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Clinical governance - quality and safety

Clinical governance is an initiative to ensure that NHS organisations have in place a framework to support continuous improvement in the quality of care. This includes having policies and procedures to safeguard patient care and, importantly, promoting an organisational culture that encourages patients, visitors and staff to report any concerns they may have or make suggestions for improvement. NHS organisations are expected to demonstrate that concerns, comments or suggestions are investigated and that remedial action is put into place where needed.

The quality of our services and the safety of our patients are given the highest priority at Papworth Hospital NHS Foundation Trust. The Care Quality Commission (CQC) acts as the regulator of health and adult social care in England and requires each NHS Trust to annual register their compliance with essential standards of safety and quality, which respect the dignity and protect the rights of our patients and service users. This regulation and registration system is focused on outcomes and places the views and experiences of people who use the services at its centre, ensuring that Papworth Hospital can demonstrate ongoing improvements in the quality and safety of the services we provide.

Measuring what matters

The standards are set and monitored by the Care Quality Commission (formerly the Healthcare Commission) and Papworth Hospitals NHS Foundation Trust has met the requirements of all of the essential standards to achieve compliance and Registration with the CQC for 2011/12. Within the essential standards there are 28 outcomes, each reflecting a specific part of the Health and Social Care Act (Regulated Activities) Regulations 2009 and the Care Quality Commission (Registration) Regulations 2009 and the 28 outcomes are grouped into six key areas:

  1. Involvement and information
  2. Personalised care, treatment and support
  3. Safeguarding and safety
  4. Suitability of staffing
  5. Quality and management
  6. Suitability of management

The Trust is committed to working with its local stakeholders and, as part of the annual assessment and registration process, local stakeholders will have the opportunity to comment on the Trust’s achievement against the essential standards including:

The Overview and Scrutiny Committee(s)

  • Patient and Public Involvement and Membership Forum
  • Strategic Health Authority
  • Board of Governors

Further information on the requirements for compliance with the Health and Social Care Act (Regulated Activities) Regulations 2009 and the Care Quality Commission (Registration) Regulations 2009 can be found on the Care Quality Commission website: www.cqc.org.uk

Papworth Hospital monitors its achievements and progress on improving quality and safety through a mechanism of quarterly and annual reporting:

Quarterly Quality and Risk Reports


Q1 - April - June 2019/20


Q4 - January - March 2018/19 (Including annual summary 2018/19)
Q3 - October - December 2018/19
Q2 - July - September 2018/19
Q1 - April - June 2018/19


Q4 - January - March 2017/18 (including annual summary 2017/18)
Q3 - October - December 2017/18
Q2 - July - September 2017/18
Q1 - April - June 2017/18