standards
  • New Therapies & Procedures
  • Support for patients with mental health needs

Responsiveness Sub-Board – Chaired by the Chief Operating Officer

Its duties are to ensure appropriate strategies are in place for action, reporting and monitoring in relation to all allocated areas which include (although not exhaustively):

  • Capacity Planning
  • Access to services
  • Delivery of key targets

Workforce Sub-Board – Chaired by the Director of Workforce

Its duties are to ensure appropriate strategies are in place for action, reporting and monitoring in relation to all allocated areas which include (although not exhaustively):

  • Workforce Strategy & Planning
  • Professional and post graduate Educational Strategies
  • Recruitment
  • Corporate values, behaviours and culture & staff engagement
  • Professional registration
  • Performance Development Plans and Appraisals
  • Learning and development (including. mandatory, risk and induction training)
  • Occupational Health and wellbeing
  • Whistle-blowing
  • Equality & Diversity (staff)
  • Sickness and absence management
  • Payroll and Electronic SR system