Download Date approved by Committee / Group

QUALITY & GOVERNANCE COMMITTEE
TERMS OF REFERENCE
February 2015
1.
Constitution
1.1
The Board has resolved to establish a committee of the Board to be known as the
Quality & Governance Committee (the Committee), which is accountable to the Trust
Board.
1.2
The Committee has only those powers delegated in these Terms of Reference.
2.
Purpose
2.1
This Committee of the Trust Board has the responsibility to review all aspects of the
Trust’s quality and clinical governance. The committee should enable the board to
obtain assurance that standards of care meet the standards laid out by the NHS
constitution and other regulatory bodies, in particular the Care Quality Commission.
The committee should ensure that governance structures are in place to ensure
processes and controls are able to meet the following priorities:
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Safety and excellence in patient care
Prioritise and manage risk within clinical care
Ensure the effective and efficient use of resources to deliver evidence based
clinical practice
Protect patients and staff from harm
The Committee is responsible for supporting the Board in receiving assurance
relating to its duties under the NHS Constitution, plus all other statutory, regulatory
and best practice requirements. The Committee is also responsible for the review of
all aspects of the risk management process regarding clinical, quality and safety and
obtaining assurance on all aspects of the Trust’s declarations and its registration by
the Care Quality Commission.
2.2
Particular focus will be to cover the five domains of the CQC inspection framework
answering the questions of the Trust; Is it safe? Is it effective? Is it caring? Is it
responsive to people’s needs? Is it well led?
3.
Authority
3.1
The Committee is authorised by the Board to act within its terms of reference and
where relevant all members of staff are directed to cooperate with any request made
by the committee. The Committee is authorised to obtain any internal information as
is necessary to fulfil its function as laid out in these terms of reference.
3.2
The Committee is authorised by the Board to obtain outside legal or other
professional advice if it considers this necessary.
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4.
Membership and Attendance
4.1
Membership of the Committee is as follows:
Core Members
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Three Non Executive Directors
Representative from Patients’ Council
Director of Nursing
Medical Director
Director of Operations
Director of Human Resources
Heads of Nursing
Associate Medical Directors
Associate Director of Governance & Patient Experience
Head of Governance
Attending Members
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Director Infection Prevention and Control/Lead Infection Prevention and Control
Nurse
Leads for Adult and Child Safeguarding
HR Managers Operations and Workforce & Organisational Development
Chair Drugs and Therapeutics Committee (deputised by Lead Pharmacist/Lead
Nurse Medicines Management)
Attending members will receive papers and attend the meeting at their discretion or at the
request of the Chair
4.2
The Trust Chairman will invite a Non Executive Director to Chair.
4.3
In the absence of the Committee Chairman a suitable deputy shall be designated by
either the Committee Chairman or Trust Board Chairman.
4.4
The membership of the Committee will be kept under regular review to ensure that it
best reflects the requirements of governance within the Trust.
4.5
Executive Directors are expected to prepare for and attend each committee meeting
unless exceptional reasons apply where they can be absented. Where an Executive
Director cannot attend a deputy must attend on his or her behalf.
4.6
Clinical leadership is important to the effectiveness of this committee and accordingly
Head of Nursing or Divisional Directors representing the Trust’s divisions are
expected to prepare for and attend each committee meeting unless exceptional
reasons apply where they can be absented. Where a Head of Nursing or Divisional
Director cannot attend a designated clinical lead deputy must attend on his or her
behalf.
4.7
The Committee may require any member of Trust staff to attend or report to a
meeting, particularly when the committee is discussing areas of risk, incident, or
operations of the Trust. In particular the Committee may invite the Divisional
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Managers and representatives from the clinical teams to attend its meetings to
provide assurance on key governance and risk issues. Except in instances that result
in impacting on clinical care, any requests to attend must be prioritised as the first call
on staff time.
4.8
Any Trust Board Member is welcome to attend without invitation.
5.
Quorum
5.1
A quorum must be five members of whom:
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Two must be Non-Executive Directors
Two must be Executive Directors (one clinical)
One member must be a Doctor and one member must be a Nurse
Divisional representation must be present
6.
Frequency of Meetings
6.1
Meetings will be held every two months. These meetings are expected to be held
unless exceptional reasons arise that may require their deferment or cancellation.
This deferment or cancellation will require the agreement of both the Committee
Chairman and Executive Lead.
6.2
Urgent business that requires immediate attention shall be managed as is deemed
appropriate in consultation with the Chairman of the Committee. Extraordinary
meetings may be called only by agreement with the Committee Chairman or Trust
Board Chairman.
7.
Secretariat
7.1
The Associate Director of Governance & Patient Experience will ensure that the
Trust’s Corporate Secretariat provides a secretary and will provide the following
support to the Chair and Members of the Committee:
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7.2
Ensuring release of notice of meetings
Agreement of the agenda with the chairman and collation of the papers
Ensuring agendas and relevant documentation are forwarded to the committee
or person required to attend, no later than five (5) working days before the
meeting
Ensuring the recording of minutes and matters arising plus any topics to be
carried forward
Ensuring that minutes and matters are arising are circulated in a timely manner
(within 2 weeks expected timescale)
Ensuring that the committee action log is presented in an up to date and
completed form
Ensuring conflicts of interest are declared and minuted accordingly
Ensuring that the Committee is able to meet the requirements of local and
national reporting timelines (Approval of Annual Quality Account and other
Annual Returns)
No changes will be made to the agreed agenda unless approved by the Committee
Chair or the Executive Lead.
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8.
Duties
The Committee will seek to obtain sufficient assurance on the five CQC domains – safe,
caring, effective, responsive, well led.
The duties of the Committee include:
8.1
Ensuring that controls being established or in place are operating efficiently and
effectively to deliver the Trust’s principal objectives relating to the quality and safety
of care. To support high standards of safe clinical care and governance.
8.2
Considering any matters relating to quality and clinical governance and management
of clinical risk within the Trust that the Committee determines should be examined or
addressed, and to provide assurance to the Board on the effectiveness of the Trust’s
governance and management of clinical risk. The Committee will, in particular,
receive assurance data/information such as incidents, complaints, claims, and
external assessments or recommendations, with a view to continuous improvement.
8.3
Supporting the Audit & Assurance Committee’s role on scrutinising overall assurance
and the effectiveness of compliance mechanisms within the Trust.
8.4
The Committee is also responsible for:
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Supporting the Board in receiving assurance relating to its duties under the NHS
Constitution
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Oversight of clinical risk in support of the Audit and Assurance Committee role
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Seeking
assurance
of
organisational
learning
from
experiences,
recommendations or reports from external agencies, ensuring follow up where
needed
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Oversight of issues arising from serious incidents, actions plans, and learning
outcomes including awareness, analysis and review of themes and trends
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Seeking assurance of effective staff support and management, including staff
experience and organisational development
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Oversight and review of the effectiveness of the work of supporting committees
and work groups including responding to any significant issues highlighted
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Monitoring the Trust’s compliance with Care Quality Commission regulations
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Oversight of the Board Assurance Framework areas allocated to the Committee
9.
Committees reporting to the Quality & Governance Committee
9.1
The following Committees will be accountable to the Quality & Governance
Committee with Sub-committee reporting as below and in appendix II:
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Safety

Infection Prevention and Control Committee
o Antimicrobial Strategy Group
o Water Safety Group
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Safeguarding Committee
Effective
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Drugs & Therapeutics Committee
o Medicine Management Group
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Clinical Advisory Group
o Hospital Medical Advisory Committee
o Venous Thromboembolism Committee
o Morbidity and Mortality reviews
o Organ Donation Committee
o Hospital Transfusion Committee
o Research and Development
o Resusc and Critical Care Committee
Caring
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Nursing & Midwifery Committee (to include Tissue Viability)
o Nursing Policy and Practice Council
o Nurse Resource Council
Responsive
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Patient Experience and Review Group
o Equality and Diversity Group
Well Led
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Staff Experience & Engagement Group
Education Committee
9.2
The Committee will receive regular assurance reports and minutes from these
accountable committees.
9.3
The Committee will receive minutes of the Risk Management Committee as oversight
of clinical risk
9.4
To assist in its activities, the Committee will receive Divisional Quality Assurance
Reports and supporting evidence of Divisional Governance meetings and/or
alternative agreed arrangements. Through this mechanism the Committee will also
receive the following assurance reports:
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Maternity Services
Children’s Services
Nutrition Steering Group
10.
Reporting
10.1
The approved minutes of the Committee shall be provided to the Board. The Chair of
the Committee shall draw to the attention of the Board any matters of significance or
particular concern.
10.2
The Committee shall receive the minutes of any reporting management groups.
These groups will escalate any issues that require the attention of the Quality &
Governance Committee. The Committee shall approve the terms of reference of its
sub-groups.
10.3
The Committee will report annually to the Board on its work through the quality
account/governance statement.
11.
Attendance
11.1
Executive Directors or their designated deputy will attend all meetings. The standard
for attendance for Directors is at least 80% of all meetings. This will be a standing
item on a yearly basis monitored by the Associate Director of Governance and
Patient Experience.
12.
Monitoring
12.1
The Committee’s Terms of Reference will be reviewed at least annually.
13.
13.1
14.
Element to be monitored
The function of the Quality & Governance Committee
and its Terms of Reference.
Lead
Non Executive Director (Chair)
Director of Nursing (Lead Executive)
Tools
Self Assessment
Frequency
Annual Basis
Reporting Arrangements
The Quality & Governance Committee will provide
regular briefings on its activities to the Trust Board.
Other Matters
The Committee’s Terms of Reference will be reviewed at least annually.
Corporate Statements
Date approved by
Committee / Group:
Date accepted by Weston
Trust Board:
Date due for Review:
Date Reviewed:
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TRUST BOARD
Overview of Assurance Framework & Corporate Risk
Register
Quality & Governance
Committee
Oversight of Clinical Risk
Audit & Assurance
Committee
Assurance – System &
Evidence
(Corporate Risk
Register)
Executive Management
Group - Corporate Risk
Review
Risk Management Committee
Bottom up assessment of risk
Divisional risk registers – reported to Risk
Committee (clinical, non clinical &
operational)
Divisional actions to mitigate risk
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Proposed committee structure
September 2014
Appe ndix 2
Business management
A ssurance
Patients'
Council
IPR/BAF/Board
Reports
Executiv e
Management
Group
Senior
Management
Meeting
Serv ice
Gov ernance
meetings
Serv ice
Gov ernance
meetings
Specialty
Meetings
Specialty
Meetings
Div isional
Gov ernance
Emergency
Div isional
Gov ernance
Planned Care
Senior
Management
Meeting
Key
Board & delegated subcommittees - pink
Established committees - blue
Proposed new committees - green
Div isional
Board
(Emergency )
Div isional
Board
(Planned)
Joint
Negotiating
Committee
Trust Board
Remuneration
& Terms of
Serv ice
Business
Planning &
Deliv ery Group
Policy &
Practice
Group
Nursing
Resource
Group
Quality &
Gov ernance
Committee
Staf f
Experience &
Engagement
Clinical
Adv isory
Group
Nursing &
Midwif ery
Committee
Saf eguarding
Committee
VTE
Committee
Inf ection
Prev ention &
Control
Morbidity &
Mortality
Rev iews
Education
Committee
Junior D rs
Forum
Local
Negotiation
Committee
Medicines
Management
Group
Drugs &
Therapeutics
Committee
Postgraduate
Education
Committee
Undergraduate
Education
Committee
Gillian Hoskins
Associate Dir ector for Gover nance & Patient Exper ience
Weston Area Healthcare Tr ust
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Audit &
Assurance
Committee
Patient
Experience
Rev iew Group
Equality &
Div ersity
Group
HMAC
Organ
Donation
Committee
Hospital
Transf usion
Committee
Research &
Dev elopment
Resus &
Critical Care
Committee
Charitable
Funds
Risk
Management
Committee
Health & Saf ety
& Security
Committee
Health
Inf ormatics
Committee
Radiation
Protection
Committee
Inf ormation
Gov ernance
Committee
Medical R ecords
Adv isory Group
Emergency
Planning &
Preparedness
Counter Fraud
Steering Group
Policy
Gov ernance
Group (v irtual)
Finance
Committee
Capital
Planning
Medical
Equipment
Committee