AH ANNUAL REPORT 2018

During the year the Trust sustained its high rate of
incident reporting via the NRLS system, which from last
year placed it among the best performers for patient
safety incident reporting nationally: the most recent
data – March 2018 – positioned Alder Hey third in the
country and the highest reporter among specialist
paediatric trusts. This ongoing trend demonstrates the
commitment of staff to the Trust’s Quality Improvement
culture and the benefits to be gained from open
reporting and learning from incidents. As part of the
overall risk management improvement plan, work
to improve the functionality of the Ulysses incident
reporting system continued during the year. Risk
registers continue to be used interactively throughout
the organisation and are fully embedded in the Trust’s
governance structures including the Executive Team,
the Board, its sub-committees and Divisional Risk and
Governance Groups to better drive the management
and mitigation of risks. During the year extensive
work has taken place to validate all risk registers at
departmental level, ensuring that each identified risk
has been reviewed and mitigating actions updated as
appropriate. In addition, work continues to improve
the risk register format and associated reports and
supporting local areas in completing and reviewing
risks. Training sessions continue to be available to all
staff, including one to one and/or team sessions on
request. In addition, Ulysses system one to one training
is provided to new starters, with refresher training
available on request.
The Board of Directors maintained its regular and
robust oversight of the Board Assurance Framework
during the year, with the assurance committees also
keeping their related risks under regular review. The
report continues to support the delivery of the Board
agenda and has contributed towards the achievement
of a positive statement from the Trust’s Internal Auditors
under the annual review of the Assurance Framework
which states that:
‘The organisation’s Assurance Framework is structured
to meet the NHS requirements, is visibly used by the
Board and clearly reflects the risks discussed by the
Board.’
The opinion recommended attention be given to
ensuring that Board assurances are clearly identified
within the BAF: ‘some of the assurances detailed within
the BAF could be clearer in terms of scope, frequency
and reporting to the Board. This would also enable the
Board to more directly connect the papers received
with the BAF risks’. This will be taken forward during
2018/19.
The Trust received a rating of ‘substantial assurance’
confirmed by the Director of Audit Opinion for 2017/18.
THE RISK AND CONTROL
FRAMEWORK
Implementation of the Trust’s Risk Management
Strategy is monitored through the Integrated
Governance Committee. The Board of Directors
and its assurance committees have maintained their
focus on key risks during the year. The strategy was
reviewed and updated during the year; it provides a
robust framework for the systematic identification,
assessment, treatment and monitoring of risks, whether
the risks are clinical, organisational, business, financial
or environmental. Its purpose is to minimise risks to
patients, staff, visitors and the organisation as a whole
by ensuring that effective risk management systems
and processes are implemented in all areas of service
provision, and that these are regularly reviewed. The
key elements of the strategy include:
• a definition of risk management;
• the Trust’s policy statement and organisational
philosophy in relation to risk management as an
integral part of our corporate objectives, goals and
management systems;
• strategic vision for risk management across the
organisation;
• roles, responsibilities and accountabilities;
• governance structures in place to support risk
management, including terms of reference of key
committees.
The Board Assurance Framework, which focuses on
identifying and monitoring the principal strategic risks
to the organisation at corporate level, is embedded
within the Trust and is regularly reviewed and updated.
The Assurance Framework has been reviewed by the
Board of Directors on a monthly basis during the year; it
covers the following elements:
• identification of principal risks to the achievement of
strategic objectives;
• an assessment of the level of risk in-month,
calculated in accordance with the Trust’s risk matrix,
described below;
• internal controls in place to manage the risks;
• identification of assurance mechanisms which relate
to the effectiveness of the system of internal control;
• identification of gaps in controls and assurances;
• a target risk score that reflects the level of risk that the
Board is prepared to accept; and the actions taken by
the Trust to address control and assurance gaps.
Risks are analysed to determine their cause, their
potential impact on patient and staff safety, the
achievement of local objectives and strategic
objectives, the likelihood of them occurring or recurring
and how they may be managed. Risks are evaluated
Alder Hey Children’s NHS Foundation Trust 72
Annual Report & Accounts 2017/18