Governance is a word used to describe the ways that organisations ensure they run themselves efficiently and effectively. It also describes the ways organisations are open and accountable to the people they serve for the work they do. 

Good governance is maintained by the structures, systems and processes we put in place to ensure the proper management of our work, and by the ways we expect our staff to work. 

It is also about how we scrutinise our performance and deal with poor practice and other problems together with how we identify and manage risks, whether in terms of patient care, visitors to the Trust to our staff, and to the organisation as a whole.  

The governance framework 

In 2006, The Department of Health defined integrated governance as: “Systems, processes and behaviours by which trusts lead, direct and control their functions in order to achieve organisational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations.” 

The structures, systems, processes and behaviours NHS bodies have for ensuring good governance include: 

  • Constitution, Standing Orders, Standing Financial Instructions and Scheme of Reservation and Delegation 
  • requirement for a statutory board, and requirements on the committees that support the board 
  • how line managers operate, including codes of conduct and accountability 
  • business planning 
  • procedural guidance for staff 
  • risk register and assurance framework 
  • internal audit 
  • scrutiny by external assessors including the Care Quality Commission, HSE and external audit etc 

Health and safety  

The basis of British health and safety law in the United Kingdom is the Health and Safety at Work Etc Act 1974. The Act sets out the general duties which employers have towards employees and members of the public. In broad terms the employer has a duty to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees and anyone affected by its acts or omissions. The Governance team has responsibility for developing policies and procedures to ensure that the Trust has adequate systems in place to ensure compliance with the Act.  

This takes the form of a Trust Health and Safety Policy which highlights the organisational arrangements with individual and collective responsibilities, specific related polices, staff consultation, health and safety training, provision of advice and guidance and the ongoing monitoring and reviewing of performance (via audits/inspections etc). 

Policy management 

Within the Governance department we manage the process for the development, consultation, ratification of approved Trust documents. This includes strategy, policy, procedures and clinical guidelines. 

Manual handling  

Manual handling is a mandatory training requirement for all staff in the trust and is included on the corporate induction, clinical and non-clinical yearly updates.  Manual handling is covered by many pieces of legislation including the Health And Safety At Work Etc Act 1974 and the Manual Handling Operations Regulations 2016. 

Fire safety  

The primary remit of all NHS organisations with regard to fire safety is the safety of patients, staff and visitors.  For all premises under the Trust’s control we select and effectively implement a series of measures to achieve an acceptable level of fire safety taking into account: 

  • the Regulatory Reform (Fire Safety) Order 2005  
  • all other relevant legislation and statues 
  • the guidance in Health Technical Memorandums (HTM) 
  • the advice and approval of building control and fire and rescue authorities   
  • The department provides competent assistance and advice on all matters relating to Fire Safety, ensuring the Trust complies with the Regulatory Reform (Fire Safety) Order and relevant HTM.   

Medical devices  

The main requirements of the Medical Devices Regulations (MDR) came into force in June 2002. The aim of the regulations isto ensure: 

  • that there was safety requirements for all products  
  • that obligations are placed on manufacturers to ensure that devices are safe and fit for their intended purpose  
  • a wide range of instruments and equipment are covered from anaesthetic machines, to beds to walking sticks  

Medical devices are one of those topics that touch every department and area within the Trust. Whether it is procurement and finance that help support the buying and regulating of the devices, research that can assist with clinical trials, or clinical staff that use and train on the devices. Every clinical member of staff will use a medical device in some way. 

Emergency preparedness, resilience and response (EPRR) 

The NHS needs to be able to plan for, and respond to, a wide range of incidents and emergencies that could impact on health or patient care. These could be anything from extreme weather conditions to an outbreak of an infectious disease, or a major accident/incident. The Civil Contingencies Act (CCA) 2005 requires NHS organisations to show that they can deal with such incidents while maintaining services to patients. To ensure compliance with this requirement, we have developed an overarching ‘Major Incident Plan’ supported by ‘Business Continuity’ plans and specific plans to deal with ‘Loss of key suppliers and staff,’ ‘Heatwave’, ‘Fuel Shortage’ and ‘Floods’. These plans are tested on a regular basis via annual desktop exercises, live exercises and communication cascades, to ensure the arrangements are robust and fit for purpose. 


Quality and effectiveness

Commitment to quality 

The Walton Centre is committed to providing high quality care to its patients and their families and to continuously improving the quality of its services and safeguarding high standards. 

Issues of clinical quality are addressed at the highest level by the Divisional Risk and Governance Committee and Quality Committee. 

The Quality Strategy which incorporates patient and family experience has been approved by Trust Board. The overall aim of the strategy is to ensure that the clinical care, patients' experiences and outcomes provided by the Trust are of the highest quality. The strategy brings together quality initiatives to form a cohesive quality monitoring and improvement programme. 


Clinical audit 

The overall aim of clinical audit is to improve patient outcomes by improving professional practice and the general quality of services delivered. This is achieved through a continuous process where healthcare professionals review patient care against agreed standards and make changes, where necessary, to meet those standards. The audit is then repeated to see if the changes have been made and the quality of patient care improved. 

The Trust is committed to improving services by measuring practice through both local and national audit. This will ensure that we know if:

  •          Current practice meets required standards
  •          Current practice follows published guidelines
  •          Clinical practice is applying the knowledge that has been gained through research
  •          Current evidence is being applied in a given situation. 

The Healthcare Quality Improvement Partnership (HQIP) was established to promote quality in health and social care services in the UK, and in particular to increase the impact of clinical audit. Further information on clinical audit can be found at Clinical audit is discussed at Clinical Effectiveness Services Group which is chaired by the Medical Director and includes the Director of Nursing and Governance and clinical leads from across the Trust. 

Page last updated: 05 January 2022