Quality Governance Committee Assurance Report - July 2025
Meeting: Trust Board – Public Meeting
Date: 9 July 2025
Report Title: Quality Governance Committee Assurance Report
Agenda Item: PUB25/07/3.3
Committee Date: 25 June 2025
Meeting Chair: Catherine Glickman, Non-Executive Director and Committee Chair
Meeting quorate: YES
Purpose: Assurance
Link to Strategic Objective: Provide outstanding quality of care and performance.
Summary of items considered at the meeting:
| Issue | Consideration | Resolution | Assurance |
|---|---|---|---|
| Private Ambulance Services (PAS) | Since the start of the contract in April, improving metrics were reported: shift fill is at 95% and on-scene times and conveyance rates are improving. PAS had taken over the Infection Prevention and Control (IPC) audits, carrying out scheduled and unannounced visits. | The Committee congratulated the team on the strong start to the new contract and noted the report. An update on performance will come to the next meeting. | Substantial |
| Quality Metrics and Integrated Performance Report (IPR) | The Director of Quality talked through the two reports, explaining that in future the IPR will be generated automatically, with narratives to context the data. Over time, this will replace the current Quality Metrics report. In his commentary, the Director of Quality highlighted Infection Prevention Control of stations needed to be improved (specifically waste management and out of sight cleaning), as did Vehicle cleaning. Safeguarding was in a strong position. Overdue complaints and medicines management had both seen significant improvements. | The Committee welcomed the automation and simplification of the IPR. The IPC action plan was noted. The complaint handling improvement was praised (100 overdue in December to 14 in April). Overdue actions – it was confirmed that the number currently stood at eight (down from 27), all being low risk; data on overdue actions will be a standard item in the IPR going forward. | Substantial |
| Handover 45 (HO45) | The Head of Patient Safety confirmed HO45 had had a positive impact in the last 6-months, reducing the frequency and level of harm to patients. Acutes were performing consistently better on handover times, with a couple of exceptions with delay spikes. One incident of fatal harm in Norfolk and Waveney (N&W) has been subject to a Patient Safety Incident Investigation (PSII); results to be shared with EEAST. | The Committee were very pleased that HO45 is meeting the objective of releasing crews to attend other patients. The push to reduce handover times at acutes to a 15-minute target and the use of Datix to record incidents at handover was seen as very positive. In conjunction with other activities, HO45 was contributing to the improvement in C2 performance. | Reasonable |
| Frequent Caller/High Intensity Review | Richard Smith, EOC, talked through the actions since the Internal Audit in 2024. All had been actioned, except for a dedicated system (seen as too expensive): tracking was being managed through manual methods. | The Committee was pleased that the actions had been implemented, welcomed the use of data to manage the High Intensity users and wondered if the methodology could be applied to other areas of activity. | Reasonable |
| Category 2 Segmentation | The revised C2 principles were implemented in May 25. To date, from March to June, navigation had reduced from 15mins 24secs to 5mins 4secs (target <5mins) and validation from 46mins 31secs to 24mins 55secs (target <20mins). This was at 80% staffing: if fully staffed, could increase volume managed and numbers validated. One safety incident had been declared with no harm. EEAST was performing second in the country. | The Committee was impressed by the achievements 6-weeks in, with a recognition that there were opportunities in Category 3-5 calls. It was agreed that the Committee should receive an update on performance over the Summer months in September. | |
| Patient Safety Incident Review Framework (PSIRF): 6-month review | The Head of Patient Safety talked through the two reports issued to date: Missed STEMIs – since the report had been published, zero incidents of harm; Non-Conveyance – three harm incidents, a significant reduction: this report had been shortlisted for a HSJ award on embedding PSIRF. | The Committee congratulated everyone on the reports and implementation of the learnings in the field: the improvement in care was clear. The themes agreed for 2025/26 were: PTS Injury (due in September); Pre-hospital Resus; Meds Adrenaline 1:1000; effective pain assessment pre-hospital. A key learning from the first reports was that more time should be scheduled to work on Serious Incidents. | |
| Mental Health ‘Right Care, Right Person’ | The Deputy Clinical Director updated: ‘Right Care, Right Person’ had been implemented with the police forces across the East of England. All areas had Mental Health Response Cars except Cambridgeshire and Peterborough (C&P) and Bedfordshire & Luton (B&L), which had stopped 70% of conveyances. Roles and responsibilities had been agreed with the police, specifically on the ‘primary’ individual who made the decision at an incident, ie. the clinician under the Mental Capacity Act rather than the police or individual where they were incapable of making an informed decision. | The Committee discussed the role of Mental Health Response Vehicles. They also worked through who was the ‘primary’ individual under the Mental Capacity Act, discussing how EEAST staff were trained to know and exercise this role. The major piece of training is the Level 3 Safeguarding mandatory training, but a further module specifically on Mental Capacity was recommended – this was under discussion about whether it should be mandatory. The Committee asked to be updated on the final recommendation. | Substantial |
| Regulatory Assurance | The Director of Quality updated the Committee that EEAST had moved to the Exit Criteria and ‘business as usual’ following the CQC findings in November. The full CQC report was still awaited. | The Committee welcomed that EEAST had moved to the exit criteria, recognising culture and engagement needed longer to embed. | Limited |
| Claims and Litigation Annual Report 2024/25 | Claims had reduced in-year (from 63 to 37) but complexity and longer lead times were still adding to the workload. There had been no Prevention of Future Death notices in 2024/25, but one had been received in April 2025. | The Committee discussed the nature of cases, the April Prevention of Future Death notice and welcomed the report, recognising the sterling work done by the team in conjunction with EEAST staff and coroners. The Committee noted that a further report will come once the benchmarking data for 2024/25 is available. | |
| Medicines Management Annual Report 2024/25 | The Deputy Clinical Director presented the report: cost management and waste had both improved. The actions following the CQC report now ensured that investigations were thorough, and controlled drugs tightly managed. | The Committee welcomed the overall performance, which was strong, noting the tight control now applied to investigations, which was now a standard item on the Medicines Management meeting. Investigations of moving the Controlled Drugs Register to electronic, rather than paper, based systems were being investigated. | |
| Medical Devices Assurance Report 2024/25 | The Head of Medical Devices presented the report which demonstrated another year of strong control and progress, with ISO re-accreditation achieved in January 2025. | The Committee congratulated the team on achieving the ISO reaccreditation, the first ambulance service to achieve it, demonstrating the grip that the team had over the portfolio of devices. | |
| Clinical Audit Plan 2024/25 | The 2024/25 Plan was completed in full, the third year this has been achieved. 2025/26’s targets had been shared, some of which were above the Commissioners’ targets, eg. ROSC at Hospital and Utstein. | The Committee congratulated the team on another year of full audit completion. | Reasonable |
| Board Assurance Framework | The new framework had been agreed by the Board; this was the first time it had been reviewed by the Committee – combining the risks. Judgment of the risk ratings were proposed. | The Committee agreed with combining the two risks given the controls were the same and agreed to work with the framework to test risk in future meetings. The risk ratings were supported on this first report. | Reasonable |
| Group Assurance Report | Reports were received from Patient Safety, Clinical Best Practice, Medicines Management, and Safeguarding. | Comprehensive updates to the Committee, providing good assurance. | |
| Quality Governance Annual Report and Terms of Reference | The Company Secretary presented the report, Terms of Reference and the Committee’s evaluation of performance. | The Committee approved the Report and Terms of Reference, for submission to the Audit and Risk Committee. On the evaluation, it was agreed the Committee worked effectively but the agenda was very full which curtailed debate at times. |
Matters for escalation or referral:
None
