AH ANNUAL REPORT 2018

Recommendations

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2.2.4 Actions arising from Local Clinical Audits There were a total of 173 local audits registered in the reporting period 1st April 2017 to 31st March 2018. There are 39 (23%) local audits completed. There are 113 (66%) audits that will continue in 2018/19. There are three audits not yet started and 18 audits have been cancelled (11%). The reports of the completed local clinical audits were reviewed by the provider in the reporting period April 1st 2017 to March 31st 2018 and examples of the outcomes are listed below. Local Audit Patient satisfaction survey for same day ENT pulse oximetry service Audit to assess if appropriate radiographs are being sent upon referral to the Oral and maxillofacial surgery department for Orthodontic extraction cases. Audit of surgical site infections in patients undergoing appendicectomy. Audit of Quality of Documentation for Paediatric Surgical Patients. Actions The project was discussed and presented at the Alder Hey ENT (Ear, Nose and Throat) Department Clinical Governance meeting in December 2017. Action/Recommendation: • This study was originally only conducted with one consultant’s patients. We have now rolled out the same day pulse oximetry service to another consultant. • Re-audit in 12 months. The audit was presented at the Alder Hey Oral and maxillofacial surgery department post clinic meeting in June 2017. Action/Recommendation: • Ensure we write to all Orthodontic Practices and consultants audited with the results. Remind them of the importance of enclosing all necessary radiographs. • Set up a new trust email address which is verified so that orthodontic practices can directly email across the appropriate images to the department. • Contact the Alder Hey scanning department to see if it is possible to keep the radiographs sent with the referrals and provide them to the OMFS department to sort through so they are not only scanned on but also retained and can be referred to at the patient appointment. • Re-audit in 3 months. The audit data were submitted to the National Getting It Right First Time (GIRFT) Surgical site infection audit database. Action/Recommendation: • Data were submitted to the National database for Getting It Right First Time. • Data will be reviewed with similar data from other centres before presentation and change in practice decided. • Continuous data collection till August 2018. The audit was presented as departmental teaching in September 2017. Action/Recommendation: • Individuals were reminded about the standards required and advised that this would be re-audited. • Re-audit in 3 months. Alder Hey Children’s NHS Foundation Trust 88 Annual Report & Accounts 2017/18
Local Audit Audit of Paediatric Difficult Airway Equipment Availability An audit to assess provision of information provided to patients prior to regional anaesthesia. Parents feedback of experience of breastfeeding support whilst in Alder Hey Audit of annual screening tests performed in children with complex nephrotic syndrome. Audit of MRI (Magnetic Resonance Imaging) Brain investigation ordering and results within the community paediatrics department. Audit of renal biopsy in the renal transplant patient. Actions The audit is due for presentation as a poster at the Association of Paediatric Anaesthetists Annual Scientific Meeting in May 2018. Action/Recommendation: • Networking with the airway and paediatric anaesthetic leads in each hospital in the region is required to understand the barriers to adopting a standardised paediatric airway equipment list and a standardised airway trolley layout. • Recommend the adoption of a standardised paediatric airway trolley with a standardised layout and contents list in every hospital in the region. • Re-audit in 12 months. The audit was presented at the Alder Hey Anaesthetic department update meeting in September 2017. Action/Recommendation: • Improve the availability of current information leaflets. • Develop new information leaflet for peripheral nerve block. • Re-audit in 12 months. The project was presented at the Alder Hey LiA (Listening into Action) meeting in July 2017. Action/Recommendation: • Trust policy has been updated with clear guidelines for staff on process to follow when feeding breastfeeding mums. Policy is awaiting ratification. • Also the parents information leaflet has been updated to include this information. • Re-audit in 12 months. The audit was discussed in July 2017 and findings presented in the Alder Hey Surgery departmental audit meeting in October 2017. Action/Recommendation: • Improvement could be made in measuring a number of markers, including Vitamin D, Parathyroid hormone (PTH) and measles serology. • Rationalising blood tests and placing a robust system to ensure they are measured. • Develop Nephrotic syndrome guidance for annual screening. • Re-audit in 2 years. The audit was presented at the Alder Hey Community Paediatrics Departmental meeting in October 2017. Action/Recommendation: • Update existing guideline. • Re-audit once new guidelines are in place. The audit was written up in July 2017 with a discussion and presentation at the Alder Hey Renal Unit meeting to be arranged. Action/Recommendation: • To continue current practice. • Audit confirmed that biopsy was performed for good clinical indication. • Re-audit in 4 years. Alder Hey Children’s NHS Foundation Trust 89 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
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KEY RISKS TO DELIVERY IN 2017/18 Th
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Regulatory Ratings NHS Improvement
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Expenditure Operating expenses tota
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ALDER HEY USES MRI/ CT DATA TO CREA
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Louise Shepherd CBE - Chief Executi
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Mags Barnaby - Interim Chief Operat
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NHS IMPROVEMENT’S WELL LED FRAMEW
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Clinical Educators The Trust has ag
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All complainants are offered the op
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Page 44 and 45: accordance with Non-Executive remun
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Page 48 and 49: SALARY AND PENSION ENTITLEMENTS OF
Page 50 and 51: STAFF REPORT Analysis of Trust staf
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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
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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
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Page 70 and 71: STATEMENT OF THE CHIEF EXECUTIVE’
Page 72 and 73: During the year the Trust sustained
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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 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
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Page 102 and 103: • A Data Quality dashboard is emb
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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
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Page 114 and 115: • Improved the quality of room bo
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Page 120 and 121: F. The Alder Play App Aims: • To
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Page 134 and 135: 3.3.8 Peri-operative Care The focus
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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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