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performance metrics. Reporting processes have year. Alder Hey continues to be placed in segment ‘2’
continued to develop with a significant refresh of the under NHS Improvement’s Single Oversight Framework
Trust’s Corporate Report taking place in the latter – providers offered targeted support - reflecting the
part of the year to ensure alignment with strategic and Trust’s previous financial position against control total.
national objectives. A revised report both in terms of
content and format was phased in from February 2018 The Board’s main assurance committees each provides
and will be fully implemented from April 2018 as a an annual report on its work to the Board, describing
consequence of this work. how the committee has fulfilled its terms of reference
and annual work plan and outlining key areas of
The Trust has been keen to ensure that it optimises focus during the year, together with an overview of its
the Quality Governance Framework first published priorities for the coming year. These are also submitted
by Monitor in 2010, subsequently adopted by NHS to the Audit Committee for it to assure itself that the
Improvement and which also informs the Well activities of the committees are contributing effectively
Led Governance Framework published by NHS to the Trust’s overall control environment and that the
Improvement and revised in June 2017. The Trust has work of the assurance committees is directly linked
continued to undertake regular self-assessments of to the Board Assurance Framework. The assurance
its position against each element of the framework, committees review their terms of reference on an
under the auspices of the Clinical Quality Assurance annual basis to provide assurance to the Board that its
Committee; this exercise was completed on three structures continue to reflect the changing needs of the
occasions during 2017/18 – May, September and organisation and the environment in which it operates,
December. including clear lines of accountability.

This ongoing consideration of the Quality Governance The Trust has continued to incorporate Equality Impact
Framework meant that the Board was sighted on Assessments into the organisation’s decision making
the developmental benefits for the organisation processes. The purpose of this was to secure better
from commissioning an independent review under integration from a process perspective and ensure
the Well Led Governance Framework. The review that the Trust is properly responding to the different
was undertaken by Mersey Internal Audit Agency in needs of staff and patients to meet its statutory and
partnership with AQuA (Advancing Quality Alliance) policy obligations, as well as its own values and the
from November 2017, involving a wide range of senior commitments made under the NHS Constitution. The
staff from the Trust as well as taking in the views of EIA process is carried out in relation to the development
Governors and external stakeholders. The draft report of Trust policies or procedures, service redesign
was received in February 2018; its overall conclusion or development, strategic or business planning,
was that Alder Hey was well-led, stating: ‘It is an organisational changes affecting patients, employees or
organisation that has lived values, a talented Board, both, procurement, cost improvement programmes and
a determined strategic intent and a momentum to the commissioning or decommissioning of services.
developing a clinical leadership model.’ The report sets Subsequently, the EIA process was embedded into the
out a range of developmental recommendations across Quality Impact Assessment process to inextricably link
the CQC’s eight well led Key Lines of Enquiry; it is the the two key priorities.
intention of the Board to hold a workshop session early
in 2018/19 facilitated by the review leads from which the The Corporate Report remains the principal mechanism
Trust’s response and priorities for action will be agreed, for ensuring that the Board and its committees receive
with timescales for completion. timely, accurate and comprehensive information on
the performance of the organisation. The report is kept
The Board undertook its annual formal gap analysis under review by the Executive Team to ensure that it is
against the conditions contained within its Provider fulfilling this function as effectively as possible; the Non-
Licence during the year. With regard to Condition FT4 Executive Directors provide regular feedback on the
– NHS foundation trust governance arrangements, report and on the presentation of individual indicators;
the exercise did not identify any material risks to during the year the Trust’s most recently appointed
compliance with this condition. NED took a special interest in the development of
the report and this oversight remains ongoing. As
A comprehensive gap analysis of the Trust’s Corporate described above, the review undertaken in 2017/18 was
Governance Statement under the Provider Licence, more detailed and has resulted in a significant refresh
was undertaken in May 2018 ahead of the formal intended to improve the clarity of the information
declarations required by NHS Improvement This did presented.
not identify any material gaps in compliance. The Board
continues to keep its governance arrangements under The principal risks to the organisation during 2017/18
regular review and itself appraised of any new guidance were focused predominantly on three main areas:
or best practice advice that is published through the financial sustainability in a challenging environment; the

Alder Hey Children’s NHS Foundation Trust 75 Annual Report & Accounts 2017/18