Quality Governance Committee Assurance Report - July 2025
Meeting: Public Board
Date: 5 November 2025
Report Title: Quality Governance Committee Report to Board
Agenda Item: Pub25/11/3.2
Committee Date: 24/09/2025
Meeting Chair: Julie Thallon Non-Executive Director
Meeting quorate: YES
Purpose: Assurance
Link to EEAST Strategic Mission:
- Patient Mission
- Productivity Mission
Summary of items considered at the meeting:
| Issue | Consideration | Resolution | Assurance |
|---|---|---|---|
| Integrated Performance Report | Current performance and issues discussed. Specific concern highlighted around IPC and a link with Make Ready. IPC is identified across several papers at this Committee meeting. | A deeper dive of IPC across all areas was discussed. As considerable work has been undertaken previously agreed to bring a paper to next meeting with an update, aligned to the IPR discussion to assess whether improvements are being sustained. | Good |
| Clinical Strategy | Committee discussed and approved the moves to close the previous clinical strategy and discussed the draft proposal and principles for the new strategy. It was noted that there has been no patient involvement in the strategy to date. | Patient involvement will be progressed in accordance with the Board discussion due 8th October. All agreed supportive of direction of travel but with some significant discussions still needed around scope of authority and control for EEAST within the wider systems. Option 2 in the paper approved. | Good |
| LeDeR Review | The paper detailed a review of safeguarding for patients with learning difficulties. | Committee agreed that this was a good audit, but it was not what had been originally requested. Concern was raised about the commitment to learn from the outputs from the LeDeRs which remains outstanding and further work needs to be undertaken. | Good for the audit presented. No assurance for original request. |
| Patient Safety Report | This was a good report and welcomed by Committee. The link between HO45 and incidents is clear with a decline in incidents and resultant harm reduced in line with the number of delays with hospital handover. The joint review of incidents with our lead commissioner has also been useful and successful but this is likely to be discontinued in the ICB restructure. | Continue to share the impact of HO45 on the quality and safety of care with acute partners and the systems more widely. Committee members asked that the withdrawal of ICB partners in the incident review process should be reconsidered. | Good |
| Access to Stack Update | More calls are being passed and accepted but a higher number are being returned. This is a result of capacity issues and the result of the receiving organisations triage. There continue to be some challenges with ensuring staffing levels. | Capacity in community services continues to be an issue and does result in calls being referred back to EEAST despite them being triaged and suitable for another service. This is being fed back into system wide discussions. Some confusion around availability of roles to support A2S – this is now being resolved and is expected to improve staffing levels. | Moderate |
| Private Ambulance Services | Committee discussed the current service from the private providers including the increased hours which have been secured ahead of the winter. | PAS providers score consistently well against quality & safety indicators. They are subject to the same inspections and audits as EEAST provided services. A review of the decision to reduce PAS services from April given that this decision needed to be reversed. This was previously discussed at Board and will be overseen by Audit Committee. | Good |
| CQC Update on progress | Progress noted but slowing now due to the difficulty of the remaining actions. The trust continues to wait for the report from the last inspection over a year ago. | Ongoing review and attention to the more challenging actions continues. | Good |
| BAF | Risks discussed including the possible increase of the risk score for SR2 given the section 29 enforcement notice. | Further work is ongoing on refining the BAF. Committee discussed the potential increase in score to risk SR2 but agreed that although the risks persist the mitigations are appropriate and delivering. | Moderate |
| Group Reports | Reports received from the two groups who had met since the last Committee meeting. Both provided substantial assurance to CRG. | Committee accepted and agreed the recommendations of the CRG. | Substantial |
| Regulatory Update | Committee had CQC update in previous paper. Brief verbal update on NICE and HSE. | Noted | Good |
