NHS Provider Licence - Self-Certification

As an NHS Trust, our Board must self-certify that we can meet the obligations set out in the NHS provider licence, which includes requirements to comply with NHS Acts, the Constitution, and with governance requirements. Regular self-certification provides assurance that NHS trusts are compliant with the conditions of their NHS provider licence.

The two conditions that our Board must review to ensure that effective systems are in place to demonstrate compliance are Condition G6 and Condition FT4.

Condition G6 requires the Trust to have processes and systems that:

• identify risks to compliance with the licence, NHS acts and the NHS Constitution
• guard against those risks occurring

The Trust must confirm compliance:

Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution.

Condition FT4 requires the Trust to have systems and processes that supports good governance:

• including ensuring a compliant approach by reviewing effectiveness of Board and Committee structures, reporting lines, performance and risk management systems.

The Trust must confirm compliance:

1. The Board is satisfied that the Licensee applies those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS.

2. The Board has regard to such guidance on good corporate governance as may be issued by NHS Improvement from time to time.

3. The Board is satisfied that the Licensee has established and implements:

(a) Effective board and committee structures

(b) Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees

(c) Clear reporting lines and accountabilities throughout its organisation

4. The Board is satisfied that the Licensee has established and effectively implements systems and/or processes:

(a) To ensure compliance with the Licensees duty to operate efficiently, economically and effectively

(b) For timely and effective scrutiny and oversight by the Board of the Licensees operations

(c) To ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions

(d) For effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensees ability to continue as a going concern

(e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making

(f) To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence

(g) To generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery

(h) To ensure compliance with all applicable legal requirements |

5. The Board is satisfied that the systems and/or processes referred to in paragraph 4 (above) should include but not be restricted to systems and/or processes to ensure:

(a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided

(b) That the Boards planning and decision-making processes take timely and appropriate account of quality of care considerations

(c) The collection of accurate, comprehensive, timely and up to date information on quality of care

(d) That the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care

(e) That the Licensee, including its Board, actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources

(f) That there is clear accountability for quality of care throughout the Licensee including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.

6. The Board is satisfied that there are systems to ensure that the Licensee has in place personnel on the Board, reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS provider licence.