Quality Committee

Annual Report

1 April 2024 to 31 March 2025

1. Period covered by this report

This report covers the work of the Quality Committee for the financial year 1 April 2024 to 31 March 2025.

2. Introduction¹

The Quality Committee has been formally established by the Board of Directors as one of its sub-committees.  The Quality Committee has responsibility for providing assurance on: the effectiveness of the Trust’s quality, including patient safety, systems and processes; the quality, including patient safety, of the services provided by the Trust; and the control and management of quality, including patient safety, related risks within the Trust.

The committee will monitor and report to the Board of Directors on the effectiveness of these systems and processes, with its key duties being to seek assurance that:

• systems and processes are effective
• the quality, including patient safety, of services that the Trust provides is good and continuously improving
• the quality of the experience of people using our service is good and continuously improving.

The committee carries out its duties to provide assurance to the Board of Directors.  In addition to this, it is authorised to seek information that will allow it carry out its purpose.  It will:

• Seek assurance on systems and processes to ensure monitoring and assessment of the quality, including patient safety, and improvements in services
• Seek assurance on the mechanisms to involve service users, carers, the public and partner organisations in improving services
• Seek assurance on the systems for identifying, reporting, mitigating and managing quality, including patient safety, related risks including the monitoring of incidents, investigations and deaths; and complaints, claims, and compliments
• Review the Board Assurance Framework to seek assurance on behalf of the Board that those strategic risks where it has been listed as an assurance receiver, are being effectively controlled; that the risk score (which has been determined by the executive team) is at the right level; and that any gaps are being addressed appropriately.  It may also inform any deep-dive which it may wish to undertake into any area on which is requires further assurance.
• Seek assurance on compliance against the Care Quality Commission’s registration and notification requirements and action plans in response to CQC inspection.
• Monitor, scrutinise and provide assurance to the Board of Directors on the Trust’s compliance with national standards, including the Care Quality Commission’s Fundamental Standards, and the quality elements relating to NHS England’s System Oversight Framework, the quality elements within the NHS Standard contract, NICE guidance and CQUIN schemes.
• Seek assurance on the quality impact assessments for key strategic programs of work
• Receive assurance on the work carried out and reported to the Trustwide Clinical Governance Group, including: Quality Plan; Quality Report; Infection Prevention and Control; Safeguarding; Research and Development; Clinical Audit and NICE; Continuous Improvements; and Measuring outcomes across Trust services
• Receive assurance on activity within operational services that contributes to the understanding and improvement of quality, including patient safety, within the Trust.
• Review the draft Internal Audit Annual work plan so it can be assured on the sufficiency of the work the Auditors will carry out in respect of clinical matters. Assurance on this sufficiency (or comments on any matters that should be included) will be provided to the Audit Committee to allow it to approve the overall plan.
• Have oversight of relevant data and specific initiatives in relation to the Equality and Inclusion Agenda as requested by the Board of Directors, recognising the importance of inclusion and accessibility in delivering quality services.
• Carry out the duties of the Maternity Board Safety Champion, with the chair of the committee being the named champion.
• Carry out the role of Hip Fracture, Falls and Dementia Champion
• Carry out the role of Learning from Deaths Champion
• Carry out the role of Children and Young People Champion
• Carry out the role of Resuscitation Champion
• Carry out the role of Safeguarding Champion
• Carry out the role of Palliative and of Life Care Champion

This report covers the work the committee has undertaken at the meetings held during 2024/25.  It seeks to assure the Board on the work it has carried out and the assurances received, and to demonstrate that it has operated within its Terms of Reference.

¹ Information taken from the revised Terms of Reference which were ratified on 28 November 2024

3. Assurance

The committee receives assurance from the executive director members of the committee and from the subject matter experts who attend the meetings as required dependant on the agenda items being discussed. Assurance is provided through written reports, both regular and bespoke, through challenge by members of the committee and by members seeking to validate the information provided through wider knowledge of the organisation; specialist areas of expertise; attending Board of Directors’, and Council of Governors’ meetings.

The committee is assured that it has the right membership to provide the right level and calibre of information and challenge and that the right reporting methods, structures and work plans are in place to provide oversight on behalf of the Board in respect of performance in the areas covered by its Terms of Reference.

Part of its assurance role is to receive the Board Assurance Framework (BAF); a primary assurance document for the Board which details those key controls in place to ensure that the risks to achieving the strategic objectives are being well managed. The BAF lists those committees that are responsible for receiving assurance in respect of the effectiveness of those controls, and the Quality Committee will be asked to note, in particular, those where it is listed as an assurance receiver to ensure that it had received sufficient assurance through the reports that come to the committee or to commission further information where there was a lack of assurance (actual or perceived). These are:

• SR1- If there is a breakdown of quality including safety assurance processes, we risk not being able to maintain standards of safe practice, meeting population health needs and compliance with regulatory requirements.
• SR2 – There is a risk that we fail to make the improvements outlined in the Quality Strategic Plan and that this has an impact on how we understand and act on the care of those who use our services.

The committee views an extract of the BAF, containing the details for SR1 and SR2, at each meeting.

4. Terms of reference

In October 2024 the Terms of Reference for the Quality Committee were approved by the members. In November 2024, they were ratified by the Board of Directors.

5. Effectiveness of the Quality Committee

The committee reviewed its effectiveness in May 2024. It agreed that it remained effective and that no further developments were required.

In October 2024, a representative from The Value Circle observed a quality committee meeting as part of an independent review of the Trust’s Well Led governance arrangements. It was reported that the committee demonstrated a strong sense of ‘we’re all in this together,’ fostering collaborative discussions and easing the handling of difficult issues through a focus on teamwork. It was also noted that the meeting was chaired effectively, fostering an open, transparent, and respectful environment.

6. Meetings of the Quality Committee

In 2024/25 the committee met formally on 11 occasions. All committee meetings were held virtually. The dates on which the committee has met during the year are as follows:

• 11 April 2024
• 9 May 2024
• 13 June 2024
• 11 July 2024
• 12 September 2024
• 10 October 2024
• 14 November 2024
• 12 December 2024
• 16 January 2025
• 13 February 2025
• 13 March 2025

7. Membership of the Quality Committee and attendance at meetings

Membership of the Quality Committee is made up of two non-executive directors; the Director of Nursing and Professions, the Chief Operating Officer and the Medical Director. The Chief Financial Officer and the Director of People and Organisational Development are also members of the committee and attend meetings as appropriate dependant on the agenda items being discussed.

The committee is chaired by a non-executive director (NED), Dr Frances Healey, and Zoe Burns-Shore is the other regular NED member of this committee. Should the NED chair be unable to chair the meeting this role will fall to another NED.

Subject area experts are invited to attend the meetings as appropriate, to provide expertise and knowledge on the areas that they are responsible for. On these occasions, they are attendees and do not count towards to membership of the meetings as outlined in the Terms of Reference.

The Trust also invites governors to observe Board sub-committee meetings.  This opportunity allows governors to observe the work of the committee, rather than to be part of its work as they are not part of the formal membership of the committee. Governors observe Board sub-committee meetings in order to get a better understanding of the work of the Trust and to observe non-executive directors appropriately challenging the executive directors for the operational performance of the Trust.

Attendance at Quality Committee meetings by substantive members

Attendance at Quality Committee meetings by formal attendees

Attendance at Quality Committee meetings by governors

8. Reports made to the Board of Directors

The Chair of the Quality Committee makes an assurance, escalation and advisory report regarding the most recent meeting of the committee to the next available Board of Directors’ meeting.  This report seeks to assure the Board on the main items discussed by the committee and should it be necessary to escalate to the Board any matters of concern or urgent business which the committee is unable to conclude. The Board may then decide to give direction to the committee as to how the matter should be taken forward or it may agree that the Board deals with the matter itself.

Where the Board wants greater assurance on any matters that are within the remit of the Terms of Reference of the committee the Board may ask for these to be looked at in greater detail by the committee. The table below outlines the dates that the assurance and escalation reports were presented by the Chair of the Quality Committee to the Board of Directors meetings.

9. The work of the Quality Committee during 2024/25

During 2024/25 the committee has carried out its role in accordance with its Terms of Reference. Further details of all of these areas of work can be found in the minutes and papers of the committee.

A high-level presentation of areas of work on which the committee has received assurance and during 2024/25 are as follows:

Quality risks, priorities and strategy

• The committee is the assurance lead for the Board Assurance Framework Strategic Risks 1 and 2. At each meeting in 2024/25 the committee viewed strategic risks one and two so that it could be mindful of its responsibilities to assure that these risks were being adequately controlled through the course of the meetings.
• The Committee received the Quality Account 2023/24 in May 2024, and has received updates on specific quality improvement areas designated as Quality Improvement Priorities. It also received a summary from service users on what they would like to see in future Quality Accounts.
• The Committee received the draft Internal Audit Plan and the Clinical Audit Priority Plan for 2025/26 and was assured that they addressed the appropriate risk areas.
• The committee received updates on the work undertaken to embed the Quality Strategic Plan. It was assured that the work undertaken, and the work that was planned, will continue to further embed the Quality Strategic Plan within the organisation.

Reports the Committee receives frequently

• The committee reviewed the Combined Quality and Workforce Performance Report at each meeting.
• The committee received a quarterly report on Complaints, Concerns, PALS, Compliments and Patient Safety (which included data on Claims, Central Alert System compliance and compliance with some other types of safety notifications, reported incidents, Serious Incidents and Duty of Candour). It was assured that that the Trust had good systems for understanding quality issues raised through these sources and working to improve them.
• The committee received the Safer Staffing Six Monthly Update Reports, which encompass national requirements for monthly public reporting of levels of nurse staffing in inpatient services. It agreed that it was assured on the arrangements in place to monitor, support and mitigate any impact of reduced staffing levels or skill mix in relation to patient safety.
• The committee received regular verbal updates on the work of the Trust Wide Clinical Governance Group, the Nursing and Professions Council, the Trustwide Safeguarding Committee and the CQC Steering Group.
• The Infection Prevention and Control Group provided monthly updates and an annual report to the committee. The committee also reviewed the Infection Prevention Board Assurance Framework. It was assured that the Trust continued to follow all national infection, prevention and control guidance.
• The committee received reports which provided a summary of the Trust’s progress against its 2024/25 organisational priorities. It was assured on the Trust’s position in relation to quality priorities at the end of quarter two. It was also assured that the Trust had robust systems and processes in place for monitoring and supporting the delivery of each priority’s high-level milestones and underpinning tasks.

Annual reports

• The committee reviewed presentations from the following services, which provided the highlights of their Annual Quality Reports, focusing on how the services had scored themselves against the Learning, Culture and Leadership (LCL) Framework and the STEEEP dimensions of quality to enable the conditions for high quality care to flourish:
  • Acute and Crisis Service
  • Children and Young People’s Mental Health Service (Mill Lodge)
  • Children and Young People’s Mental Health Service (Red Kite View)
  • Children and Young People’s Mental Health Service (Deaf CAMHS)
  • Forensic Service
  • Older People’s Service
  • CONNECT Eating Disorders Service
  • Rehabilitation Service and Community Rehabilitation Enhanced Support Team
  • Gender Identity Service
  • Community Mental Health Teams
  • Liaison Service
  • Perinatal Service
  • OpCourage
  • Addictions Plus Service
  • Attention Deficit Hyperactivity Disorder Service
  • Northern Gambling Service
  • Leeds Autism Diagnostics Service
  • Personality Disorder Service
  • Learning Disability Service
• The committee received the Patient Experience and Involvement Progress Report which provided an update on the progress made against the priorities and aims identified in the Patient and Carer Experience and Involvement Strategy. It was assured on the systems and processes in place to involve and collect feedback from the Trust’s service users and carers.
• The committee received the Research and Development Annual Report for 2023/24.
• The committee received the Restrictive Interventions Annual Report for 2023/24. The committee agreed on the need for inpatient environments to become safer and less stimulating for individuals that are neurodivergent. It also suggested that the Trust should consider setting a target for having zero incidents of prone restraint to administer intramuscular injections.
• The committee received the Safeguarding Annual Report for 2023/24. It was pleased to hear that mandatory training figures had consistently reached the expected compliance rate and acknowledged the flexible approaches used by the team to deliver this training. It also acknowledged the work that had been undertaken in response to a limited assurance internal audit report on sexual safety, noting that a follow up audit had been completed with the findings to be presented at a future Audit Committee meeting.
• The committee received the Medicines Optimisation Group Annual Report for 2023/24. It agreed that the Medicines Optimisation Group was fulfilling its Terms of Reference and was assured on the systems for understanding and acting on quality issues involving medication.
• The committee reviewed reports which provided a summary of the approach taken by the Trust to develop its efficiency and productivity programme and detailed the schemes that had been through quality and equality impact assessments. The committee welcomed the reports and praised the thoroughness of the quality impact assessments that had been undertaken.
• The committee received the Learning from Deaths six-monthly reports. It was assured of the work ongoing within the Trust to improve mortality review and subsequent improvement action across the organisation.
• The committee received and discussed a report which contained a high-level summary of the metrics from the 2023 National Staff Survey that were relevant to quality, to enable an understanding of the Trust’s culture, processes and the impact on the quality of care.
• The committee received a report which outlined how the reporting of falls was organised in the Trust, shared current data on reported falls including triangulated data from different data sources, and described the plans for improvement work going forward. It agreed that, while the report provided assurance on the work carried out to ensure the Trust learned from incidents, further information and assurance was required on the work that would be carried out to update the Trust Falls Procedure to make it more evidence based and to ensure training around falls was monitored.

Additional updates

• The committee received an update on the progress made following the implementation and roll out of the National Partnership Agreement, Right Care, Right Person. It acknowledged this was a complex change that the Trust and partners appeared to be working on together in the right spirit. It noted the governance structure that had been established which would allow any risk and learning to be identified within the Trust and across the system and was assured on the work that had been carried out.
• The committee received a report which summarised the work undertaken to identify and understand the reasons for delays in discharge summaries, the plans that had been developed to address the problems and recommendations for continued monitoring, governance, and oversight. It was assured on the improvement work that was being carried out.
• The committee received a report which outlined the key findings from two surveys that had been developed to gather insights into the performance of outcome measures across services and understand the challenges clinicians faced and the barriers to the effective implementation of outcome measures
• The committee received a report which provided an overview of how the Trust’s local PSIRF priorities had been formulated and described the further work that was required to support the implementation of PSIRF.
• The committee received and supported a proposal for the Trust to move to in house training for a Nasogastric Tube (NG) insertion across both the Children and Young People’s Mental Health Service’s sites and the CONNECT service.
• The committee received an update on the development of the Trust’s Quality and Culture Dashboard priority project, which aimed to improve data-driven insights into organisational culture and quality metrics. Whilst awaiting the Quality Dashboard, the Quality Committee has seen iterative changes in the quality data it receives on a routine basis, including sight of indicators relevant to quality processes through copies of data routinely provided to the Finance and Performance Committee, and breakdowns of restrictive practice by underlying reason.
• The committee received a paper which set out the quality oversight arrangements for the Provider Collaboratives that the Trust is either Lead Provider for or involved in across West Yorkshire. The Quality Committee has confirmed at Board that the phrasing in its Terms of Reference relating to care the trust ‘provides’ encompasses care within its services and care it purchases for its service users (e.g. out of area placements) but does not encompass any commissioner role the trust takes on as part of a Provider Collaborative.
• In May 2024, the committee received a report outlining the current arrangements established to ensure the quality of out of area (OOA) placements and supported a proposal to move to arrangements where key quality surveillance metrics for OOA placements are reported as a matter of routine through the Trust’s clinical governance arrangements, including to Quality Committee, where that is the case for in-trust patients. In October 2024, the committee received a report which provided an overview of numbers and length of stay for those who were placed in OOA acute and psychiatric intensive care unit (PICU) beds from the 1 September 2024 to 31 November 2024. It noted that there had been difficulties in accessing quality data for service users that were in spot purchased OOA beds. It agreed on the importance of the committee as a minimum receiving data on restraint, seclusion and self-harm to be assured on the quality of the OOA placements and suggested that further discussions should take place to ascertain why quality data could not be shared.
• The committee received regular updates on the work being undertaken in response to the findings of an observation and engagement audit that was completed in 2023, which included the roll out of a training package on therapeutic observations, the collection of feedback from service users on their experience of observations, a review of Datix incidents and a review of complaints. The committee was assured by the update provided.
• The committee received a report which outlined the approach and timescales for the implementation of the new Risk Assessment and Management Plan (RAMP) template. It acknowledged the complexities of this work and welcomed the positive feedback received by staff who had used the tool. It also thanked colleagues within the IT Service for supporting this work. The committee agreed that it was assured on the approach taken and progress made to change the Trust’s approach to clinical risk assessment.
• The committee reviewed the Safeguarding: Sexual Safety (Follow Up) Internal Audit Report, which had received an opinion of significant assurance. The committee agreed that although it had previously received assurance on the improvement work that had focused on sexual safety, it required further assurance on the governance processes in place to ensure individual sexual safety allegations were reviewed, recorded and resolved appropriately.
• The committee reviewed the Clinical Governance Internal Audit Report, which had received an opinion of limited assurance. The committee noted that the audit had focused primarily on meeting structures. It discussed the findings and recommendations made within the report and was informed of the work that would be carried out in response to the findings. The committee noted that a follow up audit would be completed once the recommendations had been implemented.
• The committee received and discussed a report which summarised the Trust’s implementation plan for the National Early Warning Score 2 (NEWS2).
• The committee reviewed the Preparations for Care Quality Commission Follow-up Internal Audit Report. It noted that the audit had received an opinion of moderate assurance and was reassured that progress was being made with the actions recommended within the report.
• The committee received an update on the progress the Trust had made in improving health equity. It noted that the first draft of the new Improving Health Equity Strategy 2024-29 had been developed and work was underway to engage with Trust staff and external partners to agree priorities and objectives.
• The committee received a report which provided an overview of activity relating to the CQC from June 2024 to November 2024. It noted that the Trust had not yet received draft reports following the inspections at Red Kite View, Mill Lodge and the Mother and Baby Unit, however it had received a letter from the CQC providing an overview of the preliminary findings from its inspections. It was assured by the work that had been undertaken in response to these findings.
• The committee received a report which provided an update on all aspects of resuscitation in the Trust, including emergency incidents, training, do not attempt cardiopulmonary resuscitation (DNACPR), ReSPECT, the system used to manage the Trust’s emergency equipment and the work of the Resuscitation Committee. It received reassurance that there were no concerns around the quality of the CPR being delivered, noting that reports from the defibrillators post use had suggested that the CPR being delivered was good.

Part B of the Quality Committee

• The Quality Committee holds a private Part B meeting to discuss information that is personal to individual staff or patients, or for other limited reasons (e.g. need to protect detail related to methods of self-harm).

10. Conclusion

The Chair of the Quality Committee would like to assure the Board of Directors that the committee has fulfilled its Terms of Reference during 2024/25. Throughout the year the committee has monitored quality and gained assurance on how quality matters are considered and addressed. It has added value by maintaining an open and professional relationship with officers of the Trust and has carried out its work diligently; discussed issues openly and robustly; and kept the Board of Directors apprised of any possible issues or risks.

Members of the Quality Committee would like to thank all those who have responded to its requests during the year and who have supported it in carrying out its duties.

Dr Frances Healey

Non-executive Director and Chair of the Quality Committee 

3 April 2025

Kerry McMann        

Head of Corporate Governance

3 April 2025                                                                           

Appendix 1 – Terms of Reference

A link to the current Terms of Reference of the Quality Committee can be found here