AH ANNUAL REPORT 2018

Recommendations

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Local Audit How often are high ferritin levels associated with serious illness (a retrospective service evaluation of diagnosis in patients with ferritin >10,000 μg/L) Audit on the pathway for single ventricle hearts in Alder Hey Children’s Hospital Audit of the referral pathway for prolonged neonatal jaundice Actions The audit was presented at the Rheumatology department academic meeting in October 2017. The audit will be presented in national meetings (British Society for Rheumatology (BSR) and Royal College of Paediatrics and Child Health (RCPCH) annual meetings) as part of a national audit. Action/Recommendation: • To contribute towards national guidelines. • To discuss with other specialities including cardiology to increase awareness and provide details of investigations to carry out when highly elevated ferritin level (HEF) is detected. • Update existing training to increase awareness about HEF and link with secondary HLH (a severe and potentially fatal inflammatory condition) and investigations needed. • Re-audit once the revised national guidance is in place. The audit was presented at the Alder Hey Cardiology/Cardiothoracic Department Quality Assurance meeting in November 2017. Action/Recommendation: • A checklist has been created to be used alongside the current guideline. • Re-audit to compare compliance before and after the addition of the checklist in 12 months. The audit was presented to the Alder Hey Community team and the Gastroenterology Consultant in January 2018. Action/Recommendation: • Designing a pathway for managing prolonged jaundice in the community and in hospital. • No Re-audit was required as this was a study to see the pattern of actions in the community - designed to help in making a pathway for jaundiced babies. Audit of boys undergoing emergency scrotal exploration to assess outcome for testis and surgical technique The audit was presented at the Alder Hey Department of Surgery audit meeting in January 2018. Action/Recommendation: • Possible implementation of a standard technique, pending further data collection. • Re-audit in 12 months. A survey of patient use of social media for information about Clubfoot Treatment for radial club hand at Alder Hey Children’s Hospital. A service evaluation. The audit was sent for presentation at the EFORT congress (European Federation of National Associations of Orthopaedics and Traumatology) in January 2018. Action/Recommendation: • Parents should be encouraged to use social media to learn about clubfoot. • Re-audit in 12 months. The audit was presented at the British Society for Surgery of the Hand (BSSH) Autumn meeting in November 2017. Action/Recommendation: • To continue the use of this technique, and to consider its use a primary procedure in the future. • A Re-audit could be undertaken, but will require a time gap of 5-6 years. Alder Hey Children’s NHS Foundation Trust 92 Annual Report & Accounts 2017/18
Local Audit ADHD (Attention Deficit Hyperactivity Disorder) prescription audit What is a post tonsillectomy bleed? Audit of blood loss during scoliosis correction in Duchenne Muscular Dystrophy. Service Evaluation of Dental Treatment done as a ‘piggyback’. Actions The audit was presented at the Alder Hey Community Paediatrics Department meeting in October 2017. Action/Recommendation: • To update and disseminate ADHD guidelines, • Adhere to guidelines. • To ensure guidelines are readily available to all prescribers. • To facilitate regular case review and Multi disciplinary Team meetings. In complex cases discuss with the lead clinician for that patch. • To Re-audit at an agreed timescale with the team. The audit was presented at the Alder Hey E.N.T. (Ear, Nose and Throat) Department weekly meeting in November 2017. Action/Recommendation: • Update to existing policy to include advice to give post operatively. • Follow up phone calls for four weeks then repeated after changes to policy. • Re-audit in 1 month. The audit was discussed with the senior author in January 2018. A date for presentation is to be confirmed at the Alder Hey Department of Surgery local Mortality and Morbidity meeting. Action/Recommendation: • Continue current practice. • No changes to practice needed as there was no change in primary outcome measure. • Re-audit in 5-10 years (extremely low volume of patients make it difficult to obtain significant numbers for analysis). The audit was presented at the Alder Hey Department of Paediatric Dentistry governance meeting in March 2018. Action/Recommendation: • Appropriate radiographs to be obtained to aid assessment. Justification for absence of radiographs should be recorded. • Patients identified for piggyback should have the consent process started at the time of assessment and treatment planning. • All patients for piggyback dental treatment to be assessed by appropriate staff. • Follow up and preventative care arranged for all patients. • Prospective Re-audit in 3 months after dissemination of findings. Alder Hey Children’s NHS Foundation Trust 93 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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have resulted in Memoranda of Under
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The Community Cluster Developed wit
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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
Page 68 and 69: Segmentation Alder Hey has been pla
Page 70 and 71: STATEMENT OF THE CHIEF EXECUTIVE’
Page 72 and 73: During the year the Trust sustained
Page 74 and 75: The Divisions report against CQC Fu
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Page 78 and 79: Nursing, Deputy Director of Nursing
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 88 and 89: 2.2.4 Actions arising from Local Cl
Page 90 and 91: Local Audit Retrospective Audit of
Page 94 and 95: Local Audit Emollient and bath pack
Page 96 and 97: Local Audit Has the introduction of
Page 98 and 99: The Quality Account deals with rese
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Page 102 and 103: • A Data Quality dashboard is emb
Page 104 and 105: in improved ward to board reporting
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
Page 112 and 113: Are you: 95 17% 8 1% Parent/Carer P
Page 114 and 115: • Improved the quality of room bo
Page 116 and 117: When a child has an asthma attack t
Page 118 and 119: The awards and review schedule is h
Page 120 and 121: F. The Alder Play App Aims: • To
Page 122 and 123: Developing a System of 7 Day Workin
Page 124 and 125: of staff and governors, assess each
Page 126 and 127: • Working with external organisat
Page 128 and 129: the Tate Exchange programme during
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Page 132 and 133: • To complete and roll out the ne
Page 134 and 135: 3.3.8 Peri-operative Care The focus
Page 136 and 137: 3.3.9 Best in Operative Care The Be
Page 138 and 139: Improvements: • Increased the Bla
Page 140 and 141: 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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