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  • Wirral Community Trust
  • Wirral Community Trust
  • Wirral Community Trust
  • Wirral Community Trust
Annual Report 2014-15


Wirral Community NHS Trust has a duty to produce detailed annual reports for the whole organisation providing information about our progress and performance over the last financial year.

You can access the report in this section of the website, alternatively you can download a PDF version of the full document and accounts.

A summary annual report is also available.

The report will be formally presented at our Annual General Meeting (AGM) on 9 September 2015.

Welcome to our Annual Report and Accounts 2014/15 which presents what we have achieved over the last year and demonstrates how we are continuing to develop a reputation for clinical excellence, performance, delivery and innovation. We have a strong, clear vision and a set of values that were developed with and are supported by our staff and stakeholders.

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 2014/15 illustrates our actions and achievements in providing high quality community health services that are safe, effective, caring, responsive and well led.

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 and expectations of the people who use them.

In September 2014, the Care Quality Commission (CQC) carried out a comprehensive review of all our services and we are proud to have received an overall rating of 'Good'. The inspection considered how safe, caring, effective, responsive and well led our services are and we continue to be registered with the CQC with no conditions.

Our quality governance assurance framework was inspected during August and September 2014 by Monitor, the NHS Regulator. The results of this review were also very positive.

We are now entering the final stages of our assessment for foundation trust (FT) status. A strong, viable and independent community FT is a vital component in the local health and social care economy, providing the focus to respond to the service and financial challenges faced.

This year we have made significant investment in ensuring our staff are fully engaged with and informed about our five year strategy and two year implementation plan. We were delighted to welcome over 600 of our staff to a series of business planning events where they could engage directly with our Executive Team on our plans for the future. Ensuring everyone across the organisation understands how they can contribute to the future success of the trust is key to our sustainability.

Our cost improvement programme (CIP) remains a challenge, but as an independent NHS organisation we have always maintained a strong financial position. Further savings of £3.6m are planned in 2015/16, and across the organisation our staff continue to look for ways of doing things differently whilst delivering high quality care.

We continue to develop and implement the Vision 2018 strategy for a healthier Wirral 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 vision aims to provide better outcomes for the population of Wirral through integrated services which are run efficiently and achieve high standards of care.

This year we have been delighted to announce that Wirral has been chosen by NHS England to be part of a national pilot for a new healthcare model to help shape a 21st Century NHS. The pilot known as Vanguard, will support a new way of delivering more joined-up care in line with the Vision 2018 strategy.

It presents an exciting opportunity for the trust, as we are well placed to be central to the new model, which will see patients receiving health and social care away from hospital, closer to their home or community health centre.

Our vision is simple, to be the outstanding provider of high quality integrated services to the communities we serve. We will achieve this thanks to the dedication, energy and passion for quality care that our staff and volunteers deliver every day.

Best wishes


FrancesStreet                                        SimonGilby6

Frances Street                                                                    Simon Gilby

Chairman                                                                          Chief Executive


Wirral Community NHS Trust provides high quality primary, community and public health services to the population of Wirral and its surrounding areas.


Our vision and governance arrangements are aligned to our four strategic themes:


Our Patients

  • Putting our patients and communities at the centre

Our Services

  • Leading, developing and delivering high quality services

Our People

  • Valuing the individual, the team and the organisation

Our Sustainability

  • Supporting sustainable delivery

These themes support our vision - To be the outstanding provider of high quality integrated services to the communities we serve.


Our services are delivered by dedicated and innovative health professionals and supported by equally committed staff behind the scenes, around 1,463* in total.


Our services are local and community-based, provided from around 50 sites across Wirral, including our main clinical bases, St Catherine's Health Centre in Birkenhead and Victoria Central Health Centre in Wallasey.


Our three Walk-in Centres are located in Eastham Clinic, Victoria Central Health Centre and the Arrowe Park site, whilst our purpose built call centre facility at Riverside Park manages bookings for many of our services. We have no inpatient beds.


Trust services are grouped into five divisions: Nursing, Therapies, Unplanned Care, Lifestyles and Primary Care, which collectively delivered over 1.1m contacts during 2014/15.


From our community nursing, health visiting and sexual health services to our Walk-in Centres, Livewell programme and therapy services, our priority is to care for everyone as an individual, taking a holistic approach to care and working in partnership to bring about a patient journey that is, where possible, seamless. Our services and their divisions are shown at figure 1.


Figure 1: Services and Divisions (showing patient contacts for 2014/15)




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 number of staff differs from that disclosed in the financial statements, as the NHS Manual for Accounts requires that 'the average number of employees is calculated as the whole time equivalent number of employees under contract of service in each week in the financial year, divided by the number of weeks in the financial year'. Whereas the number of staff disclosed in the annual report is based on headcount.


Our Wirral population comprises around 320,000 residents across 145,000 households (based on projections from the 2011 census).


Birkenhead and Wallasey, adjacent to the River Mersey, are the largest and most densely populated areas of Wirral. Alongside these core urban areas of dense and high population, Wirral has suburban towns and rural areas, all in a relatively small geographical area of 60 square miles. There are pronounced extremes, with affluent areas very close to communities experiencing significant levels of poverty and deprivation.


The Black and Minority Ethnic (BME) population 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.


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 Wirral's most deprived areas.


Wirral has a relatively high older population and a relatively low proportion of people in their twenties and thirties compared to England and Wales as a whole. There are over 40,000 carers in Wirral representing about 13% of the population, a higher % than the regional or national average (11% and 10% respectively).


An increase in the number of people living with long term conditions is a product both of having both an ageing population and one in which many people engage in damaging behaviours associated with social deprivation.


This will continue to have a considerable impact on health and social care services, as the number of older people presenting with health-related problems increases, particularly the numbers of those with dementia, frailty and other conditions which may be long term and life limiting.



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 three organisations:

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

We deliver Physiotherapy and Podiatry 'Any Qualified Provider' (AQP) contracts on Wirral. We have also been successful in being commissioned to deliver these services outside of Wirral by West Cheshire and Liverpool Clinical Commissioning Groups.

Vision 2018

Overarching many of the commissioning intentions in Wirral, and arguably the most significant strategic driver for Wirral Community NHS Trust (WCT), is the Wirral health and social care system's joint strategy, Vision 2018.

The Vision 2018 programme, led by Wirral Clinical Commissioning Group (CCG), 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.

Vision 2018 will transform health services and social care in Wirral, whilst supporting people to take more responsibility for looking after their own health. Its guiding principles are to:

  • improve health and wellbeing outcomes
  • improve patients' and service users' experience
  • reduce the cost of health and social care

The Vision 2018 work 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. In early 2015 it was reinforced by a successful 'Vanguard' bid by the local health economy, which will accelerate this programme.

Strategic and operational risk

Vision 2018 addresses some systemic risks of constrained resources and increasing demand within the health and social care economy, risks that are common to all parts of the country. Pressures affecting every NHS trust include the requirement to balance annual efficiency savings, operate within a contestable market and meet stringent regulatory standards.

Strategic risks affecting the trust are identified and managed through the Board Assurance Framework, recorded against the trust's strategic themes. Operational risks are managed through the trust's organisational risk register, as related in the Annual Governance Statement.

Foundation trust application

As an aspirant foundation trust our quality, performance and sustainability is regulated by the Care Quality commission (CQC) and Trust Development Authority (TDA).

In November 2014 we received a rating of 'Good' following a CQC Chief Inspector of Hospitals inspection. This was a key part of the trust's foundation trust application process. In March 2015 the TDA Board recommended that Wirral Community NHS Trust's application pass to the Monitor stage of assessment.

Annual plan

A draft of the trust's annual plan, 2015/16, was submitted to the TDA in April 2015 within the required timescales.



Each of our five year strategic objectives are aligned to organisational goals in our two year business plan, which are periodically reviewed and refreshed in light of our achievements and changes within the trust or to our operating environment.


Our strategic objectives and goals link to divisional and team plans and ultimately to our employees' personal objectives. These links help to ensure that each member of staff can identify and value their contribution to our achievements. Behind each of our goals are a series of measures to allow us to closely monitor our progress.

Our patients and community

Our services

Our peopleOur sustainability 

The trust has many underpinning strategies, and risks to the achievement of our strategic objectives are monitored through the Board Assurance Framework. Since these objectives were set in early 2014 we have made significant progress.


Performance review


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. Notable achievements in the last year include:

  • In November 2014 we received a rating of 'Good' following a CQC Chief Inspector of Hospitals inspection.

  • The NHS Trust Development Authority Winter Report, (covering August 2013 -January 2014) recorded the trust as one of only 14 trusts to be reported as having no identifiable concerns.

  • The trust was the joint third safest community trust, based on data submitted to the national 'Safety Thermometer' in 2013/14.

  • In 2014 we were one of only 11 community healthcare organisations to be named in the 'Top 100 places to work in healthcare' by the Health Service Journal.

  • The trust's SystmOne Team were recognised as Team of the Year 2014 at the prestigious ISDNetwork Awards for their work on SystmOne IT implementation.

  • Compassion in Practice Awards 2014 – the trust's Community Dental Service were finalists for their approach to helping children feel at ease when going to the dentist.

  • The Queen's Nurse Title was awarded to Health Visitor Jo Chwalko.

  • We achieved 72% flu vaccine uptake in the eligible workforce 2014/15 - the top performing community trust.

  • Our Wirral Pressure Ulcer Care Collaborative has been selected for poster display at the International Forum on Quality and Safety in Health Care in April 2015.

Staff awards

The trust held its third annual For You Thank You Staff Awards in February 2015. Held to celebrate and recognise the exceptional work of staff from across the trust, nearly 70 nominations were received for individuals and teams across the eight categories.

This year the trust launched its Patient Choice Award which generated a huge response from the public. Members of Staff Council and public members of the trust were involved in the judging process and the event was well received by all involved.



Our services have 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 have achieved a high level of performance against the community indicators that we are measured against, with 78% of Key Performance Inidicators (KPIs) at or within set tolerance levels. Performance has fallen slightly on levels seen in 2013/14 which has been driven chiefly by challenges associated with meeting smoking cessation targets during a time when significant numbers of people are choosing to use e-cigarettes. During 2014/15 we have also continued to roll out a new IT system, SystmOne, for a significant number of our clinical services. Evidence from the implementation of this system has shown that performance has significantly increased during the latter half of the year.


Management of targets is consolidated into our overall comprehensive performance management framework which provides a consistent process to measure and monitor performance across all levels within the organisation.


In 2014/15 we had around 1.1 million patient contacts across our core service divisions and for a third year:

  • treated all patients within the 18 week target
  • delivered a range of urgent care services, such as Walk-in Centres and GP out of hours. In all cases we achieve those national indicators which are key to supporting the delivery of system wide urgent care

We are working with NHS Providers (formerly the Foundation Trust Network) to support the development of Community Outcome Indicators and have worked closely with our commissioners in 2014/15 to further better define our key measures of service performance and ensure more attention is placed upon the outcomes of care we deliver.


Putting our patients and communities at the centre

Below are examples of some of the service developments and other highlights.


Work placements and volunteers - engaging with our community

During 2014/15 the trust built on the work of previous years and continued to provide its work placement programme and develop new volunteer placements across the trust. Our work placement programme was included in Health Education England's Widening Participation Directory of Best Practice and we were asked to help develop a new national guide to providing work placements.


We hosted 20 placements for students in years 12 and 13 during a three week period in June and July and supported more throughout the year. Students have enjoyed their placements and found them valuable in helping identify future careers.


We now have volunteers in teams and services including our Breast Feeding Support Group and Speech & Language Therapy. We continued to work closely with our allied charities: the League of Friends and Wirral Heartbeat. We worked with the League of Friends to improve the process by which trust services may apply for funding and saw a significant increase in the number of requests.


Equality and Diversity Strategy

Last year we reported on the launch of the Equality Diversity & Human Rights Strategy for the trust and the identification of equality objectives for 2013-17. Since last year key actions have progressed and our equalities agenda has seen significant development.

Part of that development has been the LGBT and Disability Staff Support Groups which continue to meet regularly with new members attending. A series of equality events reflecting a range of different equality and diversity topics have been held including World Alzhiemer's Awareness Day and Black History Month.

The role of our Equality & Diversity Champions has been refreshed with more focus on changing culture through raising awareness of equality issues. We have also established a Community Panel with members from a variety of community backgrounds who have specific understanding of the needs of people from the nine protected groups, to help shape our equality and diversity plans. They will help us to understand barriers and identify any gaps.

Other achievements include the development of an equalities training matrix and a new Equality Action Plan evidenced across the refreshed NHS Equality Delivery System (EDS2) Framework. This new way of capturing the progress we are making and also how we can identify barriers allows the trust not only to demonstrate legal compliance with the Equality Act 2010 but more importantly to identify, develop and share good practice across trust services and ensure the care of the patient is at the heart of everything we do.

Human Rights

Human rights are a practical framework for making decisions in difficult situations. For example, to ensure that staff are protected from violent or abusive patients while also having regard to the interests of the patient.

The trust's Equality Diversity & Human Rights strategy identifies not only our approach but also the key actions we are taking to make progress for our patients and staff alike. The FREDA Principles (Fairness, Respect, Equality, Dignity, and Autonomy) are at the heart of the trust's vision and values.

By listening to what staff and patients told us and based upon our equalities review, our equality objectives serve as the starting point for addressing need for both patients and workforce. These objectives will help us to ensure that our Human Rights based approach will protect both our patients and our workforce.

Learning and development / Workforce development

In 2014/15 we supported 95 staff to access academic modules at local universities to enable them to respond to the needs of services and the patients they care for. In addition to areas relating to prescribing and clinical examination examples of other modules are:

  • supporting patients with long term conditions
  • tissue viability for care of wounds
  • safeguarding vulnerable groups

We are delivering dementia awareness training for all clinical staff to ensure we can provide outstanding care, compassion and support for those with dementia and their carers.

We support our leaders with management development programmes and we link with the NHS Leadership Academy for our nationally recognised leadership courses.

In 2014/15 we have provided learning opportunities for many students, including medical, nursing, speech & language therapy, dieticians, podiatry and health visiting students.

Right staffing


Our right staffing project is central to our ambition to deliver safe, caring and effective services. We have excellent staff who care deeply and we recognise that in order to support them to do the best job they can do, we need the right staff in the right place at the right time with the right skills.


The right staffing project has helped us to work out how many community nurses we need to deliver safe, caring services to our housebound population. In addition, our walk in centres are now able to provide the right level of staffing every day based on the number of people we estimate might need the service on that day.


We plan to continue this work until we are satisfied that we understand what staff and skills are required in all our services.


Pressure Ulcer Prevention Project 2014/15

Pressure ulcers have continued to be a noticeable clinical risk within the trust and the wider health economy. A reduction in pressure ulcers reported by trust staff from 741 during 2013/14 to 595 during 2014/15, shows how the focus is supporting patient safety.

The pressure ulcer prevention project this year has focused on 3 core elements:

  • Development of frontline leaders of pressure ulcer prevention and management. A programme of education and practical assessment has been developed between the trust and Wirral University Teaching Hospital NHS Foundation Trust (WUTH) to develop a cohort of pressure ulcer champions.

  • Awareness education. A project has been completed with 8 Wirral Care Homes / Care Providers to identify baseline pressure ulcer prevention knowledge, provide further education and improve collaborative shared care planning.

  • Support for formal care providers and general pressure ulcer awareness. Wider awareness of pressure ulcers has been encouraged through public engagement during International STOP pressure ulcer day 20th November 2014. There is now acknowledgement that all trust services can be used to raise wider awareness of pressure ulcer risk.

Information governance (IG) Training

During 2014/15, 96% of our staff completed on-line information governance training. This includes how we ensure patient information is managed safely and securely and is appropriately shared when necessary as part of the patient clinical care pathway.


Achieve level 2 on IG toolkit

Of the 39 standards assessed, 38 are applicable to us and we achieved level 2, the required level, in all. In addition, we achieved level 3 in 9 standards (24%) compared to 5 (13%) in 2013/14.


Leading, developing and delivering high quality services

Below are examples of some of the service developments and other highlights.


Community Dental Service

Providing oral health care and dental treatment for children and adults that have an impairment, disability and/or complex medical condition, the service received excellent feedback from the Care Quality Commission during their Comprehensive Inspection.


The CQC said, "We considered this to be an exemplary service with robust systems for identifying, investigating and learning from patient safety incidents and a strong emphasis within the service on reducing harm or prevent harm from occurring. Staff displayed high levels of compassion, kindness and respect at all times. The service was responsive to people's needs and people from all communities could access treatment. Staff were forward thinking and innovative in their approach".


Following a competitive tender process, the service was selected as the preferred bidder along with partner Bridgewater Community Healthcare NHS Trust to deliver Specialised Dental Services across Wirral, West Cheshire and Vale Royal. The new service went live on 1 April 2015.


Community Nursing

West Kirby Community Nursing Team have demonstrated their commitment to providing the highest standards of care to patients. They have been involved in a range of clinical audits evidencing consistent achievement of meeting care standards for patients including:

  • record keeping
  • end of life care
  • leg ulcer care
  • pressure ulcer care

They participated in the introduction of a two layer compression bandaging system to promote patient compliance with venous leg ulcer treatment and have also been involved in a pilot of new equipment for patients who require a Doppler assessment /reassessment. The team also piloted the use of new wipes for the cleansing of skin of patients with leg ulcers which demonstrated improved healing rates, reduced manual handling risks for staff and released time to care.

Integrated Care Coordination Team, Eastham pilot

As part of the Vision 2018 work programme, 2014/15 saw the introduction of a pilot Integrated Care Coordination Team (ICCT), based at Eastham. This has led to the introduction of a further three teams, all with geographical footprints aligned to council wards and servicing GP clusters. These teams ensure a fully coordinated response to the needs of patients with complex, long term conditions.

The core team of staff in these integrated, co-located teams consist of Social Workers, Assessment Support Officers, Assessment Re-ablement Officers, Multi-Disciplinary Team (MDT) Co-ordinators, Community Matrons, Community Nurses, Therapists, CPNs and Admissions Prevention services. These core staff have close links to the wider community based health and social care services.


Hello my name is...

In our recent Care Quality Commission inspection report, our staff were recognised as being compassionate and caring. For us this was great feedback and a welcome reminder to our excellent staff that they do a great job every day.

Building on this feedback the trust is now involved in the 'Hello My Name Is ...' campaign. This is a national campaign started by Dr Kate Granger, a cancer sufferer and clinician. Kate noticed that during her own treatment, not all health workers, including doctors and nurses introduced themselves to her. She suggested that this simple introduction is the first rung on the ladder to providing compassionate care and often getting the simple things right, means the more complex things will follow more easily and naturally.'


Patient experience

All clinical services use the patient experience questionnaire to learn from feedback provided by patients, families and carers. The questionnaire also collects information about who is using the service so that we have a better understanding of people's needs associated with different groups of patents.

As a trust we have increased the participation of patients, families and carers and achieved more than a 10% increase in completing the patient experience questionnaires.

To improve feedback we have developed patient experience questionnaires especially for children and young people and people who have a disability due to brain injury and have installed feedback kiosks in our GP out of hours and walk-in centres.

Since 2014 we have participated in the NHS friends and family test (FFT) an important opportunity for patients to provide feedback on our services. Our monthly results are available on our website.

0-19 Health and Wellbeing Service

The new service, delivered by the trust and our partners Barnardo's, Brook and Home-Start Wirral helps improve the current and future health and wellbeing of children and young people, help reduce health inequalities, respond to local need and provide universal and targeted support as required.

The 0-19 Health and Wellbeing Service includes:

  • health visiting and family nurse partnership support
  • infant feeding support
  • school nursing and immunisations
  • work with primary and secondary schools on nutrition, oral health and contraception
  • weight management support for children, young people and their families
  • targeted work around drugs, alcohol and smoking
  • support for young carers
  • personal, informative, tailored advice and support
  • emotional health and wellbeing support
  • drop-in support


Offering a range of free health and wellbeing activities, our public health teams had approximately 54,000 contacts with people of all ages across the Wirral. Supporting individuals to make positive lifestyle choices, the Livewell programme looks to encourage people to:

  • Get more active
  • Eat healthier
  • Quit smoking
  • Lose weight
  • Relax and unwind

Clients receive a free lifestyle assessment with a health trainer to look at what support they could benefit from. They are then signposted to the appropriate sessions which may include; a box fit session; attendance at the wellness gym, cook yourself slim; chair based exercise or a stop smoking group session. People who are giving up smoking can also attend the Breathwell, Singwell group focused particularly on those with chronic obstructive pulmonary disease.

Livewell have an allotment where people can meet weekly and tend to the vegetable and flower plot. All the vegetables grown there can be taken home and used to cook healthy meals using the recipes provided.


Valuing the individual, the team and the organisation

Below are examples of some of the service developments and other highlights.


Staff Survey


The results of the national NHS staff survey for 2014 show levels of staff engagement, job satisfaction and motivation. They also reflect on working conditions, communication, training and management practice. The results for the Trust are a great reflection on what we all try hard to achieve everyday - making this a good place to work and provide care.


The indicator for overall staff engagement has improved to 3.79 and nationally was above average when compared to other community trusts.


Some key results are:

  • for 26 of the 29 key findings we scored better or average compared with other community trusts
  • best in the country for staff receiving an appraisal in the last 12 months for second year running
  • significant improvements in the quality of appraisals and staff receiving E&D/Health & Safety training – all previous target areas following staff survey feedback
  • significantly higher score than other trusts for the support provided to staff by immediate line managers

The five highest ranking scores:


staff survey


Since April 2014 we have also been running our quarterly Staff Friends and Family test, asking if our employees would recommend our trust as a place for treatment and as a place to work. Results are published on StaffZone, the trust's intranet.


Staff attendance


Staff sickness remains one of our priorities. We have had a wellbeing strategy in place to improve attendance and support staff to remain in or to return to work.


We recognise that there is still work to do to ensure we manage all forms of absence consistently and robustly. In 2014/15 the sickness rate for the organisation was 4.9% and whilst this figure is higher than we had aimed for, the Trust continues to perform well when compared to other Community Trusts. We have put in place incremental targets for 2015/16 and 2016/17.


Staff Council


The Staff Council meet regularly with members of the board to discuss matters that affect staff at work. Following staff council elections in 2014/15 there is increased representation of services across the trust and it continues to be a valuable communication channel that helps to shape organisational culture. These are a few of the things that the Staff Council has influenced or been directly involved in:

  • articulating staff views at times of reorganisation and relocation
  • dialogue with the board regarding the experiences of front line staff
  • reintroducing the staff retirement course
  • supported the promotion of the Hello my name is... campaign with staff
  • supported with the shortlisting for the staff awards
  • contributed to the plans for CQC visits in September 2014

Staff engagement


In April/May 2014, 600 of our staff attended a series of interactive business planning events where they could engage directly with our Executive Team on our plans for the future.


The events were attended by a cross section of services and staff at all levels of the organisation. The events supported the trust's ambition to ensure that there is a clear connection between the five year strategic objectives, two-year organisational goals, divisional and team plans and ultimately to our employees personal objectives. This golden thread will help ensure that ALL members of staff, irrespective of grade, can see how they contribute to us achieving our goals and remaining a successful organisation.



In a new and innovative approach to corporate induction, the trust has introduced 'Onboarding'. This is a web portal which allows newly appointed members of staff to access essential trust material and information (videos & presentations) before they start. We believe we are one of the first NHS Trusts to introduce Onboarding where new employees can find out about the type of organisation we are. The site looks at our culture, staff benefits, opportunities for learning, how to prepare for your first day and important facts on topics such as infection prevention and internet usage.

Onboarding replaces the previous corporate induction which took place once individuals had started in their job. It now means that new starters come prepared and ready to play their part here at the trust as soon as they start work on their first day.


Supporting sustainable delivery

Below are examples of some of the service developments and other highlights.



The SystmOne project team have successfully implemented;

  • full patient administration system functionality across health visiting, community nursing, specialist nursing, phlebotomy and Livewell services
  • full electronic patient records across health visiting, palliative care, Parkinson's and tissue viability services
  • the deployment of the initial, holistic and risk assessments for community nursing leading towards full electronic patient records.

The team, consisting of clinicians and project support staff, have worked tirelessly to support services and the trust in providing the foundations for the delivery of leading edge clinical care supported by the meaningful adoption of informatics and technology.


In February 2015, our internal auditors, Mersey Internal Audit Agency, completed a review of activity reporting with SystmOne which provided Significant Assurance.


Ideas scheme, Innovation fund, Research programme

The trust recognises that participation in research and working innovatively provides multiple benefits across the organisation and health and social care economy.


In addition to the development of a clinical innovation fund, we set up an ideas scheme encouraging staff to share their ideas with the trust's senior management team for consideration. Staff can view all the ideas online and see how they are progressing. Through advances made, the trust contributes to the delivery of high quality care, with improved outcomes for patients.


The trust is currently working with the National Institute for Health Research, Local Clinical Research and Academic Health Science Networks. A framework to support the expansion of research and innovation throughout the trust will be developed during 2015/16, to ensure that we achieve our research ambitions.


System Improvements

We have improved our data collection of duty of candour information to fulfill our reporting obligations to our commissioners, and our Datix system is now being use to manage:

  • NICE guidance resulting in improved reporting and communication
  • On call incident logs allowing for greater visibility and action plans reported to on call duty manager
  • CQC compliance tool improving the return process and visibility
  • Health, safety and security risks

Financial performance


The trust received total income of £70,020k for delivering healthcare services in 2014/15. The majority of this income was received from NHS Wirral Clinical Commissioning Group (CCG); however the trust also received a significant level from other bodies including NHS England and Wirral Metropolitan Borough Council.

  • The trust achieved the statutory duties required, by Parliament, of all NHS Trusts in 2014/15; our fourth successful year of operation as a standalone NHS Trust.

  • The trust ended the year with a normalised surplus of £875k, which was £25k below plan
  • The majority of expenditure incurred relates to staffing costs.

  • The trust's expenditure on the capital programme related to planned investment in IT infrastructure to continue the roll out of mobile working across services.

  • The trust performed well against the financial risk ratings applied to NHS providers by the independent regulator Monitor. The continuity of service risk rating measures the liquidity and capital service cover of NHS Foundation Trusts and in the future all providers of NHS care. Had the trust been subject to this regime in 2014/15, we would have received an overall risk rating of 4 out of 4, the highest level of financial performance.

Quality Impact Assessment of Cost Improvement Programmes


We have placed the need to maintain service quality at the heart of our Cost Improvement Programme (CIP) governance structure. Each CIP scheme must produce a Quality Impact Assessment (QIA) which is ultimately signed off by the Director of Nursing & Performance and Medical Director. Our CIP governance arrangements include:

  • a clear and consistent approach to identification, implementation and monitoring
  • QIAs and Equality Impact Assessments
  • plans with descriptions of savings (total and profile), interdependencies, documented assumptions, risks and issues and confidence levels for finance and performance

Caring for the environment

Since the creation of the trust in April 2011 we have implemented a bespoke sustainability approach for our organisation. We have:

  • maintained an established Environmental Management System, based on the ISO14001:2004 standard
  • reduced our carbon emissions to 2,199 tonnes CO2 equivalent;
  • recovered or recycled 64% of our waste – equivalent to 119 tonnes
  • engaged with local suppliers to monitor and reduce the amount of energy used and waste produced to help meet our sustainability objectives
  • continued to assess the viability of using renewable energy sources to generate energy at our properties and reduce carbon emissions and costs
  • implemented an Estate-wide space optimisation programme, resulting in improvements in energy and water efficiency, and minimising waste production and transport between sites through reduced Wirral CT occupied premises
  • assessed our St. Catherine's redevelopment against the BREEAM standards (Building Research Establishment Environmental Assessment Methodology) and achieved an 'Excellent' rating at Post Construction assessment stage

Estates Utilisation

The estate continues to perform well in terms of energy efficiency, in particular as a result of the space optimisation programme implemented throughout 2014/15. Areas in need of further improvement have been assessed alongside the development of premises and Estates space utilisation work as part of the Estates Strategy.


Further improvements in general environmental management will continue to make improvements across the trust's estate, with 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 is committed to conducting all aspects of its activities with due consideration to sustainability, whilst providing high quality patient care in line with the NHS Carbon Reduction Strategy and Sustainable Development Strategy for the Health and Care System.



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.


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 2014/15. 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" incidents. 'LNE' refers to additionally defined local 'never incidents' which set even higher standards than those required nationally.


patients community


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 2014/15 the trust was monitored against 144 separate KPIs, of which 78% were rated as either "Green" or "Amber" based on thresholds set by the commissioners. Whilst performance of 78% is below the trust's ambition to have at least 90% of KPIs rated as Green or Amber, 2014/15 saw significant challenges related to achieving public health targets for smoking cessation. The unprecedented growth in the use of e-cigarettes significantly impacted on the number of people opting to use smoking cessation services to stop smoking.


our services


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, 85% of whom are patient-facing and 90% of whom are women. The largest staff groups are nursing, physiotherapists and clinical support.


The trust maintained its excellent record of ensuring everyone had an appraisal and was set a personal development plan for the year ahead. The trust has recently developed an electronic approach to supporting corporate induction, Onboarding, which will ensure the improved performance seen at the end of 2014/15, continues into next year. Whilst the sickness absence figure for 2014/15 was higher than we had aimed for, the Trust continues to perform well when compared to other Community Trusts. We have put in place incremental targets for 2015/16 and 2016/17.


our people


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. Whilst the use of bank & agency staff during 2014/15 represented a significant cost burden, overall the Trust managed within its resources, achieving just under the planned surplus levels. After a slower start than hoped significant progress was made during the latter part of 2014/15 ensuring the Trust delivered on its £3.4m cost improvement programme.


our sustainability



Financial review


Wirral Community NHS Trust has met all of its statutory financial duties for 2014/2015, our fourth successful year of operations as a standalone NHS Trust.


Our financial performance is in line with the plans approved by the Trust board in March 2014 and is evidence of the continued financial strength of the Trust as well as the effectiveness of the financial planning, monitoring, forecasting and control within the organisation. The Trust's accounts are presented in summary form at the end of this document.


The Trust performance against its statutory duties is summarised below:




The Trust ended the year with a normalised surplus of £875k, which was £25k below plan.


All other financial duties have also been achieved namely maintaining cash expenditure within the External Financing Limit (EFL), maintaining capital expenditure within the Capital Resource Limit (CRL) and achieving a capital absorption rate of at least 3.5%. As well as delivering the statutory requirements of an NHS Trust, we have also continued to monitor our financial performance against Monitor's financial regime for Foundation Trusts in shadow form. The Trust's Foundation Trust Continuity of Services Risk Rating (CoSRR) is 4 out of 4; the best risk rating.


Analysis of Income


The Trust received total income of £70,020k for delivering healthcare services in 2014/15. The majority of this income is received from NHS Wirral Clinical Commissioning Group (CCG); however the Trust also receives a significant level of income from other bodies including NHS England and Wirral Metropolitan Borough Council, as per the table below.




The full breakdown of income for 2014/15 is shown below:


Analysis of Income Received 2014/15


annual income analysis


Analysis of Expenditure


The majority of expenditure incurred relates to staffing costs, £46,675k. The overall expenditure of the Trust in 2014/15 was £68,042. A breakdown of expenditure is shown below.



Analysis of Expenditure 2014/15


expenditure analysis


Revaluation of Trust's Estate


The Trust obtained an independent revaluation of its land and building assets in 2014/15 that resulted in a net upward valuation of £613k on buildings and £21k on land.


Capital Expenditure


The Trust spent £1,788k on its capital programme, remaining within the approved limit of £1,840k. The Trust's expenditure included planned investment in IT infrastructure, £0.9m, and was in line with both financial and IMT investment strategies to support the roll out of the agile working scheme. Other capital investment included £0.8m in estates refurbishment and £0.1m on medical equipment.


Public Sector Payment Policy


The Trust is required to pay its suppliers promptly in line with the Better Payment Practice Code, aiming to pay all undisputed invoices within 30 days. The Trust's Public Sector Payment Policy Performance is shown below:


payment policy


Performance was below the level expected of an NHS Trust which is 95% and work is required in 2015/16 to address this under performance.


Liquidity and Working Capital Management


At 31st March 2015 the Trust held working capital balances of £2,161k. This was made up of £2,565k of cash at bank and equivalent, £7,576k of money owed to us in the form of accounts receivable and £8,321k owed to other bodies and individuals as accounts payable and £341k of stock and inventories.


The Trust is committed to managing its working capital balances in an effective and efficient manner including the maintenance of a strong liquidity position in line with Monitor's requirements. In 2014/15 all our cash balances were held in the government banking service.


External Auditors


The Trust's External Auditors for 2014/15 are Grant Thornton. They charged the Trust a total of £43,200* for their work in this financial year.


*Note 5 of the accounts £46k = £43,200 + 20% VAT = £51,840 (less £6,000 rebate on fees)


Counter Fraud


The Trust is committed to the prevention, detection and remedy of any fraud committed against ourselves or our partners. We have a dedicated counter fraud service which helps develop an anti-fraud culture as well as supporting the trust's management in identifying and investigating individual incidents of fraud. The counter fraud service is provided by the North West Commissioning Support Unit.


Cost Improvement Plans and Efficiencies


As with the vast majority of public sector service providers, the Trust faces significant financial challenges as part of the difficult economic circumstances. The trust's financial planning process for 2014/15 identified a CIP requirement of £3,375k. These savings have been delivered above target at £3,381k.


Long Term Financial Plans


This report sets out the Community Trust's vision, values and strategic objectives for the next 5 years. In addition to this work we have developed a comprehensive financial model covering the same time period. Effective financial planning will form a key part of the Trust submission to become a Foundation Trust with the three tests for foundation trust status being that the Trust can show it is:

  • Legally constituted
  • Well governed, and
  • Financially stable

The Trust's plans show that whilst it will remain financially stable with good levels of performance against Monitor's financial risk ratings throughout the planning period, the required level of cost improvements will remain between 4% and 5% annually, equating to the release of some 24.4% of total costs by 2019/2020. This will present a significant challenge and the Trust has put in place a process to support this delivery and also to ensure that whilst the Trust does all that is necessary to deliver on this financial position, quality is not impaired by the need to deliver efficiencies. To this end all CIP schemes require the completion of a detailed Project Initiation Document (PID) and Quality Impact Assessment (QIA) to be signed off by the Trust's Director of Quality and Nursing, and Medical Director. The Business Efficiency and Modernisation Group (BEMG) has been established to keep the CIP target and achievement under constant review.


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 2015 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 2014/15 and the Trust's long term financial plans and considers the Trust meets the requirements to be considered a going concern.



Senior Managers' 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 2015. 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 2015
  • Sets out tables of information showing details of the salary and pension interests of all directors for the year ended 31 March 2015; 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 Organisational Development 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.


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.

Download Directors' information.


Pension Benefits

Download pension benefits information.


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 2014-15 was £112,500 (2013-14: £112,500). This was 5.5 times (2013-14: 5.6 times) the median remuneration of the workforce, which was £20,626 (2013-14: £19,950).


In 2014-15, 1 employee received remuneration in excess of the highest-paid director (2013-14: 1). Remuneration ranged from £462 to £120,949 (2013-14: £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.


Off-payroll Engagements


The Trust had the following off-payroll engagements during the year:


*This also includes board members who were in post for part-year as described in the annual governance statement.


The off-payroll engagement arose as a result of the departure of the former Director of Finance and Development and was to fill the vacant post on an interim basis whilst a permanent replacement was recruited.

As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members.

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.





Sustainable Development Management Plan

Since the creation of the Trust in April 2011 we have realigned and recalculated our activity to the new organisational structure and have produced a draft update of our Sustainable Development Management Plan. The NHS Wirral Carbon Reduction Strategy (effectively the SDMP) was published in 2009, and reviewed by the Community Trust in 2014/15.

In 2014/15 the Trust has continued with the maintenance of an established Environmental Management System, based on the ISO14001:2004 standard, enabling us to monitor the Trust's sustainability performance against key performance indicators 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 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.

Adaptation to climate change will pose a challenge to both service delivery and infrastructure in the future. It is therefore appropriate that we consider it when planning how we will best serve patients in the future. As such sustainability issues form an integral part of our Estates Strategy and our approach to managing risk.

In addition to our focus on carbon, we are also committed to reducing the wider environmental and social impacts associated with the procurement of goods and services. This is set out within our policies on sustainable procurement.
The NHS places a burden on the transport infrastructure, whether through patient, clinical or other business activity. This generates an impact on air quality and greenhouse gas emissions. It is therefore important that we consider what steps are appropriate to reduce or change travel patterns and are included in our Sustainable Transport Plan. The STP produced for NHS Wirral was adopted by the Trust.

Carbon Emissions

The NHS aims to reduce its carbon footprint by 10% between 2009 and 2015. In 2014/15 The Trust's measured Greenhouse Gas emissions from energy use were 2,199 tCO2e (tonnes of CO2 equivalent); an increase of 145 tCO2e on the previous reported year. These figures are provisional and pending final verification for the 2014/15 ERIC return. Although there was an increase from 2013/14 to 2014/15 there is a long term plan for a reduction in carbon emissions associated with gas and electricity consumption going forward.


carbon emissions


As an organisation our main impact areas are associated with our premises (gas and electricity) and business travel as a result of the community based nature of our services.

Carbon emissions have reduced overall over the last three years as a result of the implementation of the NHS Wirral Carbon Reduction Strategy (produced in 2009), an investment in energy efficiency of the Community Trust Estate properties (e.g. replacement of old building stock, improved thermal insulation in existing properties, building controls and installation of Solar PV) and also the implementation of the Estates Efficiency strategy which optimises space occupancy and use across the Trust Estate.

carbon emissions table

We do not currently purchase renewable energy for use but the Trust generates 0.046% of our energy on site from the 4kWhp Solar PV system installed at Fender Way Health Centre in January 2011.



Waste recycling initiatives have been implemented across the estate, with all locations encouraged to recycle paper, cardboard, bottles, cans and mixed recyclable waste.

We recover or recycle 119 tonnes of waste, which is approximately 64% of the total waste we produce.




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. It oversees 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 2 non-voting Directors. Further details on the governance framework and composition of the board are included in the Annual Governance Statement (AGS).

During 2014/15, the Trust Board considered the new Fit and Proper Persons Regulations and implemented processes to ensure compliance. See also Annual Governance Statement.

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.


In March 2015, Frances was re-appointed as Chairman of the Trust Board by the NHS Trust Development Authority (TDA) using powers delegated by the Secretary of State for Health, for a further two years.


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.


In March 2015, Brian was re-appointed to the Trust Board by the NHS Trust Development Authority (TDA) using powers delegated by the Secretary of State for Health, for a further two years.


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 and will be due for re-appointment during 2015/16.

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.


In March 2015, Chris was re-appointed to the Trust Board by the NHS Trust Development Authority (TDA) using powers delegated by the Secretary of State for Health, for a further two years. Chris is the chairman of the Quality & Governance Committee.


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.


In light of changes to the NHS Trust Regulations 1990 in April 2014 "to allow a person that provides primary care be appointed as a non-executive director of an NHS trust", Murray's position on the Trust Board was recommended and approved by the Trust Board to be formalised as a substantive NED, rather than an Associate NED. This was subsequently approved by the NHS Trust Development Authority in December 2014 for 2-year tenure. Murray is the chairman of the Education & Workforce Committee.


Executive Directors


During 2014/15, there were changes to the Executive structure, all of which were approved by the Trust Board and subsequently approved by the NHS TDA.


The Annual Governance Statement (AGS) provides further detail on the key changes.


Simon Gilby, Chief Executive - Simon joined the Trust in April 2012 and has a wealth of experience in the NHS at local, regional and national levels. Immediately prior to joining, he spent a short period with NHS South Yorkshire supporting the implementation of national policy. For the five years before that he was the Managing Director of Sheffield Primary Care Trust Community Services. Previous roles include Chief Executive of Sheffield West Primary Care Trust and Chief Executive of Southern Derbyshire Health Authority.


Steve Wilson, Director of Finance and Development - Steve was an Executive Director of the Trust from May 2011 until July 2014 when he left to pursue an opportunity at NHS England. Steve began his NHS career on the National Financial Management Training Scheme in 1996 and subsequently held a number of posts in community, acute and specialist NHS organisations. Prior to joining the Trust, Steve was Deputy Director of Finance followed by Acting Director of Finance at NHS Manchester.


Roy Jackson - Interim Director of Finance - Roy held an interim position with the Trust from August 2014 to December 2014. Roy was an experienced finance professional having worked for 28 years within the NHS previously holding Director of Finance positions at both commissioning and provider organisations.


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).


John Lancaster, Director of Operations* - John was an Executive Director of the Trust from April 2011 until January 2015 when he retired from his position. John had worked for the NHS for over 30 years and in Wirral since 2007. His career was diverse and included senior management roles in both Acute Trusts and Primary Care organisations, including Head of Unplanned Care and Head of Provider Services in NHS Wirral.


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 Quality and Nursing - 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 as Director of Quality & Nursing. During 2014/15, changes to the Executive structure combined the responsibilities of the Director of Operations and the Director of Quality & Nursing in to a single Executive Director post, Director of Quality and Nursing . 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, Interim Director of Development* - Val has been in post, as interim Director of Development since January 2015 on a 6-month secondment from Cheshire and Wirral Partnership NHS Foundation Trust (CWP). Val brings a wealth of experience from CWP where she is a Service Director. Whilst in post, Val has been leading the integration agenda through Vision 2018 including the Long Term Conditions work stream and taking operational responsibility for the clinical divisions.


* Non-voting members of the Board

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


So far as the chair and members of the Trust Board are aware, there is no relevant audit information of which the Trust's auditor is unaware, and they have taken all the steps that they ought to have taken in order to make themselves aware of any relevant audit information and to establish that the Trust's auditor is aware of that information.


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 two further Non-Executive Director members (Alan Wilson and Dr Murray Freeman). 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.


Additional disclosures


Pension Liabilities


See note 1.6 in the accounts and the remuneration report.


Directors'/Members' interests


A Register of Interests is completed annually by all members of the Trust Board. This is available at page 49.


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 shows that the annual sickness rate for the year April 2014/March 2015 was 4.9%. Whilst this figure remains above the North West average figure and the Trust's target figure of 4.2%, the Trust continues to perform well when compared to other Community Trusts. The detail on sickness absence data is also reported in the Quality Account 2014/15.


The average number of days lost per employee in 2014/15 was 10.9 (2013/14 - 10.4)


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 CD-ROM. 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 that will be 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.


Disclosure of personal data related incidents - Information Governance (IG)

There were zero IG 'Serious Incident Requiring Investigation' (SIRIs) that required reporting to the Information Commissioners Office (ICO) during 2014/15. The Trust acknowledged however that from June 2013 the IG Toolkit Incident Reporting Tool should be used to report level 2 IG SIRIs to the Department of Health, the ICO and other regulators.

The Annual Governance Statement provides further information on Information Governance including compliance with the IG Toolkit.

Employee consultation


In 2014/15 we developed a new Partnership and Recognition Agreement with our trades' union representatives demonstrating the commitment to establishing and maintaining a climate of trust, mutual respect and openness based on regular information sharing, problem solving and learning. The Joint Forum meets on a bi-monthly basis and is the mechanism for conducting consultation and negotiation with trades' union representatives.


There is an established Organisational Change Policy which ensures that information regarding the development of services is shared with affected staff and their representatives at the earliest opportunity.


Staff Council continues as an important vehicle for staff engagement. During 2014/15 elections were held to elect new staff council representatives including a chair, following the end of tenure of a number of members. For the majority of 2014/15 the Staff Council met on a monthly basis but from January 2015, it was agreed to move to a 6-weekly meeting schedule.


The Trust has a briefing process cascaded through Heads of Service and Divisional Managers which delivers key information from the Board to all employees. We also have a staff bulletin, produced weekly, to provide access to a range of information to staff.


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.


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.


Health, Safety and Security


RIDDOR Reportable Incidents




The Local Security Management Annual Report is presented to the Audit Committee to demonstrate compliance against the standards set by NHS Protect. The report summarises security related incidents for 2014/15, drawing comparisons where possible, with the two previous financial years.

The table below indicates that there were 118 incidents reported under the category Non Physical Abuse.

incidents table

Counter Fraud

The Trust is committed to the prevention, detection and remedy of any fraud committed against ourselves or our partners. We have a dedicated counter fraud service which helps develop an anti-fraud culture as well as supporting the trust's management in identifying and investigating individual incidents of fraud. An update report is provided to the Audit Committee at each of its meetings with a work plan for the year and annual report submitted annually at the start of the financial year.


Better payments practice code


The Better Payment Practice Code requires the Trust to pay its suppliers within 30 days of receipt of goods or a valid invoice whichever is later. In 2014-15 the Trust paid 91.2% (2013-14: 92.1%, 2012/13: 87.7%) of invoices within 30 days.

Details of compliance with the code are given in note 8 to the accounts.

Prompt payment code


The Trust is a signatory to the Prompt Payment Code.


Emergency preparedness

Wirral Community NHS Trust contingency arrangements are concerned with the Trust's ability to continue to operate its business processes to deliver its services and to mitigate the effects of disruption, whatever the cause.


Under the Civil Contingencies Act 2004 the Trust as a Category 1 responder must work with other responders to assess risks, develop and maintain plans, share information and co-operate on civil contingency response, and can manage incidents events while maintaining services to patients.


The Major Incident Plan outlines how as a Trust we will plan for, respond to and recover in the event of an emergency, meet our responsibilities as an operational responder and comply with relevant guidance and legislation.


The major incident plan is built on the principles of risk assessment, cooperation with other partners, emergency planning, communication and information sharing. To assist in a response to a major incident the Trust has access to a fully resourced major incident room including satellite phone, laptops, internet access etc. at its headquarters and a backup room at an alternative location.


The Trust operates a well tried and tested 'on call' senior management rota to manage and support business continuity. The on call duty manager also provides advice in relation to out of hours incidents/medical emergencies. The rota is updated regularly and supported by an on call duty manager's Standard Operating Procedure which provides details of the specific incident pathways to follow.


The Trust has business continuity plans in place at a divisional and service level which are aligned to national plans and reviewed annually. These plans support coordinated and clinically safe responses to unplanned/unprecedented increases in demand. The Trust ensures that the plans reflect the requirements of the EPRR (Emergency Planning Resilience and Response) agenda through membership of the Cheshire Local Health Resilience Forum and the Merseyside Local Health Resilience Forum.


Over the last 12 months, The Trust has sought to develop further its Emergency Preparedness arrangements including the following development exercises and training:

  • On Call Manager Training
  • Risk management and Business Continuity Training
  • Ebola Exercise - Walk In Centres
  • Cheshire and Merseyside LHRP Ebola exercise
  • Emergency Preparedness Awareness Session for Divisional Managers and Service leads.

Principles of Remedy

The Trust follows the six principles set down by the Parliamentary and Health Service Ombudsman in 'Principles for Remedy' (revised February 2009). The aim is to provide redress for any instances of injustice or hardship as a result of maladministration or poor service.


The principles involve:

  • Getting it right
  • Being customer focused
  • Being open and accountable
  • Acting fairly and proportionately
  • Putting things right
  • Seeking continuous improvement.

The Trust has met these principles by:

  • incorporating the NHS complaints procedures into our own policy;
  • the Chief Executive takes a personal interest in all complaints and the quality of investigation and response;
  • having a Patient Experience Service which aims to resolve many problems or concerns without the need for a formal complaint;
  • having in place a 'losses and compensations' procedure;
  • regular reporting to the Trust Board of complaints received as part of the Trust's performance monitoring
  • an opportunity for NEDs to 'dip sample' complaints records

Exit packages and severance payments

In 2014/15 the Trust made no compulsory redundancy payments.


In 2014/15, 26 people were approved under the Mutually Agreed Resignation Scheme (MARS) in line with the nationally agreed scheme and approved by the NHS Trust Development Authority. See note 8.4 in the accounts.


Off payroll engagements


In 2014/15 the Trust made one off-payroll engagement associated with the interim Director of Finance, in post for a period of 5 months, from August-December 2014. This is reported in the Remuneration Report.


In accordance with Chapter 2 Annex 3 of the Manual for Accounts, the table below details the number of posts, as of 31 March 2015, that met the criteria of board members and or senior officials with significant financial responsibility; both off-payroll and on-payroll.


off payrol engagements


*This also includes board members who were in post for part-year as described in the annual governance statement.


Employee gender distribution


The figures reflecting the breakdown of gender distribution of employees within the Trust during 2014/15 are included in the table below:


gender distribution

Responsibility for preparing the Accounts


The Chief Executive is our designated Accounting Officer with the duty to prepare the accounts in accordance with statutory requirements.


Wirral Community NHS Trust Board of Directors


Register of Interest for the financial year 2014/15



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 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.

During 2014-15 the Board met in public on 11 occasions and on each occasion members of the Board convened in a formal private session to focus on matters considered commercial in confidence. In May 2014 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 2014-15.

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

There were a further 2 non-voting Directors; Director of HR and Organisational Development and Director of Operations.

In April 2014, the National Health Service Trusts Regulations 1990 were changed to remove restrictions around NHS trust chair and NED appointments; in particular, "to allow a person that provides primary care be appointed as a non-executive director of an NHS trust". In September 2014 and in the context of this new guidance, the position of one of the Non-Executive Directors was recommended to be formalised as a substantive NED, rather than an Associate NED of the Trust Board. This was subsequently approved by the NHS Trust Development Authority (TDA) in December 2014.

One of the Non-Executive Directors acts as the Senior Independent Director (SID) for the Trust.

In March 2015 the Chairman and two Non-Executive Directors were re-appointed by the NHS Trust Development Authority using powers delegated by the Secretary of State for Health for a further two years. The remaining Non-Executive Director will be due for re-appointment during 2015/16.


The Director of Finance & Development left the Trust in July 2014 with interim arrangements in place ahead of the substantive Director of Finance & Resources commencing in post in January 2015.


The Director of Operations retired from the Trust in January 2015 which prompted a review of the executive structure. The NHS Trust Development Authority (TDA) was consulted regarding the changes to the structure and the Trust Board approved the recommendations in December 2014.

The key changes were;

  • The responsibilities of the Director of Operations and the Director of Quality & Nursing were combined in to a single Executive Director post, with voting rights. This supported the alignment of the operational and clinical leadership agenda and provided an effective focus for the delivery of these responsibilities and the integration of the safety, quality and delivery agendas.

  • To support this the role of the Medical Director was reviewed to enhance the responsibility for scrutiny in respect of service quality.

  • The establishment (and recruitment) of a new Executive Director, Director of Business Development & Strategy, with responsibility for strategy, planning and business development. The recruitment to this post commenced in March 2015 with appointment made in April 2015.

  • An interim Director of Development has been in post since January 2015 for a period of 6-months.

The revised executive structure therefore comprises the following;

  • Chief Executive
  • Director of Finance & Resources
  • Medical Director
  • Director of Nursing & Performance
  • Director of Human Resources & Organisational Development (non-voting)
  • Director of Business Development & Strategy (non-voting) - interim Director of Development in post

Additional governance roles are also undertaken by members of the executive team as outlined in the table below;




The names of board members, who served during the year, and their biographical details, are included in the Directors' report.

The Trust Board has considered the new Fit and Proper Persons Regulations (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 5) and implemented processes to ensure on-going compliance both for all new appointments at director level, or equivalent, and existing directors, or equivalent of the Board. As such, all existing directors have completed a self-declaration confirming compliance with the test.

The table below shows the attendance record for each board member compared to the maximum number of meetings they could have attended in 2014-15. 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 table on the next page provides detail on committee chairmanship and membership.


directors table


^ Non-voting members

 *Mark Greatrex, Director of Finance & Resources, in post from January 2015

**Roy Jackson, interim Director of Finance & Development, in post from August - December 2014

***John Lancaster, Director of Operations, retired from the Trust in January 2015

****Val McGee, Interim Director of Development, in post from January - March 2015

*****Steve Wilson, Director of Finance & Development, left the Trust in July 2014

1 Chris Allen had a period of illness in September 2014.

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)


Sub-Committees of the Board - Chairmanship and Membership


board table


As part of the Trust'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 also provided to the Trust Board, once approved.

The table below provides an overview of the duties of each committee of the Board. The primary role of each is to provide assurance to the Board on the areas of responsibility.


board table 2


The Trust Board has also considered the role of the Council of Governors in the governance structure of the FT organisation and has developed the constitution which sets out the purpose and powers, and governance arrangements of the Trust as a Foundation Trust. This work has also involved regular engagement with members (of which the Trust has now achieved its target of 5000 public members) and partner organisations to provide further information on the role of the foundation trust governor.


The Trust continues to embrace the Board Governance Assurance Framework (BGAF) as a tool to support on-going assessment of current capacity and capability. The framework underpins the Trust's assessment in the Board Governance Memorandum (BGM), initially completed in June 2012, and subsequently externally reviewed in June 2013. During 2014-15 the board received a quarterly report on progress against specific recommendations highlighted following the last external assessment conducted by Grant Thornton in 2013. The board has also received a quarterly report on board composition in the context of any changes to the environment or skill gaps during 2014/15.

The Board has considered the future development of the BGAF in the context of the advent of the Monitor 'Well-led framework for governance reviews' and is taking advice from the TDA in relation to the introduction of the new framework.

In April 2014 each committee of the Board completed an annual review of performance and effectiveness against objectives, as set out in the terms of reference.

As an aspirant FT, during 2014-15 the Trust has continued to report monthly to the Trust Development Authority on progress against a set of board statements and a subset of Monitor's provider licence conditions, and has declared full compliance against all indicators and relevant conditions. The compliance statement is underpinned by the principles in the '2014/15 Accountability Framework for NHS Trust Boards - Delivering for Patients'.

For the 2014/15 TDA Accountability Framework, the Trust anticipates a green rating for 18 of 21 indicators. Sickness absence is rated as amber; although there is no tolerance set this rating is consistent with the trust's own focus in moving towards an absence rate of 4.2% or less. The trust had one Never Event recorded in 2014/15 (the only one since the trust's formation in 2011). The threshold for this indicator is zero so this is rated red. The 2014 staff survey result for 'recommending the trust as a place to work' was 60% against a pass: fail threshold of 61% so this is also rated red.

The Trust does not deliver elective in-patient care. We have locally agreed waiting time targets for non-inpatient work which are subject to internal audit reviews. During 2014/15 internal audit completed a review of activity reporting, particularly related to the implementation of SystmOne, which provided Significant Assurance.

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.

We have set out below those areas where the Trust has drawn on best practice available including those aspects of the UK Governance 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

Quality Governance

The 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 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. As such, the Board is committed to ensuring that quality forms an integral part of its philosophy, practices and business plans with responsibility for driving this being accepted at all levels of the organisation.

The Quality Strategy for 2014-15 built upon the successful delivery of previous Quality Strategy and Quality Accounts and ensured that quality services were delivered in the organisation in response to the specific requirements of our patients, the public, commissioners and regulators.

Quality Governance is the combination of structures and processes at and below board level to deliver trust-wide quality services. The Trust Board has embraced the Quality Governance Assurance Framework (QGAF) recognising that when implemented effectively, assessment against the framework can provide boards with assurance over the effective and sustainable management of quality throughout their organisation.

During 2014-15 the Trust has continued to monitor progress against the QGAF and during July/August 2014 Monitor conducted a detailed review of quality governance within the Trust. After reviewing the evidence Monitor agreed that there were many elements of good practice, some areas of development required with two areas highlighted as amber/red; the review concluded with a score of 4.0 for the Trust. An action plan was developed to take account of the feedback from Monitor and the Quality & Governance Committee reviewed progress on a monthly basis with quarterly reporting to the Trust Board.

In January 2015, the QGAF action plan and assurance against the four areas of quality governance was reviewed with a revised QGAF score of 3.5 approved by the Board.

The quality account 2014-15 provides evidence of progress against quality goals set for the year and highlights aspirational goals for the forthcoming year. 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 2014-15 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 2015. 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.

The Trust has a robust programme of clinical audit in place and during 2014-15, 36 clinical audits were planned and completed. The key quality outcomes from the audits are reported in the quality account. Other methods of internal quality assurance include frontline focus/quality visits, 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 compliant with the CQC 'Essential Standards of Quality and Safety' and this is monitored via the compliance group which reports to the Quality and Governance Committee. During the latter part of 2014-15 the Trust also considered a new model for providing assurance in the context of the new CQC 'Fundamental Standards of Quality and Safety', from April 2015.

In September 2014 the CQC conducted an announced inspection of the Trust, through the Chief Inspector of Hospitals regime. The trust was rated as 'good' overall and an action plan to address the areas of improvement is monitored by the Quality & Governance Committee on a monthly basis and reported to the Board for assurance on a quarterly basis. The CQC identified 6 'must do' actions, all of which were completed on track by the end of March 2015.
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 achieved level 2 of the Information Governance Toolkit (version 12.0) with 96% of all staff completing and passing the Information Governance e-learning training during 2014-15.

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, updated and approved by Board in January 2015. 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 raising concerns about any risks. These include, but are not limited to; raising concerns policy, on-line incident reporting via the Datix system, regular quality forums, information governance policies and processes, and leadership and patient safety walkrounds.

Risk management training is also mandatory for all staff and is a key part of the organisation's corporate and local induction.

Following the Monitor review of the trust's quality governance processes, a detailed programme of work was undertaken to review the Board Assurance Framework (BAF) and its links with the operational risk register to ensure sufficient rigor around the board's focus on risks to strategic objectives. This work included, but was not limited to, a review of the principal risks and the risk journey to ensure 'top down' and 'bottom-up' risks are cross-referenced with the BAF, each principal risk is risk rated and linked to any relevant risks recorded on the operational risk register and the role of each committee strengthened in relation to the review of the BAF.

The Trust has identified 23 principal risks (strategic risks) against its 15 strategic objectives, themed according to four strategic areas. The strategic risks noted against each strategic theme in the table below, summarise the risks currently recorded on the BAF.


risk table


Each risk on the BAF is rated according to the risk matrix. Any with a risk rating of >12 are reviewed for progress and mitigating actions.

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
  • Management of contractual relationships

The risk and control framework


During 2014-15, the Board has continued to review the BAF on a quarterly basis and as mentioned above, a detailed programme of work completed to consider the feedback following Monitor's review of quality governance processes.

The work completed has informed the assurance framework review completed by internal audit (MIAA) which concluded that "an assurance framework has been established which is designed and operating to meet the requirements of the AGS and provides reasonable assurance that there is an effective system of internal control to manage the principle risks identified by the organisation"

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.

The risk management framework, as set out in the risk management strategy, allows the board to review risks all of which have been escalated through the Quality and Governance Committee, the principal committee that monitors areas of risk across the organisation.

During 2014-15 this committee received a monthly update on risk management through the Quality & Patient Experience Report and with effect from December 2014 this committee has received a monthly Risk Management Report providing assurance on the management of risk and an opportunity to scrutinise the detail of high-level risks and those not progressing.

The Board receives a monthly high-level risk report that requires board review and action as appropriate. Any areas of risk identified through the Trust's risk management framework or audit are the responsibility of the relevant executive director to address and ensure mitigation where appropriate.

The Quality, Patient Experience and Risk Group (QPER) discuss and monitor responses to all reported risks, incidents, concerns and complaints. This group ensures that lessons learned from incidents, complaints, audits, research and other sources are shared across the organisation and enable views from patients and the public to be considered. The group provides assurance to the Quality and Governance Committee which advises the board of all significant risks, areas for development and exceptional good practice ensuring lessons are learnt and shared from incidents, concerns and complaints.

To support this process, a tracking tool has been developed to monitor the management of operational risks and provides assurance to the board by presenting a monthly organisation-wide risk management score. A tolerance of 90% is set to reflect a healthy risk management position and measures are taken if the score drops below this level.

During 2014-15 the Trust reported 19 SUIs (Serious Untoward Incidents) to NHS England via the national reporting and learning system (NRLS) in accordance with Department of Health protocols, and reported one wrong site surgery never event. All SUIs are fully investigated and themes are reviewed and learning is shared across the Trust to prevent them from reoccurring. There were zero IG SIRIs (Serious Incident Requiring Investigation) that required reporting to the ICO (Information Commissioners Office). The Trust acknowledged however that from June 2013 the IG Toolkit Incident Reporting Tool should be used to report level 2 IG SIRIs to the DH, ICO and other regulators.


All risk registers and incident reports are centralised on an electronic database, Datix, and scrutinised monthly by the QPER which reports directly to the Quality & Governance Committee. The Datix system allows greater data interrogation through the development of dashboards to monitor trends and provides greater assurance to board members.

The Trust commissions the services of Wirral Fraud & Probity Service to provide a bespoke anti-fraud agenda. There is an annual risk-based work plan in place. The Trust utilises the services of two fully accredited counter fraud specialists both of whom are fully accredited and experienced.

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.
There were 5 incidents of fraud which required further investigation; these investigations resulted in £435.42 being recovered during 2014-15.

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 2014-15.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 2014-15 provides Significant Assurance.

"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 particular objective at risk".

Internal audit conducted 14 reviews during 2014-15 of which 9 received significant assurance and 5 received limited assurance. The Trust provided a response to each of the reviews with action plans in place to deliver on the recommendations.

Significant Issues

As Accountable Officer I confirm that there are no significant issues to report.





Simon Gilby                                                                    2 June 2015
Chief Executive
Wirral Community NHS Trust


Independant Auditor's Report 

Download the Independent Auditors Report.





Our future



During 2015/16, WCT will develop a new Patient Engagement Group to help ensure services and planning are patient-focussed, improving the patient experience and patient care outcomes. This group will sit alongside many others that already involve trust members.

The trust will participate in NHS England's Open and Honest Care and Sign up for Safety programmes.


We will continue to work with our Right Staffing Steering Group, developing benchmarks for staffing in each service by undertaking a capacity and demand review, using national evidence and benchmarking against other services and trusts.

Over the coming year, as well as fully implementing Integrated Care Coordination Teams, WCT will be part of the development of a 'Single Front Door' triage system at the Arrowe Park Hospital site. This project will introduce a primary care assessment to all walk-in patients, with signposting to the appropriate service following a single assessment.

2015/16 will also see the embedding of our new 0-19 Health and Wellbeing Service, and work on service development plans agreed with commissioners, including the development of a strengthened community provision of cardiology services and implementing the outcome of reviews of the Parkinson's disease service.


This year we plan further innovation across the trust by:


  • Conducting a minimum of four innovation projects via the trust's innovation fund
  • Supporting each clinical service to share their team level quality improvement and promote best practice
  • Promoting the use of quality improvement methodologies
  • Focusing on quality improvements that are determined by patients and / or prevent patient harm

Over the course of 2015/16, WCT will be utilising the NHS Leadership Academy's Healthcare Leadership Model to support the development of a Leadership Framework incorporating talent management and succession planning. This will further an ethos of leadership at every level of the organisation.

WCT will implement the new Care Certificate to new health care support staff, in line with the national schedule. Revalidation for our nurses will also be introduced in 2016 to check that the people on the NMC register are up to date and fit to practice throughout their careers.

As we reach the final stage of our application to become an NHS foundation trust we expect to hold elections for public and staff members to join a Council of Governors. Our trust governors will represent the interests of local people and hold the trust to account on their behalf.

In 2015/16 the trust will continue to work as a key partner in the Vision 2018 programme, 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, supported by a recent successful Vanguard bid.

WCT will further review our estate usage with the aim of making most efficient use of the space we own and lease whilst providing the best care for patients and effective support for front line services. The trust's head office will move to St Catherine's Health Centre during 2015.

We will continue to develop Business Intelligence capability through implementing Service Line Reporting and team-level presentation of near-real time data so that all teams understand their performance, best practice may be identified and variations reduced.

The trust will continue to embed an improved approach to organisational risk management, so that strategic, organisational risks are rated and linked to our operational risk register. This enables the trust board to focus on risks that might stop the trust achieving its strategic objectives.

Our 5,000 public members engage with the trust in many ways. Members receive our magazine For You, with invitations to events and activities. Many take part in trust groups. In the past year we have established member involvement in groups such as the Community Equality Panel, Medicines Management Group and Practice Research Steering Group.

In the coming year we will be developing a new Patient Experience Group with trust members and staff. This group will help us ensure services and planning are patient-focussed to improve the patient experience and patient care outcomes.

We also expect to hold elections to our Council of Governors. This will be part of the final stage of our application to become an NHS foundation trust. Governors are elected by public and staff members and appointed by partner organisations. As a group they represent the interests of local people. The trust board becomes accountable to them for its performance.

During 2014/15 we have been informing people about what governors do and the election process. We hope as many enthusiastic and committed people as possible will stand for election this year. We will support our new governors with an induction and development programme, making sure they have the information and training they need to be able to fulfil their new duties. We will provide on-going support to our governors. They will meet regularly to make sure the trust is performing well and planning to meet people's needs.




Last Updated: Wednesday, 02 November 2016 14:36

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