Annual Self-Certification 2025

Meeting: Trust Board – Public Meeting

Date: 7 May 2025

Report title: Annual Self-Certification

Agenda Item: PUB25/05/6.1

Author: Stanley Mukwenya, Deputy Director of Corporate Affairs

Lead Director: Simon Chase, Chief Paramedic and Director of Quality

Purpose: Decision approval Assurance: Limited Link to CQC domain: Caring, responsive, effective, well-led, safe Link to Strategic Objective:

• Be an exceptional place to work, volunteer and learn.
• Provide outstanding quality of care and performance.
• Be excellent collaborators and innovators as system partners.
• Be an environmentally and financially sustainable organisation.

Link to Strategic Risk:

• SR5: If we do not clearly define our strategic plans, we will not have the agility to deliver the suite of improvements needed.
• SR6: Ability to ensure sufficient capacity and capability to ensure sustainable change.

**Equality Impact Assessment:**No negative impact identified.

Purpose: To present the Trust’s self-certification against conditions of the NHS Provider Licence in accordance with the self-certification guidance and under specific conditions of the NHS provider licence.

Recommendation: To approve the content of the self-certification for signature by the Chair and Chief Executive. Note that the self-certification must be published on the Trust’s website within one month following Board approval.

Executive summary:

All NHS Trusts are required to self-certify on an annual basis that they are compliant with the conditions set out in their NHS provider license. This is routinely monitored through the assurance framework, however, also requires self-certification that the Trust has effective systems to ensure compliance with the NHS provider license, NHS legislation and regard to the NHS constitution (condition G6 self-certification) and that they have complied with governance arrangements (condition FT4).

Self-Certification 2024/25

The Trust’s self-certification for 2024/25 applies a response option of ‘Confirmed’ or ‘Not Confirmed’ to each declaration statement or component. It is up to each provider how it undertakes the self-certification process.

In assessing the Trust’s compliance with the declarations and identifying any risks/mitigations, factors relevant to 2024/25 have been considered.

These include:
• CQC inspection findings • NSH England or other enforcement undertakings

Condition FT4 Self-Certification

The Condition FT4 self-certification assesses the Trust’s systems and processes for good governance.

The Board is asked to ratify that the Trust confirms three of the six assertions within this self-certification. The assurance for this includes:

• The Trust has a robust and embedded Board Governance and Assurance Framework, Standing Orders, Standing Financial Instructions, Reservation of Powers and Scheme of Delegation which is reviewed on an annual basis.
• There is a robust and embedded sub-committee assurance and escalation reporting, which has been assessed and re-aligned in line with the strategic objectives.
• The Trust is on track to close the remaining actions associated with the original s29a Warning Notice.
• The Integrated Performance Report continues to be developed to ensure robust assurance is provided, not only at Board but also at Committee level, including pro-active oversight of statistical variation.

Given that the Trust has a section 64 warning from the CQC and a warning notice from the Health and Safety Executive, the Trust cannot confirm compliance with assertion FT4(4), (5)(a) or FT4(6). These are aligned to the areas of concern outlined within the proposed legal undertakings and relate to:

• The Trust has failed to meet national ambulance targets, and as such is non-compliant with its license conditions as required under FT4(6).
• Concerns in relation to staff training, staffing levels, investigation of controlled drug incidents, call wait times, the culture of the service, and acting on information from staff to develop and improve the service, demonstrating the need to strengthen systems and processes to ensure compliance with the Trust’s duty to operate efficiently, economically and effectively (FT4(4)(c), FT4(5)(a) and a failure to ensure compliance with healthcare standards binding on the Trust (FT4(5)(c).

Condition G6 Self-Certification

The Board is asked to ratify that the Trust confirms that all necessary measures were taken to comply with the license conditions and has in all circumstances acted with regard for the NHS constitution. Further assertions are not applicable to EEAST.

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

Appendix 1. – Condition FT4 Self-Certification Appendix 2. – Condition G6 Self-Certification