2023-03-31-accounts

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Hospice of the Good Shepherd Company Limited by Guarantee Group Financial Statements For the year ended 31st March 2023

Company Registration Number : 1843427 Charity Number : 515516

Our Year in Numbers............................................................................................................................... 4 Chair’s Report.......................................................................................................................................... 5 Trustees' Report (Incorporating Directors' and Strategic Reports) ........................................................ 6 About Us.............................................................................................................................................. 6 Public Benefit Statement .................................................................................................................... 6 Our Vision , Mission & Values .................................................................................................................. 7 We have a range of strategic aims to ensure we deliver the best quality care. ............................. 7 Our Values Underpin Everything We Do ......................................................................................... 7 Looking Back at our 2022/2023 Charitable Activities Highlights ............................................................ 8 Our In-Patient Unit .............................................................................................................................. 8 Our Clinics ........................................................................................................................................... 9 Medical Out-Patients .................................................................................................................... 10 Complementary Therapy .............................................................................................................. 10 Living Well ......................................................................................................................................... 10 Bereavement Support ....................................................................................................................... 10 Adult and Children and Young People’s Counselling Services at the Living Well ......................... 10 Being your voice ................................................................................................................................ 11 Delivering against our Quality Priorities ........................................................................................... 11 Our Quality Highlights 2022/2023 Consultant in Palliative Medicine .............................................. 12 High Sheriff Award ............................................................................................................................ 12 Clinical Learning and Education ........................................................................................................ 13 Homelessness work .......................................................................................................................... 13 Feedback about the homelessness work .......................................................................................... 14 LGBTQIA+ .......................................................................................................................................... 14 Helping People Live Well ................................................................................................................... 15 Legacy Art Project ............................................................................................................................. 15 Patient Support Volunteering ........................................................................................................... 16 How we funded our achievements 2022/2023 .................................................................................... 17 Donations & Legacies .................................................................................................................... 17 Other Trading Activities ................................................................................................................ 17 Charitable Activities ...................................................................................................................... 17 Investments ................................................................................................................................... 17 Donors and Events ............................................................................................................................ 18 Community Fundraising and Challenge Events................................................................................. 18 Gifts in Wills ...................................................................................................................................... 20 Retail & Lottery ................................................................................................................................. 20 Retail ............................................................................................................................................. 20 Lottery ........................................................................................................................................... 20 Trusts and Foundations ..................................................................................................................... 21

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Investments ....................................................................................................................................... 22 How we spent your donations .............................................................................................................. 23 Our passionate and dedicated people .................................................................................................. 24 Support.............................................................................................................................................. 24 Safeguarding ..................................................................................................................................... 24 Promoting Equality, Diversity & Inclusion ........................................................................................ 25 Freedom to Speak Up ....................................................................................................................... 25 Our Equality and Diversity Work ....................................................................................................... 25 Technology ............................................................................................................................................ 26 Looking Forward and delivering our Strategy ....................................................................................... 27 Structure, Governance and Management Statement of Trustees' Responsibilities............................. 31 Our Senior Management Team......................................................................................................... 32 Subsidiary Undertakings ................................................................................................................... 33 The Board and Subsidiary Committees ............................................................................................. 33 Terms of Reference for Our Committees .......................................................................................... 33 Our Board ...................................................................................................................................... 33 Care Committee ............................................................................................................................ 34 Clinical Governance Committee.................................................................................................... 34 Finance & Fundraising Committee ................................................................................................ 35 Health, Safety & Estates Committee ............................................................................................. 36 Information Governance Committee ............................................................................................ 36 People & Development and Remuneration Committee ............................................................... 37 Chief Executive .................................................................................................................................. 37 Corporate Governance ...................................................................................................................... 37 Risk Management and Assurance ..................................................................................................... 38 Financial Review .................................................................................................................................... 40 Management of reserves .................................................................................................................. 40 Statement of Trustees' Responsibilities for the Financial Statements and Corporate Governance .... 41 Independent Auditors' Report Financial Statements ........................................................................... 42 Consolidated Statement of Financial Activities (Incorporating a Consolidated Income and Expenditure Account) 46 Balance Sheet for the year ended 31st March 2023 ............................................................................ 47 Consolidated Cash Flow Statement for the year ended 31st March 2023 ........................................... 48 Notes to the Financial Statements for the year ended 31st March 2023 ............................................ 49 Notes to the Financial Statements for the year ended 31st March 2023 cont. ........................... 50 Our Supporters ...................................................................................................................................... 74 Community and Corporate Supporters............................................................................................. 74 Our Hospice Community Fundraising Groups ................................................................................... 74 Patrons and celebrity supporters ...................................................................................................... 74

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Our Year in Numbers We have 350 volunteers who support our team across all areas of the hospice We supported 170 people on our inpatient unit We received legacies to the value of £336k We provided 498 support sessions for carers We provided 1665 Living Well Sessions for our patients We cared for 51 patients via the virtual Ward delivering 208 consultations 1951 bereavement counselling sessions provided for adults and children Our retail shops and café generated an income of £903k Q) y,fvwd&tr Our weekly hospice lottery generated an income of £758k We claimed £133k back from HRMC in gift aid Our combined annual raffles generated an income of £76k Hospice of The Good Shepherd Annual Report and Account5- Year Ending 31, March 2023

Chair’s Report

Welcome to the 2022/23 annual report for the Hospice of the Good Shepherd reflecting a year of continued progress as we support and make a difference to the lives of those impacted by a palliative care diagnosis in the West Cheshire and Deeside communities.

The year began with an easing of Covid restrictions and cases, but we remained on constant watch as the country learned to adapt and live with the virus. I remain proud of the way in which all our staff worked to protect our patients. However, the shadow of Covid continued to affect our fund raising with either cancelled or reduced numbers at many of our events.

A major challenge during the year was caused by the continued national shortage of nursing staff which resulted in difficulty to both recruit and retain nurses. The Board made the difficult decision to match Agenda for Change, NHS England Terms and Conditions, for our clinical staff which although significantly increased our costs, has meant that we are fully staffed and able to deliver a full care service to our patients. We have also continued our work with Liverpool University to educate medical students to help bring through the next generation of palliative clinical staff which is incredibly important to the Hospice. Additional pressure on costs followed the Russian/Ukraine war with increases in energy prices and subsequent inflation. These, along with the cost-of-living crisis, continue to negatively impact both our income and cost base where we now only receive 22% of our costs from statuary income. The rest, over £4 million, must be achieved through fundraising and we remain heartened by the continued and greatly valued support of the public who enter our lottery, buy raffle tickets, spend in our shops, run marathons, and donate in so many other ways. The whole team here thank them enormously and without their support, we would have to offer a very much reduced service. However, operating losses continue to rise, and we remain dependant on vital legacy income which unfortunately, we cannot be certain of.

This is why the Board and senior management team have been working on a new five-year strategy, setting out the services that the Hospice should offer and the best way in which to deliver them. New Strategic Aims and Objectives have been set and we are already measuring our performance against them. A vital part of this approach must include how we can work proactively with the newly established Cheshire and Merseyside Integrated Care Board and the newly formed West Cheshire Place to demonstrate the importance of the services provided by the Hospice and aim to increase the statuary income paid to the Hospice.

This is my final report as Chair of the Board, and it has been my privilege to be involved with such a special organisation over the last five years. I would like to thank my fellow Trustees for their time, commitment, advice, and support. I’m delighted that an existing Trustee, Yvonne Emmett Cannell agreed to succeed me as Chair from 1[st] April 2023. Yvonne is an accountant by profession and brings a wealth of senior leadership experience at Board level in the NHS, Local Government, and the charity sector. I wish Yvonne every success in her new role and although I’m stepping down as Chair, I will remain a Trustee and hope to support the Hospice in any way that I can.

Finally, I would like to express my sincere thanks to our CEO, Rhian, her Senior Management Team and all the wonderful staff at the Hospice for their outstanding commitment to providing the highest quality of care for patients living with life limiting illness, through to end of life care and bereavement support to their families.

Robert Mee - Chair of Trustees, Hospice of the Good Shepherd

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Trustees' Report (Incorporating Directors' and Strategic Reports)

The Trustees, who are also directors for the purposes of company law, are pleased to present their Annual Directors report together with the Financial Statements of the charity for the year ending 31st March 2023 which are also prepared to meet the requirements for a Directors Report and Accounts for Companies Act purposes.

The financial statements comply with the Charities Act 2011, the Companies Act 2006, the Memorandum and Articles of Association, and Accounting and Reporting by Charities: Statement of Recommended Practice applicable to charities preparing their accounts in accordance with the Financial Reporting Standard applicable in the UK and Republic of Ireland (FR102) (effective 1[st] January 2019).

About Us

The Hospice of the Good Shepherd wants all people living in West Cheshire and Deeside with a life shortening illness, and those important to them, to have access to care and support wherever and whenever they need it. We want to help people live well until they die and to support those affected by the death of a relative or friend. Our care is designed to meet the needs of each individual and we try to do this through a combination of expert clinical care, community support, education and partnership working with other organisations with the same aspiration. Last year we provided care and support to 122 inpatients, 254 patients attending either our Living Well Services or outpatient clinics and 100 carers across West Cheshire.

Our specialist multi-disciplinary team includes doctors, nurses, physiotherapists, occupational therapists, social worker, chaplain, counsellor, music and art therapists and complementary therapy practitioners. Together they provide care and support to patients and those close to them.

Our care comprises support with social emotional spiritual and psychological issues as well as physical care to help with symptoms such as pain. Our patients have life limiting illnesses including advanced cancer, heart failure, respiratory failure, renal disease, and progressive neurological diseases such as Motor Neurone Disease.

We want people to live as well as possible, making sure they get the best possible care at the end of their lives whilst maintaining their dignity and respecting their wishes.

There is no charge for the care and support we provide, meaning that the services provided by our multidisciplinary team will be free at the point of delivery to everyone irrespective of their background.

Public Benefit Statement

The Hospice aims to serve the public by ensuring that everyone in Cheshire West, Chester, Ellesmere Port and Deeside has access to excellent high-quality specialist palliative care and support when they have illnesses which no longer respond to curative treatment. Our main activity continues to be the delivery of specialist medical and nursing care to patients and their families. The Trustees have regard to the Charity Commission guidance on public benefit. To achieve this, we have established a set of strategic priorities, and our business plan is based on these priorities.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Our Vision , Mission & Values

Our mission for the Hospice of the Good Shepherd is to provide the highest quality specialist palliative care for the people of West Cheshire, Deeside and surrounding areas who have progressive, advanced lifelimiting illnesses. Our main activity continues to be the delivery of a specialist medical and nursing service to patients and their families by a skilled and dedicated multi-professional team.

We have a range of strategic aims to ensure we deliver the best quality care.

Our Values Underpin Everything We Do

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Looking Back at our 2022/2023 Charitable Activities Highlights

Our In-Patient Unit

Our Inpatient Unit consists of 10 beds, run by a dedicated and professional team of clinical and palliative care consultants, medical and nursing staff, physiotherapists, occupational therapist, administrators, social workers, complementary therapists, and our spiritual care team.

Each patient admitted to our Inpatient Unit (IPU) is treated with dignity and care and has access to 24-hour specialist palliative care. Our catering staff provide a delicious menu of home cooked food, and our housekeeping staff ensure the Hospice is clean and tidy every day. The Hospice also provides support for their families, friends, and carers.

There are several reasons people are referred to us for Inpatient care. Our main aim is to enhance quality of life, and we do all we can to ensure that everybody is comfortable during their stay. Whilst we care for people at the end of their life, around 40% of our patients go home after a stay with us.

Our team of staff have specialist training in many different areas. Together, they not only provide excellent nursing and medical care, but they also look after emotional, spiritual, social and psychological needs.

We have a mixture of single rooms combined with a 4 bedded ward and these are allocated depending on the individual needs of our patients. Patients may be admitted to our inpatient wards for:

Control of symptoms, for example pain or nausea/sickness.
Rehabilitation following treatment.
Care in the last days of life.

Each bed has a TV, with headsets for those in bays. Free Wi-Fi access is available, and we have a selection of talking books. A member of our catering team visits our patients each day to go through our menu of freshly prepared home cooked meals. In 2022/23, we have cared and treated for 170 people and supported their family, friends, and carers on the lead up to, during and after their loved ones stay with us. This equated to an average bed occupancy of 82% and an average length of stay of 13.6 days.

The Hospice received 22% funding contribution toward the cost of the Inpatient Unit and charitable activities from the Cheshire and Merseyside Integrated Care Board for 2022/23, a reduction of 1% on the previous year. Although we support patients from North Wales, the Hospice receives no fixed funding from Betsi Cadwalader Health Board.

Historically the Hospice has not matched NHS pay banding, however, in January 2023 we took the decision to match Agenda for Change, for our clinical staff. This has significantly increased our costs, however it has allowed us to recruit and retain nursing staff, without whom we would be unable to deliver services to our patients.

We have also continued our work with Liverpool University to educate medical students to help bring through the next generation of palliative clinical staff which is incredibly important to the Hospice.

Our Medical Director and teams of Speciality Doctors have worked to develop the treatments that can be delivered in our acute care setting. Increased access to intravenous therapies on the in-patient unit helps

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

us keep patients here at the Hospice and avoiding unnecessary patient transfers between us and the Countess of Chester.

Whilst we have been recruiting additional nursing staff, and to maximise the use of our Speciality Doctors we also piloted a virtual ward. During this pilot we saw 51 patients on our Virtual Ward delivering over 208 sessions.

The Hospice continues to provide a 24-Hour Telephone Advice line for health and social care professionals within the West Cheshire Area. This line is provided by nursing and medical staff who give clinical advice and support out of hours or signpost to other professionals where appropriate.

In line with our plan, we also rolled our integrated Single Point of Referral initiative which is a collaborative alliance between the Hospice, Countess of Chester Hospital, and the Community Specialist Palliative Care Teams. These teams come together triaging patients during a daily meeting where the referral is passed to the most appropriate service, to include our own services. We continue to support the Fountains Medical Centre, the designated GP practice for the care homes in the Chester catchment area and the wider GP community in West Cheshire and Deeside where we take our referrals from, all of which will help reduce hospital admissions and help patients achieve their preferred place of care and death.

Our Clinics

As well as the palliative care offered by the Hospice in our in-patients beds, we also provide a range of care in our out-patient clinics. Of those who attend these clinics, many have been discharged from a stay at the Hospice and others have been referred by their healthcare professional.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

As with all our services, these out-patient attendances are provided free of charge by experienced, qualified professionals. We do not receive funding from the Integrated Care Board for these clinics; these must be funded from charitable donations.

Medical Out-Patients

Our specially trained Hospice doctor or Hospice consultant will meet with all patients referred to our outpatients department (either for initial or follow-up appointments). Clinics are held on various weekdays by our medical team. Patients can attend with their family or carer if required. Each patient’s symptoms and conditions are assessed and monitored. Following consultation with our patients, and with the support of Redrow Homes, we now have a dedicated waiting room to provide a more private waiting area. To ensure seamless delivery of care the out-patients team works closely with all other medical professionals involved in a patient’s care, such as the GP, hospital consultant, Macmillan nurse or district nurse. In 2022/23 we held 248 Outpatients appointments.

Complementary Therapy

The Hospice offers a range of complementary therapies to both patients and carers. These therapies are delivered by trained staff and can be helpful in reducing stress and anxiety, thus easing physical pain, and assisting symptom control. During the year, there were 667 sessions provide to patients and their carers.

Living Well

Our dedicated team of skilled staff and volunteers continued to support patients and carers to ‘live well’ and improve the quality of their life. By working with them to provide guidance so that informed choices can be made our team help improve symptom management, manage, and address individual concerns and enhance coping strategies.

The Living Well Centre provides a range of support therapies, including medical, nursing, rehabilitation, and well-being support. During the year, the team delivered 1,665 sessions. We are fortunate that we receive some funding from Trusts and Foundations who recognise the important of Living Well Services, but we receive no funding from the Integrated Care Board. In the main these services are funded from charitable donations.

Bereavement Support

Adult and Children and Young People’s Counselling Services at the Living Well

Our dedicated, professional, and empathic team of counsellors and volunteers provided support to 536 adults and 101 children with pre and post bereavement support through 1951 sessions.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

We are fortunate that we receive some funding from Trusts and Foundations who recognise the important of Bereavement, but we receive no funding from the Integrated Care Board. In the main these services funded are from charitable donations.

Being your voice

The Hospice is committed to ensuring that the voice of our service users and the local community are integral to service development and improvement. The Hospice of the Good Shepherd is a founding member of the Cheshire and Mersey Hospices Collaborative, which our CEO, Rhian Edwards Chairs. Rhian also sits on the Board of Hospice UK.

We continue to partner with the End-of-Life Partnership, Strategic Collaborative Cheshire, our Hospice External Stakeholders Group and are now an active member of the new Northwest Hospice Forum. We have also continued with our Service User Group and in growing its membership we will be reviewing the Terms of Reference for this group to ensure that we achieve maximum patient participation and involvement.

All these partnership approaches seek to address the ever-increasing demands of service provision, education, training, and workforce development. These collaborations demonstrate a region wide commitment to working in partnership to improve palliative and end of life care for all patients, regardless of demography or diagnosis.

Delivering against our Quality Priorities

Our clinical services operational plan for 2022/23 had nine objectives that linked to our strategic aims, with each of these objectives seeking to achieve improvements in these key areas:

Patient Safety - This means delivering care in a way that minimises harm by using effective approaches that reduce unnecessary risks.
Clinical Effectiveness - This means delivering care that is based on evidence and people’s individual needs.
Patient Experience - This means delivering care which people can easily access and feedback is welcomed. People feel they are listened to, and their preferences are taken into account.

Table 1 highlights the 8 of 9 quality priorities that were achieved in 2022/2023.


		Quality Priority
Quality Area	Quality Priorities we wanted to achieve
		Achieved


Patient Safety	Implementation of a Quality Safety System to report and analyse incidents, complaints, audit and policies and procedures.
	Introduce a new Clinical System for patient records (EMIS), a system that is linked to the local community services and GP Records.
	To continue to have an annual audit cycle, to review care, report on any improvements that are required.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

	To undertake a Quality Improvement Project for handover and incorporating Safety Huddles
	To reduce errors associated with the supply, storage, prescribing, administration, and disposal of medicines (controlled drugs & non- controlled drugs).
Clinical Effectiveness	Increased access to intravenous therapies on the in-patient unit
Patient Experience	Increased provision and referrals into LWS with improved patient experience
	Increase Service User Group membership by 10%
	Implement and evaluate “I Want Great Care” New, real time Patient Satisfaction Survey, publish the results on the Hospice website.

Table 1. Quality Priorities 2022/2023

Our Quality Highlights 2022/2023 Consultant in Palliative Medicine

In March 2022, we welcomed Dr Alison Coackley, our new Medical Director and Consultant in Palliative Medicine to provide medical leadership at the Hospice and collaborative working across local healthcare providers. During 2022/2023 the role has brought in-depth specialist knowledge to undertake assessment and management of physical, psychological, and spiritual symptoms to reduce suffering and distress which in turn has increased the skill, knowledge and confidence within the health and social care workforce through education and training. We have increased our outpatient capacity and complex clinical decision-making where medical and personal interests are finely balanced by applying relevant ethical and legal reasoning alongside clinical assessment. Further provision of specialist advice and support has been provided to the wider care team who are providing direct core level palliative care to the person.

High Sheriff Award

In February 2023, we had a special visit from the High Sheriff. She spent a lot of time chatting to patients,

staff and volunteers across the organisation and she was very impressed with our services. She also gave the Hospice team a very special High Sheriff’s Community Award.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Clinical Learning and Education

In 2023, we launched our new ‘You Matter’ People and Development Strategy. Alongside our mandatory e- learning and face to face training programmes delivered by our training provider Blue Stream, there have been further learning opportunities to continuously develop and for staff to attain professional qualifications.

A Health Care Assistant completed their Nursing Associate apprenticeship and is now employed as our first Nurse Associate on the Inpatient Unit.
A Staff Nurse has commenced a post graduate certificate for ‘Transforming Integrated Palliative Care’.
A Senior Staff Nurse completed a Leadership and Management qualification with the End-of-Life Partnership.
Through partnership working with universities, we have facilitated professional placements for Medical, Nursing and Social Work students. In addition, our Living Well Centre Senior Staff Nurse delivered a bespoke seminar to student nurses regarding creative healthcare.

Homelessness work

Following the benefits gained from a Hospice UK Masonic Foundation grant 2019 – 2021, we have joined with our colleagues in Central and East Cheshire in providing a Homelessness Palliative Care Service across the whole of Cheshire. All three hospices were awarded a grant from Cheshire CCG (now Cheshire and Merseyside Integrated Care Board) in October 2021 to continue the work which was extended for West Cheshire until December 2023.

The average age of death of a homeless person is 46 for men and 43 for women.

Hospice UK and CQC have both published reports that demonstrate the inadequate care the homeless population receive at end of life. Our current work has highlighted that homeless people have complex multiple comorbidities and significant mental health issues which result in complex health and social care needs in the last year of their life. For those who are homeless both physical and mental health is very poor. There are typically between 1000 and 1500 contacts with different services each quarter across the whole of Cheshire.

All agencies are working together to ensure that each patient has access to the right care and support at the right time. This collaboration enables improvements to the existing health inequalities for those people who are homeless by:

Providing education around palliative and end of life care for health and social care professionals who work with the homeless population with malignant and non-malignant life limiting conditions.
Providing direct support to members of the homeless community with advanced disease.
Supporting with hospital appointments.
Advocating with regards to their housing needs due to their diagnosis.
Providing advice and support to specialist and generalist health care professionals with regards to the management of their additional complex needs.
Working with the Hospice directly to support the patient during an inpatient stay.

Alongside the Hospice UK Masonic Foundation Grant there had been a small amount of additional funding to deliver a counselling service to support the work. This was delivered by our Hospice counsellors via the dedicated GP practice for people experiencing homelessness. As a result of its success the Hospice was invited to become a partner of the Cheshire West and Chester Borough Council Multi Agency Rough Sleepers

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Service (MARS) to provide free and confidential one to one trauma informed counselling to referred individuals with a history of rough sleeping.

*Since introducing EMIS were have been able to quantify the number of people we have reached through this service

Feedback about the homelessness work

The mother of a patient who had intermittent admissions to the Hospice prior to their death thanked us for the wrap around care provided to their family and their son. Mum described the special touches which included the fresh flowers given, the doctor who introduced art back into her son’s life. Mum is now a member of our service user feedback group to help shape our future services.

“There were no words to describe the special aura of the Hospice including the feeling of being part of a wider family, the Hospice enabled me to be mum and not the carer and the massage and counselling services have been excellent”.

LGBTQIA+

In 2021 we appointed our first LGBTQ+ Development Facilitator following a successful grant application from St Lukes Hospice on behalf of the three Hospices within the Cheshire footprint.

We extended the position to October 2023 to support the hospices to:

To provide better access to appropriate care and support for members of the LGBTQIA+ community who have a life limiting illness/lifestyle.
To provide education & awareness within our combined workforce and build capacity in small groups of staff who will act as champions into the future.
To work to create appropriate care if that is not readily available.
Liaison with Chester Pride to create dialogue with the region’s LGBTQIA+ community for research, consultations, and focus groups, to ensure the community voice can shape the service provision.
Achieve the LGBTQ+ kite mark for each hospice, through the Navajo Merseyside scheme.

The LGBTQ+ facilitator has worked across all the hospices and has developed and delivered training which continues to be rolled out to all staff and volunteers. Several clinical staff also completed ‘The NHS Rainbow Training’, to demonstrate that staff are aware of the issues that LGBTQIA+ people can face when accessing healthcare. We recruited LGBTQ+ champions to act as a point of

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

contact within the organisation for advice or support. Work is ongoing regarding raising awareness.

We were awarded the Merseyside and Cheshire Navajo Charter Mark in Autumn 2022 along with St Lukes and East Cheshire Hospice’s. The Navajo Merseyside and Cheshire Charter Mark is an equality mark sponsored by In-Trust Merseyside. It is supported by the LGBTIQA+ Community networks across Merseyside – a signifier of good practice, commitment and knowledge of the specific needs, issues and barriers facing LGBTIQA+ people in Merseyside.

Helping People Live Well

Our Living Well patient Mark is an example of how the breadth of services and support we offer can really make a difference. When Mark was referred to the Hospice he was shocked as his only experience of the Hospice was that it was somewhere people go to die and he therefore thought he must be much more unwell than people were telling him, and he did not want to come. However, his wife Eleanor suggested that he tried the Living Well Centre for one week. Since then, Mark has really made the most of the opportunities that the Living Well Centre offers. Mark is also an active member of our Service User Participation Group to support the development of future services.

Mark said “I attended a 6-week taster course that included Reiki, Indian Head Massage, aromatherapy and sessions on mindfulness and relaxation. All of these sessions were great in helping me to relax and deal with the stress of my illness as well as helping me to deal with the physical impact. I also attend the weekly Coffee and Chat sessions which is a great way to meet with other people who are using the services and support each other. Everyone is so welcoming and friendly and if you are facing a particular challenge, they know how you are feeling. In fact, I find Coffee and Chat so beneficial that I always block out Tuesday morning in my diary. Having had the opportunity to attend some of the art therapy sessions, I have rekindled my love of art, painting and drawing and am putting this to good use by selling both paintings and greetings cards that I have created to raise much needed funds for the Hospice. I am still at the stage in life where I want to try new experiences and the support I have from the Living Well Centre helps with this. I have now built up the confidence to be able to travel again and recently my wife and I went on an amazing holiday to Sorrento in Italy. The Living Well Centre really is helping me to “live well”!

Legacy Art Project

The Legacy Artwork Project was a new initiative introduced earlier in the year for our patients attending the Living Well Centre. The ethos of the project was to enable the patients to create a piece of artwork that would leave a legacy of their life and reflect their experience. Whilst working on their pieces of art the patients spent time talking to each other about their lives and experiences. It also generated some amazing conversations with family and loved ones about shared memories and experiences and encouraged conversations that might not otherwise have happened. Bev, Judith & Mark have shared their art below.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Mark’s Legacy Painting

Bev’s Legacy Painting

Judith’s Legacy Painting

Patient Support Volunteering

The Patient Support Volunteering role was initially developed at the start of the Covid-19 lockdown to offer support to our nursing team to allow them more time for direct face to face patient care. However, it has proved to be such a valuable role that we have continued it and plan to add to our numbers.

Ed Jordan is one of our Patient Support Volunteers. This role is one of care and compassion and is a vital supporting role on our Inpatient Unit. The role is varied and includes chatting to and supporting our in-patients, reading to them, or taking them for a walk. We all know how important a lovely cup of tea is and this role also helps provide refreshments to both patients and their visitors as well as helping patients with their meals. This role also assists our nurses with any tasks they need help with, such as folding and preparing aprons and PPE and generally just being an extra pair of hands to answer the door or telephone. It really is a vital, hands-on, and rewarding role.

Our 350 volunteers support all departments at the Hospice, and we are forever grateful for their support as we know that without them our Hospice just would not be able to operate. Volunteering at the Hospice benefits our patients, Hospice staff and of course the volunteer themselves. We understand that volunteering can make a real difference. In June 2022, we held an Afternoon Tea in a marquee in the Hospice grounds as part of our “Community Engagement Week” to present some of our fantastic volunteers with certificates and pin badges in recognition of their long service. It was inspiring to see so many of our

volunteers’ receiving awards, especially those that received their 20-, 25- and 30years’ long service awards.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

How we funded our achievements 2022/2023

Our income in 2022/23 was £4.6m (2021/22: £4.6m). Although we raised the same amount of money this year, it is evident that the cost-of-living crisis had a huge impact on fundraising this year, as people have less to give. Despite the extremely challenging circumstances, this income is down to the incredible commitment of our fundraisers, volunteers, and staff. Our income can be broken down into monies given through grants, earned from investments and through trading, and fundraising and funding from the CCG/ICB.

----- Start of picture text -----
INCOME
Investments
0% Donations and Legacies
CCG/ICB Grant
18%
19%
Charitable Activities
10%
Other Trading
Activities
53%
----- End of picture text -----

Donations & Legacies

This is money that is donated by our supporters, either directly or through their fundraising activities or money that comes to us when someone kindly leaves a gift in their Will; this is a vital income stream for us.

Other Trading Activities

This is money raised through our weekly lottery, high street charity shops, our eBay channel, on-line shop, café and seasonal trading activities.

Charitable Activities

The hospice receives direct grant support from Government funding grants from charitable trusts and foundations.

Investments

This is income from our investment portfolio and bank interest.

During 2022/23, we have continued to invest in generating more sustainable regular income, in particular from our other Trading Activities. This helps generate money we can rely on, and means we are able to plan for the future. We are committed to being responsible and respectful with our fundraising, and continue to be registered with the Fundraising Regulator, abiding by their code of practice and regulations and the Gambling Commission for our lottery.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Donors and Events

Our generous donors are helping us to keep the Hospice doors open and services running. We are thankful to every partner who engaged their customers and employees in fundraising activities, our campaign partnerships, and those who provided gifts in kind. An amazing example of support with gift in kind was the support we received from Redrow Homes who very kindly donated the time and skills of their interior design team to create a new relaxing outpatient waiting room complete with decorating and soft furnishings. They also decorated the main wall of our café creating a photo-wall gallery using our

historic photo library.

We were selected as Charity of the Year for a number of organisations during the year, which helped to raise both funds and awareness. These organisations recognise the vital role the Hospice plays in their community supporting their staff and colleagues.

We launched some new fundraising initiatives with our corporate partners which included Lock up Your Boss, Corporate Challenge and Christmas Bauble Campaigns and these raised over £20k.

During the year we received corporate sponsorship for several events including our Sparkle Walk and annual Gala Ball. Held in March 2023 we sold 340 tickets for the and the event generated an income of £40k. In total

£749K (2021/22 £609K) was raised from fundraising events and corporate support.

Community Fundraising and Challenge

Events

Following some difficult years with Covid we were able to hold fundraising events again. This included two new successful events, our 7 Locks in 7 miles Canal Walk and our Hospice Hounds Dog walk. Our challenge events including our sky dive and fire walk also proved very popular. We launched our first Christmas mail appeal campaign which resulted in an income of £10k.

We reviewed our community fundraising strategy and strengthened the team with an additional community fundraiser in April 2022 which led to a significant increase in community income. We are incredibly fortunate to receive continue support from our local community who hold fundraising events on our behalf and continue to champion our cause which this year also included the Farndon Soap Box Rally and the Cosmic Cape music festival. Thanks to this fantastic support our community fundraising generated an income of £275K (21/22 £222K). We continue to receive the support of our local dedicated Hospice Support Groups, many of whom started fundraising over 35 years ago.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023 18

In May 2022, we had over 200 riders travelling around the roads of Cheshire in support of the Hospice supporting our Motorbike Ride Out.

In June 2022, we raised £20k during our Chester Sparkle Walk with almost 300 people walking around Chester.

With the support of the local community, we held the first ever Farndon Soap Box Rally raising over £30k for the Hospice.

1530 Santa’s dashing through the streets of Chester raising £20k

In August 2022, we planted over 1000 metal gerberas in the grounds of Chester Cathedral raising £36k+

200 walkers raising £11k in September 2022.

We collected and recycled 2826 Christmas trees raising over £37k

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Gifts in Wills

We continue to be incredibly grateful to the generosity of people who leave a gift in their Will, which this year equated to £336k. Gifts in Wills are a vital source of income to the Hospice (21/22 £579k).

Knowing that people may wish to support us, but that they may not have the disposable income at the time, we continue to invest in legacy marketing, including our popular regular monthly Wills Clinics, kindly provided free of charge by Oliver and Co Solicitors.

Retail & Lottery

Retail

Our 6 charity shops continued to generate substantial income for the charity and our retail team are supported by an army of volunteers who play such an important part in supporting our staff.

We took delivery of our new electric powered van to improve our logistics and help reduce our carbon footprint.

We installed a new Electronic Point of Sale System (EPOS) which increased efficiency and increased gift aid by £50K. Our supporters continued to donate high quality stock and furniture allowing us to increase our retail income.

However, following Covid we have found it difficult to recruit new volunteers to our charity shops. Recruitment and retention of volunteers will remain a focus for us as we continue to open more shops in line with our Retail Strategy.

A combination of a full year's trading following the previous year's closures due to Covid 19 plus improvements made to operation processes resulted in an income of £903k (2021/22 £651K) which

was an excellent performance from the staff and volunteers who work in this part of the operation.

Lottery

Our Hospice lottery continues to operate successfully generating a sustainable income of £758k (2021/22 £783k).

In total our retail and lottery operations generated an income of £1,660K (2021/22 £1,434K)

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Trusts and Foundations

Grants are an important part of our income that help to sustain and to grow our charitable activities. Typically, we apply for funds for specific services and equipment.

Reflect, our child bereavement service provides vital support to young people within our catchment area. We were fortunate to continue to receive grant support from BBC Children in Need to support this project. The demand for this service increases year on year and we would not be able to continue this service without their support. We also receive funding from The Volant Trust and Assura to support this service.

We were fortunate to receive generous funds from the Carers Trust to continue our Carers Groups that run every week in our Living Well Centre and provide complementary therapies for carers.

A significant grant from Cheshire West Council has helped us improve our environmental footprint as well as reduce our energy costs through funding additional solar panels.

We would like to give special thanks to all Trusts and Foundations whose money is helping us continue our vital work or to buy equipment that helps us support patients, families, and their carers.

Assura

BBC Children in Need

Cheshire Community Foundation

Cheshire West and Chester Council

Hospice Aid UK

Hospital Saturday Fund

Mason Bibby 1981 Charitable Trust

Masonic Charitable Foundation

Maud Beattie Charitable Trust Medicash UK

Pennycress Trust

Sir Donald & Lady Edna Wilson Charitable Foundation

The Albert Hunt Trust

The Marjory Boddy charitable trust

The Screwfix foundation The Sir Jules Thorn Charitable Trust

The Volant Charitable Trust The Westminster Foundation Trefula Trust

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Investments

Our fixed asset investment portfolio continues to be used to underpin our ongoing activities and maintain capital to support future development. The growth of the portfolio is designed to supplement our reserves and our other income-generating activities for the medium to long term. We have engaged external investment managers, Investec, monitored by the Financial Conduct Authority, who manage a balanced portfolio on our behalf.

Due to the current economic climate and associated market volatility, the investment portfolio for made a loss of £28k (2021/22 gain £12K).

The Board operates a diversified investment policy, balancing risk with income and capital growth. The Trustees nominate and appoint advisers, brokers and/or fund managers and will agree the terms of appointment. No investments are made without the prior approval of the Trustees. The advisers provide professional investment advice and will assist in the review of performance and future strategy. Our policy is not to invest in any stocks or shares in businesses involved in activities inconsistent with our values.

The Trustees are mindful to maintain a balanced portfolio and regularly monitor the performance of the investments via the Finance and Income Committee.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

How we spent your donations

Our charitable expenditure amounted to £4.9m (2021/22: £4m). Like all business and our community, we faced the additional pressure on our costs with increases in energy prices and the subsequent rise in inflation.

We undertook an annual review of our salaries for non-clinical staff many of whom were paid under the median benchmark resulting in issues to both recruit and retain staff. We made a one-off cost of living payment to them in Autumn 2022.

In 2021 we had commenced consulting with our medics about SAS (Staff, Associate specialist, and Specialty doctor) resulting in a change in contracts in the Summer 22. We also commenced a consultation in the Autumn of 2022 with our clinical staff about moving to Agenda for Change (NHS England Terms and Conditions). From 1[st] January 2023 for all clinical staff, we are paying salaries at the AFC level. All these changes have significantly increased our costs towards the end of the financial year.

We have continued to make sure every penny counts, whilst delivering our agreed strategies which has seen us invest in technology so as to better support patients or achieve improvements for how we work as an organisation.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Our passionate and dedicated people

We simply couldn't achieve what we do without our incredible staff and volunteers. In the year to March 2023, we employed 133 staff with a wide range of skills, knowledge, professional qualifications, and experience and had the support of 350 volunteers.

Support

Our aim is for our staff to be well-rewarded and to be paid a salary that is competitive and benchmarked externally against other charities of a similar size and location. We do not have any bonus schemes or performance-related pay but are looking to introduce this in the future. We have introduced Agenda for Change (NHS) terms and conditions for all of our IPU staff and Clinical Director and also have SAS terms and conditions for our doctors. Staff not on these terms and conditions are on a different pension scheme and different sickness scheme.

In 2021 we invested in a Benchmarking tool with our aim to pay our staff the median salary. Currently 89% are paid the median and we review pay regularly with our People and Development Committee and Board of Trustees.

In addition to the NHS pension scheme for pre-existing members of clinical staff we also run an autoenrolment pension scheme for the benefit of our staff who are not members of the NHS scheme. The autoenrolment scheme involves employee and employer contributions. The auto enrolment scheme is managed on our behalf by Royal London and the finances are completely independent of the charity's finances. The charity's contributions are recognised within our statement of financial activities, in the month in which the salaries are paid.

We continue to operate a hybrid working policy and enjoy the benefits this brings to the Hospice and staff as well as easing some car parking pressures and helping with recruitment and retention. Our staff’s physical and mental wellbeing remain a priority and has driven the improvements to our Employee Assistance Programme and Flexible Benefits in the summer of 2021, which continues to be in use.

Safeguarding

To protect our staff and volunteers, we take safeguarding extremely seriously and have a policy in place which was reviewed and updated as things have changed throughout the pandemic. All staff undertake mandatory Safeguarding training as appropriate and applicable to their role.

We have also made significant improvements to our volunteer experience and will be launching a Volunteer Handbook in 2023. We have developed our volunteer database and carried out a volunteer wide audit. We continue to attract high quality, high calibre volunteers to the Hospice and benefit from their skills and knowledge in many areas of the Hospice including patient and family services, retail, fundraising, lottery, and support services. They bring a wealth of experience, passion and commitment from diverse backgrounds and careers.

We recognise the invaluable contribution our support group volunteers make in both raising funds and raising our profile in the local community. We would like to take this opportunity to acknowledge their contribution and thank them for their continued commitment, dedication, and support.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Promoting Equality, Diversity & Inclusion

Freedom to Speak Up

The Hospice of the Good Shepherd actively encourages staff engagement. We are registered with the National Guardian Office and have four Freedom to Speak up officers across all disciplines. We facilitate staff and volunteer engagement groups represented by each team every two months.

Following our staff and volunteer survey facilitated by Birdsong Charity, we have continued to monitor our ‘6 to fix, 6 to stick’ action plan to improve staff and volunteer satisfaction and engagement. So far, we have implemented the Agenda for Change terms and conditions for our nursing staff which has enhanced our recruitment and retention programme.

Our Equality and Diversity Work

The Hospice has prioritised equality, diversity, and inclusion (EDI) in our business plan, and we now have a dedicated Equality and Diversity role shared between St Lukes, East Cheshire Hospice, and ourselves. Through this role we have now achieved the Navajo Charter recognition and continue to progress in this area.

Our Equality and Diversity Steering group, chaired by the Director of People and Development, meets quarterly to review and plan for increased access to services by all members of the community as well as addressing workforce issues. Due to a significant homeless population in our catchment area, we have focussed on this client group over several years. During 2022/2023 we have increased of awareness to enable the accessibility of services for people with protected characteristics.

A report is shared with the Board each quarter to highlight the priorities and progress in EDI for the Hospice.

We work with the Wirral Multicultural Centre to access face to face translation services for patients and carers where English is not their first language, in addition we can access a telephone service, Language Line, for urgent translation and have also worked with a deaf translator to support a patient. Protected characteristics are monitored to highlight any specific needs and we work to the Accessible Information Standard 2017 (DCB1605 Accessible Information).

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Technology

We made a significant and timely investment in technology in 2022/23. This included the deployment of a new patient management system (EMIS) that gives us shared access to patients’ GP records and community services. We were very grateful to have received a grant of £100k to contribute to the associated deployment and project management costs of the migration to EMIS from the Integrated Care Board. This was a one-off payment and will mean the Hospice now has increased running costs £20k per annum. However, with the improvements in being able to access patient information from the GPs in our locality and the wider community, migrating to EMIS was the right thing for us to do for patient care. As part of this deployment, we also upgraded our computer servers which has now given us a more stable and efficient platform to work from and will minimise any down time to our patient management systems.

With the end of the Cheshire Clinical Commissioning Group, who had up until last year managed our payroll, we successfully moved our payroll to Cascade our HR system provider. This cloud-based solution is providing more agility and a greater level of integration with other systems for better data management.

We have also continued to develop and expand the use of our HR system Cascade and as part of this, developed and implemented a fully integrated online e-recruitment solution. This has streamlined our recruitment processes and enabled us to broaden our reach with job adverts to attract a high number of good quality and more diverse applicants. We will continue to develop this into 2023/24 with the onboarding phase.

Our colleagues in Retail saw the deployment of a new till system, and a vehicle tracking system. As well as significantly improving how we can now manage gift aid, we now have real-time sales performance data and can better manage the delivery and collections of donated goods.

With the significant changes during the year, we were unable to implement our Patient Satisfaction survey, “I Want Great Care,” but, this will be implemented March 2024.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Looking Forward and delivering our Strategy

As outlined in our outgoing Chair’s report, the Trustees and Senior Management Team have been working on a new five-year strategy setting out the services the Hospice should offer and the best way in which to deliver them.

Our vision is that everyone impacted by a progressive life-limiting illness is able to receive excellent support and care, whenever and wherever they need it. To achieve this, our role is to provide high-quality, safe, compassionate, person-centred care, support and treatment for people, families and carers impacted by a progressive life-limiting illness and living in the West Cheshire & Deeside community.

To operationalise our strategy, we have the following activities planned for 2023/24 that link back to our Strategics Aims (SA) , our defined Strategic Objectives (SO) and Quality Priorities (QP) (Table 2):

SA 1 - Promote equitable access to optimum quality care and support. SA 2 - Evidence a safe, effective, caring, responsive and well led organisation. SA 3 - Foster a culture that prioritises our values and maximises opportunities for skills and development. SA 4 - Deliver sustainability through continuous quality improvement and innovation.

The golden thread that underpins the delivery of our revised Strategic Aims will be our values and how we as a team go about our work to achieve them. We will consult with our staff about what our culture and behaviours need to be. How we behave with each other will help us to drive our strategy forward.

Alongside this work, we will also review our brand. We know the heart and DNA of the Hospice are the services we provide and the staff we employee to deliver them. Though we also recognise that for an organisation the brand is often referred to as the face that an organisation puts forward to the world. Reviewing our brand will help us make sure that our public face is exactly what it needs to be to ensure we identify and stay relevant to our community and ensure we are reaching all areas of the community including those hard to reach areas that may not have identified that we are also there for them.

Strategic Objective 2022/2023	SA 1	QP
SO1 - Maximising our reach. ▪ Ensure our resources and services are used to maximum capacity. ▪ Ensuring the website has accessible, relevant information for service users & the broader public requiring information on hospice services & palliative care. ▪ Move to weekend admissions.	X	X
SO2- Maximising our impact through creativity and innovation. ▪ We will identify opportunities for delivering services differently. ▪ We will Identify patient groups who are underrepresented and developaplan for targetingthem	X	X
SO3- Developing our collaborative relationships. ▪ Chairing and joint working with the Cheshire and Merseyside Hospice Collaborative.	X	X

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

▪ Membership of and working with Hospice UK to lobby for better funding and support for the Hospice Sector.
SO4- Influencing the improvement of palliative care across the locality. ▪ Active Membership of the Cheshire West Palliative and End of Life Care Steering Group	X
SO5- Adapting our services to meet the demands on changing needs. ▪ Maximise the use of our electronic clinical systems to improve responsiveness to individualised patient care and advance care planning. ▪ Agree a plan for ongoing and sustained development and management of patient website/information. ▪ Ensure we have a broad representation at the Hospice external stakeholder group which will inform development of Hospice services, ensure the local community are referred appropriately to Hospice services and Hospice staff are familiar with external services which can enhance the patient and carer experience.	X
SO6- Operating an open and transparent culture. ▪ Develop and implement a bespoke Patient Safety Incident Response Plan and Policy. ▪ Develop and implement a Safeguarding Forum to enhance Hospice best practices to ensure that adults and children are safeguarded. ▪ Improve the effectiveness of the Hospice policy and procedurequalitymanagement system.		X		X
SO7- Embracing opportunities to learn and improve. ▪ Through our annual audit cycle and incident management, review the quality of our care and identify areas for improvement. ▪ Implement the guidance regarding the Managing Medical Device standards.		X		X
SO8- Optimising the use of data throughout the organisation. ▪ Maximise the use of our electronic clinical systems to improve responsiveness to individualised patient care and advance care planning. ▪ Design and develop a data reporting system to measure clinical outcomes to demonstrate positive clinical outcomes due to Hospice care. ▪ Enhance patient and service user feedback activity to include utilising all methods through the innovation of digitalplatforms.		X		X
SO9- Support the health and wellbeing of all our people. ▪ Introduce an Employee Net Promoter Score in October 2023 and use this feedback with 2024 Engagement Survey results to ensure the Hospice of the Good Shepherd			X

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

continues to be viewed as a great place to work. ▪ To continue to develop the Hospice Staff and Volunteer Focus Groups to ensure the views and feedback from staff and volunteers across the Hospice are received and supportingthe health and wellbeingof staff and volunteers.
SO10- Providing a great employee experience which attracts and retains talent. ▪ To support Hospice Managers in the development of Staff and Volunteer Engagement Action Plans to ensure feedback from staff and volunteers is acted on and improvements are made. ▪ To further develop Hospice Reward & Recognition as part of the Hospice People Strategy in 2024/25 to ensure that staff and volunteers receive fair and competitive reward and recognition. ▪ To launch a volunteer recognition scheme in line with the new Hospice values in 2024/25 to support volunteer engagement and recognition.	X
SO11 - Inclusion and belonging for all. ▪ Work in partnership with our Service User Participation Group to enhance the quality and accessibility of Hospice information. ▪ To develop an EDI Strategy for the Hospice in 2024 to capture and set out the Hospice commitment to ongoing improvement in all aspects of EDI. ▪ To improve the capture and use of IPU EDI Data. ▪ To monitor improvements in inclusivity and access to Hospice services. ▪ LGBTQ Training for all staff and volunteers and integrate as part of induction for new starters.	X	X
SO12 - Supporting learning. ▪ To ensure high completion rates (above 90%) for mandatory training for all non-clinical and clinical staff to ensure our staff are trained and equipped to do their roles effectively. ▪ To support the development of staff through identified and prioritised development via PDP’s and 1-2-1 discussions throughout 2024/25 and contribute to the achievement of the Hospice Business Priorities. ▪ To roll out Autism Training and Awareness in line with new mandatory requirements which will ensure all our staff are skilled in identifying and supporting people with autism.	X
SO13 - Harnessing talents and maximising opportunities for development. ▪ To identify and support the development of aspiring leaders in the Hospice through leadership development opportunities gifted to the Hospice and other leadership development initiatives.	X

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

▪ To use the Hospice Succession Planning Framework for timely and effective succession into key roles as appropriate. ▪ To complete a volunteers audit to ensure up to date and accurate records are in place for all our volunteers and an accurate assessment of their skills and knowledge as far as possible.
SO14 - Strong financial management and governance assurance ▪ Recruitment of a new Head of Finance. ▪ Roll our Multi Factor Authentication		X
SO15- Developing relationships with the wider community or working in partnership with the wider community. ▪ Continue to build quality relationships with our key stakeholders and identify opportunities to collaborate to further improve palliative care and funding in our locality or nationally.		X	X
SO16- Leading improvement, change and innovation. ▪ In line with our procurement framework, we will tender for our back-office IT services. ▪ Work with our partners to seek further improvements in ways to sharepatent medical data.		X	X
SO17 Embedding digitally enabled solution. ▪ Continue to develop and improved usage of EMIS our Patient Data system. Enhance patient and service user feedback activity by deployingI Want Great Care.	X	X	X
SO18- Enabling new ways of planning for the future. ▪ Review how we are using our resources and estate to ensure we are there to meet the changing needs of our population to include the growing need for specialist palliative care and support.		X	X
SO19 - Commitment to improving our environmental and social impact. ▪ Relaunch our Environment Staff Focus Group		X

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Structure, Governance and Management Statement of Trustees' Responsibilities

The Hospice of the Good Shepherd is an independent charity (registration no. 515516) operating as a private company limited by guarantee (01843427).

The Hospice is governed by a Board of Trustees and run by the Chief Executive and the Senior Management Team made up of a Medical Director, Director of Clinical Services, Director of Income Generation, Director of People and Development and Finance Manager. The Hospice is registered with, and inspected by, our regulators the Care Quality Commission (CQC).

Our Trustees and their Committee responsibilities are listed below.

C – Chair *– Member		Committee and Sub-Committees	Committee and Sub-Committees	Committee and Sub-Committees	Committee and Sub-Committees
Trustee	Board	Care	Clinical Governance (subcommittee)	Finance & Income	Health, Safety & Estates	Information Governance	People, Development & Renumeration
Robert Mee	C			*
Gary Barr Appointed 13.09.2022	*					*
Bill Benoy	*			C			*
Suzanne Crutchley Appointed 09.11.2022	*					*
Isabelle Hughes	*	C	C
Lesley Mills Appointed 15.11.2022	*	*	*
Justine Watkinson	*						*
Neil Fergusson	*	*	*
Mike Davies	*	*		*
Martin Howlett(SIRO)	*					C
Yvonne Emmet Cannell (formerlyBottomley)	*			*
Jamie Christon	*				*		C

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Our Senior Management Team

Chief Executive Office Rhian Wyn Edwards Director of Clinical Services Liz Taylor Director of Income Generation Caroline Siddall Director of People and Development Julie Davies Director of Finance & Operations Angeline Chikuruwo (Resigned January 2023) Medical Director/ Consultant in Palliative Dr Alison Coackley Medicine (Caldicott Guardian) Director of Quality and Improvement Lisa Parker (Appointed January 2023) Principle Registered Address Hospice of the Good Shepherd, Gordon Lane, Backford, Chester, CH2 4DG Auditors Xeinadin Audit Ltd. 116 Duke St Liverpool L1 5JW Bankers NatWest PLC Chester Commercial Office, 2[nd] Floor, 33 Eastgate Street. Chester CH1 1LG Investment Advisors Investec Wealth & Investment Ltd 100 Old Hall Street Liverpool L3 9AB

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Subsidiary Undertakings

The Hospice of the Good Shepherd has one wholly owned subsidiary, Hospice of Good Shepherd Promotions Limited (Company Number 3350371). This company shares its registered office with Hospice of Good Shepherd.

Hospice of Good Shepherd Promotions Limited conducts trading activities selling donated goods and greetings cards and other purchased goods for sale in Hospice of Good Shepherd retail shops and at events, as well as the café located at Gordon Lane, with all profits being covenanted to Hospice of the Good Shepherd. The results and year end position of the subsidiary are shown in Note 8 to the financial statements. Our Lottery is regulated by the Gambling Commission, Operating Licence No. 000 005134 N 100425 013 and Remote Operating Licence 000 005134 R 322300 004.

The Board and Subsidiary Committees

The Board of Trustees is responsible for governance of Hospice of the Good Shepherd. The Trustees as members are also Directors of Hospice of the Good Shepherd. As set out in the Memorandum and Articles of Association, the Chair of the Trustees is nominated by the Board of Trustees and elected by them.

New Trustees are appointed following a selection process using a range of methods to attract potential new members. When considering new Trustees, the Board considers specialist skills required through a skills audit. New Trustees are appointed by a majority of the Board of Trustees, initially for a period of three years, but can be invited to serve for a further three-year term. New Trustees are provided with an induction, giving them an overview of the responsibilities and activities carried out by the charity. Training on external and organisational issues is provided as required.

The Board of Trustees and Executive Directors meet at least four times a year, and as members at an Annual General Meeting, and is responsible for setting an appropriate strategy for the charity. It also ensures that relevant performance measures are in place. The Board receives regular reports on all aspects of the charity's work.

There are six established Committees and one Sub-Committee. The members of these Committees include Trustees meeting with Executive Directors and are also attended by external advisors when required. The Terms of Refence for these Committees are summarised below.

Terms of Reference for Our Committees

Our Board

The Board has ultimate responsibility for directing the affairs of the Hospice in accordance with its Memorandum and Articles of Association. The Trustees have control of the charity and its property and funds. The Trustees will set clear aims and objectives, establish priorities, safeguard the charity’s assets, and use them effectively and exclusively for the beneficiaries of the Hospice.

The Board, as a whole, and trustees individually, accept collective responsibility for ensuring that the charity has a clear and relevant set of aims and an appropriate strategy for achieving them.

To agree the charity’s vision and values ensuring that they are reflected in all of the charity’s activities.
To ensure that the ethos and culture of the organisation underpins delivery of the charity’s activities.
To assess compliance and quality in accordance with legislation and best practice.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

To monitor and control activities within the Hospice.
To monitor the financial income and expenditure of the organisation maintaining its financial stability.
To regularly review which matters are reserved to the board and which can be delegated to subcommittees where appropriate.
To obtain assurance from the minutes and executive summaries from Board Sub-Committees and to scrutinize and act upon the recommendations.

Care Committee

To provide the Board of Trustees with assurance that adequate and appropriate governance structures, processes and controls are in place which ensure that the organisation delivers quality care and services and provides a safe environment for patients, families and visitors to the Hospice.

Take delegated responsibility on behalf of the Board of the Hospice of the Good Shepherd by undertaking the following objectives:

To develop quality monitoring systems for:
Clinical quality.
Patient experience.
Patient safety.
Policies and procedures.
Thematic incident reviews and learning arising from Clinical Governance Group.
To review key performance indicators and objectives:
To identify key performance indicators and review at each committee meeting.
To monitor performance.
To define aspirations and financial impact relating to developments in clinical services.
To review levels or income from statutory funding.
To review and develop organisational plans and objectives.
To ensure risk management is maintained:
To review the committee risk register and escalate matters of concern to the Board.
To ensure care services are delivered in accordance with legal requirements and recommended best practice.
To approve and recommend decisions in relation to care matters:
To advise on new emerging models of care.
To advise on workforce development.
To assist in the formulation of the strategic plan in relation to care and once accepted, recommend to the Board for approval.
To recommend strategy and plans of care.
To review and approve minutes of the Clinical Governance Group.

Clinical Governance Committee

Duties and responsibilities of Clinical Governance Committee

Clinical governance committee is accountable for continuously improving the quality of our services and safeguarding high standards of care by creating an environment in which clinical excellence can flourish.
Effective clinical governance contributes to the safety and quality of patient care.
Good clinical governance must support the early identification of risks and concerns that lead to individual, team and wider organisational learning.
Reporting on its progress /assurance to the Care Committee and CEO.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Clinical governance improves the quality of care, by

Monitoring, and where relevant, enforcing compliance with standards and regulations.
Sharing information and intelligence in relation to patient safety.
Promoting a culture of continuous improvement and learning.
Acting decisively to protect the patients when risks to patient care or well-being emerge.
Making sure there are clear lines of accountability throughout the Hospice and visible leadership from Boards.
Encouraging and actively supporting the professional development of Clinical and Medical staff is also an important feature.

Finance & Fundraising Committee

Take delegated responsibility on behalf of the Board of the Hospice of the Good Shepherd by undertaking the following objectives:

To review in detail, the annual revenue budget and once accepted, recommend it to the Board of Trustees for approval.
To discuss and agree a revenue strategy and financial contingency plan for periods of reduced income streams.
To examine the monthly financial performance of the Hospice of the Good Shepherd and the Promotions Company in conjunction with capital expenditure and cash flow implications, and advise the Board of Trustees, accordingly, recommending any remedial action where appropriate.
To discuss and agree financial analysis and investigates tasks required to be undertaken.
To assist in the formulation of a medium-term capital strategy (5 year), and once accepted, recommend it to the Board of Trustees.
To review the annual capital budget which includes an emergency capital budget for unplanned capital items, and once accepted, recommend it to the Board of Trustees for approval.
To review annually and agree a capitalisation policy and recommend any changes to the Board of Trustees for approval.
To note capital expenditure by the Chief Executive for which provision exists within the Capital Budget and emergency capital budget agreed by the Board of Trustees.
To commend unbudgeted capital expenditure requests over £15,000 for approval by the Board of Trustees.
To review the investment policy annually and monitor the performance of the investment portfolio, meeting with fund managers on a 6 monthly basis to discuss portfolio performance.
To review the reserves policy of the Hospice, discuss and agree the level of reserves that are appropriate, and once agreed, present the reserves policy acceptable to the Board of Trustees.
To assist in the formulation of financial plans and strategies and, once accepted and recommend them to the Board of Trustees for approval.
To review in detail the statutory accounts and, once accepted by the Committee, recommend them to the Board of Trustees for approval.
To discuss and agree external accounting and audit services required.
To provide assurance to the Board of Trustees that the organisation is adhering to the financial strategy approved by the Board or identify where this is not the case.
To provide a forum for discussion, representation and consultation on matters relating to the financial affairs of the Hospice.
To seek approval of policies and procedures from time to time where deemed appropriate.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

To identify key performance indicators and review at each committee meeting.
To review the committee risk register and escalate matters of concern to the Board.
To approve overall banking arrangements.
To assist in the formulation of the strategic plan in relation to Income Generation and once accepted, recommend to the Board for approval.
To monitor the delivery of the Strategy and ensure these are detailed in the Hospice Business Plan.
To monitor Income Generating activities against appropriate legal and regulatory requirements.
To seek approval of policies and procedures from time to time where deemed appropriate.
To identify key performance indicators and review at each committee meeting.
To review the committee risk register and escalate matters of concern to the Board.

Health, Safety & Estates Committee

Take delegated responsibility on behalf of the Board of the Hospice of the Good Shepherd by undertaking the following objectives:
To assist in the formulation of the strategic plan in relation to Health and Safety and once accepted, recommend to the Board for approval.
All Health and Safety policies and procedures will be reviewed periodically.
To consider the Health and Safety implications of the whole estate of the Hospice, including externally occupied buildings.
To incorporate discussions and decisions relating to the maintenance and the development of the Hospice estates.
To ensure adequate resources to meet the needs of the service and to ensure that we are compliant with relevant Health and Safety legislation.
To ensure that incidents and near misses are logged and investigated appropriately and actions are progressed effectively.
To ensure that we have sufficient and relevant insurance cover to limit our exposure to risk in the event of litigation.
To review and approve policies and procedures.
To review the committee risk register and escalate matters of concern to the Board.

Information Governance Committee

Take delegated responsibility on behalf of the Board of the Hospice of the Good Shepherd by undertaking the following objectives:

To ensure that information is dealt with legally, securely, efficiently, and effectively in the course of Hospice business.
To improve the overall handling of personal information held by the Hospice.
To contribute to and develop good working practices.
To provide adequate training to ensure that Hospice employees are aware of their responsibilities.
To review current data retention.
To review the security of databases.
To review the Information Asset register and ensure departments keep it updated.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

To ensure incidents are logged and investigated appropriately and actions are progressed effectively. The Information Commissioners Office to be informed of necessary incidents within the relevant timeframe.
To review and approve policies and procedures.
To review the committee risk register and escalate matters of concern to the Board.
To assist in the formulation of the strategic plan in relation to Information Governance and once accepted, recommend to the Board for approval.

People & Development and Remuneration Committee

Take delegated responsibility on behalf of the Board of the Hospice of the Good Shepherd by undertaking the following objectives:

To give assurances that training processes throughout the Hospice are contributing to the overall drive to deliver quality care and services to patients and their families to develop staff to their full potential and to enable them to carry out their roles effectively.
To determine the salary and the terms and conditions of the Chief Executive.
To approve the salary and other terms and conditions of service recommended by the Chief Executive for all Hospice employees.
To consider the potential for an annual cost of living increase and propose to the F&I Committee if appropriate.
To consider and agree new posts or changes to existing posts and structure required to meet the needs of the service.
To consider any recommended severance packages.
To assist in the formulation of the strategic plan in relation to people matters and once accepted, recommend to the Board for approval.
To review and approve key policies and procedures.
To identify key performance indicators and review at each committee meeting.
To review the committee risk register and escalate matters of concern to the Board.

Chief Executive

Authority to conduct the day-to-day activities of the Hospice of the Good Shepherd is delegated to the Chief Executive, who is responsible for ensuring that the Board’s strategy and policies are carried out. The Senior Management Team reports to the Chief Executive and meets every two weeks.

Corporate Governance

The Trustees complete an annual review against the charity governance code to highlight any areas for potential Improvement. This Is used to develop the charity's future policies and internal procedures to ensure we continue to follow best practice.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Risk Management and Assurance

The Trustees with the support of the SMT consider the major strategic, business and operational risks that face the charity each year when preparing the budgets and business plans.

The charity has detailed organisational and departmental risk registers which are reviewed regularly by the Senior Management Team and quarterly by each Committee and the Board. Significant new risks are brought to the attention of this Committee and the Board as necessary to ensure they are being actively managed and wherever possible suitable mitigation is put in place. A traffic light system is used to rank the key organisational risks with controls agreed and documented providing a revised score for each risk. Our assurance framework then monitors progress and application of the controls, with the Board also giving direction when further action needs to be taken to improve our controls.

During the assessment process we identified the following major organisational risks (classified as red based on their score) as at the date of signing:

Major Risks	Controls
The Hospice continues to anticipate year- on-year deficits before legacy income, especially with the move to Agenda for Change Salaries for our Clinical Staff, high inflation, and our grant from the Integrated Care Board, insufficient to cover the cost of our Nursing and Medical staffing; a current shortfall of £1million. As a result, our current free reserves are 4 months of forecast expenditure which is outside of the recommended Charity Commission for resilience. The Boards target is 6 months.	Continued monitoring and scrutiny of all costs is in place as reserves remain lower than target. Daily monitoring of cash and bank balances. Monthly monitoring of income and expenses against budget and three-year projections. Monthly monitoring of balance sheet and key solvency measures. Regular monitoring of movements in freely available Reserves. Annual budgeting and update of three-year projections. Joint working with the Integrated Care Board with the view to securing sufficient long-term support, with the ambition being for the ICB to cover the medical and clinical costs of the Charity as per the 2022 Health and Social Care Act.
Failure to attract, recruit and retain the right staff and volunteers for key posts. across the organisation.	NHS Agenda for Change terms and conditions and honouring continuous service for clinical staff SAS contracts for medics. Benchmarking of non-clinical staff roles with ambition to pay the median salary. Succession planning. Apprenticeships Volunteer strategyand development

Major Risks

Controls

The Hospice continues to anticipate year-
on-year deficits before legacy income,
especially with the move to Agenda for
Change Salaries for our Clinical Staff, high
inflation, and our grant from the Integrated
Care Board, insufficient to cover the cost of
our Nursing and Medical staffing; a current
shortfall of £1million. As a result, our current
free reserves are 4 months of forecast
expenditure which is outside of the
recommended Charity Commission for
resilience. The Boards target is 6 months.

Continued monitoring and scrutiny of all
costs is in place as reserves remain lower
than target.
Daily monitoring of cash and bank balances.
Monthly
monitoring
of
income
and
expenses against budget and three-year
projections.
Monthly monitoring of balance sheet and
key solvency measures.
Regular monitoring of movements in freely
available Reserves.
Annual budgeting and update of three-year
projections.
Joint working with the Integrated Care
Board with the view to securing sufficient
long-term support, with the ambition being
for the ICB to cover the medical and clinical
costs of the Charity as per the 2022 Health
and Social Care Act.

Failure to attract, recruit and retain the right
staff and volunteers for key posts.
across the organisation.

NHS Agenda for Change terms and
conditions
and
honouring
continuous
service for clinical staff
SAS contracts for medics.
Benchmarking of non-clinical staff roles with
ambition to pay the median salary.
Succession planning.
Apprenticeships
Volunteer strategyand development

Regular monitoring and review of the risks identified is a priority for the Hospice to support control and mitigation of each risk. The Trustees believe the major risk facing the Hospice is growing our reserves to

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

protect our financial position. In addition, with the known national shortage of nursing and medical staff, we will always have to run the operation at safe staffing levels and consequently we flex our operational capacity of our In-Patient Unit to ensure we are always operating safely.

In addition to the above, full risk assessments are undertaken as required under the Hospice’s Health and Safety and Infection Control Policies.

Staff and volunteers as appropriate are required to complete annual mandatory training covering Information Governance, Fire Safety, Manual Handling, Food Hygiene, Infection Control, Safeguarding, Equality and Diversity and Dignity at Work together with Incident Awareness and Quality Control.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Financial Review

Details of the results for the year are shown in the Statement of Financial Activities and Notes forming part of the Financial Statements. The Trustees have noted the results for the year and remain mindful of the continuing difficulties of operating in the current financial climate. The Group Statement of Financial Activities is set out beginning on page 41 of these accounts. The Trustees report a deficit for the year of (£361,232) (2022: surplus of £579,239).

The introduction of the SAS contracts and NHS Agenda for Change terms for pay has impacted on expenditure if the Hospice. The SAS and NHS Agenda for change were adopted due to the Hospice being unable to recruit or retain nursing and medical staff, both crucial to the running of the Hospice and its operation as an acute medical centre for those patients at end of life.

Our non-clinical staff, which includes our finance, facilities and administration teams are equally as important as the clinical staff ensuring the smooth and safe running of the hospice’s services. Our Income Generation team raise the funds needed to provide the £4m shortfall in funding that we need to run our hospice.

We need to ensure that we can continue to retain and attract staff in a competitive employment market.

The deficit for the year of £(361,232) is after receipt of legacy income of £336,351. The Hospice has experienced a deficit which has exposed us to significant pressure given the comparative low level of free reserves which in March 2023 stood at £1,593k (approximately four months of forecast expenditure) Free reserves have decreased from £1,855k to £1,593k in March 2023 which represents around four months of forecast expenditure compared with our target level of reserves of six months of forecast expenditure.

Our financial investment portfolio reduced in value by -£28k, finishing the year at £533,326 (2021/22 £560,532) this due to the current financial climate.

Management of reserves

The Trustees annually review our reserves policy to take account of uncertainties in the health economy and potential fluctuation in fundraising income. This is with a view to match variable income streams with the fixed level of expenditure incurred in delivering our services. This will help protect the long-term viability of the Hospice.

Our contracted income is predominantly supplemented from retail, lottery, and fundraising income, including legacies. The aim of the charity is to maintain sufficient reserves to support six months’ running costs to accommodate any unexpected funding issues. The charity would like to hold sufficient cash reserves (50%) to meet its immediate short-term needs with the balance held in investments (50%).

This policy allows us to react to challenging economic circumstances and potential threats and liabilities. We are also committed to spending prudently to achieve our aim of delivering charitable activity in the short term.

The calculation of the required level of reserves is an integral part of our planning, budgeting, and forecasting cycle. The current financial climate, for 2022/23 means we remain cautious regarding any continuing impact on income generation whilst maintaining our ambition to increase our free reserves to six months of projected expenditure in line with the stated policy.

At March 2023, group reserves stood at £5.1m (2022: £5.5m). This was made up of restricted funds £202k (2021/22 £263k), and unrestricted reserves of £4.9m (2022: £5.2m). We recorded a deficit in the year on our unrestricted general fund of £ (273k) (2020/21 £441k). This included the (-£28k) loss on our investment portfolio (2021/22 £11k surplus)

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023 40

Statement of Trustees' Responsibilities for the Financial Statements and Corporate Governance

The Trustees (who are also Directors of Hospice of the Good Shepherd for the purposes of the Companies Act) are responsible for preparing the Trustees' Annual Report (incorporating the Directors' report) and the financial statements in accordance with applicable law and United Kingdom Accounting Standards, including Financial Reporting Standard 102 The Financial Reporting Standard applicable in the UK and Republic of Ireland (United Kingdom Generally Accepted Accounting Practice).

Company law requires the Trustees to prepare financial statements for each financial year which give a true and fair view of the state of affairs of the charitable company and the group and of the income and expenditure of the charitable group for that period. In preparing these financial statements, the Trustees are required to:

Select suitable accounting policies and then apply them consistently.
Observe the methods and principles in the Charities SORP.
Make judgments and accounting estimates that are reasonable and prudent.
State whether applicable UK Accounting Standards have been followed, subject to any material departures disclosed and explained in the financial statements.
Prepare the financial statements on the going concern basis unless it is inappropriate to presume that the charitable company will continue in business.

The Trustees are responsible for maintaining proper accounting records which disclose with reasonable accuracy at any time the financial position of the charitable company and enable them to ensure that the financial statements comply with the Companies Act 2006. They are also responsible for safeguarding the assets of the charitable company and the group and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

As far as the Trustees are aware:

There is no relevant audit information of which the charitable company's auditors are unaware.
The Trustees have taken all steps that they ought to have taken to make themselves aware of any relevant audit information and to establish that the auditors are aware of that information.
The Trustees are responsible for the maintenance and integrity of the corporate and financial information Included on the charitable company's website. Legislation in the United Kingdom governing the preparation and dissemination of financial statements may differ from legislation in other jurisdictions.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Independent Auditors' Report Financial Statements

REPORT OF THE INDEPENDENT AUDITORS TO THE MEMBERS OF HOSPICE OF THE GOOD SHEPHERD (COMPANY LIMITED BY GUARANTEE)

Opinion

We have audited the financial statements of Hospice of the Good Shepherd (the ‘parent charitable company’) and its subsidiary (the ‘group’) for the year ended 31 March 2023 which comprise the Statement of Financial Activities, the Balance Sheet, the Cash Flow Statement and notes to the financial statements, including a summary of significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and United Kingdom Accounting Standards, including Financial Reporting Standard 102 The Financial Reporting Standard applicable in the UK and Republic of Ireland (United Kingdom Generally Accepted Accounting Practice).

In our opinion the financial statements:

give a true and fair view of the state of the group’s and parent charitable company’s affairs as at 31 March 2023, and of the group’s incoming resources and application of resources, including its income and expenditure, for the year then ended;
have been properly prepared in accordance with United Kingdom Generally Accepted Accounting Practice; and
have been prepared in accordance with the requirements of the Companies Act 2006 and the Charities Act 2011

Basis for opinion

We conducted our audit in accordance with International Standards on Auditing (UK) (ISAs (UK)) and applicable law. Our responsibilities under those standards are further described in the Auditor’s responsibilities for the audit of the financial statements section of our report. We are independent of the group and parent charitable company in accordance with the ethical requirements that are relevant to our audit of the financial statements in the UK, including the FRC’s Ethical Standard, and we have fulfilled our other ethical responsibilities in accordance with these requirements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.

Conclusions relating to going concern

In auditing the financial statements, we have concluded that the trustees' use of the going concern basis of accounting in the preparation of the financial statements is appropriate.

Based on the work we have performed, we have not identified any material uncertainties relating to events or conditions that, individually or collectively, may cast significant doubt on Hospice of the Good Shepherd’s ability to continue as a going concern for a period of at least twelve months from when the financial statements are authorised for issue.

Our responsibilities and the responsibilities of the trustees with respect to going concern are described in the relevant sections of this report.

Other information

The trustees are responsible for the other information. The other information comprises the information included in the trustees’ annual report, other than the financial statements and our auditor’s report thereon. Our opinion on the financial statements does not cover the other information and, except to the extent otherwise explicitly stated in our report, we do not express any form of assurance conclusion thereon.

In connection with our audit of the financial statements, our responsibility is to read the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or our

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

knowledge obtained in the audit or otherwise appears to be materially misstated. If we identify such material inconsistencies or apparent material misstatements, we are required to determine whether there is a material misstatement in the financial statements or a material misstatement of the other information. If, based on the work we have performed, we conclude that there is a material misstatement of this other information, we are required to report that fact.

We have nothing to report in this regard.

Opinion on other matters prescribed by the Companies Act 2006

In our opinion, based on the work undertaken in the course of the audit:

the information given in the trustees’ report for the financial year for which the financial statements are prepared is consistent with the financial statements; and
the trustees’ report has been prepared in accordance with applicable legal requirements

Matters on which we are required to report by exception

In the light of our knowledge and understanding of the group and parent charitable company and its environment obtained in the course of the audit, we have not identified material misstatements in the trustees’ report.

We have nothing to report in respect of the following matters in relation to which the Companies Act 2006 requires us to report to you if, in our opinion:

adequate accounting records have not been kept by the parent charitable company, or returns adequate for our audit have not been received from branches not visited by us; or
the parent charitable company’s financial statements are not in agreement with the accounting records and returns; or
certain disclosures of trustees’ remuneration specified by law are not made; or
we have not received all the information and explanations we require for our audit.

Responsibilities of trustees

As explained more fully in the trustees’ responsibilities statement, the trustees (who are also the directors of the charitable company for the purposes of company law) are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view, and for such internal control as the trustees determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error.

In preparing the financial statements, the trustees are responsible for assessing the group’s and parent charitable company’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless the trustees either intend to liquidate the group or the parent charitable company or to cease operations, or have no realistic alternative but to do so.

Auditor’s responsibilities for the audit of the financial statements

We have been appointed auditor under the Companies Act 2006 and Section 151 of the Charities Act 2011 and report in accordance with those acts.

Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor’s report that includes our opinion. Reasonable assurance is a high level of assurance but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of these financial statements.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Irregularities, including fraud, are instances of non-compliance with laws and regulations. We design procedures in line with our responsibilities, outlined above, to detect material misstatements in respect of irregularities, including fraud. The extent to which our procedures are capable of detecting irregularities, including fraud are set out below.

Capability of the audit in detecting irregularities

Irregularities, including fraud, are instances of noncompliance with laws and regulations. We design procedures in line with our responsibilities, outlined above, to detect material misstatements in respect of irregularities, including fraud. The extent to which our procedures are capable of detecting irregularities, including fraud are set out below.

In identifying and assessing risks of material misstatement in respect of irregularities, including fraud and noncompliance with laws and regulations, our procedures included the following:

• We enquired of management and those charged with governance, which included obtaining and reviewing supporting documentation, concerning the charity’s policies and procedures relating to:

Identifying, evaluating, and complying with laws and regulations and whether they were aware of any instances of non-compliance;
Detecting and responding to the risks of fraud and whether they have knowledge of any actual, suspected, or alleged fraud;
The internal controls established to mitigate risks related to fraud or non-compliance with laws and regulations.

• We inspected the minutes of meetings of those charged with governance.

• We obtained an understanding of the legal and regulatory framework that the charity operates in, focusing on those laws and regulations that had a material effect on the financial statements or that had a fundamental effect on the operations of the charity from our professional and sector experience.

• We communicated applicable laws and regulations throughout the audit team and remained alert to any indications of non-compliance throughout the audit.

• We reviewed any reports made to regulators.

• We reviewed the financial statement disclosures and tested these to supporting documentation to assess compliance with applicable laws and regulations.

• We performed analytical procedures to identify any unusual or unexpected relationships that may indicate risks of material misstatement due to fraud.

• In addressing the risk of fraud through management override of controls, we tested the appropriateness of journal entries and other adjustments, assessed whether the judgements made in making accounting estimates are indicative of a potential bias and tested significant transactions that are unusual or those outside the normal course of business.

Because of the inherent limitations of an audit, there is a risk that we will not detect all irregularities, including those leading to a material misstatement in the financial statements or non-compliance with regulation. This risk increases the more that compliance with a law or regulation is removed from the events and transactions reflected in the financial statements, as we will be less likely to become aware of instances of non-compliance.

The risk is also greater regarding irregularities occurring due to fraud rather than error, as fraud often involves intentional concealment, forgery, collusion, omission or misrepresentation.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

A further description of our responsibilities for the audit of the financial statements is located on the Financial Reporting Council’s website at: www.frc.org.uk/auditorsresponsibilities.This description forms part of our Report of the Independent Auditors.

This report is made solely to the charitable company’s members as a body, in accordance with Chapter 3 of Part 16 of the Companies Act 2006 and section 144 of the Charities Act 2011 and regulations made under section 154 of that Act. Our audit work has been undertaken so that we might state to the charitable company’s members those matters we are required to state to them in an auditor’s report and for no other purpose.

Use of our report

This report is made solely to the charitable company's members, as a body, in accordance with Chapter 3 of Part 16 of the Companies Act 2006. Our audit work has been undertaken so that we might state to the charitable company's members those matters we are required to state to them in an auditors' report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the charitable company and the charitable company's members as a body, for our audit work, for this report, or for the opinions we have formed.

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Consolidated Statement of Financial Activities

(Incorporating a Consolidated Income and Expenditure Account)

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Balance Sheet for the year ended 31st March 2023

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Consolidated Cash Flow Statement for the year ended 31st March 2023

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Notes to the Financial Statements for the year ended 31st March 2023

Hospice of The Good Shepherd Annual Report and Accounts – Year Ending 31[st] March 2023

Notes to the Financial Statements for the year ended 31st March 2023 cont.