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,  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 further reduction in delays. The Board will need to ensure the Time to Lead project and Winter Planning reduces this risk for next winter.


Quality Metrics

Infection and prevention control targets and Covid actions 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 a record 10 times greater than complaints. 

Our performance on Ambulance Care Quality Indicators ( ROSC, survival to discharge, Sepsis, Stemi and Stroke) remain generally above national averages. The Committee asked for greater assurance on getting better medicine management audit results at the next Committee


Serious Incidents

We have seen  SIs halve to c2 pw since the end of January as handover rates have improved (compared to 1 a week previously). Over halve  of SIs are still related to delays reaching patients. 

Our principal 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.


Group Assurance Report

This Committee relies heavily upon the work of sub groups and expressed concern at assurance remaining at moderate. 

The Executive leads and their teams are asked to ensure good attendance at sub groups and a raising of assurance levels.


Committee Annual Review

QGC members positively agreed or strongly agreed with 77 of 81 responses to the annual effectiveness survey. The remaining 4 being neutral.

Some duplication was noted with PAF, Board and Transformation Committees.

Recognising a positive but difficult year caused by handover delays and unprecedented SIs, the Committee Chair “looked forward to further enhancement to data focussing upon the benefits realisable from today’s plans and actions.”

QGC approved: the annual effectiveness report, that it had operated within its Terms of Reference, areas for focus and the workplan for 2023-24.The report with its recommendation has now been submitted to the Audit Committee.

CQC Update Our s31CQC action plan has been submitted to the regulators for lifting. We are also gathering evidence for the possible lifting of 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 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
Quality Improvement Strategy 2018-2022 This closure report reflected that the original 2018 plan had few measurable outputs. The Three year review target to improve staff survey results relating to QI were missed. The Committee welcomed the lessons learnt approach to this review and recommended that the Transformation Committee consider it in a wider context of project management within the Trust. Limited


Matters for escalation or referral




 Board Assurance Framework

The Board is asked to support improvements with the delivery of the Clinical Strategy, Time to Lead and the development of a robust Winter Plan. 


Committee Annual Review

Audit Committee 

To provide assurance to the Board that the Committee had operated within its Terms of Reference and agreed the areas of focus and workplan for 2023-24. 

Chair Actions

The Audit Committee to review stakeholder mapping and management with  particular focus upon patient voice and effective ICB relations. 

To ensure that the Trust is offering the most relevant and effective engagement across the Trust to collaborate successfully in delivering patient and public engagement.

QI Strategy Review

The Transformation Committee is asked to consider / reconsider project planning in the light of this review.

To ensure that the Trust learns  lessons from this approach and  identifies opportunities to build in effective project management into our transformation and change programmes.

Next Section: Performance and Finance Committee Assurance Report