GOVERNANCE COMMITTEE. Terms of Reference

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1 GOVERNANCE COMMITTEE Terms of Reference These Terms of Reference are used as evidence for: Care Quality Commission Standard numbers: NHSLA Risk Management Standards for Acute Trusts: 1.3 NHSLA CNST Maternity Clinical Risk Management Standards: Other (please specify): 1. Accountability 1.1 The Governance Committee is accountable to and will report directly to the Board of Directors. 2. Purpose 2.1 To scrutinise and review the systems in place to ensure, monitor and improve the quality of healthcare provided for, or delivered to, patients 2.2 To ensure that the Trust has a strategy which allows for: the continuing identification and prioritisation of risks a description of action taken to manage each key risk the identification of how risk is measured 3. Membership 3.1 The Governance Committee shall be appointed by the Board of Directors. The membership shall consist of: A Non-Executive Chairman appointed by the Board of Directors At least two Non-Executive members appointed by the Board of Directors who shall act as deputy when required. The Chief Executive The Medical Director The Director of Finance and Business Development The Director of Nursing & Patient Care The Director of Human Resources The Chief Operating Officer Divisional Manager Facilities Consultant in Occupational Health Director of Infection Prevention and Control Review Date: December 2010 Page 1 of 5

2 Chairmen of all reporting committees A Lead Nurse Head of Patient Governance Divisional Managers from each clinical division 3.2 The Board of Directors will review the membership of the Committee annually to ensure that it best reflects the requirements of governance within the Trust. Members will be required to attend at least half of the committee meetings in any one year 3.3 The Chairman will serve for three years. The Non-Executive members will serve for three years and be eligible for re-appointment for a further three years. 3.4 No deputies will be appointed. Deputies may be present at specific meetings, in the absence of members. Deputies will not have voting rights at the meetings they attend. 3.5 Individuals may be co-opted for specific projects. 4. A Quorum 4.1 A quorum will consist of not less than five members of the Committee, one of whom shall have substantial relevant clinical expertise and three of whom will be as follows: Two Non-Executive Directors, one of whom should chair the meetings The Medical Director or a Clinical Director. 5. Procedures 5.1 The Governance Committee shall appoint a secretary to prepare agendas, keep minutes and deal with any other matters concerning the administration of the Committee. 5.2 Any member of staff may raise an issue with the Chairman, normally by written submission. The Chairman will decide whether or not the issue shall be included in the Committee s business. The individual raising the matter may be invited to attend. 6. Frequency of Meetings 6.1 Meetings will be held no less than six times in each accounting year. 6.2 The Governance Committee may require the attendance of any director, or member of staff, and the production of any document it considers relevant to Clinical Governance / Risk Management. 6.3 Extraordinary meetings may be called at the request of any three members of the Governance Committee or the Chairman of the Board of Directors. Review Date: December 2010 Page 2 of 5

3 7. Duties and Responsibilities The Governance Committee shall consider any matters relating to Clinical Governance and Risk Management within the Trust that it determines to be desirable. The Committee shall examine any matters referred to it by the Board of Directors. 7.3 The Committee shall have the following specific duties and responsibilities: The implementation, development and ongoing management of Clinical Governance within the Trust The establishment and maintenance of procedures and systems of internal control designed to give reasonable assurance that all aspects of governance are in place To review and implement the Trust s Risk Management Strategy To co-ordinate and prioritise all areas of risk in the Trust To monitor the Trust s Risk Register To review and analyse trends arising from incidents To oversee the work of committees considering Governance / Risk Management issues (see appendix A) and to receive action notes from such committees To review the Assurance Framework before presentation to the Board of Directors To oversee external reviews of the Trust s Governance arrangements To review the draft Governance Annual Report before presentation to the Board of Directors To consider the content of any report on governance issues involving the Trust and review the proposed response before making a recommendation to the Board of Directors To consider items highlighted to it from the divisional governance groups To satisfy itself that the Royal Devon & Exeter NHS Foundation Trust is meeting the requirements of Governance best practice. Financial governance is overseen by the Audit Committee To conduct an annual review of the committee s effectiveness and comment on this in the annual report Chair of Governance Committee to attend ad hoc meetings of the Trust s Audit Committee Review Date: December 2010 Page 3 of 5

4 8. Review 8.1 The Board of Directors will review the terms of reference of the Committee annually to ensure that it remains fit for purpose and is best facilitated to discharge its duties. Internal audit will review the terms of reference via the review of risk management processes that is undertaken annually. Anomalies will be reported via the audit committee to relevant managers. Review Date: December 2010 Page 4 of 5

5 Board of Directors Governance Committee Management Assurance Clinical Audit & Effectiveness Committee Decontamination Committee Drugs & Therapeutics Committee Emergency Preparedness Steering Group Environment & Waste Management Group Fire Safety Committee Health & Safety Committee Hospital Transfusion Committee Infection Control Committee Information Governance Committee Involving People Steering Group Medical Devices Group National Standards Local Strategy Committee Non-Medical Professionals Governance Committee Patient Environment Action Group Patient Safety Steering Group Radiation Safety Committee Resuscitation Committee Safeguarding Adults Steering Group Security Forum Divisional Governance Groups Independent Assurance Audit Committee Review Date: December 2010 Page 5 of 5

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