Quality and safety committee
Terms of Reference
Approved by Trust Board 28 April 2026
All Trust Board Committees are responsible for scrutinising and providing assurance to Trust Board on key issues allocated to them by the Board. Agendas are set to enable Trust Board to be assured that scrutiny processes are in place to allow the Trust’s strategic objectives to be met and to address and mitigate risk.
The Terms of Reference of the Committee are reviewed annually and, if appropriate, amended to reflect any changes to the Committee’s remit and role, any changes to other committees and revised membership. The Committee is a non-executive committee of the Board and has no executive powers other than those specifically delegated in these terms of reference. Committees are expected to conduct their business in accordance with the 7 principles of public life (Nolan principles): selflessness, integrity, objectivity; accountability; openness; honesty; and leadership.
Purpose
The Quality and Safety Committee provides assurance to Trust Board on service quality and the application of controls assurance in relation to clinical services. It scrutinises the systems in place for effective care co-ordination and evidence-based practice and focuses on quality improvement to ensure a co-ordinated holistic approach to clinical risk management and clinical governance is in place, protecting standards of clinical and professional practice. On behalf of the Trust Board, it will have an oversight of clinical risks, providing additional scrutiny of any such risks which are outside the Trust’s Risk Appetite, giving assurance to the Board around the management of such risks.
Membership
The Quality and Safety Committee is chaired by a Non-Executive Director. Two other Non- Executive Directors (NED) also sit on the Committee as well as relevant Directors of the Trust.
Membership as at: 1 April 2026
Chair – Non-Executive Director – Margaret Kitching Non-Executive Director – Mike Ford
Non-Executive Director – Nat McMillan
Lead Director – Chief Nurse / Director of Quality & Professions – Caroline Johnson
Chief Medical Officer – Professor Subha Thiyagesh
Chief Operating Officer – Adele Fox
Attendance
The Deputy Director of Nursing, Quality & Professions is in attendance at each meeting. Clinical representatives and relevant Trust officers are invited to meetings as appropriate to ensure the remit of the Committee is adequately covered. The Chief Executive, other Directors, and relevant officers attend the Quality and Safety Committee by invitation. Administrative support is provided by the Personal Assistant to the Chief Nurse / Director of Quality and Professions.
In addition, from April 2026 onwards, a representative will be invited as an observer from each of West Yorkshire and South Yorkshire Integrated Care Boards, as part of the oversight of quality at Place.
Quorum
The quorum will be two Non-Executive Director members and the Lead Director (or nominated Director) plus one other Director. Members are expected to attend all meetings. In the unusual event that the Chair is absent from the meeting, the Committee will agree another Non- Executive Director to take the chair. In the absence of executive Director members, deputies are permitted to attend, however they will not form part of the quorum.
Frequency of meetings
The Committee will meet a minimum of ten times per year.
It is the responsibility of the lead Director to ensure items are identified for the Committee’s agenda in line with the Committee’s terms of reference, its work programme agreed at the beginning of each year and the current risks facing the organisation and to agree these with the Chair of the Committee.
Authority
The Committee is authorised by Trust Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is also authorised by Trust Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.
Sub-committees
To fulfil its duties and to ensure the Trust complies with its statutory responsibilities and duties, the Committee will receive reports from identified sub-groups including but not limited to:
- Drugs and Therapeutics (Medicines Management)
- Safeguarding (vulnerable adults and children)
- Infection Prevention and Control
- Reducing Restrictive Physical Interventions group
- Clinical Governance Group
- Improving Clinical Information Group
- Clinical Ethics Advisory Group
- Improving Clinical Information Group
- Physical Health
- Nutrition Steering Group
- QUIT
Duties
The Committee provides assurance to Trust Board on service quality, practice effectiveness and the application of controls assurance in relation to clinical services and ensures the Trust is discharging its responsibilities with regard to clinical governance and clinical safety.
Strategy and policy
- To approve relevant strategies and policies on behalf of the Trust Board
- To monitor implementation of strategic objectives relevant to clinical governance, care delivery and practice effectiveness, such as implementation of care management processes and clinical information management, providing assurance to Trust Board that these are appropriately managed and resourced.
Clinical quality
- To provide assurance to Trust Board that appropriate and effective clinical governance arrangements are in place throughout the organisation through receipt of exception reports from relevant Directors to demonstrate that they have discharged their accountability for parts of their portfolios relating to assurance of clinical quality. This covers the areas of practice effectiveness, drugs and therapeutics, infection prevention and control, diversity, information governance and clinical documentation, reducing restrictive physical interventions, medical education, safeguarding children and adults, research and development, regulatory compliance, and health and
- To provide assurance to Trust Board that the Trust is meeting national requirements for clinical quality, clinical governance and clinical
- To assure Trust Board that the Executive Management Team and Care Groups have systems in place that encourage and foster greater awareness of clinical quality, clinical governance and clinical safety throughout the organisation, at all
Compliance
- To monitor, scrutinise and provide assurance to Trust Board on the Trust’s compliance with national standards, including the Care Quality Commission, the quality elements relating to NHS England (NHSE) and NICE
- To provide assurance to the Trust Board that the Trust is compliant with relevant legislation.
- To provide assurance that the Trust has effective arrangements for the prevention and control of infection, safeguarding adults and children, information governance and records management.
Clinical safety management
- To provide assurance to the Trust Board that environmental risks, including those identified as a result of PLACE inspections or environmental audit, are addressed and monitor appropriate action plans to mitigate these
- To provide assurance to the Trust Board that robust arrangements are in place for the proactive management of complaints, adverse events and incidents, including scrutiny of quarterly and annual reports on incidents and complaints and implementation of action plans.
- To provide assurance to Trust Board that there are robust systems for learning lessons from complaints, adverse events and incidents, and action is being taken to minimise the risk of occurrence of adverse
- As delegated by Trust Board, to monitor implementation of action plans relating to reviews of complaints by the Health Service Ombudsman and of action plans identified through independent inquiry reports relating to the Trust
Public and service user experience
- To provide assurance that there are appropriate systems in place to enable the views and experiences of service users and carers, and clinicians to shape service
Monitoring
The Committee will monitor its performance both in terms of providing assurance to Trust Board and in terms of ensuring it meets the remit as set out in its terms of reference through agreement of an annual work plan, inclusion in the work plan of any items delegated to the Committee by Trust Board and through the Assurance Framework, monitoring implementation of the annual work plan, assessment of the Committee’s performance through an annual self- assessment, and an evaluation of the Committee’s performance through an annual report to Trust Board.
The Committee will assess, measure and evaluate its impact, both quantitatively and qualitatively, and include the outcome of this in its annual report to the Audit Committee and to Trust Board.
Reporting to Trust Board
Trust Board will receive the minutes of Committee at the next Trust Board meeting following the Committee meeting wherever practical. The Committee will also report to the Board annually on its work (see above).
All Trust Board Committees have a responsibility to ensure they foster and maintain relationships and links between Committees. When a new Committee is formed it is incumbent upon all Committees to ensure that there are clear lines of accountability and that workplans / responsibilities are aligned and work is not duplicated. Each Committee also has a responsibility to ensure action identified and agreed is placed within the organisation either through the Executive Management Team or other internal groups, such as Trust-wide Action Groups (TAGs).
Reports being received as per the internet meetings governance framework
Ensure that the terms of reference template allows for the clear capture of information required by and reporting requirements into each committee
Next review due: April 2027
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