AH ANNUAL REPORT 2018

performance metrics. Reporting processes have
continued to develop with a significant refresh of the
Trust’s Corporate Report taking place in the latter
part of the year to ensure alignment with strategic and
national objectives. A revised report both in terms of
content and format was phased in from February 2018
and will be fully implemented from April 2018 as a
consequence of this work.
The Trust has been keen to ensure that it optimises
the Quality Governance Framework first published
by Monitor in 2010, subsequently adopted by NHS
Improvement and which also informs the Well
Led Governance Framework published by NHS
Improvement and revised in June 2017. The Trust has
continued to undertake regular self-assessments of
its position against each element of the framework,
under the auspices of the Clinical Quality Assurance
Committee; this exercise was completed on three
occasions during 2017/18 – May, September and
December.
This ongoing consideration of the Quality Governance
Framework meant that the Board was sighted on
the developmental benefits for the organisation
from commissioning an independent review under
the Well Led Governance Framework. The review
was undertaken by Mersey Internal Audit Agency in
partnership with AQuA (Advancing Quality Alliance)
from November 2017, involving a wide range of senior
staff from the Trust as well as taking in the views of
Governors and external stakeholders. The draft report
was received in February 2018; its overall conclusion
was that Alder Hey was well-led, stating: ‘It is an
organisation that has lived values, a talented Board,
a determined strategic intent and a momentum to
developing a clinical leadership model.’ The report sets
out a range of developmental recommendations across
the CQC’s eight well led Key Lines of Enquiry; it is the
intention of the Board to hold a workshop session early
in 2018/19 facilitated by the review leads from which the
Trust’s response and priorities for action will be agreed,
with timescales for completion.
The Board undertook its annual formal gap analysis
against the conditions contained within its Provider
Licence during the year. With regard to Condition FT4
– NHS foundation trust governance arrangements,
the exercise did not identify any material risks to
compliance with this condition.
A comprehensive gap analysis of the Trust’s Corporate
Governance Statement under the Provider Licence,
was undertaken in May 2018 ahead of the formal
declarations required by NHS Improvement This did
not identify any material gaps in compliance. The Board
continues to keep its governance arrangements under
regular review and itself appraised of any new guidance
or best practice advice that is published through the
year. Alder Hey continues to be placed in segment ‘2’
under NHS Improvement’s Single Oversight Framework
– providers offered targeted support - reflecting the
Trust’s previous financial position against control total.
The Board’s main assurance committees each provides
an annual report on its work to the Board, describing
how the committee has fulfilled its terms of reference
and annual work plan and outlining key areas of
focus during the year, together with an overview of its
priorities for the coming year. These are also submitted
to the Audit Committee for it to assure itself that the
activities of the committees are contributing effectively
to the Trust’s overall control environment and that the
work of the assurance committees is directly linked
to the Board Assurance Framework. The assurance
committees review their terms of reference on an
annual basis to provide assurance to the Board that its
structures continue to reflect the changing needs of the
organisation and the environment in which it operates,
including clear lines of accountability.
The Trust has continued to incorporate Equality Impact
Assessments into the organisation’s decision making
processes. The purpose of this was to secure better
integration from a process perspective and ensure
that the Trust is properly responding to the different
needs of staff and patients to meet its statutory and
policy obligations, as well as its own values and the
commitments made under the NHS Constitution. The
EIA process is carried out in relation to the development
of Trust policies or procedures, service redesign
or development, strategic or business planning,
organisational changes affecting patients, employees or
both, procurement, cost improvement programmes and
the commissioning or decommissioning of services.
Subsequently, the EIA process was embedded into the
Quality Impact Assessment process to inextricably link
the two key priorities.
The Corporate Report remains the principal mechanism
for ensuring that the Board and its committees receive
timely, accurate and comprehensive information on
the performance of the organisation. The report is kept
under review by the Executive Team to ensure that it is
fulfilling this function as effectively as possible; the Non-
Executive Directors provide regular feedback on the
report and on the presentation of individual indicators;
during the year the Trust’s most recently appointed
NED took a special interest in the development of
the report and this oversight remains ongoing. As
described above, the review undertaken in 2017/18 was
more detailed and has resulted in a significant refresh
intended to improve the clarity of the information
presented.
The principal risks to the organisation during 2017/18
were focused predominantly on three main areas:
financial sustainability in a challenging environment; the
Alder Hey Children’s NHS Foundation Trust 75
Annual Report & Accounts 2017/18