Wirral Community NHS Trust Annual Report and Accounts 2015/16 by Wirral Community Health and Care NHS Foundation Trust

Table of Contents The Performance Report Overview ........................................................................................................................................... 4 Performance Analysis ..................................................................................................................... 16 The Accountability Report Corporate Governance Report ....................................................................................................... 26 Remuneration & Staff Report ......................................................................................................... 47 Independent Auditors Report …………………………………………………………………………………… 58 The Financial Statements ...............................................………………………………………………………61

2 Wirral Community NHS Trust Annual Report and Accounts 2015-16

The Annual Report and a full copy of the Annual Accounts 2015-16 will be made available by the end of June 2016 when it will be available on our website at www.wirralct.nhs.uk. A limited number of printed copies will be sent to official statutory and non-statutory bodies. A summary of this report and accounts will be available as part of our Annual General Meeting. Paper copies of the Annual Report are available to members of the public free of charge and copies of this document can be made available in other formats on request. If you require a copy in large print, audio CD or in another language, please contact the Patient Experience Officer (See below).

Your Health Services - Your Thoughts We are always interested to know what you think about the services we provide. If you have a compliment, comment, concern or complaint, please get in touch via: • • • •

Our online feedback form at www.wirralct.nhs.uk Tel: 0800 694 5530 or 0151 514 6311 Email: patient.experience@wirralct.nhs.uk Or write to: FREEPOST-COMMUNITY NHS TRUST-PATIENT This is the full Freepost address. No stamp is required.

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Performance Report Message from the Chief Executive - a review of the performance of Wirral Community NHS Trust 2015-16 Welcome to our Annual Report and Accounts 2015-16 which presents what we have achieved over the last year and demonstrates how we are continuing to develop a reputation for clinical excellence, performance, service delivery and innovation. I joined the Trust in August 2015 at a very exciting time in its development. I have thoroughly enjoyed my return to Wirral, having grown up and trained as a nurse here in my early career. I am immensely proud of the organisation and our staff; what we have achieved over the last 12 months and our ambitions for the future. We have a clear vision and a set of values that were developed with and are supported by our staff and stakeholders. They reflect our commitment to providing the best possible standards of clinical care, show how we are listening to patients, staff and partners and how we have worked with them to deliver services that meet the needs of the people who use them. We have worked hard to both meet and exceed the standards and expectations of our patients, our commissioners and our partners. This report alongside our Quality Account for 2015-16 illustrates our actions and achievements in providing high quality community health services that are safe, effective, caring, responsive and well led. This has been a significant year for the trust and at the time of writing this report I am delighted to confirm that Wirral Community NHS Trust was authorised as a Foundation Trust with effect from 1 May 2016. We believe that a strong, viable and independent community FT can be a system leader and transformation agent to further develop the local health and social care economy, providing the focus to respond to the service and financial challenges that all partners face. Despite an increasingly challenging financial environment we have met all of our statutory financial duties, achieved our efficiency programme and delivered a financial surplus at year-end. We have delivered a restructure of our clinical divisions aligning our service delivery to the highest need. We have also embarked upon a large-scale transformation programme â&#x20AC;&#x2DC;Transforming Care Togetherâ&#x20AC;&#x2122; which will ensure our clinical divisions are more integrated and patient focused whilst achieving improvements in quality alongside financial and efficiency savings. We have continued to play a pivotal role in the Healthy Wirral programme in partnership with Wirral Clinical Commissioning Group, Wirral Borough Council, Wirral University Teaching Hospital NHS Foundation Trust and Cheshire and Wirral Partnership NHS Foundation Trust. The Healthy Wirral vision is aimed at providing better outcomes for the population of Wirral through integrated services which are run efficiently and achieve high standards of care. We have embraced the NHS Five Year Forward View and have fully engaged in the development of local Sustainability and Transformation Plans which will introduce a new approach to help ensure that health and care services are place-based and built around the needs of local populations. Our staff have continued to deliver to the highest possible standards and we are delighted that their expertise and dedication has been recognised at a number of national awards. Similarly, our patients and

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their carers and families continue to support us with 92% of our patients, on average, recommending the trust to their family and friends. We reported one never event during 2015-16 which related to a wrong tooth extraction. All recommendations made by an external expert have been fully implemented and we are monitoring to ensure improvements are achieved and sustained. The year ahead provides exciting opportunities for the trust alongside some real challenges. The board recognises that there needs to be a continued focus on transformation both organisationally and across the wider health and social care system as we experience on-going changes to NHS systems and structures. We will continue to build on this in the coming year to move from â&#x20AC;&#x2DC;good to greatâ&#x20AC;&#x2122;; to deliver the demanding programme of service transformation required to remain economically sustainable, and in particular to ensure we are at the centre of the local and regional integration and collaboration agenda. We are confident that our trust has what it takes to meet these challenges and respond to these opportunities. On behalf of the Trust Board, I would like to thank all of our staff and volunteers for their dedication, energy and passion, in what has been a very successful year for Wirral Community NHS Trust. As Accountable Officer, I confirm that to the best of my knowledge and belief, the information contained in this Annual Report & Accounts 2015-16 is fair, balanced and understandable.

Karen Howell Chief Executive 2 June 2016

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Review of the year - highlights of 2015-16 We are proud of the high quality of our services and are delighted when this is recognised by others, whether through review and inspection or awards. Some of our key achievements of the last year include:

•

Our Friends and Family (FFT) score was 92% exceeding our target of 85%. Our Community and Specialist Nursing, Heart Support, Health Visiting, Livewell and Therapy Services achieved an FFT of 100% throughout 1 most of 2015-16 .

•

In the national NHS staff survey, we scored higher for overall staff engagement than the average for community trusts, and staff rated us better than the national average compared with all community trusts for recommending the trust as a place to work or receive treatment.

•

We were successful in securing the 0-19 years’ service in Cheshire East and welcomed 150 members of staff and volunteers to the Trust.

•

We have been recognised amongst the top 25 trusts in the country for openness and transparency and ranked as ‘good’ in the new Learning from Mistakes league table.

•

98% of staff had an appraisal and development plan during 2015-16; an improvement on 2014/15 when 95% completion was achieved. During this year, we have also developed the “Leadership for All” programme which will be included within the appraisal process for 2016/17.

•

We achieved an improved rating within our information governance toolkit submission. Of the 38 standards, we achieved level 3 (the highest level) in 12, an improvement from 2014-15. We also achieved the highest level of assurance from an internal audit review.

•

Following our comprehensive CQC inspection in September 2014 and our overall rating of ‘good’; we have worked hard during 2015-16 and fully implemented all the recommendations made as a result of this process.

•

We reviewed our Raising Concerns processes and appointed a ‘Freedom to Speak Up’ Guardian in line with recommendations from the Francis Review.

•

We held our first open staff recruitment day on 27 February with over 200 potential candidates attending.

•

We held our first Equality and Diversity Health Summit in November 2015 to present our EDS2 actions and progress to Healthwatch and local partners, who agreed with our assessment and that the evidence was presented in such a way they were able to understand. This event will now become an annual part of our EDS2 assessment

•

We achieved and delivered all of our financial statutory duties; we posted a full year surplus position of £1,075k, an above plan performance.

•

We achieved our efficiency target to deliver £4,636k of savings.

The above data represents 6,465 responses (April 2015 to February 2016).

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•

Our performance against the Financial Stability Risk Rating (FSRR) (adopted in June 2015 to replace the Continuity of Services Risk Rating) delivered a score of 4, the highest level that can be achieved.

•

We achieved and sustained an improved performance in relation to our contractual Key Performance Indicators (KPIs).

•

We successfully relocated our Headquarters and almost 130 members of staff to St Catherine’s Health Centre, a much more modern environment which also contributed to the achievement of £0.45m savings.

•

Members of our staff and projects have been shortlisted for national awards including the British Journal Nursing Awards, the Nursing Times Awards, the Journal of Health Visiting Awards, the RCNi Awards (formerly the Nursing Standard Nurse Awards) and the NHS North West Leadership Recognition Awards and Patient Experience Network.

•

Members of our staff have published articles in the British Journal of Nursing on End of Life care and wound cleansing, and our Tissue Viability Lead Specialist Nurse was awarded the Queen’s Nurse Award.

•

We established our first Council of Governors in November 2015, in readiness for our authorisation as a Community NHS Foundation Trust. The Council of Governors has an important job overseeing the running of the trust and representing the interests of members and the public.

And finally, to recognise the exceptional work of staff from across the trust and volunteers, we held our annual ‘For You Thank You’ Staff Awards in February 2016. Almost 150 nominations were received for individuals and teams across the twelve categories, including Employee and Team of the Year, Volunteer of the Year and the Patient Choice Award, in which patients, families and carers nominated individuals or teams for outstanding care and patient experience that went beyond their expectations. Members of Staff Council, our newly elected governors and public members of the trust were all involved in the judging process and the event was a wonderful celebration, enjoyed by all.

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Who we are Located in Wirral in North West England, we provide high-quality primary, community and public health services to the population of Wirral and parts of Cheshire and Liverpool. We play a key role in the local health and social care economy as a high performing organisation with an excellent clinical reputation. Our expert teams provide a diverse range of community health care services, seeing and treating people right through their lives both at home and close to home. We employ almost 1,500 members of staff 2, 90% of who are in patient-facing roles. Our workforce represents close to 70% of the costs of the organisation and are our most important and valued resource. We have a turnover of approx. ÂŁ70m. Our vision recognises the important role we play in delivering integrated care with partners in the local health economy. Our vision is:

To be the outstanding provider of high quality, integrated care to the communities we serve.

The values at our HEART Health is our passion, with patients at the heart of everything we do Exceptional care as standard Actively supporting each other to do our jobs Responsive, professional and innovative Trusted to deliver Our ethos is captured in the motto: For You, With You. This is a promise to our communities about how we work with them to provide exceptional community health services.

What we do Our services are local and community-based, provided from around 50 sites across Wirral, including our main clinical bases, St Catherineâ&#x20AC;&#x2122;s Health Centre in Birkenhead and Victoria Central Health Centre in Wallasey. We are also commissioned to deliver podiatry services outside of Wirral by West Cheshire Clinical Commissioning Group and Liverpool Clinical Commissioning Group (under an Any Qualified Provider contract). Since October 2015 we have also provided integrated 0-19 services in Cheshire East comprising health visiting, school nursing, family nurse partnership and breastfeeding support services from 13 bases. We have no inpatient beds.

Based on total headcount

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Our services collectively delivered around 1.1 million face to face contacts during 2015-16. The number of patient contacts by service and division are shown below.

Division

Adult & Community

Primary & Unplanned Care

Children & Wellbeing

Service Integrated Continence Paediatric Continence Community Nursing/Matrons (14 teams + night service) Community discharge team Integrated Specialist Palliative Care Parkinson/Alzheimers Tissue Viability Heart Services (Heart Failure, Intermediate Heart Centre, Cardiac Rehabilitation) Speech and Language Therapy Community Physiotherapy & MSK Podiatry Dietetics Community Equipment Service Wheelchairs (West Cheshire) Wheelchairs (Wirral) Phlebotomy Single Point of Access (Telephone Contacts) Deep Vein Thrombosis Outpatients & Minor Injuries Walk-in Centre Dental Service Ophthalmology GP Out of Hours All Day Health Centre Health Visitors & Family Nurse Partnership Public Health Sexual Health

Total

Contacts 2015/16 7,515 1,693 338,624 4,041 8,400 817 573 11,613 23,660 71,804 44,200 6,561 8,331 1,043 2,334 201,393 21,433 15,970 12,917 79,021 6,575 303 54,576 18,815 65,603 38,668 29,746 1,076,229

A new divisional structure was implemented in 2015-16 to best align services with patient needs and the wider integration agenda. Following the restructure, Trust services are grouped into three divisions: Adult & Community Services, Urgent and Primary Care, and Children & Wellbeing Services. In addition, our clinical support services include: Infection Prevention & Control, Quality & Governance and Safeguarding. Further support services include Business Intelligence, Communications & Marketing, Estates Management, Finance, Human Resources, and Information Technology. The current structure of the organisation, including its corporate functions, is shown below.

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Who we serve We serve a Wirral population of around 320,000 residents across 145,000 households. It is very likely that most will come into contact with our services at some point either as a patient, carer, or relative of a patient or as one of our members or volunteers. Wirral has a relatively high older population (aged 65 and above) compared to England and Wales as a whole. We know this is set to increase, putting greater pressure on the NHS and driving the growth in provision of community health services. As a community trust we will play a vital part in enabling people to not only live longer, but live more healthy, active and independent lives. Variations in life expectancy are amongst the highest in England. The Marmot Indicators (2012) show that the gap in life expectancy between the most and least affluent areas within Wirral was 14.6 years for men and 9.7 years for women, and Wirral had the largest gap in Disability Free Life Expectancy (DFLE) for males and females of any authority in England (20.0 years for men, 17.1 years for women). Damaging lifestyle behaviours such as smoking and obesity are all more prevalent in Wirralâ&#x20AC;&#x2122;s most deprived areas. The BME (Black and Minority Ethnic) population of Wirral increased from 3.5% (approx. 11,000 people) in 2001 to 5% (approx. 16,000 people) in 2011. More BME residents live in Birkenhead than any other part of Wirral. Local services are accessed by a lower proportion of BME residents than population estimates suggest. We also serve Cheshire East which borders Cheshire West and Chester to the west, Greater Manchester to the north, Derbyshire to the east and Shropshire and Staffordshire to the south. Cheshire East has a population of 372,700 (July 2014) (22.2% of which are aged 0-19) and an area of 116,638 hectares, making it the third largest unitary council in the North West. Approximately 40% of the population live in rural areas and the remainder in the two major towns of Crewe and Macclesfield and smaller towns of Wilmslow, Congleton, Sandbach, Poynton, Nantwich, Middlewich, Knutsford and Alsager.

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Cheshire East is a relatively affluent borough, nearly 55% of children live in areas that are amongst the 30% least deprived nationally. This overall picture of affluence can mask the 18% of children in Cheshire East who live in the most deprived 30% of areas, these children experience worse health outcomes than their peers in other parts of the borough. Life expectancy for both men and women is higher than the England average; however life expectancy is 8.8 years lower for men and 6.8 years lower for women in the most deprived areas of Cheshire East than in the least deprived areas.

Our business environment We value greatly our excellent working relationships with all of our partners and commissioners. These interdependent relationships are becoming ever more important as the local health economy pursues more integrated working to improve the quality and efficiency of health and social care. The majority of our services are provided through block contracts with the following organisations: • • • •

NHS Wirral CCG NHS England (through the Local Area Team) Wirral Metropolitan Borough Council Cheshire East Council

Sustainability and Transformation Plans (STP) The new Sustainability and Transformation Plans (STP) introduce a new approach to help ensure that health and care services are planned by place rather than around individual institutions. To do this, the intention is for health and social care organisations to work together across geographic ‘footprints’ to narrow the gaps in the quality of care, the population’s health and wellbeing, and in NHS finances. Wirral Community NHS Trust sits within the Cheshire and Merseyside footprint. Competitive focus Whilst the integration agenda and place-based planning have been and will continue to be, key business drivers, the trust has also considered the potential challenge in the development of the contestable market, including: • • • •

block contracts movement to activity-based and PbR outcome based commissioning tender and procurement practices commissioner led ‘any qualified provider’ initiatives

We have considered the competition we face from other organisations including neighbouring NHS trusts and private providers. We have also calculated the risk to our trust based on potential loss of services. No services judged at high risk pose a threat to the Trust’s on-going sustainability. Foundation trust application The Trust was authorised as a Community NHS Foundation Trust with effect from 1 May 2016. This will enable us to continue providing high quality, person-centred services, as an equal and leading partner

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within the health and care economy, fit for purpose and sustainable both locally and as part of a wider Sustainability and Transformation Plan (STP) footprint. Additionally, foundation trust status will bring greater financial freedoms, empowerment and sense of shared purpose for staff and stakeholders. In readiness for Foundation Trust status and to ensure compliance with the FT code of governance, we elected our first Council of Governors in November 2015 comprising of public, staff and appointed governors from partner organisations.

Our strategy Our vision and values, our assessment of population need and our understanding of local and national priorities have informed our strategic themes and priorities for 2014-2019. Our strategic themes and objectives are highlighted below.

Healthy Wirral Arguably one of the most significant strategic drivers for the Trust is the Wirral health and social care system’s joint strategy, Healthy Wirral. Led by Wirral Clinical Commissioning Group, the Healthy Wirral programme addresses the pressures that are building within the wider health and social care economy. If unaddressed these will challenge the continued provision of sustainable and effective services: more people with complex health conditions; greater patient expectations; increasing cost of new drugs and technologies; and, an anticipated shortfall in the funding that would be needed to address these factors. WCT is fully aligned with, and a key partner in, this programme. Through transforming GP and other primary care, community health, hospital and social care services in Wirral, it will mean: • • • • •

community based health services (e.g. access to GPs, community nurses and social workers) seven days a week more hospital services in the community, with consultant led teams health and social care professionals working together for people with on-going needs specialist inpatient hospital care for those that need it support for people to look after themselves and stay healthy

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•

a clearer understanding of population health and risk stratification

The Healthy Wirral programme will be a key mechanism by which the health and social care system in Wirral responds to the opportunities presented by NHS England’s Five Year Forward View.

Strategic and operational risk The Trust’s corporate strategy for risk management is preventative, aimed at influencing behaviour and developing a culture within which risks are recognised and addressed. Strategic risks affecting the trust are identified and managed through the Board Assurance Framework (BAF), which is aligned to the Risk Management Framework, and linked to the organisation’s Performance Management Framework. The strategic risks noted against each strategic theme in the table below, summarise the risks monitored via the BAF.

Operational risks are managed through the trust’s organisational risk register and in accordance with the trust’s Risk Strategy, as described in the Annual Governance Statement (at page 33).

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Statutory Basis The legislation under which we were established was the National Health Service Act 2006 and according to the establishment order, Wirral Community National Health Service Trust came into force on 1st April 2011. We had a revised version of our Establishment Order passed by Parliament in July 2013 which is referred to in the Trust’s Annual Governance Statement. The accounts for the year ended 31 March 2016 have been prepared by Wirral Community NHS Trust under section 232 (15) of the National Health Service Act 2006 in the form which the Secretary of State has, with the approval of Treasury, directed.

Going Concern The Trust Board has reviewed the financial performance in 2015-16 and the Trust’s long term financial plans and considers the Trust meets the requirements to be considered a going concern. From 1 May 2016 the Trust was awarded Foundation Trust status and from this date will operate under the appropriate rules and regulations managed by NHS Improvement (formerly Monitor), the Trust’s financial regulator.

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A summary of our performance during 2015-16 In 2015-16 our services continued to deliver high quality responsive care to Wirral residents from numerous clinical sites and in many cases in the patient’s own home. •

We had around 1.1 million patient contacts across our core service divisions. This represents a significant increase in activity in some of our services most notably community nursing, the walk-in centres and GP out of hours.

•

We delivered a restructure of our clinical services to three distinct divisions - Adult & Community Services, Urgent and Primary Care, and Children & Wellbeing Services.

•

We achieved, and sustained, an improved performance in relation to our contractual KPIs.

•

We met all of our contractual quality indicators (further information is included in our annual Quality Account 2015-16).

•

We achieved all of our financial statutory duties in 2015-16.

•

We achieved our efficiency programme of £4,636k savings with 88% of schemes delivered recurrently.

•

We received positive staff survey results with 20 of the key findings (compared to community trusts nationally) scoring better than average and 7 of the key findings demonstrating the best score compared to other community trusts.

•

We have continued to play a pivotal role in the Healthy Wirral programme working closely with partners across Wirral. This has included significant service developments during 2015-16 including the creation of the Integrated Care Coordination Hubs (ICCH) and the Single Front Door.

•

We launched our ‘Transforming Care Together’ programme to ensure that our clinical services develop in a way that supports the vision for better and more sustainable care through communitybased models of care coordinated around people’s needs.

The KPIs associated with each of the four strategic themes together with some key achievements and developments is discussed in more detail in the performance analysis section.

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Performance Analysis Key Performance Indicators The trust has achieved a high level of performance against the indicators that we are currently measured against. There are a number of sources of performance measures that are both internally and externally imposed. The key areas of performance targets are as follows: •

Strategic - our overall balanced scorecard measures our performance against strategic objectives linked to our overall vision

•

Operational - internal targets related to our day-to-day operational performance and delivery of individual services

•

Contractual - a series of trust wide and service level KPIs defined within the contract for clinical services

•

Care Quality Commission (CQC) - ensuring compliance with all CQC guidance and regulations

•

Trust Development Authority (TDA) - the TDA’s Accountability Framework sets out a range of key indicators, financial and non-financial by which the TDA assesses a non-FT trust’s performance

•

Monitor Compliance Framework - the Compliance Framework for Foundation Trusts (FT’s) set by Monitor identifies performance requirements and financial targets for all FT’s.

These are consolidated in our balanced scorecard management framework which provides a consistent process to measure and monitor performance across different levels of the organisation aligned around our vision and strategic themes. Service delivery against our Key Performance Indicators is closely monitored across our divisions. Any KPI reported at ‘red’ will initiate two streams of actions; • understanding the reasons for underperformance and, • drawing up action plans to deal with these issues Once an area of underperformance has been identified, progress in monitored monthly at an Integrated Performance Group which reports directly to the Trust Board. The tables on the following pages provide an analysis of performance against each strategic theme together with some key achievements or developments during 2015-16.

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Our Patients and Community The first of our four strategic themes focuses on our patients and community and the needs of commissioners. The table below illustrates the key performance indicators (KPIs) identified for this theme in 2015/16. The KPIs range from national targets requiring us to see patients in our walk in centres and minor injuries units within 4 hours of arrival, through to nationally defined “never” events.

Our Patients and Com m unity Period

KPI

Month

Trend* Year-end YTD G

Mar-16

18 Week Wait

Mar-16

A & E Access Indicators

Mar-16

Zero Avoidable Healthcare Acquired Infections

Serious Untoward Incidents (STEIS)

Complaints acknowledge in 3 working days

Mar-16

Information Governance Incidents (IG Toolkit Level 2)

Mar-16

Zero Never Events**

Mar-16 Mar-16

Never Events We reported one never event during 2015-16 which related to a wrong tooth extraction. This incident related to a wrong tooth extraction which was disclosed immediately to the patient and a full apology provided. As this was the second incident of this nature in a two-year time period, we worked closely with an external expert who led the investigation and made recommendations for improvement. All recommendations made by an external expert have been fully implemented and we are monitoring to ensure improvements are achieved and sustained. IG Toolkit compliance Level 2 We achieved an improved rating within our information governance toolkit submission during 2015-16. Of the 38 standards, we achieved level 3 in 12, improvement of 3. This reflects the value we place on protecting people’s personal data and privacy. This achievement has been further endorsed by an internal audit review giving High Assurance. A&E Access Indicators As in previous years, we exceeded the national standard of treating over 99% of patients at our Walk-in Centres within the 4 hour target, with over 85% of patients seen in less than 2 hours. We have also been working with partners and the Emergency Care Improvement Programme (ECIP) to support the challenges of 4 Hour A&E waits. The ECIP has commended our Single Point of Access service

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and our Integrated care Co-ordination Hubs as good practice. Further detail in relation to our performance against these KPIs is detailed in the Quality Account 2015-16.

Our Services The second strategic theme area focuses on delivering the care Commissioners have appointed us to deliver, and as such, the second area of the trust’s balanced scorecard contains all the contractual indicators. These are monitored on a monthly and on a cumulative basis to ensure areas of challenging performance are highlighted to responsible managers and action plans are put in place to address any issues. By the end of 2015/16 the trust was monitored against 107 separate KPIs, of which 78% were rated as either “Green” or “Amber” based on thresholds set by the commissioners. The Trust’s performance against the KPIs of CCG commissioned services improved significantly during 2015-16.

Our Ser vic es The Trust is currently reporting against a total of 107 service level KPIs At the end of March 2016 it is reporting green against 68 of these indicators, amber against 14 and red against 23 on a YTD basis. 2 are rated as purple as they are outside the Trust's control

Green

Red

Amber

Green

Red Purple 2

Amber Purple The Trust aims to deliver 90% of all service Level KPIs at green or amber. Performance since April 2015, as a variance against the 90% plan is shown here.

Mar-16

CQUIN

The positive achievement of the majority of KPIs is due to the dedication and professional skill of our staff, supported by the introduction of a new performance management framework in 2015-16. This framework provides a clear process for escalating and resolving issues relating to quality; triangulating and scrutinising quality performance alongside contractual, finance and workforce performance. It is notable that almost half of the underperforming KPIs are related to the Trust’s Lifestyle Services where external factors, for example the growth in e-cigarettes, have significantly impacted (reduced) on the number of clients seeking to engage with smoking cessation services. We were disappointed that 2015-16 saw the loss of some services including Leasowe Primary Care Centre, the Falls Team, the Community Equipment Store, the Independent Living Centre and the Smoking Cessation and Weight Management teams. Community Trusts face difficult times in terms of the repeated tendering of services and we continue to work closely with our commissioners and our staff to provide highquality services that both meet the needs of our commissioners and our service users, within the financial envelopes available.

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Commissioning for Quality and Innovations (CQUIN) During 2015-16 we had many examples of providing excellent clinical care, including the achievement of our CQUIN schemes and quality objectives in areas such as integrated pathways and safeguarding standards. Service developments The Trust has continued to play a pivotal role in the Healthy Wirral programme and during 2015-16 this has included some significant initiatives including; • • •

Integrated Care Co-ordination Hubs (ICCHs) Community Rapid Response Service, and Single Front Door at Arrowe Park A&E

Integrated Care Coordination Hubs (ICCH) The creation of our ICCHs has allowed health and social care professionals to work as one team providing seamless care and support to vulnerable patients. Based in Birkenhead, Wallasey, West Wirral and South Wirral, collectively they help improve quality of life, restore confidence and avoid needless admissions to hospital. Our aim is that people will have one assessment, one care plan and one key coordinator. Patients and service users will benefit from a consistent and seamless approach to their health and social care needs. Single Front Door Our ‘Single Front Door’ project brings together clinicians from the trust and from WUTH to jointly triage patients who attend Accident and Emergency. They signpost patients to the most appropriate place for that individual such as a Walk-in Centre, GP or pharmacy. In its first month the Single Front Door redirected 15% of patients. Phase 2 will concentrate on what staffing is required to treat and discharge appropriate patients, to further improve the rate of avoidable admissions. Launch of the ‘Transforming Care Together’ programme We have been on our transformation journey since 2013 and started phase two with the launch of our Transforming Care Together programme during 2015-16. Our key priorities for transformation are to: • • • • • •

embed Integrated Care Coordination Hub (ICCH) based teams promote self-care and independence through partnerships with people and community based assets apply technological solutions to support care delivery implement effective clinical triage and appropriate allocation of care across our integrated hubs, supporting continuity of care and improved outcomes work with partners in the co-design of care pathways systematically align a 90 day improvement cycle to all quality improvements

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Our People The third strategic theme of the balanced scorecard focuses on the people and staff of Wirral Community NHS Trust. In total the Trust employs almost 1,500 staff 3, 85% of whom are patient-facing and 90% of whom are women. The largest staff groups are nursing, physiotherapists and clinical support. Our workforce represents close to 70% of the costs of the organisation, and is therefore our most important and valued resource.

Our People Month

Trend*

Year-end YTD

Period

KPI

Mar-16

Sickness & Absence

Mar-16

CIP Delivery

Mar-16

Staff Appraisal (2015/16)

Mar-16

Corporate Onboarding

Mar-16

Local Induction

Mar-16

LD Self Assessment

Mar-16

FT Pipeline

Sickness absence Whilst the sickness absence figure for 2015-16 was higher than target, at 4.7%, it marked an improvement on 2014-15 (4.9%) and the Trust continues to perform well when compared to other Community Trusts. The Education & Workforce Committee monitors staff sickness on a monthly basis. Onboarding Corporate Onboarding was introduced for 2015/16 as an evolution of the Trustâ&#x20AC;&#x2122;s Corporate Induction programme. As a result the Trust met its target to ensure at least 95% of all new starters had undertaken Onboarding before joining the Trust. Since going live in April 2015, 285 new staff have been welcomed to the trust through the On boarding process. Feedback on the site and the process is requested on a continuous basis from each new starter and their comments and suggestions have helped us to continue to shape the site, making it, and keeping it, fit for purpose. As staff no longer need to be released to attend the session, hours are kept for service delivery. Approximately 1,500 hours of patient facing contact have been saved and staff are more prepared when they have first contact with patients. Cost Improvement Programme (CIP) delivery We achieved our target of ÂŁ4,636k efficiency savings with 88% of schemes delivered recurrently. This was a significant achievement and puts the trust in a strong position to deliver savings in 2016-17.

Based on total headcount

20 Wirral Community NHS Trust Annual Report and Accounts 2015-16

The Business Efficiency and Modernisation Group (BMEG) supported by the Programme Management Office (PMO) oversees the agreement of CIP plans for all service and corporate areas reporting to the Finance & Performance Committee. These strengthened governance arrangements have been subject to an internal audit review during 2015-16, which provided Significant Assurance. Performance Appraisal In 2015-16 98% of all eligible staff had an appraisal and development plan. This achievement was further endorsed with an internal audit review of the appraisal process which specifically looked at the governance and reporting frameworks in place, and provided Significant Assurance. The ‘Leadership for All’ programme was also launched in 2015-16 to provide an opportunity for all staff to consider their leadership skills and future development. Foundation Trust Authorisation The Trust was delighted to be authorised as a Community NHS Foundation Trust with effect from 1 May 2016. This was a tremendous achievement for the organisation and its entire staff who worked tirelessly through the rigorous assessment process. As a Community NHS Foundation Trust, we will be; • free from central government control and able to decide how to improve services for patients • able to retain any surpluses to invest in new services, and borrow money to support these investments • accountable to the local community, with local people able to become members and governors

21 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Our Sustainability The final strategic theme of the trust’s balanced scorecard focuses on the key drivers of the organisation’s sustainability, principally its use of resources. Overall the Trust managed within its resources, achieving just over the planned surplus levels, whilst fully delivering on its CIP programme for the year. The Trust has assessed itself against the Monitor financial risk rating and scores itself at a 4 (the highest level).

Our Sus tainability KPI

Period

Month

Trend*

Year-end YTD

Mar-16

Net I & E

Mar-16

CRL

Mar-16

Liquidity

Mar-16

Overall Financial Rating

Mar-16

Community Dataset

Mar-16

IT System Adoption

The Trust met all of its statutory financial duties for 2015-16, our fifth successful year of operations as a standalone NHS Trust. The Trust performance against its statutory duties is summarised below:

Statutory Duty Trust Planned Surplus (before impairment) Capital Cost Absorption Rate Capital Resource Limit (CRL) External Financial Limit (EFL)

Target

Outturn

£681k surplus

£1,075k surplus

3.5%

£1,851k

£1,767k

£121k

(£2,073k)

As an independent organisation we have always maintained a strong financial position. We have consistently delivered on Income and Expenditure (I&E) targets, CIPs, cash and external financing targets and capital expenditure limits. Whilst we didn’t meet the 95% public sector payments policy in 2015-16, we performed well. Despite another challenging year in 2015-16, we again performed strongly in all areas and were pleased to receive a letter from the Chief Executive of NHS Improvement thanking us for our continued focus on financial performance and maintaining a surplus. In 2015-16 we posted a full-year surplus position of £1,075k and we achieved our target of £4,636k savings with 88% of schemes delivered recurrently. Our long-term financial planning has demonstrated that we are able to meet the financial rigour required of a Foundation Trust, with planned achievement of ‘4’ on the Financial Stability Risk Rating (FSRR) for each of the next five years.The Trust’s accounts are presented at the end of this report.

22 Wirral Community NHS Trust Annual Report and Accounts 2015-16

IT support In 2015-16 the Trust further invested in IT related initiatives, particularly in mobile working across the services. The transfer of all clinical services onto SystmOne, where functionally beneficial, continued during the year providing better management of patient/service user care and increased productivity for our staff. In addition, at the end of 2015-16 the Trust insourced ICT (Information and Communications Technology) service delivery from the North West Commissioning Support Unit providing more control of service provision and greater influence and delivery of the IM&T strategy. This also resulted in the transfer 11 members of staff to the Trust. Sustainable Development Management Plan The Trust has a Sustainable Development Management Plan (SDMP) that assists in clarifying objectives on sustainable development. This has been in place since the establishment of the Trust in April 2011 and reviewed each year. The plan has Board level accountability through the Finance and Performance Committee and ensures that sustainability issues have visibility and ownership at the highest level of the organisation. The SDMP helps the Trust to; • • • • • • •

Meet the minimum requirements of sustainable development Save money through increased efficiency and resilience Ensure the health and wellbeing of the local population is protected and enhanced Improve the environment in which care or the functions of the organisation are delivered for service users and staff Have robust governance arrangements in place to monitor progress Demonstrate a good reputation for sustainability Align sustainable development requirements with the strategic objectives of the organisation

In 2015-16 the Trust has continued to make good progress in the implementation of the SDMP action plan. We have continued with the maintenance of an established Environmental Management System, based on the ISO14001:2004 standard which enables us to monitor our performance against KPIs such as carbon emissions, utility consumption and waste. We have taken a particular focus on implementation and certification of the Environmental Management System at the largest freehold site owned by the Trust; St. Catherine’s Health Centre. The Trust acknowledges that adaptation to climate change will pose a challenge to both service delivery and infrastructure in the future and it has therefore become a key consideration as we plan how we will best serve patients in the future. As such sustainability issues form an integral part of our Estates Strategy. In 2015-16 audits on all trust properties were conducted; these will tell us how efficiently energy has been used in each building. Additionally, each property has been issued with a Display Energy Certificate (DEC) which is displayed on each reception desk. We have a Sustainable Transport Plan (STP) in place for the Trust which considers the burden NHS organisations place on the local transport infrastructure, whether through patient, clinical or other business activity. Similarly, the Trust is committed to reducing the wider environmental and social impacts associated with the procurement of NHS goods and services; this is set out within our policies on sustainable procurement.

23 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Our commitment to reducing the carbon footprint As a part of the NHS, we recognise our duty to contribute to the whole system ambition of reducing the carbon footprint; following the establishment of the Trust in 2011 this was agreed as a 28% reduction by 2020 using 2013 as a baseline. We are making good progress towards this and anticipate having exceeded our ambition to reduce our carbon emissions by 2.5% in 2015-16 due to the efficiency measures put in place across our owned and occupied properties. Below is a summary of our performance to achieve this aim. Carbon Emissions Carbon emissions have reduced over the last three years as a result of the implementation of the NHS Wirral Carbon Reduction Strategy (produced in 2009), and an investment in energy efficiency of the Trust properties including replacement of old building stock, improved thermal insulation in existing properties, and installation of Solar Photovoltaics (PV). The Trust has also implemented the Estate Efficiency Strategy which optimises space occupancy and utilisation. Our highest impact areas are associated with gas and electricity use at our premises, and business travel as a result of the community based nature of our services. In 2015-16 it is anticipated, pending final verification for the ERIC return, that the Trustâ&#x20AC;&#x2122;s measured Greenhouse Gas emissions from energy use were 1,273 tCO 2 e (tonnes of CO 2 equivalent); a reduction of 178 tCO 2 e on 2014-15. The figures below provide an overview of the Trustâ&#x20AC;&#x2122;s energy use.

Waste Waste recycling initiatives have continued to be implemented across the Trust during 2015-16, with all locations encouraged to recycle paper, cardboard, bottles, printer and toner cartridges, portable batteries, both Zinc and Lithium types and mixed recyclable waste. In 2015-16 we recovered or recycled 119 tonnes of waste; approximately 64% of the total waste we produced.

24 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Water usage The table below provides an overview of our water usage and spend in 2015-16 compared to the previous two years. Water

2013-14

2014-15

2015-16

22142

22672

8679

tCO 2 e

36,320

61,471

89,850

Mains

Water & Sewage Spend (£)

The table below provides a summary of total energy consumption.

Total energy consumption Relative energy consumption Water consumption Business travel road

2015-16

2014-15

2013-14

5,160MWh

4,538MWh

7,260MWh

0.23 MWh/square metre 8,679 m3

0.28 MWh/square metre 22,672 m3

0.25 MWh/square metre 22,142 m3

818 tCO 2 e

691 tCO 2 e

▲ ▼ ▼ ▬

25 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Accountability Report Corporate Governance Report The Directors’ Report The Board of Directors The Board of Directors has overall responsibility for ensuring that we are delivering high quality services that are efficient and effective. They oversee the running of the Trust, make the decisions that shape future direction, monitor performance, ensure accountability and look for opportunities to improve. The Board is made up of the Chairman, Non-Executive Directors, Chief Executive and other Executive Directors. The Chief Executive and Executive Directors are full-time members of staff who bring skills and expertise from their positions in key areas of the Trust. The Chairman and Non-Executive Directors work part-time. They each bring insight and experience from a range of professional backgrounds. They are not involved in the day-to-day running of the organisation but offer an independent view which both constructively challenges and contributes to the performance and management of the Trust. The Trust’s Establishment Order reflects its composition; •

Non-Executive Chairman

•

4 Non-Executive Directors

•

4 Executive Directors

There were a further 3 non-voting Directors. Further details on the governance framework and composition of the board are included in the Annual Governance Statement (AGS). Details of the Directors Non-Executive Directors Frances Street, Chairman - Frances was appointed Chairman of Wirral Community NHS Trust by the NHS Appointments Commission in January 2011. She has extensive experience in NHS leadership, having served as Chairman of NHS Wirral, Birkenhead and Wallasey Primary Care Trust (PCT), and a Non-executive Director of Wirral Hospital Trust and Wirral Health Authority. Frances is also Chairman of Johnnie Johnson Housing Trust, a Governor of Birkenhead Sixth Form College and vice-chairman of North West Cancer Research. Frances’ current term of office, approved by the NHS Trust Development Authority, will run until March 2017. Brian Simmons, Chairman of Audit Committee - Brian was formerly the Assistant Chief Officer and Finance Director for the Cheshire Constabulary. Brian joined the Civil Service in 1972 working in accounts and audit for the Property Service Agency. He has also worked as Business Services Director for a Ministry of Agriculture Science Laboratory. Brian is a fellow of the Chartered Institute of Management Accountants.

26 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Brian’s current term of office, approved by the NHS Trust Development Authority, will run until June 2017. Alan Wilson - Alan has extensive banking, business advisory and business development experience from a career in the banking industry and subsequent work with corporate finance and accountancy practices. He currently assists a Wirral based leasing company as well as running his own consultancy business. Alan has worked previously in the public sector in a Non-Executive capacity at Wirral University Teaching Hospital NHS Foundation Trust (WUTH) where he was chair of the Audit Committee. Alan is the chairman of the Finance & Performance Committee. Alan’s current term of office, approved by the NHS Trust Development Authority, will run until August 2017. Chris Allen - Chris retired from her position as Chief Executive of Forum Housing Association in March 2015; a position held for 29 years. She was Vice Chair of Wirral Community Health Council (WCHC) when it was in existence representing the Voluntary, Community and Faith sector. This included working in partnership with health professionals during the early transitions between Primary Care Groups (PCG) and PCTs. Chris holds a number of other roles including Council member and Foundation Governor at the University of Chester and she is a Director with Greater Merseyside Connexions Partnership. Chris was awarded the British Empire Medal in January 2013 for services to the community across Merseyside. Chris is the chairman of the Quality & Governance Committee. Chris’ current term of office, approved by the NHS Trust Development Authority, will run until March 2017. Murray Freeman - Murray has been a GP in Rock Ferry for over 30 years and has a particular interest in palliative care and end of life care. Over the years he has held a number of additional posts including GP Trainer, Cancer Lead for NHS Wirral, Chairman of Wirral Local Medical Committee, Medical Director of Wirral Community Healthcare NHS Trust and most recently GP Executive Member of Wirral Health Commissioning Consortium. Murray is also a specialist advisor to the CQC. Murray is the chairman of the Education & Workforce Committee. Murray’s current term of office, approved by the NHS Trust Development Authority, will run until December 2016. Tony Snell - Tony Snell was appointed to the Trust Board as an Associate Non-Executive Director in June 2015 but resigned from the post in October 2015. Executive Directors During 2015-16, there were new appointments to the Executive structure as outlined below. Simon Gilby, Chief Executive - Simon left the Trust in July 2015. Karen Howell, Chief Executive - Karen joined the trust as Chief Executive in August 2015. Karen grew up in Wirral where she also trained and worked as a nurse in her early career. She is a highly experienced regional and national health leader with 25 years at board level. Prior to joining the trust Karen’s previous roles included: Managing Director for Specialised and Tertiary Commissioning for NHS Wales, Interim Chief Executive at Hywel Dda University Health Board, NHS Wales Mental Health Lead, Northwest Regional Clinical Director for Prison Health, DH national director high secure services, DH national policy lead medium secure services, Director of Forensic Services at Merseycare NHS Trust,

27 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Director of Nursing/Deputy CEO at Halton & St Helens Primary Care Trust. Karen is a Registered Nurse and has a MSc in Law and Biomedical Ethics from the University of Liverpool. Mark Greatrex - Director of Finance & Resources - Mark joined the Trust in January 2015 bringing 25 years NHS experience. Prior to joining the Trust, Mark was Deputy Director of Finance at a specialist hospital NHS Foundation Trust and has held a number of previous senior level finance roles. Mark is a member of the Chartered Institute of Management Accountants (CIMA). Dr Ewen Sim, Medical Director - Since leaving Edinburgh Medical School in 1990, Ewen has had a varied career in healthcare holding a range of Junior Doctor posts including Histopathology and A&E. He has also worked at the North West Deanery and at the Department of Health regulating working conditions of doctors in training. He came to Wirral in 2001 to train as a GP and is now a GP partner in Fender Way Health Centre. Prior to joining Wirral Community NHS Trust in June 2011 as a Medical Director he was a Clinical Director in Liverpool. Ewen was a union leader for doctors in the British Medical Association in charge of education and training, working with the General Medical Council, the British National Formulary and the Royal College of General Practitioners. He is also a founder member of the Postgraduate Medical and Education Training Board (now part of the GMC). Sandra Christie - Director of Nursing and Performance - Sandra is a nurse and health visitor by background and has had a varied career in the NHS covering operational and strategic management, service improvement and quality development. Sandra has worked for the NHS for over 30 years and joined the Trust Board in 2013. Sandra is passionate about quality and improving care for patients and is a Florence Nightingale Leadership scholar. Jo Harvey, Director of Human Resources and Organisational Development*- Jo has over 15 years’ experience as a Human Resources professional and has worked in the NHS since 2002. Prior to the role of Director of Human Resources at Wirral Community NHS Trust, Jo was Human Resources Director for NHS Wirral and before that the Assistant Director of Human Resources at United Lincolnshire Hospitals NHS Trust. Previously Jo worked for ten years in both managerial and HR roles in the Civil Service, at the Lord Chancellor’s Department and OFSTED. She is a member of the Chartered Institute of Personnel and Development. Val McGee, Director of Integration & Partnerships* - Val joined the trust on secondment from Cheshire and Wirral Partnership in January 2015. Val brings a wealth of experience with over 30 years operational and strategy management in the NHS. Val’s previous roles include Service Director for Wirral-wide mental health and learning disabilities services and 3 years as Deputy Director of Operations at CWP. Phil Clow, Director of Business Development & Strategy* - Phil joined the Trust in September 2015 with 17 years of public sector experience, having joined the NHS in 2008 through the NHS Gateway to Leadership programme and prior to that working for the Environment Agency in various roles including Programme Manager for flood risk management in the East of England. Prior to joining the trust, Phil was the Director of Commissioning at North Tyneside CCG. Phil grew up on the Wirral, and now lives in Parkgate. * Non-voting members of the Board

28 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Board Committees The Board is supported by the following committees: • • • • •

Audit Committee Remuneration Committee Quality & Governance Committee Finance & Performance Committee Education & Workforce Committee

Statement as to disclosure to auditors Each director of the board knows of no information which would be relevant to the auditors for the purposes of their audit report, and of which the auditors are not aware and has taken all the steps they ought to have taken to make themselves aware of any such information and to establish that the auditors are aware of it. The Audit Committee The Audit Committee has a key role to play in the production of the Trust’s annual report and annual accounts. The Audit Committee is chaired by Brian Simmons, Non-Executive Director with three further Non-Executive Director members (Chris Allen, Murray Freeman and Alan Wilson). This is in line with the Treasury’s guidance of at least three Non-Executive Directors. The Audit Committee works closely with both internal and external auditors and supports the Trust Board in ensuring that effective controls are in place to deliver value for money, transparency and probity in financial matters. The committee has delegated authority to approve the Trust’s annual financial statements and advises the Board on the adequacy and effectiveness of internal controls, as well as the arrangements for managing risk and wider control and governance processes. Register of Directors’ Interests A Register of Interests is completed annually by all members of the Trust Board. See page 31. Disclosure of personal data related incidents - Information Governance (IG) There was one IG SIRIs (Serious Incident Requiring Investigation) that required reporting to the ICO (Information Commissioners Office) in 2015-16. This was fully investigated via a rapid SBAR (Situation, Background, Assessment, and Recommendation) and reported to the Quality & Governance Committee. A formal response was received from the ICO confirming that no further action had been deemed necessary due to the particular facts of the case and the remedial measures put in place by the Trust. The Annual Governance Statement provides further information on Information Governance including compliance with the IG Toolkit.

29 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Statement of the Accounting Officers responsibilities The Chief Executive is our designated Accounting Officer with the duty to prepare the accounts in accordance with statutory requirements. As far as she is aware there is no relevant audit information of which the Trustâ&#x20AC;&#x2122;s auditors are unaware, and the Chief Executive has taken all the steps that she ought to have taken to be aware of any relevant audit information and to establish that the Trustâ&#x20AC;&#x2122;s auditors are aware of that information. As the Accounting Officer, the Chief Executive confirms that this annual report and accounts as a whole is fair, balanced and understandable and that she takes personal responsibility for them.

30 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Wirral Community NHS Trust Board of Directors - Register of Interest for the financial year 2015-16 Name

Interest Registered

Christine Allen Non-Executive Director

Director - Forum Creative Enterprises Director - Foundation Enterprises Northwest Director/Trustee - GMCP Council Member/Foundation Governor - University of Chester Magistrate - Wirral Bench Trustee - Life Church, Wirral Trustee - Frontline Church, Liverpool Family member - owner of Forever Green Foods (catering company)

Sandra Christie Director of Nursing & Performance

No interest to declare.

Phillip Clow Director of Business Development & Strategy

No interest to declare.

Dr Murray Freeman Non-Executive Director

General Practitioner - Victoria Park Practice CQC specialist advisor Trustee - Wirral Information Resource for Equality & Diversity (WIRED) Spouse - employed by Wirral Community NHS Trust

Simon Gilby Chief Executive

Independent Chairman - Social Enterprise Network (Liverpool Region)

(Left Wirral Community NHS Trust on 31/07/15)

Mark Greatrex Director of Finance & Resources/Deputy Chief Executive

No interest to declare.

Jo Harvey Director of HR & Organisational Development

No interests to declare.

Karen Howell Chief Executive

Chair â&#x20AC;&#x201C; Investment Club

(Joined Wirral Community NHS Trust on 03/08/15)

31 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Val McGee - Director of Integration & Partnerships

No interests to declare.

Dr Ewen Sim - Medical Director

Partner in GP Practice - Fenderway Health Centre Volunteer - Advocacy in Wirral (Charity) Member - British Medical Association Associate Member - Royal College of GP’s Member - Liverpool Medical Institution Chairman - Wirral Practitioners Study Group Invited member - Clinical Forum, Wirral CCG Education and Training Lead (appointed ) - Wirral CCG

Brian Simmons Non-Executive Director

No interest to declare.

Dr Tony Snell Associate Non-Executive Director

CQC specialist advisor

(Left Wirral Community NHS Trust on 31/10/15)

Frances Street Chairman

Director - Sun Valley Ltd Chair - ‘Johnnie’ Johnson Housing Trust Deputy Chair - North West Cancer Research Governor - 6th Form College

Alan Wilson Non-Executive Director

Managing Partner - Alan Wilson Consultancy

32 Wirral Community NHS Trust Annual Report and Accounts 2015-16

ANNUAL GOVERNANCE STATEMENT

Name of Organisation:

Wirral Community NHS Trust

Organisation Code:

RY7

Scope of Responsibility As the Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the Trust’s policies, aims and objectives, whilst safeguarding quality standards, the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the Trust is administered prudently and economically and that resources are applied efficiently and effectively. I acknowledge my responsibilities as set out in the Accountable Officer Memorandum. The Governance Framework The Trust Board functions as a corporate decision-making body considering the key strategic issues facing the Trust in carrying out its statutory and other functions. The arrangements in place for the discharge of statutory functions have been checked for any irregularities and are legally compliant. During 2015-16 the Board met in public on 10 occasions and on each occasion members of the Board convened in a formal private session to focus on matters considered commercial in confidence. In December 2015 and January 2016 the Board met in private session only. According to the standing orders of the Trust, the chairman may call a meeting of the board at any time and one-third or more members of the board may request a meeting in writing to the chairman. These provisions have not been enacted during 2015-16. The Board comprises Non-Executive and Executive Directors who share equal responsibility for the Board’s decisions and for the direction and control of the organisation.

The Trust’s Establishment Order reflects its composition; • • •

Non-Executive Chairman 4 Non-Executive Directors 4 Executive Directors

The board structure for 2015-16 comprised of; • • • • • • • •

Chief Executive Chairman Director of Finance & Resources/Deputy Chief Executive Medical Director Director of Nursing & Performance Director of Human Resources & Organisational Development (non-voting) Director of Business Development & Strategy (non-voting) Director of Integration & Partnerships (non-voting)

33 Wirral Community NHS Trust Annual Report and Accounts 2015-16

â&#x20AC;˘ â&#x20AC;˘

Non-Executive Directors (including Senior Independent Director) Associate Non-Executive Director

The Director of Integration & Partnerships was formalised in the executive structure in September 2015, following discussions with partners across the health economy, the TDA and Monitor. Interim arrangements had previously been in place and a secondment with majority funding by the trust and funding in part from the CCG and Cheshire & Wirral Partnership (CWP) was agreed by the trust board. This role focuses on whole-system integration through the Healthy Wirral programme and drives relevant implementation in the trust. In June 2015 the final Non-Executive Director re-appointment was confirmed by the TDA using powers delegated by the Secretary of State for Health for a further two years. All other Non-Executive Directors were re-appointed in early 2015 as reported in the Annual Governance Statement for 2014/15. In July 2015 following an open recruitment process and with full support from the TDA, an Associate NonExecutive Director was appointed to the Trust Board. This was initially on a two-year term however, the post holder resigned from the post in October 2015. A decision is yet to be taken on any replacement to this post; the chairman is supporting a capacity and skills audit review of the Non-Executive group. Additional governance roles are undertaken by members of the executive team as outlined in the table below; Post

Director of Nursing & Performance

Governance roles

Responsible for

Director of Infection Prevention & Control (DIPC)

Infection Prevention & Control Service and related policies. Publishing an annual IPC report. Ensuring best practice principles are followed, appropriate recruitment processes followed and job-specific training provided. Attends partnership boards. Publishing an annual safeguarding report. Helps the board make strategic decisions in view of their effect on the quality and safety of patient care. Overseeing compliance with the CQC regulatory framework Protecting the confidentiality of serviceuser information, enabling and applying the highest standards for appropriate information sharing. Ensures all incidents involving controlled drugs are reported correctly, communication with Local Intelligence Network. Provides local leadership in developing systems of appraisal and clinical governance; lead for End of Life Care. Managing information risks to the organisation; oversight of information

Safeguarding Lead Officer

Executive Nurse

Nominated Individual (CQC) Medical Director

Caldicott Guardian

Accountable Officer for Controlled Drugs

Director of Finance

Responsible Officer (RO) for Medical Registrations & Revalidation Senior Information Risk Owner

34 Wirral Community NHS Trust Annual Report and Accounts 2015-16

& Resources (Deputy Chief Executive)

security incident reporting and response.

Director of Business Development & Strategy

Security Management Director

Overseeing and providing strategic management and support for all security management work within the organisation

Accountable Emergency Officer

Ensuring that the NHS England core standards for Emergency Planning Resilience and Response are met

Non-Executive Directors have also been aligned to key roles and activity within the organisation including a non-executive lead for safeguarding and complaints, and a Non-Executive Director has been appointed to the role of Freedom to Speak Up Guardian. The names of board members, who served during the year, and their biographical details, are included in the Directorsâ&#x20AC;&#x2122; report. The Trust Board continues to comply with the Fit and Proper Persons Regulations (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 5) and adhered to the processes established when appointing the Director of Business Development & Strategy during 2015-16. The table below shows the attendance record for each board member compared to the maximum number of meetings they could have attended in 2015-16. It also reflects that members of the Non-Executive and Executive team, who are not formal members of committees, may attend to contribute to discussions on specific topics. The Chief Executive is not a formal member of any sub-committee of the board and therefore assumes a roaming brief to support and contribute as required. The Chief Executive does attend the Audit Committee at least annually to sign off the Annual Report & Accounts.

April 2015 March 2016

Public Board

Rem Committee (at least annual)

Audit Committee

Quality & Governanc e Committee (Monthly)

Finance & Performan ce Committee (Monthly)

Education & Workforce Committee (Monthly)

9 8 9

3 2 1

1 3 4

7 9 11

10 9 8

5 8 11

9 10 3 (out of possible 4)

3 3 -

4 4 -

11 11 2 (out of possible 3)

10 12 2 (out of possible 3)

10 11 2 (out of possible 3)

Number of Meetings

Non-Executive Directors Frances Street Chris Allen Murray Freeman Brian Simmons Alan Wilson Tony Snell*

Executive Directors

35 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Sandra Christie ^Phil Clow**

Simon Gilby***

Mark Greatrex ^Jo Harvey Karen Howell****

^Val McGee

Ewen Sim

4 (out of possible 4) 4 (out of possible 4) 9 9 5 (out of possible 6) 10

1 (out of possible 2)

1 (out of possible 1)

6 (out of possible 7)

1 (out of possible 2)

2 (out of possible 4)

3 1 (out of possible 3)

3 -

10 6 (out of possible 8)

12 4 (out of possible 8)

10 1 (out of possible 8)

2 (out of possible 3) 9

^ Non-voting members *Tony Snell, Associate Non-Executive Director in post from June - October 2015 **Phil Clow, Director of Business Development & Strategy, in post from end of September 2015 ***Simon Gilby, Chief Executive, left the Trust in July 2015 ****Karen Howell, Chief Executive, in post from August 2015

36 Wirral Community NHS Trust Annual Report and Accounts 2015-16

The committee structure reporting to the Trust Board is clearly defined through the terms of reference and reporting arrangements. The Board has formally delegated specific responsibilities to the committees listed below, full minutes of which are reported to Board. • • • • •

Quality & Governance Committee (Monthly) Finance & Performance Committee (Monthly) Education & Workforce Committee (Monthly) Remuneration & Terms of Service Committee (at least once per annum) Audit Committee (4 meetings per annum)

The table below provides detail on committee chairmanship and membership. Sub-Committees of the Board - Chairmanship and Membership

Committee

Non-Executive Director(s)

Director(s)

Audit Committee

Brian Simmons (Chair) Alan Wilson Murray Freeman Chris Allen

By invitation (not formal members)

Finance & Performance Committee

Alan Wilson (Chair) Brian Simmons Frances Street

Director of Finance & Resources Director of Nursing & Performance Director of Business Development & Strategy Director of Integration & Partnerships

Quality & Governance Committee

Chris Allen (Chair) Murray Freeman Brian Simmons

Director of Nursing & Performance Medical Director Director of HR & OD

Education & Workforce Committee

Murray Freeman (Chair) Chris Allen Alan Wilson

Director of HR & OD Director of Nursing & Performance Medical Director Director of Integration & Partnerships

Remuneration Committee

Frances Street (Chair) Chris Allen Murray Freeman Alan Wilson Brian Simmons

By invitation (not formal members)

37 Wirral Community NHS Trust Annual Report and Accounts 2015-16

As part of the Trustâ&#x20AC;&#x2122;s governance arrangements, the chair of each committee presents a report on the matters considered and any decisions taken at its meetings at the next meeting of the Trust board, with full minutes provided once approved. The table below provides an overview of the duties and accountabilities of each committee of the Board. The primary role of each is to provide assurance to the Board on the areas of responsibility. Committee

Duties and accountabilities

Quality & Governance

Approving and monitoring implementation of the quality strategy. Agreeing the annual clinical audit plan. Reporting to Board on all aspects of quality, governance and compliance. Receiving assurance that trust meets all relevant statutory/ regulatory obligations in relation to quality, clinical governance and compliance. Advising the Board of all significant risks, areas for development and exceptional good practice, ensuring lessons are learned and shared. Reviewing instances where the statutory Duty of Candour requirements are applied. NOTE: Mechanisms that ensure treatment is safe, effective, well-led, responsive and caring include the work of governance groups which feed the Board via this committee.

Finance & Performance

Monitoring the financial and contractual/ commissioning performance of the trust against objectives/targets. Ensuring appropriate governance after FT authorisation.

Education & Workforce

Co-ordinating, developing, prioritising, monitoring, reviewing and overseeing implementation of workforce, organisational development and learning and development plans and monitoring effectiveness.

Remuneration & Terms of Service

Advising the trust about appropriate remuneration and terms of service for the Chief Executive, all on the VSM pay scale / other managers on local pay.

Audit

Ensuring an effective internal audit function that meets Public Sector Internal Audit Standards. Reviewing findings / ensuring implementation. Scrutinising the risks and controls which affect the trustâ&#x20AC;&#x2122;s business. Receiving regular reports on the work / findings of the internal and external auditors and local counter fraud team. Receive assurances from the clinical audit function. Approving the trustâ&#x20AC;&#x2122;s annual quality account. Receiving the annual report and accounts.

38 Wirral Community NHS Trust Annual Report and Accounts 2015-16

The Trust Board has also considered the role of the Council of Governors in the governance framework of the organisation and the trust’s first Council of Governors (currently operating in shadow form) was elected in November 2015. The Trust has finalised its FT constitution and aligned processes to the FT code of governance. During 2015-16 the Trust continued to report monthly to the TDA on progress against a set of board statements and a subset of Monitor’s provider licence conditions, and declared full compliance against all indicators and relevant conditions. The compliance statement is underpinned by the principles in the ‘2015/16 Accountability Framework for NHS Trust Boards - Delivering for Patients. In January 2016, the TDA advised that the monthly returns were no longer required. The Trust Board also continued to regularly review progress and compliance against the Board Governance Assurance Framework (BGAF) and the Quality Governance Assurance Framework (QGAF) when they were in operation. However following the publication of the Well-led Governance Framework in 2015, the Trust has worked closely with Monitor (as part of the on-going assessment for Foundation Trust status) to complete a thorough review using the new framework. This has included the completion of a detailed self-assessment, which has subsequently been reported to the Trust Board on a quarterly basis and the development of the Quality Governance and Strategy Memoranda. This work has required the Trust Board to review its performance and that of its subcommittees against the four domains of the framework and the ten underpinning questions. The self-assessments completed for Q3 and Q4, 2015-16 were rated Green. In November 2015 and most recently in March 2016, the Trust Board also supported the Chairman in making the well-led board statement on behalf of the trust, confirming that the whole Trust Board had confidence in the arrangements in place for each area set out in the well-led framework. The Trust expects to be fully compliant with the applicable elements of the TDA’s Accountability Framework for 2015/16. The Trust performs well against national targets in the framework such as the 4 hour standard for its type 3 A&E attendances. The Trust recognises that until all national data is collected and the TDA have identified upper and lower deciles of performance across the country the final position cannot be known. For example the Trust expects to be well within the normal range (when compared to other trust’s nationally) for its sickness absence levels, but nonetheless locally a stretch target has been set of 4.2% and therefore internally the organisation rates itself as amber being slightly above this level. Elective waiting time data does not apply to the Trust. The Trust was authorised as a Community NHS Foundation Trust on 1 May 2016 and is subsequently reviewing its governance framework to reflect the statutory duties, regulatory requirements and its Foundation Trust constitution. Corporate Governance The NHS Act 2006, Health and Social Care Act 2012 and subsequent regulations set out the legal framework within which the Trust operates. The Trust recognises that effective corporate governance, along with clinical governance, is essential to achieve its clinical, quality and financial objectives. Fundamental to effective corporate governance is having the means to verify the effectiveness of this direction and control, achieved through independent review and assurance.

39 Wirral Community NHS Trust Annual Report and Accounts 2015-16

NHS Trusts are not required to comply with the UK Corporate Governance Code, however, we have set out below those areas where the Trust has drawn on best practice available including those aspects of the code considered to be relevant. Leadership

The Trust has an effective board which is collectively responsible for the long-term success of the organisation

Effectiveness The Board and committees of the board have an appropriate balance between members skills, experience, independence and knowledge which is reviewed on a quarterly basis Accountability The Board presents a fair, balanced and understandable assessment of the organisation through sound risk management and internal control systems Remuneration The Trust has a transparent procedure for developing policy on executive remuneration, delegated to the remuneration & terms of service committee Sustainability The Trust Board takes a long-term view about what the Trust is aiming to achieve through the development and scrutiny of strategic plans. The Trust is playing a key role in systemwide strategic planning. In assessing its corporate governance arrangements, the Trust Board has completed a detailed selfassessment of its processes and structures through the well-led governance framework. In readiness for becoming an NHS Community Foundation Trust, the trust has reviewed the specific requirements described in the Health and Social Care Act 2012, including the FT code of governance. Quality Governance Quality Governance is the combination of structures and processes at and below board level to deliver trust-wide quality service, and as such the Trust Board recognises that quality is an integral part of its business strategy and to be most effective, quality should be the driving force of the organisation’s culture. The Trust Board recognises that quality is not a programme or a project within the organisation and it is not the responsibility of any one individual to implement the quality agenda. The Quality Strategy for 2015-16 outlined the board’s quality priorities in four areas: • • • •

Putting people at the heart of quality Advancing quality Measuring quality Balancing cost and quality

The strategy is based on a continuous quality improvement model, developed with staff and supported by internal quality improvement workshops. The quality goals are developed with the Quality and Governance Committee and performance against them are published annually in the Quality Account. The trust has an excellent track record of achieving its quality goals and the annual Commissioning for Quality and Innovation (CQUIN) schemes. The CQUIN schemes for 2015-16 were a combination of national and local measures and included Dementia and Delirium, Urgent Care, Integrated Therapy Pathway and Single Point of Access development.

40 Wirral Community NHS Trust Annual Report and Accounts 2015-16

The Quality Account 2015-16 provides evidence of progress against the quality goals set for the year and highlights aspirational goals for the forthcoming year. The Quality Account is developed in consultation with the Quality & Governance Committee and the content is based on the information regularly shared and scrutinised by the committee on a monthly basis through quality reports. It reflects the Trust’s commitment to providing the highest possible standards of clinical quality, and demonstrates how the Trust listens to patients, staff and partners, working with them to deliver services that meet the needs and expectations of the people who use them. The Quality Account 2015-16 is reviewed by external partners including HealthWatch, and the Local Authority and CCG who provide supporting statements; it will be formally approved by the Audit Committee prior to publication in June 2016. Following the publication of the Well-led Framework in 2015 the Trust Board completed a thorough selfassessment process and reported Green against the four domains of the framework. The Quality Governance Memorandum was also developed and describes how the trust complies with good practice in relation to quality governance. The Trust has a robust programme of clinical audit in place and during 2015-16, 25 clinical audits and 16 governance audits were planned and completed. The key quality outcomes from the audits are reported in the annual Quality Account. Other methods of internal quality assurance include, infection prevention and control audits, safeguarding audits, all complemented by an internal audit programme of work led by Mersey Internal Audit Agency (MIAA).

The trust is required to demonstrate compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. The Trust Board is responsible for ensuring compliance with these regulations at all times and the work of the Quality & Governance Committee regularly monitors compliance against the standards highlighting any risks of non-compliance. The quality & governance team leads a programme of quarterly compliance selfassessments to support teams in ensuring compliance and to provide appropriate assurance to the Trust Board. In addition a CQC risk based assessment process has been established consisting of focused outcome assessments of services selected for assessment on the basis of intelligent monitoring data. During 2015-16 the Trust completed the implementation of the findings and subsequent actions from the announced CQC inspection of the Trust in September 2014. The trust was rated as ‘good’ overall and an action plan to address the areas of improvement was monitored by the Quality & Governance Committee. The Trust achieved level 2 of the Information Governance Toolkit (version 12.0) with 95% of all staff completing and passing the Information Governance e-learning training during 2015-16; this has been further endorsed by an internal audit review giving High Assurance. The Information Governance Group monitors performance of action plans designed to meet the requirements of the information governance toolkit and reports to the Quality and Governance committee. The Trust fully endorses the Francis report (2013) and the recommendations in relation to the duty of openness, transparency and candour (173 to 184) and has adopted 10 principles underpinning ‘Being Open’ as supported by the National Patient Safety Agency (NPSA). A Raising Concerns Policy has been developed and the Trust Board is committed to the policy as part of its approach to openness and honesty. The policy identifies a Non-Executive Freedom to Speak-Up Guardian. The Trust has also considered the recommendations on improving productivity in the Carter Review through the relevant governance processes in the organisation.

41 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Risk Assessment The Trust’s corporate strategy for risk management is preventative, aimed at influencing behaviour and developing a culture within which risks are recognised and addressed. This process is aligned to controlling clinical and non-clinical risks and to support a persuasive safety culture. The Trust operates within a clear risk management framework which sets out how risk is identified, assimilated into the risk register, reported, monitored and escalated throughout the corporate governance structure. This framework is set out in the risk management strategy, which was updated and approved by Board in March 2016. Risks are recorded at service, divisional and organisational level forming the Trust’s risk register. The risk management strategy sets out the responsibility and role of the Trust Board, the Chief Executive and Executive Directors in relation to risk management with overall responsibility for the management of risk lying with the Chief Executive, as Accountable Officer. The process of risk management has been embedded within the organisation and cascaded to service areas to assist with the development of an organisation-wide risk awareness culture. In addition to the risk management strategy, the Trust has developed a number of policies and systems which encourage staff at all levels to be involved in identifying and reporting risks. These include, but are not limited to; Policy for the Identification and Management of Risk which aligns to the Risk Management Framework, on-line incident reporting via the Datix system, leadership and patient safety walkrounds and a new Performance Management Framework implemented across the organisation in 2015-16.

Risk management training is also mandatory for all staff and is a key part of the organisation’s corporate and local induction. The Trust Board has a Board Assurance Framework (BAF) in place, aligned to the Risk Management Framework, and linked to the organisation’s Performance Management Framework. The BAF records the principal risks that could impact on the Trust achieving its strategic objectives and provides a framework for reporting key information to the Board. The Trust Board is updated at each meeting on any changes to the Board Assurance Framework via the Integrated Performance Report which provides a summary of risks escalated via the sub-committees linked to the principal risks, together with data informing the setting of risk tolerance and target levels. The Trust completed a review of the principal risks in the BAF in 2015-16; there are 27 principal risks (strategic risks) against its 15 strategic objectives, themed according to four strategic areas. Each risk on the BAF is rated according to the risk matrix. Any with a risk rating of >15 are reviewed for progress and mitigating actions. The strategic risks noted against each strategic theme in the table below, summarise the risks currently recorded in the BAF.

Strategic Theme

Strategic Risk

Mitigating Actions

Our Patients & Community

Failure to recognise report or act upon patient safety risks whilst failing to identify the right patients and engaging

Robust Quality Governance processes Maintenance of CQC registration without conditions

42 Wirral Community NHS Trust Annual Report and Accounts 2015-16

with them effectively and noncompliance with statutory duties.

Impact: Loss of CQC registration, poor CQC Chief Inspector of Hospitals Report, poor reputation

Our Services

Failure to understand commissioner needs and effectively manage contractual relationships whilst responding to market changes

Impact: Loss of contracts, inability to grow business and position as credible partner for integration Our People

Failure to engage effectively with our workforce and implement an effective workforce plan and leadership framework to support the change required.

Impact: Inability to meet contractual requirements/CIP, affecting ability to deliver financial requirements and deliver safe care.

Our Sustainability

Failure to use our resources to best effect to support the delivery of CIP savings and drive change through innovation.

Robust governance & risk management processes Embedding our values and a â&#x20AC;&#x2DC;fair blame cultureâ&#x20AC;&#x2122; Invest resources to focus on improving quality of services to develop reputation as provider of choice Quality impact assessment for CIP process pre and post implementation Leadership Walkrounds programme Exec to Exec meetings with commissioners and other key stakeholders Board to Board sessions with key stakeholders HealthyWirral programme board representation Business development process includes strategic fit criteria Membership of Health and Wellbeing Board Business Intelligence and PMO function Implement revised organisational change policy Staff engagement activities Leadership Walkrounds Embedding vision and values including in the recruitment process Performance management framework National staff survey and local e-surveys Joint Forum and Staff Council monthly meetings Learning and development gaining additional skills (e.g. customer experience, business acumen Robust financial management Scenario planning Contingency planning Develop analysis of market opportunities Diversify contractual arrangements across a wide range of commissioners

43 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Impact: Failure to meet financial requirements and drop in FSRR.

Robust CIP management arrangements regular reporting to and monitoring by Finance & Performance Committee and Board Prudent financial arrangements Additional income generation Service redesign and other efficiency measures

The key strategic risk areas identified in-year relate to; • • • •

Commissioning intentions and contracting decisions preventing organisational development, putting services at risk Ability to respond and deliver competitively to market changes The scale of organisational change and the impact of significant service developments on organisational capacity Cultural transformation

The risk and control framework During 2015-16, the Trust Board has led the work to refresh the BAF to ensure the principal risks have a clearer link to the strategic objectives and reflect the environment in which the Trust is operating, and that the operational impact of these risks is clearly articulated. The BAF is recognised as a key tool to drive the board agenda by ensuring the board focuses attention on those areas which present the most challenge to the organisation’s success. This has been further strengthened with the implementation of the Performance Management Framework. The refresh of the BAF has been reviewed as part of the independent accountants (KPMG) Historic Due Diligence review (Financial Reporting Procedures), a key stage of the Foundation Trust assessment process. The work completed on the BAF has also informed the annual assurance framework review completed by internal audit (MIAA) which concluded that “the organisation’s Assurance Framework is structured to meet the NHS requirements, is visibly used by the Board and clearly reflects the risks discussed by the Board”. The Risk Management Framework and the implementation of the new Performance Management Framework allow the board to consider operational risks escalated by the relevant committees and reported in the Integrated Performance Report. During 2015-16, each committee of the Board received a monthly risk management report providing assurance on the management of operational risk associated with each committee’s duties and accountabilities providing an opportunity to scrutinise the detail of high-level risks and those not progressing. An Integrated Performance Group has been established with the primary purpose of ensuring the organisation has effective processes in place to deliver continuous integrated performance improvement, ensuring patients are kept safe, that risk is effectively managed and operational services meet their financial targets. This group reports by exception to the committees and provides assurance to the Trust

44 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Board on the effectiveness of operational delivery specifically in relation to KPIs, quality and safety, risk management and finance. At divisional level the Quality, Patient Experience and Risk groups (QPER) and the business & performance meetings provide a focus on divisional and service level performance and risk; these groups from each of the 3 clinical divisions report to the Integrated Performance Group. All risk registers and incident reports are centralised on an electronic database, Datix. During 2015-16 the Trust recorded 35 SUIs (Serious Untoward Incidents) classified as severe-harm or death. All SUIs are investigated and reported to NHS England via the national reporting and learning system (NRLS) in accordance with Department of Health protocols. In 2015-16 one wrong site surgery never-event was reported. All internal and external reporting requirements were completed within the timescales outlined within the never-event framework and an RCA investigation was conducted led by a local NHS Provider organisation to ensure openness and transparency whilst maximising learning. The investigations from all SUIs are reviewed to ensure any themes and learning is shared across the Trust to prevent them from reoccurring. There was one IG SIRIs (Serious Incident Requiring Investigation) that required reporting to the ICO (Information Commissioners Office) in 2015-16. This was fully investigated via a rapid SBAR and reported to the Quality & Governance Committee. A formal response was received from the ICO confirming that no further action had been deemed necessary due to the particular facts of the case and the remedial measures put in place by the trust. The Local Counter Fraud Specialist (LCFS) provision for the Trust has historically been provided by the North West Commissioning Unit (NWCSU) but since November 2015 following the demise of the NWCSU, this support has been provided by Mersey Internal Audit Agency (MIAA). The Trust has a fully accredited and nominated Anti-Fraud Specialist supported by a team which includes an Assistant Director, Senior Manager and Investigations Manager. MIAA provides a bespoke anti-fraud agenda for the trust delivering a range of services. The LCFS undertakes any mandatory risk measurement exercises as instructed and required by NHS Protect, using FRAT (Fraud Risk Assessment Tool) to assess areas at increased risk of exploitation. This ensures adequate resources are always readily available to address emerging areas of risk should the need arise. All reports of fraud are dealt with professionally, diligently and in line with all current legislation and the requirements of NHS Protect. The Director of Finance & Resources is briefed on a monthly basis and the Audit Committee receive an update at each meeting. Trust staff have access to a 24/7 fraud advice and reporting line and are regularly reminded of the need to be vigilant. The Trust has developed a fraud & corruption policy and a bribery policy which are accessible to all staff via Staff Zone. The Trust has robust processes in place to detect any potential allegations of fraud which are reported to the Audit Committee. During 2015/16, there were 3 incidents of fraud which required further investigation, one has been referred to Merseyside Police and 2 are on-going.

45 Wirral Community NHS Trust Annual Report and Accounts 2015-16

The effectiveness of risk management and internal control In accordance with Public Sector Internal Audit Standards, the Director of Internal Audit has provided an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes (i.e. the organisation’s system of internal control) during 2015-16.This is achieved through a risk-based plan of work, agreed with the Senior Management Team and approved by the Audit Committee. The purpose of the Director of Internal Audit Opinion is to contribute to the assurances available to the Accountable Officer and the board which underpin the board’s own assessment of the effectiveness of the organisation’s system of internal control. The overall opinion for 2015-16 provides Significant Assurance. It confirms that “there is a generally sound system of internal control designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weaknesses in the design or inconsistent application of controls put the achievement of a particular objective at risk

Internal audit conducted 11 reviews during 2015-16 of which 1 received high assurance, 6 received significant assurance, and 2 received limited assurance. In relation to all audit reviews, the Trust provided a managerial response with action plans in place to deliver on the recommendations made. In particular, of those reviews receiving limited assurance, either all recommendations have been fully implemented or an action plan is in place to address the risk areas identified. Significant Issues As Accountable Officer I confirm that there are no significant issues to report.

Karen Howell Chief Executive Wirral Community NHS Trust

2 June 2016

46 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Remuneration Report The tables shown on the following pages provide information on the remuneration and pension benefits for senior managers for the year ended 31 March 2016. These tables are subject to external audit review. What this report covers This report to stakeholders: • • • •

Sets out the Trust’s remuneration policy Explains the policy under which the Chairman, Executive Directors, and Non-executive Directors were remunerated for the year ended 31 March 2016 Sets out tables of information showing details of the salary and pension interests of all directors for the year ended 31 March 2016; and Details of the pay multiples from the Trust’s highest paid director to the median paid member of staff within the Trust.

Role of the Remuneration Committee The Remuneration Committee is a committee of the Trust Board. An effective committee is key to ensuring that Executive Directors’ remuneration is aligned with stakeholders’ interests and that directors are motivated to enhance the performance of the Trust. Membership of the Remuneration Committee The members of the committee are the Chairman and all Non-Executive Directors. Committee meetings are considered to be quorate when the Chairman and two Non-Executive Directors are present. The Chief Executive and Director of Human Resources and Corporate Affairs also attend in an advisory role but are not members of the committee and do not participate in any discussion or decision making in respect of their own remuneration or other terms of service. Service Contracts All Executive Directors have service contracts, which are usually awarded on a permanent basis, unless the post is for a fixed term. Directors have a three month notice period within their contracts of employment. Termination payments are made in accordance with contractual agreements. Remuneration policy for Executive Directors Directors’ posts (with the exception of the Chief Executive and Medical Director) are currently evaluated using the national Agenda for Change Job Evaluation Framework. The Chief Executive and Medical Director posts are evaluated using the North West Strategic Health Authority Job Evaluation Panel. All executive posts are subject to approval by the Remuneration Committee. Any pay awards are agreed by the committee. Directors participate in an annual appraisal process which identifies and agrees objectives to be met. This is supported by a personal development plan. The Trust does not operate a performance related pay scheme.

47 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Remuneration policy for the Chairman and Non-executive Directors Increases in the remuneration of the Chairman and Non-executive Directors are agreed nationally by the Department of Health and implemented locally by the Trust.

48 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Directors’ Remuneration for the year ended 31 March 2016 Name and title Note

2015-16 Salary (bands of £5,000)

Expense payments (taxable) (Rounded to the nearest £00)

All pensionrelated benefits (bands of £2,500) £000

Total (bands of £5,000)

Salary (bands of £5,000)

All pensionrelated benefits (bands of £2,500) £000

Total (bands of £5,000)

£000

Expense payments (taxable) (Rounded to the nearest £00)

£000

30 – 35 5 – 10 5 – 10 5 – 10 5 – 10 0–5

20 – 25 5 – 10 5 – 10 5 – 10 5 – 10 -

35 – 40

1,300

75.0 – 77.5

115 – 120

110 – 115

3,700

115 - 120

85 – 90

3,200

85 – 90

30 – 35

1,200

5.0 – 7.5

40 – 45

60 – 65

3,700

–

65 – 70

95 – 100

80 – 82.5

175 – 180

20 – 25

42.5 – 45.0

65 – 70

80 – 85

47.5 – 50.0

130 – 135

75 – 80

27.5 – 30

105 - 110

80 – 85

6,100

15.0 – 17.5

100 – 105

80 – 85

5,700

7.5 – 10.0

95 – 100

£000

Non-executive Directors Frances Street - Chairman Chris Allen Brian Simmons Murray Freeman Alan Wilson Tony Snell Executive Directors Simon Gilby – Chief Executive Karen Howell – Chief Executive Steve Wilson – Director of Finance and Development John Lancaster – Director of Operations Mark Greatrex – Director of Finance and Resources and Deputy Chief Executive Sandra Christie – Director of Nursing and Performance Jo Harvey – Director of Human Resources and Organisational Development

2014-15

£000

49 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Dr Ewen Sim – Medical Director Roy Jackson – Interim Director of Finance Val McGee – Director of Integration and Partnerships Phil Clow – Director of Business Development and Strategy

50 – 55

12.5 – 15.0

60 – 65

50 – 55

2.5 – 5.0

55 - 60

110 – 115

90 – 95

15 – 20

40 – 45

3,400

40 – 45

Notes 1 Steve Wilson left the Trust on 31 July 2014 2 John Lancaster retired from the Trust on 31 January 2015 3 Mark Greatrex joined the Trust on 5 January 2015 4 Roy Jackson was Interim Director of Finance from 1 August 2014 to 31 December 2014 5 Val McGee joined the Trust on secondment as Director of Integration on 19 January 2015 6 Phil Clow joined the Trust on 1st September 2015 7 Tony Snell was a Non-executive Director from June 2015 to October 2015 8 Simon Gilby left the Trust on 31st July 2015 9 Karen Howell joined the Trust on 1st August 2015

Taxable expense payments relate to the taxable benefit on the provision of lease cars and participation in salary sacrifice schemes.

50 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Pension Benefits

Name and title

Real increase in pension at pension age (bands of £2,500) £000

Real increase in pension lump sum at pension age (bands of £2,500)

Total Lump sum at Cash accrued pension age Equivalent pension at related to Transfer pension age accrued Value at 1 at 31 March pension at 31 April 2015 2016 (bands March 2016 of £5,000) (bands of £5,000) £000 £000 £000 50 – 55 160 – 165 957

Simon Gilby - Chief Executive

2.5 – 5.0

£000 10 – 12.5

Mark Greatrex - Director of Finance and Resources and Deputy Chief Executive Jo Harvey - Director of Human Resources and Organisational Development Dr Ewen Sim - Medical Director

2.5 – 5.0

7.5 – 10.0

20 – 25

60 – 65

0 – 2.5

10 – 15

0 – 2.5

Sandra Christie - Director of Nursing and Performance Val McGee - Director of Integration and Partnerships Phil Clow - Director of Business Development and Strategy

2.5 – 5.0

0 – 2.5

Cash Real Equivalent increase Transfer in Cash Value at Equivalent 31 March Transfer 2016 Value £000

£000

1,214

270

327

35 – 40

192

208

20 – 25

60 – 65

351

367

7.5 – 10.0

30 – 35

100 – 105

614

682

15 – 20

45 – 50

224

226

As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members. Karen Howell is not a member of the NHS Pension Scheme and therefore there is no pension disclosure.

51 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Cash Equivalent Transfer Values A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiaries) pension payable from the scheme. CETVs are calculated in accordance with the Occupational Pension Schemes (Transfer Values) Regulations 2008. Real Increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period. Pay Multiples Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce. The banded remuneration of the highest paid director in Wirral Community NHS Trust in the financial year 2015-16 was £97,500 (2014-15: £112,500). This was 4.7 times (2014-15: 5.5 times) the median remuneration of the workforce, which was £20,926 (2014-15: £20,626). Both the banded remuneration of the highest paid director and pay multiple have reduced from 2014-15 due to changes within the trust’s Board of Directors and the effect of salaries paid to individuals for only part of the financial year. In 2015-16, no employees received remuneration in excess of the highest-paid director (2014-15: 1). Remuneration ranged from £1,661 to £93,944 (2014-15: £462 to £120,949). Total remuneration includes salary, but excludes non-consolidated performance-related pay, benefits in kind, employer pension contributions, and the cash equivalent transfer value of pensions. This is a departure from the guidance with the Department of Health Manual for Accounts; however the Trust does not consider that this has a material impact on the figures reported

52 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Staff Report Number of senior managers by band Band 8a Band 8b Band 8c Band 8d Band 9

38 8 6 2 2

The overall staff turnover figure for 2015-16 was 17%; higher than the figure for 2014-15 which was 14.6%. This increase is largely attributable to the number of services that have left the organisation as a result of TUPE or redundancy. When removing staff that have transferred in and out of the organisation via TUPE and excluding those who have been made redundant, the turnover figure for 2015-16 is 13.9% (2014-15 12.4%). Staff numbers An analysis of staff numbers, according to the employee definitions in the Information Centreâ&#x20AC;&#x2122;s Occupational Code Manual is provided below.

Occupation Headcount Code 4 M 23 G 108 H 414 N 688 S 254 U 2 Z 5 Total 1493

M G H N S U Z

Medical and dental staff Administration and estates staff Health care assistants and other support staff Nursing, midwifery and health visiting staff Scientific, therapeutic and technical staff Healthcare science Other

53 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Staff composition - employee gender distribution The figures reflecting the breakdown of gender distribution of employees within the Trust during 2015-16 are included in the table below: 2015-16

Headcount

Directors male (including Non-Executives)

58.3%

Directors female (including Non-Executives)

41.6%

37.5%

62.5%

All Employees male

8.90%

132

All Employees female

91.10%

1362

Other senior managers male (band 8b and above) Other senior managers female (band 8b and above)

Workforce diversity

Age

Gender

Ethnicity

Disability

Sexual orientation

Religious belief

Those in the 41 to 50 age group represent the highest proportion of our workforce, followed by the 51 to 60 age group. 67.1% of the workforce is aged 41 or over. 41% are over 50. The majority of our workforce is female; men represent 10.5% of the total profile of our workforce. This is representative of a typical community health care trust. 95% of our staff classified themselves as ‘White British’. The following two top categories are; ‘White- Irish’ (1.5%) and ‘White any other white background’ (0.9%). 2.5% of our staff is drawn from other ethnic groups. 2.7% of our staff have classified themselves as having a disability. 96% of our staff state they do not have a disability and 1.3% have not declared their status. The trust is proud to have been awarded the Two Ticks symbol, demonstrating our positive attitude towards the recruitment of disabled people. Our workforce statistics show that 83.4 % of staff state that they are heterosexual whilst 0.2% describe themselves as gay or lesbian. 16% have chosen not to disclose their sexuality. We do not have statistics on transgender staff. The majority of our staff (52.9%) record their religion as Christianity. 35.9% of staff have not disclosed their religion. Of the remaining 10.1%, the majority (4.1%) are state they are atheists. Hinduism, Islam, and Judaism are the other religions listed (all 0.4%); 6.4% of staff state their religion as “other”.

54 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Sickness Absence Data The information for staff sickness is provided by the Department of Health for all NHS bodies. Information from the Electronic Staff Record (ESR) system reports the annual sickness rate for the year 2015-16 was 4.7%. This figure was higher than the Trust’s target figure of 4.0% but lower than reported for 2014/15. The average number of days lost per FTE in 2015-16 was 10.0 5 (2014-15 - 11.01). Equality disclosures The policy in relation to disabled employees The Trust is a ‘Positive about Disabled People’ employer and is therefore entitled to display the Jobcentre Plus ‘Two Ticks’ symbol for advertising , corporate material and publications. The Trust has a set of equality objectives which include equal opportunities training for all staff to eliminate discrimination against disabled employees. All relevant policies are assessed for their impact on disabled staff, and adjustments are made to support disabled employees to gain and continue employment with the Trust. As part of meeting our duties under the Equality Act 2010; the Trust has recently revised its Equality and Diversity Strategy which includes a revised Equality Analysis process and also to foster good relations the introduction of a Disabled Staff Network to support staff to share concerns and issues with the Trust to improve their working lives. The policy on equal opportunities Wirral Community NHS Trust aims to be a leading organisation for promoting Equality and Diversity in Wirral. We believe that any modern organisation has to reflect all the communities and people it serves, in both service delivery and employment, and tackle all forms of discrimination. We need to remove inequality and ensure there are no barriers to health and wellbeing. We aim to implement this by: • becoming a leading organisation for the promotion of Human Rights Equality and Diversity, for challenging discrimination, and for promoting equalities in service delivery and employment; • creating an organisation which recognises the contribution of all staff, and which is supportive, fair and free from discrimination; and • ensuring that Wirral Community NHS Trust is regarded as an exemplary employer. The Trust has made a commitment to valuing diversity and achieving equality; the Trust’s vision is that NHS care in Wirral will have a culture of fairness, equality, and respect for diversity that is evident to everyone.

HSCIC - Sickness Absence Publication - based on data from the ESR Data Warehouse

55 Wirral Community NHS Trust Annual Report and Accounts 2015-16

The following principles underpin our work: • • • • • • • •

support and respect for everyone’s Human Rights as a fundamental basis for our work with people identifying and removing barriers that prevent people we serve from being treated equally treating all people as individuals respecting and valuing with their own experiences and needs finding creative, sustainable ways of supporting Human Rights, improving equality and increasing diversity working with the people who use our services and staff towards achieving equality learning from what we do - both from what we do well and from where we can improve using everyday language in our work; and working together to tackle barriers to equality across our organisation.

The Trust produces an annual equality report along with a workforce equality report and patient equality report, all of which are publicly available in July of each year. Expenditure on consultancy The Trust incurred consultancy costs of £141k which consisted of additional support for the Foundation Trust application and estates management consultancy. See also note 5 in the accounts. Off-payroll Engagements The Trust had no off-payroll engagements during the year (2015-16) - NIL return. Exit packages and severance payments The detail about payments on termination of employment during 2015-16 is referenced in the financial accounts note 7.4 and 7.5.

56 Wirral Community NHS Trust Annual Report and Accounts 2015-16

Cost allocation and charges for information The Trust will generally not charge for information that it has chosen to publish in its Publication Scheme. In accordance with HM Treasury ‘Managing public money’ guidance, charges may be levied for hard copies, multiple copies or copying onto media such as a CDROM. Information that is available from the Trust’s website will be free of charge, although any charges for internet service provider and personal printing costs would have to be met by the individual. For those without internet access, a single print out of the information available on the website will be available by post or personal application. The Trust will not provide print outs of other organisations’ websites. The duty to comply with a request for information does not arise if the Trust judges that the cost of compliance with the request would exceed the appropriate limit established in national Fees Regulations. The Trust will provide advice and assistance to applicants to investigate ways of bringing costs within appropriate limits. If the Trust estimates that the cost of compliance with the request for information exceeds the appropriate limit set by the Fees Regulations the applicant will be notified in writing of the estimated cost. The Trust will follow the national Fees Regulations for general rights of access under the FOI Act.