• 5th edition of the IPR, using validated November 2025 data; focuses on exceptions, variation and  emerging risks with metrics continuing to be refined in line with the National Oversight Framework, CWPi and Board Assurance Framework
• Four Alert areas in November:
  • Urgent Community Response 2‑hour performance deteriorated to 65.5% - work underway with the national team to support drawing down data from two organisations to ensure this data set is correct. Further work is underway to review processes. 
  • Sickness absence rose to 6.7%, a 16‑month high, driven by mental health and musculoskeletal issues. Focused work underway to address this.
  • Recorded patient debriefs after severe behavioural incidents remain low at 43% vs 100% target - work underway to ensure data is correctly recorded, as 'declines' for a patient debrief are often due to symptom acuity and it is the 'offer' of debriefs that should be recorded.
  • National Cost Index worsened to 122.79 (from 115.21).
• Six 'advise' metrics, including rising readmission rates, ASD waiting list nearly double target, increased violence incidents, and Mental Health Act compliance issues.
• National Oversight Framework: Trust score improved from segment 4 → 3
• 'Clinically ready for discharge' improvement is sustained but not yet at target.

Alerts

• Risk Management Internal Audit: Moderate assurance—progress noted with corporate risk register, but constrained by capacity limitations. Will be revisited in 6 months' time to ensure addressed.

Advise

• Internal Audit Progress Report (Q3):
  • Financial Controls audit achieved Substantial assurance.
  • Sickness absence controls and data quality audits underway.
• Anti‑fraud compliance progressing, including incorporating new requirements of 'Failure to Prevent Fraud' legislation (Sept 2025 implementation).

Assurance

• Internal audit action tracker progress noted, in the timely completion of actions.
• External audit 2025/26 preparatory work underway.
• Risk Appetite Statement and Risk Management Policy approved for Board submission.
• Freedom to Speak Up: Good assurance; focus on ambassador support and improved thematic analysis.
• Clinical Audit processes robust, with further strengthening planned 2026/27.
• New Legal Services Policy approved.
• Review of losses and special payments noted.

Risk appetite statement and risk management policy 

The proposed Risk Appetite Statement and an updated Trust Management policy was revised by the Audit Committee at their January 2026 meeting and commended to Board for approval. The Risk Appetite statement sets out the acceptable level of risk across a number of key areas, which includes a 'significant' acceptable level of risk for tackling health inequalities and encouraging innovation.

The Risk Appetite Statement was approved and will be reviewed annually.

The revised Risk Management Policy was also approved.

Alerts

• Sickness absence remains >6%, driven by mental health (37%) and MSK (16%). This will be a key part of the next round of care group Spotlight sessions, as part of wider focused work in this area.
• Employee relations risks due to delayed investigations and prolonged suspensions; request for scoping and strengthened restorative practice.
• Real Living Wage (RLW): Committee supported continuation and pursuing accreditation. Following a discussion by the Board, the following was approved:
  • Continuation of the RLW pay supplement from 1 April 2026 for all staff whose basic pay falls below the RLW rate. Agreed for a further 3 years before next review.
  • Progressing RLW Employer accreditation.

Advise

• Anti‑racism and antisemitism: overview of work received by the Committee, following November Board approval of anti-racist statement. Agreed approach, including further staff training.
• Workforce planning submission completed; final plan due Feb 2026.
• Staff networks reviewed; capacity challenges for chairs noted.
• Staff survey uptake improved; early indicators show mixed experience results.

Assurance

• Gender Pay Gap Report

The introduction of the NHS England EDI Improvement Plan (2023) has set expectations that trusts eliminate gender and ethnicity pay gaps, with disability reporting to follow by 2026.

The Report provides the figures and an action plan to eliminate any gaps: with good progress, but further work to do. In summary:

• Median ordinary gap reduced to 2.71% (vs 5.11% last year).
• Mean gap improved to 12.71%.
• Bonus gap reduced significantly (median 40%), though mean bonus gap increased (55%).

Further work will include: improving equity and transparency, addressing any barriers that exist for part-time staff and deepening engagement to understand challenges.

The Board approved the report.

Alerts

• Medium‑term plan:
  • Rising bank and agency costs is a risk and was noted
  • Reviewed/agreed the final responses to the Board Assurance Statement
• The Board noted that Cheshire West and Chester (CWAC) will tender Starting Well Services in 2026.

Advise

• The Committee received an update on the Alderley options appraisal.
• ADHD Monitoring Clinic discharge issue was discussed, with an options appraisal in place to resolve
• GP discharge summary compliance continues to affect multiple care groups.
• The Trust has reported to the ICB that it will meet its financial plan for 2025-26.
• Business continuity reporting introduced.

Assurance

• Month 9 financial position:
  • £809k surplus (ahead of plan).
  • Year to date deficit £476k, ahead of plan by £2.2m.
  • Efficiency requirement £14.9m fully transacted (100%).
  • Agency spend reduced significantly vs previous years; on track for NHSE reduction target.
  • Better Payment Practice Code performance remains high (~94–97%).
• Strong improvements in SMH Emergency Department wait times and flow following Level 4 support.

Risks

• Work is ongoing to determine whether the risk around Cyber Security should remain on the corporate risk register or whether a recommendation to move to the BAF is appropriate.
• Risk around medium‑term bank/agency expenditure (as per Alerts above).

Alert:

• Integrated Quality Report (IQR) received containing validated data for October 2025. The report was noted as developing well, with further improvements expected once the scheduling of the Quality Committee is changed in 2026/27 so that planned quality metrics can be pulled through.

Advise:

• Governance and management of the current investigation management resource to be scoped
• Outstanding updates from the 2023/24 quality schedule include: Green Light Toolkit and NHS Dementia pathways/ associated NICE guidance (both in progress)

Assurance

• ‘Safety, Effectiveness, Experience’ (SEE) Quality through Ward Accreditation programme. Progress with the mobilisation of the programme was highlighted.
• The first version of the Integrated Quality Report (IQR) was received, to support quality measures at organisational level provided through the Integrated Performance Report (IPR). Future reporting will develop over time.
• The Trust’s Nominated Individual has confirmed with the Care Quality Commission (CQC) the completion of the actions required to address the regulatory breaches detailed in the 2025 well-led inspection report - further work will take place to assess the extent to which these actions are embedded.
• Five Quality & Equality Impact Assessment (QEIA) received and not approved with further work required.

The Committee reviewed and approved the following reports, which were endorsed by the Board:

• Safeguarding 2025/26 mid-year report:

Assurance was received that the Trust is meeting its safeguarding responsibilities under the Children Acts (1989 & 2004), Care Act (2014), and Regulation 13 of the Health and Social Care Act (2008). The Quality Committee noted achievements, including full assurance against audits, launch of new safeguarding templates and level 3 training, and successful partnership initiatives, and noted ongoing mitigations and an improvement focus in relation to both challenges and emerging priorities.

• Infection Prevention and Control (IPC) 2025/26 mid-year report ​​

Assurance was received that the Trust is compliant with the Health and Social Care Act 2008 (revised 2022): Code of Practice on the prevention and control of infections. The Quality Committee noted the report provided assurance of strong IPC performance, details key achievements including successful awareness campaigns, and describes how risks are actively monitored with mitigations in place.​​​​​​​

• Learning from Lives and Deaths annual report (2024/25)

CWP has continued to learn from the deaths of people under its care, by reviewing each death through case record reviews and applying best practice. Significant work in the areas of mortality and learning have included:

• The development of new policies and procedures to support and guide staff with legal responsibilities and accountabilities.
• The introduction of improved reporting systems and processes to support learning and improvement.
• The participation in/ completion of audits (including positive results received through the NHS England inquests audit, and agreement to participate in the National Audit of Care at End of Life mental health spotlight audit).
• The provision of training (including structured judgement review training as a requirement of 2017 NHS England guidance).
• The identification of key learning through various safety critical workstreams/ meetings.

A number of areas were highlighted including:

• Reconfiguration of Lead Provider Collaboratives (LPCs) – a number of options currently being considered. The Commissioning Team is preparing a Strategic Commissioning Discussion Document in each of the three LPCs. These will make recommendations for action across each patient pathway (not just the specialised element) up to March 2028 and will be shared with ICB colleagues in Jan 26 in support of their new strategic commissioning role.
• Healthcare Passport in Eating Disorder Services – a Healthcare Passport has been developed by experts with experience which will be used for eating disorder patients to take into hospital. It will summarise their healthcare journey and what is important to each individual, helping to avoid the need to repeat this with different healthcare professionals.