Quality Governance Committee Assurance Report - May 2025
Meeting: Trust Board – Public Meeting
Date: 7 May 2025
Report Title: Quality Governance Committee Assurance Report
Agenda Item: PUB25/05/2.2
Committee Date: 26 February 2025
Meeting Chair: Catherine Glickman, Non-Executive Director / 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) | The Committee received a full update. Overall standards were comparable to EEAST, with the reduction in shift-fill compliance in December improving since the start of the year. PTS activity has decreased as contracts with Trusts have gone to other providers. An application has been made to the CQC to have the PAS improvement notice lifted. | The Committee welcomed the transparency of the report, recognising that EEAST had made the decision to only work with Trusts that were open to co-creation. The Committee was pleased that the team were enforcing contractual requirements and monitoring the risks in a financially volatile sector. | Reasonable |
| Quality Metrics | The Director of Quality gave an overview of the metrics, specifically improving the closure of complaints through active management Duty of Candour communications, templates for frequent issues and tracking at Accountability forums. Medicines Management was discussed in detail, given the CQC findings at their recent inspection. | The Committee welcomed the focus on complaint closure. On Medicines Management, they were concerned that the reports to the Committee showed strong compliance, compared with the CQC observations. The Committee supported the new KPI of learning from every investigation and the focus on the storage and security of Controlled Drugs, including how keys are managed. Vehicle cleaning, which was not at target, has improved in February to meet target and is expected to maintain improvement. The new cleaning contract is improving station standards, linked to clear definition of what EEAST and the contractor are each responsible for. | Substantial |
| Handover 45 | The Medical Director updated the Committee on the first 2-months of operation. Overall, there have been less incidents in patient safety this year. Two incidents of fatal harm have been raised with the relevant ICBs – an important concern is that, despite pre-alerts, delays were experienced at some A&Es, with the potential to cause harm. | The Committee found the update very helpful: the improvement to December was positive, with a deterioration in one ICB in January. Concerns remained that Cambridgeshire and Peterborough were yet to confirm when they would move to the 45-minute protocol: this would come under pressure in 2025/26 given NHS England’s guidance. | |
| Flu Vaccination | The Director of Quality explained that the lower take up (33%) this year was reflective of NHS trends overall, however EEAST could have executed the campaign more effectively. Late delivery of the Covid vaccine, issues with refrigerated storage, and a late start to the campaign were all felt to be part of the low rate. Last year a vaccination rate of 68% had been achieved. | The Committee asked the team to look at what Norfolk and Waveney had done to achieve much higher rates and supported more co-ordinated execution later this year. The NHS target for vaccination was 70%. | |
| Access to the Stack | The individual ICB performance metrics were presented: a particular highlight was that the Unscheduled Care Co-ordination Hubs (UCCH) represented around 33% of the Hear & Treat cases. Concerns remain about the Cambridgeshire and Peterborough hub, which has been raised with the ICB. Auto-reject rates have also been raised with the ICBs. | The Committee welcomed the comprehensive report and insights. They supported continuing to identify gaps in service to help the ICBs understand where they should invest to reduce the pressure on acutes, and to continue to invest in ICB relationships to create the right teams in the community. The presentation of UCCH performance data to the Performance Committee was discussed. | Substantial |
| Regulatory Assurance | The Director of Quality updated on the CQC inspection which was ongoing. | The Committee supported the progress made and will continue to monitor progress against the Must Dos and Should Dos. | Limited |
| Board Assurance Framework | The residual risks remain high, specifically given the recent CQC inspection. | The Committee supported the ratings; they discussed how the risks could be reviewed following the discussions at the meeting, to reflect whether assurance was higher, lower or neutral. This approach to risk management will be taken up at the Board Risk Management Workshop in March 2025. | Reasonable |
| Group Assurance Report | The Committee reviewed the report. | The Group update was comprehensive, however given the Medicines Management gaps raised by the CQC, it was agreed that the Committee Chair should attend the Medicines Management Group meeting to understand the protocols that are being put in place. | Moderate |
| Infection Prevention and Control Annual Report 2023/24 | The report was presented for discussion and approval: the Head of Infection Prevention and Control confirmed that the report would be submitted for approval earlier in 2025/26. | The Committee recognised the work done by the team and where there had been challenges. The annual report was approved for publication. | Approved report for publication |
| Clinical Audit Plan: Update on 2024/25 Plan and 2025/26 Proposal | The 2024/25 Plan was on track for 100% completion, with the annual summary to come to the Committee later in the year. 2025/26’s audit topics were discussed and the rationale explained. | The Committee were impressed by the 2024/25 achievements and agreed the 2025/26 Audit Plan as proposed. | Reasonable |
| Quality Account Priorities 2025/26 | The themes were presented to the Committee and the rationale explained for selection. | The AI work will be done in the EOC, linked to the Corpuls software and the ePCR. The Committee agreed the priorities. | Reasonable |
Matters for escalation or referral:
None.
