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Quality Governance

What is Quality Governance?

Quality Governance provides a framework for organisations and individuals to ensure the delivery of safe, effective and high quality healthcare.  Its purpose is to help organisations, like hospitals, and their staff, monitor and improve standards of care.

The Trust is regulated by the Care Quality Commission (CQC) and we work closely with them to ensure our services provide people with safe, effective, compassionate and high-quality care, underpinned by continuous quality improvement.  The key lines of enquiry undertaken by the CQC and monitored by the Trust as part of its compliance reviews are:-

  • Safe – patients protected from abuse and avoidable harm
  • Effective – care and treatment achieves good outcomes and promotes good quality of life and is evidence based, where possible
  • Caring – patients involved and treated with compassion, kindness, dignity and respect
  • Responsive – services organised to meet patients’ needs
  • Well-led – leadership, management and governance assure the delivery of high-quality patient-centred care, supports learning and innovation and promotes an open and fair culture

The CQC monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and the CQC publish what they find, including performance ratings to help people choose care.  Since 1 April 2015, the Fundamental Standards define the basic standards of safety and quality that should always be met, and introduce criminal penalties for failing to meet some of them.  For the Trust's latest inspection reports see the Care Quality Commission (CQC) page.

Within the Trust, there are several corporate functions which report directly into the Governance and Assurance Team overseeing quality governance:- Patient Relations; Patient Safety; Health and Safety; Patient Clinical Audit and Effectiveness (including NICE); Policy Approval and Ratification; Quality Improvement;  Legal Services.

Collectively these teams work together to ensure our patients receive safe, effective and caring treatment under the umbrella of a Quality Strategy. 

Throughout 2012 and 2013 a series of reports were published following findings of reviews undertaken in response to serious lapses in care resulting in significant harm to patients and reputational damage to individual hospitals and NHS Trusts (Francis, Berwick and Keogh).  The reports raised significant concerns relating to the voice of the patient and carers, organisational cultures, patient safety and care and compassion and highlighted the requirement for fundamental change in the oversight, scrutiny and accountability across providers and regulators of care.

In response to these reports, the Trust has undertaken annual reviews of the recommendations and has sought over time to implement changes to address gaps in assurance arising from the self- assessments undertaken.  The reviews are scrutinised by both our Quality and Safety Committee and Trust Board.

For more information on the CQC go to

For more information on NICE go to

For more information on the Health and Safety Executive go to