WAHT Board Response to NHS Improvement Requirement for Self-Certification 2019

University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) was formed on 1 April 2020 following the merger of University Hospitals Bristol NHS Foundation Trust and Weston Area Health NHS Trust.

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Self-certification 2019

Trust Declaration Response

1 Introduction

1.1 NHS Trusts are exempt from holding a provider licence but Directions from the Secretary of State require NHS Improvement to ensure that NHS Trusts comply with conditions equivalent to the licence. The current Oversight Framework uses the licence as a basis for oversight – but self-certification is now also required.

1.3 Two declarations are required by the NHS provider licence namely;

•Condition G6(3) – Providers must certify that their Board has taken all precautions necessary to comply with the licence, NHS Act and NHS constitution

•Condition FT4 (8) – Providers must certify compliance with required governance standards and objectives

1.4 As with the Quality Account and Annual Report, Board sign off is required - as well as publication of the self-certification declaration on the Trust website. The Board agreed its position as follows at its Extraordinary Meeting on 24 May 2019.

2. Requirements of Condition G6(3)- due 31 May 2019

2.1 The Board is satisfied that we have in place effective systems and processes to ensure compliance with the requirements imposed on us under the NHS Acts and the NHS constitution

Agreed response

CONFIRMED – - noting risk and mitigation described in the Performance Report and Annual Governance Statement of the 2018/19 Annual Report

3. Requirements of Condition FT4 (8) – due 30 June 2019

3.1 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

Agreed response

CONFIRMED – as described in the Annual Governance Statement included in the 2018/19 Annual Report

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

Agreed response

CONFIRMED – as described in the Annual Governance Statement included in the 2018/19 Annual Report

3.3 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

Agreed response

CONFIRMED - noting risk and mitigation described in the Performance Report and Annual Governance Statement of the 2018/19 Annual Report

3.4 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 and NHS Improvement.
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);
To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making;
To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence;
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
To ensure compliance with all applicable legal requirements.

Agreed response

CONFIRMED – as described in the 2018/19 Annual Report

3.5 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:

That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided;
That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations;
The collection of accurate, comprehensive, timely and up to date information on quality of care;
That the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care
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
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.

Agreed response

CONFIRMED – as described in the 2018/19 Annual Report

3.6. 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.

Agreed response

CONFIRMED – as described in the 2018/19 Annual Report

Gillian Hoskins

Trust Board Secretary

1 June 2019