AH ANNUAL REPORT 2018

Recommendations

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Indicator Indicator Description Target Weighting Financial Value e-referrals Make services and outpatient appointments for GP referrals to available on the NHS e-Referral Service. Quarter 3 Performance Submit reports 0.25% £117,140 Achieved Improving services for people with mental health needs who present to A&E Transitions out of Children and Young People’s Mental Health Services Submit reports 0.25% £117,140 Achieved Submit reports 0.25% £117,140 Achieved NHSE North West Specialist Commissioner CQUINs 2017/18 Indicator Target Weighting Financial Value Clinical Utilisation Review Submit quarterly report Quarter 3 Performance 0.94% £945,000 Fully achieved Haemtrack – Patient home monitoring Haemoglobinopathy Improving Pathways through Operational Delivery Networks Patient Participation Submit reports Participation in ODN 0.074% £74,000 Fully achieved 0.15% £150,000 Fully achieved Medicines Optimisation Submit report 0.1% £99,000 Fully achieved Paediatric Networked Care Assess compliance with minimum data set and submit report 0.21% £210,000 To be assessed in Quarter 4 Planned Transition to Adult Services for patients with Complex Neurodisability Submit report 0.37% £371,258 Fully achieved Locally priced Service Redesign and Clinical Practice Benchmarking To be confirmed 0.15% £150,000 To be assessed in Quarter 4 Alder Hey Children’s NHS Foundation Trust 100 Annual Report & Accounts 2017/18
2.2.7 Statements from the Care Quality Commission (CQC) Alder Hey is required to register with the Care Quality Commission and its current registration is in place for the following regulated activities: diagnostic and screening procedures, surgical procedures, treatment of disease, disorder or injury and assessment or medical treatment for persons detained under the 1983 Act. Alder Hey remains registered without conditions. The Trust received a short notice inspection one core service – Community paediatrics – and an unannounced inspection of four other core services – Critical Care, End of Life, Outpatients and Diagnostics – in February <strong>2018</strong>. It also underwent a comprehensive well led review. The outcome of this inspection is awaited. Outstanding Care The Care Quality Commission has not taken any enforcement action against Alder Hey during 2017/18. CQC undertook a national thematic review of CAMH services, focusing on 10 sites across the country, of which Liverpool was one. Alder Hey in collaboration with partner agencies took part in this review which found: • Knowledge of the pathways amongst GPs and A&E Departments needs to be developed via the partnership • The myriad of entry points to the pathway are not always clear to all referrers and it may be confusing what the role and function of each partner is • All partners need to ensure their websites and published ‘offers’ are valid and current. There was evidence however of partnership agreements being developed. • There are opportunities for more seamless contracting arrangements across the partnership • Data sharing and multiple systems that don’t speak to each other was seen as problematic although it was acknowledged that there is a commitment to develop this and evidence such as data sharing agreements in place • Funding challenges were acknowledged and noted • Website excellent source of information however needs more promotion across all partners in the city. In response to the national report, Alder Hey has suggested strengthening the governance and contracting arrangements for the Liverpool partnership and is keen to play a lead role in this. Alder Hey received an unannounced inspection of three of its core services in April 2017 – Community CAMHS, Surgical care and Medicine – together with a well led review. The reports resulting from this inspection were published in October 2017 and the Trust developed a detailed action plan in response to the recommendations. This plan has been monitored on a monthly basis by the Trust’s Clinical Quality Assurance Committee and Integrated Governance Committee. 2.2.8 Data Quality Alder Hey Children’s NHS Foundation Trust submitted records during 2017/18 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included patient’s valid NHS Number was: • 99.9% for admitted patient care; • 100 % for outpatient care; • 99.7% for accident and emergency care. The percentage of records in the published data which included patient’s valid General Medical Registration Code was: • 100% for admitted patient care • 99.9% for outpatient care; • 100% for accident and emergency care Alder Hey Children’s NHS Foundation Trust will be taking the following actions to improve data quality: • A suite of data quality reports will continue to be run daily and weekly to ensure data is monitored and corrected where necessary. • Ongoing work is monitored by the Data Quality Steering Group which meets monthly • Continue to work closely with the Information Department to identify any data issues or areas of data weakness, which will be investigated and remedial action agreed. • The Data Quality policy has been updated to include escalation process for “repeat offenders” who continue to make mistakes when recording data Alder Hey Children’s NHS Foundation Trust 101 Annual Report & Accounts 2017/18
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A E H E LD Y R ANNUAL REPORT & ACCO
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©2018 Alder Hey Children’s NHS F
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A MESSAGE FROM OUR CHAIR AND CHIEF
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PERFORMANCE REPORT OVERVIEW The fol
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Teenage Cancer Trust Honorary Patro
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OUR CQC RATINGS The Trust’s curre
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• Applied clinical research perfo
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The Trust’s performance against n
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‘Alder Play’ A new approach to
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KEY RISKS TO DELIVERY IN 2017/18 Th
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Regulatory Ratings NHS Improvement
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Expenditure Operating expenses tota
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ALDER HEY USES MRI/ CT DATA TO CREA
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Louise Shepherd CBE - Chief Executi
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Mags Barnaby - Interim Chief Operat
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NHS IMPROVEMENT’S WELL LED FRAMEW
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Clinical Educators The Trust has ag
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All complainants are offered the op
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have resulted in Memoranda of Under
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The Community Cluster Developed wit
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Alder Hey’s collaborative campaig
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accordance with Non-Executive remun
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(R) Indicates that the individual i
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SALARY AND PENSION ENTITLEMENTS OF
Page 50 and 51: STAFF REPORT Analysis of Trust staf
Page 52 and 53: approach to internal materials and
Page 54 and 55: EXIT PACKAGES 2016/17 Exit Package
Page 56 and 57: As in 2016, we surveyed all staff i
Page 58 and 59: NHS FOUNDATION TRUST CODE OF GOVERN
Page 60 and 61: Governor Constituency Class Term of
Page 62 and 63: Throughout our membership activitie
Page 64 and 65: Attendance at Board of Directors an
Page 66 and 67: External Audit In April 2017 new re
Page 68 and 69: Segmentation Alder Hey has been pla
Page 70 and 71: STATEMENT OF THE CHIEF EXECUTIVE’
Page 72 and 73: During the year the Trust sustained
Page 74 and 75: The Divisions report against CQC Fu
Page 76 and 77: organisation’s ability to continu
Page 78 and 79: Nursing, Deputy Director of Nursing
Page 80 and 81: THE YOUNG PEOPLE’S CANCER UNIT RE
Page 82 and 83: PART 2: PRIORITIES FOR IMPROVEMENT
Page 84 and 85: 2.1.2 Quality Improvements in 2017/
Page 86 and 87: National Confidential Enquiries Par
Page 88 and 89: 2.2.4 Actions arising from Local Cl
Page 90 and 91: Local Audit Retrospective Audit of
Page 92 and 93: Local Audit How often are high ferr
Page 94 and 95: Local Audit Emollient and bath pack
Page 96 and 97: Local Audit Has the introduction of
Page 98 and 99: The Quality Account deals with rese
Page 102 and 103: • A Data Quality dashboard is emb
Page 104 and 105: in improved ward to board reporting
Page 106 and 107: Clinical Incidents Reported 2013/14
Page 108 and 109: Reducing Hospital Acquired Infectio
Page 110 and 111: 3.3.2 PRIORITY 2 - Increase Engagem
Page 112 and 113: Are you: 95 17% 8 1% Parent/Carer P
Page 114 and 115: • Improved the quality of room bo
Page 116 and 117: When a child has an asthma attack t
Page 118 and 119: The awards and review schedule is h
Page 120 and 121: F. The Alder Play App Aims: • To
Page 122 and 123: Developing a System of 7 Day Workin
Page 124 and 125: of staff and governors, assess each
Page 126 and 127: • Working with external organisat
Page 128 and 129: the Tate Exchange programme during
Page 130 and 131: experience. Medication errors are t
Page 132 and 133: • To complete and roll out the ne
Page 134 and 135: 3.3.8 Peri-operative Care The focus
Page 136 and 137: 3.3.9 Best in Operative Care The Be
Page 138 and 139: Improvements: • Increased the Bla
Page 140 and 141: and continues to work towards findi
Page 142 and 143: In November 2017, the National Qual
Page 144 and 145: 3.3.14 Management of Complaints and
Page 146 and 147: Target or Indicator (per 2013/14 Ri
Page 148 and 149: I would recommend the Trust’s app
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Commentary from Clinical Commission
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STATEMENT OF DIRECTORS’ RESPONSIB
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• feedback from local Healthwatch
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AN EVENING CELEBRATING THE PASSION,
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STATEMENT OF COMPREHENSIVE INCOME N
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STATEMENT OF CHANGES IN EQUITY FOR
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NOTES TO THE ACCOUNTS 1. ACCOUNTING
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1.6 Expenditure on Other Goods and
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of Financial Position’ by the tru
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through the expected life of the fi
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Exchange gains or losses on monetar
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3.3 Overseas Visitors (Relating to
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5.1 Operating Expenses 2017/18 £00
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7.1 Retirements Due to Ill-Health D
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11. FINANCE EXPENDITURE Finance exp
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15. PROPERTY, PLANT AND EQUIPMENT 1
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15.3 Property, Plant and Equipment
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20. TRADE RECEIVABLES AND OTHER REC
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24. OTHER LIABILITIES 26. FINANCE L
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30. OTHER FINANCIAL COMMITMENTS The
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32.2 Carrying Values of Financial A
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32.5 Maturity of Financial Liabilit
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34. RELATED PARTIES (CONT’D) In a
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KEY AUDIT MATTERS Key audit matters
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AN OVERVIEW OF THE SCOPE OF OUR AUD
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“A matter is significant if, in t
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Alder Hey received visits from both
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AH ANNUAL REPORT 2018

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