Page 79 - H:\Annual Report\

need for focused validation and a plan is in progress • Internal Audit provides quarterly reports to the Audit
to implement this structure This will be audited as part Committee and full reports to the Director of Finance
of the Data Quality Audit Plan 2017/18 . Clinical and and other Trust Officers;
non-clinical staff have been trained in accurate data
• the Director of Finance also meets regularly with
inputting which will ensure we are stopping and starting
internal and external Audit Managers;
RTT accurately (amongst other benefits the new system
will bring). • the Integrated Governance Committee holds
Divisions and corporate departments to account for
We continue to engage with the ‘Civil Eyes’ Programme the effective management of their key risks;
who benchmark the majority of children’s hospitals
• other explicit review and assurance mechanisms
in the UK and Northern Ireland across a range of include divisional risk registers linked to the
indicators and specialty areas to ensure we are not an
Operational Plan and a range of independent
outlier. The second year of the Trust’s participation in assessments against key areas of control, as set out
the Clinical Utliisation Review has meant that we have in the Assurance Framework;
continued to focus on clinical activity validation with
• continuous registration without conditions by the
the clinical coding team and clinical teams, to allow
them to review, benchmark and improve clinical activity Care Quality Commission 1st April 2010 onwards;
recording. • retention of the Trust’s Human Tissue Authority
Licence; all HTA standards were met on inspection
REVIEW OF EFFECTIVENESS and areas of good practice highlighted in the report;
• retention of Clinical Pathology Accreditation for the
As Accounting Officer, I have responsibility for
reviewing the effectiveness of the system of internal year.
control. My review of the effectiveness of the system of
Any significant internal control issues would be
internal control is informed by the work of the internal
reported to the Board via the appropriate Committee.
auditors, clinical audit and the executive managers and
clinical leads within the NHS foundation trust who have
responsibility for the development and maintenance I receive reports from the Royal Colleges and following
Deanery visits. In addition, there are a range of other
of the internal control framework. I have drawn on the
independent assessments against key areas of
content of the quality report attached to this Annual
control which are co-ordinated and monitored under
Report and other performance information available
the auspices of the Trust’s External Visits policy, for
to me. My review is also informed by comments made
by the external auditors in their management letter and example:
other reports. I have been advised on the implications • A planned, study specific inspection by the Medicines
of the result of my review of the effectiveness of the and Healthcare products Regulatory Agency (MHRA)
system of internal control by the Board, the Audit of our Research Epilepsy Studies;
Committee and Integrated Governance Committee, and
• The Pharmacy Aseptic Services Unit underwent two
a plan to address weaknesses and ensure continuous
audits from Specialist Pharmacy Service North (NW),
improvement of the system is in place.
in August 2017 and in March 2018;
The process that has been applied in maintaining and • The annual PLACE inspection of the hospital’s
reviewing the effectiveness of the system of internal facilities from a patient’s perspective; and
control includes the following elements:
• An assessment against the United Kingdom
• the Board of Directors provides active leadership of Accreditation Service (UKAS) ISO 15189:2012 Medical
the Trust within a framework of prudent controls that Laboratories Accreditation.
enable risk to be assessed and managed;
The Board of Directors is committed to continuous
• the Audit Committee, as part of an integrated
improvement and development of the system of
governance structure, is pivotal in advising the Board
internal control and the recommendations from all
on the effectiveness of the system of internal control;
visits and inspections are monitored through the Trust’s
• the Committees of the Board are key components governance processes until completion.
by which I am able to assess the effectiveness and
CONCLUSION
assure the Board of risk management generally
and clinical risk in particular via the Clinical Quality
Assurance Committee, supported by the Clinical In conclusion, for 2017/18 no significant internal control
Quality Steering Group and by the Integrated issues have been identified.
Governance Committee which was established to Signed: Louise Shepherd LOUISE SHEPHERD
strengthen the Trust’s overall risk and governance CBE
arrangements; Chief Executive
22nd May 2018

Alder Hey Children’s NHS Foundation Trust 79 Annual Report & Accounts 2017/18