The Board of Directors set the strategic direction as outlined in the trusts five year service plan and updated by way of an annual three year plan that is submitted to Monitor. The Board assures itself that risks to the delivery of the principal objectives are effectively managed through the Board Assurance Framework.
How the Board of Directors assures itself
The Board of Directors are the decision makers for the organisation. The Standing Orders set out the arrangements for the exercise of functions including delegation of powers. The Standing orders form part of the Constitution.
The Board of Directors can delegate powers to make decisions on their behalf to sub groups who then submit the minutes of their meetings showing the decisions they have made. These delegated powers are reported in both the Trusts Scheme of Delegations and in the committees Terms of Reference.
The Board of Directors need to ensure that that the governance systems and processes in the organisation are effective and achieve the organisational objectives and targets of KGH;
The minutes of each meeting of the Board of Directors sub groups are submitted to each Board meetings.
The Board of Directors Standing Orders form part of the Constitution (see “how we make decisions”)
Trust Management Committee
The Trust Management Committee is a senior decision making body that reports to the Board of Directors providing operational and clinical direction.
The Trust Management Committee is responsible for:-
The Audit Committee receives reports from both internal and external Auditors. The minutes of the Audit Committee meetings are submitted to Trust Board Meetings. Auditors reports include the Annual Audit Letter.
The Audit Committee is responsible for;
Governance and Assurance. Overseeing the Trusts governance and assurance process, including finance and for reviewing, prior to submission the Trust Board the Statement of Internal Control (see link below). The Clinical Governance and Risk Management Committee had responsibility for assuring the Board on the matter of Clinical, Corporate, Information and Research Governance
Audit Reports. Responsible for reviewing and recommendations on both the Internal and External audit reports.
Financial Reporting and Performance. Reviewing quarterly performance reports against objectives and risk.
Key Trust documents. Review proposed Changes to Standing Orders and Standing Financial Instructions
Performance Finance and Resources Committee (PFR)
The PFR Committee is responsible for a number of areas including;
Finance. Reviewing the Trusts financial performance, identifying any significant concerns to the Trusts Board.
Information Governance. Consider the status of Trust compliance, agree annual plans, review deviations from plan and non – compliance with legislation and directives
Funds held on trust. Annually review and make recommendations to ensure the use of available funds is maximised.
Controls Assurance. To receive an annual report from the Head of Internal Audit regarding compliance with statement of internal control.
Asset Management and Capital Planning. Approval of Capital business cases below £250,000
Service Visits. To develop and implement a programme of service visits with the aim of conducting a programme of audits designed to ensure that overall performance as reported to the Board in regular reports can be evidenced at an appropriate level of assurance.
Corporate Governance. Scrutinise and monitor the content and functioning of the Corporate Assurance Framework in respect of agreed corporate objectives.
Human Resources. Scrutinise and monitor agreed aspects of the Trust’s Human Resources performance.
The Governance Committee monitors the strategic direction for governance and the management of risk within the Trust. The core purpose of this Committee is to provide assurance to the Trust Board that the structures, systems and processes in place will deliver the Trust’s key clinical objectives and ensure continuous improvements in the quality and safety of patient care to promote improvement and excellence. The committee is responsible for the integrated management and monitoring of all activities which impact on the delivery of clinical care.
The committee is responsible for;
All governance matters including the production of the Annual Quality Governance Report.
Governance sub groups - oversee and respond to issues raised
Clinical Risks and Quality Issues - respond to significant and extreme risks and issues
Corporate Governance programmes - oObtain assurance that programmes of work are in place
External Reviews - to oversee the Trusts progress in the participation and preparation
Corporate Research and Information Governance - monitor the adequacy of systems
Board Assurance Framework - monitor and review the committees work programme in line with the priorities listed.
Clinical Governance is the accountable delivery of a patient – centered, ever improving, safe and high quality service. It is an umbrella term used to describe activities which aim to improve or maintain the quality of patient care.
The Director of Nursing and Quality and the Associate Director Quality Governance are responsible for overseeing the implementation of clinical governance within the Trust.
The Remuneration Committee meet as required to consider and decide the appropriate remuneration and terms of service for executive, non executive and corporate directors of the Trust including any subsequent proposals to change those arrangements. In addition the Committee will decide the annual inflation adjustment for all executive and corporate directors and all staff retaining local (non Agenda for Change and Medical & Dental) contracts. In so doing, the Committee shall have proper regard to the organisation’s circumstances and performance and to the provisions of any national arrangements for such staff.
The Director of Finance has prime responsibility for the Trust’s Charitable Funds as defined in the Trust’s Standing Financial Instructions.
A Charitable Funds Committee met regularly to review the Trusts fundraising strategy. This committee reports directly to the Board of Directors.
Board of Directors meeting documents - www.kgh.nhs.uk/about-us/trust-board/meetings/
Board Assurance Framework (Reviewed January, April, July & October 09) - www.kgh.nhs.uk/about-us/trust-board/meetings/
Monitor – KGH Constitution
Charitable funds - www.kgh.nhs.uk/about-us/fundraising-and-donations/