The Christie Foundation Trust Annual Report and Accounts 2021-22

The Christie NHS Foundation Trust Annual Report & Accounts 2021-22

4 and remains the Trust’s top risk moving into 2022/23. The Trust notes that the ISAE 3402 Service Auditor Report for the Electronic Staff Record (ESR) was qualified in respect of controls over the segregation of duties for changes to the NHS Hub. The Trust has considered the reported issues and the mitigating controls in place at the Trust and does not consider them a significant risk to the Trust’s operations. Throughout 2021/22, the Trust was operating under an altered financial regime where we were funded on a ‘block income’ basis with additional funding for the exceptional costs associated with delivering services during the COVID-19 pandemic. We, like most other organisations in the NHS, have an overarching risk with regards to staffing gaps due to national shortages in some occupations such as nursing, radiology, rotational junior medical staff and radiotherapy staff. We have identified this could lead to a negative impact on engagement levels and the delivery of services. The risk score has increased to 20 on our risk register up to end of quarter 4 and a range of actions in place to ensure recruitment and retention work programmes are now in place. We have not identified any principal risks to compliance with the NHS Provider licence and throughout the 2021/22 financial year, the Trust has achieved a score of 1 for Use of Resources and 1 for Governance, the best scores possible.

We have a mature risk and quality management system as tested by the CQC in the 2018 inspection. The inspection rated us as Outstanding for the core standards reviewed and the well led domain. Board Committees of Audit and Quality Assurance are wholly Non-Executive Director led and have an annual work plan which also includes a review of the Committee’s effectiveness. There are strong reporting lines and the minutes of the meeting and any escalations are formally reviewed at the Board of Directors meeting. Executives are only in attendance at these Board Assurance Committees. The reports provided to the Audit and Quality Assurance Committees are, in the main, audits that have been carried out by the internal audit function and this provides the Board with independent assurance. At their monthly public meetings, the Board of Directors receive the integrated performance and quality report and this is discussed in detail. Through the risk management systems, all business cases and policies have an equality impact assessment (EIA) and will not be approved without the EIA being reviewed by the approving Committee. We have a workforce plan that is updated annually and is signed off by the Board of Directors. Our workforce planning process has been developed in accordance with

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