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THE RISK AND CONTROL
During the year the Trust sustained its high rate of
incident reporting via the NRLS system, which from last FRAMEWORK
year placed it among the best performers for patient
safety incident reporting nationally: the most recent Implementation of the Trust’s Risk Management
data – March 2018 – positioned Alder Hey third in the Strategy is monitored through the Integrated
country and the highest reporter among specialist Governance Committee. The Board of Directors
paediatric trusts. This ongoing trend demonstrates the and its assurance committees have maintained their
commitment of staff to the Trust’s Quality Improvement focus on key risks during the year. The strategy was
culture and the benefits to be gained from open reviewed and updated during the year; it provides a
reporting and learning from incidents. As part of the robust framework for the systematic identification,
overall risk management improvement plan, work assessment, treatment and monitoring of risks, whether
to improve the functionality of the Ulysses incident the risks are clinical, organisational, business, financial
reporting system continued during the year. Risk or environmental. Its purpose is to minimise risks to
registers continue to be used interactively throughout patients, staff, visitors and the organisation as a whole
the organisation and are fully embedded in the Trust’s by ensuring that effective risk management systems
governance structures including the Executive Team, and processes are implemented in all areas of service
the Board, its sub-committees and Divisional Risk and provision, and that these are regularly reviewed. The
Governance Groups to better drive the management key elements of the strategy include:
and mitigation of risks. During the year extensive
• a definition of risk management;
work has taken place to validate all risk registers at
departmental level, ensuring that each identified risk • the Trust’s policy statement and organisational
has been reviewed and mitigating actions updated as philosophy in relation to risk management as an
appropriate. In addition, work continues to improve integral part of our corporate objectives, goals and
the risk register format and associated reports and management systems;
supporting local areas in completing and reviewing
• strategic vision for risk management across the
risks. Training sessions continue to be available to all organisation;
staff, including one to one and/or team sessions on
request. In addition, Ulysses system one to one training • roles, responsibilities and accountabilities;
is provided to new starters, with refresher training • governance structures in place to support risk
available on request. management, including terms of reference of key
committees.
The Board of Directors maintained its regular and
robust oversight of the Board Assurance Framework The Board Assurance Framework, which focuses on
during the year, with the assurance committees also identifying and monitoring the principal strategic risks
keeping their related risks under regular review. The to the organisation at corporate level, is embedded
report continues to support the delivery of the Board within the Trust and is regularly reviewed and updated.
agenda and has contributed towards the achievement The Assurance Framework has been reviewed by the
of a positive statement from the Trust’s Internal Auditors Board of Directors on a monthly basis during the year; it
under the annual review of the Assurance Framework covers the following elements:
which states that:
• identification of principal risks to the achievement of
‘The organisation’s Assurance Framework is structured strategic objectives;
to meet the NHS requirements, is visibly used by the • an assessment of the level of risk in-month,
Board and clearly reflects the risks discussed by the calculated in accordance with the Trust’s risk matrix,
Board.’ described below;
• internal controls in place to manage the risks;
The opinion recommended attention be given to
ensuring that Board assurances are clearly identified • identification of assurance mechanisms which relate
within the BAF: ‘some of the assurances detailed within to the effectiveness of the system of internal control;
the BAF could be clearer in terms of scope, frequency
• identification of gaps in controls and assurances;
and reporting to the Board. This would also enable the
Board to more directly connect the papers received • a target risk score that reflects the level of risk that the
with the BAF risks’. This will be taken forward during Board is prepared to accept; and the actions taken by
2018/19. the Trust to address control and assurance gaps.
The Trust received a rating of ‘substantial assurance’ Risks are analysed to determine their cause, their
confirmed by the Director of Audit Opinion for 2017/18. potential impact on patient and staff safety, the
achievement of local objectives and strategic
objectives, the likelihood of them occurring or recurring
and how they may be managed. Risks are evaluated
Alder Hey Children’s NHS Foundation Trust 72 Annual Report & Accounts 2017/18
