Cheshire and Wirral Partnership NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation
• Environmental sustainability – sustainable development

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust’s strategy followed dedicated work to engage with people who use services. The trust used a variety of methods to engage with people in the development of the trust’s strategy including in-person events, social media, and electronic surveys. Survey results from people using the trust’s inpatient and community services showed mostly positive results in relation the trust’s culture. The trust’s inpatient survey showed people felt staff supported them and listened to them. In community services, there was a range of experiences including positive and negative interactions with staff. In the trust’s primary medical services, people told us they felt the trust was receptive to feedback and actioned improvements where they were identified. In community end of life services, people told us they felt supported and listened to by staff. The trust’s governors were positive about the trust’s culture and described their experience of working with the trust as open, honest and transparent.

Leaders knew the trust’s vision and values. Leaders could describe the trust’s strategy and the strategic objectives. However, leaders could not consistently identify or describe how the implementation of the strategy had led to meaningful or measurable change within the trust or the system. Leaders told us that there were some strategic objectives which were difficult to measure in terms of impact. Leaders recognised that the systems to monitor and review progress against delivery of the strategy and relevant local plans needed to be strengthened. The trust had started work to reset and refocus the trust’s strategy on the highest priority objectives within the established eight strategic objectives. Identifying these ‘true north’ objectives was part of the Cheshire and Wirral Partnership improvement approach (CWPi) aligned to the NHS England NHS IMPACT (Improving Patient Care Together) approach to shaping strategy which was being developed through a steering group chaired by the trust’s Medical Director and reporting to the trust’s Quality Committee, and was due to formally launch shortly after the on-site element of the well-led review. CWPI was described in the trust’s committee papers as a programme which would enhance deployment of the trust’s strategy. Leaders consistently demonstrated their commitment to compassionate and inclusive leadership. They were positive about the trust’s culture and the board had prioritised equality and diversity within board development sessions. Leaders were committed to promoting inclusion within the trust. NHS Staff survey results showed staff felt positive and proud to work in the trust. The trust was the highest ranked in the country for staff reporting that they enjoyed working with colleagues in their team. The latest National Quarterly Pulse Survey results showed the trust had high scores for staff engagement.

The trust provided examples of how partners had been engaged in the development of the trust’s strategy. Partners, including those with established relationships with the trust, gave inconsistent feedback on whether they had been involved in the development of the trust’s strategy. However, the trust provided examples of how longstanding partners, prior to the formal creation of the ICS, had been engaged in the development of the trust’s strategy. Partners were satisfied that the trust’s strategic objectives were aligned to the objectives and priorities within the local system. Most partners expressed concerns about whether the trust could deliver on the strategy. There was inconsistent feedback in relation to the trust’s culture. Partners with positive feedback described how the trust had an open, transparent and learning culture. Most felt the trust had a culture which was person-centred and inclusive. Those with negative feedback described the trust as guarded and at times defensive. In our survey of partners in stakeholder engagement events, most partners agreed that the trust met the description of the shared direction and culture quality statement.

The trust’s vision was ‘Helping to improve the lives of everyone in our communities’. The trust’s values were called the 6Cs and were care, compassion, competence, communication, courage and commitment. The values were well-established in the trust and were also in place at the time of our previous inspection in 2020. The trust’s strategy “Imagining the Future: helping to improve the lives of everyone in our communities” was launched in 2021 and consisted of eight strategic objectives. The trust’s strategy was supported by several enabling strategies that the trust had developed, namely the following: • communications strategy • digital strategy • effectiveness strategy • estates & infrastructure strategy • patient & carer experience strategy • people strategy • quality improvement strategy • research strategy • information management strategy The trust was developing a quality management system to underpin CWPi, which was intended to provide data and assurance to the board, the board's committees and management on the performance and progress of the trust against the agreed strategic objectives and the metrics put in place. The trust had processes in place to identify and address behaviours that were inconsistent with the values of the NHS. The trust’s grievance and disciplinary policies were within their review dates at the time of our assessment. We reviewed three examples of grievance, and all had been completed in line with the trust’s process although two took considerable time to be resolved. Processes to ensure staff remained fit and proper for their roles were not always effective. The trust did not have a process to recheck staff with external bodies such as the disclosure and barring service.

The trust’s governors were positive about the trust’s senior leaders and described their experience of working with the trust as open, honest and transparent. We observed the trust’s board meeting, quality committee, people committee, and finance, performance and digital committee. In all meetings we saw leaders acting with integrity, credibility and kindness. The trust actively supported diverse communication needs and ensured meetings were accessible. We saw how the trust supported staff and leaders to contribute to committee meetings including through prepared videos to introduce agenda items.

Staff told us some leaders were visible within the trust. Leaders told us they undertook regular visits to frontline services. These visits improved leadership visibility and ensured leaders were able to triangulate the information received through the trust’s governance systems, particularly in relation to staff experience, which was a priority in the trust’s people enabling strategy. The trust had identified four types of visits to frontline services including night visits and ‘working shift’ visits which included an executive director working a shift in frontline services. In February – July 2024, the board had undertaken 49 service visits including 4 visits at night and 3 working shifts. The trust had introduced a digital form to capture feedback from service visits. The form had a low completion rate, and so the trust was reviewing the governance process to improve the feedback process. Leaders told us the trust valued and recruited diversity at senior levels. The trust’s board described themselves as diverse in skills and experience and lived experience of using services. The culture of the board was described as people focussed, values-based and with a focus on empathy. Leaders could describe succession planning within the trust. They had identified areas where succession planning would require additional or external support.

Partners told us the trust’s board had the experience, capability and personal values to lead the trust. Most partners were positive about individual leaders and shared examples of positive partnership working. There were mixed comments about whether the board had the capacity with some partners telling us that individual board members carried large portfolios which stretched leadership capacity. Most partners told us leaders were visible within services and most told us leaders were visible within the local system. Some partners shared that the board’s clinical leaders were predominantly from mental health backgrounds and so the board did not fully reflect the diverse nature of the services provided by the trust. In our survey of partners in stakeholder engagement events, we received mostly neutral feedback in relation to this quality statement.

The trust’s board comprised of seven executive directors including the chief executive and seven non-executive directors including the trust’s chair. The executive team held a range of individual portfolios covering areas including quality, effectiveness, risk management, finance, procurement and organisational development. The trust’s executive team had remained relatively stable with one director joining the trust within the last year. The trust’s non-executive team had more newly appointed directors and had expanded to improve capacity and better fit the diversity of the trust’s services. The role of the medical director was held by two directors as a joint post with shared voting rights. One of the trust’s medical directors was the board lead for the Mental Health Act and Mental Capacity Act. The director of nursing, therapies and patient partnership was the board lead for learning from deaths and learning from lives and deaths – People with a learning disability and autistic people (LeDeR). The trust did not have a board-level lead for specific services such as learning disabilities. There was a board development plan in place with six sessions planned for 2024. The development plan for 2024 was being facilitated by an external agency and focussed on the board’s priority of equality, diversity and inclusion matters, and other national imperatives. As part of this programme of work, the board had supported the development of their organisational ‘People’ strategic theme, being overseen by the trust’s People enabling strategy, the aim of which was to make the trust a ‘workplace where people want to stay, and a place we are proud to be from’ Fit and proper persons checks were in place for all directors in line with the requirements of the regulation. All files we reviewed showed the trust had completed appropriate checks of directors’ suitability for their roles. All directors had received an annual appraisal within the previous year.

Most staff felt able to speak up within the trust. The 2023 NHS Staff Survey showed that 71% of staff agreed the statement ‘I feel safe to speak up about anything that concerns me in this organisation’. This was higher than the national average of 68% although slightly lower than the trust’s 2022 score of 73%. The trust’s survey response rate for the 2023 survey was 44% which was lower than the national median but an increase of 2.4% compared with the 2022 survey. Most staff felt leaders would act to address concerns. The NHS Staff Survey showed 59% of staff agreed with the statement ‘If I spoke up about something that concerned me, I am confident my organisation would address my concern’. This was slightly lower than the trust’s 2022 score of 60% but higher the national average of 56%. Leaders told us they encouraged staff to speak up and raise concerns. The board undertook service visits to support frontline staff to share their experience. The 2 freedom to speak up Guardians told us there was a lack of protected time to undertake the guardian role and the trust had responded to this with plans to change the model of speaking up. The freedom to speak up guardians told us they had implemented triangulation meetings to identify and share themes and trends from concerns raised by staff through multiple routes within the trust. The meetings included teams representing human resources, organisational development, well-being services, trade unions and equality, diversity and inclusion groups.

Partners felt the trust did have a culture where staff could feel free to raise concerns. There was mixed feedback and confidence in whether leaders would take effective action to address concerns. Some felt this might be a motivating factor for staff to raise concerns outside of the trust. Partners raised concerns about the relatively low numbers of concerns recorded by the trust through the freedom to speak up route. The data available prior to the well-led review showed 16 concerns had been raised by staff in 2022/23. This had increased to 34 in 2023/24. The trust reported that during 2023/24, they had taken direct action to raise the profile of speaking up and had promoted senior leaders’ awareness of the trust’s Speaking Up strategy. The numbers of staff raising concerns at the trust was generally in line with other trusts, with the trust placed as the fifth of thirteen by numbers of concerns raised in 2023/24 in similar sized NHS trusts within the North West In our survey of partners in stakeholder engagement events, most partners did not believe the trust met the description of the freedom to speak up quality statement.

The trust had a freedom to speak up policy which had been recently reviewed and implemented in November 2023. The policy had been updated to reflect changes in guidance from the National Guardian’s Office. The trust required all staff to undertake freedom to speak up mandatory training. The ‘Speak Up’ training was a module for all staff to complete and a further ‘Listen Up’ module was for managers and supervisors within the trust. The trust had appointed two freedom to speak up guardians who undertook this role alongside their role of associate directors of nursing and therapies. The guardians were supported by three associate freedom to speak up guardians who acted as freedom to speak up ambassadors within the trust. There was a further cohort of 14 speak up ambassadors across the trust. The trust’s model of freedom to speak up was due to change. In July 2024 the board agreed to replace the current dual nursing and guardian roles within the trust with a pilot involving an external freedom to speak up guardian provider. The trust’s director of nursing, therapies and patient partnerships was the executive board level lead for freedom to speak up. There was also a non-executive freedom to speak up lead. The trust board received a bi-annual (six-monthly) report into freedom to speak up. The latest report showed the numbers of staff raising concerns via the trust’s freedom to speak up process had increased since the previous year. The data available prior to the well-led review showed 16 concerns had been raised by staff in 2022/23. This had increased to 34 in 2023/24. The numbers of staff raising concerns at the trust was generally in line with other trusts, with the trust placed as the fifth of thirteen by numbers of concerns raised in 2023/24 in similar sized NHS trusts within the North-West.

The trust scored equal to or better than the national average for all 4 of the WRES metrics in the 2023 NHS staff survey for staff from all other ethnic groups combined, indicating better experiences for these staff members when compared nationally. White staff at the trust scored better for all 4 of the metrics, indicating less positive for staff from all other ethnic groups when compared to white staff. This was in line with national trends. The trust performed better than the national average for 5 of the 7 WDES metrics below from the 2023 NHS staff survey, which indicated better experiences for staff with long term conditions or illnesses at the trust when compared nationally. However, staff without a long-term condition or illness scored better for all 7 of the metrics, indicating less positive experiences for staff at the trust with a long-term condition or illness compared to those without. The trust showed poor results, compared with other trusts, for colleagues experiencing discrimination on the grounds of sexual orientation and disability. For staff members who indicated that they experienced discrimination on the grounds of their sexual orientation, the score had increased 3.5% in 2019 to 9.9% in 2023. For those who experienced discrimination on the grounds of disability, the score increased from 11.2% in 2019 to 20.7% in 2023. The trust performed well in comparison to all other trusts for questions relating to culture and treatment from other members of staff. Nine in ten staff agreed with the statement ‘I enjoy working with the colleagues in my team’. Leaders told us equality, diversity and inclusion was the focus of board development and a key priority for the trust. Leaders told us the board had a strategic focus on equality, diversity and inclusion in recognition of the ambition in the trust’s strategy around health inequalities and workforce equity.

Partners told us the trust embraced equality, diversity and inclusion. They felt the trust actively promoted equality, diversity and inclusion both internally and within the local system. Partners were aware of the trust’s staff equality, diversity and inclusion networks. Partners were positive about the commitment demonstrated by leaders to supporting equality, diversity and inclusion. In our survey of partners in stakeholder engagement events, we received mostly neutral feedback in relation to this quality statement.

The trust monitored equality, diversity and inclusion in line with the NHS Workforce Race Equality Standard. Ethnic diversity in staff groups (5.7%) was lower than the national average (24.2%) but did reflect the diversity of local people accessing services (6.9%). Diversity in the trust board was 20% which was higher than national averages. White staff represented 100% of staff at non-clinical management grades at band 8c or above. There was higher diversity in clinical management grades at all bands. The trust had processes to monitor fairness in recruitment and career progression to ensure equally good outcomes for staff in equality groups. The WRES metrics for 2023 showed the white staff had a higher likelihood of being appointed from shortlisting compared to staff from equality groups. Metrics for disciplinary and capability processes showed staff from equality groups were more likely to enter disciplinary processes than white staff. Both metrics had showed the outcomes for staff from equality groups had deteriorated since the previous year. The trust had an action plan to address the indicators with improvement identified in the WRES and WDES reports. Progress against the action plan was monitored by updates to the board’s people committee. The trust monitored gender pay gaps and the board received an annual report. Whilst the data for 2023 was better than public sector averages, it showed the trust’s gender pay gap had increased since the previous year. Staff networks were in place to promote equality, diversity and inclusion. The trust had three staff networks. These were the Rainbow Tree Network for staff who identified as LGBT+ and their allies; the Diversity Alliance for staff from a diverse ethnic background and their allies; and the Equity and Inclusion Network for staff who lived with a disability and their allies. Each staff network had an executive sponsor.

Staff, both during and prior to our assessments of frontline services, told us the trust did not always have effective governance systems and escalation processes to ensure services were safely staffed. Staffing levels were repeatedly cited as the top risk faced by services, particularly in inpatient mental health services. The board received a six-monthly safer staffing report, and leaders told us there were daily processes to ensure frontline services had sufficient staff to provide safe care. Leaders had commissioned an external governance review which reported in October 2023. The trust had implemented some of the recommendations from the review including the establishment of a finance, performance and digital board committee. The trust’s integrated governance framework had not been updated following the changes made after the external review and leaders told us it was likely the framework would be removed as it was no longer necessary. Leaders could refer matters between committees where there were cross-cutting issues. Most leaders expressed confidence in the trust’s systems to manage risk and were satisfied with the trust’s board assurance framework. The board assurance framework included six risks to the delivery of the trust’s strategic objectives. The top three risks related to demand in inpatient mental health services, commissioning in ADHD services, and staffing levels. These were consistently highlighted by leaders as the top risks faced by the trust, although the risk in commissioning in ADHD services did not have a trust-wide scope or impact and so the risk to the delivery of the trust’s strategy was not clearly defined within the board assurance framework. Leaders noted risk scores over time since 2022 had remained static for two risks, increased slightly for financial risk and decreased slightly for commissioning in ADHD services. Mitigating actions for risks were updated where there were changes to report, however most risks were identified prior to the implementation of the trust’s strategy in 2021.

Partners were aware of the changes made to the trust’s governance systems and processes following the external governance review. Whilst the changes were regarded as improvements, some partners told us the trust needed to do more to ensure there was sufficient oversight of risks and performance in frontline services and care groups. Partners told us they had not been asked to be involved in the external governance review. Partners told us the trust board had informal processes to ensure information related to cross-cutting issues was shared between committees. There was mixed feedback in relation to confidence in data and information provided to partners by the trust. In our survey of partners in stakeholder engagement events, we received mostly negative or neutral feedback in relation to this quality statement. Feedback forms received from partners were more positive about the trust’s governance systems. NHS England allocate trusts and ICBs to one of four segments indicating the scale and nature of a trust’s support needs, from no specific support needs (segment 1) to a requirement for mandated intensive support (segment 4). The trust was allocated to segment 2 indicating a low level of support needs. However, following our inspection, the integrated care board made a recommendation to NHS England for a review of the trust’s segmentation, indicating that the trust had been identified as needing additional oversight and support.

Governance The trust had governance structures, systems and processes in place, including sub-board committees and care group meetings. Leaders regularly reviewed these structures although frameworks had not been updated to reflect changes to governance structures. The trust’s integrated governance framework was approved in September 2022. Since the implementation of the framework, the trust had commissioned an external review of the well-led key question which was completed in October 2023. The external review led to changes in the governance structure of the trust which meant that the integrated governance framework did not reflect the governance structure of the trust. The trust’s board had six committees which were: • Audit Committee • Commissioning Assurance Committee • Finance, Performance and Digital Committee • Nomination and Remuneration Committee • People Committee • Quality Committee The finance, performance and digital committee was the newest committee of the board and had been established in response to the findings of the external review, replacing the previous operational committee. Non-executive and executive directors were clear about their areas of responsibility. Each committee of the board was chaired by a non-executive director and supported by one or more non-executive directors as members. Papers for board meetings and other committees were of a reasonable standard and contained appropriate information. Leaders had recognised that the board regularly received papers with lengthy narrative and there was improvement needed to the summaries of board papers to identify key themes and recommendations. Appropriate governance arrangements were in place in relation to Mental Health Act administration and compliance. The trust monitored the use of the Mental Health Act through audits of Mental Health Act documentation. Governance of the Mental Capacity Act was more limited. The trust had identified that auditing Mental Capacity Act adherence wasan area of improvement and had plans to implement audits. The trust had systems to monitor compliance with mandatory training, supervision and appraisal. Mandatory training compliance was mostly in line with the trust’s target. Supervision and appraisal rates were below the trust’s target. A partnership arrangement was in place for the provision of psychiatric liaison services although appropriate governance arrangements were not evidenced by the trust. The trust could not provide evidence to show service level agreements were in place for the provision of psychiatric liaison services to partner organisations. Where cost improvements were taking place there were arrangements to consider the impact on patient care. Leaders monitored changes for potential impact on quality, equality and sustainability. There were processes to manage the financial sustainability of the trust and to assess potential impact on quality and equality from service changes. Information Management The board did not always receive holistic information on service quality and sustainability. The trust did not have an integrated performance report or alternative process for gathering, analysing and escalating performance data to the board consistently and regularly. Instead, the board received performance data within specific reports which were presented in line with the board’s business cycle, for example, the board received appraisal, supervision and mandatory training data in March 2024. As this data was presented within the trust’s six-monthly safer staffing report, it was not presented in subsequent board meetings in May and July and would not be due to be presented again until September 2024. The trust had systems to ensure the board’s committees had performance data relevant to their areas of focus. As part of the trust’s Quality Account patient safety priority, the trust had started to introduce systems to collate data routinely collected by wards/ service teams and produce dashboards to support them in the process of daily continuous improvement in key domains of quality and safety common across services groupings, but also specific to each team. The trust was piloting live, digital dashboards across a number of wards, with plans to introduce dashboards for all wards and at least two community teams per care group by the end of March 2025. The trust’s quality committee received a ‘Providing High Quality Care Report’ which provided data for both mental health and community health services. The trust’s committee chairs provided a chair’s report to the board detailing the risks requiring escalation, the areas discussed by the committees and the decisions made. This process meant that whilst executive and non-executive directors were sighted on quality and performance data in the board committees where they were members, the trust did not have an effective process to ensure all members of the board had the same degree of insight into data. The board did not regularly receive information to support an understanding of performance across all sectors. The trust delivered inpatient and community mental health services, community health services and primary medical services. The trust’s board papers, and our observations of the trust’s board meeting and committee meetings, showed that the board did not regularly receive information related to the trust’s primary medical services, and rarely received information in relation to the trust’s community health services. Mental health services, particularly the trust’s inpatient mental health services, were often the most discussed area of focus for the board. Risk Management The trust did not have effective arrangements for identifying, recording and managing risks, issues and mitigating actions. Risks were escalated through the responsible Executive director portfolio holder, however the trust recognised a need to improve its risk management processes to strengthen the effectiveness of arrangements for identifying, recording and managing risks, issues and mitigating actions. Staff had access to risk registers at team, service and care group levels and were able to escalate concerns as needed. However, risks within care groups and other areas of trust were escalated through different systems leading to the trust maintaining multiple risk registers on several systems. The trust was working to streamline risk management processes and ensure all staff could report and escalate risks through a single system. The trust board had identified the most significant risks faced by the trust in a board assurance framework. The trust’s board assurance framework included six risks to the delivery of the trust’s strategic objectives. The top three risks related to demand in inpatient mental health services, commissioning in ADHD services, and staffing levels. Recorded risks were aligned with what leaders said were on their ‘worry list’. These were consistently highlighted by leaders as the top risks faced by the trust, although the risk in commissioning in ADHD services did not have a trust-wide scope or impact and so the risk to the delivery of the trust’s strategy was not clearly defined within the board assurance framework. Leaders noted risk scores over time since 2022 had remained static for two risks, increased slightly for financial risk and decreased slightly for commissioning in ADHD services. Mitigating actions for risks were updated where there were changes to report, however most risks were identified prior to the implementation of the trust’s strategy in 2021. Information governance systems were in place including confidentiality of patient records. The trust had completed the Data Protection & Security Toolkit assessment. An independent team had audited it, and the trust acted where needed. There were processes to ensure the integrity and confidentiality of data, records and data management systems. The board received an ‘Annual Information Governance Board Report’. There were 303 information governance incidents during 2023/24 which was a 6% decrease from the previous year. The trust declared full compliance with the 2023/24 Data Security and Protection Toolkit.

The trust received 199 responses to the patient survey for community mental health services. The trust achieved the highest score out of all trusts nationally in: Overall experience, Mental health team, Involvement in care, and Respect, dignity and compassion. Detailed analysis of responses showed a split between positive and negative sentiments and detailed both good and poor aspects of care. Some commented that staff worked with them to provide the most suitable care, support, and medication, discussing various options and respecting the person’s preferences. Negative responses included that patient care was not always individualised and, for some, care did not meet their needs and preferences. Sometimes, people did not always feel involved in their care which often affected their trust in the service. The trust received 58 usable responses to the patient survey for inpatient mental health services. The trust scored in the top 80% or in line with the highest scoring trusts in responses to almost half of the survey’s questions. The trust did not provide survey results or similar examples of collated patient feedback from users of the trust’s community health services. The trust did not provide action plans resulting from the inpatient or community mental health services’ surveys, although the recommendations from these surveys were provided. The trust’s results in the GP patient survey met or exceeded the local and national results for overall experience for the trust’s three GP surgeries. The trust’s governors told us they felt supported to undertake their roles and represent local communities. Governors received induction and training for their roles. Governors could access specific workshops and were supported to undertake visits to services.

Leaders gave examples of how the trust worked in partnership with other organisations both within the local system, the North-West and nationally. The trust headed three lead provider collaboratives (LPCs), an adult eating disorder collaborative covering the North-West region, and a child and adolescent mental health services collaborative and perinatal mental health services collaborative for Cheshire and Merseyside. Leaders told us the LPCs employed experts by experience to contribute their views to service development. The involvement of experts by experience in the trust’s child and adolescent mental health services lead provider collaborative had been recognised with a national award. Leaders told us the board had identified leads for the three geographical areas where the trust delivered most services. The trust’s chair and one of the medical directors took lead responsibility for Cheshire East. The trust’s chief executive led in relationships in Chester and Cheshire West, and the director of operations led in Wirral with support from one of the trust’s medical directors. Leaders had taken on leadership roles within the local system. The trust’s chief executive was the senior responsible officer for the Cheshire and Merseyside mental health programme. The trust’s chair was also the chair of the partnership board for the Mental Health, Learning Disabilities and Community Services (MHLDC) provider collaborative in Cheshire and Merseyside.

In our survey of partners in stakeholder engagement events, we received mostly positive or neutral feedback in relation to this quality statement. We received positive comments from partners about the trust’s approach to partnerships and the communities. Most described the trust as an active partner within the local system although some suggested the trust needed to do more to be visible within the system. Partners gave us examples of how the trust had supported system working. In January 2024, the trust signed up to the Cheshire and Merseyside Anchor Institute Framework, which committed the trust to using its size and reach into communities, alongside partner institutions, to support and improve local social and economic conditions.

The trust’s strategy was based on three measures of future success which included the needs of communities, health inequalities, and capacity and resources. All eight of the trust’s strategic objectives were focussed, in part, on improving partnerships and/ or communities, with the first – improving health, care and wellbeing – committing the trust to reducing health inequalities. The trust had a process to respond to complaints from people using services and those who had accessed services. We reviewed five complaints and found in most cases the trust had not acted fully in accordance with the complaints process. The trust’s learning from experience report identified themes, trends and learning from serious incidents, inquests, and complaints. The report presented to board in May 2024 showed there had been a monthly increase in the number of complaints in quarters 1 and 2 in 2023-24 compared to the same period in 2022-23. Communication/information, staff attitude and dissatisfaction with access to services were the top three issues in complaints during quarter 2 of 2023-24. The trust could not provide evidence to show service level agreements were in place for the provision of psychiatric liaison services to partner organisations. The trust was the host of the Cheshire and Wirral Community Wellbeing Alliance, a partnership of NHS trusts, local authorities, voluntary and community services focussed on supporting people with mental health needs.

People using services were involved in improvement and innovation. The trust hosted an annual conference in 2022 and 2023 to engage with autistic people, people with a learning disability and their families and carers on research. A further conference was planned for October 2024 with a focus on growing older with intellectual disabilities. The trust had externally recruited four patient safety partners who were involved in learning and innovation in relation to patient safety. Their role was to act as the voice of people who use services to help improve patient safety. The partners were also members of the trust board’s quality committee.

In the 2023 NHS Staff Survey, the trust scored 5.9 for the people promise element ‘We are always learning’ which was similar to the national average, and an increase from 5.7 in 2022. Leaders told us the trust had introduced an international research programme, accredited by the World Health Organization, to develop research capability through structured training for frontline staff. The programme was in its third year with 18 completed research projects and trajectory to deliver 30 by the end of year 3. The trust had a research department, a research strategy, and two academic centres to support research. The board received an annual research report. The 2022-23 report noted the trust’s research performance which included 20 trials, 461 study participants and over 40 publications. Leaders were proud of the trust’s annual ‘Big Book of Best Practice’ which had reached the ninth year by 2022-23 with almost 100 submissions of examples of best practice, innovation and quality improvement received every year. The trust had a regular quality improvement report for staff, patients and stakeholders which was reported to the board and the trust’s quality committee. The report detailed progress with quality improvement projects in the trust’s frontline services and assured the board of the effectiveness of the delivery of the trust’s Quality Improvement enabling strategy The trust had an internal audit plan, an annual audit cycle and had completed 23 clinical audits in the past 12 months covering areas including covert medication, restrictive practice and adherence to NICE guidelines. Supporting the use of clinical audits to drive improvement was identified as a priority in the trust’s Effectiveness enabling strategy Leaders described innovation to improve safety, including pilots of live data-driven digital dashboards in services, which had been developed using the evidence-base in the research literature around the measurement of safety. These allowed frontline staff to easily monitor, anticipate and act and respond to new and emerging risks to safety according to five domains, through daily continuous improvement. As one of the trust’s Quality Account priorities, all wards, and at least two community teams per care group, were planned to have dashboards by March 2025. Leaders told us the trust had trained over 200 staff in quality improvement methodology. Leaders described specific quality improvement in frontline services including initiatives to improve access to services and reduce out of area placements.

The trust had ten accreditations from external partners including four wards which had been accredited by the Royal College of Psychiatrists. Four wards were undertaking the accreditation process. Partners were positive about the trust’s approach to learning, improvement and innovation. Partners told us the trust had a learning culture. Partners were aware of the trust’s research focus and told us about examples of quality improvement. The ‘Big Book of Best Practice’ was referenced by several partners as an example of how the trust demonstrated quality improvement. In our survey of partners in stakeholder engagement events, we received mostly positive or neutral feedback in relation to this quality statement.

The trust had processes to ensure staff accessed professional development and support to provide care. Supervision and appraisal rates were below target. Compliance data was last reported to the board in March 2024. Clinical supervision rates for all inpatient services varied between 63% and 74% from August 2023 to January 2024. Clinical supervision rates for all community services combined were 85% in January and had been no lower than 79% since August 2023. Appraisal rates for inpatient services varied between 59% and 74% from August 2023 to January 2024, although specialist mental health services in West Cheshire achieved consistently lower compliance. Appraisal rates for community services varied between 73% and 77% from August 2023 to January 2024. Mandatory training compliance was 83% in inpatient services and 89% in community services, against a target of 85%. Supervision, appraisal and mandatory training data from the trust’s primary medical services was not included within the trust’s report. The trust confirmed that appraisal compliance in these services was 64% and clinical supervision compliance was 89%. The trust had systems to learn from deaths, inquests, patient safety incidents and alerts from national bodies. The trust’s processes for learning from deaths focussed on engagement to ensure they were family-centred and included a holistic review of the full life of patients who died whilst in the care of the trust. This meant that incident investigation reports sometimes took longer to complete. Leaders expressed confidence in the trust’s initial incident review processes which ensured immediate learning from incidents was identified and shared. Leaders told us the trust was actively recruiting additional investigators to improve the timeliness of incident investigations. By January 2024, 15 investigation reports had not been provided to the ICB within 3 months in line with the trust’s policy, and 80% of these had had more than one extension granted. In the previous quarter, the trust had experienced delays with 5 incident investigations, and this theme continued into quarter 1 2024/25.

Leaders were aware of the trust’s impact on environmental sustainability. They were able to provide examples of where the trust had made changes to reduce the trust’s carbon footprint, which had been delivered as a result of the priority areas in the Estates & Infrastructure enabling strategy. These examples included an investment in mobile technologies, improved room usage/ reduction in the trust’s estates footprint, and re-use/ re-development of existing sites. The trust’s director of operations was the board level lead for the trust’s green plan.

Partners gave us examples of the personal commitment demonstrated by the trust’s leaders to environmental sustainability. Partners were aware the trust had a green plan.

The trust had a green plan for 2022-2025 as a component of the trust’s Estates & Infrastructure enabling strategy. The green plan identified how the trust would manage the environmental impact of implementing the eight strategic objectives of the trust’s overall strategy and how it would set out the pathway to deliver the Government’s net zero plan. The plan included nine ‘principal areas of focus’ in areas including travel and transport, estates and facilities, supply chain and procurement and climate adaption. The trust had processes to prevent and control infections. The trust’s board received an annual and mid-year infection prevention and control report. There were low numbers of outbreaks of communicable disease. The trust had launched new ‘Building a net zero NHS’ e-learning module for all staff. The latest annual update on progress with the trust’s green plan was presented in March 2024 and noted that 55% of staff had completed the training. The report also noted that the trust was designing a new green plan reporting dashboard to monitor the delivery of the trust’s plan. The trust had introduced Green Champions who led on internal engagement on environmental sustainability. There were 181 staff identified as Green Champions.