Solent NHS Trust Assurance Committee - Terms of Reference

Transcription

1 Solent NHS Trust Assurance Committee - Terms of Reference The below Terms of Reference have been developed to ensure they are fit for purpose when authorised as Foundation Trust, subject to ratification at that point. Items indicated by [brackets] therefore indicate where the function/reporting line will be amended. Reference to the Committee shall mean the Assurance Committee. Reference to the Board shall mean the Trust Board [and Board of Directors, once authorised as a Foundation Trust]. 1 Constitution 1.1 Solent NHS Trust Board [Board of Directors] resolves to establish a Committee of the Board to be known as the Assurance Committee (the Committee). The Committee has no executive powers, other than those specifically delegated in these Terms of Reference. These Terms of Reference will be reviewed at least annually by the Trust Board to ensure they are still appropriate. 1.2 Once authorised as a Foundation Trust, the Assurance Committee will be required to adhere to the Constitution of the Trust, the Terms of Authorisation and Code of Governance issued by the Independent Regulator for NHS Foundation Trusts. 1.3 As a Committee of the Board, the Standing Orders of the Trust shall apply to the conduct of the working of the Assurance Committee. 1.4 The Committee will work closely with the Audit & Risk Committee for those aspects of governance associated with assurance and internal control and will report to the Audit & Risk Committee on matters as requested by the Committee. 1.5 Purpose & Level of Accountability The Committee is responsible for seeking assurance and scrutinising all matters relating to quality and regulatory compliance; including seeking assurance of progress against action plans across the organisation including those generated for example, from CQC visits. To enable the Board to obtain assurance that high standards of care are provided by the Trust, and in particular, that adequate and appropriate governance structures, processes and controls are in place throughout the Trust to: promote quality, safety and excellence in patient care; identify, prioritise and manage risk; ensure the effective and efficient use of resources protect the health and safety of Trust employees. Ensure that all statutory requirements are complied with Page 1 of 5

2 2 Membership 2.1 The Committee is appointed by the Trust Board and comprises: Non Executive Director (Chair) Two Non Executive Directors (excluding the Chair of the Audit & Risk Committee) Executive Directors o Chief Executive o Chief Operating Officer o Director of Finance o Director of Human Resources & Organisational Development o Director of Nursing & Quality o Medical Director Chairs of reporting Subcommittees; o Chair of Emergency Planning Committee o Chair of Medicines Management Committee o Chair of Health & Safety Committee o Chair of Infection Prevention & Control Committee o Chair of Quality & Risk Committee o Chair of Dignity & Safeguarding Committee o Clinical Leads Formatted: Font: Bold Formatted 2.2 It is acknowledged that the Chairs of the reporting subcommittees may well be an Executive Team lead and therefore by virtue of their role be a member of the Committee. 2.3 Suitable nominated deputies must be identified where a member is unable to attend a meeting. 3 Attendees 3.1 Attendees to the Committee will be: Company Secretary Chairs of Divisional Clinical Governance Groups for matters concerning assurance within the clinical divisions on a rotational basis, as agreed within the Committee s Agenda Cycle Head of Risk Management Head of Information Governance- for matters concerning IG assurance. Head of Quality Clinical Leads Other persons as required and invited by the Chair 4 Secretary 4.1 The Executive Committee Secretary or their nominee shall act as the secretary of the committee. 4.2 The administration of the meeting shall be supported by the Executive Committee Secretary who will arrange to take minutes of the meeting and provide appropriate support to the Chairman and committee members. 4.3 The agenda and any working papers shall be circulated to members five working days before the date of the meeting. Page 2 of 5

3 5 Quorum 5.1 To ensure appropriate balance, no business shall be transacted at the meeting unless the following are present; The Chair or a nominated deputy a minimum of one other Non-Executive Director a minimum of two Executive Directors being either Chief Executive, Medical Director, Chief Operating Officer, Director of Nursing & Quality or Director Human Resources & OD. 6 Frequency 6.1 Meetings will be held on a bi-monthly basis. 6.2 Additional meetings can be called by the Chair of the Committee if it is deemed necessary. 7 Notice of meetings 7.1 Meetings of the committee shall be summoned by the secretary of the committee at the request of the Chairman. 7.2 Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the committee, any other person required to attend and all other non-executive directors, no later than 5 working days before the date of the meeting. Supporting papers shall be sent to committee members and to other attendees as appropriate, at the same time. 8 Minutes of meetings 8.1 Minutes of the meeting will be shared with the members following agreement by the Chair. 9 Duties 9.1 Objectives: To be assured that processes are in place to assess and monitor performance concerning all aspects of quality To be assured that effective processes are in place to achieve all areas of regulatory compliance including CQC and NHSLA requirements (and those of Monitor once authorised as a Foundation Trust). To seek assurance that the development of all clinical governance activities within the Clinical Divisions improve the quality of care throughout the Trust as well as assuring the Trust Board of the organisation s compliance with national and local statutory requirements with regard to clinical care. 9.2 The Committee will seek assurance on all aspects of Quality (including patient safety & experience, infection control, health and safety, safeguarding, risk management, research & development, clinical effectiveness and audit) as well as Regulatory Compliance. 9.3 The Committee will seek assurance and scrutinise exception reporting from its reporting subcommittees, being: Emergency Planning Committee Page 3 of 5

4 Medicines Management Committee Health & Safety Committee Infection Prevention & Control Committee Quality & Risk Subcommittee (including exception reporting on SIRIs and Complaints) Dignity & Safeguarding Subcommittee The IM&T and Information Governance Subcommittee will be required to provide assurance reports on IG matters. The Chairs of the above listed subcommittees will submit minutes to the Committee and will identify any exceptions or causes for concern regarding lack of assurance or risks. The Chairs of the subcommittees will provide exception reports to the Committee outside of their usual reporting cycles. 9.4 The Committee will also seek assurance from the Divisional Clinical Governance Groups on all aspects of clinical governance including; health and safety, medicines management, emergency planning, Infection control, risk, information governance, quality (which will also include, for example, complaints and falls) and safeguarding. Each Divisional Clinical Governance Group will be required to attend and provide assurance at the Committee on a rotational basis. 9.5 The Committee will scrutinise the Corporate Risk Register and seek assurance that action plans are being addressed to mitigate identified risks and gaps. 9.6 The Committee is responsible for approving policies and procedures on behalf of the Trust Board, following agreement at the NHSLA & Operational Policy Steering Group. 9.7 The Committee will approve Terms of Reference for its reporting subcommittees. 9.8 The Committee will also seek assurance from other functions concerning Trust business where there are regulatory compliance issues and will require the relevant management lead to provide regular assurance reports. 9.9 The Committee will scrutinise and approve each subcommittee s Annual Report detailing how assurance is provided according to its terms of reference and individual objectives. The Committee will then onwardly assure the Board appropriately within its Annual Report To approve the Trusts Annual Quality Accounts before submission to the Board. To also: Agree the annual safety plan and seek assurance that actions are being managed Agree the annual patient experience plan and seek assurance of its implementation Review the Quality Statements 9.11 To receive and approve the various annual programmes from each of the Page 4 of 5

5 reporting subcommittees listed in section 9.3, including: annual Clinical Audit Programme, and making recommendations to the Audit &Risk Committee concerning the internal audit work programme, To review the Trusts Risk Management Strategy prior to presentation to the Board for approval. To also: o Seek assurance that the Trusts Risk Management Policy is being adhered to o Seek assurance that effective emergency planning and o disaster recovery plans are being managed and tested Seek assurance that appropriate action is taken in response to SIRIs, complaints and litigation and that examples of good practice are disseminated within the Trust To receive the Trusts Health & Safety Annual Report prior to presentation to the Board for approval and seek assurance that appropriate action is being taken regarding the management of the Health & Safety agenda. 10 Authority 10.1 The committee has no powers, other than those specifically delegated in these Terms of Reference The committee is authorised: to seek any information it requires from any employee of the Trust in order to perform its duties to call any employee to be questioned at a meeting of the committee as and when required To hold Executive Directors through their service, managers, senior managers and clinicians, accountable for the quality and regulatory compliance of services. 11 Reporting 11.1 The Committee Chairman will submit the minutes to the Trust Board and will highlight any issues the Board should be informed of or areas where assurance is insufficient/of concern The Committee will present an Annual Report to the Trust Board against its duties as outlined in the Terms of Reference The committee shall make whatever recommendations to the Trust Board it deems appropriate on any area within its remit where action or improvement is needed. Version 1.0 Agreed at IGAP (Assurance Committee): Date: 30 TH November 2011 Agreed at Trust Board Date: January 2012 Date of Next Review Date: Before Jan 2013 Page 5 of 5