Board summary July 30 2025

Chris Lynch, Non-Executive Director, provided an update on the most recent People Committee meeting in July.

• Bank Staff Survey showed positive response, but rising incidents of patient/public violence—referred to Quality Committee; and concerns raised with the system level decision regarding the standardised bank rate and the morale impact.
• Approved the review of Equality, Diversity, Inclusion and Human Rights Policy including ensuring considerations for those with neurodiversity and ensuring reflection of best practice.
• Mutally agreed resignation scheme approved for corporate/non-clinical roles to support Q3 cost-efficiency targets.
• Terms of Reference 2025/26 reviewed and aligned with CWPi priorities.

For info: workforce KPIs

• Current sickness absence rate is 6.3%; the lowest rate among North West mental health trusts.

• Turnover has steadily improved, now at 8.75%, consistently below the 9% target for the last two
  months.

• Time to hire steady at 59.3 days - a Rapid Improvement Event (RIE) was held this quarter focusing on quality, speed, and effectiveness of internal recruitment.

• Sharp and sustained reduction in agency cost down 54.2%.

Non-Executive Director Liz Harrison provided an update on the Finance, Performance and Digital Committee meetings:

• Month 3 Finance Report shows a strong cash position. National capital bids pending; efficiency programme progressing well. Concerns raised over unresolved system risk in M12 (£5.4m). No response to Board’s letter; follow-up to ICB planned, highlighting CWP efficiencies achieved for the wider system.
• Reasonable assurances provided on corporate growth reductions, noting the importance of remaining on the current trajectory for the remainder of the year to achieve the target. Continuing with support from the CWP Rapid Delivery Unit.
• Clinically ready discharges up due to new ICB funding panel; concerns over impact on emergency admissions and placements.
• Cyber security was also reviewed; current NHS Resolution cover maintained due to low risk and limited insurance options.
• In June, SMH inpatient staffing headroom increased to 22% per benchmarking; bank/agency spend expected to decrease.
• In June the Green Plan 2025/26 Annual Report, Health & Safety and Fire Annual Report discussed in readiness for Board approval. Board approved.

Isla Wilson, Chair, "Our congratulations to the finance team for being highly commended as "team of the year" at the North West Healthcare Financial Management Association Awards."

Finance Report June (M3)

• The efficiency challenge for 2025/26 is £14.9m. The efficiency target has been profiled 40% delivery April – September and 60% October – March. This is to allow schemes to begin in the first few months of the year and accelerate in the second half of the financial year. For the full year, £11.4m has been transacted with the remaining £3.5m plans in progress. This represents 77% of the total annual target has been achieved and there is no gap currently in year. Recurrently, £9.5m has been transacted with £3.3m plans in progress thus leaving a recurrent gap of £1.7m yet to be identified and will roll into the following financial year if not achieved. This is an improvement of £8.1m since month 2.

Julie Higgins, Non-Executive Director, provided an update on the latest Quality Committee meeting: 

• The Quality Committee reflected on past meetings and assessed future responsibilities, aligning with well-led principles. It agreed to expand the Clinical Practice & Standards Sub-committee’s business cycle, strengthening governance and driving improvement. The Committee also reviewed its 2025/26 terms of reference, considering changes to internal governance and approaches to risk and performance management.
• Committee received and approved the Infection Prevention and Control Annual Report (2024/25) and Safeguarding Annual Report (2024/25), recommending both for Board endorsement. Noted an extension to delivery timeframes for improvement actions arising from the Trust’s regulatory well-led review. Board noted, assured and approved.

Gary Flockhart, Director of Nursing: “The reports demonstrate significant achievements and our role in meeting our obligations but not the dynamic system the teams are having to work within, including the increasing complexity and demand for example, the increase in measles cases.”

Safeguarding Annual Report: "it is important to reflect on a period marked by significant achievements, notable challenges, and profound growth in our health safeguarding efforts. Our commitment to protecting and promoting the well-being of vulnerable populations has driven numerous initiatives, improvements, and collaborations that underscore our dedication to excellence in safeguarding practices."

Infection Prevent and Control Annual Report: "Our excellent standards of IPC are delivered by clinical and therapeutic staff alongside our dedicated facilities team including cleaners and porters and our estates team who maintain our buildings, ensure we have a safe water supply and ventilation systems. I recognise the challenges all our teams have faced this year, and I would like to thank you all for your hard work, commitment and support throughout the year."

• Phase two of SMH inpatient safer staffing review endorsed; further review by Finance, Performance & Digital Committee.
• Progress on SEE Quality through Ward Accreditation Programme; Quality Committee to oversee compliance.
• Received sub-committee updates (Clinical Practice & Standards, Safeguarding, Learning from Lives and Deaths).

• Committee received updated actions responding to January 2025 inspection findings. CWP rated Good overall; Outstanding for caring. Two Regulation 17 breaches noted (risk oversight & strategy implementation).
• Actions aligned with key frameworks: Risk Management Policy, Performance Accountability Framework, and four Board-endorsed strategic themes. Action plan accepted by CQC (June 2025); shared with ICB.

Faouzi Alam, Medical Director, “We have worked really hard on ensuring we have the right structure; Quality Committee terms of reference; now working on all the sub-committees to align to the same philosophy. We have a long way to go for the metrics and so therefore giving current partial assurance."

Tim Welch, CEO, “This discussion has been incredibly valuable. Our goal is always to strive forward whilst focusing on actionable plans and milestones within our control.”

• CQC final confirmation expected late September; follow-up discussion on 21 October.
• Sustainable improvement evidence to feature in 2025/26 Annual Governance Statement.

Tim Welch, “Thank you for all the great work that has gone into producing our IPR. This is a big first step and draws together performance metrics that are scrutinised via a number of sub-committees into one central report. Feedback is actively sought to develop this even further, and the task and finish group will continue to guide its evolution. The IPR will ultimately serve as a central resource for committees of the Board to evaluate and assure the quality of care across CWP."

To highlight alerts: Percentage of patients in crisis to receive face-to-face contact within 24 hours is on a downwards 6-month trend and requires further investigation.	Assurance: This metric has highlighted some issues with data quality in the way that this is produced and will be rectified for future reports. The data report currently includes single point of access activity that isn't a crisis service.
CRFD (Clinically Ready for Discharge) continues to be above 5% target.	CYPF Care Group have an escalation process in place to bring together health and social care colleagues to overcome barriers to discharge. Fortnightly NHSE meeting with each place commissioners (LA and ICB) to identify and address barriers and identify/track escalations MADE meetings (at place). SMH significant work has also been done to improve processes following the introduction of an ICB panel and this is now working well. A multiagency discharge meeting happens every week with partners from the ICB and local authorities.
72 hour follow-ups continue to below internal target of 95%.	A new SystmOne 72 hour follow up template went live in June. This should reduce the scope for internal misreporting. The target will also be re-set from an aspirational target of 95% to match the external target we are measured against which is 80%, at least until once the new processes are bedded in.

• The IPR aligns with multiple strategic and regulatory frameworks including the Board Assurance Framework, Performance Assessment Framework, Information Strategy, well-led principles, national good governance standards, and the System Oversight Framework. Its development also supports actions identified within the CQC well-led improvement plan and the Auditors’ Annual Report (2024/25).
• A developmental approach will be taken over the next nine months to improve the IPR’s design, functionality, and impact. Initial limitations noted include partial automation, incomplete quality metrics, data currency (report reflects May 2025), and assurance gaps linked to metric ownership and analytical capability. These are being actively addressed through governance structures and spotlight sessions.

• The Committee received an overview of the new Board Assurance Framework (BAF) for 2025/26. This follows implementation of the Trust’s new Risk Management Policy (approved September 2024), with oversight led by the Executive Risk Management Group.
• The BAF has been remodelled in response to the CQC well-led inspection (Regulation 17 breach), transition to Segment 3 of the Single Oversight Framework, and alignment with the Trust’s eight strategic objectives and four CWPi improvement themes. Six strategic risks have been identified, with further work planned over summer 2025 to refine risk scoring, controls, assurances, and gap closure actions.
• The BAF replaces the previous Integrated Governance Policy and reflects Board-level engagement during the February 2025 workshop, which reviewed indicative risks and agreed the focus for next-stage development. 
• This will be brought to September Board.