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using the Trust Framework for the Grading of Risks. In addition, a range of further actions were agreed and
This framework provides a consistent approach to the are currently at varying stages of implementation; these
grading of risks arising within the Trust and enables comprise:
all risks to be graded in the same manner against the
• Development and implementation of step by step
same generic criteria. This allows for comparisons
guides for risk management including:
to be made between different types of risk and for
judgements and decisions about risk appetite and the - Step by step guide for managing risks on the
prioritisation of resource allocation to be made on that risk register
basis. It enables decisions to be taken about the level of - Step by step guide process for adding a risk to
management of each risk within the Trust.
the risk register
A key philosophy of this strategy is to facilitate greater - Step by step guide to reporting incidents
embedding of risk management across the Divisions - Step by step guide for managers to manage
and corporate functions in the Trust. In order to achieve incidents
that, each Division and corporate function has a lead
• Introduction of investigation logs including lessons
for risk and governance who acts as the focus of the
learned and actions for improvement for incidents,
various aspects of governance and risk management
complaints, safeguarding, infection control etc)
within their area. They coordinate all such work and
liaise with the Risk Management team and with other • A 12 month schedule of monthly investigation
governance professionals across the Trust. Regular assurance meetings
updates to departmental and divisional risk registers
• A new 12 month schedule of risk revalidation
are fed in to the Corporate Risk Register. The Integrated
meetings held monthly with all divisions and
Governance Committee engages in an active analysis
corporate functions individually
of the Corporate Risk Register at each meeting,
including consideration of risk escalation and de- • Reintroduction of 12 month schedule of policy
escalation, which in turn links to the Board Assurance assurance meetings
Framework.
• Implementation of Quality assurance rounds across
50 teams scheduled over 12 months, with executive
During 2016/17, the Trust implemented a model of and non-executive attendance.
devolved governance within the clinical Divisions,
giving clearer responsibility and ownership of risk The Trust remains registered with CQC without
and governance at local level. To further strengthen
conditions and is fully compliant with the registration
the risk and governance capability at senior level, the requirements. In April 2017 the Trust underwent an
Trust appointed to a new role of Associate Director of unannounced inspection by CQC, maintaining the
Nursing and Governance commencing in May 2017,
overall ratings awarded in 2015 of ‘Good’ for the
with the post-holder taking ownership of the ongoing hospital overall with a rating of ‘Outstanding’ in the
Risk Management Improvement Plan and refreshing
Caring domain. The Trust is also rated ‘Good’ in the
this to reflect latest developments. Significant progress Well-led domain, reflecting the focus on improving
was made to embed the devolved governance model the Trust’s risk and governance arrangements since
during 2017/18 and at the same time great strides were
the previous inspection, although there were some
made toward the new phase of the Risk Management additional recommendations made with particular
Improvement Plan. The Associate Director of Nursing
reference to risk management at individual service and
and Governance undertook a root and branch review departmental level. This action was incorporated into
of the Trust’s risk management systems and processes the Trust’s Risk Management Improvement Plan and
during the first part of the year and this informed an
implemented as described above.
updated improvement plan. She presented a progress
report to the Audit Committee in January 2018 detailing
In terms of monitoring compliance with registration
actions taken to date, including: requirements and essential standards, the Clinical
• Implementation of a Trust-wide consistent risk Divisions provide assurance via regular submissions
validation process to take place on a monthly basis of their key issues reports through to the Clinical
with each Division and department; Quality Steering Group (CQSG). This incorporates a
set of quality indicators reflecting the Trust’s Quality
• Sharper focus at the Integrated Governance
Strategy, Quality Aims and associated KPIs. The
Committee on the underpinning assurance processes
key issue reports include compliance against CQC
behind each risk and mitigations in place to achieve
standards and other regulatory targets. They also
target risk ratings;
incorporate assurance against clinical effectiveness,
• Risks rated 15 or above to be assigned a responsible patient experience and patient safety indicators such as
Executive until score assessed at 12 or below via incidents, risks, medication errors and infections.
effective mitigation.

Alder Hey Children’s NHS Foundation Trust 73 Annual Report & Accounts 2017/18