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NHS IMPROVEMENT’S WELL regular basis as the national landscape around good
LED FRAMEWORK governance, quality and leadership has evolved.

NHS Improvement introduced updated guidance for The Clinical Quality Assurance Committee continued its
organisations on the use of the well-led framework work to oversee the development of the Trust’s Quality
in June 2017. The Alder Hey Board had agreed to Strategy during the year, seeking assurance from a
commission an external review under the previous variety of sources to ensure that it remains sighted on
guidance in April 2017; as part of this it had undertaken any risks as they emerge, for example the roll-out of
an initial self-assessment at that point and made the the new sepsis pathway. The Committee instituted a
decision to commission MIAA (Mersey Internal Audit programme of in depth ‘Quality Assurance Rounds’
Agency) in partnership with AQuA (Advancing Quality to inform the Trust’s ward to Board governance.
Alliance). The review itself did not commence until These have been extremely well received across the
November 2017 owing to a number of Board members hospital and the programme encompasses over 50
being involved in the delivery of the management visits to ensure full coverage of every service. The
contract at Liverpool Community Health NHS Trust Committee also monitors the delivery of the Quality
between May and the end of October. Aims, incorporating measures of clinical effectiveness,
patient safety and positive patient experience, via the
The comprehensive review was carried out in Corporate Report which was redesigned during the
accordance with the revised guidance and therefore year to better support the Trust’s quality improvement
had a strong focus on integrated quality, operational approach.
and financial governance and was based upon a
number of key lines of enquiry developed by CQC The Integrated Governance Committee, chaired by
to test out leadership, culture, system working and the Trust’s Senior Independent Director, has delegated
quality improvement. The methodology for the review authority to seek assurance on the management of
consisted of four key areas of interlinked activity to risk across the whole of the organisation’s activities
enable in depth triangulation of the findings; these were: and to hold each responsible officer to account for
a desktop document review; one-to-one interviews; the effective management and mitigation of risks in
board and sub-committee observation and on-line their area. It operates an assurance mechanism that
surveys. The review involved some 40 people; as well links together the Board Assurance Framework and
as the Trust’s Board members and senior managers, Corporate Risk Register, which in turn is informed by
views were also sought from a range of external individual Divisional and departmental risk registers.
stakeholders including commissioners. The Committee provides a structured process to test
controls and ensure that strategic and operational risks
The draft report from the review was received in late are being addressed as part of a coherent system
February 2017; it states that ‘The overall conclusion from ward to Board; this was revised and further
from our review is that the Trust is well-led. It is an strengthened during the year as part of the current
organisation with lived values, a talented Board, a phase of the risk management improvement plan,
determined strategic intent and a momentum to which has included a comprehensive risk register
developing a clinical leadership model.’ Whilst the revalidation process.
Board welcomes such a positive conclusion, it is
equally concerned to ensure that the developmental The work of the Audit Committee complements this by
plan derived from such a rich and informative process discharging its responsibility for the maintenance of an
is created and owned by the whole Trust leadership. effective system of internal control across the totality of
A workshop session to discuss the recommendations integrated governance and risk management. During
from the report is to take place in the first quarter the year it received a report on the progress of the risk
of 2018/19 to agree the priorities that will inform the management improvement plan.
Board’s work plan for the next period.
The Board Assurance Framework is scrutinised by the
QUALITY GOVERNANCE Board at its meeting each month to enable the Board to
be fully sighted on key risks to delivery and the controls
The Trust’s performance against the Quality put in place to manage and mitigate them, as well as
Governance Framework - originally published by enabling all members to have an opportunity to identify
Monitor in 2010 and now adopted by NHS Improvement key issues, concerns or changes.
– has continued to be monitored via the Clinical Quality
Assurance Committee on a quarterly basis. The Well Further details about the Trust’s approach to the
Led Framework was developed from the Quality well-led framework and quality governance can be
Governance Framework, thus Alder Hey’s approach found within the Quality Report (page 81) and Annual
has been to review its governance arrangements Governance Statement (page 71).
and underpinning systems and processes on a

Alder Hey Children’s NHS Foundation Trust 32 Annual Report & Accounts 2017/18