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ANNUAL GOVERNANCE Executive lead for risk management and is accountable
STATEMENT to the Board and the Chief Executive for the Trust’s
risk management activities; she is also responsible
for embedding compliance with CQC standards
SCOPE OF RESPONSIBILITY across the organisation. The Associate Director of
Nursing and Governance is the operational lead for
As Accounting Officer, I have responsibility for risk management, accountable to the Chief Nurse
maintaining a sound system of internal control that and has line management responsibility for the Trust’s
supports the achievement of the NHS foundation trust’s Risk Management team. They are responsible for
policies, aims and objectives, whilst safeguarding ensuring that the Trust’s risk management systems and
the public funds and departmental assets for processes are effective and operate in accordance with
which I am personally responsible, in accordance best practice. The Chief Nurse is also the Executive
with the responsibilities assigned to me. I am also lead for Facilities and is responsible for the effective
responsible for ensuring that the NHS foundation trust management of risk in those areas. The Director for
is administered prudently and economically and that Human Resources retains an overview of statutory
resources are applied efficiently and effectively. I also and mandatory training for the organisation and is
acknowledge my responsibilities as set out in the NHS responsible for Health and Safety management. The
Foundation Trust Accounting Officer Memorandum. Director of Finance is responsible for ensuring that the
Trust carries out its business within sound financial
THE PURPOSE OF THE governance arrangements that are controlled and
SYSTEM OF INTERNAL monitored through effective audit and accounting
CONTROL systems. He is also responsible for Information
Management and Technology risk. The Director
of Corporate Affairs is responsible for Information
The system of internal control is designed to manage
Governance and is the nominated Senior Information
risk to a reasonable level rather than to eliminate all risk
Risk Owner, whilst the Chief Nurse is the Trust’s
of failure to achieve policies, aims and objectives; it can
Caldicott Guardian.
therefore only provide reasonable and not absolute
assurance of effectiveness. The system of internal Divisional Associate Chief Operating Officers and their
control is based on an ongoing process designed to
senior teams, including Associate Chief Nurses and
identify and prioritise the risks to the achievement of the
Heads of Quality, are responsible for ensuring that risk
policies, aims and objectives of Alder Hey Children’s
management systems within the Divisions are effective
NHS Foundation Trust, to evaluate the likelihood of
and also meet the objectives outlined within the Risk
those risks being realised and the impact should they Management Strategy. Divisional Boards have a key
be realised, and to manage them efficiently, effectively
role in assuring the effectiveness of risk management,
and economically. The system of internal control has
including regular scrutiny of Divisional risk registers.
been in place in Alder Hey Children’s NHS Foundation
Associate Chief Nurses and Heads of Quality monitor
Trust for the year ended 31st March 2018 and up to the
and review incidents, risk assessments, claims and
date of approval of the annual report and accounts.
complaints and ensure that agreed actions are carried
CAPACITY TO HANDLE RISK out and feedback is given to staff.
Ward and department line managers ensure that
Every member of staff at Alder Hey has an individual
relevant staff are trained on Ulysses, the incident
responsibility for the management of risk within the reporting system and that incidents are reported and
organisation. Managers at all levels must understand
actions taken when required. They provide feedback
the Trust’s Risk Management Strategy and be aware
to staff, ensuring that Trust policies, procedures and
that they have the authority to manage risk within their
guidelines are followed to minimise risk and share
area of responsibility.
learning from incidents and near misses. Individuals are
responsible for reporting any identified risks in order
As Chief Executive and Accounting Officer, I have
that they can be addressed and are accountable for
overall responsibility and accountability for risk
ensuring their own competency and that their training
management. The Chief Executive is informed of
needs are met in discussion with their line managers.
significant risk issues via the established reporting
They attend induction and statutory and mandatory
mechanisms and assurance committees, ensuring that training as required, including risk management. They
her role for risk management is fulfilled. The Medical
ensure that they practice within the standards of their
Director is accountable to the Board of Directors and
professional bodies, national standards and Trust
the Chief Executive for clinical risk management and
policies, procedures and guidelines.
clinical governance; he reports to the Chief Executive
and the Board as appropriate. The Chief Nurse is the
Alder Hey Children’s NHS Foundation Trust 71 Annual Report & Accounts 2017/18
