Self-Certification Provider Licence

This provides assurance that LCHS complies with the terms of its Licence and sets out a broad outline of the licence conditions and any issues for Board to note.

A. General conditions (G) – general requirements applying to all licensed providers.

B. Condition FT4 – Corporate Governance Statement

A.    General licence conditions (G)




A.    General licence conditions (G)

1. Provision of information

Obligation to provide NHS Improvement with any information it requires for its licensing functions.

The Trust is currently obliged to provide NHS Improvement with any information it requires and, within reasonable parameters, to publish any information NHS Improvement requires it to. We have systems in place to identify and respond to routine and ad-hoc requests. Formal articulation of this Condition, therefore, does not present any issues for the Trust.

2. Publication of information

Obligation to publish such information as NHS Improvement may require.

3. Payment of fees to NHS Improvement

Gives NHS Improvement the ability to charge fees and for licence holders to pay them.

There are currently no plans to charge a fee to Licence holders. Trust Board should note that there is, currently, no provision in the budget should such a requirement become payable.

4. Fit and proper persons

Prevents licensees from allowing unfit persons to become or continue as members of the trust board, executive directors or non-executive directors.

The Care Quality Commission (CQC) published the fit and proper person requirements. The Trust has included the requirement for members of Trust Board to make an annual declaration against the requirements and has robust arrangements in place for new appointments to the Board (whether non-executive or executive).


Declarations have been completed and received for all board members in April/ May 2022.

5. NHS Improvement guidance

Requires licensees to have regard to NHS Improvement guidance.

The Trust responds to guidance issued by NHS Improvement. Each Executive has a responsibility to review guidance relating to their areas of responsibility and bring any matter to the attention of the other Executive and Board (and to Board Committees).

6. Systems for compliance with licence conditions and related obligations

Requires providers to take reasonable precautions against risk of failure to comply with the licence.

Reviews of the provider licence are undertaken to take into account its conditions within the Board Assurance Framework and risk processes – failure to comply with the licence is reported to Quality and Risk and Finance, Performance and Investment Committees and escalated to the Board as necessary.


LCHS has a Risk Management Strategy that provides a framework for managing risk across the Trust in line with best practice and Department of Health and Social Care Guidelines.


The Board Assurance Framework provides assurance regarding the delivery of LCHS’s strategic aims and objectives.


Independent Assurance is provided as and when required by LCHS’s internal and external auditors.

7. Registration with the Care Quality Commission (CQC)

Requires providers to be registered with the CQC and to notify NHS Improvement if their registration

is cancelled.

The Trust is registered with the Care Quality Commission (CQC).

8. Patient eligibility and selection criteria

Requires licence holders to set transparent eligibility and selection criteria for patients and apply these in a transparent manner.

The LCHS website sets out the service directories for each service. The Trust has an access policy recently updated that complies with NHSI guidance and best practice. This is made available to the public on the Trust website.

Pricing conditions (P)

1. Recording of information

Obligation of licensees to record information, particularly about costs.

The Trust responds to guidance and requests from NHS Improvement. Information provided is approved through the relevant and appropriate authorisation processes. The Trust has established financial systems independently audited which provide service cost information.

2. Provision of information

Obligation to  submit          the above to NHS Improvement.

3. Assurance report on submissions to NHS Improvement

Obliges licensees to submit an assurance report confirming that the information provided is accurate.

4. Compliance with the national tariff

Obliges licensees to charge for NHS health care services in line with national tariff.

All contracts are agreed annually with Commissioners and are in line with the national tariff where applicable.

5. Constructive engagement concerning local tariff modifications

Requires licence holders to engage constructively with commissioner and to reach agreement locally before applying to NHS Improvement for a modification.

Choice and competition (C)

1. Patient choice

Protects patients’ rights to choose between providers by obliging providers to make information available and act in a fair way where patients have a choice of provider.

The Trust has in place a service directory setting out the services available. Regulators monitor the Trust’s compliance with the legal right of choice as part of contract monitoring in line with NHS Standard Contract requirements.

2. Competition oversight

Prevents providers from entering into or maintaining agreements that have the effect of preventing, restricting or distorting competition to the extent that it is against the interests of health care users.

Trust Board considers that it has no arrangements in place that could be perceived as having the effect of preventing, restricting or distorting competition in the provision of health services. The Trust is aware of the requirements of competition in the health sector and would seek legal and/or specialist advice should Trust Board decide to consider any structural changes, such mergers or joint ventures.

Integrated care condition (IC)

1. Provision of integrated care

Requires Licensee to act in the interests of people who use healthcare services by facilitating the development and maintenance of integrated services.

The Trust actively works with its partners, through formal and informal mechanisms, to foster and enable integrated care and is involved in projects aimed at developing new ways of working and new models of delivery.


B.    Condition FT4 - Corporate Governance Statement - NHS trusts




B.    Condition FT4 - Corporate Governance Statement - NHS trusts

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


The Trust monitors and reviews its systems and processes to ensure they comply with good governance.


LCHS has a robust governance structure in place and systems to ensure effective assurance management including a scheme of delegation, risk management strategy, standing financial instructions, standing orders policy and a policy framework. Executive Directors and Non-Executive Directors agree to the NHS codes of conduct and accountability, to embody the LCHS Way; We Listen, We Care, We Act, We Improve; and declare any interest for publication on a Register of Interests at every Board meeting.

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


New requirements are highlighted through national and regional networks and the Board is apprised through monthly development sessions.

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; and

c.     Clear reporting lines and accountabilities throughout its organisation


Board and committee structures are outlined in the Schedule of Matters Reserved to the Board and Scheme of Delegation and the Trust’s governance structure. Changes made to the executive portfolios and organisational governance structure have been incorporated into the updated Governance Manual suite (Schedule of Matters Reserved to the Board; Scheme of Delegation, Standing Orders and Standing Financial Instructions).


During the 2021-22 financial year 3 Non-Executive Directors (NEDs) joined LCHS’ Board as the new chairs of the Finance, Performance, People and Innovation Committee and Quality and Risk Committee and as a lead for partnership working in the system.


The Board has five assurance committees – Finance, Performance, People and Innovation Committee, Quality and Risk Committee, Trust and Charitable Funds Committee (system-wide committee), Remuneration Committee and the Audit Committee. These committees assess the assurance available to the Board in relation to risk management, review the Trust’s non-clinical and clinical and management processes and raise issues that require the attention of the Board. The chairs of these committees report to the Board and each committee is charged with reviewing its effectiveness annually.


The Board scheme of delegation, SFIs and standing orders were approved in January 2022. Accountability structures for all directorates are in place. Individual accountabilities are understood through job descriptions and contracts.

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


a.     To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively;

b.     For timely and effective scrutiny and oversight by the Board of the Licensee’s 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 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 has a formal schedule of matters reserved for its decision and delegates certain matters to committees. The Board has a reporting and development programme, which includes all matters the Board is required to consider by statutory, regulatory and other forms of guidance. It also has a range of strategic and operational performance information, which enables it to scrutinise the effectiveness of the Trust’s operations and deliver focused strategic leadership through its decisions and actions in line with the Well-Led framework. The Board maintains its commitment that discussion of patient safety will always be high on its agenda.


The Finance, Performance, People and Innovation Committee (FPPIC) considers financial performance, productivity and use of resources. The Board has agreed standing orders and standing financial instructions, which provide the framework for ensuring appropriate authorisation of expenditure commitments in the Trust. The Board’s processes for managing its resources include approval of annual budgets for both revenue and capital and for reviewing financial performance against these budgets.


The Trust’s performance management framework is aligned to the directorate management structure. Although stepped down for part of 2021-22 to reduce the burden, in line with NHSEI guidance, directorate’s performance and the agility of the Trust has been demonstrated through its ability to support the Lincolnshire system to respond to Covid-19. LCHS has activity and collaboratively provided support to partner Trusts.


The Quality and Risk Committee reviews a range of quality indicators and progress against CQC standards, quality impact, patient safety and experience. The Trust quality account priorities updates for 2021-22 have been reported into the Q&RC throughout the year. Systems of internal control are subject to regular audit and the Audit Committee has provided independent oversight and challenge. There are robust accountability systems in place to monitor effectiveness and efficiency schemes. The Board committee calendar ensures up-to-date information is provided to meetings for scrutiny and assurance.  


The Trust has a Risk Management Strategy which is endorsed by the Trust Board. The strategy and supportive documents were completely revised and collaboratively rewritten, including an extensive review, overhaul and alignment of the Trust Risk Appetite Statement to the Strategic Aims and objectives, ratified by Board in March 2022.  


The risk management process is owned by Trust Board with Executive Directors delegating oversight and ownership of all risks on the Trust Corporate Risk Register and the Corporate Operational Risk Register to Deputy Directors for management, accountability and appropriate and effective mitigating action. All risks on the Trust Corporate Risk Register are reviewed at least monthly by Executive Directors and Deputies.


The Board Assurance Framework (BAF) and Corporate Risk Register (CRR) provide the framework through which high-level risks are considered and managed.  The Board and committees receive the BAF and CRR on a frequent basis, bi-monthly and monthly, respectively.


LCHS has an annual planning process that ensures business plans are developed and supported. The governance, risk and control processes in place ensure the Trust remains compliant.

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 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 including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate


There is an effective objective setting and performance review process in place for board members, portfolios are reviewed on an annual basis and skills are refreshed and kept up to date through monthly development sessions as well as a range of development opportunities.  A robust quality and equality impact assessment processes are in place and overseen by the  Deputy Director of Nursing and Quality and the Deputy Director of People, respectively. Business intelligence is reported through the Finance, Performance, People and Innovation Committee (FPPIC) on a monthly basis.


A range of quality indicators, safeguarding, effectiveness of care, infection prevention and control, children in care, safety measures, complaints, PALS and compliments, volunteering services, pFFT and patient engagement and experience, incidents, well-led, safer staffing, learning from deaths and emergency planning programmes are reported through the Quality and Risk (Q&R) Committee. Trust performance is reported to Q&R each month against the CQC key lines of enquiry: Safe, Effective, Caring, Responsive and Well Led. It asks the question: are our patients receiving high quality care? Board members are also actively involved in service improvement and connecting with staff through the 15 steps programme. Clear escalation routes are in place to ensure matters are referred the relevant local assurance group, feeding into a specialist group and then a Trust Board Committee and to Board as required. Committees of the Board each have a standing item on bi-monthly Board agendas allowing them to escalate to the Board.

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.



LCHS has in place a formal and rigorous appointments process to the Board and Trust positions. The recruitment process incorporates panel and stakeholder assessments against the LCHS Way values and behaviours.  Executive responsibilities and those across directorate structures are reviewed and refined on a regular basis.

Signed on behalf of the Board of directors



 Maz Fosh

Maz Fosh, Chief Executive

Signature: Elaine Baylis signature

 Elaine Baylis, Chair