Governance

This issue was highlighted in the Grant Thornton report where similar recommendations are made to what is set out above. NHSL has taken steps to address the issue. However, it …

I accordingly recommend that a similar procedure should be considered when technical advisers (particularly engineers) are providing specific technical advice in relation to a project such as the RHCYP and …

The governments of the UK, Scotland, Wales and Northern Ireland should each simplify and reduce the number of structures with responsibility for preparing for and building resilience to whole-system civil …

The role and functions of HM Coastguard should be set out in up-to-date legislation.

We have illustrated throughout this Report how Maidstone and Tunbridge Wells NHS Trust relied on reassurance rather than assurance in monitoring its processes. The Board must review its governance structures …

Maidstone and Tunbridge Wells NHS Trust Board must have greater oversight of licensed activity in the mortuary. It must ensure that the Designated Individual is actively involved in reporting to …

Maidstone and Tunbridge Wells NHS Trust should treat compliance with Human Tissue Authority standards as a statutory responsibility for the Trust, notwithstanding the fact that the formal responsibility under the …

The Chief Nurse should be made explicitly responsible for assuring the Maidstone and Tunbridge Wells NHS Trust Board that mortuary management is delivered in such a way that it protects …

Maidstone and Tunbridge Wells NHS Trust should treat security as a corporate not a local departmental responsibility.

NHS trusts should ensure that senior managers, including the Chief Executive, have a clear understanding of the role of the Designated Individual, their lines of accountability, and the individual legal …

NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as well as reporting upwards when required.

All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include the presentation of a formal report, by the …

Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage and care of deceased people.

Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent regard to other regulated activities within trust governance …

The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased people in NHS mortuaries and body stores.

Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include …

There must be a process to ensure that, where there is a requirement for funding to strengthen mortuary security, it is expedited and considered at the highest levels within the …

There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as the Designated Individual, their direct contact with the …

The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must be visible to scrutiny at the relevant statutory …

Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee the services they provide. This should include Standard …

All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be reviewed by a security expert who is able …

A formal role be given within IBCA for an advisory body consisting of people infected and affected, covering a range of experience broadly representative of those groups, and (if those …

That NHS Trusts and Health Boards should be required to deliberate on peer review findings and give favourable consideration to implementing the changes identified with a view to ensuring comprehensive, …

I recommend that an Arms Length Body (ALB) should be set up to administer the compensation scheme, with guaranteed independence of judgement, chaired by a judge of High Court or …

The governance structure for the delivery of a major project such as a light rail scheme should follow published guidance and ensure clarity regarding the respective roles of various bodies …

Risk identification and management should be integral to major public-sector contracts, employing probabilistic forecasts, critical review of mitigation claims, constant governance challenge, early warning detection, and quality-focused evidence rather than …

Where other government bodies, such as Ofgem, or contractors or other third parties are involved in the implementation of a project, the 'home' Department must retain overall control and overall …

The processes within a Department for approving new expenditure and business cases including, where it forms part of that process, the role of Casework Committees, should be thoroughly re-designed to …

Public expenditure rules should be sufficiently flexible so that false economies can be avoided. In order to deliver a policy objective, Departments should not be required to choose a more …

The Department of Finance's distinctive role in scrutinising business cases should be searching and sceptical, guarding against over-reliance on the assurances offered by the applicant Department.

Particularly where a policy initiative is demand-led, novel, complex and/or likely to be lengthy, consideration should be given to increasing Department of Finance involvement from an early stage and on …

Ministers should always be advised of any conditions attached to the approval of a policy or project by the Department of Finance. The Department of Finance should also require, and …

The finance function within a Department should exert the necessary authority and capability to fulfil the requirements of 'Managing Public Money Northern Ireland', namely to retain a firm grasp of …

Civil servants who are responsible for holding and monitoring a budget should have to demonstrate core requirements in financial literacy and an understanding of how public spending operates, including what …

Any imperative to spend a budget within a given timeframe should not be allowed to take precedence over how that budget is used and the longer term benefits and overall …

The checks and balances within a Department designed to catch problems early failed over many years in DETI to identify certain of the risks of the RHI or their materialisation. …

The protocol for relations with HMT, namely that the Northern Ireland Department of Finance must be the sole conduit of formal communication, should be reinforced and widely understood across the …

The Code of Conduct issued to Northern Ireland Ministers in 2007 (contained within the Northern Ireland Ministerial Code 2006) should be revised and brought up to date reflecting the findings …

We recommend that the government addresses, as a matter of urgency, this gap in responsibility and liability.

Record keeping should be subject to rigorous, routine and regular audit.

Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of the family.

The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.

Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.

Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.

All Trust Board Members should receive induction training in their statutory duties.

Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI related patient deaths.

Trusts should monitor compliance and take disciplinary action against breach.

Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.

All Trust Boards should ensure that appropriate governance mechanisms are in place to assure the quality and safety of the healthcare services provided for children and young people.

All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a nominated non-executive Director.

Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.

Trusts should appoint a compliance officer to ensure compliance with protocol and direction.

Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.

All Trust Boards should consider the findings and recommendations of this Report and where appropriate amend practice and procedure.

The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.

The University Hospitals of Morecambe Bay NHS Foundation Trust should continue to prioritise the work commenced in response to the review of governance systems already carried out, including clinical governance, …

Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.

Scottish Government should develop local healthcare Associated infection (HAI) Task Forces within each Health Board area.

Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive or, at least, to an executive board member.

Health Boards should ensure that the ICM is responsible for reporting to the Board on the state of HAI in the organisation.

Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the Chief Executive and the Board.

Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through the management structure.

Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to the level above in the hierarchy.

Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy on public involvement.

Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority.

In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the Board or Boards responsible.

Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.

Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.

In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance with fundamental standards, and the provision and publication …

All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it …

Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.

The Royal College of Nursing should consider whether it should formally divide its "Royal College" functions and its employee representative/trade union functions between two bodies rather than behind internal "Chinese …

All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as …

Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety …

Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards of health service bodies which are not foundation …

Each provider organisation should have a board level member with responsibility for information.

Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent …

Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the …

Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council …

Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of …

The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to …

The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality standards at the same time as complying with …

The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with the Department of Health and whether the appropriate …

The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its …

There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper …

A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications …

A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.

An independent self regulatory body should be governed by an independent Board. In order to ensure the independence of the body, the Chair and members of the Board must be …

Decisions on complaints should be the ultimate responsibility of the Board, advised by complaints handling officials to whom appropriate delegations may be made.

Serving editors should not be members of any Committee advising the Board on complaints and any such Committee should have a composition broadly reflecting that of the main Board, with …

The appointment of the Chair of the Board should be made by an appointment panel. The selection of that panel must itself be conducted in an appropriately independent way and …

The responsibility for recognition and certification of a regulator shall rest with a recognition body. In its capacity as the recognition body, it will not be involved in regulation of …

The appointment panel: (a) should be appointed in an independent, fair and open way; (b) should contain a substantial majority of members who are demonstrably independent of the press; (c) …

The role of recognition body, that is to say, to recognise and certify that any particular body satisfies (and, on review, continues to satisfy) the requirements set out in law …

It should be possible for the recognition body to recognise more than one regulatory body, should more than one seek recognition and meet the criteria, although this is not an …

In passing legislation to identify the legitimate requirements to be met by an independent regulator organised by the press, and to provide for a process of recognition and review of …

The appointment of the Board should also be an independent process, and the composition of the Board should include people with relevant expertise. The requirement for independence means that there …

The members of the Board should be appointed by the same appointment panel that appoints the Chair, together with the Chair (once appointed), and should: (a) be appointed by a …

The opportunity should be taken to consider amending the Data Protection Act 1998 formally to reconstitute the Information Commissioner's Office as an Information Commission, led by a Board of Commissioners …

Funding for the system should be settled in agreement between the industry and the Board, taking into account the cost of fulfilling the obligations of the regulator and the commercial …

The Information Commissioner's Office should take the opportunity to review its organisation and decision-making processes to ensure that large-scale issues, with both strategic and operational dimensions (including the relationship between …

The standards code must ultimately be the responsibility of, and adopted by, the Board, advised by a Code Committee which may comprise both independent members of the Board and serving …

The Board should require, of those who subscribe, appropriate internal governance processes, transparency on what governance processes they have in place, and notice of any failures in compliance, together with …