The Christie NHS FT Annual Report & Accounts 2019-20

Annual Governance Statement

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. Up until quarter 4 2019/20, the Trusts top risk related to the challenges in meeting the 24/62 day national cancer waiting time standards. If the standards are not met this could impact patients by causing delays to their care and treatment. There could also be a potential reputational risk of non-compliance with national cancer standards at Trust and Cancer Network level. This risk is currently scored at a 20 on our risk register and there are a range of mitigating actions with a small number of clinical service lines within the organisation and also work on cancer pathways across Greater Manchester to ensure delivery of these key cancer standards. A clinical review is undertaken of the pathway of every patient that breaches the 62 day target to look at any adverse impact of the delay on their care. This is reported to the Quality Assurance Committee. 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

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 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

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