AH ANNUAL REPORT 2018

using the Trust Framework for the Grading of Risks.
This framework provides a consistent approach to the
grading of risks arising within the Trust and enables
all risks to be graded in the same manner against the
same generic criteria. This allows for comparisons
to be made between different types of risk and for
judgements and decisions about risk appetite and the
prioritisation of resource allocation to be made on that
basis. It enables decisions to be taken about the level of
management of each risk within the Trust.
A key philosophy of this strategy is to facilitate greater
embedding of risk management across the Divisions
and corporate functions in the Trust. In order to achieve
that, each Division and corporate function has a lead
for risk and governance who acts as the focus of the
various aspects of governance and risk management
within their area. They coordinate all such work and
liaise with the Risk Management team and with other
governance professionals across the Trust. Regular
updates to departmental and divisional risk registers
are fed in to the Corporate Risk Register. The Integrated
Governance Committee engages in an active analysis
of the Corporate Risk Register at each meeting,
including consideration of risk escalation and deescalation,
which in turn links to the Board Assurance
Framework.
During 2016/17, the Trust implemented a model of
devolved governance within the clinical Divisions,
giving clearer responsibility and ownership of risk
and governance at local level. To further strengthen
the risk and governance capability at senior level, the
Trust appointed to a new role of Associate Director of
Nursing and Governance commencing in May 2017,
with the post-holder taking ownership of the ongoing
Risk Management Improvement Plan and refreshing
this to reflect latest developments. Significant progress
was made to embed the devolved governance model
during 2017/18 and at the same time great strides were
made toward the new phase of the Risk Management
Improvement Plan. The Associate Director of Nursing
and Governance undertook a root and branch review
of the Trust’s risk management systems and processes
during the first part of the year and this informed an
updated improvement plan. She presented a progress
report to the Audit Committee in January 2018 detailing
actions taken to date, including:
• Implementation of a Trust-wide consistent risk
validation process to take place on a monthly basis
with each Division and department;
• Sharper focus at the Integrated Governance
Committee on the underpinning assurance processes
behind each risk and mitigations in place to achieve
target risk ratings;
• Risks rated 15 or above to be assigned a responsible
Executive until score assessed at 12 or below via
effective mitigation.
In addition, a range of further actions were agreed and
are currently at varying stages of implementation; these
comprise:
• Development and implementation of step by step
guides for risk management including:
- Step by step guide for managing risks on the
risk register
- Step by step guide process for adding a risk to
the risk register
- Step by step guide to reporting incidents
- Step by step guide for managers to manage
incidents
• Introduction of investigation logs including lessons
learned and actions for improvement for incidents,
complaints, safeguarding, infection control etc)
• A 12 month schedule of monthly investigation
assurance meetings
• A new 12 month schedule of risk revalidation
meetings held monthly with all divisions and
corporate functions individually
• Reintroduction of 12 month schedule of policy
assurance meetings
• Implementation of Quality assurance rounds across
50 teams scheduled over 12 months, with executive
and non-executive attendance.
The Trust remains registered with CQC without
conditions and is fully compliant with the registration
requirements. In April 2017 the Trust underwent an
unannounced inspection by CQC, maintaining the
overall ratings awarded in 2015 of ‘Good’ for the
hospital overall with a rating of ‘Outstanding’ in the
Caring domain. The Trust is also rated ‘Good’ in the
Well-led domain, reflecting the focus on improving
the Trust’s risk and governance arrangements since
the previous inspection, although there were some
additional recommendations made with particular
reference to risk management at individual service and
departmental level. This action was incorporated into
the Trust’s Risk Management Improvement Plan and
implemented as described above.
In terms of monitoring compliance with registration
requirements and essential standards, the Clinical
Divisions provide assurance via regular submissions
of their key issues reports through to the Clinical
Quality Steering Group (CQSG). This incorporates a
set of quality indicators reflecting the Trust’s Quality
Strategy, Quality Aims and associated KPIs. The
key issue reports include compliance against CQC
standards and other regulatory targets. They also
incorporate assurance against clinical effectiveness,
patient experience and patient safety indicators such as
incidents, risks, medication errors and infections.
Alder Hey Children’s NHS Foundation Trust 73
Annual Report & Accounts 2017/18