Clinical governance - quality and safety

Clinical governance is an overarching framework through which NHS organisations support continuous improvement in the quality and safety of our delivery of care and treatment to our patients. This includes having policies and procedures to safeguard patient care and, importantly, promoting an organisational culture that encourages patients, visitors and staff to report any concerns they may have or make suggestions for improvement. NHS organisations are expected to demonstrate that concerns, comments or suggestions are investigated and that remedial action is put into place where needed. We are also committed to learning from where things go wrong and promoting  a culture of open transparency through duty of candour.

All NHS Trusts are regulated and monitored by the Care Quality Commission (CQC) and Royal Papworth Hospitals NHS Foundation Trust has met the requirements of all of the essential standards to achieve compliance and Registration with the CQC following the opening of our new hospital in 2019. We also achieved Outstanding across all Key Lines of Enquiry in our full Trust CQC inspection later that same year.

Further information on the requirements for compliance with the Health and Social Care Act (Regulated Activities) Regulations 2009 and the Care Quality Commission (Registration) Regulations 2009 can be found on the Care Quality Commission website:

At Royal Papworth Hospital NHS Foundation Trust we want quality and safety to be our core philosophy and to be at the heart of every decision that we make. Our expertise, reputation and network places us in a unique position to lead the way in delivering excellence in care through our cardiothoracic, respiratory and transplant services with outstanding:

  • Patient experience and engagement: developing and improving our services for and with the patients who need them
  • Patient safety: with a focus on eliminating avoidable harm to patients.
  • Effectiveness of care: using clear, consistent processes and standards to deliver successful treatment assessed by clinical outcome measures and the patient’s experience.

Papworth Hospital monitors its achievements and progress on improving quality and safety through a mechanism of quarterly and annual reporting:

Quarterly Quality and Risk Reports


Q4 - January - March 2022/23 (Including annual summary 2022/23)
Q3 - October - December 2022/23
Q2 - July - September 2022/23
Q1 - April - June 2022/23


Q4 - January - March 2021/22 (Including annual summary 2021/22)
Q3 - October - December 2021/22
Q2 - July - September 2021/22
Q1 - April - June 2021/22


Q4 - January - March 2020/21 (Including annual summary 2020/21)
Q3 - October - December 2020/21
Q2 - July - September 2020/21
Q1 - April - June 2020/21


Q4 - January - March 2019/20 (Including annual summary 2019/20)
Q3 - October - December 2019/20
Q2 - July - September 2019/20
Q1 - April - June 2019/20


Q4 - January - March 2018/19 (Including annual summary 2018/19)
Q3 - October - December 2018/19
Q2 - July - September 2018/19
Q1 - April - June 2018/19


Q4 - January - March 2017/18 (including annual summary 2017/18)
Q3 - October - December 2017/18
Q2 - July - September 2017/18
Q1 - April - June 2017/18