The Christie Foundation Trust Annual Report and Accounts 2021-22

Annual Governance Statement

into account when considering strategic decisions, business cases and quality matters. The Board, in order to be assured that it is meeting the outcomes required by the Care Quality Commission, has engaged the internal auditors to carry out quality spot checks and also to review elements of the well led outcomes. The outcome of the audits and compliance reviews are presented to the Board on an annual basis in April to show adherence with the CQC standards. The 2018 CQC inspection outcome showed the Trust to be Outstanding in the key lines of enquiry and for the well led domain. The information below sets out the current top corporate risks to the organisation and their risk score. The Trust’s top risks in 2021/22 related to finance, workforce, cancer waiting times and digital services with some risks as a direct impact of the COVID-19 global pandemic. In quarter 1, the top risk related to Trust wide digital disruption and strategic delivery due to end of life, out of support computer room hardware and significant capacity limitations, posing a risk of networked infrastructure failure and the Trust financial position. Risk of failure of key equipment and capacity issues impacting on the aseptic service were the top patient safety risks in quarter 2 and 3. There continues to be a range of mitigating actions in place and these risks currently score below 15 on our risk register and continue to be monitored. The impact of COVID-19 on the Trust financial position continues into quarter

The work will be prioritised over the next three years to link with major parallel strategies e.g. Our Strategy and the National Patient Safety Strategy. The operational delivery of the incident reporting and risk register system, electronic patient record and prescribing systems across the in-patient and outpatient setting will all assist and support the delivery of safer care and practice. The high level Committee structure for the management of safety and risk is effective in ensuring that the Trust’s systems and processes are as safe as possible. Membership of these Committees is multi disciplinary and is chaired by medical leaders and includes representation by other key members of Trust staff. There is an annual review of the effectiveness of the terms of reference and any issues are managed at that point. There are mature risk management policies and procedures in place, with an underpinning process to ensure that these policies consider all aspects of risk when in development or review. These policies and procedures were tested by the CQC during their comprehensive inspection in 2018. There is a mature system of clinical audit across all departments and teams in the Trust, with encouragement to prioritise projects that deliver improvements for our patients. There are processes to follow up where there is weak assurance of the standards of care so that appropriate actions are taken. The Board on an annual basis reviews its risk appetite and this is shown in the public Board papers. The risk appetite statement is taken

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