Condition G6 and FT4 Self Certification

Meeting:

 Public Board

Date:

 10.05.2023

Report Title:

Condition G6 and FT4 Self Certification 

Agenda Item:

PUB23/4/10 

Author:

Stanley Mukwenya, Deputy Director of Corporate Affairs

Lead Director:

Emma de Carteret, Director of Corporate Affairs and Performance 

SR5: If we do not clearly define our strategic plans we will not have the agility to deliver the suite of improvements needed

X

SR6: If we do not deliver sustainable regulatory compliance and develop positive relationships, we will have limited ability to deliver our strategy

Equality Impact Assessment

No negative impact identified

X

Recommendation:

To approve the condition G6 and FT4 self-certification for publication.

Purpose

The purpose of this paper is to ask the Board to approve the draft annual self-certification against the NHS Provider License.

Executive Summary

All NHS Trusts are required by NHSE to self-certify that they are compliant with the conditions set out in their NHS Provider License. This is routinely monitored through the Single Oversight Framework. The Board is required to confirm it is compliant with the following certification or explain why it can’t certify itself as compliant.

Condition FT4

The Trust must self-certify compliance with required governance standards and objectives.

The Trust has a governance framework and structures to support decision making, underpinned by robust process and systems of accountability ensuring quality, performance issues are monitored and addressed. The Trust has a risk strategy, policy and appetite statement outlining direction and level of risk it is willing to accept. Policies and procedures are in place to support consistence including regular use of dashboards to monitor progress on performance and periodic audits targets.

• The Trust was rated overall as ‘Requires Improvement’ with ‘Good’ in Caring domain by the CQC in the last inspection (July 2022). However, HSCA 2008 Section 29a and 31 notices imposed against the Trust in 2020 remain active. Measures continue to be implemented and monitored to address compliance with national ambulance targets.
• As part of improvement plans accomplishments, the Trust successfully recruited to the Executive Team building up on leadership needs, board members completed phase 1 and 2 development sessions to strengthen board effectiveness. Furthermore, the CQC moved the Trust Well-Led domain rating from Inadequate to Requires Improvement. Improvements continue to be made in response to concerns raised by the CQC on safeguarding and organisational culture not aligning with the values of the Trust. As such, it is recommended that a “non-compliant” declaration is made as a result of these enforcement undertakings acknowledging breach of license conditions (SOF4).

Condition G6

The Board is asked to certify that necessary precautions applicable to EEast were taken to comply with the licence, NHS Legislation and Constitution.

The condition G6 and FT4 self-certification are recommended to Trust Board for approval.