AH ANNUAL REPORT 2018

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Attendance at Board of Directors and Key Board Committee Meetings Number of Meetings Held 2017/18 Sir David Henshaw Board of Directors Audit Committee Clinical Quality Assurance Committee Resources and Business Development Committee Workforce and OD Integrated Governance Committee Research, Education & Innovation Committee 12 5 11 10 6 7 2 12 5 11 10 6 7 2 Louise Shepherd 10 Not a Member Not a Member Not a Member Not a Member Not a Member 0 Ian Quinlan 12 Not a Member Not a Member Not a Member Not a Member Not a Member 1 Steve Igoe 10 5 4 Not a Member Not a Member 7 Not a Member Claire Dove 10 Not a Member Not a Member 8 5 Not a Member Not a Member Anita Marsland 9 4 11 Not a Member Not a Member Not a Member Not a Member Jo Williams 12 Not a Member 8 Deputised 1/1 Not a Member Not a Member Not a Member Jeannie France- Hayhurst 11 1 11 Not a Member 3 Not a Member Not a Member John Grinnell 11/11 5 Attendee 8 8 Not a Member 6 Not a Member Margaret Barnaby 5/5 Attendee Not a Member 6/7 4/7 1/5 1/5 Not a Member Adam Bateman 7/7 Attendee Not a Member 3/3 3/3 1/1 1/2 Not a Member Erica Saunders 12 Attendee 5 Attendee 9 Not a Member Not a Member 7 2 Melissa Swindell 11 Not a Member 8 7 6 7 2 Steve Ryan 10 Not a Member 8 Not a Member 2 4 1 Hilda Gwilliams 10 Not a Member 7 Not a Member 2 0 0 Pauline Brown Not a Member Not a Member Not a member Not a member Not a member 5 Deputised for Hilda Gwilliams Not a Member David Powell 8/11 Attendee Not a Member Not a Member Not a Member Not a Member 1 1 Alder Hey Children’s NHS Foundation Trust 64 Annual Report & Accounts 2017/18
Attendance at Board of Directors and Key Board Committee Meetings (Cont’d) Board of Directors Audit Committee Clinical Quality Assurance Committee Resources and Business Development Committee Workforce and OD Integrated Governance Committee Research, Education & Innovation Committee Louise Dunn 2/4 Attendee Not a Member Not a Member 2/2 Attendee Not a Member Not a Member 0 Mark Flannagan 6/7 Attendee Not a Member Not a Member 4/7 Attendee 3/3 Not a Member 1 Due to her role as lead for the Cheshire and Merseyside Five Year Forward View, the Board agreed that Louise Shepherd would cease to be a formal member of the Trust’s assurance committees for the period in order to accommodate this important national work. The Deputy Chief Executive represented Mrs Shepherd at these meetings. AUDIT COMMITTEE <strong>REPORT</strong> The Audit Committee is comprised of Non-Executive Directors only, excluding the Trust Chair. The Committee was chaired by Steve Igoe throughout the year, a Non-Executive Director with ‘recent relevant financial experience’ which is best practice. The Director of Finance and Director of Corporate Affairs together with the Operational Director of Finance are invited to attend and the Committee may request the attendance of the Chief Executive and any other officer of the Trust to answer any points which may arise. Attendance by members is set out above. The aim of the Audit Committee is to provide one of the key means by which the Board of Directors ensures effective internal control arrangements are in place. In addition, the Committee provides a form of independent check upon the executive arm of the Board. As defined within the NHS Audit Committee Handbook (2014), the Committee has responsibilities for the review of governance, risk management and internal control covering both clinical and non-clinical areas. In discharging these duties the Committee is required to review: • Internal financial control matters, such as safeguarding of assets, the maintenance of proper accounting records and the reliability of financial information. • Risks regarding disclosure statements (for example the Annual Governance Statement) which are supported by the Head of Audit Opinion and other opinions provided • The underlying assurances as detailed in the Board Assurance Framework. • The adequacy of relevant policies, legality issues and Codes of Conduct. • The policies and procedures related to fraud and corruption. The conduct of this remit is achieved firstly, through the Committee being appropriately constituted, and secondly by the Committee being effective in ensuring internal accountability and the delivery of audit and assurance services. Internal Audit The Internal Audit service is provided by Mersey Internal Audit Agency (MIAA), an independent NHS organisation. The Director of Audit Opinion and Annual Report for 2017/18 reports that MIAA have demonstrated their compliance with NHS mandatory Internal Audit Standards. Internal Audit provides an independent and objective appraisal service embracing two key areas: • The provision of an independent and objective opinion to the Accountable Officer, the Board and the Audit Committee on the degree to which risk management, control and governance support the achievement of the agreed objectives of the organisation. • The provision of an independent and objective consultancy service specifically to help line management improve the organisation’s risk management, control and governance arrangements. Alder Hey Children’s NHS Foundation Trust 65 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
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 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 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
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
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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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