AH ANNUAL REPORT 2018

NHS IMPROVEMENT’S WELL
LED FRAMEWORK
NHS Improvement introduced updated guidance for
organisations on the use of the well-led framework
in June 2017. The Alder Hey Board had agreed to
commission an external review under the previous
guidance in April 2017; as part of this it had undertaken
an initial self-assessment at that point and made the
decision to commission MIAA (Mersey Internal Audit
Agency) in partnership with AQuA (Advancing Quality
Alliance). The review itself did not commence until
November 2017 owing to a number of Board members
being involved in the delivery of the management
contract at Liverpool Community Health NHS Trust
between May and the end of October.
The comprehensive review was carried out in
accordance with the revised guidance and therefore
had a strong focus on integrated quality, operational
and financial governance and was based upon a
number of key lines of enquiry developed by CQC
to test out leadership, culture, system working and
quality improvement. The methodology for the review
consisted of four key areas of interlinked activity to
enable in depth triangulation of the findings; these were:
a desktop document review; one-to-one interviews;
board and sub-committee observation and on-line
surveys. The review involved some 40 people; as well
as the Trust’s Board members and senior managers,
views were also sought from a range of external
stakeholders including commissioners.
The draft report from the review was received in late
February 2017; it states that ‘The overall conclusion
from our review is that the Trust is well-led. It is an
organisation with lived values, a talented Board, a
determined strategic intent and a momentum to
developing a clinical leadership model.’ Whilst the
Board welcomes such a positive conclusion, it is
equally concerned to ensure that the developmental
plan derived from such a rich and informative process
is created and owned by the whole Trust leadership.
A workshop session to discuss the recommendations
from the report is to take place in the first quarter
of 2018/19 to agree the priorities that will inform the
Board’s work plan for the next period.
QUALITY GOVERNANCE
The Trust’s performance against the Quality
Governance Framework - originally published by
Monitor in 2010 and now adopted by NHS Improvement
– has continued to be monitored via the Clinical Quality
Assurance Committee on a quarterly basis. The Well
Led Framework was developed from the Quality
Governance Framework, thus Alder Hey’s approach
has been to review its governance arrangements
and underpinning systems and processes on a
regular basis as the national landscape around good
governance, quality and leadership has evolved.
The Clinical Quality Assurance Committee continued its
work to oversee the development of the Trust’s Quality
Strategy during the year, seeking assurance from a
variety of sources to ensure that it remains sighted on
any risks as they emerge, for example the roll-out of
the new sepsis pathway. The Committee instituted a
programme of in depth ‘Quality Assurance Rounds’
to inform the Trust’s ward to Board governance.
These have been extremely well received across the
hospital and the programme encompasses over 50
visits to ensure full coverage of every service. The
Committee also monitors the delivery of the Quality
Aims, incorporating measures of clinical effectiveness,
patient safety and positive patient experience, via the
Corporate Report which was redesigned during the
year to better support the Trust’s quality improvement
approach.
The Integrated Governance Committee, chaired by
the Trust’s Senior Independent Director, has delegated
authority to seek assurance on the management of
risk across the whole of the organisation’s activities
and to hold each responsible officer to account for
the effective management and mitigation of risks in
their area. It operates an assurance mechanism that
links together the Board Assurance Framework and
Corporate Risk Register, which in turn is informed by
individual Divisional and departmental risk registers.
The Committee provides a structured process to test
controls and ensure that strategic and operational risks
are being addressed as part of a coherent system
from ward to Board; this was revised and further
strengthened during the year as part of the current
phase of the risk management improvement plan,
which has included a comprehensive risk register
revalidation process.
The work of the Audit Committee complements this by
discharging its responsibility for the maintenance of an
effective system of internal control across the totality of
integrated governance and risk management. During
the year it received a report on the progress of the risk
management improvement plan.
The Board Assurance Framework is scrutinised by the
Board at its meeting each month to enable the Board to
be fully sighted on key risks to delivery and the controls
put in place to manage and mitigate them, as well as
enabling all members to have an opportunity to identify
key issues, concerns or changes.
Further details about the Trust’s approach to the
well-led framework and quality governance can be
found within the Quality Report (page 81) and Annual
Governance Statement (page 71).
Alder Hey Children’s NHS Foundation Trust 32
Annual Report & Accounts 2017/18