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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

2017/18

Q1 - April - June 2017/18 

2016/17

Q4 - January - March 2016/1 (including annual summary 2016/17)
Q3 - October - December 2016/17 
Q2 - July - September 2016/17 
Q1 - April - June 2016/17 

2015/16

Q4 - January - March 2015/16 (including annual summary 2015-2016) 
Q3 - October - December 2015/16 
Q2 - July - September 2015/16 
Q1 - April - June 2015/16 

Quarterly Quality and Safety Reports

2014/15

Q4 - January - March 2014/15 (including annual summary 2014-2015) 
Q3 - October - December 2014/15 
Q2 - July - September 2014/15 
Q1 - April - June 2014/15 

2013/14

Q4 - January - March 2013/14 (including annual summary 2013-2014) 
Q3 - October - December 2013/14 
Q2 - July - September 2013/14 
Q1 - April - June 2013/14 

2012/13

Q4 - January - March 2012/13 (including annual summary 2012-2013) 
Q3 - October - December 2012 
Q2 - July - September 2012 
Q1 - April - June 2012 

2011/12

Q4 - January - March 2011/12 (including annual summary 2011-2012) 
Q3 - October - December 2011 
Q2 - July - September 2011 
Q1 - April - June 2011 

2010/11

Q4 - January - March 2010/11 (including the annual summary 2010-2011) 
Q3 - October - December 2010/11 
Q2 - July - September 2010/11 
Q1 - April - June 2010/11 

Annual Clinical Governance Reports

The Governance Annual Report summary for 2010/11 is included in the
Q4 - January - March 2010/11 Report 

Previous Reports

The Governance Annual Report summary for 2009/10 is included in the
Q4 - January - March 2009/10 Report 

The Governance Annual Report summary for 2008/09 is included in the
Q4 - January - March 2008/09 Report 

The Governance Annual Report summary for 2007/08 is included in the
Q4 - January - March 2007/08 Report 

Clinical Governance Annual Report for 2006/07 

Quarterly Clinical Governance Reports

2009/10

Q4 - January - March 2009/10 (including Annual Summary 2009 - 10) 
Q3 - October - December 2009/10 
Q2 - July - September 2009/10 
Q1 - April - June 2009/10 

2008/09
Q4 - January - March 2008/09 Report (including Annual Summary 2008 - 09)
 
Q3 - October - December 2008/09 
Q2 - July - September 2008/09 
Q1 - April  - June 2008/09 

2007/08
Q4 - January - March 2008 Report (including Annual Summary 2007 - 08)
 
Q3 - October - December 2007/08 
Q2 - July - September 2007/08 
Q1 - April - June 2007/08 

2006/07
Q4 - January - March 2006/07
 

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How can I help?

As a patient, carer or staff member, you will have a unique view of the way in which Papworth Hospital delivers its services. You may have suggestions for changes in practice that you feel would make our services better and safer. There may be aspects of our service that you find particularly good and wish to comment on. Alternatively, you may have a complaint about a recent experience that you would like us to look at. Your feedback is important to us, as it helps us to monitor the quality of care and services provided and highlight areas in need of improvement.

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