Board Committees and TOR QPS Committee

BOARDCOMMITTEESANDTERMSOFREFERENCE
DocumentationControl
Reference
Dateapproved
ApprovingBody
Implementationdate
Version
Supersedes
Consultationundertaken
Targetaudience
Distribution:Policyand
Procedure(s)
SupportingProcedure(s)
CorporateGovernanceFramework
Chapter7
TrustBoard
8
NUHVersion7(1October2009)
DirectorsGroupandAudit
Committee(codifiesBoarddecisions
uptoandincluding5August2010)
AllStaff
Allstaff
N/A
ReviewDate
Twomonthsbeforetheinceptionof
theNUHfoundationtruststatus,or
September2011,whichevercomes
first.
LeadExecutive
ChiefExecutive
Author/LeadManager
TrustSecretary
FurtherGuidance/Information
TrustSecretary
DeputyTrustSecretary
NottinghamUniversityHospitalsNHSTrust
BoardCommitteesandTermsofReference
ChapterSeven
Version8(September2010)
COMMITTEESTRUCTURES
TrustBoard
TheTrustBoardisresponsiblefordeterminingthestrategic
directionoftheTrust,agreeingitspolicyframeworkandmonitoring
theperformanceoftheTrust.Itsstatutoryobligationsaresetoutin
thecodesofconductandaccountability,publishedbythe
DepartmentofHealth.
TrustBoardCommittees
ThereareninecommitteesoftheTrustBoard,whichsupportitin
settingthetrustsstrategicdirection,inmonitoringandensuring
thatthestrategiesarebeingtakenforwardandthatthe
responsibilitiesforBoardassurancearebeingmet.
AuditCommittee
RemunerationandTermsofServiceCommittee
FinanceandInvestment Committee
CommitteefortheAppointmentoftheChief
ExecutiveasExecutiveDirector
CommitteefortheAppointmentofOther
ExecutiveDirectors
EthicsofClinicalPracticeCommittee
AdvisoryAppointmentsCommittee
DonationCommittee
Quality,RiskandSafetyCommittee
AndanyothersuchcommitteesastheBoardshall,
fromtimetotime,determine
Termsofreferenceforeachofthesecommitteescanbefoundattached.
ChapterSeven
TRUSTBOARD
TheBoardsstatutoryobligationsaresetoutintheCodesof
ConductandAccountabilitypublishedbytheDepartmentof
Health.
NHSBoardshavesixkeyfunctionsforwhichtheyareheld
accountablebytheNHSExecutiveonbehalfoftheSecretaryof
State:
Tosetthestrategicdirectionoftheorganisationwithinthe
overallpoliciesandprioritiesoftheGovernmentandtheNHS,
defineitsannualandlongertermobjectivesandagreeplansto
achievethem
Tooverseethedeliveryofplannedresultsbymonitoring
performanceagainstobjectivesandensuringcorrectiveaction
istakenwhennecessary
Toensureeffectivefinancialstewardshipthroughvaluefor
money,financecontrolandfinancialplanningandstrategy
Toensurethathighstandardsofcorporategovernanceand
personalbehaviouraremaintainedintheconductofthe
businessofthewholeorganisation
Toappoint,appraiseandremunerateseniorexecutives,and
Toensurethatthereiseffectivedialoguebetweenthe
organisationandthelocalcommunityonitsplansand
performanceandthattheseareresponsivetothecommunitys
needs.
Infulfillingthesefunctions,theBoardshould:
Specifyitsrequirementsfororganisingandpresentingfinancial
andotherinformationsuccinctlyandefficientlytoensurethe
Boardcanfullyundertakeitsresponsibilities
ChapterSeven
Beclearwhatdecisionsandinformationareappropriateand
drawupStandingOrders,aScheduleofDecisionsReservedto
theBoardandStandingFinancialInstructionstoreflectthis
Establishperformanceandqualitytargetsthatmaintainthe
effectiveuseofresourcesandprovidevalueformoney
Ensurethatmanagementarrangementsareinplacetoenable
responsibilitytobeclearlydelegatedtoseniorexecutivesforthe
mainprogrammesofactionandforperformanceagainst
programmestobemonitoredandseniorexecutivesheldto
account
EstablishAuditandRemunerationCommitteesonthebasisof
formallyagreedtermsofreferencewhichsetoutthe
membershipofthecommittee,thelimittotheirpowersandthe
arrangementsforreportingbacktothemainBoard
Actwithinstatutoryfinancialandotherconstraints.
ChapterSeven
AUDITCOMMITTEE
TERMSOFREFERENCE
Constitution
TheBoardherebyresolvestoestablishacommitteeoftheBoard
tobeknownastheAuditCommittee(TheCommittee).The
CommitteeisanonexecutivecommitteeoftheBoardandhasno
executivepowers,otherthanthosespecificallydelegatedinthese
TermsofReference.
Membership
TheCommitteeshallbeappointedbytheBoardfromamongstthe
nonexecutivedirectorsoftheTrustandshallconsistofthree
members.Aquorumshallbetwomembers.TheBoardshall
appointoneofthemembersaschairoftheCommittee.The
ChairmanoftheTrustshallnotbeamemberoftheCommittee.
Attendance
TheDirectorofFinanceandappropriateInternalandExternal
Auditrepresentativesshallnormallyattendmeetings.TheChief
Executiveandotherexecutivedirectorsshouldbeinvitedto
attend,butparticularlywhentheCommitteeisdiscussingareasof
riskoroperationthataretheresponsibilityofthatdirector.
TheChiefExecutiveshouldbeinvitedtoattendannually,to
discusswiththeCommitteetheprocessforassurancethat
supportstheStatementonInternalControl.
TheCommitteehastherighttoexcludeexecutivedirectorsor
otherattendeesduringconsiderationofanypartofCommittee
business.Ifnecessary,meetingsoftheCommitteeshallbe
convenedandattendedexclusivelybymembersoftheCommittee
and/ortheTrustsExternalAuditorsorHeadofInternalAudit
ChapterSeven
AtleastonceayeartheCommitteeshouldmeet:
privatelywiththeExternalAuditors
privatelywiththeInternalAuditors
privatelywiththeExternalandInternalAuditors
TheTrustSecretary,ortheirdesignateddeputy,shallbeSecretary
totheCommitteeandshallattendtotakeminutesofthemeeting
andprovideappropriatesupporttotheCommitteechairand
members.
Frequency
TheCommitteeshallgenerallymeetsixtimesayear.Atleastone
oftheseeachyearshallbeaprivatemeetingoftheCommittee
andtheSecretarytoundertakeanannualselfassessmentand
relatedprocesses.
TheExternalAuditororHeadofInternalAuditmayrequesta
meetingiftheyconsiderthatoneisnecessary.
Authority
TheCommitteeisauthorisedbytheBoardtoinvestigateany
activitywithinitstermsofreference.Itisauthorisedtoseekany
informationitrequiresfromanyemployeeandallemployeesare
directedtocooperatewithanyrequestmadebytheCommittee.
TheCommitteeisauthorisedbytheBoardtoobtainoutsidelegal
orotherindependentprofessionaladviceandtosecurethe
attendanceofoutsiderswithrelevantexperienceandexpertiseifit
considersthisnecessary.
Duties
ThedutiesoftheCommitteecanbecategorizedasfollows:
Governance,RiskManagementandInternalControl
TheCommitteeshallreviewtheestablishmentandmaintenanceof
aneffectivesystemofintegratedgovernance,riskmanagement
andinternalcontrol,acrossthewholeoftheorganizations
ChapterSeven
activities(bothclinicalandnonclinical)thatsupportsthe
achievementoftheorganizationsobjectives.
Inparticular,theCommitteewillreviewtheadequacyof:
allriskandcontrolrelateddisclosurestatements(inparticular
the
StatementonInternalControlandalldeclarationsof
compliance,togetherwithanyaccompanyingHeadofInternal
Auditstatement,externalauditopinionorotherappropriate
independentassurances,priortoendorsementbytheBoard
theunderlyingassuranceprocessesthatindicatethedegreeof
the
achievementofcorporateobjectives,theeffectivenessofthe
managementofprincipalrisksandtheappropriatenessofthe
abovedisclosurestatements
thepoliciesforensuringcompliancewithrelevantregulatory,
legalandcodeofconductrequirements
thepoliciesandproceduresforallworkrelatedtofraudand
corruptionassetoutinSecretaryofStatesDirectionsandas
requiredbytheCounterFraudandSecurityManagement
Service
Incarryingoutthiswork,theCommitteewillprimarilyutilisethe
workofInternalAudit,ExternalAuditandotherassurance
functions,butwillnotbelimitedtotheseauditfunctions.Itwillalso
seekreportsandassurancesfromdirectorsandmanagersas
appropriate,concentratingontheoverarchingsystemsof
integratedgovernance,riskmanagementandinternalcontrol,
togetherwithindicatorsoftheireffectiveness.Thiswillbe
evidencedthroughtheCommitteesuseofaneffectiveAssurance
Frameworktoguideitsworkandthatoftheauditandassurance
functionsthatreporttoit.
InternalAudit
TheCommitteeshallensurethatthereisaneffectiveinternalaudit
functionestablishedbymanagementthatmeetsmandatoryNHS
InternalAuditStandardsandprovidesappropriateindependent
assurancetotheCommittee,ChiefExecutiveandBoard.
ChapterSeven
Thiswillbeachievedby:
considerationoftheprovisionoftheInternalAuditservice,the
costoftheauditandanyquestionsofresignationanddismissal
reviewandapprovaloftheInternalAuditstrategy,operational
planandmoredetailedprogrammeofwork,ensuringthatthisis
consistentwiththeauditneedsoftheorganizationasidentified
intheAssuranceFramework
considerationofthemajorfindingsofinternalauditwork(and
managementsresponse),andensurecoordinationbetween
theInternalandExternalAuditorstooptimiseauditresources
ensuringthattheInternalAuditfunctionisadequatelyresourced
andhasappropriatestandingwithintheorganisation
annualreviewoftheeffectivenessofinternalaudit
reviewanymaterialobjectiontotheInternalAuditplansand
associatedassignmentsthatcannotberesolvedthrough
negotiation.
ExternalAudit
TheCommitteeshallreviewtheworkandfindingsoftheExternal
AuditorappointedbytheAuditCommissionandconsiderthe
implicationsandmanagementsresponsestotheirwork.Thiswill
beachievedby:
considerationoftheappointmentandperformanceofthe
ExternalAuditor,asfarastheAuditCommissionsrulespermit
discussionandagreementwiththeExternalAuditor,beforethe
auditcommences,ofthenatureandscopeoftheauditasset
outintheAnnualPlan,andensurecoordination,asappropriate,
withotherExternalAuditorsinthelocalhealtheconomy
discussionwiththeExternalAuditorsoftheirlocalevaluationof
auditrisksandassessmentoftheTrustandassociatedimpact
ontheauditfee
reviewallExternalAuditreports,includingagreementofthe
annualauditletterbeforesubmissiontotheBoardandanywork
carriedoutsidetheannualauditplan,togetherwiththe
appropriatenessofmanagementresponses
ChapterSeven
OtherAssuranceFunctions
TheCommitteeshallreviewthefindingsofothersignificant
assurancefunctions,bothinternalandexternaltotheorganization,
andconsidertheimplicationstothegovernanceofthe
organization.
Thesewillinclude,butwillnotbelimitedto,anyreviewsby
regulatoryorprofessionalbodieswithresponsibilityforthe
performanceofstafforfunctions(e.g.royalcolleges,accreditation
bodies,etc.)
Inaddition,theCommitteewillreviewtheworkofothercommittees
withintheorganisationwhoseworkcanproviderelevant
assurancetotheCommitteesownscopeofwork.
Inreviewingtheissuesconcerningclinicalriskmanagement,the
Committeewillwishtosatisfythemselvesontheassurancethat
canbegainedfromtheclinicalauditfunction.
Management
TheCommitteeshallrequestandreviewreportsandpositive
assurancesfromdirectorsandmanagersontheoverall
arrangementsforgovernance,riskmanagementandinternal
control.
Itmayalsorequestspecificreportsfromindividualfunctionswithin
theorganization(e.g.clinicalaudit)astheymaybeappropriateto
theoverallarrangements.
FinancialReporting
TheCommitteeshallreviewtheAnnualReportandFinancial
StatementsbeforesubmissiontotheBoard,focusingparticularly
on
ChapterSeven
thewordingintheStatementonInternalControlandother
disclosuresrelevanttotheTermsofReferenceofthe
Committee
changesin,andcompliancewith,accountingpoliciesand
practices
unadjustedmisstatementsinthefinancialstatements
majorjudgmentalareas
significantadjustmentsresultingfromtheaudit
TheCommitteeshouldalsoensurethatthesystemsforfinancial
reportingtotheBoard,includingthoseofbudgetarycontrol,are
subjecttoreviewastocompletenessandaccuracyofthe
informationprovidedtotheBoard.
Reporting
TheminutesofCommitteemeetingsshallbeformallyrecordedby
theTrustSecretaryandsubmittedtotheBoard.TheChairofthe
CommitteeshalldrawtotheattentionoftheBoardanyissuesthat
requiredisclosuretothefullBoard,orrequireexecutiveaction.
TheCommitteewillreporttotheBoardannuallyonitsworkin
supportoftheStatementonInternalControl,specifically
commentingonthefitnessforpurposeoftheAssurance
Framework,thecompletenessandembeddednessofrisk
managementintheorganizationand theintegrationof
governancearrangements.
OtherMatters
TheCommitteeshallbesupportedadministrativelybytheTrust
Secretary,whosedutiesinthisrespectwillinclude:
AgreementofagendawithCommitteeChairandattendeesand
collationofpapers
Takingtheminutes
Keepingarecordofmattersarisingandissuestobecarried
forward
AdvisingtheCommitteeonpertinentareas
ChapterSeven
10
Appendix1
PrinciplesthatunderpintheAuditCommittee:
1.
Whereanauditreportiscriticalorhasbeengivenlimited
assurance,theleadofficerfromtherelevantdepartment
shallberequestedtoattendtheAuditCommitteemeetingto
provideanupdateonactionstakentoaddressthe
recommendationsinthatreport.
2.
Whereanauditreporthasbeengivensignificantassurance,
theleadofficerfromtherelevantdepartmentshallbe
advisedthattheitemwillbediscussedattheAudit
Committeemeetingandshallbegiventheoptiontoattend
thatmeeting.
3.
Whereanauditreportrelatestoafollowupauditandhigh
riskrecommendationsarestilloutstanding,theleadofficer
fromtherelevantdepartmentshallberequestedtoattend
theAuditCommitteemeetingtoprovideanupdateon
actionstakentoaddresstheserecommendations.
4.
Anauditrecommendationsselfassessmentreport,which
includesalogofauditreportssubmittedtotheAudit
Committeeandanyoutstandingactions,shallbesubmitted
toeachmeetingoftheAuditCommitteeforreview.
ChapterSeven
11
REMUNERATIONANDTERMSOFSERVICECOMMITTEE
TERMSOFREFERENCE
Membership
TrustChairman
Allothernonexecutivedirectors
Quorum
Nobusinessshallbetransactedunlessthemeetingisquorate.
ThequorumistheTrustChairmanandtwoothernonexecutive
directors.
InAttendance
ChiefExecutive(excludingmatterspertainingtotheCEO)
DirectorofHumanResources(excludingmatterspertainingtothe
DirectorofHumanResources)
TrustSecretary(excludingmatterspertainingtotheTrust
Secretary)(actsasSecretarytotheCommitteeandprovides
appropriatesupporttotheChairmanandcommitteemembers)
Frequency
Meetingsshallbeheldasandwhenrequiredandgenerallyatleast
twiceeachyear.
Reporting
TheminutesoftheRemunerationandTermsofService
CommitteemeetingsshallbeformallyrecordedbytheTrust
Secretaryand(subjecttotheneedtoprotectmattersofindividuals
confidentiality)submittedtotheBoard.TheChairmanofthe
CommitteeshalldrawtotheattentionoftheBoardanyissues
whichrequiredisclosuretothefullBoard,ornecessitateanyBoard
action.
ChapterSeven
12
Authority
TheCommitteeshallreporttotheBoard(viatheCommittees
minutes)abouttheCommitteesexerciseofitsdelegatedauthority.
TheCommitteeshallreporttotheBoardanyrecommendationsit
maywishtomake.TheBoardshallusesuchreportsasthebasis
foritsowndecisions,butremainultimatelyaccountableforthem.
TheminutesoftheBoard'smeetingsshouldrecordsuch
decisions.
Duties
InaccordancewithanydirectionoftheSecretaryofStateand
havingregardtoanynationalguidanceorarrangements,the
Committeeshallundertakethefollowingduties.
1.InregardtotheChiefExecutive,theotherexecutivedirectorsof
theBoardandtheotherseniorofficersreportingdirectlytothe
ChiefExecutive
Toexercise,onbehalfoftheBoard,delegatedauthorityforthe
following:
(a) Anynecessarydecisionsonappropriate
remunerationandtermsofservice,including:
(i)
Allaspectsofsalary(includingany
performancerelatedelements/bonuses)
(ii) Provisionsforotherbenefits,includingpensions
andcars
(iii) Arrangementsforterminationofemployment
andothercontractualterms
(b) Tobeassuredthatsuchofficersarefairlyrewarded
fortheirindividualcontributiontotheTrusthaving
properregardtotheTrust'scircumstancesand
performanceandtotheprovisionsofanynational
ChapterSeven
13
arrangementsforsuchmembersandstaffwhere
appropriate
(c) Tomonitorandevaluateperformanceof
designatedofficers(seesection3)and
(d) Tobeassuredconcerning,andwherenecessary
decideupon,theapplicationofappropriate
contractualarrangementsincludingtheproper
calculationandscrutinyofterminationpayments
(takingaccountofsuchnationalguidanceasis
appropriate).
2.InregardtoTruststaffwhoareemployedonlocaltermsand
conditions(i.e.notemployedonnationalarrangements)
Toexercise,onbehalfoftheBoard,delegatedauthorityforthe
following:
(a) Anynecessarydecisionsaboutappropriate
remunerationandtermsofservice.
3.InregardtotheChiefExecutiveandtheotherexecutive
directors
(a)Receiveanannualreport,fromtheTrustChairman,
ontheperformanceoftheChiefExecutive.
(b)Receiveindividualannualreports,fromtheChief
Executive,ontheperformanceoftheexecutive
directors.
4.GeneralMatters
TodrawtotheattentionoftheBoard,andwherenecessarymake
anyrecommendationsconcerning,anygeneralmattersof
remunerationandtermsofservicepolicyorpracticeforanyorall
groupsoftrustemployees.
ChapterSeven
14
ChapterSeven
15
NOTTINGHAMUNIVERSITYHOSPITALSNHSTRUST
FINANCEANDINVESTMENTCOMMITTEE
TERMSOFREFERENCE
Authorisation
TheBoardhasagreedtoestablishacommitteeoftheBoardtobe
knownastheFinanceandInvestmentCommittee.(TheFinancial
PerformanceandServiceEfficiencyMonitoringCommitteeis
herebydissolved).
Remit
OnbehalfoftheTrustBoardinrespectofFinance:
todefinethefinancialplanningprinciplesandperformance
indicatorsfortheplanningperiod,includingassessmentof
theimpactonquality:
theachievementofitsstatutoryfinancialduties
othermetricstobemanagedandtheirtrajectories
provisionalfinancialplans,priortoapprovalbythe
Board
anyothermatters,asdirectedbytheBoard
tomonitoronaregularbasistheTrustsfinancialposition,in
appropriatedetail,withparticularregardto:
theachievementofitsstatutoryfinancialduties
thecontrolofexpenditure
theadequacyoffinancialforecastingandreporting
proposedrevisionstotheplan,priortoapprovalbythe
Board
theimpactofthefinancialpositiononquality
OnbehalfoftheTrustBoardinrespectofInvestment:
ChapterSeven
16
to define the Trusts philosophy andobjectivesinrespect of

treasury management including cash investment and
managementofallelementsofworkingcapitalinthecontext
oftheTrustsagreedstrategywithparticularregardto:
establishingtheoverallmethodology,processesand
controls
ensuringthatrobustprocessesarefollowedand
monitoring of investments and other working capital
performance
todefinetheTrustsinvestmentphilosophyandobjectivesin
respect of capital expenditure and commitments, service
developmentsandothersignificantrevenuecommitmentsin
the context of the Trusts agreed strategy with particular
regardto
establishingtheoverallmethodology,processesand
controlswhichgoverninvestments
ensuringthatrobustprocesses(evaluationoffitwith
theTrustsoverallstrategyappropriateuseofexternal
consultants,qualityassuranceandapprovalof
businesscases)arefollowedand
evaluating, scrutinising and monitoring of investments
andresultantbenefits
evaluating, scrutinising and monitoring of performance
in relation to key infrastructure (estate, capital,
informationtechnology)
Inordertoundertakeitsresponsibilities,thecommitteeshall
receivesuchreportsasitthinksfit,including(butnotlimitedto):
Afinancereportwhichsetsoutdirectorateperformanceon
financialdeliveryoftheircurrentyearcostimprovement
programmes.(ThisreportshallbepresentedbytheDirector
ofFinanceandProcurement)
Acapitalprogrammereportwhichsetsoutprogresswith
proposedandapprovedschemes(Thisreportshallbe
presentedbytheDirectorofFinanceandProcurement)
ChapterSeven
17
Atreasurymanagementreportwhichsetsoutactivityand
performanceofcashinvestmentandmanagementofall
elementsofworkingcapital.(Thisreportshallbepresented
bytheDirectorofFinanceandProcurement)
RelationshiptotheTrustsManagementStructure
Nothinginthesetermsofreferenceshallpreclude
DiscussionbytheBoard,atitsregularmonthlymeeting,of
anymatterswhichitdeterminesarenecessaryto
demonstratethatitisdischargingitsstatutoryresponsibility
ofstewardshipforpublicfunds
Therespective,substantive,rolesoftheAuditCommittee
andtheQuality,SafetyandRiskCommittee,ascurrently
agreedbytheBoard.
DiscussionatregularoperationalmeetingsoftheTrust(for
example,butnotlimitedto,theDirectorsGrouporits
committees)ofanymatterswhichtheChiefExecutiveorhis
seniorofficersdeemarenecessarytoensuredeliveryofthe
Trustsperformancetargets.
Membership
ThreeNonExecutiveDirectors(notincludingTrustChairman),one
ofwhomshallchair
ChiefExecutive
DirectorofFinanceandProcurement
MedicalDirector
DirectorofNursing&MidwiferyandServiceImprovement
DirectorofHumanResources
InAttendance
ChiefOperatingOfficer
DirectorofICTServices
DirectorofEstatesandFacilities
AssociateDirector(Strategy)
TrustSecretary(SecretarytotheCommittee)
ExternalAuditor(bystandinginvitation)
ChapterSeven
18
Otherofficersasmayberequired,asandwhen,forindividual
meetings
Quorum
NobusinessshallbeconductedunlesstheCommitteeisquorate.
The quorum is at least three substantive members including one
Non Executive Director. In the absence of the committee
Chairman,anotherNonExecutiveDirectorshallpreside.
ChapterSeven
19
Frequency
TheCommitteeshallholdmonthlymeetings,timedtoprovidethe
optimumefficiencyinrelationtoitsinformationanddecision
makingneeds(thiswillgenerallybeattheendofthemonth).
Committees
TheCommitteeisauthorisedtoestablishitsowncommittees(i.e.
subcommitteesoftheBoard)providedthattheseareessential,
consistentwiththeoverallremitofthecommitteeandforthe
shortestdurationfeasible.
Reporting
TheCommitteeChairmanshallensurethatregularfeedbackon
theCommitteesactivitiesisprovidedtotheBoard.
ChapterSeven
20
COMMITTEEFORTHEAPPOINTMENTOFTHECHIEF
EXECUTIVEASEXECUTIVEDIRECTOR
TERMSOFREFERENCE
TheCommitteeshallbeconstitutedinaccordancewithEL(97)84
AppointmentstotheMostSeniorPostsintheNHS
MembershipandQuorum
TrustChairman
TwoNonExecutiveDirectors
OneExternalAssessor(nominatedbytheSHA,normallytheSHA
ChiefExecutive)
OneExternalAssessor(apersonofstandingandexperiencein
thefield,selectedinconsultationwiththeSHAChiefExecutive)
Frequency
Whennecessary
Reporting
TotheTrustBoardforratificationofappointment
Duties
TorecommendtotheTrustBoardtheappointmentofthe
ChiefExecutiveasanExecutiveDirector
TorecommendtotheTrustBoardthetermsofsuch
appointment
andsubjecttothepowersoftheRemunerationandTermsof
ServiceCommittee
Todetermineallothermattersrelatingtotheappointment
andtenureoftheChiefExecutiveasanExecutiveDirector
ChapterSeven
21
COMMITTEEFORTHEAPPOINTMENTOFOTHEREXECUTIVE
DIRECTORS
TERMSOFREFERENCE
TheCommitteeshallbeconstitutedinaccordancewithEL(97)84
AppointmentstotheMostSeniorPostsintheNHS
MembershipandQuorum
TrustChairman
ChiefExecutive
TwoNonExecutiveDirectors
OneExternalAssessor(nominatedbytheSHA)
OneExternalAssessor(apersonofstandingandexperiencein
thefield,selectedinconsultationwiththeSHAChiefExecutive)
Frequency
Whennecessary
Reporting
TotheTrustBoardforratificationofappointment
Duties
ToappointtheExecutiveDirectors,otherthantheChief
Executive
Tofixthetermsofsuchappointment
and,subjecttothepowersoftheRemunerationandTermsof
ServiceCommittee
Determineallothermattersrelatingtotheappointmentand
tenureoftheExecutiveDirector
ChapterSeven
22
ADVISORYAPPOINTMENTSCOMMITTEE
TERMSOFREFERENCE
RoleandPurpose
ThearrangementsforappointmentstoNHSConsultantposts
arestipulatedinstatutoryregulations:TheNHS(Appointment
ofConsultants)Regulations1996,asamended.Theseare
supportedbyTheNationalHealthService(Appointmentof
Consultants)RegulationsGoodPracticeGuidance,published
bytheDepartmentofHealthinJanuary2005.
Theregulationsprovideforappointmentstobemadevia
AdvisoryAppointmentsCommittees(AACs).
TheTrustBoardhasdelegatedtoAACstheauthoritytomake
decisionsonallappointmentsandforappointmentstobe
reportedtotheTrustBoardatasubsequentmeetingwherethe
decisiontoappointisunanimous.IftheCommitteecannot
makeaunanimousdecision,themajorityrecommendationwill
bereferredtotheTrustBoardforratification,beforeanofferof
appointmentismade.
Membership
MembershipisaslaiddowninRegulations.Theseallowforsome
flexibilitywhichwillbeexercised,asfollows:
REGULATION
TRUSTARRANGEMENTS
alaymember(oftenthe
ChairoftheTrustor
anotherNonExecutive
Director)
ThiswillnormallybetheChairman
oracurrentNonExecutive
Director,butifnoneoftheseis
availableaformerNonExecutive
DirectorfromtheTrustoroneofits
predecessorswillactaslaychair
anexternalprofessional
TherelevantRoyalCollegeor
assessor,appointedafter Facultywillbeaskedfora
ChapterSeven
23
representative
consultationwiththe
relevantcollegeorFaculty
theChiefExecutive(ora
BoardlevelExecutiveor
AssociateDirector)
ThiswillbetheChiefExecutiveor
delegatedtoanotherTrustDirector
themedicalordental
directoroftheTrust(or
personwhoactsina
similarcapacityatthat
hospital)ortherelevant
directorofpublichealth
forpublichealth
appointments
ThiswillbetheMedicalDirectoror
oneoftheDivisionalClinical
Directors.Inexceptional
circumstancesthiswillbeaClinical
DirectorofadifferentDirectorate,
withtheagreementoftheChief
ExecutiveandMedicalDirector
aconsultantfromthe
Trust,who,ifavailable,
shouldbefromthe
relevantspecialty
ThiswillusuallybetheClinical
DirectoroftherelevantDirectorate,
orifnotavailable,aConsultant
fromthespecialtyastheirdeputy
inthecaseof
appointmentstoposts
whichhaveeither
teachingorresearch
commitmentsorboth,the
committeemustalso
includeaprofessional
membernominatedafter
consultationwiththe
relevantuniversity
TheUniversityofNottinghamwill
beinvitedtohavearepresentative
onallNUHConsultant
appointments
AnAACmaynotproceedifanycoremember(ortheirappointed
deputy)isnotpresent.
Reports
AllconsultantappointmentswillbereportedinfulltotheTrust
BoardandtotheOperationalManagementExecutive.
ChapterSeven
24
Inaddition,eachDirectorateshouldnotifyICTofConsultant
appointments,forinclusionintheWaitingTimesBookletsenttoall
GPsandClinicalAssessmentServices.
FrequencyofMeetings
Asrequired
ChapterSeven
25
DONATIONCOMMITTEE
TERMSOFREFERENCE
Constitution
TheBoardherebyresolvestoestablishacommitteeoftheBoard
tobeknownastheDonationCommittee(TheCommittee).The
CommitteeisanonexecutivecommitteeoftheBoardandhasno
executivepowers,otherthanthosespecificallydelegatedinthese
TermsofReference.
Authority
TheDonationCommitteewillhavetheauthoritytomakeand
implementdecisionsondonationpolicyandpracticeensuringfull
consultationwithclinicalandmanagementstaffasintegraltothe
implementationprocess.
Purpose
Toinfluencepolicyandpracticeinordertoensurethatorgan
donationisconsideredinallappropriatesituations.
Toidentifyandresolveanyobstaclestothis.
Toensurethatadiscussionaboutdonationfeaturesinall
endoflifecare,whereverlocatedandwhereverappropriate,
recognisingandrespectingthewishesofindividuals.
Tomaximisetheoverallnumberoforgansdonated,through
bettersupporttopotentialdonorsandtheirfamilies
Objectives
Toensurethepurposeisachieved,theCommitteeisresponsible
forthefollowing:
Toleadondonationpolicyandpracticeacrossthetrust,to
raiseawareness,andtoensurethatdonationisaccepted
andviewedasusual,notunusual.
Tomaximiseorgandonation.
ChapterSeven
26
Toensurelocalpoliciesandalloperationalaspectsof
donationarereviewed,developedandimplementedinline
withcurrentandfuturenationalguidelinesandpolicies.
Tomonitordonationactivityfromallareasofthehospital
primarilyfromCriticalCareareas,includingEmergency
Medicine.Ratesofdonoridentification,referral,and
approachtothefamilyandconsenttodonationwillbe
collectedthroughtheUKTransplantPotentialDonorAudit.
ToensuresubmissionofthedatatoNHSBloodand
Transplantonanagreedbasisandtoreceiveandanalyse
comparativedatafromotherhospitals.
ToreporttotheMedicalDirectornotlessthanquarterly,and
totheBoardnotlessthansixmonthly,oncomparative
donationactivityandanyremedialactionrequired.
Toparticipateinallrelevantnationalauditprocessesto
reviewauditdataondonationactivitytomonitorstandards,
testadherencetolocalpolicyandinstigateanyrequired
actions.
Toactivelypromotecommunicationaboutdonationactivityto
allappropriateareasofthehospitalandtoensurethatthe
informationisreceivedandunderstood.
Toensureadiscussionaboutdonationfeaturesinallendof
lifecarewhereverappropriateandtoensurethisisreflected
inthelocalendoflifepolicies,proceduresandpathways.
Membership
Lay(nonemployee)member(Chair)
Consultantsurgeonorphysicianrepresentingorgan
transplantation(ViceChair)
ClinicalDonationChampion
DonorTransplantCoordinator
ClinicalLeadorseniornurseIntensiveCareUnit
ClinicalLeadorseniornurseEmergencyMedicine
ConsultantNeurosurgeon
ClinicalleadorseniornurseforPaediatricIntensiveCare
Unit
ConsultantPalliativeCareorleadnurseforpalliativecare
OperatingtheatrerepresentativeSeniornurse
ChapterSeven
27
EthicsCommitteerepresentative
Chaplaincy(multifaith)representative
PatientGrouprepresentative
Localdonorfamily
Quorum
NomeetingoftheCommitteeshallcommenceunlessitisquorate.
ThequorumoftheCommitteeisasfollows:
Consultantsurgeonorphysicianrepresentingorgan
transplantation(ViceChair)
And
ClinicalDonationChampion
And
DonorTransplantCoordinator
and
Atleastoneofthefollowing:
o ClinicalLeadorseniornurseIntensiveCareUnit
o ClinicalLeadorseniornurseEmergencyMedicine
o ConsultantNeurosurgeon
and
Atleastoneofthefollowing:
o EthicsCommitteerepresentative
o Chaplaincy(multifaith)representative
o PatientGrouprepresentative
o Localdonorfamily
Deputiesmayattendanymeeting,buttheywillnotcounttowards
aquorum.
Frequency
TheCommitteeshallmeetquarterly.
Reporting
TheminutesofCommitteemeetingsshallbeformallyrecordedby
theCommitteessecretaryandreportedtotheMedicalDirector.
TheMedicalDirectorshallreporttotheBoardbiannuallyonthe
workoftheCommittee.
ChapterSeven
28
ETHICSOFCLINICALPRACTICECOMMITTEE
TERMSOFREFERENCE
Constitution
TheBoardherebyresolvestoestablishanadvisorycommitteeof
theBoardtobeknownastheEthicsofClinicalPracticeCommittee
(Thecommittee).Thecommitteehasnoexecutivepowers.Its
purposeistoactassourceofgeneraladviceandlearningonthe
ethicalprinciplesunderlyingdecisionsinhealthcareandclinical
practiceofthetrust.
Membership
Themembershipofthecommitteeshallcomprisethefollowing:
AnonexecutivedirectoroftheBoard(whoshallbe
chairman)
Avicechairman(whoshallgenerallybeaclinician)
Fourfurtherlaymembers,(whoshallnotbeemployeesof
thetrust)chosenfortheirprofessionaland/orpersonal
expertiseandexperience
Fourseniormedicalcliniciansemployedbythetrust
Twoseniornursingcliniciansemployedbythetrust
Twoalliedhealthprofessionalsemployedbythetrust
Twofurtheremployeesofthetrust,chosenfortheir
professionaland/orpersonalexpertiseandexperience,one
ofwhomshallbeamemberoftheDirectorsGroup.
Furtherindividualsmaybecooptedatthediscretionofthe
committeechairman,actingonbehalfoftheBoard.
Appointmentstothemembershipofthecommitteeshallbe
reviewedatleasteverythreeyears.
ChapterSeven
29
Quorum
Nomeetingofthecommitteeshallcommenceunlessitisquorate.
Thequorumisfivesubstantivecommitteemembers,providedthat
thisincludesatleast:
Thechairman,orthevicechairmanoronelaymember(one
ofwhomshallactaschairman)
Oneotherlaymember
Twoemployeesofthetrust
Attendance
Atthediscretionofthecommitteechairman(or,intheirabsence,
thepersonpresiding),otherindividuals(whethertrustemployees
orotherwise)maybeinvitedtoindividualmeetingsofthe
committeetogivesupportoradviceonindividualmattersunder
discussion.Fortheavoidanceofdoubt,suchindividualswill
neithercounttowardsthecommitteesquorum,norplayaformal
roleinanydecisionsmadebyit.Thechairman(orotherperson
presiding)shallensurethat,undernocircumstanceswillany
patientconfidentialinformationbesharedwithindividualswhoare
notemployeesofthetrust.
Frequency
Thecommitteeshallmeetasandwhenrequired,asagreedbythe
substantivecommitteechairman.
Secretary
Thecommitteeshallappointasecretary,whowillberesponsible
foragreeinganagendawiththechairman,arrangingforthe
distributionofmeetingpapers,preparingtimelyminutesofeach
meetingandensuringthatanyagreedfollowupactionistaken.
Authority
ThecommitteeisauthorizedbytheBoardtoconsideranyactivity
withinitstermsofreference.
ChapterSeven
30
Duties
Thecommitteeshall,onreferralviathesecretaryorthechairman
(includingbyreferralfromcommitteemembers)consideractualor
potentialethicalissuesarisingforthecareand/ortreatmentof
potential,current,orformerpatientsofthetrust.Forexample(non
exhaustive),suchissuesmayarisein:
theimplementationofpoliciesforpatienttreatmentandcare
newinitiativesand/orpoliciesandproceduresforpatient
treatmentandcare
theimplicationsoflegaldecisionsaffectingpatienttreatment
andcare
dilemmasarisingfromthetreatmentandcareforpatients.
Membersofthecommitteemayfromtimetotime,supportthetrust
by participating in the teaching of ethical issues within the trust.
The committee shall not provide advice on the management of
individualcases,except whereageneraldiscussion ofthe ethical
issuesinvolvedclarifiestheproblemfortheresponsibleclinician.
Fortheavoidanceofdoubt,thecommitteewillnothaveanyrolein
providing ethical approval for research projects (this being the
responsibilityofanotherbody).
Reporting
Thechairmanshallensurethatminutesofeachmeetingare
producedinatimelymanner.Theunratifiedminutes(whichhave
beenapprovedindraftformbythechairmanortheperson
presidingattherelevantmeeting)shallbesubmitted,for
information,totheAuditCommittee,theDirectorsGroupandRisk
ManagementCommittee.Theunratifiedminutesshallalsobe
submittedtothenextmeetingofthecommitteeforformal
approval.
Thechairmanshallalsoensurethatanannualreportofthe
committeesworkispreparedandsubmittedtotheBoard.
ChapterSeven
31
Thechairmanshallensurethatneithertheminutesnortheannual
reportshallcontainanyinformationwhichcouldconstitute
(whetherdirectlyorindirectly)anybreachofpatientconfidentiality.
Intheeventthatitisnecessarytoraiseanymattersofurgency,
outsidetheusualreportingarrangements,thecommitteechairman
(or,intheirabsence,thepersonpresiding)shallcontactthe
medicaldirectororthetrustsecretaryaccordingly.
Remuneration
Substantivemembersofthecommittee,whoareneithernon
executivedirectorsnoremployeesofthetrust,shallreceive
reimbursementofreasonabletravellingexpensesattherate
currentlyapplicabletononexecutivedirectors.
Indemnity
TheBoardhasadoptedthefollowing(NHSstandard)indemnity
statementconcerningtheactivitiesofnonexecutivedirectors:
Achairmanornonexecutivememberordirectorwhohasacted
honestlyandingoodfaithwillnothavetomeetoutofhisorher
ownpersonalresourcesanypersonalcivilliabilitywhichisincurred
intheexecutionorpurportedexecutionofhisorherboard
function,savewherethepersonhasactedrecklessly.
Nationalguidancestatesthatthisindemnitymaybeextendedto
laymembersofthosecommitteeswhichhavedelegatedpowersto
makedecisionsortakeactionsonbehalfofNHSboards.
Inrespectoftheactivitiesofthiscommittee,theBoard
acknowledgesthatthecommitteedoesnothaveanydelegated
executivepowers.However,insofarasthecommitteeandits
membersconductitself/themselveswithinthesetermsof
reference,theBoardagreesthatthisindemnityshouldalsobe
extendedtothosesubstantivemembersofthecommitteewhoare
notemployeesofthetrust.
ChapterSeven
32
NOTTINGHAMUNIVERSITYHOSPITALSNHSTRUST
QUALITY,RISKANDSAFETYCOMMITTEE
TERMSOFREFERENCE
Authorization
TheBoardhasagreedtoestablishacommitteeoftheBoardtobe
knownastheQuality,RiskandSafetyCommittee.
Remit
In respect of the quality, risk and safety agenda, the committee
will,onbehalfoftheBoard:
define the strategy for quality and safety and supporting
performanceindicatorsincludingscrutinyandassessmentof
assuranceinrelationto:
thedischargingoftheTrustsstatutoryduties
achievement of other relevant metrics and their
trajectories
relevantbusinessandactionplans,priortoapprovalby
theBoard
the risks identified for hospital services and patient
care
the Annual Quality Account prior to approval by the
Board
performance against CQC standards, NHSLA
standardsandrelevantaspectsofALE
monitorandseekassuranceontheTrustsobligationsforthe
qualityandsafetyofpatientcare,inappropriatedetail,with
particularregardto:
theachievementofitsstatutoryregistrationobligations
(quarterly)
ChapterSeven
33
therelevantaspectsoftheBAF(quarterly)
InternalAuditreportsandassurances(monthly)
theimplementationoftheTrustsRiskManagement
Policy(Biannually)
theformalreviewandapprovalofallrisksscoring20or
aboveonthetrustagreedRiskAssessmentTool
(whennecessary)
theformalmonitoringofassuranceinrelationto
deliveryofagreedactionsplanstomitigateallrisks
containedwithinthetrustsSignificantRiskRegister
(monthly)
thedeliveryofitsTermsofReferenceandsupporting
workplan(biannually)
theachievementofitsstatutoryobligationsrelatingto
safeguardingchildrenandyoungpeopleand
vulnerableadults,healthandsafety,decontamination,
firesafetyandemergencyplanning.(quarterlyona
rollingprogramme)
infectionpreventionandcontrol,includinghealthcare
associatedinfections(monthlyaspartofqualityand
safetyreport)
untowardincidents,includingthosedeemedserious
(monthlyaspartofqualityandsafetyreport)
patientexperienceandfeedback(monthly)
researchgovernance(Biannually)
thedeliveryofallsubcommitteeworkplans(monthly
throughthemonthlyexceptionreports)
theongoingreviewofallquality,riskandsafetyrelated
policies(quarterly)
anyothermatters,asdirectedbytheBoard(as
required)
Themonitoringfrequenciesdefinedabovewillbeincorporatedinto
theQRSCannualworkplan(approvedannuallybytheBoard)
Inordertoundertakeitsresponsibilities,thecommitteeshall
receivesuchreportsasitthinksfit,including(butnotlimitedto):
ChapterSeven
34
Amonthlyqualityandsafetyreportwhichsetsout
performanceagainstthekeymetricsidentified.Thisreport
shallbepresentedbytheMedicalDirector.
Amonthlycomplaintsandcomplimentsreportwhich
analysesandreportsthefeedbackreceivedfrompatients
andtheirfamiliesandcarers.Thisreportshallbepresented
bytheDirectorofNursing.MidwiferyandService
Improvement.
Annualreportsforthekeystatutoryandpolicyobligations(to
bepresentedbytherelevantresponsibleofficerin
accordancewiththeQRSCworkplan).
Summary reports of the findings and recommendations of
seriousincidentinquirypanelsandactionplans.(Monthly)
Monthly summary reports and formal minutes from each
QRSCSubCommitteemeeting
Quarterly reviews of each subcommittee work plan to
monitordelivery
RelationshiptotheTrustsManagementStructure
Nothinginthesetermsofreferenceshallpreclude
DiscussionbytheBoard,atitsregularmonthlymeeting,of
anymatterswhichitdeterminesisnecessarytodemonstrate
thatitisdischargingitsresponsibilityforqualityandsafety.
Therespective,substantive,rolesofothercommittees,as
agreedbytheBoard.
DiscussionatregularoperationalmeetingsoftheTrust(for
example,butnotlimitedto,theDirectorsGrouporits
committees)ofanymatterswhichtheChiefExecutiveorhis
seniorofficersdeemarenecessarytoensuredeliveryofthe
Trustspriorities.
ChapterSeven
35
Membership
TheTrustChairman(whoshallchair)
TwootherNonExecutiveDirectors
ChiefExecutive
DirectorofFinanceandProcurement
MedicalDirector
DirectorofNursing,MidwiferyandServiceImprovement
InAttendance
ChiefExecutivesTeammembers(whoarenotExecutive
Directors)
ClinicalDirectors
PathwayLeads
ChairsofthefollowingsubcommitteesoftheQuality,Riskand
SafetyCommittee(ifnotalreadyincludedabove):
TheClinicalRiskCommittee(CRC),
TheClinicalEffectivenessCommittee(CEC)
TheOrganisationalRiskandPatientPartnershipCommittee
(ORPPC)
TheTrustInformationGovernanceCommittee(TIGC)
TheTrustHealth&SafetyCommittee(THSC)
TheInfectionControlOperationalGroup(ICOG)
DeputyDirectorofInfectionControlandPatientSafety
Other officers as may be required, as and when, for individual
meetings
MonitoringAttendance
Forthepurposesofmonitoringattendance,onlynamedattendees
willbecounted.Deputiesmayattendthemeetingbutthewillnot
becountedaspartoftheformalattendance.Itisexpectedthat
namedattendeeswillattendaminimumof80%ofallscheduled
meetings.SeeAppendix1.
ChapterSeven
36
Quorum
Nobusinessshallbeconductedunlessthecommitteeisquorate.
Thequorumisatleastthreemembers,(whichmustincludeone
nonexecutivedirector).Intheabsenceofthecommittee
Chairman,anothernonexecutivedirectorshallpreside.
Frequency
Thecommitteeshallholdmonthlymeetings,timedtoprovidethe
optimumefficiencyinrelationtoitsinformationanddecision
makingneeds.
Committees
Thecommitteeisauthorizedtoestablishitsowncommittees(i.e.
subcommitteesoftheBoard)providedthattheseareessential,
consistentwiththeoverallremitofthecommitteeandsitforthe
shortestdurationfeasible.ThecommitteesreportingtotheQuality,
RiskandSafetycommitteeshallbe
TheClinicalRiskCommittee(CRC),
TheClinicalEffectivenessCommittee(CEC)
TheOrganisationalRiskandPatientPartnershipCommittee
(ORPPC)
TheTrustInformationGovernanceCommittee(TIGC)
TheTrustHealth&SafetyCommittee(THSC)
TheInfectionControlOperationalGroup(ICOG)
Aftereverysubcommitteemeeting,asummaryreportdetailing
anyissuesfortheQuality,RiskandSafetycommitteetoconsider
willbeproducedandsubmitted,togetherwithformalminutesof
eachmeeting.CRC,CEC,ORPPCandICOGwillsubmitmonthly
reportsandminutesandTHSCbimonthlyreportsandminutes.
Eachsubcommitteeshallhavetermsofreferencewhichsupport
theroleofQuality,RiskandSafetycommittee.
Eachsubcommitteewillproduceanannualworkplanwhich
capturestheworkitwillundertakeduringtheyeartodeliverits
owntermsofreferenceandtosupportthetermsofreferenceof
ChapterSeven
37
theQuality,RiskandSafetycommittee.Allsubcommitteework
planswillbeformallyreviewedquarterlyandsignedoffbythe
quality,riskandsafetycommitteeatleastannually.
ReportingtotheBoard
ThechairmanoftheQuality,RiskandSafetycommitteeshall
providemonthlyverbalfeedbackonthecommitteesactivitiesat
eachBoardmeetingwhichwillberecordedintheBoardminutes.
MinutesfromeachQuality,RiskandSafetycommitteemeetingwill
becirculatedinthepapersforeachBoardmeeting.
TheQuality,RiskandSafetyCommitteeshallproduceanannual
reportonitsactivitieswhichitwillsubmittotheBoardinMay,with
asixmonthlyupdatereportwhichwillbesubmittedtotheBoardin
Novembereachyear.
MonitoringofDelivery
TheBoardwill,atleastannually,formallyreviewperformance
againstthedutiescontainedwithinthesetermsofreferencein
ordertoassureitselfoftheeffectivenessofthecommittee.
ChapterSeven
38
Appendix1
MembershipMay2010March2011
P.Barrett
J.Tabreham
I.Hall
P.Homa
G.Nolan
S.Fowlie
J.Leggott
Improvement
D.Mortimer
NonExecutiveDirector(Chair)
NonExecutiveDirector(ViceChair)
NonExecutiveDirector
ChiefExecutive/ChairofICOG
ActingDirectorofFinanceandProcurement
MedicalDirector
DirectorofNursing,MidwiferyandService
InAttendance
M.ODaly
P.Wozencroft
C.Lovatt
A.Fearn
J.Simpson
J.Worrall
TrustSecretary
AssociateDirectorofStrategy
DirectorofCommunications&Engagement
DirectorofICTServices,SIRO&ChairofTIGC
DirectorofEstates&FacilitiesManagement
ChiefOperatingOfficer
J.Evans
J.Skoyles
K.Girling
N.Sturrock
S.Ryder
A.Zaman
J.Lemberger
N.Welch
ClinicalDirector
ClinicalDirector
ClinicalDirector
ClinicalDirector
ClinicalDirector
ClinicalDirector
ClinicalDirector(untilAug2010)
ClinicalDirector
A.Brooks
R.Morris
E.Marder
J.Birchall
A.Haynes
PathwayLeadClinician
M.Reid
N.Beasley
DeputyMedicalDirector,ChairofCRC
DeputyMedicalDirector,ChairofCEC
ChapterSeven
39
K.Kirkwood
N.Mart
L.Abolins
AssociateDirectorofAssurance(QRSC
Secretary)&ChairofORPPC
HeadofOrganisationalQuality,RiskandSafety,
ChairofTHSC
DeputyDirectorofInfectionPreventionControl
andPatientSafety
ChapterSeven
40
Appendix1
EqualityImpactAssessmentReport
1.
2.
NameofPolicyorService
CorporateGovernanceFrameworkChapter7
ResponsibleManager
MikeODaly
3.
NameofpersonCompletingEIA
MikeODaly
4.
DateEIACompleted
10August2010
5.
DescriptionandAimsofPolicy/Service(includingrelevance
toequalities)
Thisdocumentprovidesthetermsofreferenceofthe
committeesoftheBoard.
6.
BriefSummaryofResearchandRelevantData
Thereisnoresearchorrelevantdataatthepresenttime.
7.
MethodsandOutcomeofConsultation
Consultationshavebeencarriedoutwiththefollowing:
(ThisdocumentcodifiesdecisionsmadebytheBoardupto
andincluding5August2010)
DirectorsGroup
AuditCommittee
8. ResultsofInitialScreeningorFullEqualityImpact
Assessment:
EqualityGroup
Age
Gender
Race
SexualOrientation
Religionorbelief
Disability
DignityandHuman
ChapterSeven
AssessmentofImpact
None
None
None
None
None
None
None
41
Rights
WorkingPatterns
SocialDeprivation
None
None
9. Decisionsand/orRecommendations(includingsupporting
rationale)
Fromtheinformationcontainedinthepolicy,itmydecision
thatafullassessmentisnotrequiredatthepresenttime.
10. EqualityActionPlan(ifrequired)
N/A
11. MonitoringandReviewArrangements(includingdateofnext
fullreview)
ThispolicyandEIAbereviewedtwomonthsbeforetheinception
oftheNUHfoundationtruststatus,orSeptember2011,whichever
comesfirst.
ChapterSeven
42
Appendix2
WeAreHereForYouMissionStatement:
ThisTrust is committedtoprovidingthehighestquality of careto
ourpatients,sowecanpledgetothemthatwearehereforyou.
This Trust supports a patient centred culture of continuous
improvement delivered by our staff. The Trust established the
Values and Behaviours programme to enable Nottingham
University Hospitals to continue to improve patient safety,
outcomes and experiences. The set of twelve agreed values and
behaviours explicitly describe to employees the required way of
working and behaving, both to patients and each other, which
would enable patients to have clear expectations as to their
experienceofourservices.
ChapterSeven
43
Appendix3
EMPLOYEERECORDOFHAVINGREADTHEPOLICY
TitleofPolicy/Procedure:
BOARDCOMMITTEESANDTERMSOFREFERENCE
Ihavereadandunderstandtheprinciplescontainedinthenamed
policy.
PRINTFULLNAME
ChapterSeven
SIGNATURE
DATE
44

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