2025-03-31-accounts

Group financial statements

for the year ended 31st March 2025 Company Limited by Guarantee Company registration number: 1843427 Registered charity number: 515516

Contents

Contents ..................................................................................................................................... 2 Chair’s Statement and Report.................................................................................................... 5 Our Year in Numbers ................................................................................................................. 7 Our Purpose, Vision and Values ................................................................................................. 8 Our Strategic Priorities ........................................................................................................... 8 Our Care .............................................................................................................................. 8 Our Culture ......................................................................................................................... 8 Our People .......................................................................................................................... 8 Our Resources ..................................................................................................................... 8 Our Vision ............................................................................................................................... 9 Our Mission ............................................................................................................................ 9 Our Values .............................................................................................................................. 9 Strategic Aims ............................................................................................................................ 9 Our Achievements and Performance ...................................................................................... 11 Our In-Patient Unit ................................................................................................................... 11 24 Hour Advice Line ............................................................................................................. 13 Single Point of Referral ......................................................................................................... 13 Our Living Well and Family Support Services ....................................................................... 14 Carers Support ...................................................................................................................... 14 Complementary Therapy ..................................................................................................... 15 Counselling, Bereavement Support and Spiritual Care ........................................................ 15 Safeguarding ......................................................................................................................... 15 Clinical Learning, Education and Development ................................................................... 16 Quality and Improvement .................................................................................................... 17 Risk Management System ................................................................................................ 17 Patient Safety.................................................................................................................... 18 Patient Satisfaction Summary .......................................................................................... 19 How we funded our achievements 2024/2025 ....................................................................... 19 Donations & Legacies ....................................................................................................... 20 Other Trading Activities .................................................................................................... 20 Grants ............................................................................................................................... 20 Investments ...................................................................................................................... 21

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Income Generation Activities ........................................................................................... 21 Corporate Support and Events ......................................................................................... 21 Community Fundraising and Challenge Events ................................................................ 21 Trading Company – Retail, Lottery and Café .................................................................... 23 Retail ................................................................................................................................. 23 Lottery............................................................................................................................... 23 Gifts in Wills ...................................................................................................................... 23 Trusts and Foundations .................................................................................................... 24 Investments ...................................................................................................................... 24 How we spent your donations ......................................................................................... 25 Our passionate and dedicated people ..................................................................................... 26 Our People ............................................................................................................................ 26 Freedom to Speak Up ........................................................................................................... 26 Volunteers ............................................................................................................................ 26 A volunteer view .................................................................................................................. 28 Our Equality and Diversity Work .......................................................................................... 29 Support Services, Technology and Sustainability .................................................................... 30 Supporting the environment ................................................................................................ 30 Continuing our aims for the future ...................................................................................... 30 Trustees' Report (Incorporating Directors' and Strategic Reports) ......................................... 32 Public Benefit Statement .................................................................................................. 32 Structure, Governance and Management Statement of Trustees' Responsibilities ............... 33 The Board ............................................................................................................................. 33 Appointment of Trustees ..................................................................................................... 34 Committee Meetings............................................................................................................ 34 Board of Trustees ............................................................................................................. 35 Delegated Decision Making .............................................................................................. 36 Senior Management Directorates ........................................................................................ 36 Key Management Personnel ................................................................................................ 37 Subsidiary Undertakings ....................................................................................................... 38 Corporate Governance ......................................................................................................... 38 Risk Management and Assurance ........................................................................................ 39 Financial Review ....................................................................................................................... 40 Management of reserves ..................................................................................................... 41

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Statement of Trustees' Responsibilities for the Financial Statements .................................... 42 Independent Auditors' Report Financial Statements .............................................................. 44 Consolidated Statement of Financial Activities ....................................................................... 46 Balance Sheet for the year ended 31st March 2025 ............................................................... 48 Consolidated Cash Flow Statement for the year ended 31st March 2025 ...................... 49 Notes to the Financial Statements for the year ended 31st March 2025 ............................... 50

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Chair’s Statement and Report

Welcome to the 2024/25 Annual Report for the Hospice of the Good Shepherd

The year 2024/25 has been a challenging one for the hospice, but it has also had many success stories and positive moments, and I hope the results in the Annual Report demonstrate that even through difficult times we continue to deliver high quality and compassionate care to our local community.

In August 2024, concerns were raised regarding the hospice having sufficient senior level medical staffing cover for a specific period of time. Following a visit from the CQC, a condition was imposed under Section 31 of the Health and Social Care Act 2008. Due to these issues around senior medical staffing we took the decision to temporarily reduce our bed capacity from 10 beds to 5 to ensure continued patient care and safety. These conditions and the Section 31 were subsequently lifted following evidence of a sustainable contingency plan to ensure the hospice had the senior medical cover needed. Following the CQC visit the Hospice received a rating of Good for its Caring and Effective services, however, due to the medical staffing issues experienced at that time, we received an overall rating of Requires Improvement. Our team are working hard to improve the issues highlighted in the CQC report and I am pleased to share with you that we have recently recruited a new palliative care consultant to join our medical team.

As ever, one of our major challenges continues to be the lack of adequate and fair funding from the government to a sector that is an essential part of the health system and one that, sadly, continues to be overlooked. Our hospice is not alone is this situation and you will have seen national press coverage highlighting the funding issues being experienced by many hospices including the Hospice of the Good Shepherd. In November 2024 the Government announced grant funding of £100 million for UK hospices to be delivered over a 2-year period, however this funding can only be used for capital projects and does not help us with our ever-increasing day to day running costs. As a result of the increase in Employers National Insurance contributions and the National Living Wage our costs will increase by £180K next year. Our grant from the Integrated Care Board remains low at a 17% contribution to our expenditure.

Since taking on the role of Chair of the hospice I have met so many patients, carers and families and I am always overwhelmed by the feedback and comments they give about how the hospice team has helped them during what is probably the most difficult time of their lives. It makes me incredibly proud to be involved in this hospice and of our amazing team, but it also brings home that there is so much more that we could do for those that we aim to support and serve. We have included one of our patient stories in this report to demonstrate the amazing work our team continues to deliver.

As we continue to campaign for more funding, I would like to take this opportunity to express my immense thanks to all those who tirelessly fundraise for us. Our communities fundraising activities and the many donations we receive are fundamental to providing key services for our community.

Results

For 2024/2025 financial year the hospice delivered a net operating loss of £ (258) k, with an overall surplus of £717k. We were very fortunate to receive legacy income of £1m and a one-off donation of £200k which

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Our Year in Numbers

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Our Purpose, Vision and Values

The Hospice of the Good Shepherd wants all people living in West Cheshire and Deeside with a life limiting 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 their lives as well as they can until they die and to support those affected by the death of a relative or friend who was in our care.

Our care is designed to meet the needs of each individual, and we aim to do this through a combination of expert clinical care, community support and working in partnership with other organisations across our community. Our specialist multi-disciplinary team provide care and support to patients and those close to them. Our care and support mean’s different things for different people. Some people come to us for care at the end of their life, others for help in managing their symptoms. Many patients access our services via our Living Well Centre where they benefit from specialist support to allow them to stay at home for as long as possible.

Our care comprises support with social, emotional, spiritual and psychological issues as well as physical care to help with symptoms and pain control. 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.

Our Strategic Priorities

Our Care

Our Culture

Our People

Our Resources

We will continue to provide high quality, safe, compassionate, person-centred care across all the services we provide.

We will lead, grow and develop an open, engaging culture with our colleagues and service users and develop collaborative relationships with our commissioners and communities.

We aspire to be an organisation where our people have the skills, behaviours, and values necessary to deliver excellent services.

We will strive for financial sustainability, foster innovation and achieve efficiency through continuous quality improvement.

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Our Vision

Striving for Excellence is at the Heart of Everything We Do

Our Mission

Is 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 life-limiting 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.

Our Values

Our five core values were established with collaboration from our entire team. These values provide the framework against which we engage with each other, with our patients and their families, with our donors and supporters and with our stakeholders.

Strategic Aims

Our five-year strategy for 2023-2028 was built upon our aims and priorities in previous years and sets out our ambitions and goals for the following years and how we plan to support our community and develop our care in line with the needs of our community.

Strategic Aim 1

To promote equitable access to optimum quality care and support.

• We will maximise our reach

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• We will maximise our impact through creativity and innovation

• We will influence palliative care locally

We will adapt our services to meet the demands and changing needs

Strategic Aim 2

To evidence a safe, effective, caring, responsive and well led organisation

• We will operate an open and transparent culture

• We will embrace opportunities to learn and improve.

• We will optimise the use of data throughout the organisation

Strategic Aim 3

To foster a culture that prioritises our values and maximises opportunities for skills and development.

• We will provide a great employee experience which attracts and retains talent

• We will seek for inclusion and belonging for all

• We will support learning

• We will harness talents and maximise opportunities for development

Strategic Aim 4

Deliver sustainability through continuous quality improvement and innovation

• We will provide strong financial management and governance assurance

• We will develop relationships and work in partnership with the wider community

• We will lead improvement, change and innovation

• We will embed digitally enabled solution

• We will enable new ways of planning for the future

• We will commit to improving our environmental and social impact

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Our Achievements and Performance

All our clinical departments and clinical teams operate under the leadership and guidance of the Director of Clinical Services (DoCS). Our DoCS is our Care Quality Commission (CQC) Registered Manager, Designated Safeguarding Lead and Controlled Drugs Accountable Officer.

During August 2024, concerns were raised regarding the adequacy of senior-level medical staffing within our Inpatient Unit (IPU), which prompted an inspection by the Care Quality Commission (CQC). As a result, a condition was imposed under Section 31 of the Health and Social Care Act 2008. Following a subsequent inspection later that month, the hospice was rated ‘Good’ for both its Caring and Effective services. However, due to the medical staffing challenges at the time, the overall rating was ‘Requires Improvement’. Since then, we have taken significant steps to strengthen our medical team, including the recruitment of a new palliative care consultant. We are pleased to confirm that the Section 31 condition has now been lifted.

Our In-Patient Unit

Our Inpatient Unit consists of 10 beds and is run by a dedicated and professional multi-disciplinary team: including a medical team, nursing team, physiotherapists, occupational therapists, clinical administrators, social workers, counsellors, complementary therapists, spiritual care team and a full complement of housekeeping and catering staff.

Every patient admitted to our Inpatient Unit (IPU) is treated with compassion, dignity and respect, their care is delivered in a way that maintains their privacy and promotes their independence. Every patient has access to 24-hour specialist palliative care advice and support.

The hospice catchment area covers the West Cheshire region. Services provided to our patients is partly funded by the ICB, who contributed 15% of our income for 24/25, our fundraising team raised the other 85%. We also accept referrals to support people that live in Deeside and Northeast Wales: Whilst the Hospice receives no fixed annual grant funding from Betsi Cadwalader University Health Board (BCUHB) charges are applied on a per-patient basis back to the Welsh Health Board.

Our catering staff provide a wide range of home cooked, nutritious food that is aligned with patients’ preferences and dietary requirements. Food is available 24-hours a day for patients. Our housekeeping team maintain a clean, hygienic, and well-presented environment to support people’s comfort, dignity and wellbeing.

The hospice also offers support, information and reassurance to the family, friends, and carers of our patients, recognising their essential role in the lives of the people we care for.

People are referred to our IPU for a range of reasons, including symptom management, end of life care and assessment of complex needs. Our vision is to ensure that everyone impacted by a progressive life limiting

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illness receives excellent care and support whenever they need it. Our accommodation includes a combination of single rooms and a 4 bed bay, with room allocation based on individual needs, preferences, and clinical considerations Whilst we do care for people at the end of their life, almost half of the patients that are admitted onto the IPU go home again with robust support and care provided by the integrated working of our NHS System Partners and our Living Well Services. The care of all the patients accessing the IPU is discussed at the weekly hospice Multi-professional Meeting (MDT), this ensures that care is safe, effective and responsive to the individual patient’s needs.

In 2024/25, we have cared for 72 people on the IPU as well as supporting their family, friends, and carers. This equated to an average bed occupancy of 46% , with an average length of stay at 14 days. This is a reduction on the number of patients we supported last year due to our temporary reduction in bed numbers during the year.

Our clinical staff are highly trained and have specialist expertise across a wide range of areas to ensure safe, effective and personalised care. Collectively they provide comprehensive care that includes nursing, medical, emotional, spiritual and psychological support, tailored to individual needs.

Dedicated care and support when it's needed the most

Teams from across the hospice came together in November 2024 to create a very special moment for patient Michelle and her young family.

In November 2024, Michelle, aged 43, was admitted to the Hospice. Her sons Harry, aged 9 and Alfie, aged 10 knew Michelle was very ill, as dad Jeff had always been very open throughout Michelle’s illness. Jeff was then faced with explaining to their two young sons, that mummy was so ill that she would not be able to be part of the family Christmas celebrations.

Michelle’s son Harry had the idea: That they would have Christmas early, so that they could celebrate Christmas together as a family for one last time. The idea was discussed with the nursing team, and in true hospice style, the nurses didn't hesitate to create Christmas early for Michelle and her family. What followed next was one of the most touching, and memorable initiatives our hospice team has undertaken.

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Michelle was the only patient in our four bedded bay, and the staff overnight found time to create a cosy “living room” with a fireplace and hearth complete with family photos. There was even a fully decorated Christmas tree. Every corner of the room was made to look and feel like Christmas. The big day was set for 15[th] November, and on that day the family wore their Christmas jumpers; there were presents for Harry and Alfie and gifts from them to their mum, as well as festive food. And of course, the day was made even more special with a visit from Santa himself to hand out the gifts. Even though Michelle couldn’t participate fully, everything was done within her view and the family and our team made sure she was involved in every part of the celebrations.

Jeff said “The effort everyone had gone to just blew me away. They really went above and beyond and everyone in the hospice was talking about it. It made us all feel so special”. Everything that happened really opened my eyes to what hospice care is really all about.”

Each department within the hospice team worked together to create this very special memory for Michelle’s family, from the clinical teams, housekeeping and catering team, fundraising team and the facilities team, everyone came together in a very short time frame to deliver a very special Christmas Day.

24 Hour Advice Line

During 2024/25 the Hospice paused the Nurse led 24-Hour Telephone Advice line for health and social care professionals within the West Cheshire Area. Collaborative work is well under way with NHS System Partners and ICB Commissioners to consider a Cheshire wide consultant led Palliative Medicine Advice Line for the future. The Hospice continues to provide 24/7 consultant advice to all IPU patients.

Single Point of Referral

We have continued to develop the Integrated Single Point of Referral initiative which is a collaborative alliance between the Hospice of the Good Shepherd, Countess of Chester Hospital Specialist Palliative Care Team and Cheshire and Wirral Partnership Community Specialist Palliative Care Team. The teams meet Monday to Friday at 1pm at the Hospice site. All new referrals (not including direct counselling referrals), into the services come through the Single Point of Referral electronic system that is managed by a clinical co-ordinator.

Collectively and with senior medical oversight the multi-professional teams come together to triage and allocate each new referral to the appropriate service, ensuring the right patient has access to the right team at the right time .

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The multidisciplinary team (MDT) also meets weekly as three distinct teams, ensuring coordinated, patient centred care through shared decision making.

Our Living Well and Family Support Services

Our dedicated team of trained nurses, counsellors, social worker and complimentary therapists, alongside our volunteers continued to support patients, family, friends, and carers to ‘live well’ and improve the quality of their life. By working collaboratively with patients to provide guidance and support, our team empowers individuals to make informed choices, helping them manage symptoms, address personal concerns, develop effective coping strategies and to plan for the future. As with the IPU, the vision of the Living Well Services is to ensure that anyone impacted by progressive life limiting illness has access to excellent care and support.

The Living Well Centre provides a range of support therapies, including nursing, rehabilitation, and wellbeing support. During the year, 1669 patients and/or carers attended sessions in the Living Well Centre.

The Hospice is fortunate to receive selected funding from Charitable Trusts and Foundations who recognise and value the importance of our Living Well Services, unfortunately the hospice does not receive any statutory funding from the NHS ICB for Living Well Services, in the main these services are funded from charitable donations.

Our Living Well Centre operates 4 days a week and services include our very popular Coffee and Chat Peer Support Group, our rolling programme of Living Well Day Sessions covering topics like: Breathlessness Management, Fatigue Management, Strength and Balance and Advanced Car Planning. The sessions are inclusive and accessible to anyone across West Cheshire who has a progressive life limiting illness.

All the patients who access the Living Well Centre are discussed at the monthly Living Well Centre MDT.

Carers Support

Carer support services play a vital role in enhancing the wellbeing of those who care for others. By offering emotional support and practical advice, these services help reduce carer stress, reduce the risk of burnout and improve the carer’s ability to sustain their role. Supporting carers not only supports wellbeing and resilience, but it also contributes to better outcomes for the people they care for. With the generous support of a grant from Cheshire West and Chester Council (CWAC), we support the carers of our patients through both one to one and group sessions. Carers are also able to access a free course of complementary therapy sessions.

During the year with the support of the grant from CWAC, and in an effort to make our services more accessible, we have taken our Carer Support group sessions out into our wider community in areas such as Malpas and Neston as we recognise that people with carer responsibilities find it challenging to leave their

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loved ones for any length of time. 281 Carers from across West Cheshire have accessed 502 Carer Support Sessions.

Complementary Therapy

The Hospice offers a range of complementary therapies to both patients and carers. These therapies are delivered by trained complimentary therapists in a purpose-built environment as well as on the IPU. Complimentary therapy plays an important role in hospice care by supporting physical, emotional and spiritual wellbeing. Therapies such as massage, aromatherapy and relaxation techniques are provided to help reduce anxiety, ease symptoms and enhance quality of life. When offered alongside clinical care, they provide a holistic approach that supports comfort and dignity. During the year, there were 1143 complimentary sessions provided to patients and their carers.

Counselling, Bereavement Support and Spiritual Care

Counselling, bereavement support and spiritual care are integral to the holistic approach that the hospice delivers through its care. These services provide emotional and psychological support to patients and their loved ones. They help navigate grief, loss and the challenges of serious illness. Spiritual care respects individual beliefs and values, offering comfort and meaning at all stages of care here in the hospice. Our team of professional counsellors, trained counselling volunteers, student counsellors and spiritual care providers have continued to provide pre and post bereavement support to our patients and their families throughout 2024/2025. Through our dedicated child bereavement service “Reflect” we have also continued to provide pre and post bereavement support to children across West Cheshire no matter where their loved died. Unfortunately, we were unable to obtain external grant funding to support this project for the 24/25 financial year. Our counselling, bereavement support and spiritual care services have supported 597 Adult Bereavement Sessions and 887 Children’s Bereavement Sessions. We have also supported 98 Music Therapy sessions.

Safeguarding

Safeguarding is a fundamental part of our commitment to provide safe, high-quality care. We have robust and up to date policies and procedures in place to protect people from abuse and neglect. Through vigilant safeguarding practices we promote the rights, safety and wellbeing of our patients and our staff.

Our Designated Safeguarding Lead (DSL) oversees all safeguarding concerns, ensuring they are identified, reported and managed appropriately, in line with regional and national guidance and regulations. We recognise that individuals with additional needs, such as learning disabilities, may be more vulnerable, and we are committed to making reasonable adjustments to ensure their voices are heard and their rights are protected. All staff and volunteers receive regular mandatory safeguarding training to help them recognise and respond confidently to concerns, including those with communication or cognitive challenges.

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The Safe Management of Medications, including Controlled Drugs

We have safe and vigorous processes in place to ensure that all medications are managed safely, this includes Controlled Drugs. A robust Service Level Agreement is in place with the local ICB, this ensures medications are readily available for our patients 7 days a week and staff are supported with any pharmacy queries and concerns. Reconciliation procedures, alongside mandated destruction of medication policies and procedures also support clinical practice. Our Controlled Drugs Accountable Officer ensures quarterly reporting into the Local Intelligence Network alongside CQC regulatory reporting. Our Board of Trustees are provided with mandated training in the Safe Management of Controlled Drugs.

Clinical Learning, Education and Development

We are committed to ensuring that all our clinical staff receive comprehensive, ongoing training and development to deliver safe, effective and person-centred care. All team members complete a structured induction, including mandatory training in areas such as safeguarding, infection prevention, and moving and handling. We regularly assess staff competencies and provide access to continued professional development opportunities. We actively encourage reflective practice and learning to support continuous improvement. Supervision and appraisals are used to identify learning needs and ensure that all staff feel supported and confident in their roles.

We have designated link nurses in all key areas such as tissue viability, dementia care and infection prevention, as examples. These link nurses receive enhanced training and act as champions within the service, sharing best practice and supporting the wider team through education, mentoring and role modelling.

In addition to comprehensive mandatory and role-specific training, we actively support staff to pursue further academic education, such as diplomas, degrees, and specialist qualifications relevant to their role. In 2024/2025, we have had opportunities to further develop the Nurse Associate role, provide leadership education to senior nurses, and support Master’s Level education for our Deputy Ward Manager and Social worker.

Students

We continue to work in partnership with academic institutions such as the University of Liverpool School of Medicine, University of Chester and Wrexham University to provide medical and nursing placements for students. We are committed to supporting students and contributing to the ongoing development of palliative care through education, training and reflective practice, the growth and development of palliative medicine and to help bring through the next generation of palliative clinical staff which is incredibly important to the hospice.

During 2024/2025 we have hosted 6 cohorts of medical students with a total of 19 students over 12 weeks. We have also hosted 15 nursing student placements, and 4 student counselling placements.

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The whole team were amazing – their teaching and attentiveness to us all whilst on placement here (nothing was too much of an ask).

Brilliant placement – all the staff were so welcoming and friendly. The teaching was brilliant.

There was so much teaching – This has been the best I feel like I have a great placement of medical understanding of palliative school so far. The teaching care now. has been amazing and of very high quality – I feel like I have learnt so much in the two weeks. We have been really well supported with our portfolios, and the timetable was so well organised and thought out. I just wish the The best teaching on placement was longer!

The best teaching on placement I’ve ever had.

Quality and Improvement

The Hospice has remained focused on quality improvements across the organisation during the year. We have continued to evaluate our work undertaking reviews and audits looking at how we can improve the care we provide. The Hospice produced the Quality Account for this reporting period in line with national guidance.

Risk Management System

Since transitioning from a paper-based reporting system to electronic Radar Healthcare in 2023, the Hospice has significantly enhanced its approach to quality, safety, and governance. The system is now fully embedded across the organisation, enabling real-time reporting and analysis through modules for incidents, compliments, complaints, concerns, and staffing red flag events. We have built regular internal audit tools and developed scheduled event monitoring to strengthen compliance and governance assurance, enhancing visibility, accountability, and alignment with regulatory frameworks. A key strength has been the creation of a comprehensive risk register, supported by heat maps that provide visual tools for interaction and scrutiny. Radar Healthcare also serves as a central repository for all policies, procedures, and supporting documentation, ensuring consistent access for all staff. Training on the system is integrated into staff induction and annual clinical mandatory training programmes, promoting confident use and a culture of continuous improvement.

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Patient Safety

We launched our Patient Safety Incident Response Plan which sets out how we intend to respond to patient safety incidents over the next 12-18 months. Our plan has been endorsed by Cheshire and Merseyside Integrated Care Board. The Patient Safety Incident Response Framework (PSIRF) sets out the national patient safety approach to developing and maintaining effective systems and processes for responding to patient safety events for the purpose of learning and improving patient safety. It is recognised that there will need to be a shift towards systems-based approaches to a learning culture to allow health care organisations including Hospices to effectively respond to and learn from events, with the purpose of reducing the risk of avoidable harm as low as reasonably possible.

We took a closer look at our patient safety incidents during 2024/2025 which has driven our areas of focus:

Medication Incidents

Documentation errors remain the highest percentage of recorded controlled drug incidents, accounting for half of the total number, this is followed by administration errors. We have implemented reviews, safe systems, policies, training and audit procedures regarding this and we will continue to explore the underlying reasons for controlled drug issues.

Pressure Ulcers

We have carried out a review regarding these incidents and they continue to decrease. Thematic analysis shows proactive care planning at the time of admission for potential at risk patients can be improved on. We will also look closer at the hospice acquired pressure ulcers in patients declining to be repositioned during the last days of life.

Falls

Upon review we established that most incidents occurred in patients who showed no signs of confusion. We will look at the contributing factors for patients who are assessed as being mobile and independent falling and how this risk can be mitigated.

Patient Experience

The hospice has maintained a robust system for reviewing feedback as an opportunity for organisational learning and improvement, ensuring our services remain responsive to the needs and concerns of all individuals within our care community.

The hospice continues to request feedback through the ‘in house’ service user feedback form. This year there was a 100% response rate with 206 people stating that the overall care provided was either good or outstanding.

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Patient Satisfaction Summary

Inpatient Unit

97% rated their experience as outstanding. 3% rated it as good.

Living Well Services 92% rated their experience as outstanding. 8% rated it as good .

Counselling Services 77% rated their experience as outstanding. 23% rated it as good.

In 2024/2025, the Hospice of the Good Shepherd launched a quality improvement initiative in partnership with our Service User Participation Group, aimed at enhancing patient and service user feedback to maximise opportunities for improving patient experience. As part of this initiative, we created a new volunteer role and successfully recruited two quality and improvement volunteers, both of whom have personal experience of living with and caring for someone who has used our services. So far, our volunteers have held 12 feedback sessions and engaged with 25 service users across the hospice, gathering valuable insights into how our services can be improved. To further support this work, we have also introduced a feedback notice board in our hospice reception area, providing a visible and accessible space for sharing ideas and experiences. Here are some of the positive feedback captured when talking about the hospice experience:

When we asked “what could we do better”, we obtained some innovative ideas to improve the patient overall experience:

• People asked for more information on complementary therapies. We co-produced a complementary therapy leaflet with our Service User Participation Group.

• People asked for the café to be available after complementary therapy. If the cafe is closed we are able to offer a hot drink to patients in the living well waiting room.

How we funded our achievements 2024/2025

Our income in 2024/25 was £6.1m (2023/24: £5.3m). Income increased by 0.8m in 24/25 We received in total £925k ICB funding for palliative care representing 15% of our total income. During the year we received £ 82 k from grant income announced by the Government, this was distributed by HUK. This grant was restricted to capital expenditure, and we used it to purchase essential patient equipment that we would not usually have been able to buy. Donations and Legacy income generated £1,915k an increase of £800k from 23/24, retail income generated £1,167k an increase of £120k from 23/24, our lottery generated £745k (23/24 £753k). Investments and Interest generated £66k , (23/24 £87k) Despite

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challenging financial circumstances, the success of our charitable income is due to the incredible commitment of our local community, volunteers, and staff. Our income can be broken down into monies given through grants, earned from investments and through trading, fundraising and funding from the CCG/ICB.

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, Christmas cards, café and seasonal trading activities.

Grants

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

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Investments

This is income from our investment portfolio and bank interest.

Income Generation Activities

During 2024/2025, we have continued to invest in generating more sustainable regular income 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.

Corporate Support and Events

We would like to thank our corporate partners who engaged their customers and employees in fundraising activities, who sponsored events or provided us with gifts in kind. These gifts in kind make a valuable contribution towards costs saving and to the bottom line of our event expenditure and overall, our total budget. During the year we also received corporate sponsorship for several of our fundraising events.

We have delivered a wide range fundraising events ensuring that we have activities for all to participate in ranging from our Seven Miles Seven Locks Walk through to our annual Traditional Christmas Concert.

In total £962k was generated from fundraising, events and corporate support.

Community Fundraising and Challenge Events

We continued to receive great support from our community, and this has led to growth in income from this sector. In 2022/23 we reviewed our Community Fundraising Strategy and since then we have taken the opportunity to strengthen our team again in 2024/25 to allow us to engage further with our community.

We have also developed our range of Challenge events, and the energy, enthusiasm and determination of our community is amazing to see. This income stream has increased this financial year.

We continue to receive the support of our local dedicated Hospice Support Groups, many of whom started fundraising nearly 40 years ago to enable the hospice to be built.

Our support groups are in Blacon, Hoole, Malpas, Upton and Waverton and deliver a wide range of fundraising events and activities.

Thanks to this fantastic support our community fundraising generated an income of £359k (23/24 £367K). Our Challenge fundraising generated an income £139k (23/24 £121K)

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Our London Marathon runners raised £41,421

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20 companies ran in the Panto Horse Race raising £42,000

2066 Santa Dashers raised £32,500 for the hospice

School’s seasonal fundraising raised £37,315

Over 4000 recycled Christmas Trees raised £50,252

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Gordale Christmas Grotto raised £38,997

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Our 7 Locks canal walkers raised £13,499

The Farndon Soapbox Derby raised £57,000

Foamtastic Colour Blast raised £32,241 for the hospice

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Trading Company – Retail, Lottery and Café

Trading Company Turnover for the year Operating profit for the year £1,912,426 £691,874 (23/24 £1,747,712) 9.4% increase (23/24 £683,782) 1.2% increase

Retail

Our 8 charity shops continue 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, however recruiting volunteers into our retail business is still challenging. During the year we have looked to make efficiencies in our sorting hub to speed up the sorting and distribution of stock and we have reviewed the way we rotate our unsold stock between shops to increase efficiency. Our retail team has focused on promoting the benefits of gift aid to our donors and this year we have claimed £75,185 in retail gift aid from HMRC.

Within our Cafe we have reviewed and reduced our menu to reduce the amount of stock we need to hold and the Cafe team have held a number of themed events to generate additional income.

Retail income (including our on-site cafe) for the year increased to £1,167k (2023/24 £1,024k).

Lottery

Our Hospice lottery continues to operate successfully generating a sustainable income of £745k (2023/24 £723k). We maintained our membership at approx. 12,000 members and have continued to recruit new members to the weekly drawer to counteract the natural attrition. We held 2 very successful raffles during the year generating an income of £71k.

In total our retail and lottery operations generated an income of £1,912k (2023/24 £1,748K)

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 £1,051k (23/24 £458k). The increase this legacy income can be attributed to one large gift of a property. Gifts in Wills are a vital source of income to the hospice.

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During the year we joined with Hospice UK and hospices nationally to promote Legacy Giving to local Hospice as this is such an important income stream to us. We have continued to deliver our ever-popular monthly Wills Clinics, kindly provided free of charge by Oliver and Co Solicitors who have now been supporting this initiative for over 8 years.

Trusts and Foundations

Grants are an important source of income for us and allow us to fund capital expenditure such as building improvements and essential patient equipment that we would otherwise be unable to fund.

We would like to give special thanks to all the Trusts and Foundations whose grants have supported us to continue our vital work or to buy equipment that helps us support patients, families, and their carers. During the year we received over £144k in grant income.

We continued to receive a generous grant from the Majorie Boddy Trust to help fund our Living Well service. A grant from Cheshire West Council facilitated by Ground Works allowed us to replace our broken outside lighting. We also received several grants to purchase clinical equipment to support our patients.

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, Rathbones formerly Investec monitored by the Financial Conduct Authority, who manage a balanced portfolio on our behalf.

Although the financial markets continued to remain volatile during the financial year the Hospices investment portfolio generated £34k for the year ending March 2025 (2023/2024 £57k). Interest generated a further £32k for the hospice.

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.

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How we spent your donations

Our charitable expenditure is £5.5m (2023/24: £5.2m). Like all business and our community, we face the continued additional pressure of increased staff and supplier costs, due to the rise in inflation, increase to the National Living Wage these costs are set to rise further in 25/26 with the increase announced to Employers National Insurance.

Most of our costs are attributed to salaries for our staff. Our nursing staff are paid in line with Agenda for Change (NHS England Terms and Conditions) our SAS doctors' salaries are linked to the NHS pay scales. Any salary increases agreed by the NHS are out of our control and continue to impact our salary costs. In light of this, pressure was placed on our salary budgets for 24/25 from above inflation pay increases for our clinical and medical staff. An inflationary pay increase was applied for non-clinical staff across the organisation.

During the year we purchased equipment for our IPU department and Living Well services funded by the NHSE government grant of £85k. This funded the purchase of medical equipment, plus wardrobes and bedside cabinets for patient rooms, up-to-date IT equipment, a digital patient medication locker system and installation of a computerised telephone system. The latter will reduce telephone costs for future years. Additional lighting was also installed to our car parks to improve visibility and health and safety funded by CWAC.

The ICB grant of £925,276 funded 17% of our expenditure for the year ending 31[st] March 2025. We continue to make sure every penny will count whilst delivering our agreed strategies. 68% of our costs were attributed to hospice expenditure with 32% of costs utilised to generate the income required to run the Hospice.

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Our passionate and dedicated people

Our People

We simply could not achieve what we do without our incredible staff and volunteers. In the year to March 2025, we employed 130 staff (both full and part time employees) with a wide range of skills, knowledge, professional qualifications. We also are fortunate to receive support from over 400 volunteers who give their time to us free of charge. We know that without their continuing support we would not be able to deliver our services.

We continue to operate both hybrid and flexible working policies, which help to attract and retain staff. We have an Employee Assistance Programme in place providing free mental health support, online GP service and debt advice along with salary sacrifice schemes including a cycle to work and gym membership scheme. This employee assistance scheme has been enhanced during the year to improve the benefits to our team.

During the year we launched a Well Being Task and Finish Group comprising staff from across the organisation to ensure that we continue to support our teams. We have also launched a Well Being Strategy and introduced our team of Well Being Champions

We undertake the Birdsong Charity survey at least every two years, with the next one due to take place in October 2025. We have worked with our staff to make changes following the results from the 2024 survey, this has included a focus on staff wellbeing and communication.

Freedom to Speak Up

The Hospice of the Good Shepherd actively encourages staff engagement. We are registered with the National Guardian Office and currently have one Freedom to Speak up officer. We facilitate regular staff and volunteer engagement groups represented by all departments.

Volunteers

We have over 400 volunteers who support all departments at the hospice. We are very grateful for their support as we know that without them our hospice would not be able to operate. Volunteering at the hospice not only benefits our patients, but our hospice staff and the volunteer themselves. Volunteering makes a real difference.

We continue to improve our volunteer experience, and have made significant improvements to the application process, utilising the online recruitment system making it available to prospective volunteers.

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As a result, we have been able to streamline our internal processes improving efficiency. We have further developed our volunteer database, to improve accuracy, output and effectiveness.

We have a dedicated Volunteer Focus Group that meets quarterly, to discuss hospice projects, share ideas and suggestions, and really give our volunteers a voice and an opportunity to have their say. Recent projects have included reviewing how we recruit volunteers to our busy warehouse. The group have also had vital input into how we recognise and communicate to volunteers, bringing new ideas and enthusiasm, which is very much appreciated.

In June 2024, we held our annual Volunteer Recognition event in our Hospice marquee. We were able to present 43 volunteers with long service awards ranging from 5 years to 35 plus years. The volunteers were able to enjoy a delicious afternoon tea, produced by our fabulous catering team, and celebrate their dedication and commitment together.

In December 2024 we hosted a Christmas Volunteer Thank You Evening held in the Chapel at Eaton Hall, by kind permission of the Duke and Duchess of Westminster. The evening was attended by approximately 80 volunteers who enjoyed festive carols performed by the SingMe Merseyside choir, followed by a social gathering and season refreshments. The event was enjoyed by all, and it was fabulous to be able to thank our volunteers in such prestigious surroundings.

Corporate volunteers continue to choose the Hospice as their charity of choice to offer volunteer days. This year we welcomed volunteers from Timberland, Lloyds Banking Group, M&S Bank and Sykes Cottages to name but a few. We are so appreciative of the work they get involved with helping us with maintenance tasks at the hospice or supporting our team at the warehouse with collections, sorting and PAT testing.

We recognise the invaluable contribution of all our volunteers, and we would like to take this opportunity to acknowledge their contribution and thank them for their continued commitment, dedication, and support.

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A volunteer view

Mally started volunteering with the hospice in January 2024 after his wife Rebecca died at the hospice. Mally and his family were so impressed and grateful for the care and support that Rebecca received that he really wanted to give something back. Mally was aware of the hospice and where we were based, but until Rebecca had to access our services and became an inpatient, he had no idea of how fantastic the level of care was and what a difference we made at such a difficult time in his life.

Since Mally has volunteered in our community café, he has enjoyed every single minute. Volunteering has given Mally a sense of purpose, routine, and something to look forward to each week. He enjoys meeting people and being part of the volunteer team.

Mally says: ”I would really recommend to anyone who is considering volunteering not to hesitate. I really enjoy my volunteering time and look forward to coming here every week. It's great to be part of something where you can see what you do makes a difference. I really enjoy working with the other volunteers and have made some great friends.”

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Our Equality and Diversity Work

Our Equality and Diversity Steering group meets quarterly to review and plan for increased access to services by all members of the community as well as addressing workforce issues.

In August 2024, we attended the 12[th] annual Chester Pride event, with members of the hospice team proudly walking in the parade and hosting a table in the Health and Wellbeing tent. We promoted that hospice care is open and accessible to all, reaching out and engaging with the LGBTQ+ community who attended on the day. All of our Chester City centre shops display a Pride window during this week.

In October 24 we retained the Navajo Merseyside Cheshire Manchester LGBTIQA+ Charter Mark Award for Equality, Diversity, Inclusion, Intersectionality and Equity for all, especially Gay and Gender Variant individuals.

The Charter Mark consists of ten simple assessment criteria, each asking for supporting resources. These resources can be specific documents, such as a copy of the Equality & Diversity Policy, a monitoring form, or brief details of working procedures, e.g. how and when new staff members are trained or whether there are always private areas available for service users to talk to your staff.

Members of Hospice staff and volunteers went through the assessment process, and we were delighted and proud to retain the charter mark for another 2 years, to further improve and build on all aspects of EDIIE work and principles. A number of staff from across the organisation attended an event in Liverpool to receive the Charter Mark and celebrate our achievement.

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Support Services, Technology and Sustainability

Supporting the environment

Where we can the team at the hospice works hard to ensure we respect the environment with sustainability and recycling initiatives.

During 2024/25 we re-launched our Environmental Action Group comprising staff from across all areas of the hospice

Our Estates Manager completed the Pathways to Net Zero training course delivery by the Institute of Environmental Management and Assessment.

In January 2025, our fundraising team collected over 4000 Christmas Trees from homes within the catchment area. These were then chipped and used for mulch therefore reducing landfill and saving over 50,000kg of carbon emissions. This initiative raised £50,252.

In February 2025 with the aid of a grant from Cheshire West and Chester Council we install LED lighting in our car park. Included in this new lighting are a number of solar powered lighting units which will help reduce our carbon emissions further.

Across the hospice, our teams are utilising technology to improve efficiency and reduce administration time.

During the year our shops sold 69,941 items of preloved clothing this prevented 20 tonnes of clothing going to landfill.

Continuing our aims for the future

Our plans for future business objectives are aligned with our strategic aims and the objectives of the charity.

Strategic Aim 1

To promote equitable access to optimum quality care and support.

• Utilise population health data to identify need and inform future services, particularly focusing on those underrepresented and the delivery of care where needed.

• Optimising and enhancing continuity of care through integrated partnership approach.

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• Utilising patient outcome measures to enhance and expand our care provision.

Strategic Aim 2

To evidence a safe, effective, caring, responsive and well led organisation.

• Carry out activities to improve our CQC Rating

• Deliver our Quality and Improvement strategy

• Listening to, reviewing and learning through feedback from service users, staff and the community to inform and develop our services

• Develop improved methods of communications feedback for all staff

Strategic Aim 3

To foster a culture that prioritises our values and maximises opportunities for skills and development.

• Develop our People and Volunteering Strategies

• Further embedding the well-being programme for staff and volunteers across the organisation

• Enhance our Speak Up Guardian Programme

Strategic Aim 4

Deliver sustainability through continuous quality improvement and innovation.

• Developing and strengthen our existing income streams such as legacies and fundraising, as well as exploring and testing other income generating options to develop more sustainable financial future.

• Continue to monitor and control costs and optimise procurement opportunities.

• Optimising the use of technology to provide opportunities to save money and maximise efficiency

• Develop and embed our environmental strategy across the organisation to ensure sustainable practices are integrated across the organisation.

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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 2025 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 2022, 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 FRS102.

Aims and objectives of the charity as set out in its Articles of Association the objectives of the charity are:

• To promote the relief of illness and suffering, especially of the dying.

• To provide education and training for professionals and volunteers engaged in palliative care and increase awareness among the general public of the values, principles and practice of hospice and palliative care.

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.

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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 Board

The Hospice is governed by the Board of Trustees who are responsible for the governance of the organisation.

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. Trustees are initially engaged for a period of three years but can be invited to serve for a further 2 terms of three years.

The board delegates the operational responsibility such as managing day to day affairs to the senior management team. The hospice is registered with, and inspected by, our regulators the Care Quality Commission (CQC).

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 the charity’s activities.

• To ensure that the ethos and culture of the organisation underpin delivery of the charity’s activities.

• To assess compliance and quality in accordance with legislation and best practice.

• 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.

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Appointment of Trustees

The appointment of new Trustees follows a standardised procedure. In accordance with the Charity Commission's recommendations, the importance of a diverse range of skills, experience and backgrounds is acknowledged to optimise board outcomes and reflect good governance. Recruitment of new trustees starts at the point of identification of a board gap; possible candidates are then identified either through advertising or through professional networks and contacts. New trustees are appointed by a majority of the Board of Trustees.

Appointment is only completed following a regulated recruitment process to include a formal interview, DBS check and reference requests.

Our Trustee Board is required to have a minimum of 10 and a maximum of 20 members

Induction and Training of Trustees

New Trustees undergo an induction programme aimed at building knowledge and understanding of the roles and responsibilities of a Trustee as well as understanding the roles of the senior leadership team.

Trustee training covers controlled drugs, safeguarding, fire safety, information governance, cybersecurity and other training relevant to their role. This now also includes the National Patient Safety and Oliver McGowan Training programmes. This is supported by an annual appraisal process led by the Chair.

Committee Meetings

The Board of Trustees and Executive Directors meet at least four times a year, and as members at an Annual General Meeting, The Board 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 5 established sub-committees. The members of these committees include Trustees who meet with Executive Directors and are also attended by external advisors when required.

The hospice ensures good governance through an effective committee structure. Each committee meets prior to a main Board meeting and supports the work of the Board. The Board delegate responsibility and empowers each committee to examine in detail its specific area and provide proper scrutiny to assure the Board of good governance.

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Board of Trustees

Yvonne Emmett Cannell, Chair of the Board

Mike Davies, Vice Chair of the Board and Chair of Estates and Health and Safety Committee Bill Benoy, Treasurer and Chair of Finance and Fundraising Committee Robert Mee – Chair of People and Development Committee Suzanne Crutchley – Chair of Information Governance Committee Neil Fergusson – Chair of Care Committee Gary Barr Justine Watkinson (until 25.06.2024)

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Lesley Mills

Elizabeth Redmond

Sophie Blinkhorn (appointed 25.06.2024)

Lucy Wardle (appointed 25.06.2024) David Gillbert (appointed 24.06.2025)

Delegated Decision Making

A Scheme of Delegation approved by the Board is in place that sets out in detail the matters and powers delegated to the Chief Executive and the Senior Management Team

Senior Management Directorates

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Key Management Personnel

CHIEF EXECUTIVE

Rhian Wynn Edwards Caroline Siddall Interim Chief Executive from 24/09/24

DIRECTOR OF CLINICAL SERVICES Liz Taylor Retired 31[st] May 2024 Claire Royce from 12[th] August 2024

DIRECTOR OF INCOME GENERATION Caroline Siddall

DIRECTOR OF QUALITY AND IMPROVEMENT Lisa Parker

DIRECTOR OF PEOPLE AND DEVELOPMENT Julie Davies until 30[th] June 2024

HEAD OF PEOPLE AND DEVELOPMENT Laura Smith from July 2025

MEDICAL DIRECTOR AND PALLIATIVE CARE CONSULTANT Dr Alison Coackley until 07[th] May 2024

HEAD OF FINANCE Yvonne Thurman

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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 Rathbones Wealth & Investment Ltd 100 Old Hall Street Liverpool L3 9AB

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 7 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.

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.

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Risk Management and Assurance

The Trustees with the support of the Senior Management Team 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 the relevant sub-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. All risks as recorded on RADAR our electronic risk management system.

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 risks facing the Hospice is financial stability. There are number of factors that impact this.

• Agenda for Change and SAS doctor contracts.

• Increased Employer contributions for both National Insurance and National Living Wage

• Insufficient funding to cover core costs

We endeavour to grow our financial reserves to protect our financial position. 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.

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Financial Review

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 47 of these accounts. Details of the results for the year are shown in the Statement of Financial Activities and Notes forming part of the Financial Statements.

Our Income Generation team raise the funds needed to provide the £4.4m shortfall in funding that we need to run our hospice. We received £1,915,376 from donations and legacies (23/24 £1,116,703) an increase of £800k from the previous financial year. Our trading company for retail and lottery generated £1,912,246 (23/24 £1,747,712) an increase in income of £165k (because of a full year's income for our 2 shops added late 23/24). £962,163 was raised from fundraising events (883,617k 23/24) an increase of £78k. We received £925,276 15% of our income from the Integrated Care Board (ICB). ((23/24 £1,090,802 21%) a reduction to one off funding of £200k resulted in the overall decrease of £165k to the ICB grant after inflation).

Our financial investment portfolio increased, finishing the year at £611,968 (2023/24 £590,356). Total investments and interest amounted to £66k for the financial year (2023/24 £87k)

During the financial year a valuation was carried out by external valuers GereldEve to assess the capital value of the hospice’s assets to satisfy the requirement to conduct an impairment review in accordance with FRS 102 – the Financial Reporting Standard applicable in the UK. Assets are reported at historical cost in the hospice’s financial statements.

Pay costs make up over 70% of expenditure at the Hospice. SAS pay contracts and NHS Agenda for Change terms for pay and the continued rise in inflation has continued to impact on the expenditure of 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.

The hospice returned a surplus for the year of £717,312 the strong performance was due to £1,051k received in legacy income along with a large single donation of £200k in the financial year.

Free reserves increased by £746k as of the 31st of March 2025 the total for free reserves is £2,682k (£1,940k 2024). At the end of the financial year reserves represent 5.9 months of expenditure our target reserves are 4 months expenditure.

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It is well known that here is a funding crisis across the hospice sector. Increasing cost pressures are not being matched by increased funding. Like many hospices we expect 2025/26 to be a challenging year, we aim to maintain patient care, trustees have approved a £340k deficit budget for 2025/26. The shortfall is to be addressed in future years by maximising our income, through retail, legacy and charitable trust fundraising along with strategies to increase income from our service delivery. We will continue to maintain tight controls for our expenditure,

Management of reserves

The Trustees annually review our reserves policy to take account of uncertainties in the health of the 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 supplemented from retail, lottery, and fundraising income, including legacies. The aim of the charity is to maintain sufficient reserves to support four months’ running costs to accommodate any unexpected funding issues. The charity holds sufficient cash reserves to meet its immediate short-term needs with the remainder held in investments.

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 2024/25 means we remain cautious regarding any continuing impact on income generation whilst maintaining our ambition to retain our free reserves to four months of projected expenditure in line with the stated policy.

In March 2025, group reserves stood at £6.0m (2024: £5.3m). This is made up of restricted funds £33k (2023/24 £37k), and unrestricted fixed assets of £3.3m (2024: £3.3m) and free reserves of £2.7m.(2024 1.9m) We recorded a surplus in the year on our unrestricted general fund of £875k (2024 £(323)k).

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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

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Independent Auditors' Report Financial Statements

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Consolidated Statement of Financial Activities (Incorporating a Consolidated Income and Expenditure Account)

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Balance Sheet for the year ended 31st March 2025

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Consolidated Cash Flow Statement for the year ended 31st March 2025

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Notes to the Financial Statements for the year ended 31st March 2025

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Notes to the Financial Statements for the year ended 31st March 2025 cont.

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Notes to the Financial Statements for the year ended 31st March 2025 cont.

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Notes to the Financial Statements for the year ended 31st March 2025 cont.

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Our supporters

We would like to sincerely thank all those people who have supported the Hospice during this financial year, with their generous donations, time and gifts in kind. The support we receive makes such a difference to our patients and their families.

Hospice of the Good Shepherd

Gordon Lane, Backford, Chester, CH2 4DG

Hospice:01244 851091 Fundraising:01244 851 811 Lottery:0151 356 8899 Email:[e-mail]

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