Gmw annual report 2015 by Greater Manchester Mental Health

Annual

report&

Accounts

2014/15

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report and Accounts 2014/15

Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006

Contents Page Strategic Report ......................................................................................................... 6 Risks ....................................................................................................................... 14 Our Environment ................................................................................................. 16 Social, Community & Human Rights Issues ......................................................... 17 Directors’ Report and Management Commentary ............................................ 20 Enhanced Quality Governance Reporting ............................................................ 24 Statement of Directors’ Responsibilities in Respect of the Accounts ........... 30 Register of Interests .................................................................................................. 32 Remuneration Report ............................................................................................... 34 How we Work ............................................................................................................. 38 Council of Governors ................................................................................................ 42 Membership of the Board of Directors ................................................................. 46 Committees ................................................................................................................. 52 Foundation Trust Membership ............................................................................... 58 Quality Report ............................................................................................................ 60 Staff Survey ................................................................................................................. 62 Regulatory Ratings Report ...................................................................................... 66 Financial Review ........................................................................................................ 68 Accounting Officer’s Responsibilities .................................................................... 76 Annual Governance Statement .............................................................................. 78 Independent Auditor’s Report ................................................................................ 86 Appendix 1 – NHS FT Code of Governance ........................................................... 90 Appendix 2 – Annual Accounts ............................................................................... 98 Quality Account .......................................................................................................... 145

Annual Report 2014/15

Page 5

Strategic Report

ue and respect • we work together • we go dly • we are caring and kind • we value and reater Manchester a mile • we are welcoming and friendlyWest • weMental Health NHS Foundation Trust formally we work together • we go(GMW) the extra milebecame a foundation trust in We provide wide range of NHS services across g and kind • we value2008. and respect • we awork a large •and geographical coming and friendly wedisparate are caring and kind footprint covering Greater Manchester, North West and beyond. we go the extra mile • the we wider are welcoming ue and respect • we work together • we go dly • we are caring and kind • we valueand and Services provided include community inpatient mental health services, adult and adolescent forensic mental health services, adolescent psychiatry services, mental health a mile • we are welcoming and friendly • we and deafness services, community and inpatient alcohol and drugs services, and offender we work together we go mileservice portfolio, we operate within a complex health•services. As athe resultextra of our diverse commissioning framework. partnership working with commissioners and other g and kind • we value and respectEffective • we work providers is critical to managing this and to ensuring that we remain at the forefront of coming and friendly • we are caring and kind local planning. we go the extra mile • we are welcoming Our vision remains to deliver ‘Improved Lives and Optimistic Futures for People Affected ue and respect we work together we go by • Mental Health and Substance•Misuse Problems’. Our vision is underpinned by six strategic objectives: dly • we are caring and kind • we value and To promote recovery by providing high quality care and delivering excellent outcomes ra mile • we• are welcoming and friendly • • To work with service users t • we work together • we go the

and carers to achieve their goals

• To engage in effective partnership working • To invest in our environments • To enable staff to reach their potential and innovate • To achieve sustainable financial strength and be well-governed

We work together to achieve our values

Page 6

Greater Manchester West Mental Health NHS Foundation Trust

Strategic Report

And, our values, which articulate what we stand for as an organisation and how we will work together to achieve the best for our staff and patients: • We are welcoming and friendly • We are caring and kind • We value and respect • We work together • We go the extra mile

Strategic Goals and Initiatives We have made significant progress in delivering the strategic development plans set out in our ‘Strategic Plan for 2014 to 2019’ and our ‘Operational Plan for 2014 to 2016’. Progress is tracked via local project groups or routine meetings, as well as via our robust annual business planning process. The business planning process provides opportunity for previous year’s achievements to be acknowledged and outstanding priorities (that remain relevant and feasible) to be carried forward.

The Trafford Aim launch event

respect • we we are welc Key achievements in 2014/15 include: caring and kind • we value and respect • we work together • • Implementing a redesigned acute care pathway in Bolton, Salford and Trafford: are welcoming and friendly • we are caring and kind • we including the provision of more effective Home-based Treatment services; strengthened bed management, improved interfaces across inpatient, home- and community-based we go the extra mile • we are welcoming and frie services; and the commencement of work to develop a ‘Centre of Excellence’ for older people. This work will conclude in 2015/16 • we value and respect • we work together • we go the ex • Continuing to develop our rapid access psychiatric liaison services in Bolton, Salford and and friendly • we are caring and kind • we value and respect Trafford acute hospital settings • we are welcoming and friendly • we are ca • Embedded new designated and fit for purpose place of safety facilities for individuals respect • we work together • we go the extra mile • we are admitted on a Section 136 in Bolton and Salford are caring and kind • we value and respect • we work togeth • Expanding our Memory Assessment and Treatment Service for people with dementia, and their carers, in Salford we are welcoming and friendly • we are caring and kind • we • Continuing to consolidate and improve our Improving Access to Psychological Therapies we go the extra mile • we are welcoming and frie services • we value and respect • we work together • we go the ex • Implementing new services following a successful tender: and friendly • we are caring and kind • we value and respect • Salford Integrated Drug and Alcohol Recovery Services for Adult and Young People. Operating as prime provider with sub-contracting developed with • we arrangements are welcoming and friendly • we are ca organisations such as Great Places, Thomas Project, Salford Royal NHS Foundation Trust respect • we work together • we go the extra mile • we are and Early Break • HMP New Hall Personality Disorder Services for women are caring and kind • we value and respect • we work togeth • Trafford Drug and Alcohol Detoxification Services we are welcoming and friendly • we are caring and kind • we • Successfully tendering to provide mental health and substance misuse services at HMP Hindley and mental health services at Barton Moss Secure Children’s Centre and St. Annual Report 2014/15

Page 7

Catherine’s Children’s Centre – implementation to follow in 2015/16 • Providing additional capacity in our adolescent inpatient service (Junction 17) to respond to national demand • Investing in capital development: • Provision of new medium secure accommodation to replace old accommodation • Commencing work to re-provide our existing male low secure wards and build an education and training facility, which will provide a central ‘hub’ for our Recovery Academy and enable the re-location of Trust Headquarters • Continuing to expand our low secure and ‘locked’ inpatient care, in Widnes through a contractual Joint Venture with Priory • Progressing the implementation of a new clinical information system • Actively contributing to the development and implementation of an integrated Primary and Acute Care System to meet all health and social care needs in Salford –working in partnership with Salford CCG, Salford City Council, Salford Royal NHS Foundation Trust and Salix via an alliance contracting model and backed by NHS England as one of its vanguard sites. New integrated care system to be piloted in 2015/16.

Government and Regulatory Context We have developed an ‘Operational Plan for 2015/16’, reviewed our five-year ‘Strategic Plan for 2014 to 2019’ and our two-year ‘Operational Plan for 2014 to 2015’. We have also analysed the national (government and regulatory) context, specifically taking into account: • ‘Everyone Counts: Planning for Patients 2014/15 – 2018/19’ • ‘NHS Five Year Forward View’ • ‘The Forward View into Action: Planning for 2015/16’ • ‘The Mandate for the NHS 2015/16’ • ‘Closing the Gap: Priorities for Essential Change in Mental Health’ • Winterbourne, Berwick, Francis and Keogh inquiries and reports • Changes in regulatory policy including the Care Quality Commission’s new inspection regime • The National Tariff and our choice of the Enhanced Tariff Option ‘Everyone Counts: Planning for Patients 2014/15 to 2018/19’ established a requirement for NHS organisations to shift their focus from short-term incremental improvements to longer-term planning. Our existing ‘Strategic Plan’ responded to this by setting out plans for transforming our services over a fiveyear period, and this Plan continues to support that vision. We are committed to improving access to therapies

Page 8

Greater Manchester West Mental Health NHS Foundation Trust

The ‘NHS Five Year Forward View’ emphasises that major system changes are required to protect high quality, sustainable care for patients now and into the future. Our plans represents a credible strategy for change that will enable delivery of the required levels of performance into the long-term. Our plans also meet all operational and financial requirements in 2015/16 and we have contingencies in place to address any short-falls or unexpected difficulties. ‘The Forward View into Action: Planning for 2015/16’ (published December 2014) describes the approach organisations should start to take in 2015/16 in order to fulfil the vision set out in the ‘NHS Five Year Forward View’. The ‘Forward View into Action’ specifically identifies ‘achieving parity for mental health’ as a priority for 2015/16. This is alongside priorities for improving quality and outcomes, improving patient safety and meeting NHS constitutional standards. The introduction of access and waiting time standards in mental health in 2015/16 is one approach identified in ‘The Forward View into Action’ as a means of achieving parity. New access and waiting time standards will be implemented in the following areas and monitored via Monitor’s Risk Assessment Framework and local contracts: • Early Intervention in Psychosis – £40 million additional investment has been made available to support this • Improving Access to Psychological Therapies – £10million additional investment has been made available centrally and will be targeted towards those areas facing the greatest challenge in achieving the standards ‘The Forward View into Action’ also identifies further investment for the development of adequate and effective liaison psychiatry services, for all ages, in a greater number of acute hospitals. Targeted investment of £30million will be made available in 2015/16 for this purpose. A further £30million targeted investment will be used to support the establishment of community-based specialist teams for children and young people with eating disorders. We welcome the news that, as an outcome of the ‘NHS Five Year Forward View’ and the current impetus to significantly improve mental health services, a new taskforce has been launched to develop a new five-year strategy for mental health for people of all ages. We will take every opportunity to contribute to the work of this Taskforce. The approach to achieving parity in mental health outlined in ‘The Forward View into Action’ does not change the ambitions set out for mental health in ‘The Mandate’ to NHS England for 2015/16. As such, we will continue to deliver against pre-existing mandate objectives - including improving access to psychological therapies standards and improving diagnosis, treatment and care for people with dementia - whilst also focusing on achieving the new access and waiting time standards for mental health services. ‘Closing the Gap’ sets out 25 priorities for essential change in mental health and details how changes in local service planning and delivery will make a profound difference to the lives of people with mental health problems. We have Annual Report 2014/15

Closing the Gap sets out local service planning and delivery

Page 9

developed local responses to these priorities and will continue to implement these in 2015/16. We remain committed to quality assuring all of our activities based on the findings of the Winterbourne, Berwick, Francis and Keogh inquiries and reports, and to take steps to strengthen our systems of internal control. In 2015/16, we are planning to participate in a ‘Governance Review’ led by Monitor to assess our performance against its ‘Well-led Framework’ and determine the robustness of our governance arrangements and organisational development agenda. We are also focused on the Care Quality Commission’s new Registration Regulations, and associated fundamental standards of quality and safety, and are actively preparing for the new inspection regime. We are taking steps to strengthen our assurance process and have also commenced a regular programme of internal inspections, which will continue into 2015/16, to this end.

Quality Goals As planned, we continued to drive forward quality improvements in 2014/15. We achieved all targets set nationally for mental health providers in 2014/15, delivered our Commissioning for Quality and Innovation schemes and secured all associated income, and made significant progress against our Quality Improvement Priorities as set out in our annual Quality Account.

National and Local Commissioning Priorities We recognise the particular challenges faced in, and across, our local health economies and our plans align with our commissioners’ intentions as set out in their long-term strategic plans and associated needs assessments and strategies. We continue to work closely with our commissioners to understand the health needs of our populations and to develop and deliver services that best meet those needs within the available resources. Our main commissioners are: • Bolton, Salford and Trafford CCGs for our district services • NHS England (Cheshire and Merseyside Sub-Regional Team) for specialised services • NHS England Health and Justice Team for North West (hosted by Lancashire and Greater Manchester Sub-Regional Team) for offender health services • A number of local authorities (including, Salford, Central Lancashire, Cumbria and Wigan and Leigh) for substance misuse services District Services - CCGs have explicitly been asked to ensure that spend on mental health services rises in real terms in 2015/16 and grows at least in line with the CCG’s overall allocation growth. Our CCGs’ commissioning intentions cover the following themes: • Early intervention and prevention • Recovery – enabling the best possible outcomes for patients • Delivering an integrated approach to care to support patients’ physical, mental and social care needs • Improving Access to Psychological Therapies • Improving children and young people’s mental health • Rapid and convenient access to services Page 10

Greater Manchester West Mental Health NHS Foundation Trust

• Emergency and unplanned care - continued development of psychiatric liaison or RAID-type services • Supporting people with dementia to live healthier lives • Implementing redesigned acute inpatient services and community services • Positive or improved experience of care Supporting people with dementia to live healthier lives

We continue to address these themes in our strategic priorities for 2015/16, which are supported by our commissioners. Offender Health/Health and Justice - In terms of offender health, NHS England are partway through their four-tranche programme of re-procurement for health and social care services in prisons and healthcare in secure children’s homes across the North West. In partnership with Bridgewater Community Healthcare NHS Trust, we have participated in procurement exercises in Greater Manchester and Merseyside to date and have been awarded contracts in HMP Hindley and Barton Moss Secure Children’s Centre in Greater Manchester and St. Catherine’s Secure Children’s Centre in Merseyside. Procurement for tranche 3 (Cheshire) and tranche 4 (Lancashire) will follow in early 2015/16 and these opportunities will be assessed when the tenders are published. Specialised Services – NHS England’s review of CAMHS (Child and Adolescent Mental Health) Tier 4 services, and adult medium and low secure mental health services, will continue in 2015/16. The review will focus particularly on whether the right services are being provided in the right place and providing the required capacity. We will be an active participant in this work and recognise that changes in the way services are commissioned and delivered may follow. Substance Misuse Services – The market for alcohol and drugs services continues to be the area where we are most subject to commissioners ‘market testing’ services with a view to driving up quality and value for money. This market is fast-moving, subject to political scrutiny and occupied by a range of competing NHS and third sector providers. Commissioners are issuing requests for tenders at regular intervals (usually, three to five years). As such, opportunities for expansion, and equally risks of losing existing business, arise frequently.

Devolution We are active participants in planning for the devolution of health and social care responsibilities to CCGs and local councils in Greater Manchester during the build-up year (2015/16) and from April 2016 onwards. We are members of the mental health workstream of ‘Devo Manc’ and fully support the principles guiding this development. We recognise that mental health services may be re-shaped as this agenda progresses in order to better meet the interests and outcomes of patients and people in Greater Manchester.

Annual Report 2014/15

Page 11

Manchester Mental Health Improvement Programme We understand the long-standing challenges facing providers of mental health services in Manchester and continue to be engaged in the Manchester Mental Health Improvement Programme (MHIP). This programme of work is focused on reducing fragmentation across Manchester and enabling a more integrated approach; improving outcomes and quality; improving access; and delivering care and treatment based on assessed needs and good practice. We are committed to working with other key stakeholders to redesign services in Manchester and implement new care pathway specifications. We will continue to engage with Monitor and the CQC as this work progresses and in the event that any potential transactions would result in a material or significant change to this organisation.

Competition As more opportunities arise outside the alcohol and drugs field – for example, in health and justice and psychological therapies services - we are taking steps to share our experience across the wider organisation. We have necessarily developed a formal process for bidding/tenders, which includes market shaping, assessments and strategy and defined roles and responsibilities. Within this process, we also focus on relationship management and reputation management, and maintain a knowledge base of the local health economy, commissioner requirements and changing agendas. We will continue to seek to improve our bid maturity in 2015/16. We have also grasped opportunities to deliver services in new ways and by using different contracting models, such as prime provider models, contractual joint ventures and alliance agreements, and will continue to innovate in this regard in future years.

Summary of Board Strategic Intentions In light of this strategic context, we recommit to pursuing the direction set out in our fiveyear strategic plan for 2014 to 2019. This plan resonates with the expectations set out for mental health services in ‘The Five Year Forward View’, ‘The Forward View into Action’ and the NHS Mandate. We welcome the identification of ‘parity for mental health’ as a key priority and the introduction of access and waiting time standards, and respond to these in our plans for 2015/16.

Performance Monitoring Performance against our key priorities is monitored via a number of mechanisms. For example, our approach to business planning allocates responsibility for monitoring, supporting and performance managing the achievement of business plan priorities, throughout the year, to identified individuals (namely, Network Directors and Heads of Service). For those priorities which require resource allocation, and have therefore been developed into a business case, the individual business cases also outline how performance will be monitored. This includes via agreed performance targets; systems to record and report performance; implementation plans, including key milestones and timescales; and the approach to evaluation and evaluation criteria.

Page 12

Greater Manchester West Mental Health NHS Foundation Trust

Financial Plans The Trust has had a successful year financially, achieving a net surplus of £7.8m, and an overall Financial Risk Rating of 4. Whilst 2014/15 has been a successful year for the Trust, the coming years will continue to represent an increasing challenge to both the Trust and to the Public Sector. The NHS faces an unprecedented financial dilemma; the supply of funding is struggling to match the growing demand for healthcare. The need to deliver 4 per cent efficiency savings until 2016 is of immediate concern. Savings of a similar amount are likely to be needed after 2017. Along with all NHS organisations, we will need to identify and deliver 4 to 5% efficiency savings on an annual basis. This means an estimated £5m per year must be saved on a recurrent basis whilst we maintain the quality of services. Our Trust has an excellent track record for making efficiencies but this must continue in the forthcoming years, to ensure that we remain a financially secure organisation. ‘The Five Year Forward View’ highlighted that major system changes are required to protect high-quality sustainable care for patients now and into the future. Additional investment of £1.98bn in mental health services was announced in the autumn 2014 statement, including £150m from NHS England. We welcome this investment and will work with commissioners to ensure that the increase in funding is invested to meet the new standards for early intervention in psychosis services, access standards relating to adult Improving Access to Psychological Therapies services and liaison psychiatry services. The Trust has developed its 2015/16 operational plan in light of the challenging economic backdrop and a clear expectation that the funding provided to the NHS will need to be supplemented by making efficiencies to deal with the rising demand from an ageing population and the increased costs of new technology.

Achievements The last 12 months have been on of achievement and many successes have been awarded to us. Not only did the rapid access detoxification acute referral facility win Team of the Year at the Royal College of Psychiatrists, but GMW also won:

The Junction 17 building won the Design Project of the Year at the Design in Mental Health Network National Awards

• Design Project of the Year at the Design in Mental Health Network National Awards for GMW’s adolescent inpatient unit at Prestwich • Two Advancing Quality awards for Best Performing Trust Annual Report 2014/15

The Dementia Team with their Advancing Quality Award

Page 13

for Dementia and Best Performing Trust for First Episode Psychosis • Two awards at the Care Coordination Association for outstanding practitioners • A National Service User Award for the ‘Getting on The Psychosis Team with their Advancing Quality Award with People’ card game which is designed to help patients discuss their perception and experience of bullying

Risks Our Trust Board hold ultimate accountability for quality. The Board has established a subcommittee with delegated authority to set the strategy for quality and to ensure delivery against it. The Quality Governance Committee is chaired by a Non-Executive Director and includes other Trust Board members, lead clinicians from all clinical services and corporate leads with responsibility for risk and quality management. The structure and business of the Quality Governance Committee has been informed by an assessment against Monitor’s Quality Governance Framework, with guidance and advice from Deloitte. The Quality Governance Committee have an agreed Quality Governance Framework and leads on setting and measuring performance against the Trust’s quality priorities as set out in the annual Quality Account. Trust Board are visible within clinical services and undertake regular visits to services. This provides members with opportunities to triangulate evidence, speak to service users and staff about their experience and to ensure that there is an open and transparent culture within the Trust. The Trust Board’s Board Assurance Framework sets out the key strategic risks, which could affect delivery of our key strategic and quality priorities. The risks identified in the Board Assurance Framework are based on a collective assessment by the Trust Board of the operating environment. They are also informed by risks identified at Directorate/ service level, which are managed via local Risk Registers and reviewed at the Trust-wide Risk Management Strategy Group. Directorate risks are escalated to the Board Assurance Framework in the event that they could significantly impact upon the delivery of our strategic objectives. As quality is at the heart of all of our objectives, risks identified in the Board Assurance Framework have the potential to impact on service quality. Our current key strategic risks, and associated controls, are as follows. Where gaps in controls have been identified by the Trust Board, actions are being progressed to mitigate these. Key risks: • Acute Care Pathway – risk of the redesigned acute care pathway not being implemented effectively, which could result in quality, relationship, financial and workforce issues. Controls in place to mitigate this risk include oversight provided by the Steering Group and designated work-streams; robust business plan; and continuous engagement with CCGs and other key stakeholders during, and subsequent to, the consultation process • Implementation of the new clinical information system – risk of failure to effectively implement the new clinical information system which may impact on safety Page 14

Greater Manchester West Mental Health NHS Foundation Trust

and quality. Controls in place include oversight of the Project Board, robust business plan; engagement of Directors and clinicians in implementation and commitment of required resources • Workforce planning – risk of ineffective/insufficient workforce planning leading to inadequate resources to deliver services and lack of control over pay costs. Control in place include identification of workforce issues via annual business planning process; incorporation of key workforce indicators in monthly Directorate Performance Reports; annual development of Trust-wide Workforce Plan plus specific workforce plans for service redesigns; annual Training Needs Analysis; and cost improvement planning. • Sickness absence – risk of higher than planned sickness absence impacting on service delivery and incurring higher bank and agency expenditure. Controls in place include Sickness Management Policy; monthly Directorate sickness absence reports; designated HR Officer to support Directorates; Absence Management Training for all Line Managers; Occupational Health and Counselling service available to all staff; and monthly monitoring and assurance meetings. • Mandatory training – risk of lower than agreed compliance with mandatory training leading to inadequately trained staff. Controls in place include Induction and Mandatory Training Policy; monthly monitoring at Workforce and Education Governance Committee; adequate classroom and e-learning provision in place; resource built into staffing establishments to enable release of staff for training; and requirement to attend mandatory training made a requirement for pay progression with effect from 1 April 2014. • Compliance with targets – risk of failure to meet national and/or local targets, which may impact on patient care, Trust rating and could lead to financial penalties or intervention from regulators. Controls include Board and Directorate Performance Reports; Data Quality Reports and associated operating guidance; and scrutiny via Network Board, Performance Measures, Contract Monitoring and Quality Governance Committee meetings. • IT business continuity and disaster recovery – risk of lack of resilient IT infrastructure and business continuity/disaster recovery arrangements leading to a delay in the recovery of key clinical and consequently impacting on service delivery and patient safety. Controls include oversight of IM&T Strategy Group and investment in IT infrastructure. • Income (economic climate) – risk of uncertainty/insecurity of income as a consequence of national economic climate and commissioner intentions. Specific risk relate to competition and tendering of our existing services. Controls include financial reporting at Directorate level; signed contracts in place; Contract Monitoring meetings; annual and longer-term planning; contracts risk register; and market assessment of business development opportunities. • Devolution Greater Manchester - the implications of the framework for delegation and devolution of health and social care responsibilities in shadow and final form by April 2016 on commissioning arrangements across Greater Manchester. We are aware that from July 2015, GMW will be subject to an unannounced Care Quality Commission (CQC) ‘deep dive’ inspection where the following questions will be asked: • Are services safe? • Are services caring? • Are services responsible? • Are services effective? • Are services well-led?

Annual Report 2014/15

Page 15

As these visits will be very different from other CQC visits, over the coming months, senior executives will carry out a number of mock inspections in our services which will mirror what would be like if the CQC were to actually inspect the service. These mock inspections are a great way for us to be able to see when our teams are doing really well and when they need extra support. If improvements are needed, we can help staff make positive change.

Our Environment The pressures on the NHS have never been greater with efficiencies being sought from all services involved in the delivery of healthcare. The sustainability agenda is seen by the government as a primary enabler to achieve these efficiencies with the added benefit of releasing significant cost savings across a range of key areas of activity:

One of the many GMW buildings

• Energy and carbon management • Procurement and food • Transport and access • Water • Waste • Designing the built environment • Organisational and workforce development • Partnership and networks • Governance • Finance GMW has been at the forefront of the sustainability agenda throughout 2014/15 promoting and raising the profile of sustainability in its widest context. A number of major achievements in areas as diverse as procurement, energy, and waste have demonstrated GMW’s commitment to meet its sustainable objectives as outlined in the GMW Sustainability Strategy. The Hospital Food Standards Panel in late 2014, after working with organisations including royal colleges and nutritional experts developed a set of compulsory standards and recommendations for hospitals that encourage healthy eating, high-quality food production, sustainability and excellent nutritional care. The Department of Health advised ‘for the first time hospitals will have to meet mandatory food standards as part of a long-mooted drive to raise its standards of food across the country’. The new standards introduced for the first time the need to source food on a sustainable basis through reinforcing the need to reduce food miles and source locally whenever possible. Food Standards 1. Nutritious and appetising food and drink 2. A varied menu which includes meals suitable for all religious needs 3. Access to fresh drinking water at all times Page 16

Greater Manchester West Mental Health NHS Foundation Trust

4. Food and drink that is available at all times 5. Food that adheres to the Government Buying Standards for Food that is sustainable and locally produced where possible. The updated energy pack and video pod casts on the GMW Sustainability homepage are intended to make climate change a reality by bringing to everyone’s attention how their behaviour impacts on the environment. Engaging with service users, visitors and the GMW workforce remains as a key priority in the coming year as changing individuals’ behaviour so they become more carbon aware and consequently less carbon dependant will have the greatest impact on GMW’s fossil fuel consumption and consequently CO2 emissions. The sustainability agenda continues to gather momentum with 2015 being the next benchmark year for NHS organisations to demonstrate they have met their carbon reduction targets. The NHS is required achieve a 10% reduction in its carbon emissions when compared to the 2007 baseline. While it is anticipated that GMW will meet this target a number of energy initiatives have been incorporated into the 2015 capital programme to deliver further reductions in primary and secondary energy consumption. This ensures that our capital investment programme reflects GMW’s ongoing commitment to remaining at the forefront of low carbon technology with highly efficient infrastructure and new buildings. The NHS sustainability day on 26th March 2015 marked the start of the national publicity campaign aimed at promoting carbon reduction strategies and sustainable developments across the entire NHS. GMW was actively engaging and promoted sustainability with events centred at the Waterdale Restaurant and Conference centre. Local companies and suppliers were involved with GMW showcasing its sustainability plans for the coming year. Clinical services were involved for the first time promoting the role of local sustainability champions.

Social, Community and Human Rights Issues Greater Manchester West Mental Health NHS Foundation Trust is committed to improving the lives of our service users, carers, staff and the broader populations whom we serve. Our aspirations to achieve this corporate social responsibility are set out in “Committed to sustaining communities” within which, one of the key objectives is to implement a strategy that promotes social inclusion and the recovery model. Social inclusion and recovery are closely linked to the equality and diversity agendas, and this strategic plan incorporates the Trust’s Single Equality Scheme which sets out our arrangements for meeting our statutory duties in relation to race equality, disability equality and gender equality, as well as actions on age, sexual orientation and spirituality. Through implementation of “Equality, Inclusion, Recovery” we will continue to strive to be an organisation that: • Has the confidence and respect of service users, carers, communities, our staff and partner organisations • Provides high quality mental health and substance misuse services that meet the needs of all our diverse communities • Is fully representative of our diverse communities • Has equality and diversity embedded in its culture • Works with service users to maximise opportunities for full community engagement • Works to reduce stigma in mental health and substance misuse Annual Report 2014/15

Page 17

Supporting staff with disability

• Enhances the quality of life and challenge the exclusion of patients, carers and communities by delivering improved mental health and social care services and outcomes for individuals and communities in partnership with those communities and with our partner organisations. • Recruits, supports and retains a diverse and skilled workforce by providing training and guidance to deliver acceptable, valued and effective services with confidence. • Promotes partnership and networking with service users, carers, our workforce and partner organisations within and across the Trust’s services and geographical communities to support social inclusion and recovery. • Ensures services meet statutory obligations under relevant equalities legislation and the Human Rights Act (1998) • Engages with service users and their carers to ensure that they have equal access to a full range of housing, employment, training and leisure activities and to promote their family life The model of business for the trust is based on the following corporate objectives: • Promote recovery by providing high quality care and delivering excellent outcomes • Work with service users and carers to achieve their goals • Engage in effective partnership working • Invest in our environment • Enable staff to reach their potential and innovate • Achieve sustainable financial strength and be well-governed We recognise our responsibility to involve service users and carers in the planning and provision of services; development of proposals for change in the way services are provided; and other decisions affecting the operation of services. We take this responsibility seriously and have a strong track record of service user and carer involvement and engagements through a variety of mechanisms. A number of the established plans outlined respond to service user feedback. We will continue to work Page 18

Greater Manchester West Mental Health NHS Foundation Trust

with our service users and carers to ensure that plans remain on track and relevant to any changing priorities or needs. Our Council of Governors have actively contributed to the development and agreement of the plans. During 2014, we hosted a round of governor elections and recruited a number of new governors who have rich and varied backgrounds. Further details can be found under the Council of Governors section of this Annual Report. Where required, the views of Overview and Scrutiny Committees and commissioners have and will be sought on specific plans. We are particularly focused on enabling the following: • Market penetration – consolidate or strengthen our position in existing markets • Service development – provide a new type of service, which may or may not be an extension of existing services, in existing markets • Market development – providing a service in which we have experience (i.e. an existing service) in new markets • Diversification – providing a new type of service in new markets During the year 2014 – 2015, staff in post figures are 3136 headcount and 2897.14 WTE.

Table 1 Staff numbers according to gender As at 31 March 2015 Male

Female

TOTAL

Directors

Other Senior Managers

Employees

904

2198

3102

TOTAL

918

2218

3136

Data show number of staff Directors are Chief Exec. Chair, Executive and Non-Executive Directors Other Senior Managers are staff on Bands 8c and above, except those employed to provide clinical services eg. Psychologists Employeers are the remainder of the staff employed by the Trust in substantive posts ie. Bank and Locums excluded

The following accounts have been prepared under a direction issue by Monitor under the National Health Service Act 2006. After making enquiries, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.

Signed: Bev HumpHrey, CHief exeCutive

Annual Report 2014/15

Date: 22nD may 2015

Page 19

Directors’ Report and Management Commentary

coming and friendly • we are caring and kind we go the extra mile • we are welcoming ue and respect • we work together • we go During 2014/15 the following people were directors of Greater Manchester dly • we are caring and kind • we value and West Mental Health NHS Foundation: mile • we are welcoming and friendly • we Alan Maden, Chair e work together • we go the extra mile Jonvalue Bashford, Director and kind • we andNon-Executive respect • we work coming and friendly weNon-Executive are caring and kind Anthony•Bell, Director we go the extra mile • we are welcoming Mike Chapman, Vice Chair and Senior Independent Director ue and respect • we work together • we go Malcolm Cowen, Non-Executive Director dly • we are caring and kind • we value and Kathy Doran, Non-Executive Director mile • we are welcoming and friendly • we e work together we go the extraDirector mile Julie • Jarman, Non-Executive and kind • we value and respect • we work Professor Karen Luker, Non-Executive Director coming and friendly • we are caring and kind Terry McDonnell, Non-Executive Director we go the extra mile • we are welcoming Brian Slater, Non-Executive Director Sunita Thomson, Non-Executive Director Bev Humphrey, Chief Executive Dr Steve Colgan, Medical Director Gill Green, Director of Nursing and Operations Ismail Hafeji, Director of Finance, Information Management and Technology Andrew Maloney, Director of Human Resources and Governance Joe Peers, Director of Estates and Facilities Neil Thwaite, Deputy Chief Executive and Director of Business and Service Development

Page 20

Greater Manchester West Mental Health NHS Foundation Trust

Directors’ Report and Management Commentary

Greater Manchester West Mental Health NHS Foundation Trust recognises that equality of opportunity in employment will promote the full use of the skills and abilities of its entire workforce. Only with the help and commitment of present and future staff will the Trust be able to provide sensitive and effective health care to all its population. The Trust recognises that by developing and using the skills of the whole workforce and in recruiting from all sections of the community will it be best able to meet its core values and objectives. The Trust’s Equal Opportunity Policy aims to prevent covert acts of discrimination but also to highlight requirements and practices, which, although possibly unintentional are discriminatory in nature. It is intended to aid the development of good employment practices in respect of present and future employees.

mile • we a we are cari respect • w the extra m friendly • w value and re go the ext All staff are treated equally and fairly and friendly we value and respect • we work together • we go the ext Everyone who works in the Trust, or applies to work in the Trust, should be treated fairly and valued equally. All conditions of service and job requirements should fit with and friendly • we are caring and kind • we value and respect the needs of the service and those who work in it, regardless of age, disability, race, • we are welcoming and friendly • we are ca nationality, ethnic or national origin, gender, religion, beliefs, sexual orientation, domestic respect • westatus, work together • we go the extra mile • we are circumstances, social and employment marriage and civil partnership, pregnancy and maternity, HIV status, gender reassignment or political affiliation or trade union are caring and kind • we value and respect • we work togeth membership. we are welcoming and friendly • we are caring and kind • we Equality of opportunity means that an individual’s diversity is viewed positively and, we go the extra mile • we are welcoming and frie in recognising that everyone is different, valuing equally the unique contribution that we value respect individual experience,•knowledge andand skills can make. • we work together • we go the ext and friendly • we are caring and kind • we value and respect In September 2014, the Health Service Journal announced that GMW was in the top 100 • we are and friendly • we are ca NHS trusts to work for. Out of the 250 NHS trusts who hadwelcoming taken part in the annual NHS staff survey, GMW wasrespect showcased one of the together best to work • for. • as we work we go the extra mile • we are are caring and kind • we value and respect • we work togeth

Annual Report 2014/15

Page 21

Staff Health and Wellbeing is of upmost Importance

The Health and Safety at Work Act (1974) places a duty on every employer to prepare, and as often as may be appropriate, revise a written health and safety policy and to bring it and any revision to the notice of all relevant persons. GMW has a robust policy encompassing all employees, bank and agency staff, patients and service users, students, volunteers, visitors, contractors and members of the public. It encompasses all activities, premises and services of the Trust. The policy sets out the arrangements for health and safety management within the Trust and determines the responsibility for health and safety at all levels and the methods of communication required for the effective management of health and safety. The purpose of this policy is to provide a framework around which a safe and healthy work environment can be maintained by promoting good working practices and encouraging involvement and commitment to this policy at all levels of the Trust. Whilst legislation exists to enforce good standards of health and safety, the Trust aims not only to adhere to these standards but to improve on them. The promotion and maintenance of the physical and mental wellbeing of all staff is vitally important to the Trust. This is why we have access to a dedicated Occupational Health team of doctors and practitioners to advise the organisation on how best to manage and support an employee who is experiencing illness. Due to the geographical spread of our locations, we have to rely mainly on electronic communications which is why we send a weekly e-bulletin to all staff and rely on our website and intranet to provide staff with the latest information. Over the next 12 months, the Marketing and Communications Team are seeking to improve online availability of information for staff at our various sites. These communication methods routinely include trust performance and financial issues to reassure staff of the current position of the trust. Page 22

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report 2014/15

Page 23

Enhanced Quality Governance Reporting

extra mile • we are welcoming and friendly ect • we work together • we go the extra are caring and kind • we value and respect • we are welcoming and friendly • we are GMW is a high performing organisation, achieving all its mandatory targets set by Commissioners, the Care Quality Commission and Monitor. As well as also achieving our ork together • we go the extra mile financial targets and cost improvement efficiencies, we compare well with other similar nd kind • weorganisations value and respect • westaff work in both the national surveys and community patient survey when compared to other organisations. The findings from the 2014 Community Mental Health coming and friendly • we are caring and kind Survey for GMW were published by the Care Quality Commission (CQC). Service users we go the extra mile • we are welcoming were asked what they thought about different aspects of the care and treatment they received at GMW. ue and respect • we work together • we go GMW’s results comparable to mostand other trusts that participated in the survey and dly • we are caring and are kind • we value findings were that the vast majority of respondents gave positive answers allowing GMW mile • we are welcoming and friendly • we to score higher than most Trusts in England on the following aspects of care: e work together • we go the extra mile • Respondents felt they were always treated with dignity and respect and kind • we value and respect • we work • Respondents felt involved in decisions about medication coming and friendly • we are caring and kind • They felt care and services were organized well and that they were seen often enough we go the extra mile we are welcoming to meet their•needs • A large number felt that they were listened to carefully and were given enough time to discuss their needs and treatment • Many felt that they knew how to contact their care coordinator if they had concerns • Three quarters rated their overall experience of GMW as good or very good • Almost two thirds of respondents knew who to contact out of hours in a crisis As always there is room for improvement and this includes providing better information on medication purposes and side effects. We will also aim to improve service users’ knowledge of who their care coordinator is and how they can be accessed. It is also imperative that all service users have access to an out of hour’s mental health support telephone number and Page 24

We work closely with Carers Greater Manchester West Mental Health NHS Foundation Trust

Enhanced Quality Governance Reporting

we are committed to making this a reality under the new home-based treatment services during 2015. Although our Carers Charter has been fully embedded across the Trust, it is vital that enough information is given to families and carers as they play such an important role in the recovery and ongoing support of service users. We will ensure carers and families remain a significant priority over 2015 – 16 and beyond. However, alongside the annual community mental health survey, service users are now able to give feedback on their experiences of care and treatment provided by GMW since January 2015. Mental Health and Community Health are the latest two areas to start gathering information from thousands of patients across the country – a move that comes after the Family and Friends Test went live across all 8,000 GP practices in England where up to one million people see their doctor every day. GMW mental health inpatients are given an electronic questionnaire to complete on discharge rating how likely they are to recommend us to their friends and family. The majority of our community mental health service users receive a text message asking them the same question. Some services will also have a post box in reception areas and service users will be encouraged to complete a postcard to say how likely they are to recommend us.

However, the real strength of the FFT lies in the rich feedback that service users are able to give direct to our staff in near real time. The free-text comments offer a real opportunity to find out quickly what is working well and what can be improved, making we go the extra mile • we are welcoming and frie our services better for everyone.

• we value and respect • we work together • we go the extra Another development has been the new feature of the ‘Achieve’, Salford recovery friendly • we are caring and kind • we value and respect • we service which will work intensively with all family members to explore the impact of alcohol misuse and equip them with the tools to break harmful patterns of behaviour. • we are welcoming and friendly • we are caring an A specialist young person’s team will work with teenagers and young adults at a time welonger go the extra or mile when people can be particularly vulnerable to developing term problems using • we are welc alcohol in a way whichcaring will impact onkind their future chances, health and wellbeing. and • welife value and respect • we work together • w welcoming and kind • work togeth • we are we caring and k we work tog • we are we caring and • we work Photo from the Achieve Salford Recovery Service Launch Event mile • we a During 2014, GMW became the first UK mental health trust to implement and demonstrate we are caring and kind • we value and respect • we work toge all ten Safeward interventions on a pilot inpatient ward. The interventions involve forming • we staff areand welcoming and friendly • wemore areclosely caring and kind • we better relationships between patients, managing patient’s moods and creating discharge messages whereby patients who are being discharged leave positive messages for current and future patients about their care and time spent on the ward. Safeward principles comprise of planning, compromise, positive environments and reducing incidents which fall in line with GMW’s CQUIN targets and quality account priorities. The Safewards project will roll out to all inpatient wards by 2016. Annual Report 2014/15

Page 25

It is important that we hold ourselves accountable to external organisations to demonstrate our openness, transparency and that we are doing the very best for our service users and their families and carers. We have positive, well established relationships with GP colleagues in clinical commissioning groups (CCGs) and third sector organisations and are committed to working together for the good of the local health and social care economies. By working closely with different partners, we can ensure that mental health, drug and alcohol services remain top of the health agenda. We have a strong relationship with the Local Authority Overview and Scrutiny Committees (OSCs) in Bolton, Salford and Trafford, as well as the newly established Healthwatch and the local Health and Wellbeing Boards. We place a high value on their involvement and are glad they share our commitment to provide high quality mental health services for the communities we serve. Safeguarding children and vulnerable adults is also one of our top priorities and we work with local safeguarding boards to make sure all partners involved in the care of children and adults communicate regularly. The Board of Directors publicly scrutinises key performance and quality indicators at the public meetings of the Trust Board. As well as at Board level, our performance against local and national targets and quality indicators is subject to internal scrutiny at individual Directorate level and Trust-wide at Network Boards and the Performance Measures Group. We are also monitored by external organisations including our Commissioners through contract and quality groups, the Care Quality Commission (CQC) and Monitor. The CQC have inspected our services regularly during the last 12 months and our registration with the CQC is without any conditions, showing full compliance with the essential standards of quality and safety. Our Business Intelligence Team has established robust structures and processes to enable review and reporting against our performance requirements and other contractual commitments. These processes enable us to demonstrate our compliance with standards, as well as identifying areas for further improvement. Our Quality Account also provides assurance about the quality of services provided by GMW. The Quality Governance Committee, a formal sub-committee of the Board monitors in detail performance against key milestones and improvement priorities. We take advantage of our foundation trust status by hosting the Dragons Den initiative, which is chaired by the Trust Chair. This has funded small innovative projects across our services, which help us achieve our quality account priorities. Dragons Den Panel Front line staff and service users and carers have pitched their ideas to the Dragons, resulting in over 30 projects being funded. These work streams have helped us demonstrate improvement in areas such as physical healthcare, carers and service userâ&#x20AC;&#x2122;s experience, psychological therapies, dual diagnosis and dementia care. Some examples of the initiatives the Dragons have funded can be found in the Quality Account. The Trust is committed to ensuring that service users, carers, staff and the general public who access our services have a safe, effective and positive experience. In delivering this commitment, the Trust recognises and supports the need for care to be delivered in safe Page 26

Greater Manchester West Mental Health NHS Foundation Trust

environments with minimal risk to service users and staff and that care delivery is personcentred, evidence based, efficient and effective. We acknowledge and appreciate that Quality and Governance is everyone’s responsibility and all staff must contribute to the organisational values by: • Working within National Guidance, Trust policies and local service guidelines • Adhering to multiagency safeguarding procedures, including Prevent to protect children, young people and vulnerable adults from all forms of abuse • Identifying and managing potential risks and reporting incidents in order to protect service users, carers and staff and support lessons learnt from such events • Demonstrating transparency, openness and a duty of candour • Valuing and respecting diversity and treating service users, carers and colleagues with dignity, respect and compassion • Actively contributing to and supporting positive practice and innovation • Addressing and managing evidence of poor standards of care or negligence or abuse of service users by reporting such incidents as per Trust policy • Keeping up to date with research, developments and evidence based practice • Delivering a robust clinical audit programme and acting on results as appropriate • Supporting data collection for the monitoring and reporting of service quality to external regulators i.e. Monitor, Health and Safety Executive, Care Quality Commission, Clinical Commissioning Groups, NHS England and the NHS Litigation Authority in order to provide organisational compliance assurance The safety of service users, carers, staff and the general public is of the utmost importance. We continue to use and expand our web-based patient safety and risk management system, which are linked with our electronic medical records systems to ensure service user records can be accessed quickly and securely. These systems have continued to improve the timely management and lessons learnt from incidents and identify potential risks. As a result of our web-based patient safety and Safety is very important to us risk management system we continue to see a reduction in clinical and non-clinical claims. We have had independent verification that our incident management and risk management arrangements are strong and robust enough to ensure that patient safety is first-rate. Our Customer Care Team support and facilitate the management of complaints and compliments. When we receive a complaint, we aim to address it in a timely manner and provide individuals with all the evidence available to show that we have dealt with their concerns using a clear and transparent approach. Service users and carers are involved with meetings and projects in order to share their experiences so that we may further understand the needs of our local communities and respond by adopting our services accordingly. To further facilitate lessons learnt, safety and evidence based practice we have an annual internal audit calendar. This audit calendar is produced and agreed by the Nice Implementation & Audit Group which reports to the Board of Directors. This audit calendar captures the national, clinical and directorate audits that we undertake in order to demonstrate that we do take the provision of patient centred, equitable, safe, high quality, and evidence based care very seriously. Any weaknesses highlighted from the audit outcomes are then addressed and reassessed by repeating the audit cycle. Further Annual Report 2014/15

Page 27

assurance is provided, as required, through the procurement of Mersey Internal Audit Agency who undertook independent audits within the Trust and produced a level of assurance and recommendations for improvement. This assurance is further enhanced through our Quality Accounts. We continue to monitor our performance under the Mental Health Act to ensure that our practice is lawful and in accordance with the Code of Practice and we continue to strengthen our Trust-wide Mental Health Act management arrangements to help us achieve consistently high standards in our administration of the Act. Whilst we are recognised for already providing good quality care, demonstrated by our compliance with external regulators, we recognise that there is always room for improvement. As an organisation with a culture for continuous learning, we encourage all our staff and service users to make suggestions for quality improvement and be involved in implementing the great ideas that are adopted, in order to further enhance safe, effective and positive experiences for users of our services.

Page 28

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report 2014/15

Page 29

Statement of Directors’ Responsibilities in Respect of the Accounts

g and kind • we value and respect • we work coming and friendly • we are caring and kind we go the extra mile • we are welcoming ue and respect • we work together • we go dly • we are caring and kind • we value and The directors are required under the NHS Act 2006 and under a direction issued by mile • we are welcoming and friendly • we Monitor, to prepare accounts for each financial year. In preparing those accounts, the directors are required to ensure that: e work together • we go the extra mile and kind • we value and respect • we work • So far as the directors are aware, there is no relevant audit information* of which auditors are aware; coming and friendly • we are caring and kind • mile The directors have taken all of the steps that they ought to have taken as a director in e go the extra • we are welcoming and order to make themselves aware of any relevant audit information* and to establish nd respect • wethat work together • we go information. the the auditors are aware of that * “Relevant audit information” means information needed by the auditor in connection we are caring and kind • we value and respect with preparing their report. • we are welcoming and friendly • we are A director is regarded as mile having • taken the steps that they ought to have taken as a k together • we go the extra weall are director in order to do the things mentioned above, if they have: d • we value and respect • we work together • • Made such enquiries of their fellow directors and of the NHS Foundation Trust’s d friendly • we are caring and kind • we value auditors for that purpose, and • Taken such other steps (if any) for that purpose, as are required by their duty as a director of the NHS foundation trust to exercise reasonable care, skill and diligence.

After making enquiries, the directors have a reasonable expectation that the NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts. Accounting policies for pensions and other retirement benefits are set in note 7 to the accounts and that details of senior employees can be found in page 27 of the remuneration report.

Page 30

Greater Manchester West Mental Health NHS Foundation Trust

Statement of Directors’ Responsibilities in Respect of the Accounts

By order of the Board.

Signed:

Bev HumpHrey

ismail Hafeji

CHief exeCutive

DireCtor

D a t e : 22 n D m a y 2015

Date: 22nD may 2015

finanCe

anD

i m& t

Our Board of Directors operate to the highest corporate governance standards. It is responsible for all aspects of the performance of the Trust, including financial performance, clinical and service quality, management and performance. The Board is legally accountable for the services provided by the Trust and their key • we value and respect • we work together responsibilities include:

• we go the ext

and friendly • we are caring and kind • we value and respect

• Setting the strategic direction, having taken into account the Council of Governors’ • we are welcoming and friendly views • Ensuring that our services provide safe, clean and personal care for patients respect • we work together • we go the

• we are ca

extra mile • we are

• Ensuring robust governance arrangements are in place

are caring and kind • we value and respect • we work togeth

• Ensuring rigorous performance management so that we achieve all local and national targets we are welcoming and friendly • we are caring and

kind • we

• Ensuring that we are always compliant with our Terms of Authorisation

we go the extra mile • we are welcoming and frie

The Board has decided that certain decisions may only be exercised or made in formal • we value and respect • we work together • we go the extra Board sessions. These are set out in the reservation of powers to the Board and the Scheme of Delegation.friendly • we are caring and kind • we value and respect • we

• we are welcoming and friendly • we are caring an

Declaration of Interests

we go the extra mile • we are welc

caring and kind • we value and respect • we work together • w

The Board of Directors undertakes an annual review of its Register of Declared Interest. At welcoming and friendly • we are caring and kind • we value and each meeting of the Board of Directors, a standing agenda item also requires all Executive and Non-Executive Directors to make known an interest in relation to the agenda and we go the extra mile • we are welcoming and friendly • we a changes to their declared interests. The Register of Declared Interests for the Board of Directors is held by the Trust Secretary and is available for public inspection. Members of and respect • we work together • we go the extra mile • we the public can gain access by contacting Steph Neville, Head of Corporate Affairs, Trust Headquarters, Greater Manchester West Mental Health NHS Foundation Trust, Bury New we are caring and kind • we value and respect • we work toge Road, Prestwich, M25 3BL

Annual Report 2014/15

Page 31

endly • we are caring and kind • we value and tra mile • we are welcoming and friendly • we As an NHS Foundation Trust, Greater Manchester West Mental Health NHS Foundation • we work together • we go the extra mile Trust is required by its Terms of Authorisation to comply with the principles of best ing and kind •practice we value and respect • we work applicable to corporate governance in the NHS/health sector and with any welcoming andrelevant code of practice, in particular the NHS Foundation Trust Code of Governance friendly • we are caring and kind • we go theThe expectations of the NHS in respect of standards of corporate conduct are set out in extra mile • we are welcoming guidance issued by the Department of Health and the NHS Appointments Commission, value and respect • we work together • we go the ‘Code of Conduct Code of Accountability in the NHS’ and Monitor’s ‘The NHS endly • we are caring and kind • we value and Foundation Trust Code of Governance’. tra mile • we are welcoming and friendly • we The Code of Conduct for the Board of Directors of Greater Manchester Mental Health • we work together • we go the extra mile NHS Foundation Trust (the Trust) is consistent with this guidance and seeks to expand on and complement the Constitution for Greater Manchester West Mental Health NHS ing and kind • we value and respect • we work Foundation Trust (the Constitution). welcoming and friendly • we are caring and kind Under the provisions of the Constitution, the Trust shall have a Register of Interests to • we go therecord formally declarations of interests of Board of Directors. In particular, the Register extra mile • we are welcoming will include of all directorships value and respect • wedetails work together • and weother go relevant material interests, which both Executive and Non-Executive Board Directors have declared. endly • we are caring and kind • we value and tra mile • weMembers of the Board of Directors must declare on appointment any interests, which are welcoming and friendly • we might place, or be seen to place them in a potential conflict of interest between their • we work together • we go the extra mile personal or private interest and those arising from their membership of the Board of Directors. Board Directors are also required to declare any conflict of interest that arises in the course of conducting Trust Business, specifically at each meeting of the Board. The Register of Interests will be maintained by the Head of Corporate Affairs and shall be available for inspection by members of the public on request. The Register will be subject to annual review by the Board.

Page 32

Greater Manchester West Mental Health NHS Foundation Trust

Chair Alan Maden

Trustee Pension Fund – St Ann’s Hospice

Non Executive Directors Jon Bashford

Director of Research and Development TiFCi Senior Partner, Community Innovations Enterprise LLP Undertakes contract work across NHS & LAs across England

Anthony Bell

Non- Executive Director, Guinness Partnership Non-Executive Director, Carriocca Enterprises Vice-Principal, The Grimsby Institute of Further & Higher Education

Mike Chapman

No directorships or significant interests to declare

Malcolm Cowen

No directorships of significant interests to declare

Kathy Doran

Trustee and acting Vice-Chair of The Reader Organisation Non Executive Director of Your Housing Group

Julie Jarman

Trustee of MIND in Salford (delivers IMHA services with GMW)

Karen Luker

University nominated Non-Executive Director post Head of School of Nursing, Midwifery and Social Work, Queen’s Nursing Institute of Professor of Community Nursing, The University of Manchester

Terry McDonnell

No directorships or significant interests to declare

Brian Slater

No directorships or significant interests to declare

Sunita Thomson

Director of Goal Development Consultancy • we value and respect • we

Chief Executive Bev Humphrey

work together • we go the

and friendly • we are caring and kind • we value and respe we are welcoming No directorship or significant•interest to declare

Executive Directors

and friendly • we are

respect • we work together • we go the extra mile • we

Stephen Colgan

caring and kind • we value No are directorships or significant interests to declare

and respect • we work toge

Gill Green

No we directorships or significant interests declare are welcoming and to friendly

• we are caring and kind •

Ismail Hafeji

No directorships or significant interests to declare

Andrew Maloney

we gointerests the extra mile No directorships or significant to declare

Joe Peers

No • directorships or significant interests•towe declare we value and respect work

Neil Thwaite

No directorships or significant interests to declare

• we are welcoming and

together • we go the ext

friendly • we are caring and kind • we value and respect •

• we are welcoming and friendly • we are caring

we go the extra mile • we are w

caring and kind • we value and respect • we work together • welcoming and friendly • we are caring and kind • we value

we go the extra mile • we are welcoming and friendly • w and respect • we work together • we go the extra mile •

we are caring and kind • we value and respect • we work to

Annual Report 2014/15

Page 33

Renumeration Report

• we work together • we go the extra mile g and kind • we value and respect • we work Table 2 Remuneration of Board Members coming and friendly • we are caring and kind 2014/15 Taxable Name mile Title• we are welcoming Salary we go the extra Benefits* and Fees ue and respect • we work together • we(Bands of go To nearest £5,000) £100) £’000 £ dly • we are caring and kind • we value and Chair 40-45 A Maden mile • we areM Chapman welcoming and friendly • 0-10 we Non Executive Director (retired July 2014) e work together • weNon Executive Director (retired July go the extra mile 0-10 J Bashford 2014) and kind • we value and respect • we work Non Executive Director 10-15 Prof K Luker Non Executive Director (retired July coming and friendly • we are caring and kind 0-10 B Slater 2014) Non Executive Director 1520 e go the extraT McDonnell mile • we are welcoming and Non Executive Director 15-20 M Cowen nd respect • we work together • we go the Non Executive Director- new in 0-10 A Bell post 14/15 we are caring and kind Non Executive Director- new in • we value and respect 0-10 K Doran 14/15 • we are welcoming Post and friendly • we are Non Executive Director- new in 0-10 J Jarman Post 14/15 k together • we go the extra mile • we are Chief Executive 160-165 3,300 B Humphrey d • we value and respectDirector of Operations &Nursing • we work together • 110-115 110-115 G Green Directorof Finance and IM&T 110-115 3,100 Hafeji d friendly • we Iare caring and kind • we value A Maloney

Directorof HR & Governance

110-115

2014/15 Total Salary

2013/14 Salary and Fees

Taxable Benefits*

2013/14 Total Salary

(Bands of £5,000) £’000

To nearest £100) £

(Bands of £5,000) £’000

40-45

0-10

15-20

0-10

10-15

0-10

1015

10-15

15-20

0-10 0-10 0-10 165-170

160-165

3,400

110-115

1,100

110-115

160-165

115-120

110-115

1,800

110-115

3,700

115-120 1 110-115 1

2,800

115-120

S Colgan

Medical Director

95-100

J Peers

Director of Estates & Facilities

120-125

3,300

120-125

110-115

3,000

115-120

N Thwaite

Director of Service & Business Development

110-115

3,400

115-120

110-115

3,000

115-120

* Benefits in kind relate to the provision of lease cars to Board Members. ** There were no annual performance related or long-term performance-related bonuses paid to Board Members during 2013/14 or 2014/15

Page 34

Greater Manchester West Mental Health NHS Foundation Trust

Renumeration Report

Table 3 Pension Benefits as at 31 March 2015

Name

Title

Real Increase in Pension and Related Sum at Age 60

Total Accrued Pension and Related Lump Sum at Age 60 at 31 March 2015

Cash Equivalent Transfer Value at 31 March 2015

Cash Equivalent Transfer Value at 31 March 2014

Real increase in Cash Equivalent Transfer Value

(Bands of £2,500) £’000

(Bands of £5,000) £’000

£’000

Bev Humphrey

Chief Executive

7.5-10

255-260

1,241

1,166

Neil Thwaite

Director of Service and Business Development

5-7.5

120-125

459

423

Ismail Hafeji

Directorof Finance and IM&T

5-7.5

175-180

893

841

Gillian Green

Director of Operations and Nursing

10-12.5

185-190

993

907

Andrew Maloney

Director of HR and Governance

5-7.5

107-110

379

352

Joseph Peers

Director of Estates and Facilities

5-7.5

225-230

1,276

-1,276

As non-executive directors do not receive pensionable remuneration, there are no entries in respect of pensions for non-executive directors.

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 pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme or arrangement when the member • we to value and respect • weinwork together leaves a scheme and chooses transfer the benefits accrued their former scheme. • we go the ext The pension figures shown relate to the benefits that the individual has accrued as a and friendly • we are caring and kind • we value and respect consequence of their total membership of the pension scheme, notjust their service in a senior capacity to which the disclosure applies. The CETV and the other pension figures, • we are welcoming and friendly • we are ca include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional respect • we work together • we go the extra mile • we are pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETV5 are calculated within the are caring and kind • we value and respect • we work togeth guidelines and framework prescribed by the Institute and Faculty of Actuaries.

we are welcoming and friendly • we are caring and kind • we

Real Increase in CETV -This reflects the increase in CETV. It takes account of the increase we go the extra mile • we are welcoming and frie in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement) and uses • wefactors value and respect • of we common market valuation forth e start and end thework period.together • we go the extra

• weExpenses are caring Table 4 Governorsfriendly and Directors

and kind • we value and respect • we

• we are welcoming and friendly • we are caring an 2014/15 2013/14 Governors Total Numberin Office during the year

Directors

Governors

Directors

we go the extra mile • we are welc 17 27 14

0 12 3 11 caring and kind • we value and respect • we work together • w Aggregate Expenses Sum Paid (to the nearest £000) 0 6,900 200 6,600 Number Receiving Expenses

welcoming and friendly • we are caring and kind • we value and

Three non executive directors retired part way through the financial year 2014/15 with three new non executives subsequently joining the Board Govenor elections took place we go the extra mile • we are welcoming and friendly • we a during the year due to 2 resignations and one govenor coming to the end of term of their office. 9 new governors were elected to office in July 2014, and 1 in February 2015. and respect • we work together • we go the extra mile • we

we are caring and kind • we value and respect • we work toge

Annual Report 2014/15

Page 35

Table 5 Hutton Review of Fair Pay - Disclosure Information

Band of Highest Paid Directors Total * Mid-point of Highest Paid Director

2014/15

2013/14

£’000

165-170

160-165

167.5

162.5

2014/15

2013/14

£26,822

6.24 times

6.06 times

* - The highest paid director represents the Chief Executive.

Staff Median Total Remuneration * Ratio **

* - The calculation is based on full-time staff as at 31st March 2015 and is calculated on an annualised basis. ** - Ratio represents the median remuneration of staff compared to the mid-point of the highest paid director.

Table 6 Off-Payroll Engagements For all off-payroll engagements as of 31 Mar 14 to 1 Apr 15, for more than £220 per day and that last for longer than six months”

2014/15

2013/14

Number that have existed for less than one year at the time of reporting

Number that have existed for between one and two years at the time of reporting

No. of existing engagements as of 31 Mar 2016 Of which:

Number that have existed for between two and three years at the time of_reporting Number that have existed for between three and four years at the time of reporting Number that have existed for four or more years at the time of reporting

The Trust can confirm that all existing off payroll engagements, outlined above, have been subject to a risk based assessment as to whether assurance is required that the individual is paying the correct amount of tax. The Trust can confirm that the For all new off-payroll engagements, or those that reached six months in duration, between 1 Apr 2014 and 31 Mar 2015, for more than £220 per day and that last for longer than six months

2014/15

2013/14

No. Of Engagements

Number of new engagements, or those that reached six months induration between 01 Apr 2014 and 31 Mar 2015

Number of the above which include contractual clauses giving the trustthe right to request assurance in relation to income tax and national insurance obligations

Number for whom assurance has been requested

Number for whom assurance has been received

Number for whom assurance has not been received*

Number that have been terminated as a result of assurance not being received

Of which:

Page 36

Greater Manchester West Mental Health NHS Foundation Trust

For any off-payroll engagements of board members, and/or senior officials with significant financial responsibility, between 1 Apr 2014 & 31 Mar

2014/15 Number of engagements

Number of off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year. Number of individuals that have been deemed â&#x20AC;&#x2DC;board members and/or senior officials with significant financial responsibilityâ&#x20AC;?. This figure should include both off-payroll and on-payroll engagements.

0 0

Sickness Absence Information In accordance with FReM (Government Financial Reporting Manual) guidance the sickness absence figures have been calculated on a calender year basis for 2014/15 (January to December 2014). They are based on data from ESR Data Warehouse. The sickness absence rate is calculated by dividing the sum total sickness absence days (including non workingdays) by the sum total available days per month for each staff member). Average of 12 months (2014 calender year)

Average Full Time Equivalent 2014

6.50%

2,646

Full Time Equivalent days Available 595,415

Full Time Equivalent days Lost to Sickness Absence 38,633

Average Sick Days per Full Time Equivalent 14.6

Signed: Bev HumpHrey, CHief exeCutive

Annual Report 2014/15

Date: 22nD may 2015

Page 37

How We Work

g and kind • we value and respect • we work coming and friendly • we are caring and kind Greater Manchester West Mental Health NHS Foundation Trust has applied the principles we go the extra mile • we are welcoming of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the ue and respect • we work together • we go principles of the UK Corporate Governance Code issued in 2012. dly • we are caring and kind • we value and The Board of Directors have established governance policies to make sure we comply with mile • we are welcoming and friendly • we the Code of Governance. These include: e work together • we go the extra mile • Corporate Governance Framework Manual incorporating the Standing Orders of the and kind • weBoard of Directors, Standing Orders of the Council of Governors, Scheme of Reservation value and respect • we work and Delegation of Powers and Standing Financial Institutions coming and friendly • we are caring and kind • mile Governance Strategy and Plan e go the extra • we are welcoming and • Established role of Senior Independent Director nd respect • we work together • we go the • Regular private meetings between the Chair and Non-Executive Directors we are caring and kind • we value and respect • Non-Executive Director Performance Appraisal Process developed and agreed by the • we are welcoming friendly • we are Council of and Governors k together • we go the extra mile • we are • Formal induction programme for Non-Executive and Executive Directors d • we value and respect • we work together • • Attendance records for Directors and Governors at key meetings Comprehensive induction programme for Governors d friendly • we• are caring and kind • we value • Register of Interests of Directors, Governors and Senior Staff • Establishment of the role of Lead Governor • Comprehensive Assurance Briefing Report to all meetings of Council of Governors • Effective Council of Governors’ sub-committee structure • Council of Governors’ agenda setting process • Membership Development Strategy, Implementation Plan and Key Performance Indicators • Nominations, Remuneration and Terms of Service Committee of the Board of Directors • Nominations, Remuneration and Terms of Service Committee of the Council of Governors • Agreed recruitment process for Non-Executive Directors • High quality reports to the Board of Directors and Council of Governors • Board evaluation and development plan • Council of Governors’ presentation of performance and achievement at Annual Page 38

Greater Manchester West Mental Health NHS Foundation Trust

How We Work

Members’ Meetings • Code of Conduct for Governors • Going Concern Report • Robust Audit Committee arrangements • Governor-led appointment process for External Auditor • Whistle-blowing Policy and Counter Fraud Policy and Plan The sub-committees of the Board are: • Audit Committee • Remuneration and Terms of Service Committee • Remuneration and Terms of Office Committee • Quality Governance Committee • Charitable Funds Committee • Nominations Committee GMW is compliant of the NHS Foundation Trust Code of Governance. All other requirements are listed in the table in Appendix 1 of this Annual Report, with page references of where to find these matters which are in the public interest.

• we value and respect Table 7 - Board of Directors attendance:Alan Maden (Chair) Mike Chapman Malcolm Cowen Anthony Bell Kathy Doran

• we work together • we go the ext

and friendly • we are caring and kind 10/10 • we value and respect 3/3

• we are welcoming and friendly • we are ca 9/10

7/7 extra mile • we are respect • we work together • we go the 7/7

Julie Jarman

are caring and kind • we value and respect • we work togeth 7/7

Karen Luker

7/10caring and kind • we we are welcoming and friendly • we are

Terry McDonnell Brian Slater Jon Bashford Bev Humphrey Andrew Maloney Neil Thwaite Steve Colgan Joe Peers Ismail Hafeji Gill Green

10/10

we go the extra mile • we 3/3 are welcoming and frie

3/3 • we go the extra • we value and respect • we work together 9/10

friendly • we are caring and kind • we10/10 value and respect • we

10/10 • we are welcoming and friendly • we are caring an 9/10

we go the extra 7/10 mile • we are welc

caring and kind • we value and respect 10/10 • we work together • w 9/10

welcoming and friendly • we are caring and kind • we value and

The use of appraisal for Directors is good practice and supports the principle outlined in the NHS Foundation Trust Code of Governance that an effective Board of Directors should we go the extra mile • we are welcoming and friendly • we a lead every NHS Foundation Trust.

and respect • we work together • we go the extra mile • we

During 2014, the Trust continued its Chair and Non-Executive appraisal. The process, we are caring andofkind • weofvalue and respect • we led by the Nominations Committee on behalf the Council Governors introduced a structured, competency-based approach including self and peer assessment from the Director. The Chair conducted the Chief Executive’s performance evaluation who in turn conducted those of the Executive Directors.

Annual Report 2014/15

Page 39

work toge

The outcome of the Chair and Non-Executive Director appraisals were considered at a Council of Governors meeting during 2014. All Directors have agreed objectives and personal development plans for the following year, which has been developed alongside the Trust’s strategic objectives. The Board of Directors held dedicated development sessions throughout the year to enable detailed analysis of areas of corporate strategy. The Board received internal audit opinion on the robustness of the Trust’s processes including self-accreditation and Core Standards Assessment and Registration processes and Code of Compliance against Monitor guidance has been received.

Board of Directors – appointment and removal of chair and other non-executive directors The Council of Governors at a general meeting of the Council of Governors shall appoint or remove the chair of the trust and the other non-executive directors. The Council of Governors shall appoint the Chair and other non-executive directors in accordance with the following procedures: • The Council of Governors shall appoint a Nominations Committee, chaired by the Chair of the trust (or when a chair is being appointed, the vice-chair, unless the vice-chair is standing for appointment, in which case another non-executive director if the Chair is absent) and comprising some or all of its members. • The Nominations Committee shall seek the views of the Board of Directors as to their recommended criteria and process for selection of candidates and, having regard to those views, shall then seek, short-list and interview such candidates as the committee considers appropriate. • The Nominations Committee shall make recommendations to the Council of Governors as to potential appointments as non-executive directors and shall advise the Board of Directors of those recommendations. • The Nominations Committee shall have such terms of reference and powers as agreed by the Council of Governors. The terms of reference shall have effect as if incorporated into the Standing Orders of the Council of Governors. • Removal of the chair or another non-executive director shall require the approval of not less than three-quarters of the members of the Council of Governors.

Page 40

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report 2014/15

Page 41

Council of Governors

xtra mile • we are welcoming and friendly • • we work together • we go the extra mile The Trust has a Council of Governors responsible for representing the views and interests g and kind • we value and respect • we work of the members and partner organisations. Governors are local people, service users, coming and friendly wewho arehave caring kind carers and•staff beenand elected by their constituency members to represent their views. They also have formal duties which include the appointment of the Trust’s Chair we go the extra mile • we are welcoming and Non-Executive Directors and their termination, approval of the appointment of the ue and respect • we work together • we go Chief Executive, providing their views to the Board of Directors on Trust plans, to review the membership development strategy and to make recommendations for the Trust’s dly • we are caring and kind • we value and constitution. Being a Governor is a demanding, yet incredibly important and fulfilling mile • we are welcoming and friendly • we role. They remain our ‘critical friend’ who offer support, guidance and challenges and work closely with us to build local relationships with key stakeholders. Governors present e work together • we go the extra mile us with another opportunity for us to learn from service users and carers, the public and keyvalue stakeholders improve the services we offer. and kind • we andtorespect • we work coming and friendly • we are caring and kind Due to the close working relationship between the Council of Governors and the Board of Directors, conflicts or disagreements are aired and resolved quickly. The Lead Governor we go the extra mile • we are welcoming and Senior Independent Director play a crucial role in this. They also have regular one-toue and respect • we together • we go ones with work the Chair. dly • we are caring and kind • we value and Unlike many other foundation trusts, there is frequent and regular attendance by members of the Board of Directors at Council of Governor meetings. There is also an mile • we are welcoming and friendly • we annual joint meeting held between the Board of Directors and Council of Governors. e work together • we go the extra mile Governors help to agree the strategic direction of travel during the Trust’s Annual and kind • we value and respect • we work Member’s Meetings. Not only do they reflect on the previous year’s performance, they also agree priorities and objectives for the coming twelve months. Minutes of these meetings can be found on the Trust’s website, where there is also the facility for Governors and members to provide feedback to the Trust.

Page 42

Greater Manchester West Mental Health NHS Foundation Trust

Council of Governors

Table 8 - Council of Governors attendance Name

Attendance

Les Allen, Public: Bolton

2/3

Peter Baimbridge, Public: Salford

3/5

Fareed Bashir: Staff: Medical

3/5

Rob Beresford: Other North West

4/5

Desmond Bradley: Public: Bolton

3/3

Anne Broadhurst (Lead Governor), Service User & Carer

5/5

Paul Butcher: Public: Trafford

5/5

Jennifer Carlisle, Staff: Nursing

5/5

Hazel Carter, Public: Trafford

4/5

Steve Coen, Appointed: Salford City Council

0/5

Ann Cunliffe, Appointed: Bolton

2/4

Jonathan Elster, Public: Salford

1/1

Iris Emery, Service User & Carer

3/3

William Gallagher, Public: Bolton

1/5

Andrew Greenhalgh, Service User & Carer

3/3

Paul Ingham, Service User & Carer

1/5

Eileen Killeen, Service User & Carer

0/5

• we value and respect we Leah Madnick, Staff: Allied Health Professionals (resigned in • 2014)

work together • we go the ext 2/2

Sarah McDonald, Staff: Non-Clinical

1/3

John McLellan, Public: Salford

3/5

and friendly • we are caring and kind • we value and respect

5/5 friendly • we are ca • we are welcoming and

Alan Mitchell, Appointed: Trafford Eddie Murdoch, Staff: Non-Clinical

2/3

respect • we work together • we go the extra mile • we are Paul Pandolfo, Appointed: Inspiring Change Manchester 3/5 Margaret Riley, Service User & Carer are caring

Philip Saxton, Public: Other North West

4/5 and kind • we value and respect • we work togeth 3/5

we are welcoming and friendly • we are Sylvia Seddon, Public: Trafford 3/5caring and kind • we Julie Turner, Staff: Non-Clinical

we go the extra mile • we 2/3 are welcoming and frie

Tony Warne, Appointed: University of Salford

0/5

• we value and respect • we work together Margaret Willis, Service User & Carer 2/3 • we go the extra Joanne Wilson, Service User & Carere

friendly • we are caring and kind • we 0/5 value and respect • we

Sally Claydon, Appointed: Cloughside College (resigned in 2014)

2/2

• we are welcoming and friendly • we are caring an Andrew Morgan, Public: Bolton (resigned in 2014) 1/1 Mike Hulmes, Staff: Non-Clinical (retired in 2014) Wilf Davison, Appointed: Cloughside College

0/2 we go the extra mile • we are welc 0/1

caring and kind • we value and respect • we work together • w

All Governors are required to comply with the Trust’s Code of Conduct and declare any interests that may result in a potential conflict in their role as a Governor of the Trust. welcoming and friendly • we are caring and kind • we value and

we go the extra mile • we are welcoming and friendly • we a

and respect • we work together • we go the extra mile • we

we are caring and kind • we value and respect • we work toge

Annual Report 2014/15

Page 43

The register of interests is maintained and is available via: Steph Neville Head of Corporate Affairs Greater Manchester West Mental Health Trust NHS Foundation Trust Bury New Road Prestwich Manchester M25 3BL

The Elections During 2014, a round of elections took place to fill the following vacancies: • Public – Bolton (two seats) • Public – Salford (one seat) • Public – Trafford (one seat) • Service users and carers (three seats) • Staff – Allied health professionals (one seat) • Staff – Non –clinical (two seats) • Staff – Nursing (one seat)

The Trafford and the Nursing staff seats were uncontested, however, the member of nursing staff – Joanne Howcroft - left the Trust shortly after taking the role, so this seat remains vacant. No one stood for the seat in Salford, however, the Council has co-opted a Governor into that seat. The new governors are as follows: Public – Bolton: Les Allen and Desmond Bradley Public – Salford: Jonathan Elster Service users and carers: Iris Emery, Andrew Greenhalgh and Margaret Willis Staff – Allied health professionals: Leah Madnick Staff – Non-clinical: Sarah McDonald, Eddie Murdoch and Julie Turner

Page 44

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report 2014/15

Page 45

Membership of the Board of Directors

tra mile • we are welcoming and friendly • we work together • we go the extra mile and kind • we value and respect • we work oming and friendly • we are caring and kind Alan Maden, Chair (current terms ends December e go the extra mile • we are2015) welcoming e and respect • we work together • we go Alan was previously a Non-Executive Director at the Trust from February 2005 to September 2009 when he was formally made y • we are caring and kind • we value and Chair of the Trust. He is a retired Senior Partner of a local practice mile • we are welcoming and friendly we of solicitors•but also has a wealth of NHS experience. He was Chair of the Bury and Rochdale Health Authority from 1994 to work together • we go the extra mile 2002 and was a Non-Executive Director and Vice Chair of the Greater and kind • we value and respect • weManchester work Strategic Health Authority in April 2002. At the Strategic Health Authority’s request he was also Acting Chair oming and friendly • we are caring and kind of the Manchester Mental Health and Social Care Trust from 2002 to September 2004, in a turnaround role. e go the extra mile • we areFebruary welcoming e and respect • we work together • we go y • we are caring and kind • we value and Jon Bashford, Non-Executive Director (term of office came to an end in July 2014) mile • we are welcoming and friendly • we Jon became a Non-Executive Director in 2005. He has over 20 work together • we go the extra mile years’ experience in the statutory and voluntary sectors in the and kind • we value and respect • we work fields of drugs, alcohol and mental health both as a clinician and a senior manager. Jon has a research interest in equality and diversity and his PhD was in the area of race equality and organisational change. Jon is a senior partner with Community Innovations Enterprise (CIE) and undertakes work across the public sector including the NHS on equality, human rights, community engagement and needs assessment.

Page 46

Greater Manchester West Mental Health NHS Foundation Trust

Membership of the Board of Directors

Anthony Bell, Non-Executive Director (current terms ends July 2018) Anthony joined GMW in 2014 and is a qualified accountant. He is part-time vice principal of commercial activities at the Grimsby Institute of Further and Higher Education and non-executive director at the Guinness Partnership - a large housing association. Anthony has over 20 years of experience at board level in the education and social housing sectors, and has also had senior roles in the private sector. He is deputy chair of a managed workspace complex company, which supports developing business. Anthony has also previously been a board member and treasurer of a training placement organisation for minority groups, and an education trust which supports disadvantaged groups.

Mike Chapman, Vice Chair and Senior Independent Director (term of office came to an end in July 2014)

A Head Teacher for 27 years, Mike was appointed Non-Executive Director of GMW in 2002. He has also acted as Executive Head Teacher to support schools with problems, worked as a • we value Remodelling and respect • wetowork • we go the extr Workforce Consultant schoolstogether and represented and head teachers on a range of issues, as well as being andteachers friendly • we are caring and kind • we value and respect • a member of the Local Strategic Partnership for several years. He has served on Bolton Health Authority, and was Chair of • we are welcoming and friendly • we are cari Bolton Community Health Council and Non-Executive Director of Bolton and Wigan Health Authority. In 2011, he was awarded an respect • we work together • we go the extra mile • we are w Honorary Doctorate for services to Health Care and Education by arethe University of Bolton. caring and kind • we value and respect • we work togethe

we are welcoming and friendly • we are caring and kind • we v

Malcolm Cowen, Vice Chair (from July 2014) and we go the extra mile • we are welcoming and frien Non-Executive Director (current term ends December • we value and respect • we work together • we go the extra m 2016) Malcolm is a qualified accountant with over 30 years private friendly • we are caring and kind • we value and respect • we

sector experience and 16 years public sector experience, including • we are welcoming and friendly • we are caring and ten years as a Director of Finance for a large hospital trust. He also works closely with local interest, patient and carer groups go Offender the extra mile • we are welco and recently retired from thewe National Management Service with budgetary and financial control for 14 North West caring and kind • we value and respect • we work together • we prisons. Malcolm became a Non-Executive Director in 2009.

welcoming and friendly • we are caring and kind • we value and

we go the extra mile • we are welcoming and friendly • we ar

and respect • we work together • we go the extra mile • we a

we are caring and kind • we value and respect • we work toget

Annual Report 2014/15

Page 47

Kathy Doran OBE, Non-Executive Director (current term ends July 2018) Kathy joined GMW in 2014 and has 37 year’s public sector experience across central government and NHS providers and commissioners. For 11 years until 2013, Kathy worked in primary care and as cluster primary care trust executive. She is a former member of the National Institute of Health Research Advisory Board and is currently an advisor to NHS Employers, where she is a member of the negotiating teams for GP and dentist pay. Kathy is a non-executive director of Your Housing Group – a large North West housing association. Kathy is also a trustee and vice chair of The Reader Organisation, a Liverpool-based charity.

Julie Jarman, Non-Executive Director (current term ends July 2017) Julie joined GMW in 2014 and is currently the Programme Manager for Church Action on Poverty with responsibility for managing a programme of anti-poverty projects and national campaigning work. Julie has over 17 years’ experience of senior management in the voluntary sector both in the UK and in international development. She also works as a management coach and mentor. Julie is a trustee of two charities: MIND in Salford and HomeWorkers Worldwide.

Professor Karen Luker, Non-Executive Director (current term ends January 2016) Karen is the Head of the School of Nursing, Midwifery and Social Work at the University of Manchester and was previously the Head of the School of Health Sciences at the University of Liverpool. She was also a Non-Executive Director of the former Ashworth Hospital Authority from 1998 to 2002 and was NonExecutive Director for the former Sefton FSHA between 1992 and 1996. She became a Non-Executor Director for GMW in 2004.

Terry McDonnell, Senior Independent (from July 2014) Non-Executive Director (current term ends December 2016) Terry was Chief Executive for one of the largest hospices in the UK which offered the full range of services for end-of-life care and was regulated by the Care Quality Commission. He initially trained as a Psychiatric Social Worker but has held roles which have included management posts in local authority, the NHS and voluntary sectors for over 25 years. He was also Chair of North West Hospice Managers Group and the North West Representative of the UK Hospices Advisory Council. Terry became a Non-Executive Director in 2009. Terry is currently the chair of the Quality Governance and Post-Incident Review committees.

Page 48

Greater Manchester West Mental Health NHS Foundation Trust

Brian Slater, Non-Executive Director (term of office came to an end in July 2014) Brian has been a Non-Executive Director since 2007. He is a qualified accountant and is a retired board director of Brother UK. He has an expansive career history in large private sector businesses, with experience in business strategy, workforce design and financial improvement, including working for Deloitte and Touche. Brian is also a proprietor of a wills and estate planning company.

Sunita Thomson, Non-Executive Director (resigned September 2014) Sunita is currently the director/owner of Goal Development Consultancy and formerly had boardroom experience at Novartis Pharmaceuticals. In 2010 Sunita was regional director on a five month project delivering workshops in leadership and management in the NHS. She is also an honorary lecturer at Bolton University in patient care and equality and diversity. Sunita is a specialist member on the panel for mental health tribunals.

Executive Directors Bev Humphrey, Chief Executive Bev has been Chief Executive of the Trust from October 2006. She was previously Chief Executive for The Walton Centre for Neurosciences NHS Trust in 2004. Other NHS experience includes being Director of Performance for Cumbria and Lancashire Strategic Health Authority in 2002 and Director of Specialist Services Commissioning for Lancashire and South Cumbria in 2000. Prior to this, Bev held various managerial posts in both acute and community services in Merseyside, Essex and Lancashire, having started her career in the NHS in 1983. Bev chairs the North West Mental Health Chief Executives Group and that she is an elected Board Member of the national Mental Health Network of the NHS Confederation.

Dr Steve Colgan, Medical Director Steve was a Research Fellow at the University of Manchester for three years and has a Masters and Doctorate in Psychological Medicine. He was appointed as Consultant General Psychiatrist for the City of Salford in 1992, with responsibility for drug services. He was also Chair of the Medical Staffing Committee in 1996. Steve was appointed medical director in 1999 and continues to lead on clinical governance in addition to research and developmentâ&#x20AC;&#x2122;. More recently he has overseen the implementation of systems for medical revalidation and the revised acute care pathway

Annual Report 2014/15

Page 49

Andrew Maloney, Director of Human Resources and Governance With over fifteen years of senior HR management experience, Andrew has worked across a range of NHS sectors. From 2000 to 2004 he worked as the Assistant Director of HR for Sefton Health Authority and Sefton Primary Care Trust working on HR change management projects that supported the establishment of PCTs across Sefton. In 2004 Andrew joined The Walton Centre NHS Trust as Director of HR and in 2009 Andrew joined GMW as Director of HR and Governance in August 2009.

Joe Peers, Director of Estates and Facilities Joe is a Chartered Surveyor; he started his career in the NHS in 1976 as a Building Officer at Wigan Area Health Authority. He has worked at several NHS organisations including the East Lancashire Hospitals NHS Trust where between 1990 and 2007, he was based at Queenâ&#x20AC;&#x2122;s Park Hospital, Blackburn initially as Assistant Director before being appointed as Head of Estates. In 2007, he joined the Trust as Director of Estates and Facilities.

Neil Thwaite, Director of Development and Performance / Deputy Chief Executive Neil started his career in the NHS in 1993 and has worked across many NHS sectors including acute care, primary care, Cancer Network and a Strategic Health Authority. Neil joined GMW in 2006 and was the Executive lead for the successful Foundation Trust application. During 2014, Neil became Deputy Chief Executive of GMW.

Ismail Hafeji, Director of Finance, Information Management and Technology Ismail joined the Trust in February 2011. He has been working as an accountant in the NHS at Trusts, former Health Authorities and PCTs around the North West. His last role, before joining the Trust, was as Director of Finance, IT and Information at NHS Bolton. Ismail also has Assistant Director of Finance experience at Strategic Health Authority level and previous to this, worked as Acting Director of Finance for West Lancashire and Chorley and South Ribble PCTs.

Gill Green, Director of Nursing and Operations Gill joined the Trust in August 2011 and previously was at South West Yorkshire Partnership Foundation NHS Trust as Acting Director of Nursing, Compliance and Innovation. Previous to this she was Assistant Director of Health Services at the trust which included operational service development whilst delivering quality improvement programmes.

Page 50

Greater Manchester West Mental Health NHS Foundation Trust

Board of Director Meetings The Board of Directors meet monthly (with the exception of August). The Board comprises of the Chair of the Trust and six other Non-Executive Directors plus the Chief Executive and six Executive Directors. Part one of the meetings are held in public and part two is held in private. A quorum of seven is required for the meeting to take place. All Non-Executive Directors are considered to be independent and the Chair has no significant commitments.

Annual Report 2014/15

Page 51

Nominations Committee

e and respect • we work together • we go ly • we are caring and kind • we value and The Nominations Committee identifies suitable candidates for vacant Chair and Nonmile • we areExecutive Director posts and present recommendations to the Council of Governors for welcoming and friendly • we appointment at a general meeting. The Committee seeks the views of the Board of e work together • we go the extra mile Directors as to their recommended criteria and process for selection of candidates and, regard those views, seek, short-list and interview such candidates as and kind • wehaving value andtorespect • shall we then work the Committee considers appropriate. They’ll evaluate the balance of skills, knowledge oming and friendly • we are caring and kind and experience on the Board and, in light of this evaluation, agree a description of the role and capabilities required for any particular appointment of Non-Executive Directors we go the extra mile • we are welcoming including the Chair. The Committee then makes recommendations to the Council of e and respectGovernors as to potential appointments as Non-Executive Directors and shall advise the • we work together • we go Board of Directors of those recommendations. ly • we are caring and kind • we value and mile • we areIn 2014/15, the Nominations Committee, with advice from the Board of Directors, welcoming and friendly • we reviewed the balance, competencies and appropriateness and appointed four None work together • we go the extra mile Executive Directors with experience of financial and commercial sectors and partnership board-level in large charity and third-sector organisations. and kind • weworking valueatand respect • we work oming and friendly we are caring and kind Table 9•- Nomination Committee attendance we go the extra mile • we are welcoming Alan Maden 3/3 Mitchell 2/3 e and respect Alan • we work together • we go Sylvia Seddon 3/3 ly • we are caring and kind • we value and Jennifer Carlisle

3/3

Anne Broadhurst

3/3

Audit Committee report All Foundation Trust Boards must establish an audit committee. The Committee must be composed of at least three members who are all independent non-executive directors. At least one member of the committee must have ‘recent and relevant financial experience.’ The committee’s terms for reference provide more explanation of the committee’s key role which is to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives. This is evidenced by an effective Board Assurance Framework.

Page 52

Greater Manchester West Mental Health NHS Foundation Trust

Nominations Committee

The main role and responsibilities are outlined in Monitors’ code of governance and include the following: • Monitor the integrity of the FT’s financial statements • Review internal financial controls, internal controls and risk management • Monitor and review the effectiveness of the FT’s internal audit function • Monitor and review the effectiveness of external audit • Monitor and review the effectiveness of counter fraud • Develop and implement policy on using external auditors to supply non-audit services • Report to the council of governors any matters where action or improvement is needed and making recommendations as to the steps to be taken • Review the effectiveness of the arrangements for whistle blowing • Make recommendations to the council of governors on the appointment, reappointment and removal of external audit • Review the work of other committees including quality governance and risk management The existence of an independent audit committee is a central means by which the board we value respectare • in we work together • we ensures that effective•internal controland arrangements place. In addition the audit committee provides an independent check on the executive arm of the board.

go the extr

and friendly • we are caring and kind • we value and respect •

Table 10 - Committee members and • attendance we are welcoming

and friendly • we are car

Malcom Cowen - Chairman

5/5

Terry McDonnell

5/5

respect • we work together • we go the extra mile • we are

Anthony Bell – appointed July 2014 are caring

2/3 • we work togethe and kind • we value and respect

Jon Bashford – resigned June 2014

2/2

we are welcoming and friendly • we are2/2caring and kind • we Brian Slater – resigned June 2014 Sunita Thomson – appointed July 2014 / resigned September 2014 we go the extra mile

1/1 welcoming and frien • we are

The external auditors, internal audit, counter fraud are also invited to attend the • we value and respect • we work together • we go the extra m meetings. Other attendees include, the Director of Finance and IM&T, Director of Human friendly we areand caring and kind • we value and respect • we Resources and Governance, Chief•Executive the Head of Corporate Affairs.

• we are welcoming and friendly • we are caring and

we go the extra mile • we are welco Work of the committee in 2014/15 caring and kind • we value and respect • we work together • we The Committee met on five occasions during the 2014/15 financial year. There was

a change in membership as a result of Non-executive Directors resignations and welcoming and friendly • we are caring and kind • we value and appointments. The meetings focused on financial reporting, internal control processes, and the work of Internal and External audit, policy and procedure updates.

we go the extra mile • we are welcoming and friendly • we a

The minutes of the audit committee meeting are included on the agenda of the Trust and respect • we work together • we go the extra Board.

mile • we

we are caring and kind • we value and respect • we work toget

Annual Report 2014/15

Page 53

1. Financial reporting The Audit Committee meeting held on the 24th April 2015, included a review of the Trust’s performance as outlined in the 2014/15 annual financial statements and a commentary on the reasons for the main changes compared to the financial statements for 2013/14. Management brought to the attention of the audit committee the significant movements with regards to the accounts for the year ended 31 March 2015. The committee reviewed the Trust’ financial statements for the financial year 2014/15, in detail with a particular focus on: • Compliance with financial reporting standards • Areas requiring significant judgements in applying accounting policies • The accounting policies • Whether the accounts and annual report are a fair reflection of the Trust’s performance The Committee considered the financial statements audit risks including the areas where the Trust has applied judgement in the treatment of revenues and costs to ensure that annual accounts represented a true position of the Trust’s finances. The External Audit Plan 2014/15 highlighted two main risk issues relating to the valuation of land and buildings and recognition of deferred income and creditors. The Audit Committee discussed the approach taken by the Trust in the valuation of land and buildings. The Trust undertakes a full revaluation of its assets every three years and the next revaluation is due at the end of the 2015/16 financial year. For 2014/15, the Trust revalued the main buildings and capital works that were completed to ensure any impairment is correctly accounted for in the financial year. The Audit Committee also discussed the risk referring to the recognition of deferred income and creditors. The Trust outlined the process of classification and confirmed that the criteria used was related to the timings of the projects spending plans. As a result some items were classed as Creditors; due within one year, and other items included as liabilities extending to a longer time period.

2. Internal control In accordance with the Committee’s role, and in addition to the Director of Finance, other officers of the Trust were called to attend the Committee to provide updates regarding progress on implementation of recommendations following audit and other assurance reviews.

3. Internal Audit and Counter Fraud The Internal Audit service is provided by Mersey Internal Audit Agency (MIAA), an independent NHS organisation. The key conclusion from their work for 2014/15 as provided in the Director of Audit Opinion and Annual Report was that ‘Significant Assurance’ was given that there were generally sound systems of internal control to meet the organisation’s objectives and that controls are generally being applied consistently.

Page 54

Greater Manchester West Mental Health NHS Foundation Trust

Counter Fraud As with the Internal Audit Service, Counter Fraud is provided by the Counter Fraud Service and is hosted through Mersey Internal Audit Agency. As requested by the Committee to meet mandated requirements an Annual Report was provided outlining the delivery of the fraud plan.

4. External Audit The provision of External Audit services is delivered by the KPMG. Their work is mainly related to audit the financial statements and provide and audit opinion. The appointment of a Foundation Trusts External Auditors remains one of the important statutory duties of the Council of Governors, supported by the Audit Committee. KPMG were appointed as external auditors in December 2010, following a tender process. They were appointed for a period of three years. The guidance issued in August 2013 stated that the Audit Committee should run the process with the final decision on appointment/ re-appointment resting with the council of governors. In accordance with the guidance the Audit Committee agreed the process in 2013, for the appointment / re-appointment of external audit. The Committee reviewed the work of External Audit over the three year period since their appointment and focused on the effectiveness and value for money of the audit services over the last three years and their overall performance. The Council of Governors, at its March 2014 meeting, agreed a recommendation to extend the term with KPMG for a further two years and that the service be tendered in December 2016. The Audit Committee met with External Audit on regular occasions throughout the year to discuss their findings and the detail content of their reports. The external audit and Audit Committee members also met in private to discuss matters of a confidential nature. The Committee approved the External Audit Plan and have received regular updates from KPMG on technical issues briefings of developments in the NHS. During the course of the year the Audit Committee discussed the performance of External Audit and reviewed its effectiveness and output for the services provided and the annual cost. The total audit fee for the financial year 2014/15 was £64,825. It was made of two elements. For the ‘Accounts opinion and Resource conclusion,’ there was a cost of £50,575 and for the ‘Quality Accounts Opinion,’ a cost of £14,250. An unqualified opinion on the accounts for 2013/14 was given to the Trust. The work on the 2014/15 accounts commenced in April 2015 and will conclude with a report anticipated in May. Other matters: • The committee also provided oversight on a number of financial matters including Losses and Special Payments, Treasury management and waivers of Standing Financial Instructions • During the course of the year the Audit Committee reviewed the work and performance of both Internal and External audit by completing the audit committee handbook self-assessment checklists and feedback from committee members. • The committee also undertook a review of its own effectiveness. • The Committee also reviewed its terms of reference which were presented to the Trust Board and also agreed the audit committee work plan for the year. • During the year the committee met privately with external audit, internal audit and counter fraud. Annual Report 2014/15

Page 55

• The head of internal audit, external audit and the counter fraud specialist have direct access to the chair of the committee. Malcolm Cowen, Chair of the Audit Committee

Quality Governance Committee The Quality Governance Committee monitored quality and was the accountable committee for all risk management activity, charged with developing, implementing and evaluating a systematic approach for identifying areas of clinical and non-clinical risks in services. It reflects Monitor’s Quality Governance Framework and its focus is on strategy, capabilities, process, structures and measurement.

Table 11 - Quality Governance Committee Attendance Terry McDonnell (Chair)

5/6

Karen Luker

4/6

Mike Chapman

2/2

Kathy Doran

3/4

Julie Jarman

4/4

Bev Humphrey

3/6

Gill Green

6/6

Steve Colgan

6/6

Andrew Maloney

6/6

Neil Thwaite

5/6

Charitable Funds The aim of the Charitable Funds Committee is to ensure that the Board of Directors properly discharges its responsibilities in relation to its role as Corporate Trustee of the Charitable Funds. It does so in accordance with the NHS Acts, Charities Acts and good practice to ensure that decisions on the use or investment of funds are restricted to the explicit conditions or purpose of each donation, bequest or grant. It also makes decisions involving the use of charitable funds for investments with reference to appropriate legislation.

Table 12 - Charitable Funds Attendance Malcolm Cowen (Chair)

2/2

Jon Bashford

1/1

Anthony Bell

1/1

Ismail Hafeji

2/2

Gill Green

1/2

Remuneration and Terms of Service Committee The Remuneration and Terms of Office Committee makes recommendations to the Board on the remuneration, allowances and terms of service of other officer members to ensure they are fairly rewarded for their individual contribution to the organisation – having proper regard to the organisation’s circumstances and performance and to the provisions of any national arrangements where appropriate. It is also responsible for monitoring and evaluating the performance of individual officer members and advises Page 56

Greater Manchester West Mental Health NHS Foundation Trust

on and oversees appropriate contractual arrangements for such staff including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate.

Table 13 - Remuneration and Terms of Service Committee attendance Jon Bashford

1/1

Brian Slater

1/1

Mike Chapman

1/1

Terry McDonnell

1/1

Malcolm Cowen

1/1

Remuneration and Terms of Office Committee The Remuneration and Terms of Office Committee shall consider the remuneration and allowances, and the other terms and conditions of office, of the Chair and the other NonExecutive Directors taking into account benchmarking against other similar Foundation Trusts and taking specialist advice. It will recommend to the Council of Governors the remuneration and allowances, and the other terms and conditions of office, of the Chair and the other Non-Executive Directors and shall advise the Board of Directors of those recommendations. The committee did not meeting during 2014/15.

Annual Report 2014/15

Page 57

Foundation Trust Governors and Membership

we are welcoming and friendly • we are caring together • we go the extra mile • we are ind • we value and respect • we work together ng and friendly • we are caring and kind • we Being an NHS Foundation Trust gives us certain financial freedoms, but it also allows us to proactively users, carers and the public in decisions about services, which is go the extra mile involve • we service are welcoming and a vital part of planning and improving the patient experience. Therefore we actively seek ue and respect • weanwork together • we gocommunity with whom we work on our to recruit engaged and active membership developments and ensure we can act on the feedback they give us. endly • we are caring and kind • we value and ra mile • weTo be a member, people must either: are welcoming and friendly • we we work together • we go the extra mile • Live in the North West and be 14 years or older; ng and kind •• we value and respect • we work Be a service user or carer within the last five years; or elcoming and• friendly • we are caring and kind Be a member of staff on a permanent employment contract of more than 12 months • we go the extra mile • we are welcoming alue and respect • we work together • we go of membership endly • we areOverview caring and kind • we value and ra mile • weWe are welcoming and friendly • we have over 8,000 members and to ensure our membership is representative of the diverse area it covers, organise ourmile members into the following constituencies: we work together • we go we the extra • Staff • Service users and carers • Public

We also have appointed Governors who are not elected by members but are appointed from a number of key organisations to ensure our membership has strong links with our partner organisations. The Trust has undertaken in-depth community profiling of the locations it serves and this data will inform a membership strategy. The Trust Board is informed on a quarterly basis of the numbers and make-up of the membership profile.

Page 58

Greater Manchester West Mental Health NHS Foundation Trust

Foundation Trust Governors and Membership

Table 14 - Membership size and movements Public constituency

Last year (2014/15)

At year start (April 1)

Next year (estimated) (2015/16)

3,566

3,545

New members Members leaving At year end (March 31) Staff constituency

3,545

3,565

Last year (2014/15)

Next year (estimated) (2015/16)

At year start (April 1)

1,013

2,934

New members

2,934

Members leaving

1,013

100

At year end (March 31)

2,934

2,884

Patient constituency

Last year (2014/15)

At year start (April 1)

Next year (estimated) (2015/16)

1,605

1,592

New members Members leaving At year end (March 31)

1,592

1,582

Analysis of current membership Public constituency

Number of members

Eligible membership

Age (years): 0-16

1,422,553

17-21

459,101

22+ Unknown Total

3315 5,233,222 • we value and respect • we work together • we go the e 133

and friendly • we are caring and kind •7,114,876 we value and respe 3,544 • we are welcoming and friendly • we are

Ethnicity: White

2,904

6,361,716

Mixed

respect • we work40together • we go the110,891 extra mile • we a

Asian or Asian British

213 • we value and respect 437,485 are caring and kind • we work toge

Black or Black British Other

122

97,869

we are welcoming16and friendly • we are caring 44,216 and kind • w

Unknown Socio-economic groupings*:

62,699 we go250 the extra mile • we are welcoming and f

• we value and respect • we work together • we go the ext 866 429,265

672,341 friendly • we are 992 caring and kind • we value and respect •

C2 DE Unknown Gender analysis

735

460,181

• we are • we are caring 884 welcoming and friendly 660,274 67

4,892,815

we go the extra mile • we are w

Male

caring and kind •1,222 we value and respect •3,504,687 we work together •

Female

welcoming and friendly • we are caring and kind • we value a 57 2

Unknown

2,266

3,610,187

we go the extra mile • we are welcoming and friendly • w

* Socio-economic data should be completed using profiling techniques (e.g. postcode) or other recognised methods.

and respect • we work together • we go the extra mile If any members would like to contact their governor or a director of the Trust please contact: Steph Neville, Head of Corporate Affairs, Greater Manchester West Mental we are caring and kind • we value and respect • we work Health Trust NHS Foundation Trust, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 772 3622, Email: steph.neville@gmw.nhs.uk Or visit our website: http://www.gmw.nhs.uk/contact-us Annual Report 2014/15

Page 59

•w

Quality Report

le • we are welcoming and friendly • we are e work together • we go the extra mile g and kind • Statement we value and on respect • we work Quality from the Chief Executive welcoming and friendly • we are caring and kind • we go theThe Quality Account 2015/16 summarises some of the key improvements delivered by the extra mile • we are welcoming Trust in 2014/15 and the challenges we have set ourselves for 2015/16. With the support value and respect • we workstaff, together • we go of all our dedicated I am confident that we can meet these future challenges. endly • we are caring and kind • we value and The account also confirms that we have continued to achieve all targets set nationally tra mile • wefor mental health trusts in 2014/15, delivered our CQUIN (Commissioning for Quality and are welcoming and friendly • we Innovation) schemes and retained our ‘registration without conditions’ with the Care • we work together • we go the extra mile Quality Commission. ing and kind • we value and respect • we work As Chief Executive of Greater Manchester West Mental Health NHS Foundation Trust, I welcoming andcanfriendly • we arebest caring and kindthe information contained is the report confirm that, to the of my knowledge, • we go theis accurate. The ‘Statement of Directors Responsibilities’ summarises the steps we have extra mile • we are welcoming taken to develop the Quality Account and external assurance is provided in the forms of value and respect • we work together • we go statements from our commissioners, local Healthwatch organisation and Joint Scrutiny Committee. The report of an external audit undertaken by KPMG, which gives assurance endly • we are caring and kind • we value and on the content of the Quality Account is also included. tra mile • we are welcoming and friendly • we • we work together • we go the extra mile Signed:

Bev HumpHrey, CHief exeCutive

DateD: 29tH may 2015

We have reviewed the quality of care offered by the Trust based on performance in 2014/15 against the indicators of patient safety, clinical effectiveness and patient experience. This can be found in Appendix 1.

Statement of Directors’ Responsibilities in Respect of the Quality Account The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the Page 60

Greater Manchester West Mental Health NHS Foundation Trust

Quality Report

arrangements that foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the quality report, directors are required to satisfy themselves that:

• The content of the quality report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2014/15; • The content of the Quality Report is not inconsistent with internal and external sources of information including: o Board minutes and papers for the period April 2014 to June 2015 o Papers relating to Quality reported to the Board over the period April 2014 to June 2015 o Feedback from the commissioners dated 22nd May 2015 o Feedback from governors dated 22nd May 2015 o Feedback from Local Healthwatch organisations dated 22nd May 2015 (Healthwatch Trafford) o The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 30th April 2015 (draft) o The 2014 national patient survey dated 18th September 2014 (date of publication on CQC website) o The 2014 national staff survey from 24th February 2015 o The Head of Internal Audit’s annual opinion over the Trust’s control environment dated 30th April 2014. o CQC Intelligent Monitoring Report dated October 2015. • we value and respect • we work together • we go the • The Quality Report represents a balanced picture of the NHS foundation trust’s and friendly • we are caring and kind • we value and respe performance over the period covered; • The performance information reported in the Quality Report is reliable and accurate • we are welcoming and friendly • we are • There are proper internal controls over the collection and reporting of measures of respect • we work together • we go the extra mile • we performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; are caring and kind • we value and respect • we work toge • The data underpinning the measures of performance in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed we are welcoming and friendly • we are caring and kind • definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor’s reporting guidance (which we go annual the extra mile • we are welcoming and incorporates the Quality Accounts regulations) (published at www.monitor-nhsft. • we value and respect • we work together • we go the ext gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor-nhsft.gov.uk/ friendly • we are caring and kind • we value and respect • annualreportingmanual)

• we are welcoming and friendly • we are caring The directors confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the Quality Report.

we go the extra mile • we are w

By order of the Board

caring and kind • we value and respect • we work together • welcoming and friendly • we are caring and kind • we value

Signed: alan maDen, CHair

we go the extra mile • we are welcoming and friendly • w and respect • we work together • we go the extra mile • Date: 29tH may 2015

we are caring and kind • we value and respect • we work to

Signed: Bev HumpHrey, CHief exeCutive Annual Report 2014/15

Date: 29tH may 2015 Page 61

The NHS Staff Survey 2014

xtra mile • we are welcoming and friendly • • we work together • we go the extra mile Once again, the 2014 NHS Staff Survey has provided us with a valuable insight into how our staff feel about the work they do and g and kind • we value and respect • we workhow involved and appreciated they perceive to be. In these challenging times, feedback such as this is more crucial than ever. coming and friendly • we are caring and kind We were extremely pleased to see that GMW scored higher than average in the area of we go the extra mile • we are welcoming staff feeling satisfied with the quality of work and patient care they are able to give. We understand how important it is • forwe staffgo to feel able to do their best for their patients as ue and respect • we work together we know this is one of the main reasons staff choose a career with us – to help people and dly • we are caring and kind • we value and to see we are achieving this. make a difference to their lives. It is heartening mile • we are welcoming and friendly • we Staff reporting errors, near misses or incidents is at 93% which is higher than average and e work together weourgo the extra mile shows•that reporting mechanisms are working well and that staff feel comfortable and confident in speaking up when something and kind • we value and respect • we work goes wrong. coming and friendly • webetter are caring andinkind We also scored than average the areas of good communication between senior management and staff, as well as staff believing the Trust provides equal opportunities we go the extra mile • we are welcoming for career progression or promotion. We are pleased to see that staff feel like they ue and respect wetowork together •and we can•talk senior management thatgo we will support their career aspirations and development. dly • we are caring and kind • we value and Wewelcoming also saw that staff agree that feedback mile • we are and friendly • wefrom patients / service users is used to make informed decisions in their directorate / department. This is incredibly reassuring as we e work together • we service go the see patients, usersextra and theirmile carers as some of the best experts we have within the Trust and we use their input as a clear indication as to where our values should lie and how we should deliver their care. Other areas where we scored higher than average are the areas of work pressure felt by staff, support from immediate managers and staff job satisfaction. This is pleasing as it indicates that overall, staff are happy in their work and feel supported to do their role to the best of their ability. As always, there are areas which need improvement and over the next 12 months, we will address areas where we have not performed as well. These include the number of staff receiving their appraisal in the last 12 months as well as numbers of staff receiving health and safety training, equality and diversity training or job-relevant training, learning or development in the last 12 months. We recognise that it can be extremely challenging to release staff to go on training, especially ward-based staff, when times are busy. However, we have made this a priority area for improvement and as such we have written to each manager across the Trust, encouraging them to use their leadership skills to ensure that these priorities are met. A small amount of time invested for training and development in the short term, will reap longer term benefits and a meaningful annual Page 62

Greater Manchester West Mental Health NHS Foundation Trust

The NHS Staff Survey 2014

appraisal is the cornerstone of delivering the best service possible for our patients and service users. Realistic timelines have been put in place to ensure that every member of staff receives their annual appraisal. We also scored higher than average in staff witnessing potentially harmful errors, near misses or incidents within the last month. Whilst this is one of our lowest ranking scores, it is reassuring to note that in the wake of the Francis Report, staff feel able to see such an incident and report it, leading to lessons being learned and an open, honest and accountable environment. We feel proud that our staff feel able and safe to speak up when they see something that causes them concern. Overall we are pleased with staff survey results but we will continue to embed our Values across the Trust to ensure we continue to support and develop our Trusts’ greatest asset – the people who work for GMW.

Table 15 - Staff Survey Table – top and bottom ranking scores 2013/14 Response rate

Trust Improvement / Deterioration

2014/15

Trust

National Average

Trust

National Average

53%

50%

46%

42%

2013/14

Trust Improvement / Deterioration

2014/15

National

Decrease 7%

National

Response rate

Trust Trust • we value and respect • we work together • we go the ext Average Average

Top 5 Ranking Scores

and friendly • we are caring and kind • we value and respect

Percentage of staff reporting errors, near misses or incidents witnessed in the last month Percentage of staff agreeing that feedback from patients/service users is used to make informed decisions in their directorate/ department Work pressure felt by staff Percentage of staff reporting good communication between senior management and staff Support from immediate managers

94%

92%

• we and friendly • we are ca 93%are welcoming 92% Decrease 1 %

respect • we work together • we go the extra mile • we are

are caring and kind • we value and respect • we work togeth N/A (additional theme for 2014)

N/A (additional theme for 2014)

N/A (additional theme we are welcoming and 59% friendly 53% • we are caring and kind • we for 2014)

we go the extra mile • we are welcoming and frie

• we value and respect • we work together • we go the extra 3.01 3.07 3.01 3.07 No change

friendly • we are caring and kind • we value and respect • we 31%

30% and friendly Increase 2%• we are caring an • we are33% welcoming

31%

we go the extra mile • we are welc 3.83

3.82

3.84

3.81

Increase 0.01

caring and kind • we value and respect • we work together • w Trust Improvement /

2013/14 welcoming and friendly2014/15 • we are caring and kind • we value and Deterioration Response rate

National

Trust Trust • we are welcoming and friendly • we a we go the extra mile Average Average

Bottom 5 Ranking Scores Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month

Annual Report 2014/15

and respect • we work together • we go the extra mile • we

we31% are caring and kind • we26% value andIncrease respect • we work toge 26% 33% 2%

Page 63

Percentage of staff receiving health and safety training in the last 12 months

69%

75%

64%

73%

Decrease 5%

Percentage of staff appraised in last 12 months

86%

87%

72%

88%

Decrease 14%

Percentage of staff having well-structured appraisals in last 12 months

43%

42%

35%

41%

Decrease 8%

Percentage of staff receiving job-relevant training, learning or development in last 12 months

82%

79%

82%

Decrease 3%

Page 64

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report 2014/15

Page 65

Regulatory Ratings Report

nd • we value and respect • we work together g and friendly • we are caring and kind • we go the extra mile • we are welcoming and Monitor’s Risk Assessment Framework e and respect • we work together • we go ndly • we areRisk Assessment Framework (RAF) requires the Trust to report against the “Continuity of caring and kind • we value and Service Risk Ratings (CoSRR)”, and Governance Risk Rating. a mile • we are welcoming and friendly • we The CoSRR ratings range from 1 through to 4, with an overall rating of 4 being an we work together • we go the extra mile indication of a low level of risk. g and kind • we value and respect • we work The Governance Risk ratings are Green, Amber or Red, with a Green Governance Risk elcoming and friendly • we are caring and kind Rating being an indication that there is ongoing compliance with all the targets and we go the extra • we are indicatorsmile as set out in the Riskwelcoming Assessment Framework. lue and respect • we work together • we go Prior to the 1st October 2013, all Foundation Trusts was required to report against ndly • we arethe Compliance Framework. The Compliance Framework included the Risk ratings caring and kind • we value and Monitor used as the primary basis for assessing risk of Trusts breaching their Terms of a mile • we are welcoming and friendly • we Authorisation. The Financial Risk rating had a range from 1 to 5 with a rating of 4 or 5 being an low level risk.mile we work together • indication we go ofthe extra g and kind • The Compliance Framework Risk ratings are included as a comparison for previous year’s we value and respect • we work performance. elcoming and friendly • we are caring and kind The Trusts risk ratings under the Risk assessment Framework and the Compliance we go the extra mile • we are welcoming framework are analysed in Table 1, which shows that the Trust has complied with all of Monitor’s compliance indicators

Table 16 - Under the Risk Assessment Framework – 2014/15 Annual Plan 2014/15

Q1 2014/15

Q2 2014/15

Q3 2014/15

Q4 2014/15

Continuity of Service Risk rating

Governance Risk rating

Green

2014-15

Page 66

Greater Manchester West Mental Health NHS Foundation Trust

Regulatory Ratings Report

Table 17 - Under the Compliance Framework – Quarters 1 and 2 2013/14 Annual Plan 2013/14

Q1 2013/14

Q2 2013/14

Financial Risk Rating

Governance Risk rating

Green

2013-14

Q3 2013/14

Q4 2013/14

Table 18 - Under the Risk Assessment Framework – Quarter 3 and 4 2013/14 2013-14

Annual Plan 2013/14

Q1 2013/14

Q2 2013/14

Q3 2013/14

Q4 2013/14

Continuity of Service Risk rating

Governance Risk rating

Green

• we value and respect • we work together • we go the ex

and friendly • we are caring and kind • we value and respec

• we are welcoming and friendly • we are c

respect • we work together • we go the extra mile • we ar

are caring and kind • we value and respect • we work toget

we are welcoming and friendly • we are caring and kind • w

we go the extra mile • we are welcoming and fr

• we value and respect • we work together • we go the extr

friendly • we are caring and kind • we value and respect • w

• we are welcoming and friendly • we are caring a

we go the extra mile • we are we

caring and kind • we value and respect • we work together • w

welcoming and friendly • we are caring and kind • we value an

we go the extra mile • we are welcoming and friendly • we

and respect • we work together • we go the extra mile • w

we are caring and kind • we value and respect • we work tog

Annual Report 2014/15

Page 67

Annual Report 2014/15

ct • we work together • we go the extra mile ing and kind • we value and respect • we work Financial Review elcoming and friendly • we are caring and kind • we go the extra mile • we are welcoming he following section provides an overview on the financial alue and respect • we work together • we go performance of the Trust over the 2014/15 financial year, endly • we are caring and kind • we value and highlighting points of interest within the Annual Accounts ra mile • we are welcoming and friendly • we and the Trust’s performance against its key financial targets. we work together • we go the extra mile ng and kind • we value and respect • we work elcoming and friendly • we are caring and kind we go the extra mile • we are welcoming and 1. Introduction and respect •The Annual Accounts have been prepared in accordance with International Financial we work together • we go the Reporting Standards (IFRS), and are in line with guidance issued by Monitor, The • we are caring and kind • we value and respect Independent Regulator of NHS Foundation Trusts. The quality report is included on pages 46 to 47. The financial statements start on page 85. le • we are welcoming and friendly • we are work together • we go the extra mile • we are nd • we value and respect • we work together • 2. Summary of Financial Performance 2014/15

• The overall income and expenditure position shows a net surplus of £8.04m after nonoperating income and expenses, with an underlying operating net surplus of £8.9m • The overall Financial Risk Rating as at 31st March 2015 is 4, (see note 3 below for more detail). • The total Comprehensive Surplus, after movements direct to reserves shows a surplus of £8.03m.

3. Financial Performance – Monitor’s Regulatory Ratings (CoSRR) The Trust is required to report against the Monitor “Continuity of Service Risk Ratings” (CoSRR), and the Governance Risk Rating. The CoSRR ratings range from 1 through to 4, with an overall rating of 4 being an indication of a low level of risk. The Governance Risk ratings are Green, Amber or Red, with a Green Governance Risk Rating being an indication that there is ongoing compliance with all the targets and indicators as set out in the Risk Assessment Framework (see pages 66 to 67 for the Regulatory Rating Report). Page 68

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report 2014/15

The Trusts risk ratings under the Risk Assessment Framework are analysed in Table 1, which shows that the Trust has complied with all of Monitor’s indicators.

Under the Risk Assessment Framework 2014/15 Annual Plan 2014/15

Actual Rating 2014/15

Green

Continuity of Service Risk Rating Governance Risk rating

4. Income and Expenditure Position The following table summarises the actual performance as at the 31st March 2015 compared to the Annual Plan. For the year to 31st March 2015 Plan

Actual

£000’s

Variance

£000’s

Clinical Income

148,067

153,131

5,064

Other Income

11,268

13,406

2,138

159,335

166,537

7,202

(148,645)

(152,340)

(3,695)

(2,811)

(3,226)

(415)

Total Income Operating Expenditure EBITDA

• we value and respect • we work together • we go the e

and friendly • we are caring and kind • we value and respe 10,690 14,197 3,507

Depreciation

• we 123 are welcoming and friendly • we are 192 69

Interest Receivable Interest Expense

(209) (180) 29 mile • we a respect • we work together • we go the extra

Public Dividend Capital

(2,289)

(2,059)

230

are caring and kind • we value and respect •0we work toge Profit/(Loss) on disposal of assets 0 0 Surplus/(Deficit) before Other Nonwe are welcoming Operating Expenses Other Non-Operating Income

we go the extra mile 0• we are welcoming and f 0 0

Impairment Losses (Reversals) net (on non PFI • we value and assets) Net Surplus/(Deficit)

(2,420) (885) respect • we work together1,535 • we go the ext

3,084 and kind 8,039 4,955and respect • friendly • we are caring • we value

Elements of Comprehensive Income Comprehensive Income

and friendly8,924 • we are caring 5,504 3,420 and kind • w

(6)

• we are 3,084 welcoming8,033 and friendly • we are caring 4,949

we go the extra mile • we are w

5. Trust Income

caring and kind • we value and respect • we work together •

welcoming and friendly • we are caring and kind • we value a The Trust received a total of £166.5 million income for 2014/15. The majority of this income related to patient care (£153.1 million). Patient care income by commissioner and we go the extra mile • we are welcoming and friendly • w service is illustrated below.

and respect • we work together • we go the extra mile • w

we are caring and kind • we value and respect • we work to

Annual Report 2014/15

Page 69

Income (£’000s)

NHS England

NHS Salford CCG

NHS Bolton CCG

NHS Trafford CCG

Other CCG’s

Local Authorities

Other

Total

48,888

33,378

22,098

16,625

6,631

22,263

2,282

152,165

The Trust received £14.3 million other income (non-patient care services), with the largest single source (£4.2 million) coming from NHS North West to support education and training. The Trust received income of £2.9 million to support research and development. The Trust released deferred income of £6.5m to support the Trust’s capital programme.

6. Trust Expenditure

Page 70

Greater Manchester West Mental Health NHS Foundation Trust

Operating Expenses

Expenditure (£’000s)

Staff Costs

115,712

Premises & Transport

10,921

Supplies and Services - Clinical and General

5,969

Purchase of Healthcare from Non-NHS Bodies

5,212

Other

6,137

Drug Costs

2,453

Establishment

2,125

Research and Development Costs

2,855

Training, Courses and Conferences

957

Total Operating Expenditure

152,341

Depreciation

3,226

Impairments of Property, Plant and Equipment

885

Grand Total

156,452

The largest item of expenditure within the Trust relates to staff costs, (£115.7 million or 73.9% of operating expenses). The District Valuers valued the new buildings completed during the year, such as Eskdale Ward and the second substation on the Prestwich site. This resulted in an impairment of £885k

7. Capital Investment The Trust continued to invest in the development and improvement of its estate. The following table shows the schemes that have been undertaken during the year, totalling £13.0 million. This is a significant investment in the enhancement of patient and nonpatient facilities. Capital Expenditure Additional medium secure beds Edenfield New build Recovery Academy Additional beds at Woodlands site Low Secure Ward replacement Provision of Second Substations at Edenfield and Prestwich Meadowbrook Schemes Backlog Maintenance Schemes Relocation of Corporate Services Edenfield Schemes PARIS system Other Schemes Statutory Schemes Minor Schemes Ligature Audit Schemes Energy Improvement Scheme Vehicle replacements Total

Annual Report 2014/15

Expenditure to 31st March 2015 (£’000’s) 2,898 2,548 1,936 1,838 1,315 610 423 301 298 296 145 106 103 75 65 64 13,021

Page 71

The major capital schemes include: i)

The scheme to build additional medium secure beds on the Edenfield site is progressing well and is due for completion in 2015.

ii)

The scheme to build the Recovery Academy, a purpose-built Education and Training Facility on the Prestwich site is on schedule to be completed and commissioned by Autumn 2015.

The new facility will accommodate existing education and training functions, including library services, and enable the relocation of our Trust Headquarters. iii)

On the Woodland site, schemes to accommodate additional beds and improve facilities on Moss and Delamere wards, and the conversion of the former Day Hospital are progressing well. These are due to be completed and commissioned by September 2015.

iv)

Work commenced on the replacement of Low Secure wards on the Edenfield site. The scheme is progressing and is on target to be completed during 2016.

In addition upgrades to the IT server room, the relocation of the finance department to Harrop House, and improvements at Meadowbrook were completed during the year. As in previous years the Trust has continued to invest in backlog maintenance, statutory works, reducing ligatures and energy performance improvements.

8. Liquidity and Short Term Investments The Trust has a cash balance of £49.8 million as at the 31st March 2015, with interest receivable of £0.2 million being re-invested in the delivery of services.

9. Better Payment Practice Code – Measure of Compliance

Page 72

Greater Manchester West Mental Health NHS Foundation Trust

The Better Payment Practice Code (BPPC) requires the Trust to pay all NHS, and non-NHS trade creditors within 30 calendar days of receipt of goods or a valid invoice (whichever is later) unless other payment terms have been agreed. Where this involves a non-public sector organisation, the Trust ensures to make payments as quickly as possible.

10. Cost Allocation The Foundation Trust has complied with cost allocation and charging requirements set out in the HM Treasury Guidelines.

11. Accounting Policies The Trust has produced the Annual Accounts for 2014/15 following the NHS Foundation Trust Annual Reporting Manual 2014/15, and in-line with the requirements of International Financial Reporting Standards (IFRS). The accounting policies are approved by the Board for use in preparing the accounts and are reviewed annually to reflect any changing circumstances involving accounting regulation or guidance. Accounting policies for pensions and other retirement benefits are set out in note 1.3.2 of the accounts. Details of senior employeesâ&#x20AC;&#x2122; remuneration can be found on page 34 of the Annual Report.

12. Going Concern Following review by the Trustâ&#x20AC;&#x2122;s Board, the directors have a reasonable expectation that the Trust has adequate resources to continue to adopt the going concern basis in preparing the accounts.

Annual Report 2014/15

Page 73

13. Looking Forward Whilst 2014/15 has been successful year for the Trust, the coming years will continue to represent an increasing challenge to both the Trust and to the Public Sector. The NHS faces an unprecedented financial dilemma; the supply of funding is struggling to match the growing demand for healthcare. The need to deliver 4 per cent efficiency savings until 2016 is of immediate concern. Savings of a similar amount are likely to be needed after 2017. Greater Manchester West, along with all NHS organisations will need to identify and deliver 4 to 5 per cent efficiency savings on an annual basis. For the Trust this means an estimated £5m per year must be saved on a recurrent basis whilst we maintain the quality of services. The Trust has an excellent track record for making efficiencies but this must continue in the forthcoming years, to ensure that the Trust remains a financially secure organisation. The Five Year Forward View highlighted that major system changes are required to protect high-quality sustainable care for patients now and into the future. The Trust has developed the 2015/16 operational plan in light of the challenging economic backdrop and a clear expectation that the funding provided to the National Health Service will need to be supplemented by making efficiencies to deal with the rising demand from an ageing population and the increased costs of new technology.

NHS Funding in 2015/16 Additional investment of £1.98bn was announced in the autumn 2014 statement, including £150m from NHS England through efficiencies and reprioritisation in its central budgets. This implies a real terms funding increases of 1.6%, in line with the funding ambitions outlined in the Forward view. The additional funding seeks to address a number of priorities. For mental health investment, there is a specific reference of the following additional resources: • £40m being made available to support the introduction of specialist early-interventionin-psychosis services, • £10m for access standards relating to adult IAPT services, • £30m for liaison psychiatry services In addition to the above, CCG Commissioners have been asked to: “ ensure that mental health spend will rise in real terms in every CCG and grow at least in line with the CCG’s overall allocation growth;”

Page 74

Greater Manchester West Mental Health NHS Foundation Trust

Trust Future Financial Objectives Our overall financial objectives for the future will allow the Trust to invest in our services and improve the Trusts buildings and ward environments. In specific terms the Trust plans: • To deliver an operational surplus of more than 1% of operating income to facilitate potential investment in the improvement of services • To generate earnings before interest, tax, depreciation and amortisation of 5%, (EBITDA) • To maintain a Continuity of Service Risk Rating (CoSRR) of 4 The financial outlook and main risks faced by the Trust over the next two years are summarised below: • The main assumptions supporting the Trusts financial plan are based on the guidance in the document, “The NHS Forward View.” The national efficiency requirements of 3.5% and the changes in tariff have been factored into the financial plans. This includes the aforementioned efficiency requirement of 3.5% and assumes inflationary uplift of 1.9%. For 2015/16 the efficiency challenge of circa 4% has been included with associated tariff changes. • The Trusts major challenge over the planning period is the second year implementation of the Acute Care Pathway programme, including the enhancement of Community services and the development of the ‘Centre of Excellence,’ at the Woodlands hospital. From a financial planning perspective, the cost of investment in the community and the transition costs of moving services away from hospital locations have been included in the Trust’s plans. o With regard to Drug and Alcohol services, there are a number of risks in 2015/16 as a result of services being subject to tendering processes and migration of the commissioning of these services to Local Authorities. o The CCG commissioning processes will continue to develop in 2015-16 and the Trust needs to work with all partners, including the Local Authorities to ensure the Commissioners requirements are met. Similarly, for Specialist Services the Trust will continue to develop relationships with NHS England to ensure that the organisation continues to provide quality services whilst ensuring the Trust remains financially robust and sustainable for the future.

Annual Report 2014/15

Page 75

Statement of the chief executive’s responsibilities as the accounting officer of Greater Manchester West Mental Health NHS Foundation Trust

lcoming and friendly • we are caring and kind we go the extra mile • we are welcoming lue and respect • we work together • we go ndly • we are caring and kind • we value and a mile • we are welcoming and friendly • we we work together • we go the extra mile g and kind • we value and respect • we work lcoming and friendly • we are caring and kind we go the extra mile • we are welcoming lue and respect • we work together • we go ndly • we are The NHS Act 2006 states that the chief executive is the accounting officer of the NHS caring and kind • we value and foundation trust. The relevant responsibilities of the accounting officer, including their a mile • we are welcoming friendly • we of public finances for which they are responsibility for the and propriety and regularity answerable, and for the the keeping of mile proper account, are set out in the NHS Foundation we work together • we go extra Trust Accounting Officer Memorandum issued by Monitor. g and kind • we value and respect • we work Under the NHS Act 2006, Monitor has directed Greater Manchester West NHS Foundation lcoming and friendly • we are caring and kind Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Account Direction. The accounts are prepared on an accruals basis we go the extra mile • we are welcoming

and must give a true and fair view of the state of affairs of Greater Manchester West NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to:

• Observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • Make judgements and estimates on a reasonable basis; • State whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; • Ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance; and • Prepare the financial statement on a going concern basis. Page 76

Greater Manchester West Mental Health NHS Foundation Trust

Accounting Officer’s responsibilities

The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation and to enable her to ensure the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor’s NHS Foundation Trust Accounting Officer Memorandum.

Signed: Bev HumpHrey, CHief exeCutive

Date: 22nD may 2015

• we value and respect • we work together • we go the ex

and friendly • we are caring and kind • we value and respec

• we are welcoming and friendly • we are c

respect • we work together • we go the extra mile • we ar

are caring and kind • we value and respect • we work toget

we are welcoming and friendly • we are caring and kind • w

we go the extra mile • we are welcoming and fr

• we value and respect • we work together • we go the extra

friendly • we are caring and kind • we value and respect • w

• we are welcoming and friendly • we are caring a

we go the extra mile • we are we

caring and kind • we value and respect • we work together • w

welcoming and friendly • we are caring and kind • we value an

we go the extra mile • we are welcoming and friendly • we

and respect • we work together • we go the extra mile • w

we are caring and kind • we value and respect • we work tog

Annual Report 2014/15

Page 77

Annual Governance Statement

g and kind • we value and respect • we work coming and friendly • we are caring and kind Scope Responsibility we go the extra mileof • we are welcoming ue and respect we work together • we gofor maintaining a sound system of internal As•Accounting Officer, I have responsibility control that supports achievement of the NHS foundation trust’s policies, aims and dly • we are caring and kind the • we value and objectives, whilst safeguarding the public funds and departmental assets for which I mile • we are and friendly • we amwelcoming personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently e work together • we go the extra mile and economically and that resources are applied efficiently and effectively. I also and kind • we value and respect • we work acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting acknowledge my responsibilities as set Officer Memorandum. coming and friendly • we are caring and kind e go the extra mile • we are welcoming and nd respect • we work together • we go the The Purpose of the System of Internal Control we are caring and kind • we value and respect • we are welcoming friendly we are The system of internal control is designed to manage risk to a reasonable level rather than The system ofand internal control is•designed to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only to eliminate all risk of failure to achieve k together • we go the extra mile • we are provide reasonable and not absolute assurance of effectiveness. The system of internal provide reasonable and not absolute control is based• on on-going process designed to identify and prioritise the risks to d • we value and respect weanwork together • the achievement of the policies, aims and objectives of Greater Manchester West Mental d friendly • weHealth NHS Foundation Trust, to evaluate the likelihood of those risks being realised are caring and kind • we value and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Greater Manchester West Mental Health NHS Foundation Trust for the year ended 31 March 2015 and up to the date of approval of the annual report and accounts.

Capacity to Handle Risk I have overall accountability for ensuring an effective risk management system is in place within the Trust and I have delegated responsibility for the overall co-ordination of risk management to the Director of Human Resources and Governance. The Director of Human Resources and Governance ensures an effective overall approach to risk management including the development of the Risk Management Strategy and specifically the identification, assessment and management of risks. This also includes the responsibility for ensuring compliance with health and safety legislation, security Page 78

Greater Manchester West Mental Health NHS Foundation Trust

Annual Governance Statement

requirements (as the nominated Security Management Director) and emergency preparedness requirements (as the Accountable Emergency Officer). The Medical Director leads on clinical risk management, medicines management and safe standards of medical practice. The Director of Finance and Information Management & Technology (IM&T) leads on financial and information risk management. The Director of Nursing and Operations ensures the effective application of risk management across clinical and operational services and leads specifically on safeguarding and infection prevention. The Director of Estates and Facilities manages risk in relation to the development, management and maintenance of the Trust estate and matters relating to fire safety. The Deputy Chief Executive/Director of Development and Performance ensures effective risk management in business development and the compliance against Care Quality Commission standards. A supporting system for managing risk has been devolved to the Deputy Director of Integrated Governance (Risk) with support from the Head of Risk, Safety and Resilience. There are also clearly defined risk and clinical governance structures within directorates.

The Risk Management Strategy was reviewed in March 2014 and is currently being updated. March 2014 and is currently being updated. • we value and respect • we work together • we go the ext It provides a framework for managing risks across the organisation which is consistent with best practice and Department of Health guidance. The Strategy provides a clear, structured Thecaring Strategyand provides a clear, structured and friendly • we are kind • we value and respect and systematic approach to the management of risks to ensure that risk assessment is an integral part of clinical, managerial and financial processes the organisation. • we areacross welcoming and friendly • we are ca

The Strategy sets out the role of the Board of Directors and Sub Committees together Directors and Sub Committees together respect • we work together • we go the extra mile • we are with the individual responsibilities of, Executive Directors, managers and all staff Directors, managers and all staff are caring and kind • we value and respect in managing risk. In particular, the Risk Management Strategy Group along with • we work togeth committees for health and safety and emergency planning provides the mechanism for we are welcoming andand friendly we are caring and kind • we managing and monitoring risk throughout the Trust and reporting through to the Board. reporting•through to the Board. Board. The Audit Committee is concerned with evidence of the probity and efficiency of the probity and efficiency of the we go thethe extra mile • we are welcoming and frie management of risk in relation to the Trust’s financial, governance and clinical operations. financial, governance and clinical operations. The Quality Governance Committee oversees the system of quality governance and the system of quality and • we value and respect • we workgovernance together • the we go the extra overall assurance process associated with managing clinical service delivery effectively. The clinical service delivery effectively. The Board of Directors routinely receives minutes of all sub committees. sub committees. committees. • we value and respect • we friendly • we are caring and kind

Risk management training is provided • through thewelcoming induction programme for new staff. we are and friendly • we are caring an In addition tailored training for individual roles are identified by managers and agreed we go the extra mile • we are welc with staff through personal development plans.

caring and kind • we value and wedetails work together • w The corporate induction programme ensures that all new staff are provided with details new staff arerespect provided • with of the Trust’s risk management systems and processes and is augmented by local induction processes and is augmented by local induction welcoming and friendly are and kind • we value and organised by line managers. Mandatory training covers•a we variety of caring risk management process including health and safety, security etc.

we go the extra mile • we are welcoming and friendly • we a

Training for various staff groups on risk management is detailed in the Trust’s ‘Training is detailed in the Trust’s ‘Training and respect •management we work together • we go the extra mile Needs Analysis’. Trust policies clearly state the levels of accountability, arrangements and of accountability, arrangements and process for the management of risk across the Trust. The Trust is committed to learning is committed learning • we work we are caring and kindThe • Trust we value and to respect from incidents that have occurred and communicates its lessons learnt not just within the Trust but also with its stakeholders externally. The Board receives information on serious untoward incidents.

Annual Report 2014/15

Page 79

• we

toge

Root-cause analysis training has been provided to staff members who have direct responsibility for risk management within their area of work. Lessons learnt when things go wrong are shared through the organisation via a range of mechanisms including briefings and governance meetings. The Trust has mechanisms to act upon alerts and recommendations made by all relevant central bodies such as the National Patient Safety Agency (NPSA), National Health Service Litigation Authority (NHSLA) and the Health and Safety Executive (HSE).

The Risk and Control Framework The Risk Management Strategy establishes the formal structured approach to the identification, assessment, treatment and management of risks. The process starts with a systematic identification of risks throughout the organisation which are documented within risk registers. These risks are then analysed in order to determine their relative importance using a risk scoring matrix. Low scoring risks are managed by the area in which they are found while higher scoring risks are managed at progressively higher levels within the organisation. Achieving control of the higher scoring risks is given priority over lower scoring risks. Risk control measures are identified and taken to reduce the potential for harm. The system of internal control of quality governance risks is managed through the Risk Management Strategy Group system. Risks are added to the appropriate clinical service risk register with higher ranking risks being reviewed by the Risk Management Strategy Group through which control actions are agreed and monitored. The Risk Management Strategy Group reports directly to the Quality Governance Committee. Risk management is bedded throughout the organisation and all staff are encouraged to report incidents and raise concerns. The NHS Staff Survey for 2014 ranked the organisation better than the national average of mental health trusts in relation to the percentage of staff reporting errors, near misses or incidents. Risk management is further embedded through the annual business planning process with key risks to the delivery of Directorate plans identified as a core requirement. The key in year risks facing the organisation which have been managed and mitigated at Board level are: • Security of income as a consequence of the economic climate and commissioner intentions • Compliance with national and local targets • The effective implementation of the Acute Care Pathway • Implementation of the new clinical information system • Higher than normal staff sickness absence • Achievement of required compliance for mandatory training • Resilience of IT infrastructure and business continuity arrangements • Effectiveness of workforce planning to control pay costs The key future risks in addition to the above to be managed and mitigated are: • Development of integrated care models within local health economy • The implications of the framework for delegation and devolution of health and social care responsibilities in shadow and final form by April 2016 on commissioning arrangements across Greater Manchester. Page 80

Greater Manchester West Mental Health NHS Foundation Trust

With specific reference to Condition FT4 – NHS foundation trust governance arrangements – the Trust Board has continued to ensure that there are: • effective board and committee structures; • clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and • clear reporting lines and accountabilities throughout the organisation. The Board confirms that it has complied with Condition FT4 in-year, as at the date of this statement and that it expects to continue to comply with this condition throughout2015/16. Information governance and data security risks are managed as part of this process and assessed using the Information Governance Tool Kit. The risk register is updated with the currently identified information governance and data security risks. The Trust has a Data Quality Policy which is the responsibility of the Director of Finance and IM&T. Assurance with regard to Data Quality is provided through the Information Governance Steering Group. Potential and identified risks which may impact on external stakeholders and key partner agencies such as Local Authorities, other NHS Trusts, the judicial system, voluntary organisations and service users are handled through structured mechanisms and forums such as Overview and Scrutiny Committees, contract negotiation meetings, Council of Governor Meetings and service user forums. The Foundation Trust is fully compliant with the requirements of registration with the Care Quality Commission. As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme Regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The Foundation Trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that the organisation’s obligations under the Climate Change Act and Adaptation Reporting requirements are complied with.

Review of the Trust’s Economy, Efficiency and Effectiveness of the Use of Resources The Strategic and Operational Plans are approved by the Board of Directors and submitted to Monitor. The Operational Plan is monitored in detail by the Board of Directors on a monthly basis with key performance indicators and Monitor Metrics reviewed quarterly by the Board. A full copy of the monthly Integrated Finance and Performance Report is issued to all Board Directors and the Trust’s External Auditors. The Trust’s resources are managed within the framework set by the Governance Manual, which includes Standing Financial Instructions. Financial governance arrangements are Annual Report 2014/15

Page 81

supported by internal and external audit to ensure economic, efficient and effective use of resources. Directorate and Corporate Departments are responsible for the delivery of financial and other performance targets via a performance management framework. This is led through a monthly Directorate Management Board meeting which includes Executive Director scrutiny of performance.

Information governance Any Information Governance (IG) breaches are recorded in the Trust Datix system (incident reporting system) any breaches at a high level would be automatically sent to the Information Commissioner’s Office (ICO). GMW has not been referred to the ICO in 2014-15. However, GMW takes any IG incident seriously and has reported five IG related incidents in 2014-15. These incidents were in relation to unauthorised access to a patient’s record and patient letter’s being sent incorrectly by staff. Two incidents were reported whereby unauthorised access was undertaken by staff, accessing a patient’s record. Both incidents were investigated and the Trusts personal responsibility framework was used in dealing with the staff concerned. The action taken by the Trust was deemed appropriate and satisfactory. Three incidents where letters were incorrectly sent to the wrong location resulted in additional training provided to the staff members concerned. The ICO was assured that appropriate measures and action had been taken to reduce the risk of a reoccurrence.

Annual Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. We are an organisation that is passionate about delivering high quality care. Quality and continuous improvement is at the heart of everything we do. Through the hard work of our workforce, we have taken significant steps to improve the experience of service users and the safety and effectiveness of care in 2014/15. We have committed to making further improvements in 2015/16. The Quality Governance Committee, which is a formal sub-committee of the Trust Board, is responsible for developing and defining the Trust’s quality strategy and monitoring progress against the quality improvement priorities set out in our Quality Account. The Quality Governance Committee is chaired by a nonexecutive director and includes representation from all professional groups and services through the Quality Governance Committee, the Board is assured that clear and effective systems and processes are in place to govern quality. As described in our Quality Account, directors have taken steps to satisfy themselves that the content of our Quality Account presents a fair and balanced view and is consistent with internal and external sources of information including: • Feedback from Commissioners, governors, local Healthwatch organisations and our joint Scrutiny Committee Page 82

Greater Manchester West Mental Health NHS Foundation Trust

• Feedback from service user forums including from our Recovery Academy courses • Complaints and compliments • Our most recent national Community Mental Health Survey and Staff Survey • Local inpatient surveys • Board to Ward ‘walk-arounds’ • Video diary room events • Care Quality Commission quality and risk profiles and inspection reports • Head of Internal Audit’s opinion on the Trust’s control environment All Trust policies and procedures are available on the Trust’s intranet and representatives of all professional groups and services are encouraged to participate in consultation on new policies and/or policy updates. Newly approved policies are shared via a network of policy leads, published on the Trust’s intranet and highlighted in internal staff communications. Our staff are critical to the achievement of our quality improvement priorities. Learning and development opportunities are available for all members of staff, at every stage of their personal development. Through this, staff are equipped with the knowledge and skills needed to deliver high quality services that are positively experienced by our service users. The Trust keeps staff informed about our plans, achievements, examples of best practice and any issues facing the organisation through a range of briefings including ‘GMW Messenger’. Exceptional staff achievements are recognised and celebrated in our annual staff awards. The Trust also participates in the annual National NHS Staff Survey and acts on the feedback received from this survey to improve the working lives of our staff and help provide better care to our service users. Feedback from our service users, and other key stakeholders including carers, is central to our quality strategy. Delivering improvements in how we listen to and learn from service user feedback remains one of our quality improvement priorities for 2015/16. With regard to complaints handling, all information on complaints is included in monthly ‘Customer Care Reports’, which are reviewed in local governance meetings.. The Trust produces an annual complaints report in accordance with Regulation 18 of the ‘Local Authority Social Services and NHS Complaints (England) Regulations 2009’. Our annual complaints report is reviewed and agreed by the Quality Governance Committee. The Trust Board receives a monthly summary of complaints activity. The Trust has achieved a ‘green’ rating for performance against the Information Governance Toolkit standards. The Information Governance Toolkit provides an overall measure of the quality of data systems, standards and processes. The Trust has robust systems in place to review and report data quality and performance against our Quality Account improvement priorities and other key quality indicators. The remit of our ‘Performance Measures and Data Quality Group’ includes raising awareness of the importance of data quality, ensuring all staff are aware of their data quality responsibilities, and supporting the development of policies and procedures to improve data quality. The Trust Board receives assurance on data quality and performance via a monthly ‘Board Performance Report’. The ‘Board Performance Report’ is informed by individual directorate performance reports, which are subject to local scrutiny and monitoring. For more information on our approach to quality, please see our ‘Quality Account 2014/15’.

Annual Report 2014/15

Page 83

Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the Quality Report attached to this Annual Report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee and Quality Governance Committee and plan to address weaknesses and ensure continuous improvement of the system is in place. The assurance framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principle objectives have been reviewed. The Director of Internal Audit provides me with an opinion on the overall arrangements for gaining assurance through the assurance framework and on controls reviewed as part of the internal audit work through reviews by the Quality Governance and Audit Committees. The Board Assurance Framework is reviewed by the Board of Directors quarterly and it provides me and the Board with evidence of the effectiveness of controls in place to manage risks to achieving the organisation’s principle objectives. My review is also informed by External Audit, the National Health Service Litigation Authority and periodic audits of compliance with the Standards by the Care Quality Commission, Mental Health Commission and other external inspections, accreditations and reviews. Processes are well established and ensure regular review of systems and action plans on the effectiveness of the systems of internal control through: • Board review of Board Assurance Framework and action plans; • Audit Committee scrutiny of controls in place; • Review of serious incidents and learning by the Quality Governance Committee, including those for Risk Management and Clinical Effectiveness; • Review of progress in meeting the requirements as set by the Care Quality Commission; • Internal audits of effectiveness of systems of internal control

Conclusion No significant control issues were identified.

Signed: Bev HumpHrey, CHief exeCutive

Page 84

DateD: 22nD may 2015

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report 2014/15

Page 85

Independent Auditor’s Report

ring and kind • we value and respect • we work

welcoming and friendly • we are caring and kind We have audited the financial statements of Greater Manchester West Mental Health NHS • we go the extra mile we Foundation Trust•for theare year welcoming ended 31 March 2015 set out on pages 98 to 144. In our

opinion: value and respect • we work together • we go

endly • we are caring and kind • we value and

tra mile • we are welcoming and friendly • we

• we work together • we go the extra mile

ng and kind • we value and respect • we work

welcoming and friendly • we are caring and kind • we go the extra mile • we are welcoming

Refer to page 52 (Audit Committee Report), page 106 (accounting policy) and pages

value and respect work together • we go 128 • to we 132 (financial disclosures).

endly • we are caring and kind • we value and

tra mile • we are welcoming and friendly • we

• we work together • we go the extra mile

ng and kind • we value and respect • we work

welcoming and friendly • we are caring and kind

Page 86

Greater Manchester West Mental Health NHS Foundation Trust

Independent Auditor’s Report

Refer to page 52 (Audit Committee Report), page 115 (accounting policy) and page 136 (financial disclosures).

• we value and respect • we work together • we go the

and friendly • we are caring and kind • we value and respe

• we are welcoming and friendly • we are respect • we work together • we go the extra mile • we

are caring and kind • we value and respect • we work toge we are welcoming and friendly • we are caring and kind • we go the extra mile • we are welcoming and

• we value and respect • we work together • we go the ext

friendly • we are caring and kind • we value and respect •

• we are welcoming and friendly • we are caring

we go the extra mile • we are w

caring and kind • we value and respect • we work together • welcoming and friendly • we are caring and kind • we value

we go the extra mile • we are welcoming and friendly • w and respect • we work together • we go the extra mile •

we are caring and kind • we value and respect • we work to

Annual Report 2014/15

Page 87

Page 88

Greater Manchester West Mental Health NHS Foundation Trust

Annual Report 2014/15

Page 89

Appendix 1

le • we are welcoming and friendly • we are e work together • we go the extra mile g and kind • NHS we value and respect Trust • we work Foundation Code of Governance welcoming and friendly • we are caring and kind Relating•towe are Code welcoming of Summary of requirement Page • we go thePart of extra mile Schedule A Governance Reference Reference• we go value and respect • we work together 2: Disclose Board and A.1.1 The schedule of matters reserved for the board of Page 39 endly • we are caring and kind • we valuedirectors andshould include a clear statement detailing Council of Governors the roles and responsibilities of the council of tra mile • we are welcoming and friendlygovernors. This statement should also describe • we how any disagreements between the council of governors and the board will be resolved. The • we work together • we go the extra mile annual report should include this schedule of or a summary statement of how the board ing and kind • we value and respect • we matters work of directors and the council of governors operate, welcoming and friendly • we are caring andincluding kinda summary of the types of decisions to be taken by each of the boards and which are delegated to the executive management of the • we go the extra mile • we are welcoming board of directors. value and respect • weBoard, work together • we go Pages 46 to 2: Disclose A.1.2 The annual report should identify the chairperson, 57 the deputy chairperson (where there is one), the Nomination executive, the senior independent director Committee(s), endly • we are caring and kind • we valuechiefand Audit Committee, (see A.4.1) and the chairperson and members Remunerationand friendlyof the nominations, audit and remuneration* tra mile • we are welcoming • we Committee committees. It should also set out the number of meetings of the board and those committees and • we work together • we go the extra mile individual attendance by directors.

2: Disclose

Council of Governors

A.5.3

The annual report should identify the members of the council of governors, including a description of the constituency or organisation that they represent, whether they were elected or appointed, and the duration of their appointments. The annual report should also identify the nominated lead governor.

Page 42

Additional requirement of FT Arm

Council of Governors

n/a

The annual report should include a statement about the number of meetings of the council of governors and individual attendance by governors and directors.

Page 42

2: Disclose

Board

B.1.1

The board of directors should identify in the annual report each non-executive director it considers to be independent, with reasons where necessary.

Pages 46 to 49

2: Disclose

Board

B.1.4

The board of directors should include in its annual report a description of each director’s skills, expertise and experience. Alongside this, in the annual report, the board should make a clear statement about its own balance, completeness and appropriateness of the NHS foundation trust.

Pages 49 to 51

Page 90

Greater Manchester West Mental Health NHS Foundation Trust

Appendix 1 - NHS Foundation Trust Code of Governance

Additional requirement of FT ARM

Board

n/a

The annual report should include a brief description of the length of appointments of the non-executive directors, and how they may be terminated.

Page 39

2: Disclose

Nominations Committee(s)

B.2.10

A separate selection of the annual report should describe the work of the nominations committee(s), including the process it has used in relation to board appointments.

Pages 52

Additional requirement of FT ARM

Nominations Committee

n/a

The disclosure in the annual report on the work of the nominations committee should include an explanation if neither an external search consultancy nor open advertising has been used in the appointment of a chair or non-executive director.

Page 52

2: Disclose

Chair / Council of Governors

B.3.1

A chairperson’s other significant commitments should be disclosed to the council of governors before appointment and included in the annual report. Changes to such commitments should be reported to the council of governors as they arise, and included in the next annual report.

Page 46

2: Disclose

Council of Governors

B.5.6

Governors should canvass the opinion of the Page 42 trust’s members and the public, and for appointed governors the body they represent, on the NHS foundation trust’s forward plan, including its objectives, priorities and strategy, and their views should be communicated to the board of directors. The annual report should contain a statement as to how this requirement has been undertaken and satisfied.

Additional requirement of FT ARM

Council of Governors

n/a

If, during the financial year, the Governors have

N/A

• we valueexercised their power* under paragraph 10C** of and respect • we work together • we go the schedule 7 of the NHS Act 2006, then information

on this must be included in the annual report. This and friendly • we are caring and kind • we value and respe is required by paragraph 26(2) (aa) of schedule 7 to the NHS Act 2006, as amended by section 151 (8) of the Health and Social Care Act 2012.

• we are welcoming and friendly • we are

*Power to require one or more of the directors respect • we work together • we go the extra mile • we to attend a governors’ meeting for the purpose of obtaining information about the foundation trust’s performance of its function or the directors’ performance of their duties (and deciding whether to propose a vote on the foundation trust’s or directors’ performance).

are caring and kind • we value and respect • we work toge we are welcoming and friendly • we are caring and kind • we go the extra mile • we are welcoming and

**As inserted by section 151 (6) of the Health and Social Care Act 2012)

2: Disclose

Board

• B.6.1 we valueThe board of directors should state in the annual and respect • we work together • we go the ext Page 39 report how performance evaluation of the board,

committees, and its directors, including the • we value and respect • friendly • itswe are caring and kind chairperson, has been conducted.

2: Disclose

Board

B.6.2

• we are welcoming and friendly • we are caring

Where there has been external evaluation of the N/A board, and/or governance of the Trust, the external facilitator should be identified in the annual report and a statement made as to whether they have any other connection to the trust.

we go the extra mile • we are w

2: Disclose

Board

caring andThe directors should explain in the annual report kind • we value and respectPage • we work together • C.1.1 30 and their responsibility for preparing the annual report

accounts, and state that welcomingandand friendly •they weconsider are the caring and kind • we value annual report and accounts, taken as a whole, are

fair, balanced and understandable and provide the we go the extra mile • we are welcoming and friendly • w information necessary for patients, regulators and other stakeholders to assess the NHS foundation

trust’s business model and strategy. and respect • performance, we work together • we go the extra mile • Directors should also explain their approach to

quality governance in the Annual Governance we are caring and kind • we value and respect • we work to Statement (within the annual report). 2: Disclose

Board

Annual Report 2014/15

C.2.1

The annual report should contain a statement that the board has conducted a review of the effectiveness of its systems of internal controls.

Page 80

Page 91

2: Disclose

Audit Committee / control environment

C.2.2

A trust should disclose in the annual report:

Page 54

(a) If it has an internal audit function, how the function is structured and what role it performs; or (b) If it does not have an internal audit function, that fact and the processes it employs for evaluating and continually improving the effectiveness of its risk management and internal control processes

2: Disclose

Audit Committee / Council of Governors

C.3.5

If the council of governors does not accept the audit committee’s recommendation on the appointment, reappointment or removal of an external auditor, the board of directors should include in the annual report a statement from the audit committee explaining the recommendation and should set out reasons why the council of governors has taken a different position.

N/A

2: Disclosure

Audit Committee

C.3.9

A separate section of the annual report should describe the work of the audit committee in discharging its responsibilities. The report should include:

Pages 54 to 56

• The significant issues that the committee considered in relation to financial settlements, operation and compliance, and how these issues were addressed; • An explanation of how it has assessed the effectiveness of the external audit process and the approach taken to the appointment or reappointment of the external auditor, the value of external audit services and information on the length of tenure of the current audit firm and when a tender was last conducted; and • If the external auditor provides non-audit services, the value of the non-audit services provided and an explanation of how auditor objectivity and independence are safeguarded. 2: Disclose

Board / Remuneration Committee

D.1.3

Where an NHS foundation trust releases an executive director, for example to serve as a nonexecutive director elsewhere, the remuneration disclosures of the annual report should include a statement of whether or not the director will retain such earnings.*

N/A

2: Disclose

Board

E.1.5

The board of directors should state in the annual report the steps they have taken to ensure that the members of the board, and in particular the non-executive directors, develop an understanding of the views of governors and members about the NHS foundation trust, for example through attendance at meetings of the council of governors, direct face-to-face contact, surveys of members’ opinions and consultations

Page 39

2: Disclose

Board / Membership

E.1.6

The board of directors should monitor how representative the NHS foundation trust’s membership is and the level and effectiveness of member engagement and report on this in the annual report.

Pages 58 to 59

2: Disclose

Membership

E.1.4

Contact procedures for members who wish to communicate with governors and/or directors should be made clearly available to members on the NHS foundation trust’s website and in the annual report.

Page 58

Page 92

Greater Manchester West Mental Health NHS Foundation Trust

Additional requirement of FT ARM

Membership

n/a

The annual report should include:

Pages 58 to 59

• A brief description of the eligibility requirements for joining different membership constituencies, including the boundaries for public membership; • Information on the number of members and the number of members in each constituency; and • A summary of the membership strategy, an assessment of the membership and a description of any steps taken during the year to ensure a representative membership (see also E.1.6 above), including progress towards any recruitment targets for members.

Additional requirement of FT ARM (based on FReM requirement)

Board / Council of n/a Governors

The annual report should disclose details of company directorships or other material interests in companies held by governors and/or directors where those companies or related parties are likely to do business, or are possibly seeking to do business, with the NHS foundation trust. As each NHS foundation trust must have registers of governors’ and directors’ interests which are available to the public, an alternative disclosure is for the annual report to simply state how members of the public can gain access to the registers instead of listing all the interests in the annual report.

Pages 32 to 33 and 46

See also ARM paragraph 7.33 as directors’ report requirement. 6: Comply or explain

Board

A.1.4

The board should ensure that adequate systems and processes are maintained to measure and monitor the NHS foundation trust’s effectiveness, efficiency and economy as well as the quality of its health care delivery

Comply

6: Comply or explain

Board

A.1.5

The board should ensure that relevant metrics, measures, milestones and accountabilities are developed and agreed so as to understand and assess progress and delivery of performance

Comply

6: Comply or explain

Board

A.1.6

The board should report on its approach to clinical governance.

Comply

6: Comply or explain

Board

A.1.7

The chief executive as the accounting officer should follow the procedure set out by Monitor for advising the board and the council and for recording and submitting objections to decisions.

Comply

6: Comply or explain

Board

A.1.8

The board should establish the constitution and standards of conduct for the NHS foundation trust and its staff in accordance with NHS values and accepted standards of behaviour in public life

Comply

6: Comply or explain

Board

A.1.9

The board should operate a code of conduct that builds on the values of the NHS foundation trust and reflect high standards of probity and responsibility.

Comply

6: Comply or explain

Board

A.1.10

The NHS foundation trust should arrange appropriate insurance to cover the risk of legal action against its directors.

Comply

6: Comply or explain

Chair

A.3.1

The chairperson should, on appointment by the council, meet the independence criteria set out in B.1.1. A chief executive should not go on to be the chairperson of the same NHS foundation trust.

Comply

6: Comply or explain

Board

A.4.1

In consultation with the council, the board should appoint one of the independent non-executive directors to be the senior independent director.

Comply

6: Comply or explain

Board

A.4.2

The chairperson should hold meetings with the non-executive directors without the executives present.

Comply

6: Comply or explain

Board

A.4.3

Where directors have concerns that cannot be resolved about the running of the NHS foundation trust or a proposed action, they should ensure that their concerns are recorded in the board minutes.

Comply

Annual Report 2014/15

Page 93

6: Comply or explain

Council of Governors

A.5.1

The council of governors should meet sufficiently regularly to discharge its duties.

Comply

6: Comply or explain

Council of Governors

A.5.2

The council of governors should not be so large as to be unwieldy.

Comply

6: Comply or explain

Council of Governors

A.5.4

The roles and responsibilities of the council of governors should be set out in a written document.

Comply

6: Comply or explain

Council of Governors

A.5.5

The chairperson is responsible for leadership of both the board and the council but the governors also have a responsibility to make the arrangements work and should take the lead in inviting the chief executive to their meetings and inviting attendance by other executives and nonexecutives, as appropriate.

Comply

6: Comply or explain

Council of Governors

A.5.6

The council should establish a policy for engagement with the board of directors for those circumstances when they have concerns.

Comply

6: Comply or explain

Council of Governors

A.5.7

The council should ensure its interaction and relationship with the board of directors is appropriate and effective.

Comply

6: Comply or explain

Council of Governors

A.5.8

The council should only exercise its power to remove the chairperson or any non-executive directors after exhausting all means of engagement with the board.

Comply

6: Comply or explain

Council of Governors

A.5.9

The council should receive and consider other appropriate information required to enable it to discharge its duties.

Comply

6: Comply or explain

Board

B.1.2

At least half the board, excluding the chairperson, should comprise non-executive directors determined by the board to be independent.

Comply

6: Comply or explain

Board / Council of B.1.3 Governors

No individual should hold, at the same time, positions of director and governor of any NHS foundation trust.

Comply

6: Comply or explain

Nomination Committee(s)

The nominations committee or committees, with external advice as appropriate, are responsible for the identification and nomination of executive and non-executive directors.

Comply

6: Comply or explain

Board / Council of B.2.2 Governors

Directors on the board of directors and governors on the council should meet the â&#x20AC;&#x153;fit and properâ&#x20AC;? persons test described in the provider licence.

Comply

6: Comply or explain

Nomination Committee(s)

B.2.3

The nominations committee(s) should regularly review the structure, size and composition of the board and make recommendations for changes where appropriate.

Comply

6: Comply or explain

Nomination Committee(s)

B.2.4

The chairperson or an independent nonexecutive director should chair the nominations committee(s).

Comply

6: Comply or explain

Nomination Committee(s) / Council of Governors

B.2.5

The governors should agree with the nominations committee a clear process for the nomination of a new chairperson and non-executive directors.

Comply

6: Comply or explain

Nomination Committee(s)

B.2.6

Where an NHS foundation trust has two nominations committees, the nominations committee responsible for the appointment of nonexecutive directors should consist of a majority of governors.

Not applicable

6: Comply or explain

Council of Governors

B.2.7

When considering the appointment of nonComply executive directors, the council should take into account the views of the board and the nominations committee on the qualifications, skills and experience required for each position.

6: Comply or explain

Council of Governors

B.2.8

The annual report should describe the process followed by the council in relation to appointments of the chairperson and nonexecutive directors.

Comply

6: Comply or explain

Nomination Committee(s)

B.2.9

An independent external adviser should not be a member of or have a vote on the nominations committee(s).

Comply

Page 94

B.2.1

Greater Manchester West Mental Health NHS Foundation Trust

6: Comply or explain

Board

B.3.3

The board should not agree to a full-time executive Comply director taking on more than one non-executive directorship of an NHS foundation trust or another organisation of comparable size and complexity.

6: Comply or explain

Board / Council of B.5.1 Governors

The board and the council governors should be provided with high quality information appropriate to their respective functions and relevant to the decisions they have to make.

Comply

6: Comply or explain

Board

B.5.2

The board and in particular non-executive directors, may reasonably wish to challenge assurances received from the executive management. They need not seek to appoint a relevant adviser for each and every subject area that comes before the board, although they should, wherever possible, ensure that they have sufficient information and understanding to enable challenge and to take decisions on an informed basis.

Comply

6: Comply or explain

Board

B.5.3

The board should ensure that directors, especially non-executive directors, have access to the independent professional advice, at the NHS foundation trustâ&#x20AC;&#x2122;s expense, where they judge it necessary to discharge their responsibilities as directors.

Comply

6: Comply or explain

Board / Committees

B.5.4

Committees should be provided with sufficient resources to undertake their duties.

Comply

6: Comply or explain

Chair

B.6.3

The senior independent director should lead the performance evaluation of the chairperson.

Comply

6: Comply or explain

Chair

B.6.4

The chairperson, with assistance of the board secretary, if applicable, should use the performance evaluations as the basis for determining individual and collective professional development programmes for non-executive directors relevant to their duties as board members.

Comply

6: Comply or explain

Chair / Council of Governors

B.6.5

Led by the chairperson, the council should periodically assess their collective performance and they should regularly communicate to members and the public details on how they have discharged their responsibilities.

Comply

6: Comply or explain

Council of Governors

B.6.6

There should be a clear policy and a fair process, agreed and adopted by the council, for the removal from the council of any governor who consistently and unjustifiably fails to attend the meetings of the council or has an actual or potential conflict of interest which prevents the proper exercise of their duties.

Comply

6: Comply or explain

Board / Remuneration Committee

B.8.1

The remuneration committee should not agree Comply to an executive member of the board leaving the employment of an NHS foundation trust, except in accordance with the terms of their contract of employment, including but not limited to service of their full notice period and/or material reductions in their time commitment to the role, without the board first having completed and approved a full risk assessment.

6: Comply or explain

Board

C.1.2

The directors should report that the NHS foundation trust is a going concern with supporting assumptions or qualifications as necessary.

Comply

See also ARM paragraph 7.17. 6: Comply or explain

Board

Annual Report 2014/15

C.1.3

At least annually and in a timely manner, the board should set out clearly its financial, quality and operating objectives for the NHS foundation trust and disclose sufficient information, both quantitative and qualitative, of the NHS foundation trustâ&#x20AC;&#x2122;s business and operation, including clinical outcome data, to allow members and governors to evaluate its performance.

Comply

Page 95

6: Comply or explain

Board

C.1.4

a) The board of directors must notify Monitor and the council of governors without delay and should consider whether it is in the public’s interest to bring to the public attention, any major new developments in the NHS foundation trust’s sphere of activity which are not public knowledge, which it is able to disclose and which may lead by virtue of their effect on its assets and liabilities, or financial position or on the general course of its business, to a substantial change to the financial wellbeing, health care delivery performance or reputation and standing of the NHS foundation trust.

Comply

b) The board of directors must notify Monitor and the council of governors without delay and should consider whether it is in the public interest to bring to public attention all relevant information which is not public knowledge concerning a material change in: • the NHS foundation trust’s financial condition; • the performance of its business; and/or • the NHS foundation trust’s expectations as to its performance which, if made public, would be likely to lead to a substantial change to the financial wellbeing, health care delivery performance or reputation and standing of the NHS foundation trust. 6: Comply or explain

Board / Audit Committee

C.3.1

The board should establish an audit committee composed of at least three members who are all independent non-executive directors.

Comply

6: Comply or explain

Council of Governors / Audit Committee

C.3.3

The council should take the lead in agreeing with the audit committee the criteria for appointing, reappointing and removing external auditors.

Comply

6: Comply or explain

Council of Governors / Audit Committee

C.3.6

The NHS foundation trust should appoint an external auditor for a period of time which allows the auditor to develop a strong understanding of the finances, operations and forward plans of the NHS foundation trust.

Comply

6: Comply or explain

Council of Governors

C.3.7

When the council ends an external auditor’s appointment in disputed circumstances, the chairperson should write to Monitor informing it of the reasons behind the decision.

Comply

6: Comply or explain

Audit Committee

C.3.8

The audit committee should review arrangements that allow staff of the NHS foundation trust and other individuals where relevant, to raise, in confidence, concerns about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters.

Comply

6: Comply or explain

Remuneration Committee

D.1.1

Any performance-related elements of the remuneration of executive directors should be designed to align their interests with those of patients, service users and taxpayers and to give these directors keen incentives to perform at the highest levels.

Not applicable

6: Comply or explain

Remuneration Committee

D.1.2

Levels of remuneration for the chairperson and other non-executive directors should reflect the time commitment and responsibilities of their roles.

Comply

6: Comply or explain

Remuneration Committee

D.1.4

The remuneration committee should carefully consider what compensation commitments (including pension contributions and all other elements) their directors’ terms of appointments would give rise to in the event of early termination.

Comply

6: Comply or explain

Remuneration Committee

D.2.2

The remuneration committee should have delegated responsibility for setting remuneration for all executive directors, including pension rights and any compensation payments.

Comply

Page 96

Greater Manchester West Mental Health NHS Foundation Trust

6: Comply or explain

Council of Governors / Remuneration Committee

D.2.3

The council should consult external professional advisers to market test the remuneration levels of the chairperson and other nonexecutives at least once every three years and when they intend to make a material change to the remuneration of a non-executive.

Comply

6: Comply or explain

Board

E.1.2

The board should clarify in writing how the public interests of patients and the local community will be represented, including its approach for addressing the overlap and interface between governors and any local consultative forums.

Comply

6: Comply or explain

Board

E.1.3

The chairperson should ensure that the views of governors and members are communicated to the board as a whole.

Comply

6: Comply or explain

Board

E.2.1

The board should be clear as to the specific third party bodies in relation to which the NHS foundation trust has a duty to co-operate.

Comply

6: Comply or explain

Board

E.2.2

The board should ensure that effective mechanisms are in place to co-operate with relevant third party bodies and that collaborative and productive relationships are maintained with relevant stakeholders at appropriate levels of seniority in each.

Comply

Annual Report 2014/15

Page 97

Appendix 2

lcoming and friendly • we are caring and kind we go the extra mile • we are welcoming Foreword the Accounts lue and respect • we work to together • we go ndly • we are Greater Manchester West Mental Health NHS Foundation Trust caring and kind • we value and a mile • we are welcoming and friendly • we These accounts, for the year ended 31 March 2015, have been prepared by Greater we work together • we go the extra mile Manchester West Mental Health NHS Foundation Trust in accordance with paragraphs 24 & 25 value of Schedule the National Health Service Act 2006. g and kind • we and7 within respect • we work lcoming and friendly • we are caring and kind we go the extra mile • we are welcoming lue and respect • we work together • we go Signed: ndly • we are caring and kind • we value and Bev HumpHrey, CHief exeCutive DateD: 22nD may 2015 a mile • we are welcoming and friendly • we we work together • we go the extra mile g and kind • we value and respect • we work lcoming and friendly • we are caring and kind we go the extra mile • we are welcoming

Page 98

Greater Manchester West Mental Health NHS Foundation Trust

Appendix 2 - Annual Accounts

Statement of Comprehensive Income Note

2014/15

2013/14

£000

Operating income from patient care activities

153,131

146,043

Other operating income

13,407

11,544

166,538

157,587

(156,452)

(149,178)

10,086

8,409

Total operating income from continuing operations Operating expenses

5, 7

Operating surplus/(deficit) from continuing operations Finance income

192

164

Finance expenses

(180)

(145)

(2,059)

(1,838)

(2,047)

(1,819)

PDC dividends payable Net finance costs

• we value and respect • we work together • we go the ex

Share of profit of associates/joint arrangements

and friendly • we are caring and kind and respec Gains/ (losses) arising from transfers by absorption 34 - • we value -

- and friendly • we are welcoming • we are c

Corporation tax expense

Surplus/(deficit) for the year from continuing operations respect • we work

6,590 together • we8,039 go the extra mile • we ar

Surplus/(deficit) on discontinued operations and the are caring and kind gain/(loss) on disposal of discontinued operations Surplus/(deficit) for the year we are Other comprehensive income

- work toget • we value and -respect • we

6,590 and kind • w welcoming and friendly •8,039 we are caring

we go the extra mile • we are welcoming and fr

Will not be reclassified to income and • we value and expenditure:

respect • we work together • we go the extra

Gains/(loss) arising from transfer by absorption from caring friendly • we are demising bodies

and kind • -we value327 and respect • w

• we are welcoming and- friendly • we are caring a 6 -

Impairments Revaluations

Other reserve movements

caring and kind • we Total comprehensive income/(expense) for the period

we go the extra mile- • we are we (6)

(16)

value and respect • we6,901 work together • w 8,033

welcoming and friendly • we are caring and kind • we value an

we go the extra mile • we are welcoming and friendly • we

and respect • we work together • we go the extra mile • w

we are caring and kind • we value and respect • we work tog

Annual Report 2014/15

Page 99

Statement of Financial Position Note

31 March 2015

31 March 2014

£000

Non-current assets Intangible assets

231

Property, plant and equipment

110,320

101,423

Trade and other receivables

706

110,561

102,129

Total non-current assets Current assets Inventories

Trade and other receivables

8,177

4,126

Cash and cash equivalents

Total current assets

49,844

56,436

58,021

60,562

Current liabilities Trade and other payables

(24,034)

(19,945)

Other liabilities

(19,855)

(11,924)

Provisions

(2,723)

(3,076)

Total current liabilities

(46,612)

(34,945)

Total assets less current liabilities

121,970

127,746

Non-current liabilities Trade and other payables

Other liabilities

(2,490)

(16,567)

Provisions

(3,100)

(3,090)

(5,590)

(19,657)

116,380

108,089

92,561

92,303

4,783

4,831

470

485

18,566

10,470

116,380

108,089

Total non-current liabilities Total assets employed Financed by Public dividend capital Revaluation reserve Other reserves Income and expenditure reserve Total taxpayers’ equity The notes 1 - 37 form part of these accounts.

Signed: Bev HumpHrey, CHief exeCutive

Page 100

DateD: 22nD may 2015

Greater Manchester West Mental Health NHS Foundation Trust

Statement of Changes in Equity for the year ended 31 March 2015 Revaluation reserve

Available for sale investment reserve

Other reserves

Merger reserve

Income and expenditure reserve

Total

£000

92,303

4,831

485

10,470

108,089

At start of period for new FTs

Surplus/(deficit) for the year

8,039

251

(48)

(15)

92,561

4,783

470

18,566

116,380

Public dividend capital

Taxpayers’ and others’ equity at 1 April 2014 - brought forward

Public dividend capital received Other reserve movements Taxpayers’ and others’ equity at 31 March 2015

Statement of Changes in Equity for the year ended 31 March 2014 Revaluation reserve

Available for sale investment reserve

Other reserves

Merger reserve

Income and expenditure reserve

Total

£000

92,303

4,978

500

3,407

101,188

92,303

4,978

500

3,407

101,188

At start of period for new FTs

Surplus/(deficit) for the year

6,590

Transfers by absorption: gains/ (losses) on 1 April transfers

327

Transfers by absorption: transfers between reserves

Transfer from revaluation reserve to income and expenditure reserve for impairments arising from consumption of economic benefits

(99)

Other movements in public dividend capital in year

Other reserve movements

(48)

(15)

(16)

92,303

4,831

485

10,470

108,089

Public dividend capital

Taxpayers’ and others’ equity at 1 April 2013 - brought forward Prior period adjustment Taxpayers’ and others’ equity at 1 April 2013 - restated

Taxpayers’ and others’ equity at 31 March 2014

Annual Report 2014/15

Page 101

Information on reserves Public dividend capital Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS trust. Additional PDC may also be issued to NHS foundation trusts by the Department of Health. A charge, reflecting the cost of capital utilised by the NHS foundation trust, is payable to the Department of Health as the public dividend capital dividend.

Revaluation reserve Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse impairments previously recognised in operating expenses, in which case they are recognised in operating income. Subsequent downward movements in asset valuations are charged to the revaluation reserve to the extent that a previous gain was recognised unless the downward movement represents a clear consumption of economic benefit or a reduction in service potential.

Other reserve The balance of this reserve is from the transfer of property to the Trust in 2000-2001.

Income and expenditure reserve The balance of this reserve is the accumulated surpluses and deficits of the NHS foundation trust.

Page 102

Greater Manchester West Mental Health NHS Foundation Trust

Statement of Cash Flows Note

2014/15

2013/14

ÂŁ000

10,086

8,409

Cash flows from operating activities Operating surplus/(deficit) Non-cash income and expense: Depreciation and amortisation

3,226

2,713

Impairments and reversals of impairments

885

1,826

(Gain)/loss on disposal of non-current assets

(1)

(3,431)

(496)

(Increase)/decrease in receivables and other assets (Increase)/decrease in inventories

(3,916)

4,149

(523)

(1,178)

Tax (paid)/received

Operating cash flows movement of discontinued operations

Other movements in operating cash flows

(23)

6,327

15,400

189

164

Increase/(decrease) in payables and other liabilities Increase/(decrease) in provisions

Net cash generated from/(used in) operating activities Cash flows from investing activities Interest received Purchase and sale of financial assets

(148)

(11,278)

(9,172)

PFI lifecycle prepayments

Investing cash flows of discontinued operations

(11,223)

(9,008)

251

Purchase of intangible assets Sales of intangible assets Purchase of property, plant, equipment and investment property Sales of property, plant, equipment and investment property

Net cash generated from/(used in) investing activities Cash flows from financing activities Public dividend capital received Other interest paid

PDC dividend paid

(1,947)

(1,824)

Financing cash flows of discontinued operations

Cash flows from (used in) other financing activities

Net cash generated from/(used in) financing activities

(1,696)

(1,817)

Increase/(decrease) in cash and cash equivalents

(6,592)

4,575

Cash and cash equivalents at 1 April

56,436

51,861

Cash and cash equivalents at start of period for new FTs Cash and cash equivalents transferred under absorption accounting

Cash and cash equivalents at 31 March

49,844

56,436

Annual Report 2014/15

Page 103

Notes to the Accounts Note 1: Accounting policies and other information 1.1 Basis of preparation Monitor has directed the financial statements of NHS foundation trusts shall meet the accounting requirements of the FT ARM which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the FT ARM 2014/15 issued by Monitor. The accounting policies contained in that manual follow IFRS and HM Treasury’s FReM to the extent they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.

1.1.1 Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.

1.1.2 Going concern These accounts have been prepared on a going concern basis. International Accounting Standard (IAS) 1, requires management to assess, as part of the accounts preparation process, the NHS Foundation Trust’s ability to continue as a going concern. At the Board meeting held on 30th March 2015, the Board ratified the Trust’s ability to continue on a going concern basis. As a consequence the financial statements have been prepared on a going concern basis.

1.1.3 Consolidation 1.1.3.1 Subsidiaries, Associates and Joint Ventures In considering IAS 27 (revised) the Trust is not required to produce consolidated accounts as it has no Subsidiaries (IFRS 10) , Associates (IAS 28), and Joint Venture Arrangements (IFRS 11). 1.1.3.2 Charitable Funds From 2013-14, under the provisions of IAS 27 Consolidated and Separate Financial Statements, those Charitable Funds that fall under common control with NHS bodies should be considered for consolidation within the entities’ Returns. The Trust Board reviewed the charitable funds in March 2014 and again in 2015 and determined them not to be material and therefore not to be accounted for as a subsidiary. (reference IAS 8 ‘Accounting requirements need not be applied to immaterial items).

Note 1.2 Income Income in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the consideration receivable. The main source of income for the trust is contracts with commissioners in respect of health care services. Page 104

Greater Manchester West Mental Health NHS Foundation Trust

Where income is received for a specific activity which is to be delivered in a subsequent financial year, that income is deferred. Income from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract.

Note 1.3 Expenditure on employee benefits 1.3.1 Short-term employee benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry-forward leave into the following period.

1.3.2 Pension costs 1.3.2.1 NHS Pension Scheme Past and present employees are covered by the provisions of the NHS Pension Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of Secretary of State, in England and Wales. It is not possible for the NHS foundation trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a defined contribution scheme. Employers pension cost contributions are charged to operating expenses as and when they become due. Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the trust commits itself to the retirement, regardless of the method of payment.. 1.3.2.2 National Employment Savings Pension Scheme (NEST) Under the Pensions Act 2008 employers must offer a pension scheme to all its employees. As from the 1st July 2013, when the scheme came into operation in the Trust (its staging date), staff who are not eligible to join the NHS Pensions Scheme are automatically enrolled into NEST. This scheme is a defined contribution pension scheme created as part of the governmentâ&#x20AC;&#x2122;s workplace pensions reforms. Accounting for defined contribution plans requires the Trust to report on the amounts contributed for that period. Consequently, no actuarial assumptions are required to measure the obligation for the expense and there is no possibility of any actuarial gain or loss. The Trust settles its obligations within the annual reporting period in which the employees render the related service. Please refer to Note 7.3.7 for further details of the pension scheme.

Note 1.4 Expenditure on other goods and services Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a noncurrent asset such as property, plant and equipment.

Annual Report 2014/15

Page 105

Note 1.5 Property, plant and equipment 1.5.1 Recognition

Property, Plant and Equipment is capitalised where: • it is held for use in delivering services or for administrative purposes; • it is probable that future economic benefits will flow to, or service potential be provided to, the Trust; • it is expected to be used for more than one financial year; and • the cost of the item can be measured reliably • items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost Where a large asset, for example a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives. (see Note 15.1).

1.5.2 Measurement 1.5.2.1 Valuation All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at fair value. Land and buildings are stated in the statement of financial position at their revalued amounts as at 31st March 2013. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows: (i)

Land and non-specialised buildings – market value for existing use

(ii) Specialised buildings – depreciated replacement cost using a Modern Equivalent Asset Valuation IAS16 (34) requires that the accounts reflect changes in asset values. Where insignificant, revaluation may be necessary only every 3 or 5 years. In Monitor’s view property assets are likely to require a full revaluation at least every 5 years, with which the Trust complies. Monitor’s Financial Reporting Manual states (5.5 2014/15 FReM) : ‘There is no predetermined frequency with which assets must be re-valued. Instead, the standard requires that asset values should be kept up to date and that the frequency of revaluation will need to reflect the volatility of asset values. Where assets are subject to significant volatility, then annual revaluations may be required. Conversely, where changes in asset values are insignificant then a revaluation may be necessary only every 3 or 5 years. In Monitor’s view, property assets are likely to require revaluation at least every 5 years.’ The Trust has complied with these recommendation and its latest desk top review was carried out in 2013/14. The Trust’s most recent full revaluation took place on 31st March 2013. Properties in the course of construction are carried at cost. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Page 106

Greater Manchester West Mental Health NHS Foundation Trust

For newly acquired or newly constructed assets, a formal revaluation will only be carried out if there is an indication that the initial cost is significantly different to its fair value. Depreciation commences when assets are brought into use, starting from the first complete accounting quarter. The carrying amount for fixtures and equipment is depreciated at historic cost as this is not considered to be materially different from fair value. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure in which case it is credited to the SOCI. A revaluation decrease that does not result from a loss of economic value or services potential is recognised as an impairment charge to the revaluation reserve to the extent there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit have been taken to the SOCI. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the SOCI. 1.5.2.2 Subsequent expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. 1.5.2.3 Depreciation Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Freehold land is considered to have an infinite life and is not depreciated. Property, plant and equipment which has been reclassified as ‘held for sale’ ceases to be depreciated upon the reclassification. Assets in the course of construction and residual interests in off-Statement of Financial Position PFI contract assets are not depreciated until the asset is brought into use or reverts to the trust, respectively.

1.5.3. Revaluation gains and losses Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised in operating income. For newly acquired or newly constructed assets, a desk top revaluation is undertaken to determine the fair value of the asset. A formal revaluation will only be carried out if there is an indication that the initial cost is significantly different to its fair value. Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’.

Annual Report 2014/15

Page 107

1.5.4 Impairments In accordance with the FT ARM, impairments that are due to loss of economic benefits or service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment. An impairment arising from the loss of economic benefit or service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised. Other impairments are treated as revaluation losses. Reversals of ‘other impairments’ are treated as revaluation gains. Impairments identified by the District Valuer, as a result of the March 2015 review, have been recognised in the accounts.

1.5.5 De-recognition Assets intended for disposal are reclassified as ‘held for sale’ once all of the following criteria are met: • the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; • the sale must be highly probable i.e.: o management are committed to a plan to sell the asset; o an active programme has begun to find a buyer and complete the sale; o the asset is being actively marketed at a reasonable price; o the sale is expected to be completed within 12 months of the date of classification as ‘held for sale’; and o the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it. Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged. Assets are de-recognised when all material sale contract conditions have been met. Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as ‘held for sale’ and instead is retained as an operational asset and the asset’s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.

1.5.6 Donated, government grant and other grant funded assets Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met.

Page 108

Greater Manchester West Mental Health NHS Foundation Trust

The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment.

Note 1.6 Intangible assets Recognition Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the trust’s business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the trust and where the cost of the asset can be measured reliably. Internally generated intangible assets Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets. Expenditure on research is not capitalised. Expenditure on development is capitalised only where all of the following can be demonstrated: • the project is technically feasible to the point of completion and will result in an intangible asset for sale or use; • the trust intends to complete the asset and sell or use it; • the trust has the ability to sell or use the asset; • how the intangible asset will generate probable future economic or service delivery benefits, eg, the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset; • adequate financial, technical and other resources are available to the trust to complete the development and sell or use the asset; and • the trust can measure reliably the expenses attributable to the asset during development. Software Software which is integral to the operation of hardware, eg an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to the operation of hardware, eg application software, is capitalised as an intangible asset. Measurement Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management. Subsequently intangible assets are measured at fair value. Revaluations gains and losses and impairments are treated in the same manner as for property, plant and equipment Intangible assets held for sale are measured at the lower of their carrying amount or “fair value less costs to sell”. Amortisation Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits.

Annual Report 2014/15

Page 109

Useful economic life of intangible assets Useful economic lives reflect the total life of an asset and not the remaining life of an asset. The range of useful economic lives are shown in the table below: Min life Years 2

Intangible assets – purchased Software

Max life Years 5

Note 1.7 Revenue government and other grants Government grants are grants from Government bodies other than income from commissioners or NHS trusts for the provision of services. Where a grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match that expenditure. The Trust has not received any such grants in 2014/15.

Note 1.8 Inventories The value of stocks and works in progress are deemed to be immaterial to the accounts when consideration is given to the costs of collation and verification, this is in line with Financial Reporting Standard 18 (Page 3 {c}) and IAS 1 Presentation of Financial Statements which states that specific disclosure requirements set out in individual standards or interpretations need not be satisfied if the information is not material. The Standard also states (at paragraph 44) ‘the benefits derived from information should exceed the cost of providing it’.

Note 1.9 Financial instruments and financial liabilities 1.9.1 Recognition Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs, i.e., when receipt or delivery of the goods or services is made. All other financial assets and financial liabilities are recognised when the trust becomes a party to the contractual provisions of the instrument.

1.9.2 De-recognition All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the trust has transferred substantially all of the risks and rewards of ownership. Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires.

1.9.3 Classification and measurement Financial assets are categorised as loans and receivables Financial liabilities are classified as” ‘other financial liabilities”.

Page 110

Greater Manchester West Mental Health NHS Foundation Trust

1.9.4 Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets. The trust’s loans and receivables comprise: cash and cash equivalents, NHS receivables, accrued income and “other receivables”. Loans and receivables are recognised initially at fair value, net of transactions costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset. Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income.

1.9.5 Available-for-sale financial assets The Trust does not hold any available-for-sale financial assets. Available-for-sale financial assets are non-derivative financial assets which are either designated in this category or not classified in any of the other categories. They are included in long-term assets unless the trust intends to dispose of them within 12 months of the Statement of Financial Position date.

1.9.6 Other financial liabilities All other financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability. They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as long-term liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to finance costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets.

1.9.7 Determination of fair value For financial assets and financial liabilities carried at fair value, the carrying amounts are determined from quoted market prices, independent appraisals and discounted cash flow analysis as appropriate to the financial asset or liability. The provision for Injury Benefit liability cash flows are discounted remain at the Treasury’s discount rate of 1.3% 2014/15 (2013/14 1.8%).

1.9.8 Impairment of financial assets At the Statement of Financial Position date, the Trust assesses whether any financial assets are impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the SOCI and in the case of trade receivables, the carrying amount of Annual Report 2014/15

Page 111

the asset is reduced through the use of an allowance for irrecoverable amounts, and for other financial assets the carrying amount is reduced directly.

Note 1.10 Leases 1.10.1 Finance leases The Trust has no Finance leases as at the 31 March 2015..

1.10.2 Operating leases Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease.

1.10.3 Leases of land and buildings Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately.

Note 1.11 Provisions The Trust recognises a provision where it has a present legal or constructive obligation of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using the discount rates published and mandated by HM Treasury. For employee early departure obligations the Trust has used the HM Treasury’s pension discount rate of 1.3% 2014/15 (2013/14 1.8%) in real terms. A restructuring provision is recognised when the Trust has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with ongoing activities of the entity.

1.11.1 Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS foundation trust pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the NHS foundation trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS foundation trust is disclosed at note 29 but is not recognised in the Trust’s accounts.

1.11.2 Non-clinical risk pooling The NHS foundation trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the trust pays an annual contribution to the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership contributions, and any “excesses” payable in respect of particular claims are charged to operating expenses when the liability arises. Page 112

Greater Manchester West Mental Health NHS Foundation Trust

Note 1.12 Contingencies Contingent assets (that is, assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control) are not recognised as assets, but are disclosed in note 29 where an inflow of economic benefits is probable. Contingent liabilities are not recognised, but are disclosed in note 29, unless the probability of a transfer of economic benefits is remote. Contingent liabilities are defined as: • possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control; or • present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.

Note 1.13 Public dividend capital Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32. A charge, reflecting the cost of capital utilised by the NHS foundation trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS foundation trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets (including lottery funded assets), (ii) average daily cash balances held with the Government Banking Services (GBS) and National Loans Fund (NLF) deposits, excluding cash balances held in GBS accounts that relate to a shortterm working capital facility, and (iii) any PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the “pre-audit” version of the annual accounts. The dividend thus calculated is not revised should any adjustment to net assets occur as a result the audit of the annual accounts.

Note 1.14 Value added tax Most of the activities of the NHS foundation trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

Note 1.15 Corporation tax For 2014/15 there is to be no application of Corporation Tax liability. The Trust is a Health Service body within the meaning of s519A ICTA 1988 and accordingly is exempt from taxation in respect of income and capital gains within categories covered by this. There is a power for the Treasury to withdraw the exemption in relation to the specified activities Annual Report 2014/15

Page 113

of a Foundation Trust (s519A (3) to (8) ICTA 1988). Accordingly, the Trust is potentially within the scope of Corporation Tax in respect of activities which are not related to, or ancillary to, the provision of healthcare and where the profits there from exceed £50,000 pa, of which the Trust has none.

Note 1.16 Foreign exchange The Trust has only minimal foreign exchange transactions. Transactions that are denominated in a foreign currency are translated into sterling at the exchange rate ruling on the date of the transaction. Resulting exchange gains and losses are taken to the Income and Expenditure account. All sales of healthcare services are denominated in sterling

Note 1.17 Third party assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the NHS foundation trust has no beneficial interest in them. However, they are disclosed in a separate note to the accounts in accordance with the requirements of HM Treasury’s FReM.

Note 1.18 Losses and special payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had NHS foundation trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure). However the losses and special payments note is compiled directly from the losses and compensations register which reports on an accrual basis with the exception of provisions for future losses. Losses and special payments are disclosed in Note 33.

Note 1.19 Transfers of functions to / from other NHS bodies / local government bodies The Trust had no transfers of function from other NHS Bodies in 2014/15. Property was transferred to the Trust on 1 April 2013. The Cost and Accumulated Depreciation/ Amortisation balances from the transferring entity’s accounts were preserved on recognition in the Trust’s accounts.

Note 1.20 Early adoption of standards, amendments and interpretations No new accounting standards or revisions to existing standards have been early adopted in 2014/15. Page 114

Greater Manchester West Mental Health NHS Foundation Trust

Note 1.21 Standards, amendments and interpretations in issue but not yet effective or adopted The Treasury FReM does not require the following Standards and Interpretations to be applied in 2014-15. The application of the Standards as revised would not have a material impact on the accounts for 2014-15, were they applied in that year: IFRS 9 - Financial Instruments IFRS 9 - Financial Instruments - Subject to IFRS 13 - Fair Value - Effective from 1 April 2015 consultation. IFRS 15 - Revenue for Contract with Customers - Effective from 1 January 2017 IAS 19 (amendment) - Employer contributions to defined benefit pension schemes Effective from 2015-16 but not yet EU adopted IAS 36 (amendment) - Recoverable Amount Disclosures - To be adopted from 2015-16 (aligned to IFRS 13 adoption)

IFRIC 21 - Levies - EU adopted in June 2014 but not yet adopted by HM Treasury Note 1.22 Critical accounting estimates and judgements In the application of the Trust’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The Trust confirms that it has not used any key assumptions concerning the future or had any key sources of estimation uncertainty at the end of the reporting period, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within the next financial year that need to be disclosed under IAS 1. The provisions have been calculated having recognised an obligating event during the year and include estimates and assumptions relating to the carrying amounts and timing of anticipated payments. Other less significant areas of judgement and estimation techniques (e.g. depreciation and deferred income) have been disclosed in the Trust’s accounting policies and in the notes to the financial statements, as required by the relevant IFRS.

Note 1.23 Current Asset Investments Current Asset investments are short-term deposits which are readily convertible into known amounts of cash at or close to their carrying amounts. They are treated as liquid resources in the cashflow statement.

Note 1.24 Cash and Cash Equivalents Cash is cash in hand, and deposit with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and are readily convertible to known amounts of cash with insignificant of change in value. Cash, bank and overdrafts are recorded at the current values of these balances in the Trust’s cash book. Annual Report 2014/15

Page 115

These balances exclude monies held in the Trust bank account belonging to third parties (see third party assets 25.1). Account balances are only set-off where a formal agreement has been made with the bank to do so. Interest earned on bank accounts is recorded as “interest receivable” in the period to which it relates. Bank charges are recorded as operating expenditure in the period to which they relate.

Note 1.25 Research and development Expenditure on research and development is not capitalised.

Note 1.26 Acquisitions and discontinued operations The Trust has no acquisitions or discontinued operations to report on. Activities are considered to be ‘acquired’ only if they are taken from outside the public sector. Activities are considered to be ‘discontinued’ only if they cease entirely. They are not considered to be ‘discontinued’ if they transfer from one public sector body to another.

Note 2: Operating Segments All of GMW’s activities are in the provision of healthcare, which is an aggregate of all the individual specialty components included therein. Similarly, the large majority of the Foundation Trust’s income originates with the UK Whole of Government Accounting (WGA) bodies. The majority of expenses incurred are payroll expenditure on staff involved in the production or support of healthcare activities generally across the Trust together with the related supplies and overheads needed to establish this production. The business activities which earn revenue and incur expenses are therefore of one broad combined nature and therefore on this basis one segment of Healthcare is deemed appropriate. The operating results of the Foundation Trust are reviewed monthly or more frequently by the Trust’s chief operating decision maker which is the overall Foundation Trust Board and which includes senior professional non-executive directors. The Trust Board review the financial position of the Foundation Trust as a whole in their decision making process, rather than individual components included in the totals, in terms of allocating resources. This process again implies a single operating segment under IFRS 8. The finance report considered monthly by the Trust Board contains summary figures for the whole Trust together with graphical line and bar charts relating to different total income activity levels, and directorate expense budgets with their cost improvement positions. Similarly only total balance sheet positions and cash flow forecasts are considered for the whole Foundation Trust. The Board as chief operating decision maker therefore only considers one segment of healthcare in its decision making process. The single segment of ‘Healthcare’ has therefore been identified consistent with the core principle of IFRS8 which is to enable users of the financial statements to evaluate the nature and financial effects of business activities and economic environments.”

Page 116

Greater Manchester West Mental Health NHS Foundation Trust

Note 3: Operating Income Note 3.1 Income from patient care activities (by nature) 2014/15

2013/14

£000

4,268

3,192

111,502

103,275

2,282

3,984

33,221

32,195

1,858

3,397

153,131

146,043

Mental health services Cost and volume contract income Block contract income Clinical income for the secondary commissioning of mandatory services Other clinical income from mandatory services Other clinical income* Total income from activities

* Other clinical income for 2014/15 relates to funding received from our Lead Commissioners for service developments outside the contract. 2013/14 has been restated from £3,038k to £3,397K as income previously classed as non clinical has been reclassified as clinical income.

Note 3.2 Income from patient care activities (by source) Income from patient care activities received from:

2014/15

2013/14

£000

128,619

123,556

21,575

20,020

NHS other

1,430

978

Non NHS: other

1,507

1,489

153,131

146,043

153,131

146,043

CCGs and NHS England Local authorities

Total income from activities Of which: Related to continuing operations Related to discontinued operations

Total income from activities includes income of £153,131 2014/15 (2013/14 £146,043 ) from Commissioner Requested Services

Note 3.3 Overseas visitors (relating to patients charged directly by the NHS foundation trust) The only overseas activities are in respect of reciprocal EU treatments generating no income.

Annual Report 2014/15

Page 117

Note 4: Other operating income 2014/15

2013/14

£000

Research and development

2,922

2,447

Education and training

4,240

5,490

Profit on disposal of non-current assets Reversal of impairments Rental revenue from operating leases Income in respect of staff costs where accounted on gross basis Other income* Total other operating income

323

311

211

5,921

3,066

13,407

11,544

13,407

11,544

Of which: Related to continuing operations Related to discontinued operations

*Other Operating Income for 2013/14 has been restated from £3,425k to £3,066k as income from the provision of clinical services at Recovery First were incorrectly classified as non clinical income in 2013/14.

Other Operating Income

2014/15

2013/14

£000

202

165

Catering

153

Property Rentals

618

317

Council grant

239

VAT reclaims

155

438

Release of deferred income *

3,518

988

Other **

1,215

704

5,921

3,066

Car parking Clinical excellence awards

* Relates to the release of deferred income to match expenditure spent on Low and Medium Secure wards and the Recovery Academy. ** Relates to increase in ECT income, Interpreter fees and Court report income.

Note 4.1 Income from activities arising from commissioner requested services Under the terms of its Provider License, the trust is required to analyse the level of income from activities that has arisen from commissioner requested and non-commissioner requested services. Commissioner requested services are defined in the provider license and are services that commissioners believe would need to be protected in the event of provider failure. This information is provided in the table below: 2014/15 Income from services designated (or grandfathered) as commissioner requested services Income from services not designated as commissioner requested services Total

Page 118

2013/14

£000

153,131

146,043

13,407

11,544

166,538

157,587

Greater Manchester West Mental Health NHS Foundation Trust

Note 4.2 Profits and losses on disposal of property, plant and equipment There were no disposals of land and buildings during the year.

Note 5: Operating expenses Note 5.1 Operating expenses

Services from NHS foundation trusts Services from NHS trusts Purchase of healthcare from non NHS bodies Purchase of social care Employee expenses - executive directors Employee expenses - non-executive directors

2014/15

2013/14

ÂŁ000

1,043

460

4,684

4,883

528

578

1,037

1,023

133

136

114,542

109,119

Supplies and services - clinical

3,098

2,975

Supplies and services - general

2,871

3,043

Establishment

2,125

1,708

Research and development

2,855

1,451

Transport

1,521

1,670

Premises

9,400

9,454

486

(189)

358

2,453

2,481

Rentals under operating leases

1,172

967

Depreciation on property, plant and equipment

3,226

2,713

885

1,845

audit services- statutory audit

audit services- regulatory reporting (external auditor only)

Clinical negligence

357

492

Legal fees

496

559

Consultancy costs

200

168

Training, courses and conferences

957

1,382

Employee expenses - staff

Increase/(decrease) in provision for impairment of receivables* Change in provisions discount rate(s) Drug costs Inventories consumed

Impairments Audit fees payable to the external auditor

other auditor remuneration (external auditor only)

Patient travel Car parking & security

234

Redundancy ***

215

Early retirements

136

Hospitality

Publishing

Insurance

194

Other services, e.g. external payroll

Annual Report 2014/15

Page 119

Grossing up consortium arrangements Losses, ex gratia & special payments Other ** Total

123

1,617

772

156,452

149,178

156,452

149,178

Of which: Related to continuing operations Related to discontinued operations * Refer to note 23.1 for analysis in the movement of the provision for doubtful debts ** Other expenses has increased in year as a result of the costs incurred for the implementation of the new Patient administration system ***The termination benefits for 2013/14 included a provision for redundancy for the implementation of the Acute Care Pathways (ACP) and other restructuring costs. The ACP redundancies have been charged against provisions in year, thus reducing the termination benefits charged against employee expenses.

Note 5.2 Other auditor remuneration 2014/15

2013/14

£000

Audit-related assurance services

All taxation advisory services not falling within item 3 above

Total

Other auditor remuneration paid to the external auditor:

Note 5.3 Limitation on auditor’s liability The limitation on auditors’ liability for external audit work is £1m (2013/14: £1m).

Note 6: Impairment of assets 2014/15

2013/14

£000

Abandonment of assets in course of construction

159

Changes in market price

726

1,826

Total net impairments charged to operating surplus / deficit

885

1,826

885

1,826

Net impairments charged to operating surplus / deficit resulting from:

Impairments charged to the revaluation reserve Total net impairments

A valuation of capital builds completed during the year was undertaken by the District Valuer in February 2015, this resulted in impairments of £726k.

Page 120

Greater Manchester West Mental Health NHS Foundation Trust

Note 7: Employee benefits 2014/15

2013/14

Permanent

Other

Total

£000

Salaries and wages

91,508

8,632

100,140

97,877

Social security costs

7,234

602

7,836

7,190

11,969

996

12,965

11,899

Pension cost - other