Worksheet "FT4 declaration"
Financial Year to which self-certification relates
2022/23
Please Respond
Corporate Governance Statement (FTs and NHS trusts)
The Board are required to respond "Confirmed" or "Not confirmed" to the following statements, setting out any risks and mitigating actions planned for each one
Corporate Governance Statement
Response
Risks and Mitigating actions
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.
Confirmed
The Trust has had no conditions imposed upon it preventing it from discharging its statutory responsibilities. The Trust was
assessed as good in its 2019 CQC well led review.
#REF!
2
The Board has regard to such guidance on good corporate governance as may be issued by NHS Improvement
from time to time
Confirmed
The Board takes account of all appropriate guidance. Standing Orders and Standing Financial Instructions have been reviewed and
updated. The Audit Committee has reviewed best practice in the HFMA Audit Committee handbook and taken any action as
appropriate.
#REF!
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.
Confirmed
The Board has clear Terms of Reference as detailed in the Trust's Standing Orders. Each of the Sub-Committees has agreed Terms
of Reference which are regularly reviewed and each Sub-Committee has a NED chair with NEDs being in the majority in each
Committee. The NHS Constitution is considered against each report/paper presented to the Board and its Sub-Committees. Each
Sub-Committee monitors compliance against contractual requirements and provides assurance to the Board with identification of
risk and mitigation. There are clear responsibilities for Board and Sub-Committees in place with Chairs of Sub-Committees writing
regular clear reports (Highlighting key risks/mitigations) as well as minutes of the meetings being received once approved. There are
clear reporting lines throughout the organisation with a clear structure in place. CQC identified that 'the Trust had robust
arrangements in place for identifying, recording and managing risks, issues and mitigating actions'.
#REF!
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.
Confirmed
The Board is satisfied that:(a) The Trust operates efficiently, economically and effectively and has received an unqualified value for
money opinion from its External Auditors. In addition CQC have judged the Trust's Use of Resources to be Good. (b) Timely and
effective operational reports are received and dealt with through the Trust's Sub-Committee structure. (c) The Trust is compliant to
the various standards and has no restrictions applied by any of these regulators. (d) The Trust remains a going concern and this is
confirmed by External Audit. (e) Timely, upto date, comprehensive information is received by itself and the Sub-Committees. (f)
There is a clear Board Assurance Framework and Trust Risk Register in place to identify and manage material risks and
compliance. (g) There is regular, timely and comprehensive information on its business plans and contracts. The internal audit
provider is external to the Trust and has an annual plan which is reported to the Audit Committee. (h) Complies with its legal
requirements. (i) The External Auditors at the end of 2021/22 issued a report saying there were no significant weaknesses with
regard to the Trust's processes on Value for Money. There is a risk on financial sustainability as this relates to the uncertainty of the
medium term plans for the Black Country system. This will require future financial planning with other providers within the Black
Country system and the ICB when it is established.
#REF!
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.
Confirmed
The Trust has sufficient capability at Board level with regard to quality of care with the Executive Directors responsible through the
Chief Executive being the Medical Director and Chief Nursing Officer. In addition the appointed chair is a General Practitioner by
profession. The Trust's vision statement and objectives clearly articulate the focus on quality of care provision. The Trust Board
regularly receives patient stories, clinical and non clinical staff updates and clinical reports from the lead clinicians such as the
Director of Midwifery/Director of Infection prevention, etc. The Trust Board receives a monthly update on quality in its Integrated
Quality and Performance report and the Quality Governance and Audit Sub-Committee examine and monitor detailed areas for
improvement. This integrated approach allows the Board to provide continuous oversight for improving quality of care. The Trust's
annual quality account/annual planning processes also ensure that quality of care within the Trust is the fundamental foundation
stone upon which the Trust's plans are created.
#REF!
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.
Confirmed
The Board has reviewed its capacity and capability and has declared that the Trust Board has sufficient numbers of Directors and
skills. All Directors have complied with their fit and proper persons assessment. The CQC judged 'the Trust board to have the
appropriate range of skills, knowledge and experience to perform its role. The Board was cohesive and focused on working together
to secure best outcomes. The senior leadership team have the appropriate range of skills, knowledge and experience to ensure
appropriate scrutiny and challenge'.
#REF!
Signed on behalf of the Board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature
Signature
Name
Professor Steven Field
Name
David Loughton
Further explanatory information should be provided below where the Board has been unable to confirm declarations under FT4.
A
Please Respond
