Quality Governance Committee Assurance Report


Public Board



Report Title:

Quality Governance Committee Assurance Report

Agenda Item:


Committee Date


Meeting Chair:

Neville Hounsome, Non-Executive Director

Meeting quorate






The Board is asked to receive assurance from the business discussed at the meeting and to review the matters for escalation and referral

Link to Strategic Objective

Be an exceptional place to work, volunteer and learn


Provide outstanding quality of care and performance


Be excellent collaborators and innovators as system partners


Be an environmentally and financially sustainable organisation



Summary of Items Considered at the Meeting






 Board Assurance Framework

The continuing pressure upon the NHS system combined with both internal and external factors gives rise to a significant safety issues for patients.

The risk remains at the highest level. However, very recent improvements in handovers may be the start of a reducing risk. The  clinical strategy is being deployed including access to the stack of calls and advancing clinical  practice. The filling of vacancies and reducing abstractions as well as a number of other initiatives will help build resilience. The increasing use of hear and treat and signposting will provide a reduction in delays and the use of “no sends” (see below).

Moderate/ Reasonable

Quality Metrics

Safeguarding training achieved its year end target of 90%. Infection and prevention control targets remain broadly on track. Medicines management audit compliance has been below 90% in 4 of the last 6 months and is a concern. Numbers of compliments are falling whilst overdue SIs are increasing.

The Committee would  welcome greater clarity around action planning and trajectories relating to quality metrics.

Our performance on Ambulance Care Quality Indicators ( ROSC, survival to discharge, Sepsis, Stemi and Stroke) remain generally above national average. The Committee asked for a resourcing plan which considers increases in SIs, claims and Coroners court cases as well as planned process changes.

Moderate/ Reasonable 

Serious Incidents

We continue to declared SIs at a rate of one a day for the last year (compared to 1 a week previously). Over 3/4 of SIs are related to delays reaching patients.

Our principle activity is to work with systems partners to address flow issues into and out of hospitals (also see BAF). The Committee has asked that we test actions following SIs passed on to partner agencies “closing the loop.”

Moderate/ Reasonable 

Impact of “no send” instructions deep dive

The Committee was assured that our processes for not sending an ambulance were risk based and safe albeit that the use of this tool often provided a poor patient experience.

The Committee will receive a further deep dive into no sends in about 6 months. In the meantime as part of the Emergency Clinical Assessment Team (ECAT) expansion we are working towards reducing the number of no sends and for hear and treat rates to rise.

 High/ Substantial

Research and development annual report

The report gave many examples of good practice research (see for example p5 of the attached report).

The Committee received a high level of assurance with regards how research was approved, managed, delivered shared and reviewed.

High/ Substantial

CQC update / Continuous Improvement Assurance Framework CIAF Our s31CQC action plan has been submitted to the regulators in the hope that this condition will be lifted. We are also in the process of gathering evidence for the possible lifting of Private Ambulance Services (PAS) and management of complaints handling. Work is ongoing on closing the gap for the 9 ‘must dos’ and 7 ‘should dos’ from the more recent CQC Inspection (2022). The Committee noted good progress on the plans’ delivery with an intention to ask for the removal of the S31 notice now that all of the relevant actions have been delivered. The Continuous Improvement Assurance Framework (CIAF) is expected to be fully in place soon which could enable us to move to substantial assurance and a clearer picture of all outstanding actions and the testing of how embedded they are. Moderate/ Reasonable
Volunteer Delivery Plan The Committee supported the volunteer development plan and noted the proposed structure review being considered by ELT. The Committee welcomed the update. We discussed the wider governance questions around the oversight of volunteer activity. Moderate/ Reasonable
National Ambulance Resilience Unit audit of Emergency Planning Annual Assurance Self – assessment returns The NARU external audit of our Emergency Preparedness, Resilience and Response (EPRR) gave “Substantial Compliance” – fully compliant in most areas and partially in 5. The Committee welcomed the progress in delivering 25 of the original 28 actions from our original plan. We were advised that most of the remaining actions are continuing to be closed now the recruitment gap is high and although a plan in place, due to the volume will take a number of months to fully recruit in order to ensure a move to substantial  Assurance in our own eyes Moderate/ Reasonable


Matters for escalation or referral




No matters were referred to other Committees and no new risks escalated.



Annual Research Report 2021-22

Next Section: Performance and Finance Committee Assurance Report