AH ANNUAL REPORT 2018

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NHS FOUNDATION TRUST CODE OF GOVERNANCE The NHS Foundation Trust Code of Governance, was first published by Monitor in 2006. The purpose of the Code of Governance is to assist NHS foundation trust boards in improving their governance practices by bringing together the best practice of public and private sector corporate governance. The Code is issued by Monitor/NHS Improvement as best practice advice, but imposes some disclosure requirements which are set out in the sections below. Alder Hey Children’s NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a ‘comply or explain’ basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in 2012. The arrangements put in place by the Trust in response to the Code are set out in the sections below and elsewhere in the report as appropriate. OUR COUNCIL OF GOVERNORS 2017/18 again saw a number of changes on the Council of Governors following the annual elections. A comprehensive Induction programme continues to be delivered to enable incoming governors to understand their new role as rapidly as possible. This training is also offered to existing Governors annually as a means of refreshing their skills. A number of Alder Hey governors also took advantage of the ongoing GovernWell development programme offered by NHS Providers, which is an invaluable resource. The Council has continued to work alongside the Board to understand and contribute to the Trust’s plans for the future. The governors’ extranet provides a rapid and accessible mechanism for the Board to share information with them ensuring that they are kept up to date between formal meetings. It also equips the governors with the information they require to give feedback about the Trust’s activities to members and other stakeholders, including the host organisations of appointed governors. The governors use a variety of mechanisms to canvass the view of members and the wider community; some of these are informal and carried out through individuals’ networks and others more formal such as inviting comments via the newsletter and direct engagement at the Annual Members’ meeting. Such views are fed back to the Board throughout the year at regular formal meetings, providing an opportunity for governors to discuss key strategies with Board members. The Council met formally five times during the year; one of the meetings was held to seek approval to amend the Trust’s Constitution to ensure that appropriate governance was in place to support the Alder Hey Board’s role at Liverpool Community Health NHS Trust. Executive and Non-Executive Directors attend the Council of Governors’ meetings and the Chair and Chief Executive report on the Trust’s performance and on key strategic and operational issues and developments. This ensures that the agendas of the two bodies remain closely interlinked and appropriate decisions taken by each in accordance with its Standing Orders. The 2017 Annual Members’ Meeting was held in November at the Institute in the Park, with keynote speaker Dr. Steve Ryan, Medical Director. The title of his inspiring talk was ‘The Medical Director’s Tale - Reflections on a long and eventful NHS Career’ which was followed by presentation of the Trust’s Annual Accounts 2016/17 and the report of the Council of Governors delivered by Lead Governor, Kate Jackson. The Council re-appointed three of the existing Non- Executives during 2017/18, one for a second term of three years and two reappointments of twelve months; this was to ensure stability and continuity on the Board. The Council also re-approved the appointment of the Chairman for a final twelve month period. The governors have also continued to input into a fully inclusive process for the Chair’s appraisal and agreement of annual objectives, led by the Senior Independent Director. In addition to its statutory role, the Council contributes to the life of the hospital in a variety of ways, for example as members of the judging panel for the annual staff awards, participating in the PLACE inspection of the hospital environment and attending various assurance committee meetings. The Lead Governor continued to hold regular meetings with the governors without members of the Board present; these discussions generate items for discussion at formal Council meetings to provide governors with additional assurance on key topics such as future car parking proposals and the plans for the development of Springfield Park. In addition to the full Council meetings, governors have been involved in the Membership Strategy Committee, whose activities area summarised overleaf, as well as time-limited working groups focused on specific issues. Alder Hey Children’s NHS Foundation Trust 58 Annual Report & Accounts 2017/18
The Membership Strategy Committee continued to take forward its work plan and objectives in support of the Membership Strategy. Key activities in the year included: • Acting as Editorial Board for the members’ newsletter supported by members of the Communications and Marketing team • Exploring Social Media platforms for membership purposes • Patient experience, through developing links with members of the Children and Young Peoples’ Forum • Planning and organisation of the Annual Members’ meeting • Young advisors project • ‘Critical friend’ role in reviewing and commenting on the Quality Report Governors are contactable through the Trust’s Committee Administrator based at Alder Hey on 0151 252 5128 or by email at membership@alderhey.nhs.uk. Composition of the Council of Governors The Council of Governors is made up of 25 elected governors and 10 appointed governors from nominated organisations and comprises six staff governors (elected by staff), nine public governors, four patient governors, six parent and carer governors (elected by members). The Council represents, as far as possible, every staff group and the communities that Alder Hey serves across England and North Wales. Elected Governors are chosen as part of an independent process managed on behalf of the Trust by the Electoral Reform Service, in accordance with the Constitution. Elections to the Council of Governors take place annually, in the summer. On election or appointment all governors are required to sign the Council’s Code of Conduct and to complete their declaration of interests in accordance with the Trust’s policy. The Council of Governors operates under the leadership of the Trust Chair and its endeavours are supported by the Lead Governor, Kate Jackson who was re-elected to this role in December 2017 for a further three years (unopposed). The roles and responsibilities of governors are set out in the Trust’s Constitution and Council of Governors’ Standing Orders. Alder Hey Children’s NHS Foundation Trust 59 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
Page 8 and 9: PERFORMANCE REPORT OVERVIEW The fol
Page 10 and 11: Teenage Cancer Trust Honorary Patro
Page 12 and 13: OUR CQC RATINGS The Trust’s curre
Page 14 and 15: • Applied clinical research perfo
Page 16 and 17: The Trust’s performance against n
Page 18 and 19: ‘Alder Play’ A new approach to
Page 20 and 21: KEY RISKS TO DELIVERY IN 2017/18 Th
Page 22 and 23: Regulatory Ratings NHS Improvement
Page 24 and 25: Expenditure Operating expenses tota
Page 26 and 27: ALDER HEY USES MRI/ CT DATA TO CREA
Page 28 and 29: Louise Shepherd CBE - Chief Executi
Page 30 and 31: Mags Barnaby - Interim Chief Operat
Page 32 and 33: NHS IMPROVEMENT’S WELL LED FRAMEW
Page 34 and 35: Clinical Educators The Trust has ag
Page 36 and 37: All complainants are offered the op
Page 38 and 39: have resulted in Memoranda of Under
Page 40 and 41: The Community Cluster Developed wit
Page 42 and 43: Alder Hey’s collaborative campaig
Page 44 and 45: accordance with Non-Executive remun
Page 46 and 47: (R) Indicates that the individual i
Page 48 and 49: 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 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 100 and 101: Indicator Indicator Description Tar
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
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Reducing Hospital Acquired Infectio
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3.3.2 PRIORITY 2 - Increase Engagem
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Are you: 95 17% 8 1% Parent/Carer P
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• Improved the quality of room bo
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When a child has an asthma attack t
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The awards and review schedule is h
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F. The Alder Play App Aims: • To
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Developing a System of 7 Day Workin
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of staff and governors, assess each
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• Working with external organisat
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the Tate Exchange programme during
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experience. Medication errors are t
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• To complete and roll out the ne
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3.3.8 Peri-operative Care The focus
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3.3.9 Best in Operative Care The Be
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Improvements: • Increased the Bla
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and continues to work towards findi
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In November 2017, the National Qual
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3.3.14 Management of Complaints and
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Target or Indicator (per 2013/14 Ri
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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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