Cheshire and Wirral Partnership NHS Foundation Trust

On this page

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

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The trust’s governors were positive about the trust’s senior leaders and described their experience of working with the trust as open, honest and transparent.

We observed the trust’s board meeting, quality committee, people committee, and finance, performance and digital committee. In all meetings we saw leaders acting with integrity, credibility and kindness. The trust actively supported diverse communication needs and ensured meetings were accessible. We saw how the trust supported staff and leaders to contribute to committee meetings including through prepared videos to introduce agenda items.

Staff told us some leaders were visible within the trust. Leaders told us they undertook regular visits to frontline services. These visits improved leadership visibility and ensured leaders were able to triangulate the information received through the trust’s governance systems, particularly in relation to staff experience, which was a priority in the trust’s people enabling strategy. The trust had identified four types of visits to frontline services including night visits and ‘working shift’ visits which included an executive director working a shift in frontline services. In February – July 2024, the board had undertaken 49 service visits including 4 visits at night and 3 working shifts. The trust had introduced a digital form to capture feedback from service visits. The form had a low completion rate, and so the trust was reviewing the governance process to improve the feedback process.

Leaders told us the trust valued and recruited diversity at senior levels. The trust’s board described themselves as diverse in skills and experience and lived experience of using services. The culture of the board was described as people focussed, values-based and with a focus on empathy.

Leaders could describe succession planning within the trust. They had identified areas where succession planning would require additional or external support.

Partners told us the trust’s board had the experience, capability and personal values to lead the trust. Most partners were positive about individual leaders and shared examples of positive partnership working.

There were mixed comments about whether the board had the capacity with some partners telling us that individual board members carried large portfolios which stretched leadership capacity.

Most partners told us leaders were visible within services and most told us leaders were visible within the local system.

Some partners shared that the board’s clinical leaders were predominantly from mental health backgrounds and so the board did not fully reflect the diverse nature of the services provided by the trust.

In our survey of partners in stakeholder engagement events, we received mostly neutral feedback in relation to this quality statement.

The trust’s board comprised of seven executive directors including the chief executive and seven non-executive directors including the trust’s chair. The executive team held a range of individual portfolios covering areas including quality, effectiveness, risk management, finance, procurement and organisational development. The trust’s executive team had remained relatively stable with one director joining the trust within the last year. The trust’s non-executive team had more newly appointed directors and had expanded to improve capacity and better fit the diversity of the trust’s services.

The role of the medical director was held by two directors as a joint post with shared voting rights. One of the trust’s medical directors was the board lead for the Mental Health Act and Mental Capacity Act. The director of nursing, therapies and patient partnership was the board lead for learning from deaths and learning from lives and deaths – People with a learning disability and autistic people (LeDeR). The trust did not have a board-level lead for specific services such as learning disabilities.

There was a board development plan in place with six sessions planned for 2024. The development plan for 2024 was being facilitated by an external agency and focussed on the board’s priority of equality, diversity and inclusion matters, and other national imperatives. As part of this programme of work, the board had supported the development of their organisational ‘People’ strategic theme, being overseen by the trust’s People enabling strategy, the aim of which was to make the trust a ‘workplace where people want to stay, and a place we are proud to be from’

Fit and proper persons checks were in place for all directors in line with the requirements of the regulation. All files we reviewed showed the trust had completed appropriate checks of directors’ suitability for their roles. All directors had received an annual appraisal within the previous year.

Most staff felt able to speak up within the trust. The 2023 NHS Staff Survey showed that 71% of staff agreed the statement ‘I feel safe to speak up about anything that concerns me in this organisation’. This was higher than the national average of 68% although slightly lower than the trust’s 2022 score of 73%. The trust’s survey response rate for the 2023 survey was 44% which was lower than the national median but an increase of 2.4% compared with the 2022 survey.

Most staff felt leaders would act to address concerns. The NHS Staff Survey showed 59% of staff agreed with the statement ‘If I spoke up about something that concerned me, I am confident my organisation would address my concern’. This was slightly lower than the trust’s 2022 score of 60% but higher the national average of 56%.

Leaders told us they encouraged staff to speak up and raise concerns. The board undertook service visits to support frontline staff to share their experience. The 2 freedom to speak up Guardians told us there was a lack of protected time to undertake the guardian role and the trust had responded to this with plans to change the model of speaking up.

The freedom to speak up guardians told us they had implemented triangulation meetings to identify and share themes and trends from concerns raised by staff through multiple routes within the trust. The meetings included teams representing human resources, organisational development, well-being services, trade unions and equality, diversity and inclusion groups.

Partners felt the trust did have a culture where staff could feel free to raise concerns.

There was mixed feedback and confidence in whether leaders would take effective action to address concerns. Some felt this might be a motivating factor for staff to raise concerns outside of the trust.

Partners raised concerns about the relatively low numbers of concerns recorded by the trust through the freedom to speak up route. The data available prior to the well-led review showed 16 concerns had been raised by staff in 2022/23. This had increased to 34 in 2023/24. The trust reported that during 2023/24, they had taken direct action to raise the profile of speaking up and had promoted senior leaders’ awareness of the trust’s Speaking Up strategy. The numbers of staff raising concerns at the trust was generally in line with other trusts, with the trust placed as the fifth of thirteen by numbers of concerns raised in 2023/24 in similar sized NHS trusts within the North West

In our survey of partners in stakeholder engagement events, most partners did not believe the trust met the description of the freedom to speak up quality statement.

The trust had a freedom to speak up policy which had been recently reviewed and implemented in November 2023. The policy had been updated to reflect changes in guidance from the National Guardian’s Office.

The trust required all staff to undertake freedom to speak up mandatory training. The ‘Speak Up’ training was a module for all staff to complete and a further ‘Listen Up’ module was for managers and supervisors within the trust.

The trust had appointed two freedom to speak up guardians who undertook this role alongside their role of associate directors of nursing and therapies. The guardians were supported by three associate freedom to speak up guardians who acted as freedom to speak up ambassadors within the trust. There was a further cohort of 14 speak up ambassadors across the trust.

The trust’s model of freedom to speak up was due to change. In July 2024 the board agreed to replace the current dual nursing and guardian roles within the trust with a pilot involving an external freedom to speak up guardian provider.

The trust’s director of nursing, therapies and patient partnerships was the executive board level lead for freedom to speak up. There was also a non-executive freedom to speak up lead.

The trust board received a bi-annual (six-monthly) report into freedom to speak up. The latest report showed the numbers of staff raising concerns via the trust’s freedom to speak up process had increased since the previous year. The data available prior to the well-led review showed 16 concerns had been raised by staff in 2022/23. This had increased to 34 in 2023/24. The numbers of staff raising concerns at the trust was generally in line with other trusts, with the trust placed as the fifth of thirteen by numbers of concerns raised in 2023/24 in similar sized NHS trusts within the North-West.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff, both during and prior to our assessments of frontline services, told us the trust did not always have effective governance systems and escalation processes to ensure services were safely staffed. Staffing levels were repeatedly cited as the top risk faced by services, particularly in inpatient mental health services. The board received a six-monthly safer staffing report, and leaders told us there were daily processes to ensure frontline services had sufficient staff to provide safe care.

Leaders had commissioned an external governance review which reported in October 2023. The trust had implemented some of the recommendations from the review including the establishment of a finance, performance and digital board committee. The trust’s integrated governance framework had not been updated following the changes made after the external review and leaders told us it was likely the framework would be removed as it was no longer necessary.

Leaders could refer matters between committees where there were cross-cutting issues. Most leaders expressed confidence in the trust’s systems to manage risk and were satisfied with the trust’s board assurance framework. The board assurance framework included six risks to the delivery of the trust’s strategic objectives. The top three risks related to demand in inpatient mental health services, commissioning in ADHD services, and staffing levels. These were consistently highlighted by leaders as the top risks faced by the trust, although the risk in commissioning in ADHD services did not have a trust-wide scope or impact and so the risk to the delivery of the trust’s strategy was not clearly defined within the board assurance framework. Leaders noted risk scores over time since 2022 had remained static for two risks, increased slightly for financial risk and decreased slightly for commissioning in ADHD services. Mitigating actions for risks were updated where there were changes to report, however most risks were identified

Partners were aware of the changes made to the trust’s governance systems and processes following the external governance review. Whilst the changes were regarded as improvements, some partners told us the trust needed to do more to ensure there was sufficient oversight of risks and performance in frontline services and care groups. Partners told us they had not been asked to be involved in the external governance review.

Partners told us the trust board had informal processes to ensure information related to cross-cutting issues was shared between committees. There was mixed feedback in relation to confidence in data and information provided to partners by the trust.

In our survey of partners in stakeholder engagement events, we received mostly negative or neutral feedback in relation to this quality statement. Feedback forms received from partners were more positive about the trust’s governance systems.

NHS England allocate trusts and ICBs to one of four segments indicating the scale and nature of a trust’s support needs, from no specific support needs (segment 1) to a requirement for mandated intensive support (segment 4). The trust was allocated to segment 2 indicating a low level of support needs. However, following our inspection, the integrated care board made a recommendation to NHS England for a review of the trust’s segmentation, indicating that the trust had been identified as needing additional oversight and support.

Governance

The trust had governance structures, systems and processes in place, including sub-board committees and care group meetings. Leaders regularly reviewed these structures although frameworks had not been updated to reflect changes to governance structures.

The trust’s integrated governance framework was approved in September 2022. Since the implementation of the framework, the trust had commissioned an external review of the well-led key question which was completed in October 2023. The external review led to changes in the governance structure of the trust which meant that the integrated governance framework did not reflect the governance structure of the trust.

The trust’s board had six committees which were:

• Audit Committee

• Commissioning Assurance Committee

• Finance, Performance and Digital Committee

• Nomination and Remuneration Committee

• People Committee

• Quality Committee

The finance, performance and digital committee was the newest committee of the board and had been established in response to the findings of the external review, replacing the previous operational committee. Non-executive and executive directors were clear about their areas of responsibility. Each committee of the board was chaired by a non-executive director and supported by one or more non-executive directors as members.

Papers for board meetings and other committees were of a reasonable standard and contained appropriate information. Leaders had recognised that the board regularly received papers with lengthy narrative and there was improvement needed to the summaries of board papers to identify key themes and recommendations. Appropriate governance arrangements were in place in relation to Mental Health Act administration and compliance. The trust monitored the use of the Mental Health Act through audits of Mental Health Act documentation. Governance of the Mental Capacity Act was more limited. The trust had identified that auditing Mental Capacity Act adherence was

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Environmental sustainability – sustainable development during this assessment. The score for this quality statement is based on the previous rating for Well-led.