1. The trust’s strategy reflects clear priorities for itself as well as shared objectives with system partners.

• Do plans reflect and leverage the trust’s distinct strengths and position in its local healthcare economy?

• Are plans for transformation aligned to wider system strategy and responsive to key strategic priorities agreed at system level?

• Can the board recognise when change is required and to adapt arrangements as the organisation evolves?

• Does the board understand the key risks to delivering the strategy and ensures these are appropriately assessed and mitigated?

2. The trust is meeting and will continue to meet any requirements placed on it by ongoing enforcement action from NHS England.

• Is the trust currently complying with the conditions of its licence?

• Is the trust complying and regulatory instruments – for example, discretionary requirements and statutory undertakings and is there a board-level plan to return to compliance?

• Is it co-operating with the requirements of any national performance improvement or recovery programmes?

3. The board has the skills, capacity and experience to lead the organisation.

• Are all board positions filled and/or are there plans in place to address any vacancies? What proportion of board members are in interim/acting roles?

• Is an appropriate board succession plan in place?

• Are there clear objectives, accountabilities and responsibilities for all areas of operations including quality, delivering access standards, operational planning and finance?

4. The trust is working effectively and collaboratively with its system partners and NHS trust collaborative for the overall good of the system(s) and population served.

• Is the trust contributing to and benefiting from its provider collaborative?

• Can the board evidence that it is working effectively with the wider system, not just focused on the organisation itself – for example, in terms of sharing resources and supporting wider service reconfiguration and left shifts to community care where appropriate and agreed?

• Do the trust’s operating and financial plans align with those of its commissioning ICB or ICBs, in particular regarding activity and capital expenditure?

• Is there sufficient digital literacy at board level and is digital a core element of discussions regarding planning, delivery, assurance and risk?

• Is cyber risk included on Board Assurance Frameworks and/or corporate risk registers?

• Can the board articulate how digital is an enabler across the organisation’s operations – quality, productivity, access and safety – and supports the governance and culture of the organisation

• Are the trust’s digital plans linked to and consistent with those of local and national partners as necessary?

6. The organisation has regard to relevant NHS England guidance (supported by Care Quality Commission information, its own information on patient safety incidents, patterns of complaints and any further metrics it chooses to adopt).

• The trust can demonstrate and assure itself that internal procedures:
  • ensure required standards are achieved (internal and external)
  • investigate and develop strategies to address substandard performance
  • plan and manage continuous improvement
  • identify, share and ensure delivery of best practice
  • identify and manage risks to quality of care

• There is board-level engagement on improving quality of care across the organisation.
• Board considers both quantitative and qualitative information, and directors regularly visit points of care to get views of staff and patients.
• Board assesses whether resources are being channelled effectively to provide care and whether packages of care can be better provided in the community.
• Board looks at learning and insight from quality issues elsewhere in the NHS and can in good faith assure that its trust’s internal governance arrangements are robust.
• Board is satisfied that current staff training and appraisals regarding patient safety and quality foster a culture of continuous improvement.

8. Systems are in place to monitor patient experience and there are clear paths to relay safety concerns to the board.

• Does the board triangulate qualitative and quantitative information, including comparative benchmarks, to assure itself that it has a comprehensive picture of patient experience?
• Does the board consider variation in experience for those with protected characteristics and patterns of actual and expected access from the trust’s communities?
• Is the board satisfied that it receives timely information on quality that is focused on the right matters?
• Does the board consider volume and patterns of patient feedback, such as the Friends and Family Test or other real-time measures, and explore whether staff effectively respond to this?
• How does the organisation involve service users in quality assessment and improvement and how is this reflected in governance?
• Is the board satisfied it is equipped with the right skills and experience to oversee all elements of quality and address any concerns?
• Is the board satisfied that the trust has a clear system to both receive complaints from patients and escalate serious and/or re-occurring complaints to the relevant executive decision-makers?

• Where there are follow-up actions resulting from CQC inspections, is the trust addressing these and can the board articulate how care will improve as a result?

9. Staff feedback is used to both improve the quality of care provided by the trust and monitor and improve staff experience

• Does the board look at all relevant staff (including trainee) information to monitor the experience of working at the trust and identify areas for improvement? 
• Does the board engage in staff forums to consider how quality of care can be improved and any cultural/staff experience issues addressed? 
• Are staff surveys and other information (such as the NHS Staff Standards) routinely reported to the board and issues discussed? Are agreed actions followed up?
• Does the board monitor the diversity of staff across the organisation to ensure it is representative of its local population?

10. Staff have the relevant skills and capacity to undertake their roles, with training and development programmes in place at all levels

• Does the trust regularly review skills at all levels across the organisation?
• Does the board see and, if necessary, act on levels of compliance with mandatory training?
• Have all staff completed relevant training* and does the board see a log of avoidable staff-initiated events?

11. Staff can express concerns in an open and constructive environment

• Does the board engage effectively with information received via Freedom To Speak Up (FTSU) channels, using it to improve quality of care and staff experience?
• Are all complaints treated as serious and do complex complaints receive senior oversight and attention, including executive level intervention when required?
• Is there a clear and streamlined FTSU process for staff and are FTSU concerns visibly addressed, providing assurance to any others with similar concerns?
• Is there a safe reporting culture throughout the organisation? How does the board know?
• Is the trust an outlier on staff surveys across peers?

12. Plans are in place to improve performance against the relevant access and waiting times standards.

• Is the trust meeting those national standards in the NHS planning guidance that are relevant to it? If not, is the trust taking all possible steps towards meeting them, involving system partners as necessary?
• Where waiting time standards are not being met or will not be met in the financial year, is the board aware of the factors behind this?
  Is there a plan to deliver improvement?

13. The trust can identify and address inequalities in access/waiting times to NHS services across its patients.

• The board can track and minimise any unwarranted variations in access to and delivery of services across the trust’s patients/population and plans to address variation are in place.

14. Appropriate population health targets have been agreed with the integrated care board.

• Is there a clear link between specific population health measures and the internal operations of the trust?
• Do teams across the trust understand how their work is improving the wider health and wellbeing of people across the system?

15. Plans are in place to deliver productivity improvements as referenced in the NHS Model Health System guidance, the Insightful board and other guidance as relevant

• Does the board use all available and relevant benchmarking data, as updated from time to time by NHS England, to:
  • review its performance against peers
  • identify and understand any unwarranted variations
  • put programmes in place to reduce unwarranted negative variation?
• Is there a track record of delivery of planned productivity improvements?

16. The trust has a robust financial governance framework and appropriate contract management arrangements

• Does the trust have a work programme of sufficient breadth and depth for internal audit in relation to financial systems and processes, and to ensure the reliability of performance data?
• Have there been any contract disputes over the past 12 months and, if so, have these been addressed?
• [Potentially more appropriate for acute trusts] Are the trust’s staffing and financial systems aligned and show a consistent story regarding operational costs and activity carried out?
• Has the trust had to rely on more agency/bank staff than planned?

17. Financial risk is managed effectively, and financial considerations (for example, efficiency programmes) do not adversely affect patient care and outcomes

• Does the board stress-test the impact of financial efficiency plans on resources available to underpin quality of care?
• Are there sufficient safeguards in place to monitor the impact of financial efficiency plans on, for example, quality of care, access and staff wellbeing?
• Does the board track performance against planned surplus/deficit and where performance is lagging it understands the underlying drivers?

18. The trust engages with its system partners on the optimal use of NHS resources and supports the overall system in delivering its planned financial outturn

• Is the board contributing to system-wide discussions on allocation of resources?
• Does the trust’s financial plan align with those of its partner organisations and the joint forward plan for the system?
• Would system partners agree the trust is doing all it can to balance its local/organisational priorities with system priorities for the overall benefit of the wider population and the local NHS?

NHS England

• Uses the conditions in the NHS trust licence it issues to NHS foundation trusts (and which also applies to NHS trusts in shadow form) to regulate trusts across a range of areas, including delivery of services, quality governance and efficiency, economy and effectiveness of management
• Oversees the training of healthcare staff. Trusts liaise with it on matters like resident doctor training and NHS England has the power to remove resident doctors from trusts if conditions are unsatisfactory
• Operates a cyber assurance service to build cyber security across the NHS, assessing alignment to key standards relating to the cyber assessment framework and indicators of good practice

• Meeting national standards
• Compliance with the NHS trust licence
• Resident doctor survey
• Delivering NHS objectives
• Collaborating with NHS trusts
• Cybersecurity

Care Quality Commission

• Registers organisations to provide care in England, sets regulations covering the care trusts provide, runs an inspection and monitoring regime and publishes NHS trust ratings

With NHS England:

• Provides joint strategic leadership and alignment for quality through the National Quality Board (NQB)
• As co-signatories of the NQB guidance for system quality management, work together as part of a culture of open and honest co-operation to identify opportunities for improvement, early warning signs, concerns and risks, and take collaborative action, working with systems to mitigate and manage quality
• Ensures coherent oversight arrangements are in place for systems, ICBs and NHS trusts to ensure services are safe and effective
• Shares learning and information about quality risks/concerns in a timely and proactive way, through system quality groups, regional quality groups and wider discussions, and respecting regulatory frameworks

• Quality of care – are any sites or services operated by the NHS trust classed as ‘Inadequate’?
• Governance and culture – are there concerns for NHS England arising from the CQC’s well-led review across the whole organisation?

Medicines and Healthcare products Regulatory Agency

• Regulates medicines, medical devices and blood transfusion components

• Systems in place to ensure proper and safe use of medical equipment

Human Tissue Authority

• Regulates the removal, storage, use and disposal of human bodies, organs and tissue

• Systems in place to safely and legally handle human tissue

The Human Fertilisation and Embryology Authority

• Regulates and inspects all clinics in the UK providing in vitro fertilisation (IVF), artificial insemination and the storage of human eggs/sperm/embryos – this may include some trusts

• Systems in place to meet standards associated with IVF and related procedures

The Health & Safety Executive

• Has a national remit over matters like workplace safety, estates conditions which covers trusts

• Systems in place to ensure staff, patients and the public work in a safe environment

The Information Commissioner’s Office

• Has a national role to uphold information rights in the public interest May be in contact with trusts regarding patient confidentiality, for example setting data requirements

• Systems in place to manage data securely and in compliance with all relevant standards

NHS Counter Fraud Authority

• Investigates reports of fraud, bribery and corruption across the NHS

• Systems and culture in place to ensure zero tolerance of fraud, bribery and corruption at the NHS trust

Professional regulators:

• General Medical Council
• Nursing and Midwifery Council
• General Chiropractic Council
• General Dental Council
• General Optical Council
• General Osteopathic Council
• General Pharmaceutical Council
• Health and Care Professionals Council
• Social Work England

• Together with NHS England, ensure proper standards of practice in respective professions to protect, promote and maintain the health and safety of the public
• Most have responsibilities across the UK and all regulate professionals regardless of whether they work in the NHS or the independent sector
• As a designated body, NHS England has a statutory duty under the responsible officer regulations for GPs on the national performers list and for responsible officers from designated bodies across a wide variety of sector organisations
• NHS England must inform professional regulators where professionals fail to meet the standards. This can lead to an investigation and potentially sanctions such as conditions on practice, suspension or removal from a professional register
• Responsible for quality assuring the education and training of healthcare professionals. Most can inspect organisations that commission, oversee or provide education, and they have powers to withdraw approval from training programmes, posts or NHS trusts if they are not satisfied that education or training is being provided in a safe or effective way. In April 2023, NHS England took on the previous powers of Health Education England to regulate training NHS trusts and placement hosts

• Staff can work in and contribute to a safe, sustainable environment that ensures good morale and a healthy working culture that supports high quality care

Local Government and Social Care Ombudsman

Parliamentary and Health Service Ombudsman

• Provide an independent complaint handling service

• Evidence of patient or staff concerns at health and care NHS trusts

Health Service Safety Investigations Body

• Investigates serious patient safety risks that span the healthcare system, operating independently of other regulatory agencies

• Quality assurance arrangements at NHS trusts

Healthwatch

• Shares learning and information through system quality groups, regional quality groups and the NQB to ensure that the views and experience of people and the public inform quality improvement and risk management discussions
• Note: HM Government currently proposes abolishing Healthwatch. If followed through subject to the will of Parliament, this will need to go through a number of steps before being enacted in legislation. Until then, Healthwatch will continue to gather patient views and evidence and work together with providers and commissioners to improve local services.

• The NHS trust uses patient and public information in reviewing the care provided at the organisation
• Is there any evidence of patient concerns that might indicate issues with the provision and oversight of care provided?

Ofsted

• Investigates education settings, including secure children’s homes and SEND services

• Is there any evidence of patient concerns that might indicate issues with the provision and oversight of care provided at specific sites managed by the NHS trust?

Coroners

• Coroners investigate deaths that are unnatural or violent or where the cause is unknown or that took place in prison, police custody or another type of state detention, such as a mental health hospital

• Is there any evidence of concerns or issues – for example, organisational culture or governance – that may have led to a death at the institution?

Royal Colleges

• The professional bodies that oversee and regulate various medical specialties. These colleges set standards for training, examinations, and continuing professional development for doctors in their respective fields. They also play a role in policy and advisory work related to their specialties.

• Do information from Royal Colleges – e.g. anonymised data from surveys of their members – highlight cultural, quality of care or patient safety concerns at the trust?  

Local authorities

• Along with other roles, local authorities help develop the population health needs assessment. Trusts are expected to work with system partners to meet these needs

• Is there any evidence that the trust is not an effective system partner across its geography?

Strategy, leadership and planning

• Medium term plan/integrated delivery plan.
• Provider collaborative and other partnership model plans.
• Clear and effectively cascaded annual objectives for the board.
• Reports that set out priorities and progress in relation to health inequalities.
• Plans for delivery of research and innovation.
• Progress against neighbourhood health guidelines.
• Digital and data strategy – linked to the ICS strategy and underpinned by a sustainable financial plan.
• Examples of effective partnership, such as working to deliver data sharing, joint care records, remote consultations.
• Digital maturity self-assessment ratings/standards under What Good Looks Like framework, digital inclusion.
• System wide meeting minutes/forums on digital.
• Digital exemplar status/awards.
• Performance indicators relating to the use of digital services.
• Evidence of compliance with national digital standards.
• System wide meeting minutes/forums.
• Annual reports on health inequalities
• System wide meeting minutes/forums (for example, evidence of active participation in ICB System Quality Group).
• Annual reports on health inequalities as well as any reports which set out priorities and progress against them and improving outcomes and experiences.
• Equality impact assessments (EQIAs).
• History of filling board vacancies and position with interims
• Robust gap analysis of board skill sets.
• Clear succession planning.
• The outputs of board effectiveness reviews, for example, undertaken against the Insightful Provider Board guidance.
• Compliance with the requirements of the fit and proper person test (FPPT) framework.
• Implementation of the Management and Leadership Framework.
• Compliance with the forthcoming Code of Practice for NHS Managers.
• Operating model overview.
• Sample of board and committee papers and terms of reference demonstrate that the robustness, effectiveness and clearly defined roles of committees allow the board the time and space it needs to focus on strategic matters.
• Board effectiveness reviews, history of use of internal and external review.
• Board and committee agendas and papers.
• Board assurance framework (BAF).
• Risk registers.
• Medium-term plan and integrated delivery plan.
• Action and mitigation plans in relation to key risks and regulatory requirements.

Quality of Care (note: includes Quality Governance)

• Trust documents of delivery of CQC action plans and governance arrangements.
• Any assurance reports or external reviews, including national statutory and non-statutory inquiries, that demonstrate that actions have been addressed and compliance has been sustained.
• Clinical audit, and any publication, reports or audits shared widely across organisation and beyond, for example, clinical audit outliers and action plans. Internal or external QG reviews or audits.
• Learning from prevention of future deaths reports including national statutory and non-statutory inquiries.
• Outcomes of quality (including safety) visits/reviews including walkarounds and ward accreditations.
• Processes and systems used by the board to ensure there is sustainable quality assurance.
• Board Assurance Framework and IPR and risk registers.
• Quality committee papers and minutes.
• Quality and delivery metrics.
• Quality account and clinical and quality strategies.
• System wide quality meeting minutes and forums.
• Contribution to/ leadership of any system-wide quality improvement programme, including ICB System Quality Groups.
• Participation in and action resulting from clinical audits.
• System wide quality improvement programmes demonstrating co-productive and collaborative working arrangements.
• Examples of sharing best practice, notes in board meeting minutes or divisional level meeting notes.
• Evidence of Board knowledge and discussion of national guidance and best practice and accreditation such as clinical audits,
• Experience of Care Improvement Framework, Getting It Right First Time (GIRFT), clinical senate and application of national frameworks.
• Staff and patient surveys, feedback, complaints and other insight reports to board. Staff networks. People strategy.

• Evidence of systems to monitor patient and carer experience with clear mechanisms to relay feedback to board.
• Staff training and development update and performance reports to board.
• Any relevant third-party evidence, for example, Royal Colleges, other regulatory bodies and progress on accreditation.
• Compliance with all relevant National Patient Safety Alerts.
• Evidence from relevant provider collaboratives associated with unwarranted variation.
• Freedom to Speak Up (FTSU).
• Complaints data and reports.
• Coroner’s reports or ombudsman referrals.
• Cultural development assessments and work at board level.
• Workforce development programmes and delivery plans.
• Quality focused learning and development approach and programmes.
• Evidence from papers and minutes from the performance and quality reviews.
• External reports or audits on quality of reporting.
• Appointment and training of patient safety specialists, medication safety officers and medical device safety officers.
• IPR.
• Board and Quality Committee meeting minutes.
• Board development work plan.
• Board member leadership of improvement or innovation projects.
• Quality governance (QG) architecture including structure and reporting approach and quality governance framework.
• Internal or external QG or Well Led reviews that have included governance elements and/or audits with progress on any actions identified.
• Analysis uses statistically appropriate tools which identify and focus on relevant issues, for example, Statistical Process Control (SPC), Pareto.
• Service level performance reporting.
• Improvement programmes.
• Organisational strategy.
• Quality strategy.

People and culture

• Workforce reporting to the board, including NHS Staff Standards score
• Staff survey results and trends, both national and local. Including new Staff Standards information
• Staff forum feedback which has led to some improvements by the board.
• FTSU reporting. Duty of Candour. Complaints reporting.
• CQC views and whistleblowing and FTSU intelligence.
• In-house staff check-ins, surveys and feedback results.
• QI training and methodologies.
• Patient safety specialists, medication safety officers and medical device safety officers appointed and trained.
• Skills analysis.
• Performance management.
• Mandatory training.
• Sickness and retention data.
• Patient Safety Incident Response Framework (PSIRF) and Patient Safety Incident Response Plans (PSIRP) and how both demonstrate a just culture.
• Quality Improvement programme.
• Workforce strategies and plans for coordination and collaboration and delegation of clinical tasks.
• Partnership plans (transition of care) across pathways.
• Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES).
• NHS People Promise Indicators.
• Any other appropriate workforce data available.
• Board and People Committee minutes.
• Equality, diversity and inclusion (EDI) workforce analysis.
• Educator Workforce Strategy and alignment to the Educator Workforce Planning Framework.
• Local models for education and training.
• Skills audits.
• Staff surveys.

Access and delivery of services

• Performance against NHS Oversight Framework metric scores which relate to planning guidance priorities (NHS Oversight Framework access domain and sub-domains).
• IPR.
• Clinical audits.
• Operational plans.

Productivity and value for money

• Measurable productivity improvements over the past 12 months, evidenced through cost improvement plans (CIP) delivery reports or efficiency programme updates.
• Planning processes show the trust has actively identified and addressed unwarranted variation when setting cost reduction and service improvement plans.
• Board and sub-committee papers routinely reference national benchmarking resources and the latest available guidance. This might include NHS Model Health System, Patient Level Information Costing System (PLICS), NHS Spend Comparison Service, productivity packs and other relevant data to support financial and operational decision-making.
• The Insightful Provider Board guidance includes examples of relevant indicators and measures.

Financial performance and oversight

• Historical financial performance of the organisation.
• Year-to-date performance against plan, and risks and mitigations to the reported financial position.
• A medium-term financial plan, including a rolling 12-month cash flow forecast to ensure a reasonable cash balance is maintained.
• The financial modelling assumptions (including capex) applied in the medium-term plan are aligned with the NHS England published guidelines and aligned with the system strategy.
• Workforce, activity and financial plans are aligned, showing consistency in operational costs and activity (such as workforce plans, financial reports, cost-per-activity analysis).
• Details of how the trust is collaborating with local partners to contribute to local priorities.
• A sensitivity analysis demonstrating downside scenarios to the base case, and mitigations.
• Overall efficiency plan and detail behind significant individual efficiency schemes.
• Project initiation documents (PIDs) for CIP schemes that demonstrate consideration of realistic phasing.