Guidance for NHS trusts and foundation trusts: assessing the well-led key question

Page last updated: 1 May 2024

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Governance, management and sustainability

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

What does good look like:

The trust’s board members and senior leaders can show evidence that they understand and effectively meet their personal accountability for the organisation’s:

  • quality of care and outcomes for patients
  • workforce
  • operational and financial performance.

The trust has clear governance, assurance, risk and accountability structures. These interact well with each other and support effective decision making. They provide robust assurance that risks are effectively and sustainably mitigated, and the quality of care is consistently sustained. Trust staff at all levels are clear about roles and responsibilities.

When planning services, improvements or efficiency changes, the trust understands the impact of decisions on its workforce, quality of care, and financial sustainability, including for the wider health and care system. The trust has a robust financial governance framework. It manages financial risk effectively and actively engages with system partners to support the delivery of system-wide financial balance.

The trust’s governance and management of partnerships, joint-working arrangements and third parties is effective and supported by effective and robust assurance systems. The trust regularly reflects on and reviews its governance and leadership across the organisation to ensure continuous improvement and development. The trust has clear processes, robust data and suitable information systems to effectively identify, manage, escalate and sustainably mitigate current and future risks. These include:

  • estates and equipment
  • cyber and information governance risks to the quality of care
  • safety
  • workforce
  • operational delivery
  • finance performance.

The trust implements appropriate measures and training to minimise the impact of incidents, such as software or hardware failures, cyber-attacks and or/data breaches.

Delivering good quality care is underpinned by evidenced-based decisions, up-to-date information and knowledge and relevant data. Staff are actively supported to access up-to-date guidance on quality, standards and good practice. Clinical and internal audit processes, information governance, cyber security, and library and knowledge services function well. They have a positive impact in driving improvements in the quality of care and internal systems of control. Trusts can show evidence of effective and sustained action to resolve concerns raised.

Leaders at all levels of the organisation receive and analyse relevant, timely, accurate, valid and reliable data. This supports them to gain insight into patient experience, performance and use of resources, and make changes to improve as necessary. The trust has clear structures and systems of accountability, and it uses performance information to hold staff to account. Data is triangulated with clinical insight, observation and feedback from staff and patients to gain robust assurance.

The trust shares data and information externally with integrated care boards, place-based partnerships, and provider collaboratives. It does this in line with data protection legislation and in a timely way as required. There are processes and plans to enable the trust to be prepared to deal with emergencies such as internal incidents, significant equipment failures or extreme weather events.


Further detail and context:

Corporate governance

The trust’s board should be able to deliver effective leadership, and prudent and effective oversight of its operations. This is to ensure the trust is operating in the best interests of patients and the public. Corporate governance is how trust boards lead and direct their organisations so that decision-making and managing risk is effective, and the right outcomes are delivered for people. For trusts, this means delivering high-quality services in a caring and compassionate environment, while collaborating within integrated care systems for joined-up care. It also means complying with the triple aim duty of:

  • better health and wellbeing for everyone
  • better quality of health services for all individuals
  • sustainable use of NHS resources.

Quality governance

Quality governance in a trust is the combination of structures and processes at board level and below to lead on trust-wide quality performance. It includes:

  • ensuring required standards are achieved
  • investigating and acting on sub-standard performance.

A key part of quality governance is the need for assurance that risks are reliably understood, managed and mitigated in line with controls. This includes considering and discussing quality issues at board and management forums, with well-presented reports that highlight key risks and concerns in a clear way.

Financial governance

To enable strong financial governance, it is important that board members have sufficient understanding of financial issues and risks to make decisions and that there is a culture which supports open debate on financial matters at board level. Appropriate training for board members on topics such as finance and financial governance can be an effective way to enable this, as well as ensuring that finance reports to board and management forums are concise with the financial position clearly set out.

The role of the board

Robust corporate, quality and financial governance arrangements complement and reinforce one another. Clinicians are at the front line of ensuring patients receive good quality care. However, the board of directors takes final and definitive responsibility for improvements, successful delivery and, equally, failures in the quality of care. Effective governance therefore requires boards to pay attention to both the quality of care and quality governance, financial and operational efficiency of their organisation. Boards also set the tone of their organisation by demonstrating shared values and behaviours. They recognise their organisation’s role in an integrated care system and the wider NHS, and the risks and opportunities this may present for the quality of care. The code of governance for NHS provider trusts sets out the detail on specific governance requirements for trust boards and directors, and for governors in foundation trusts.

Emergency preparedness

The NHS Emergency Preparedness, Resilience and Response Framework details the requirements for trusts. It includes details of an annual assurance process and organisational self-assessment. This ensures trusts are properly prepared to deal with emergencies such as internal incidents, significant equipment failures or extreme weather events.


Best practice / guidance

Corporate and quality governance

NHS England: Code of Governance for NHS provider trusts

NHS England: Guidance on good governance and collaboration

NHS England: Your statutory duties: A reference guide for NHS foundation trust governors

NHS England: Addendum to Your statutory duties – reference guide for NHS foundation trust governors: System working and collaboration: role of foundation trust councils of governors

NHS England: National Quality Board

Healthcare Quality Improvement Partnership: Good governance handbook

The NHS Provider Licence

PHSO: NHS Complaint Standards

National Quality Board: National Guidance on System Quality Groups and National Guidance on Quality Risk Response and Escalation

Department of Health: Guidance on the role of the Responsible Officer

The role of the board

The Healthy NHS Board: Principles for Good Governance

Financial governance

HMFA: Are you getting the basics right?

Clinical governance

National Patient Safety Alerts and Decision Flow Chart for Patient Safety Alerts

General Medical Council: Effective clinical governance for the medical profession

Mental health standards

Code of Practice Mental Health Act 1983

Psychiatric Liaison Accreditation Network (PLAN) Standards

Digital and information governance

NHS England: Information governance

NHS England: Cyber and data security services and resources

National Cyber Security Centre: Advice & Guidance

NHS England: DAPB0086 Data Security and Protection Toolkit information standard

NHS England: Digital Technology Assessment Criteria

DHSC: Network and information systems (NIS) regulations 2018: health sector guide

PRSB: Professional Record Standards Body Standards

NHS England: What Good Looks Like - Framework

Emergency preparedness

NHS England: NHS Emergency Preparedness, Resilience: Guidance and Framework

NHS England: Severe weather

UK Health Security Agency and NHS England: Third Health and Care Adaptation Report

Cold Weather Plan for England: Action card – Commissioners (health and social care) and local authorities

UK Health Security Agency: Cold weather plan for England

Heatwave Plan for England


Link to regulations

Regulation 17: Good governance

May also consider: Regulation 12: Safe care and treatment