Compliance with NHS Provider Licence declaration
NHS Foundation Trusts are required to self-certify whether or not they have complied with the conditions of the NHS Provider Licence (which itself includes requirements to comply with the National Health Service Act 2006, the Health and Social Care Act 2008, the Health Act 2009, and the Health and Social Care Act 2012, and have regard to the NHS Constitution). The following provides the declaration for 2021:
G6 (3): General Condition 6 – Systems for Compliance with Licence Conditions
Board statements
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
Risk of certifications
The Trust remains in breach of its Provider Licence having been placed in financial and quality ‘special measures’ in 2017 (further details are provided below in respect of each of these areas). On the basis of the breaches identified, which raised concerns regarding the effectiveness of the Trust’s financial governance, quality and corporate governance arrangements, and having regard to its Enforcement Guidance, NHS Improvement (NHSI) have previously accepted Enforcement Undertakings from the Trust.
The expectations of the Board in terms of oversight and assurance are set out in Section 4 of the Enforcement Undertakings and cover requirements in respect of programme management,
Comments/Mitigating actions
The Trust’s response to both financial and quality ‘special measures’ is as outlined in this document under the relevant sections.
There is bi-monthly reporting internally on financial and quality improvement to the Trust Board and reporting monthly externally to NHSE/I, allowing both increased oversight and challenge on the progress of the agreed improvement actions and the agreement of the necessary additional support.
In relation to quality ‘special measures’, the Trust is supported by an NHSE/I Improvement Director. A bid against national quality ‘special measures’ funding was successful to support the delivery of the CQC improvement actions.
Response (confirmed/not confirmed)
Confirmed
Trade Union (Facility Time Publication Requirements) Regulations 2017
On 1 April 2017, the Trade Union (Facility Time Publication Requirements) Regulations 2017 came into force. The Regulations require the Trust, as an NHS body, to collate and publish on an annual basis, a range of data on the amount and cost of ‘facility time’ within the organisation. Facility Time is the provision of paid or unpaid time off from an employee’s normal role to undertake Trade Union duties and activities as a Trade Union representative.
Same sex accommodation
The Trust, in accordance with guidance issued in 2007, by the NHS Institute for Innovation and Improvement, has been working to improve privacy and dignity within clinical facilities, particularly focusing on ensuring that men and women have separate sleeping areas and separate toilets and bathrooms that they can reach without having to pass through (or close to) opposite sex areas.
Declaration of compliance:
The Trust is pleased to confirm that we continue to respect our patients privacy and dignity and are virtually compliant with the Government’s requirement to eliminate mixed-sex accommodation, except when it is in the patient’s overall best interest, or reflects their personal choice. We have the necessary facilities, resources and culture to ensure that patients who are admitted to our hospitals will only share the room where they sleep with members of the same sex, and same-sex toilets and bathrooms will be close to their bed area. Sharing with members of the opposite sex will only happen when clinically necessary (for example where patients need specialist equipment such as in Coronary Care, Intensive Care, High Observation Bays, or when patients actively choose to share (for instance children services). For people who sleep in shared spaces with people of the same sex, Trust staff will do everything possible to ensure dignity and privacy.
