Self Certification

NHS trusts are required on an annual basis to complete the self-certification against the condition set out in FT4 (8) of the FT Licence. The completion is on a confirmed or not confirmed basis for each declaration as appropriate. Any areas where the Trust has not confirmed must include a declaration explaining why.

Statement

Assurance

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. The Board has ensured during the year that it has applied the principle, systems and standards of good corporate governance including:
  • Continuing to develop the well Led work
  • Ensuring there is an internal audit work programme
  • Maintaining a performance management framework
  • Ensuring that there are clear lines of accountability across the organisation including reporting lines
  • Maintaining an assurance framework
  • Established an OD programme of work across the Trust

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

The Trust uses guidance released on a regular basis to ensure that it maintains high standards of corporate governance across the Trust.

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

  • Effective Board and Committee structures
  • Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and
  • Clear reporting lines and accountabilities throughout its organisation

The Trust has reviewed its effectiveness and that of the committee structure during the year.

The Trust is clear about the responsibilities the Board, the committees hold, and the responsibilities of the staff reporting to the Board and the committees.

The Trust is satisfied that there are clear lines of accountabilities across the organization.

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

  • To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively;
  • For timely and effective scrutiny and oversight by the Board of the Licensee’s operations;
  • 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;
  • for effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee’s 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; and

(h) to ensure compliance with all applicable legal requirements.

The Board receives regular reports through the Committees or directly to the Board that assures the Board that the Trust has implemented systems and processes that:

  • maintain compliance with the duty to operate efficiently, economically and effectively.
  • maintain timely, effective scrutiny and oversight
  • maintain compliance with health care standards as required by the CQC.
  • maintain effective financial decision making, management and control
  • maintain accurate, timely and comprehensive information for the Board and committees
  • maintain risk management processes
  • maintain an understanding of risk of compliance with the Conditions of the Licence
  • maintain an ongoing understanding of the delivery of business plans and challenges to delivery of annual objectives

The Board is satisfied that the systems and/or processes referred to above include but are not 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 Board’s 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; and

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

The Board is satisfied that there is sufficient capability at Board level. This is tested annually through appraisals.

The Board does plan and make decisions in a timely and appropriate way taking into account the quality of care. This is demonstrated through the Board minutes and the papers received by the Board.

The Board requires the Trust to provide accurate, comprehensive and timely information on quality of care and requires a Board Committee to concentrate on the quality of care delivered across the Trust.

Each quarter the Board hears a patient story from a patient or members of staff. Members of the Board regularly visit all sites and talk to patients and staff about the service being delivered. Board members are involved with stakeholder to discuss the service provided by the Trust and to seek ways in which the whole system can be improved to improve the high quality of care already delivered.

The Trust believes that the quality of care delivered in the organisation is of paramount importance to the patients, staff, family members, carers and the Trust. The Trust is constantly seeking way of developing and improving the quality of the delivery of the service and has put in place governance systems that ensure the escalation of issues does occur when appropriate.

The Board is satisfied that the Licensee has established the existence and effective operation of systems to ensure that it has in place personnel on the Board, reporting to the Board and within the rest of the Licensee’s organisation who are sufficient in number and appropriately qualified to ensure compliance with the Conditions of this Licence.

The Board is satisfied that the number of staff and leaders and the capabilities of those staff and leaders are of a sufficiently high level to be able to deliver high quality effective healthcare services to our patients. The Board is satisfied that the staff within the organization are appropriately quality to ensure compliance with the Conditions of this Licence are maintained.

FT4SCT_D_FY2018-19_M02_RY5

Back to Our Publications Date Last Modified 29/08/2018