Policy Template. Policy Type: Trust Wide Directorate Specific. Clinical. Policy

Transcription

1 Policy Template This is an official Northern Trust policy and should not be edited in any way Please note that the policy library on Staffnet will contain the most up to date version of Trust policies Reference No: To be completed by the Policy Unit Title: Assurance Framework Policy Author(s): Suzanne Pullins Responsible Medical Director Director: Policy Type: Trust Wide Directorate Specific Clinical Policy Yes No If yes state name and reference number of Replacement: Directorates policy to be issued to: Target Audience, ie, specific staff groups Approved by: policy being replaced NHSCT/14/751 Finance Medical & Governance Children s Mental Health & Disability Human Resources Acute Hospital Services Primary & Comm Care Nursing & User Exp Planning, Performance Management & Support Services This policy applies to all employees of the Trust, including permanent, temporary, bank staff and staff in training working within the Trust. It also applies to students, agency staff, contractors and volunteers. Insert name of Trust Committee or Scanned Signature/Typed name of AD/Dir/Clinical Dir/Assoc Med Dir Operational Date: To be completed by Policy Unit Review Date: Policy Library Categories: (Please tick as appropriate) Insert Date: Clinical & Social Care Hospital (incl Comm Hosp) Children s Hospital & Community Mental Health, Learning & Physical Disability Community Finance Estates Health & Safety Human Resources Palliative Care Major Incident Plan Infection Control Information Management Family Planning Allied Health Professions Maternity & Gynae Trust Wide NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves Page 1 of 20

2 Assurance Framework (Interim) Page 2 of 20

3 Contents Section Content Page 1.0 Summary Responsibilities Policy Statement Monitoring Evidence Base / References Personal and Public Involvement Equality Human Rights and DDA Alternative Formats Sources of Advice in relation to this document Policy Sign Off 19 Committee Structure Appendix 1 Page 3 of 20

4 1.0 Summary of Policy Introduction People need to be confident about the care that they get from organisations commissioning or providing health and social care. They want services that are accessible and are provided by competent and confident staff who will always work in their best interests. 1 The Board of Directors of the Northern Health and Social Care Trust (the Board) has a duty to provide high quality care, which is safe for patients, clients, young people, visitors and staff and which is underpinned by the public service values of accountability, probity and openness. The Board is responsible for ensuring that it has effective systems in place for governance, essential for the achievements of its organisational objectives and in line with the objectives set by Ministers. The Assurance Framework provides the structure by which the Board s responsibilities are fulfilled. The Assurance Framework is an integral part of the governance arrangements for the Northern HSC Trust and complements the Management Statement and Financial Memorandum issued by the DHSSPS. The Management Statement defines the relationship between the Minister, the Department and the Trust. It lays down the responsibilities of each party, including the Chair and Chief Executive. The Framework should be read in conjunction with the Corporate Plan. The Assurance Framework including the Principal Risk Document describe the organisational objectives, identify potential risks to their achievement, the key controls through which these risks will be managed and the sources of assurance about the effectiveness of these controls. This Framework should provide the Board with confidence that the systems, policies and people are operating effectively, are subject to appropriate scrutiny and that the Board is able to demonstrate that they have been informed about key risks affecting the organisation. The Directors of the Northern HSC Trust have: Defined corporate objectives 2 ; Identified principal risks that may threaten the achievement of these objectives; Controls in place to manage these risks, underpinned by core Controls Assurance Standards 1 DHSSPS An Assurance Framework: a Practical Guide for Boards of DHSSPS Arm s Length Bodies. March Section 1.1 page 6. 2 NHSCT, Corporate Plan 2013/ /2016. Page 4 of 20

5 Explicit arrangements for obtaining assurance on the effectiveness of existing controls across all areas. On an ongoing basis the Board will: Assess the assurances given; Identify where there are gaps in controls and/or assurances; Take corrective action where gaps have been identified and; Maintain dynamic risk management arrangements including, crucially, a regularly reviewed Principal Risk Document. 2.0 Responsibilities All employees of the Trust, including permanent, temporary, bank staff and staff in training working within the Trust, students, agency staff, contractors and volunteers should be familiar with the roles and responsibilities set out in the Policy statement. 3.0 Policy Statement Strategic Context Each year the Government sets out in its Programme for Government (PfG) and supporting budget and investment strategy, its intentions for improving public services. The PfG contains a series of Public Service Agreements committing departments to work towards particular aims and outcomes for the benefit of service users. 3 In order to produce the outcomes for which the Department of Health, Social Services and Public Safety (the Department) is ultimately responsible a strong partnership is required between the Department and those Health and Social Care organisations which commission and deliver the services that lead to those outcomes. The objectives of both partners are therefore inextricably linked. Corporate Objective Setting The Trust s Corporate Plan sets out the vision, values and principal objectives that will shape the strategic direction and priorities for the Trust. A review of these is currently being undertaken. The Trust has 5 principal corporate objectives to give a structured, consistent and concentrated focus. These are: To provide safe and effective care; 3 DHSSPS. Op. cit. Section 3.1. Page 13 Page 5 of 20

6 To create a culture of continuous improvement that supports the delivery of health and social care that exceeds recognised quality standards and meets performance targets; To use all resources wisely; To have a professional management culture with effective leadership, development of staff and teams that deliver; To involve and engage service users, carers, communities and other stakeholders to improve, shape and develop services. The Corporate Plan and the Trust Delivery Plan (TDP) set out annual targets to progressively deliver these corporate objectives. The TDP is developed annually as a response to the Department s performance indicators and the commissioning plans of the Health and Social Care Board. The Corporate Plan incorporates the Departmental / Commissioner targets and also takes a wider internal view of the organisational responsibilities of the Trust, setting a range of local targets under each corporate objective. The organisational objectives are cascaded to directorate and unit/team level, where more detailed targets and actions are set in order to support or help meet the Trust s overall aims and objectives. Individual staff members are then required to use the unit/team level information to form their personal objectives, linking their jobs to the objectives of the Trust and to Departmental objectives. This process forms an integral part of the Trust s accountability and assurance frameworks. Accountability From the wider accountability perspective, there are four broad domains of accountability which effect the Trust 4 : Corporate Control, Safety and Quality, Finance and Operational Performance and Service Improvement. Corporate control covers the arrangements by which the Trust directs and controls its functions and relates to stakeholders. This domain encompasses the policies, procedures, practices and internal structures which are meant to give assurance that the Trust is fulfilling its essential obligations generally as a public body. Some of these obligation only relate to health and social care; notably the statutory duty of quality created by Article 34 of the HPSS (Quality, Improvement and Regulation) (NI) Order 2003, and the statutory 4 DHSSPS Ibid. Section 3. Pages Page 6 of 20

7 duty to seek views from, and consult with, the recipients of health and social care created by sections 19 and 20 of the HSC (Reform) Act (NI) The second domain, safety and quality concerns the arrangements for ensuring that health and social care services, and public safety services, are safe and effective and meet people s needs. This covers a broad field and applies to all programmes of care (including health improvement and health protection) and to infrastructure. In addition to the numerous operational/professional requirements that concern or touch on safety and quality, there are more general requirements with which compliance is demanded. In the latter category, those issued by the Department include the Quality Standards 5 and most of the Controls Assurance Standards, but the most notable is the statutory duty of quality (as above). Finance covers the arrangements for ensuring financial stability, for securing value for money and for ensuring that the resources allocated to the Trust are deployed fully in the achievement of agreed outcomes. The fourth domain, operational performance and service improvement concerns fulfilling Departmental requirements for ensuring achievement of PfG and Ministerial objectives, standards and targets. Accountability to the Minister and the Department The Health and Wellbeing Investment Plans (HWIP) and the TDP are the main vehicles for conveying where, and by what means, performance indicators, efficiency savings and service improvements will be delivered. The processes to monitor delivery of these form an integral part of the Department s monitoring and accountability arrangements. The Northern HSC Trust is ultimately accountable to the Minister for Health for the delivery of health and social services to the people of Northern Ireland and for good integrated governance arrangements. The formal accountability arrangements include reporting against the achievement of service priorities, safety and quality indicators and on financial performance. Accountability with the Health and Social Care Board The Health and Social Care Board (HSCB) and the HSC Trusts are accountable to the public for the services that they commission and provide. 6 The HSCB was established in April 2009 by the Health and Social, Care 5 DHSSPS The Quality Standards for Health and Social care: supporting good governance and best practice in the HPSS. March The basis for HSC accountability is the HPSS (Northern Ireland) Order 1972 and subsequent amending legislation. Page 7 of 20

8 (Reform) Act (NI) 2009 and includes five Local Commissioning Groups (LCGs) coterminous with the Trusts, the Public Health Agency (PHA), a Business Service Organisation (BSO) and a Patient and Client Council. From the wider accountability perspective, there are two broad categories of HPSS activity; Category One: those services identified as being needed and commissioned by the HSCB from Trusts. The volume and quality of which are detailed in Service and Budget Agreements (SBAs) between the HSCB and the providers. This category includes statutory obligations of Trusts including delegated statutory functions. Category Two: this covers those duties performed by the Trust by virtue of being a public body and includes financial control, control of capital assets and corporate governance. Discharge of statutory function Executive Director of Social Work The Trust is responsible in law for the discharge of statutory functions and is accountable to the HSC Board for the discharge of those statutory functions delegated by the HSCB (relevant functions) and those conferred directly on the Trust by primary legislation. The Trust is obliged to establish robust organisational arrangement to discharge such functions effectively. The majority of these functions relate to the services provided by the Trust s social work and social care workforce. The Scheme for the Delegation of Statutory Functions (the Scheme) sets out for each service area the statutory duties delegated by the HSCB to the Trust and the accountability arrangements pertaining to these functions. The Scheme specifies the internal control and assurance processes informing the Trust s discharge of its statutory function. The Assurance Framework The Assurance Framework provides a clear and concise structure for reporting key information to the Board and is essentially, although not exclusively a Board-level instrument. The objectives that are contained in the Corporate Management Plan form the spine of the Framework. 7. It identifies which of the organization s objectives are at risk because of inadequacies in the operation of controls or where the organization has insufficient assurance 7 DHSSPS Ibid. Section 3.7. Page 8 of 20

9 about them. At the same time, it provides structured assurances about where risks are being effectively managed and which objectives are being delivered. The Framework allows the Board to make decisions on the efficient use of valuable resources and to address the issues identified in order to improve the quality and safety of services. The Trust Board can only properly fulfil its responsibilities when it has a full grasp of the principal risks facing the organisation. Based on the knowledge of risks identified, the Directors will determine the level of assurance that should be available to them with regard to those risks. There are many individuals, functions and processes, within and outside an organisation, that produce assurances. These range from statutory duties (such as those under health and safety legislation) to regulatory inspections that may or not be HSC-specific, to voluntary accreditation schemes and to management and other employee assurances. Taking stock of all such activities and their relationship (if any) to key risks is a substantial but necessary task. The Board is committed to the effective and efficient deployment of all the Trust s resources. This will require some consideration of the principle of reasonable rather than absolute assurance. In determining reasonable assurance it is necessary to balance both the likelihood of any given risk materialising and the severity of the consequences should it do so, against the cost of eliminating, reducing or minimising it (within available resources). 8 A key element in building the Assurance Framework is for the Trust Board to determine what level of independent assurance reporting is appropriate, given the risks and controls that have been identified. The most objective assurances are those derived from independent reviewers and this includes the use of Internal and External Audit, the Regulation and Quality Improvement Authority, Departmental/Ministerial inquiries or reviews. This is supplemented from non-independent sources such as multi-disciplinary audit and professional monitoring and review processes within legislative and professional regulatory guidance. The role of the Court in the regulation and the holding of the Trust to account with regard to the discharge of statutory functions is of key importance. 8 Section Page 12. Page 9 of 20

10 Risk Management The Northern HSC Trust has a Risk Management Strategy that describes the Trust s arrangements for risk identification, analysis, control and review. The Strategy is underpinned by the Trust s policy on risk and explains its approach to the acceptability of risk and its risk appetite. The management of risk is a key organisational responsibility. All staff must accept that the management of risk is one of their most important responsibilities. The Trust recognises that risk reduction and management can be enhanced by the effective involvement of stakeholders at an early stage of planning or making decisions about care, treatment or service development. The Trust is committed to promoting and maintaining an open and learning environment in which the emphasis is placed on learning lessons. The Trust has processes in place for the management and learning from adverse incidents, complaints, litigation and external reviews/inspections. Controls Assurance will remain a key process for the Trust and key Directors have been identified to be accountable for action planning against each standard. Organisational arrangements The Trust s Assurance Framework Committee Structure is set out in Appendix 1. Roles and responsibilities in respect of governance and assurance are detailed below. An important element of the Trust s Assurance Framework is the need for robust arrangements within Directorates. This is tested internally through the Trust s accountability review process. The Board of Directors is responsible for: Establishing the organisation s strategic direction and aims in conjunction with the Executive Team; Ensuring accountability to the public for the organisation s performance; Assuring that the organisation is managed with probity and integrity. Page 10 of 20

11 The Audit Committee The Audit Committee is the Trust s statutory committee which deals with all aspects of financial governance. The Audit Committee is a non- executive committee of Trust Board. Its role is to assist the Board in ensuring that an effective control system is in place. The Director of Finance and representatives from Internal and External Audit will normally attend the meetings. The Chief Executive is invited to attend audit Committee at least annually to discuss the process for assurance that supports the annual Governance Statement. In addition, other Directors are required to attend when the Audit Committee is discussing areas of risk that fall within their area of responsibility or accountability. The Assurance Committee The Assurance Committee is a newly constituted standing committee of the Board of Directors. The purpose of the Assurance Committee is to have an oversight of all aspects of integrated governance, excluding financial governance, and to ensure a robust assurance framework is maintained. The focus of this Committee will be the oversight of Integrated Governance and Assurance. The Committee is responsible for ensuring that effective and regularly reviewed structures are in place to support the implementation and development of integrated governance. A focus will be the Assurance Framework /Principal Risks to the organisation s objectives. The Executive Team The Executive Team is responsible for ensuring that the sequence of performance report, audits and independent reports, required by the Board of Directors as part of the assurance Framework is available. The Executive Team will prepare and regularly update the Principal Risk Document, which will inform the management planning, service development and accountability review process. The Assurance Group The Assurance Group is a sub-committee of the Executive Team. The undertaking of the Assurance Group is to ensure that the Assurance Committee has the information required to effectively scrutinise the Trust s undertakings and to ensure the Trust s effectiveness of the integrated governance structures within the Trust. The Assurance Group will ensure the effective functioning of the Assurance Framework s subcommittee structure. Page 11 of 20

12 Assurance Steering Groups (Appendix 1) The Assurance Steering Groups report through the Assurance Group to the Executive Team. The Steering Groups, which are chaired by Executive Directors cover the following areas: Social Care Governance Clinical Governance - Quality and Safety Corporate Governance Learning for Improvement. The Steering Groups are responsible, on behalf of the Executive Team for overseeing the assurance arrangements and work of the sub committees and expert groups of the Assurance Framework (see Appendix1). Accountabilities and Responsibilities for Governance and Assurance Arrangements The following section outlines the roles and responsibilities of the Trust Board, Non-Executive Directors, Chief Executive, Directors and Senior Managers in respect of integrated governance. Good governance requires all concerned, to be clear about their roles and responsibilities. Governance means promoting organisational values at all levels, taking informed and transparent decisions, and managing risk. Role of Trust Board The role of the Board is defined as having collective responsibility for adding value to and promoting the success of the organisation, for providing leadership to the organisation within a framework of prudent and effective controls, for setting strategic direction, ensuring management capacity and capability and monitoring and managing performance, and for safeguarding values and ensuring the organisation s obligations to its key stakeholders are met. The membership of the Board of the Trust is defined in the Establishment order to include the Directors of Social Work, Medicine, Nursing and Finance. The Board s responsibilities and functions are set out in detail within the Board s Standing Financial Orders. These are published on the Trust Board section of the Trust s website. Page 12 of 20

13 In fulfilling the responsibilities set out in Standing Orders the Board will: Implement the Assurance Framework as outlined in this document. Ensure systems of internal and independent assurance on which it relies will allow it to submit the annual Governance Statement with confidence. Identify the type and frequency of key information it requires from its members, sub-committees and senior management. Role of the Trust Chairman The Trust Chairman is directly accountable to the Minister and to the public. He has a key leadership role in the Assurance Framework. He will work closely with the Chief Executive and other Directors to ensure the effectiveness of the Framework. His role includes; leading the Board, ensuring effectiveness on all aspects of its role and setting its agenda, developing with the Board an annual cycle of business and ensuring effective communication with staff, patients, and the public and key stakeholders. He is also required to arrange the regular evaluation of the performance of the Board, its sub-committees and individual Non-Executive directors and for facilitating the effective contribution of non-executive directors and promoting constructive relationships between executive and non-executive directors. The role of the Non-Executive Directors Non-Executive Directors will assure themselves and the Trust Board that the Audit Committee, the Assurance Committee and related Committees are addressing key governance issues within the Trust. Their responsibilities include strategy by constructively challenging and contributing to the development of strategy; for performance through the scrutiny of the performance of management in meeting agreed goals and objectives and monitoring of the reporting of performance; for risk by satisfying themselves that financial and other information is accurate and that financial controls and systems of risk management are robust and defensible; for people, by determining appropriate levels of remuneration of executive directors and having a prime role in appointing, and where necessary removing, senior management and in succession planning. Non-Executive Directors are appointed through the Public Appointments Office on behalf of the local community. They, therefore, have a responsibility for ensuring the Board acts in the best interests of the public and is fully accountable to the public for the services provided by the Trust and for the public funds it uses. Page 13 of 20

14 The role of the Chief Executive The Chief Executive through his leadership creates the vision for the Board and the Trust to modernise and improve services. He is responsible for the Statutory Duty of Quality. He is responsible for ensuring that the Board is empowered to govern the Trust and that the objectives it sets are accomplished through effective and properly controlled executive action. His responsibilities include leadership, delivery, performance management, governance and accountability to the Board to meet their objectives and to the Department as Accountable Officer. As Accountable Officer, the Chief Executive has responsibility for ensuring that the Trust meets all of its statutory and legal requirements and adheres to guidance issued by the Department in respect of governance. This responsibility encompasses the elements of financial control, organisation control, clinical and social care governance, health and safety and risk management. The role of the Executive Team The Executive Team is accountable to the Chief Executive for key functions and for ensuring effectiveness governance arrangements are in place in their individual areas of responsibility. Collectively the Executive Team is responsible for providing the systems, processes and evidence of governance. The Executive Team is responsible for ensuring that the Board as a whole, is kept appraised of progress, changes and any other issues affecting the performance and assurance framework. The role of the Deputy Chief Executive The role of the Deputy Chief Executive will be confirmed when managerial restructuring is complete. The role of the Director of Finance The Director of Finance is accountable to the Chief Executive for the strategic development and operational management of the Trust s financial control systems. He with the Chief Executive is responsible for ensuring that the statutory accounts of the Trust are prepared in accordance with the DHSS&PS requirements. Page 14 of 20

15 The Director of Finance ensures that, on behalf of the Chief Executive, the Trust has in place systems and structures to meet its statutory and legal responsibilities relating to financial information, management and control. He ensures the Trust has in place Standing Orders and Standing Financial Instructions, including a Reservation of Powers and Scheme of Delegation. As part of the Trust s performance framework the Director of Finance and the Director of Planning, Performance Management and Support Services participate with the Chief Executive in the accountability review process with each Director, the review covers financial objectives, targets and governance matters. The outcome of the review/monitoring process will contribute to the Board s Assurance Framework. The role of the Medical Director - Executive Director responsible for integrated governance including Clinical Governance and the Trust s Safety and Quality arrangements. The Medical Director is accountable to the Chief Executive for the strategic development of the integrated governance arrangements, including risk management but excluding finance. This responsibility is shared with the Director of Nursing and the Director of Social Work. The Medical Director is designated as the Trust s Personal Data Guardian. The Medical Director ensures, on behalf of the Chief Executive, that the Trust has in place the systems and structures to meet its statutory and legal responsibilities relating to his area of responsibility and for ensuring that these systems are based on good practice and guidance from the DHSSPS and other external advisory bodies. The Medical Director will also act as Line Manager for the Head of Governance and Patient Safety. The Medical Director is accountable to the Chief Executive for professional medical governance within the Trust. The Trust is a designated body in respect of medical revalidation and as the Responsible Officer the Medical Director must ensure himself that systems and processes are in place to effectively deliver revalidation. The Medical Director ensures that the Trust Board receives the relevant information/annual reports required in the Board s information schedule. He will ensure that the Chief Executive and the Trust Board are kept appraised of progress and any changes in requirements, drawing to their attention gaps which may impact adversely on the Board s ability to fulfil its governance responsibilities. Page 15 of 20

16 The Executive Director of Nursing and User Experience The Executive Director of Nursing and User Experience is accountable to the Chief Executive for professional nursing governance within the Trust. She is responsible for providing strategic direction for the nursing profession and for the quality and standards of Nursing and Midwifery practice. She is accountable to the Chief Executive for ensuring that regulatory requirements are met for the Nursing Workforce. The Executive Director of Nursing is accountable to the Chief Executive for ensuring that regulatory requirements are met for the AHP/HPF Workforce. She is responsible for ensuring that the training and development needs of nursing staff and students are identified and met. She is accountable to the Chief Executive for ensuring acceptable levels of patient/care experience. The Executive Director of Nursing is the Trust s Director with responsibility for Infection Prevention and Control. The Director of Social Work Executive Director for governance in social services. The Executive Director of Social Work is accountable to the Chief Executive for ensuring that regulatory requirements are met for the Social Care Workforce. She is responsible for ensuring the effective discharge of statutory functions across all service sectors and for the establishment of organizational arrangements and structures to facilitate same. She is required to report directly to the Trust Board on the discharge of these functions, including the presentation of annual Statutory Function Report and six-monthly corporate Parenting Reports. The Executive Director Social Work is responsible for ensuring adequate arrangements for discharging the Trust s responsibility for meeting the standards associated with safeguarding the interests of children, vulnerable adults and mental health clients. The Executive Director of Social work provides professional leadership to and is responsible for the maintenance of professional standards and all regulatory issues pertaining to the Trust s social work and social care workforce. Page 16 of 20

17 Director of Planning, Performance Management and Support Services The Director of Planning, Performance Management and Support Services is responsible to the Chief Executive for leading the development of the Trust s Corporate Plan and ensuring that risks to the delivery of the Trust s objectives are identified, assessed and managed in line with the Risk Management Strategy. The Director of Planning, Performance Management and Support Services ensures that an effective planning and performance management framework is developed and implemented. Director of Human Resources The Director of Human Resources is responsible for the collation of information raised under the Whistleblowing policy and reporting of this information to the Audit Committee. Service Directors The Service Directors are: Director Primary and Community Care for Older People s Services Director of Acute Hospital Services Director of Mental Health and Disability Services Service Directors are responsible for ensuring that, within their area of responsibility, staff are aware of and comply with the processes for assuring sound governance. Directors Each Directorate will establish a Directorate Assurance Committee and develop systems and structures to support the Assurance Framework and integrated governance strategies, policies and procedures and ensure these are audited and monitored. Quality, safety and service improvement are the expected outcome to achieve improved performance overall. As part of the Trust s Performance Framework, the Chief Executive supported by the Director of Finance and, Director of Planning, Performance Management and Support Services will agree with Directors, the objectives Page 17 of 20

18 and targets for their service. Directors will cascade these through the service in line with the Trust s planning process, to inform objective setting for individuals and their subsequent appraisal and performance review. The Directorates are supported and facilitated to meet their governance requirements by their dedicated governance leads and the staff of the Governance and Patient Safety Department. Board Reporting It is essential that key information is reported to the Trust Board to provide structured assurances about where risks areas being effectively managed and objectives are being delivered. This will allow the Board to decide on an efficient use of their resources and address the issues identified to improve the quality and safety of services provided. 4.0 Monitoring To ensure the quality and robustness of the Assurance Framework it will be evaluated and reviewed by the Board annually to ensure it is fit for purpose. Any review should take consideration of the Internal Auditor s opinion statement and the outcome of other independent review to improve the robustness of the Framework. 5.0 Evidence Base/References An Assurance Framework a Practical Guide for Boards of DHSSPS Arm s Length Bodies (2009) DHSSPS The Quality Standards for Health and Social care: supporting good governance and best practice in the HPSS. March Personal & Public Involvement (PPI)/Consultation Proces All relevant Trust staff were consulted with on the development of this Framework. 7.0 Equality, Human Rights & DDA This policy has been drawn up and reviewed in the light of Section 75 of the Northern Ireland Act (1998) which requires the Trust to have due regard to the need to promote equality of opportunity. It has been screened to identify any adverse impact on the 9 equality categories and no significant differential impacts were identified, therefore, an Equality Impact Assessment is not required. Page 18 of 20

19 8.0 Alternative Formats This document can be made available on request on disc, larger font, Braille, audiocassette and in other minority languages to meet the needs of those who are not fluent in English. 9.0 Sources of advice in relation to this document Mrs Suzanne Pullins, Head of Governance and Patient Safety 10.0 Policy Sign Off (Typed name/scanned signature sufficient) Lead Policy Author Date *Dir/AD/Clinical Dir/Assoc Med Dir Date (*Delete those not applicable) 11.0 Appendices/Attachments Page 19 of 20

20 Appendix 1 Assurance Framework Committee Structure Trust Board Remuneration Committee Audit Committee Assurance Committee Charitable Funds Committee Executive Team Assurance Group Clinical Governance Steering Group Corporate Governance Steering Group Learning for Improvement Steering Group Social Care Steering Group Sub Committees to include: Patient Safety IPC Environmental Hygiene Policy Standards & Guidelines Research & Development Outcomes Review Group (inc Mortality & Morbidity) Medicines Governance Northern Prescribing Forum Nutrition Resuscitation Organ Donation Blood Transfusion Health & Safety Sub Committees to include: Security Advisory Equality Controls Assurance Emergency Planning Health Records Information Governance Medical Devices (inc Decontamination &POCTC) Radiation Protection Sub Committees to include: User Feedback (Complaints &Compliments) SAI Review Claims Reviews Learning & Development PPI Sub Committees to include: Statutory Functions Local Adult Safeguarding Partnership Safeguarding Directorate Governance and Accountability Structures Page 20 of 20