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The Divisions report against CQC Fundamental • To support the golden thread of ward to board
Standards as part of the assurance framework and reporting through transparency, by testing out and
action plans from serious incidents are also presented gaining assurance that what is reported to the Board
and monitored with dissemination to Divisions for is consistent with what is happening at a local level.
shared learning. CQSG also provides a key issues
report to CQAC for further assurance, highlighting any The programme commenced in September 2017
exceptions or risks that may need to be addressed or and by the end of March 2017 assurance rounds
escalated. undertaken. Both quantitative and qualitative
assurance has been presented by all services, via the
The Board at Alder Hey continues to review its quality presentations and walk arounds, which have shown
governance arrangements and underpinning systems to the board members a clear link between board and
and processes on a regular basis. The Clinical Quality local assurance.
Assurance Committee, whose membership includes all
Divisional Directors as well as Board directors, carries Key themes emerging from the process to date include:
out more detailed scrutiny under its delegated authority
• All services have been very clear about the vision for
from the Board for oversight of the Trust’s performance
their service, which is aligned with the Trust vision, in
against NHS Improvement’s Quality Governance
terms of building a healthier future for children, and
Framework, the delivery of the Quality Strategy
their families.
incorporating measures of clinical effectiveness, patient
safety and positive patient experience. The work of • All inpatient wards hold daily safety huddles (safety
the Audit Committee complements this by discharging huddles are short multidisciplinary briefings designed
its responsibility for the maintenance of an effective to give healthcare staff, clinical and non-clinical
system of integrated governance, risk management and opportunities understand what is going on with each
internal control across the whole of the organisation’s patient and anticipate future risks to improve patient
activities. safety and care).
• All services have demonstrated a good
As described above, new programme of Quality
understanding of the Care Quality Commission 5 key
Assurance Ward/Department Rounds was lines of enquiry, and the content of their presentations
implemented for 2017/18 which commenced fully in demonstrated this clearly.
September 2017. The purpose of this programme is to:
• All services demonstrated strong emphasis on team
• Facilitate a deep dive at ward/department/specialty
working, appreciation of colleagues from other
level into quality and performance, noting areas of disciplines, and the contribution they bring to the
good practice and any actions being taken at a local
service and patient care.
level to address areas of concern.
• The management of risk is at the centre of service
• Provide both quantitative and qualitative information provision and good evidence demonstrated of checks
to demonstrate that the services are safe, effective, and balances being in place, with the ethos of the
responsive, caring and well-led in line with the CQC’s
need for continuous improvement.
Key Lines of Enquiry (KLOE).
• The culture across services is open, honest and
• Enable the wards/departments to review standards encourages staff to speak out about mistakes and
of care being delivered via the results of the latest
problems, working together to find solutions to keep
Quality Care Assessment Tool (QCAT) where patients, staff and others safe.
completed, the ward dashboard and other quality
metrics used within the specialty. • Many of the services have achieved national
recognition because of their innovation and
• Allow specialties to provide an overview of the results
outstanding work.
of any external peer reviews of their service, and/
or benchmark against relevant national specialty • Strong evidence of excellent leadership across
services visited, and good understanding of purpose
guidance or standards.
and direction the services will be taking going
• Provide an opportunity for ward/departments and forward.
specialty staff to talk directly to Executive and Non-
Executive Directors. • Strong emphasis on recognising staff achievements
e.g. hero awards, star of the month awards.
• Enable members of the Board to familiarise
• Good evidence of communication via, newsletters,
themselves with clinical environments and the day-to-
day activities occurring at Ward/Department/specialty briefings, governance meetings, safety alerts.
level, hearing first hand from front-line staff.
The Board has continued to focus on improving the
• Enable members of the Board to consider any issues information received to describe the performance of the
facing the ward/ department that are escalated and organisation with regard to quality and other key
need their input or support to resolve.

Alder Hey Children’s NHS Foundation Trust 74 Annual Report & Accounts 2017/18