AH ANNUAL REPORT 2018

The Divisions report against CQC Fundamental
Standards as part of the assurance framework and
action plans from serious incidents are also presented
and monitored with dissemination to Divisions for
shared learning. CQSG also provides a key issues
report to CQAC for further assurance, highlighting any
exceptions or risks that may need to be addressed or
escalated.
The Board at Alder Hey continues to review its quality
governance arrangements and underpinning systems
and processes on a regular basis. The Clinical Quality
Assurance Committee, whose membership includes all
Divisional Directors as well as Board directors, carries
out more detailed scrutiny under its delegated authority
from the Board for oversight of the Trust’s performance
against NHS Improvement’s Quality Governance
Framework, the delivery of the Quality Strategy
incorporating measures of clinical effectiveness, patient
safety and positive patient experience. The work of
the Audit Committee complements this by discharging
its responsibility for the maintenance of an effective
system of integrated governance, risk management and
internal control across the whole of the organisation’s
activities.
As described above, new programme of Quality
Assurance Ward/Department Rounds was
implemented for 2017/18 which commenced fully in
September 2017. The purpose of this programme is to:
• Facilitate a deep dive at ward/department/specialty
level into quality and performance, noting areas of
good practice and any actions being taken at a local
level to address areas of concern.
• Provide both quantitative and qualitative information
to demonstrate that the services are safe, effective,
responsive, caring and well-led in line with the CQC’s
Key Lines of Enquiry (KLOE).
• Enable the wards/departments to review standards
of care being delivered via the results of the latest
Quality Care Assessment Tool (QCAT) where
completed, the ward dashboard and other quality
metrics used within the specialty.
• Allow specialties to provide an overview of the results
of any external peer reviews of their service, and/
or benchmark against relevant national specialty
guidance or standards.
• Provide an opportunity for ward/departments and
specialty staff to talk directly to Executive and Non-
Executive Directors.
• Enable members of the Board to familiarise
themselves with clinical environments and the day-today
activities occurring at Ward/Department/specialty
level, hearing first hand from front-line staff.
• Enable members of the Board to consider any issues
facing the ward/ department that are escalated and
need their input or support to resolve.
• To support the golden thread of ward to board
reporting through transparency, by testing out and
gaining assurance that what is reported to the Board
is consistent with what is happening at a local level.
The programme commenced in September 2017
and by the end of March 2017 assurance rounds
undertaken. Both quantitative and qualitative
assurance has been presented by all services, via the
presentations and walk arounds, which have shown
to the board members a clear link between board and
local assurance.
Key themes emerging from the process to date include:
• All services have been very clear about the vision for
their service, which is aligned with the Trust vision, in
terms of building a healthier future for children, and
their families.
• All inpatient wards hold daily safety huddles (safety
huddles are short multidisciplinary briefings designed
to give healthcare staff, clinical and non-clinical
opportunities understand what is going on with each
patient and anticipate future risks to improve patient
safety and care).
• All services have demonstrated a good
understanding of the Care Quality Commission 5 key
lines of enquiry, and the content of their presentations
demonstrated this clearly.
• All services demonstrated strong emphasis on team
working, appreciation of colleagues from other
disciplines, and the contribution they bring to the
service and patient care.
• The management of risk is at the centre of service
provision and good evidence demonstrated of checks
and balances being in place, with the ethos of the
need for continuous improvement.
• The culture across services is open, honest and
encourages staff to speak out about mistakes and
problems, working together to find solutions to keep
patients, staff and others safe.
• Many of the services have achieved national
recognition because of their innovation and
outstanding work.
• Strong evidence of excellent leadership across
services visited, and good understanding of purpose
and direction the services will be taking going
forward.
• Strong emphasis on recognising staff achievements
e.g. hero awards, star of the month awards.
• Good evidence of communication via, newsletters,
briefings, governance meetings, safety alerts.
The Board has continued to focus on improving the
information received to describe the performance of the
organisation with regard to quality and other key
Alder Hey Children’s NHS Foundation Trust 74
Annual Report & Accounts 2017/18