AH ANNUAL REPORT 2018

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STATEMENT OF THE CHIEF EXECUTIVE’S RESPONSIBILITIES AS THE ACCOUNTING OFFICER OF ALDER HEY CHILDREN’S NHS FOUNDATION TRUST The National Health Service Act 2006 states that the Chief Executive is the accounting officer of the NHS Foundation Trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by NHS Improvement. NHS Improvement, in exercise of the powers conferred on Monitor by the National Health Service Act 2006, has given accounts directions which require Alder Hey Children’s NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis required by those directions. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Alder Hey Children’s NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the Department of Health Group Accounting Manual and in particular to: • observe the Accounts Direction issued by NHS Improvement, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • make judgments and estimates on a reasonable basis; • State whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual (and the Department of Health Group Accounting Manual) have been followed, and disclose and explain any material departures in the financial statements; • ensure the use of public funds complies with the relevant legislation, delegated authorities and guidance; and • prepare the financial statements on a going concern basis. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief the information in the document is accurate; I have properly discharged the responsibilities set out in Monitor’s NHS Foundation Trust Accounting Officer Memorandum. Signed. Louise Shepherd LOUISE SHEPHERD CBE Chief Executive 22nd May 2018 Alder Hey Children’s NHS Foundation Trust 70 Annual Report & Accounts 2017/18
ANNUAL GOVERNANCE STATEMENT SCOPE OF RESPONSIBILITY As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. THE PURPOSE OF THE SYSTEM OF INTERNAL CONTROL The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Alder Hey Children’s NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Alder Hey Children’s NHS Foundation Trust for the year ended 31st March 2018 and up to the date of approval of the annual report and accounts. CAPACITY TO HANDLE RISK Every member of staff at Alder Hey has an individual responsibility for the management of risk within the organisation. Managers at all levels must understand the Trust’s Risk Management Strategy and be aware that they have the authority to manage risk within their area of responsibility. As Chief Executive and Accounting Officer, I have overall responsibility and accountability for risk management. The Chief Executive is informed of significant risk issues via the established reporting mechanisms and assurance committees, ensuring that her role for risk management is fulfilled. The Medical Director is accountable to the Board of Directors and the Chief Executive for clinical risk management and clinical governance; he reports to the Chief Executive and the Board as appropriate. The Chief Nurse is the Executive lead for risk management and is accountable to the Board and the Chief Executive for the Trust’s risk management activities; she is also responsible for embedding compliance with CQC standards across the organisation. The Associate Director of Nursing and Governance is the operational lead for risk management, accountable to the Chief Nurse and has line management responsibility for the Trust’s Risk Management team. They are responsible for ensuring that the Trust’s risk management systems and processes are effective and operate in accordance with best practice. The Chief Nurse is also the Executive lead for Facilities and is responsible for the effective management of risk in those areas. The Director for Human Resources retains an overview of statutory and mandatory training for the organisation and is responsible for Health and Safety management. The Director of Finance is responsible for ensuring that the Trust carries out its business within sound financial governance arrangements that are controlled and monitored through effective audit and accounting systems. He is also responsible for Information Management and Technology risk. The Director of Corporate Affairs is responsible for Information Governance and is the nominated Senior Information Risk Owner, whilst the Chief Nurse is the Trust’s Caldicott Guardian. Divisional Associate Chief Operating Officers and their senior teams, including Associate Chief Nurses and Heads of Quality, are responsible for ensuring that risk management systems within the Divisions are effective and also meet the objectives outlined within the Risk Management Strategy. Divisional Boards have a key role in assuring the effectiveness of risk management, including regular scrutiny of Divisional risk registers. Associate Chief Nurses and Heads of Quality monitor and review incidents, risk assessments, claims and complaints and ensure that agreed actions are carried out and feedback is given to staff. Ward and department line managers ensure that relevant staff are trained on Ulysses, the incident reporting system and that incidents are reported and actions taken when required. They provide feedback to staff, ensuring that Trust policies, procedures and guidelines are followed to minimise risk and share learning from incidents and near misses. Individuals are responsible for reporting any identified risks in order that they can be addressed and are accountable for ensuring their own competency and that their training needs are met in discussion with their line managers. They attend induction and statutory and mandatory training as required, including risk management. They ensure that they practice within the standards of their professional bodies, national standards and Trust policies, procedures and guidelines. Alder Hey Children’s NHS Foundation Trust 71 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
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 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 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
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
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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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