Condition G6 and FT4 Self-Certification - May 2024
Meeting: Public Trust Board
Date: 8 May 2024
Report Title: Condition G6 and FT4 Self-Certification
Agenda Item: 2.3
Author: Stanley Mukwenya, Deputy Director of Corporate Affairs
Lead Director: Jo Cripps, Interim Director of Corporate Affairs and Performance
Purpose: Decision approval
Assurance: Limited
Link to CQC domain: Caring, Responsive, Effective, Well-led and Safe
Link to Strategic Objective(s):
- 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
Equality Impact Assessment: No negative impact identified
Previously considered by: Director of Corporate Affairs and Performance
Recommendation:
- To approve the content of the self-certification for signature by the Chair and Chief Executive
- Note that NHSE’s assessment in relation to condition FT4 has been considered in assessing the Trust’s compliance and is reflected in the self-certification, Appendix 1
- Note that the self-certification must be published on the Trust’s website within a month following Board approval.
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.
Executive Summary
NHS Trusts at authorisation are issued with a ‘Provider Licence’ that sets out conditions by which they should operate. The licence forms part of the oversight arrangements for NHS providers.
An annual self-certification process is used to demonstrate compliance with specific licence conditions. This report confirms the declarations that are required each year under the specific conditions of the licence (Appendix 1) with the main body of the paper presenting the self-certification for Board approval.
Self-certification 2023/24
The Trust’s self-certification for 2023/24 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. Any process should ensure that the provider’s Board understands clearly whether the provider can confirm compliance.
In assessing Trust compliance with the declarations and identifying any risks/mitigations, factors relevant to 2023/24 have been considered. These include:
- CQC inspection findings
- NSHE or other enforcement undertakings
Condition FT4
Condition FT4 is about systems and processes for good governance. NHS providers are required to make a corporate governance statement under condition FT4(8) as to current and future compliance with condition FT4.
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 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, some of the HSCA 2008 Section 29a and 31 notices imposed against the Trust in 2020 remain active. As such, it is recommended that a “non-compliant” declaration is made because of these enforcement undertakings acknowledging breach of license conditions (SOF4).
The table below outlines the changes to condition against the Trust to date:
| Conditions | Current position | |
|---|---|---|
| S31.1 | Safeguarding | Condition lifted |
| S31.2 | Allegations | Condition lifted |
| S31.3 | DBS processes | Condition lifted |
| S31.4 | Pre-employment checks | Condition lifted |
| S31.5 | PAS | Under review - expected end of Q1 2024/25 submission |
| S31.6 | Sexual harassment and sexual assault | Under review - expected end of Q1 2024/25 submission |
| S29.1 | Action plans | Advised by CQC that this will be covered in next inspection |
| S29.2 | HR Governance | Advised by CQC that this will be covered in next inspection |
| S29.3 | HR complaints | Submitted – Awaiting decision from CQC |
- As part of improvement plans and accomplishments, in 2023/24 the Trust was moved from NOF4 to NOF3. Measures continue to be implemented and monitored to address compliance with national ambulance targets. The Trust has a stable Executive team and Board supporting its leadership needs. The Board has a development programme in place to strengthen its effectiveness.
Condition G6
The Board is asked to certify that the 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.
