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North Cumbria University Hospitals NHS Trust - 70 years of the NHS

Home > About us > How we govern our organisation

How we govern our organisation

Our overriding strategic aim as an organisation is to ensure we provide high quality, safe and effective services for all our patients. Our Trust recognises that governance and risk management in the NHS is evolving constantly and is committed to continuously improving its processes, in line with key national guidance and best practice to ensure safe, high quality care for our patients. In addition it is committed to the provision of a clear framework within which our staff can work effectively.

Our Trust is committed to a holistic approach to governance and risk management by taking those steps that are feasible to minimise the harmful effects of loss on the organisation – either loss of service quality, loss of a safe environment for staff, financial loss or loss of reputation. Governance, risk and quality have evolved and developed significantly during recent years, therefore, it is important to ensure we have a common understanding of language used to describe governance, risk and quality in our organisation:


Governance is ‘systems, processes and behaviours by which organisations lead, direct and control their functions in order to achieve organisational objectives, safety and quality of services and in which they relate to patients and carers, our staff, the wider community and our partner organisations’.

The Trust has in place a committee structure, which supports the effective governance and risk management of the organisation and the monitoring of performance.  The key committees of the organisation have agreed terms of reference, which are outlined within the Trust’s Standing Orders.  Please see details of the Trust’s key committees and the Standing Orders for more information. 

Risk Management

Risk management is ‘the term applied to the use of a logical and systematic method of identifying, analysing, evaluating, controlling, monitoring and communicating risks associated with any activity, process or function necessary to the achievement of the organisation’s objectives’. Risk management is a continuous process and it aims to influence behaviour and develop an organisational culture within which risks are recognised and addressed.


Quality is the delivery of safe, effective care which results in a positive patient experience.

Our organisation has six Core Pillars of Governance that provides an overarching framework for reviewing both clinical and corporate governance across our organisation (see below). You can find out more information concerning these pillars of governance by using the navigation headings on the left hand side of this page under How we govern our organisation.


Compliance and Regulation

This is how we conform to agreed standards through the various regulatory bodies that all NHS organisation have to comply with, for example the NHS Litigation Authority (NHSLA), the Care Quality Commission (CQC), the Clinical Negligence Scheme for Trusts (CNST) and the Health and Safety Executive (HSE). The outcomes from external agency visits, as well as meeting the required national and local performance indicators, are also included in our compliance with key standards and regulations.

Standards, Safety & Experience

These are the three core strands for how we measure quality within our organisation:

  • The Standards of care we set for our patients and staff and how we monitor and benchmark against best practice and other organisations
  • The Safety of the care we provide to our patients and the Safety of the environment we provide for our staff to work in
  • The Experiences our patients have from the care we give and the Experiences our staff have in their day to day working environment

Risk Management

This is the process within the organisation for the management of all clinical and non-clinical risks. This includes the management of incidents, near misses, and ongoing assessment of risks in clinical and non clinical areas across the organisation.

Workforce Governance

This is the system to ensure all staff are safe and supported to deliver quality patient care. This includes collective accountability to ensure fair and effective management arrangements exist for all staff, as well as how we develop our staff to meet the objectives of our organisation.

Information Governance

This ensures necessary safeguards for, and appropriate use of, patient and personal information.

Financial Governance

This is the process by which the finances and our financial plans for the organisation are monitored and reviewed. A key component of this is ensuring all staff follow the Trust’s Standing Financial Instructions and Scheme of Delegation.