• Fourth edition of the Integrated Performance Report (IPR), with validated data up to September 2025.
• Focuses on metrics of exception and emerging concerns, supported by management responses.
• Purpose: Enable Board and Committees to concentrate on areas outside expected variation, reduced assurance, and interdependent risks.
• Metrics still being refined in line with National Oversight Framework (NOF) and CWPi.
• The Board discussed issues around data quality and how this will be moved forward, including trajectory for action plans in place for both Business Intelligence resource and improved inputting of data around service activity.

Alerts:

• Sickness Absence – 6.4% (above 6% target, where we would like it to be 6% or below), early seasonal pressures; actions ongoing.
• Appraisal Compliance – 73.2% (below 85% target, where we would like it to be 85% or above), declining trend; recovery plan in place.
• Emergency Admissions >12 hrs – 87 cases (highest to date); multi-workstream response including the new MHCAS, Mental Health Crisis Assessment Service, mentioned in the Chief Executive's update at Board today. Improvement already being seen since this data capture and expected improving trajectory into quarter 4 (January-March 2026).
• 72-Hour Follow-Up – 41.4% (below 80% target, where we would like it to be 80% or above); data/reporting issues post-template change; improvement expected January 2026.
• Restrictive Interventions – Increased in SMH care group due to acuity/personalised care; further review planned.

Key risks and scores in Board Assurance Framework (BAF)

1. BAF 1 – People

   • Risk: Workforce shortages impacting care quality and culture.
   • Score: 16 (maintained).
   • Action: Focus on culture; possible new risk on “Just Culture.”
      

2. BAF 2 – Care Delivery

   • Risk: Failure to provide care in right place/time/clinician.
   • Score: 16 (maintained).
   • Action: More specificity and stronger data-driven controls requested.
      

3. BAF 3 – Finance

   • Risk: Failure to deliver financial plan/strategy.
   • Score reduced from 16 to 12 due to strong financial performance, efficiency progress, and external assurance - approved by Board.
      

4. BAF 4 – Health Inequalities

   • Risk: Unaddressed health inequalities causing variation in care.
   • Score: 12 (maintained).
   • Action: Further work to evidence equity and controls.
      

5. BAF 5 – Service Model Alignment

   • Risk: Misalignment with national 10-year plan.
   • Status: Under development; review scheduled Q3.
      

6. BAF 6 – Innovation & Improvement

   • Risk: Failure to innovate due to resource constraints.
   • Status: Under development; review scheduled Jan 2026.

Eric Solomons, Non-Executive Director, provided an update on the most recent Audit Committee, including:

• Internal audit plan amended to include sickness absence systems; significant Q3–Q4 activity required to deliver programme
• MIAA internal audit progress; cost improvement programme audit achieved substantial assurance; robust processes confirmed
• Legacy internal audit actions on CCTV and data quality flagged for review and closure
• External audit planning for 2026/27 underway; anti-fraud return rated green; Fit and Proper Persons policy updated
• Tender waiver six-monthly report noted; future reports to include benchmarking.

Chris Lynch, Non-Executive Director, provided an update on the most recent People Committee, including:

• Workforce metrics reviewed; sickness absence remains above 6% (where we would like it to be 6% or below). CWP benchmarks better than comparator North West trusts, but worse than national average. Appraisal compliance at 73% (target 85% or above).
• Medical staffing job planning compliance at 51%; improvement plan in place for December
• Guardian of Safe Working Q2 report noted with 30 exception reports (up from 4 in Q1) following a change to the reporting process. Board discussed and were assured.
• Resident Doctors 10 Point Plan assessed: 7 standards green, 2 amber, 1 red. Board approved the Plan for NHSE submission.
• Staff overall turnover (8.31%, better than the 9% target) and voluntary turnover (7%) continuing to show sustained improvement.
• Anti-Racism Framework self-assessment completed; anti-racist statement reviewed. Key areas of action include equality impact assessment training, cultural competence training and inclusive leadership training. Action plan to build an anti-racist and inclusive culture across the organisation.

This has been an ongoing focus of the Board and the anti-racism statement was endorsed and approved:

Anti-Racism Statement

Standing Together Against Racism at Cheshire and Wirral Partnership NHS Foundation Trust, our position is clear: racism, in any form, is unacceptable. We recognise that racism exists – whether visible or hidden within systems, structures, or assumptions – and we understand that standing by and doing nothing allows it to persist. We therefore operate a policy of Zero Tolerance towards any act or form of racism or racist behaviours.

Our Commitment As a Trust:

• We will not be bystanders.

• We will call out racism whenever we encounter it.

• We will continue to design and deliver services that are fair and accessible to everyone.

• We will ensure our policies, processes, and leadership reflect the diversity of the people we serve.

• We will track our progress openly, listen to feedback, and act on what we learn – See. Act. Do.

Ongoing Action

Being anti-racist is not a single action; it is an ongoing commitment from every one of us to demonstrate courage, honesty, and accountability at every opportunity.

Our promise: if racism appears, we will face it directly, remove it decisively, and learn from the experience to ensure it does not return.

Liz Harrison, Non-Executive Director, provided an update on the most recent Finance, Performance & Digital Committee, including:

• Positive performance against the better payment practice code
• System C Procurement proposal approved under delegated powers
• Development and implementation of an interim contract for Adult ADHD services in Cheshire for existing patients
• Development of the Mental Health Crisis Assessment Service (MHCAS)
• Proposals on rehabilitation service redesign received and endorsed to move forward to next steps in the governance process.

Jennie Birch, Director of Finance and Value, updated on the Capital Expenditure Plan and the Finance Report

• Board reviewed the progress on the capital plan for the current and future years and noted the actions that are now required to ensure the Trust maximises the benefits from the available capital resources in year.
• Month 7 financial position ahead of plan and the £14.9m efficiency plan identified, with £11.7m transacted recurrently.

Julie Higgins, Non-Executive Director, provided an update on the most recent Quality Committee, including:

From January 2026, the Quality Committee will have three sub-committees:

1. Infection Prevention & Control (IPC) and Health Protection Sub-committee – retained for assurance on statutory and regulatory compliance.
2. Safeguarding Sub-committee – also retained for compliance assurance.
3. Clinical Governance & Quality Improvement Sub-committee – new, replacing Clinical Practice & Standards Sub-committee and Patient and Carer Experience Sub-committee. It will oversee three sub-groups focused on patient safety, clinical effectiveness and patient experience.

• An outline proposal for the production of an integrated Quality Report was received.
• The Integrated Care Board Quality Leads meeting (October 2025) requested outstanding updates from the 2023/24 Quality Schedule around the ‘Green Light Toolkit’ and the Trust position around ‘NHS Dementia pathways and associated NICE guidance’. Assurances are required from Care Groups and these will be sought by the Medical Director through the Clinical Governance & Quality Improvement Sub-committee.
• Infection, prevention and control (IPC) training compliance was reported as an improved position, but requires further improvement.
• Strategic risks BAF2 (care location/timing) and BAF4 (health inequalities) reviewed; risk scores maintained.
• Controlled Drugs Accountable Officer Annual Report received by Committee and approved by the Board. Home Office licence delays noted with mitigations in place and agreed actions to continue to raise this nationally.

Six assessment domains:

1. Strategy, Leadership & Planning – Alignment with NHS 10-Year Plan, system objectives, and digital transformation.
2. Quality of Care – Oversight via Quality Committee; CQC ratings “Good/Outstanding”; continuous improvement through CWPi.
3. People & Culture – Workforce engagement, inclusion, anti-racist cultural review, Freedom to Speak Up, staff survey actions.
4. Access & Delivery – Challenges in waiting times and access (Trust ranked Segment 4 nationally); improvement plans in place.
5. Productivity & Value for Money – Efficiency programme, benchmarking, reduced agency spend, Model Health System data.
6. Finance & Value for Money – Strong financial governance; 2025/26 plan on track; PwC rated Trust as low risk.

• Confirmed: Strategy, Leadership & Planning; Quality of Care; People & Culture; Productivity & Value for Money; Finance & Value for Money.
• Partially Confirmed: Access & Delivery (due to performance challenges and segmentation score).
• Self-assessment completed October 2025; submitted to NHS England Northwest on 4 November 2025. 

The Board approved the Digital Strategy 2025-2030, which provides a phased, cost-conscious approach to digital transformation, balancing innovation with inclusivity and sustainability - and positioning CWP to deliver safe, efficient, and person-centred care.