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.

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