AH ANNUAL REPORT 2018

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 2018. 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