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Integrated Governance Department

Patient Safety 

Healthcare is a complex understanding.  Things sometimes go wrong in complex systems. Mid Cheshire Hospitals NHS Foundation Trust is committed to be mindful to these dangers and provide services and an environment that are safe for patients.  Despite the extraordinary hard work of healthcare professionals, patients are unintentionally harmed in hospitals every day.  The Trust is dedicated to reducing the avoidable harm to patients.  The Quality and Safety Improvement Strategy aims to improve the quality of care provided for patients and reduce avoidable harm to patients through the monitoring and measuring of quality and safety indicators.  These indicators have been chosen by staff, patients and the public and have been developed in the Trust’s 10 out of ten.

The Patient Safety Team follows guidance set by the National Patient Safety Agency, Care Quality Commission and other national bodies in ensuring that systems are in place to prevent harm to patients.  The Patient Safety Team lead on a number of patient safety initiatives such as the National Patient Safety First Campaign and more recently the Patient Safety Express.  The Patient Safety Express is a national programme to achieve rapid improvement through the widespread involvement of frontline clinicians and to engage patients and their families in the quest for harm free, safe care.

For more information please contact:

Patient Safety

Telephone: 01270 273103 / 01270 273158 or email



Clinical Governance is a term used to describe the systems, structures and processes in place within an NHS organisation, to ensure that they provide and maintain an environment which facilitates provision of quality standards of care and ensures that patients are safe and risks are managed.

MCHFT is committed to providing and improving the quality of patient services through robust systems and processes and effective leadership.  The Governance Team ensures that the Trust follows guidance set by the National Institute for Health and Clinical Excellence (NICE), Care Quality Commission, Professional Registrated bodies, National Guidance and the NHS Litigation Authority.  The governance team manages and overseas the development and implementation of new policies and procedures throughout the Trust, ensuring that they have undertaken the correct processes for ratification and have been assessed against Equality and Diversity requirements.

The team manages and provides support for the Trust regarding Information Governance to ensure that the Trust fulfils its legal requirements.  There are a range of complex legal and professional obligations that limit, prohibit or set conditions in respect of management use and disclosure of information and, similarly, a range of statutes that permit or require information to be used or disclosed.

Information Governance provides a framework to bring together all the legal rules, guidance and best practice ensuring necessary safeguards for, and appropriate use of, patients and personal information.  This provides assurance that the Trust can be trusted to maintain the confidentiality and security of personal information, by helping individuals to practice good information governance and to be consistent in the way they handle personal and corporate information.

For more information please contact:

Clinical Governance

Telephone 01270 273767/ 01270 273350

Information Governance

Telephone 01270 273350 / 01270 273812 or email


Health and Safety

The Health and Safety team support the ongoing development of a positive environment and culture which promotes the health and safety and well-being of patients, staff, visitors, contractors and others who come into contact with the hospital.  The team provide advice and support to ensure that health and safety risks are identified and managed in a proportionate manner commensurate to the level of risk the pose to the organisation.  Health and Safety is wide ranging and covers all workplace risks, topics include fire safety, asbestos, moving and handling, equipment, working at height, slips and trips, computer use, handling and use of hazardous substances, construction design and management.  The team develop policies and procedures to ensure compliance with requirements of legislation.  The main focus of the team is providing a safer and healthier work environment:

  • Reducing the number of and seriousness of incidents, injuries and cases of ill-health reported each year

  • Promoting a positive culture of incident reporting

  • Promoting the management of health and safety risks in a proportionate manner relative to the real risks

  • Enhancing experiences of everyone within the Trust by reducing health and safety related incidents.


For more information please contact:

Health and Safety Team

Telephone 01270 273413 / 01270 273746


Clinical Effectiveness

In 2009, the Mid Cheshire Hospitals NHS Foundation Trust (MCHFT) created the Clinical Effectiveness work stream to combine Clinical Audit with Research and Development (R&D).   At the same time various clinical trial teams were integrated into the R&D, bringing the work stream under a single management structure known locally as the Integrated Governance Department.  The Clinical Effectiveness is tasked with ensuring best practice via clinical research and audit so that MCHFT can deliver demonstrable improvements in patient care.

The Clinical Audit team provides services to support Clinical Audit activity throughout the Trust, based on the clinical division and specialty structure.  The main role of the Clinical Audit team is to facilitate high quality Clinical Audit projects that result in benefits and improvements in care quality for patients which, in turn, provide assurances about the quality of clinical services offered by the Trust.  At the same time, the Clinical Audit process allows changes in practice to be implemented at the local levels and using a robust monitoring and maintenance of Clinical Audit activity, the Trust aims to provide sound evidence of best practice.  This is reflected in Trust compliance with the National Health Service Litigation Authority Standard 5: Criterion 1- Clinical Audit and participation in National Comparative Audits as reported in the Trust Quality Account.

The R&D and Clinical Trial teams support the National Institute of Health Research studies and thus receive research funding support from the Cheshire and Merseyside Comprehensive Local Research Network.  The research portfolio at MCHFT covers: oncology, surgery, stroke, reproductive health, cardiology, rheumatology, dermatology, ophthalmology, as well as paediatric and community studies among others.

To find out more, please contact:

Clinical Effectiveness Team

Tel: 01270 612033 / 01270 612163

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