Board summary September 24 2025

Alerts

• Autism & ADHD Waiting Times are still seeing wait beyond 13 weeks for assessments. SPC confirms this is a persistent issue rather than random variation. Waiting lists are currently closed, and assurance is limited until additional capacity is secured through commissioning.
• Access for Children & Young People’s Mental Health Services This metric, within the NHS Oversight Framework, identifies the Trust as a significant negative outlier compared with peers. SPC shows this to be a sustained issue rather than short-term variation. A management review is underway to identify drivers and agree remedial action.
• 72-Hour Follow-Up Post Discharge Assurance is currently reduced as data reporting has been hindered by the introduction of new templates. This has created a temporary gap in visibility of compliance with 72-hour follow-up standards, which are a key patient safety measure. While corrective work is underway, assurance remains low until reliable reporting is restored and sustained performance can be evidenced.
• Management of Severe Behavioural Disturbances Processes are in place to ensure debriefs with patients and staff are completed and recorded following incidents. Early data suggests improvements, but SPC over time will be required to confirm that this reflects embedded and sustained change.

Advise

• Clinically Ready for Discharge (CRFD) A progressive increase in the percentage of patients clinically ready for discharge has been observed over the past three months. SPC indicates this is a sustained trend, not random variation.
• Inpatient Self-Harm Analysis demonstrates a link between delayed discharges (CRFD) and an increased incidence of self harm amongst patients awaiting discharge. This reinforces the importance of discharge planning and system collaboration.
• Restrictive Interventions (All) This is an NHS Oversight Framework metric where the Trust is currently a significant outlier compared with peers. Assurance is low. A deep dive is underway to understand drivers behind the higher levels of restrictive interventions, including the link to delayed discharge and staffing pressures. Findings will be reported back to the Quality Committee.
• Debriefs Following Restrictive Interventions Processes are in place, but compliance remains inconsistent. Staffing shortages impact both the ability to complete and to record debriefs.
• Sickness Rate The Trust remains an outlier in sickness absence within the NHS Oversight Framework. Assurance is low. There is emerging evidence that sickness rates are linked to increased restrictive interventions, both through staff shortages leading to greater use of interventions and through physical/psychological injury following incidents.
• Patients Waiting for ABI Services This metric has been sighted in the management response. Performance is currently constrained by staffing issues, with improvement anticipated once vacancies are resolved.

• New Risk Management Policy approved by Audit Committee and Board in September 2024; implementation ongoing
• Executive Risk Management Group established and meeting monthly with reporting into the Executive Team
• 2024/25 Board Assurance Framework reviewed following CQC well-led inspection; risks identified for remodelling and inclusion in new Corporate Risk Register
• New Board Assurance Framework for 2025/26 developed with six strategic risks aligned to eight Trust strategic objectives and four CWPi improvement themes
• Corporate Risk Register in development, currently includes 10 risks (e.g. data quality, cyber security, workforce); overseen by Risk Management Group
• Refresher training delivered to Risk Management Group members with support from CWP Education
• Internal audit of risk improvement work underway by MIAA; report due to October Audit Committee

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

• MIAA Internal Audit Progress Report reviewed for Q1 and Q2; one audit completed in Q1 with significant Q2 activity planned; no major risks to programme delivery identified
• Internal audit actions progressing well; legacy actions flagged for review and potential closure
• Data Security & Protection Toolkit Report 2024–25 highlighted significant changes across 12 domains; 8 domains met minimum standards, 4 did not—3 of which are high risk; action plan agreed to address non-compliance
• Digital strategy scoping underway to assess structure and capacity of the digital team in response to expanded cyber and governance requirements
• Corporate Governance Manual 2025 reviewed and approved. 

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

• Sickness absence remains above 6%, driven by long-term mental health and musculoskeletal conditions
• Appraisal compliance reviewed at 78%; proposal supported to reduce target from 100% to 85% to focus on quality of discussions
• Agency spend reduced beyond 30% target; bank spend increasing but overall temporary staffing costs declining
• Work continues to convert bank staff to substantive contracts
• Guardian of Safe Working Q1 report noted four exception reports, two with fines; new national framework expected later in 2025
• WRES update shows improvement in workforce demography and disciplinary outcomes
  • Concerns remain around recruitment outcomes, bullying, abuse, and discrimination affecting minority colleagues
  • The Anti-Racism review work continues and will return to board later in the year
• WDES update shows significant progress in disclosure rates, recruitment outcomes, staff engagement, and workplace adjustments
• Freedom to Speak Up Guardian Annual and Q1 reports reviewed; new external 24/7 service mobilised in Q2.

Farhad Ahmed, Non-Executive Director, provided an update on the most recent Finance, Performance and Digital Committee, including:

• Board approves the phase 5 investment of the SMH inpatient staffing workforce plan. The board are assured this is better for staff and patients.
• Data quality issues noted across reports; referred to Digital Sub-committee for deep dive
• CWPi update links to “Imagining the Future”; Committee assured by 5% recurrent CIP and 3-year planning horizon
• Month 5 financial position
  • £500k ahead of plan
  • 89% efficiency delivery rate
  • agency spend on target
  • strong cash position
  • Noted the CWP segment 3 exit criteria highlight report

Jennie Birch, Director of Business and Value, also provided an update on the latest Finance Report:

• As reported at a previous Finance, Performance & Digital Committee, the 2025/26 planned surplus requirement for 2025/26 for Cheshire & Wirral Partnership NHS FT is £3.99m.
• This includes a system risk held for C & M ICS of £5.4m which has been profiled in month 12.
• The profile of the financial plan for the £3.99m is a deficit in the first half of the financial year followed by surplus in the second half of the financial year
• CWP has overachieved on the Cost Improvement Programme
• CWP has halved it's agency spend in the last two years

Julie Higgins, Non-Executive Director, provided an update on the most recent Finance, Performance and Digital Committee, including:

• The Committee received assurance that patient safety incident investigations within the Specialist Mental Health Care Group are not being completed within policy timeframes due to capacity issues, but immediate learning responses are in place via the rapid safety review process. 
• The Committee reviewed the full Integrated Performance Report for July 2025 and discussed the potential for a nested sub-dashboard structure to improve data organisation and visibility. 
• Three improvement actions from the acute & PICU CQC report were confirmed as complete, with assurance on the remaining action to be reported in September. 
• The Committee received assurance on the Trust’s approach to managing efficiency schemes via Quality & Equality Impact Assessments and noted that Q1 Quality Schedule submissions were completed in full. Sub-committee reports were received with no escalations.
• Strategic risk BAF2 was reviewed, with assurance provided on actions in the Specialist Mental Health Care Group.
• The Committee noted improvements highlighted in the Quality Improvement Report for national QI week and received assurance from the Lived Experience, Volunteering & Engagement Network report.
• The Committee approved the Medicines Optimisation Annual Report (2024/25) and recommended it for Board endorsement.

Farhad Ahmed, Non-Executive Director, provided an update on the most recent Finance, Performance and Digital Committee, including:

• Noted the three escalations
  • Lack of signed NHSE Head Agreement with CWP for the three LPCs
  • Board to note the potential impact and risk associated with delegation of specialised commissioning responsibility from NHSE to ICBs
  • There is a vacancy for the role of Non Executive Director (NED) with oversight for the LPCs, a position which has been vacant for almost a year. It was agreed at board that this vacancy would be filled by Chris Lynch NED. 
• Next LPC Transformation Event confirmed for 27 November 2025 at Aintree Racecourse
• C&M Young People’s QTP progressing with focus on eating disorders, CARE service evaluation, and CAMHS transitions
• Helix LPC governance being finalised ahead of Seren Lodge MBU opening; Empowered LPC PARALEL pilot advancing
• December CAC meeting will focus on the Healthcare Passport developed by Empowered Experts by Experience
• Annual Review for the LPCs has been published and is available on the website. 

CWP is preparing its 2026/27 and long-term plans for Board review in November 2025, responding to major external drivers: the NHS financial reset and the 10 Year Health Plan.

The financial reset poses significant challenges, with a £178m system deficit and a target to return to balance by 2027/28. The planning approach links to CWPi and continuous improvement, with a proposed 5% recurrent efficiency target for the next two years and an additional 2.5% non-recurrent ask for 2026/27 to support flexibility and local innovation.

The strategy aims to build on recent learning and proactively manage future change.

CWP’s 2025/26 Winter Plan outlines the Trust’s response to anticipated seasonal pressures, with a focus on surge capacity, urgent and emergency care, and vaccination uptake. The plan has been developed across all care groups and submitted in collaboration with COCH. CWP leads the mental health and community physical health response for Cheshire West.

Key performance targets include reducing out-of-area beds, 12-hour breaches, and readmissions. Governance structures are in place for oversight, including Tactical Operational Groups and daily SitRep calls. The Board is asked to approve the plan and associated NHSE assurance documentation.

The Cheshire and Merseyside Provider Collaborative (CMPC) has developed a Joint Working Agreement and Committee in Common Terms of Reference to formalise and strengthen collaborative working across acute, specialist and community services. The paperwork is being reviewed at CWP. 

The board discussed the Trust Segmentation and the associated metrics following the release of the new NHS Performance Assessment Framework. The metrics, associated segmentation and league tables were published to the public on 9/08/2025. CWP has been assessed as Segment 4 within non-acute and community providers.