Board declaration in respect of Condition G5 of the Trust’s Provider Licence

Condition G5 of the Trust’s Provider Licence requires the Trust to maintain systems to monitor compliance with the Provider Licence. Under Condition G5 of its Provider Licence the Trust Board is required to carry out a review, and to make a formal declaration for the most recently ended financial year that it is satisfied, in respect of that year, that the Trust 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 had regard to the NHS Constitution.

The Board carried out its review on 25th June 2025, having regard to the following sources of evidence, summarised in a paper from the Senior Associate Director of Assurance and Compliance:

The Board Assurance Framework (BAF), which includes the Trust’s principal business objectives, including several linked to regulatory compliance obligations. For each objective the BAF notes: the key controls in place to manage risks; sources of assurance with respect to the health of those controls and the outcomes from assurance work. Where the outcomes highlight deficiencies in controls or a lack of assurance, the BAF summarises action plans which are then captured in detail, and tracked through a strategic risk register. The Board reviews the implementation of actions, and the level of risk associated with each objective every quarter, supported by more detailed reviews carried out by its sub-committees. In addition, the Board compares reductions in risk with its expectations, which are set out in the form of risk reduction trajectories over time.

The results of the most recent, completed, CQC inspection reports (into Maternity Services in March 2024 and Urgent and Emergency Care in January 2025) and the resulting action plans and progress against them.

The Head of Internal Audit’s Provision Annual Opinion, dated June 2025, and progress reports, reviewed by the Audit Committee during the year. These include the results of specific internal audits of systems relevant to Provider Licence compliance, covering data quality, risk management and governance systems.

The outcome of a Board self-assessment exercise, which considered each of the Quality Statements published by the Care Quality Commission undertaken in March 2024, and the implementation of subsequent actions.

An annual risk assessment, completed with reference to Condition G5, by the Senior Associate Director of Assurance and Compliance.

The Trust’s Fit and Proper Persons Test.

The Trust’s Values and Behaviours Framework, which is aligned to the NHS Constitution.

The Board noted the assurance from each of the above sources of evidence, alongside other sources of evidence scrutinised routinely by the Board and its sub-committees during the year, and noted the actions in place to address areas for improvement. It is important to note that the Trust has – with respect to elective activity – concentrated on meeting national targets to restore activity and clear backlogs, whilst aiming to restore activity in line with NHS Constitutional targets in all areas over time. This approach is consistent with the national approach and with national guidance.

On the basis of the above review the Board can CONFIRM compliance with the following licence requirement:

“Following a review for the purpose of paragraph 2(b) of licence condition G5, the Directors of the Licensee are satisfied, as the case may be that, in the Financial Year most recently ended (2024/25), 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”