Annual quality account April 2024 to March 2025

1 Chief executive’s introduction

Thank you for taking the time to read this statutory quality report, which accompanies our annual report as part of reflecting on care at the trust over the last twelve months. Within the annexes are a series of required declarations, including some statements from partners, but the main report seeks to focus on two things:

• the voices and views of our patients about our services and
• work undertaken to try to ensure that we improve quality of care

During the period from April 2024 to March 2025, our peer review, mortality review and clinical audit programmes have provided valuable insight into that quality of care and have been the source of adjustments and changes made by local team leaders. Care Opinion has offered those local leaders immediate patient feedback on service quality, with over a thousand stories shared. While that has led to some change too, it has reinforced a view that much of the care offered in the organisation is of good quality, consistent with most of the service ratings by the Care Quality Commission who visited us in 2019. During 2025 we will complete a comprehensive board-led review of the quality of all of our services against Care Quality Commission standards to try to update this picture and to learn across the trust from what works well in some parts of our organisation.

Learning is undoubtedly central to our quality improvement work at the trust. Since September 2024, learning half days have become a feature of how we operate. Monthly we stand down much face-to-face patient care, in order to offer a chance for teams across the organisation to consider lessons from incident reporting, external safety reports, their own experiences, and to undertake training and development. This investment of time, and chance for reflection, is a key feature of our learning and education plan for the trust, through which we look to improve safety and quality by knowledge gain and by the chance to focus on better team working and communication, the overwhelming area for improvement when we look across the lessons from what goes wrong in health and care.

In autumn 2024, we made changes to our crisis services at the trust, in order to remove the “age cut-offs” which differentiated who received which service based on someone’s birthday. People over the age of 65 now have access to the same crisis service based on need as the wider local population. This step was long planned but was reinforced by the lessons from a coronial enquiry and issue of a “regulation 28” order. Such orders, whilst rare, remain the focus of board governance of services, and a revised engagement policy to address better the needs of people who lose touch with, or step away from, services will go into effect in summer 2025. Our audit work on assertive outreach care, arising from the enquiry into care in neighbouring Nottingham, has shown the quality of what we provide, in part reflecting investments to expand services in 2023 in Rotherham and 2024 in Doncaster.

During the last year, we have reorganised many of our corporate clinical functions to better deliver on core safety and improving quality. This will culminate in publication in August of our three-year Quality and Safety Plan 2025 to 2028. We had expected to do this sooner, in 2024, but the period of delay has allowed us time to put in place the key infrastructure for implementation, reforming our corporate nursing teams to better align to our aims, and introducing a new computer system (Radar) to make it simpler for people across our organisation to report and to learn from incidents, risks, and other learning events using the patient safety incident response framework (PSIRF) model that the NHS introduced in 2023.

To apply that learning, the trust has to have in place stable teams and good support infrastructure for clinicians who see patients and care for them. We continue to invest in technology, including artificial intelligence (AI) technology, to seek to do that well. Our strong tradition of data security and information governance provides assurance on the integrity of our approach. The biggest step forward with safety of care over the last year has been the huge changes to our workforce. Reliance of agency temporary staffing has almost ceased. Our flexible, bank staffing arrangements transferred to a professional provider, NHS professionals is best able to ensure that we have qualified people working with us when the need arises. And we have hugely reduced vacancies within the trust and begun to see a fall in turnover and improvements in retention. This move to being “fully staffed” matters to care, to ensuring colleagues have time to care, and to helping us to develop teams that can improve quality.

In February 2025, the trust’s board oversaw the creation of a high-quality therapeutic care taskforce of patients, clinicians and managers, who will take forward the promises we made in our strategy that relate to inpatient care. Being an inpatient, whether it is in New Beginnings, Amber Lodge, Magnolia, Hazel, Hawthorn, or within our mental health wards, should be a purposive, therapeutic experience. Patients should only be in that environment for as long as is necessary, with most of our care offered in support of people living in their own communities, neighbourhoods and homes. The taskforce is focused on improving the consistency of care we offer in all places across the trust, levelling up approaches to learn from what works best. Having closed three wards over the past two years, and with a new specialist unit opening in autumn 2025, the trust has the bed base that it will retain to 2028, and major capital investment in Great Oaks in 2025, compliments changes to mental health environments made since 2020 at Tickhill Road and Swallownest Court.

Spreading good practice, learning from excellence, and acknowledging success are of equal importance to our improvement work as addressing preventable harms. The expansion of our awards and recognition programme in 2024, with over 300 people acknowledged for their excellent contribution, forms part of that effort. Grounded Research, the trust’s research and development department, is working ever more closely with each clinical directorate to try and ensure that studies of new treatments and techniques are developed and shared within the trust. Importantly that research and evaluation work includes children’s services at the organisation, with major research studies in parenting taking place as we work to ensure strong support for families, reducing waiting times for child and adolescent mental health services (CAMHS), and to reduce wait times for people awaiting diagnoses and support with potential attention deficit hyperactivity disorder (ADHD) and autism. It also includes work on how we provide care, with expansion of our virtual ward and remote care models, and development of major community-based services like our intravenous (IV) service in Doncaster, which prevents the need for prolonged hospital stays.

Our trust offers a diverse range of services: wheelchair care, expert continence support, diabetes care, emotional wellbeing support for new parents, forensic specialist care, and many, many other services all form part of our all-age community and mental health offer. It can be difficult to summarise that range in any single document. In 2026, all of our teams will increasingly focus on evaluating the outcomes of their care, alongside patients, carers and communities. In 2025 our focus is on core safety standards being consistently delivered. This report is largely focused on 2024 and the first months of 2025, it relates work to prepare for those improvements and it considers how we have sought to ensure good quality care, compassionately delivered, is available in our neighbourhoods, and what we have learnt from that work. I hope it illustrates the commitment of dedicated staff across our services and the openness to change that the organisation is determined to exhibit.

Toby Lewis, Chief Executive, May 2025.

2 Quality and safety at the trust this year and next year

2.1 The voices of our patients: Care Opinion and complaints

During 2024 we have changed how we hear from, and respond to, patient feedback. Previously, such feedback was “managed” by central teams, and the response was often slow, if very deliberate and professional. Our feedback system was paper based.

Now we are able to address complaints in a timely fashion, having reorganised our corporate teams: and we have adopted a range of techniques to collect and listen to patient feedback. This includes specific studies of views among patients who are detained under the mental health act, continued use of the national patient experience survey method deployed in Talking Therapies, and use of Care Opinion to help people to share their stories directly with us, and to share those same stories with anyone else, someone who may be considering seeking our care can understand the experiences of other people doing so. We see this as a major step forward, and it is a source of great insight for teams running services and providing care.

Patients’ voices are now at the centre of the way in which the trust is managed. Decision-making meetings and accountability processes in how services are evaluated rely on this feedback, with equal weighting to matters of finance, national target delivery and workforce transformation.

2.1.1 Care Opinion

A huge success this year has been the successful rollout of Care Opinion. It is amazing to think already our Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) stories have been viewed over 35,000 times. We are confident that Care Opinion provides a much-improved source of information than the previous Your Opinion Counts (YOC) system, mainly due to the transparency of the stories, which are all publicly available to view on the Care Opinion website; this can be found by searching for “RDASH Care Opinion” on any web search engine, like Google.

More than 80% of the stories are positive which is reassuring to read and hear, but we welcome those which are critical, approximately, 10% have been mildly or moderately critical. These stories give us the building blocks to improve our services and to look at them with a fresh and independent lens.

We have reviewed Care Opinion to look at what our patients are telling us and some examples are quoted below. When combined with the delivery of the key performance measure, this provides us with a comprehensive picture of performance within RDaSH; whilst numerical data such as response times, access rates and service usage are important, the positive customer feedback adds an invaluable qualitative layer. This provides insight into the impact of those measures on service users, their families and carers.

Within physical health services the virtual ward is a community-based initiative providing patients with care at home rather than requiring hospitalisation. Occupancy rates have remained consistently above the 80% target on the 1st and 30th day of the calendar month and in March 2025 remained above on all 3 points of the calendar month thus demonstrating strong and sustained performance.

In children’s services, the trust successfully met the target for the second consecutive year with regards the number of children and young people (CYP) receiving one clinical contact within a 12-month rolling period (LTP04), with 9,791 CYP accessing services, surpassing the target of 9,783. The children’s eating disorder service performed well, with 100% of the most urgent cases seen within one week across the full year and 93.18% of referrals seen within four weeks, just short of the 95% target.

For community mental health services for adults and older people (LTP01), the trust continued to exceed the target, with 10,005 individuals receiving two clinical contacts within a 12-month period, exceeding the target of 8,533. This reflects effective engagement and care provision, crucial to alleviating pressures on inpatient services and promoting recovery in the community.

Care Opinion quote: “I felt alone, worthless, worried, anxious, not good enough and guilty after I had my baby. I have had a wonderful perinatal health visitor named Nicola by my side and she has been a breath of fresh air. I’d have been lost without her and wish I could have kept her attendance much longer as her knowledge and expertise was far more than the role she was doing, she made me see my worth again and see things from a different and more healthy perspective. I can’t thank Nicola enough for her time, patience and guidance and I will be forever thankful for her”.

The joint perinatal and maternal mental health service (LTP03), in collaboration with Sheffield Health and Social Care, exceeded expectations, with 830 women receiving support during the year April 2024 to March 2025, surpassing the target of 617. This service remains a key focus for the year ahead, with a task and finish group dedicated to maintaining high performance levels.

While the trust made strides in improving access to talking therapies (LTP02a), demand still fell short of the year-to-date expectations despite ongoing efforts to engage diverse communities and strengthen referral pathways. We are particularly trying to focus on communities who really need our support in accessing talking therapies such as older people, people from world heritage communities and people with a level of learning disability. That said, the performance in quarter 4 of the year April 2024 to March 2025 outperformed the access rates for the same period in the year April 2023 to March 2024 demonstrating that the service is starting to see a gradual and sustained increase in the number of patients entering treatment. There remains a significant number of further actions to embed and sustain this change whilst also further building capacity and demand to deliver the target as we move into the year April 2025 to March 2026. For reliable recovery (LTP02b), year to date performance was 47%, just short of the 48% target, but still reflecting sustained improvement from the November 2024 position. Reliable Improvement for our talking therapies services (LTP03c) performed well achieving above the 67% target.

The metric measuring the number of SMI patients having a full annual health check (LTP08) is a Place target and, as such, data is released nationally a quarter in arrears therefore data to demonstrate achievement of this metric is not available. Internally, performance is measured against a cohort of patients with forming a register that we have internal oversight of based on quality outcomes framework (QOF) code. Performance against this measure, excluding declines, is reporting 79.36% against a 95% target. Continued focus is being placed for the year April 2024 to March 2025 on reducing the number of patients who decline elements of their health check such as BMI and blood tests. A key piece of work has commenced and is ongoing through the early part of the year April 2025 to March 2026 with GP surgeries in the three localities to cleanse and cross-reference these internal registers with those held by GPs with the goal of having 1 register per place which can be kept accurate and up to date.

A notable challenge throughout the year April 2024 to March 2025 was the high number of inappropriate out-of-area placements (LTP05). By the end of March, 19 patients remained placed outside the RDaSH footprint, and we have ranged between 7 and 37 over the year. A range of improvements were introduced, but there is a recognition of significant work to do. The trust is fully committed to addressing this issue and will be a key focus as we go into the year April 2025 to March 2026. A high-quality therapeutic care task force was launched in February 2025, acting as a think tank for quarter 1 in the year April 2025 to March 2026 to start significantly reducing out of area placements placement from quarter 2.

Neurodevelopment services (LTP09) continue to remain challenging due to the high number of referrals into these services and lengthy waiting lists in both our adult attention deficit hyperactivity disorder (ADHD) and child and young people (CYP) neurodevelopmental services remain high. While a national issue, RDaSH are prioritising this work on this due to the impact on patients and their families of lengthy waiting for assessments. The care groups have redeveloped the trajectories to build in nuances that were not already accounted for regarding capacity within the service to support with the delivery of the four-week wait by April 2026 however 4,518 (3,668 waiting as at March 2024) Adult’s remain on the ADHD waiting list and 2,872 (2,823 waiting as at March 2024) CYP remain on the neurodevelopment (ADHD and autism) waiting list as at the end of March 2025.

2.1.2 Complaints

We acknowledge that in the year April 2024 to March 2025 we did not meet the timeline standards that we expected in responding to all our complaints. We failed our complainants and their families in providing an answer to their concerns against our internal targets. But we have now altered our processes and approach and are confident of succeeding against time-commitments for response in the year ahead.

2.1.2.1 What have we achieved?

As of 31 March 2025, we have responded to all outstanding complaints from the year ended and from previously.

We have appointed to the new posts of band 5 patient safety, carer and community officers, to manage complaint responses and enable closer working with clinical directorate teams.

2.1.2.2 What have we learnt?

The significance of a robust, compassionate discussion, in as soon as near to the complaint being made, with the complainant to ensure a proportionate, succinct and timely response. It is essential that patients are engaged as equal partners in their care, and the voice of their family and carers is actively heard.

Examples of service improvement initiatives as a result of complaints include:

• patient involvement: we have more work to do to ensure that patients and their families are involved in planning their care. This really is important to accompany RDaSH promise 16 and our move from care programme approach (CPA) to patient related outcome measures (PROMs), such as dialog and Dialog+
• out of area placement: we are working to improve communication when transferring patients between services to ensure transparency and continuity of care
• training and development: enhancing the knowledge of staff in relation to the individualised needs of neuro diversity within mental health services is important and the focus of work in 2025 will be on support to healthcare assistants to have additional training in this area

2.1.2.3 What is next?

• Every quarter, the chief nurse and his team will produce a meaningful report on the changes made as a result of patient feedback, including complaints.
• We will continue to focus on timely delivery of high quality, compassionate complaint responses within our 30 and 60-day target.
• We will be using the new Radar system to capture and maximise the sharing of learning from complaints.

2.2 Community voices: volunteers

The trust’s strategy focuses on ensuring that we are open to the views and feedback of people across the community, not as ‘one-offs’ but on a consistent routine basis. One important part of that work is supporting more, and more diverse, volunteers in our organisation. They can offer us insights and perspectives on care and provide time to care for our patients. Under promise 3, we committed to “work with over 350 volunteers by 2025, to go the extra mile in the quality of care that we offer”.

2.2.1 What have we achieved?

• We have recruited 245 active volunteers within all areas of the organisation and have 60 volunteers actively going through recruitment checks.
• Several volunteers have progressed from volunteer to an RDaSH career.
• We are migrating all volunteers onto electronic staff record (ESR) from 1 May 2025 which will benefit volunteers having access to the same workforce services as staff have and will allow the trust to collect more valuable information.

2.2.2 What have we learned?

• There is a real demand in our communities for people seeking career-based volunteering and one-stop shop road shows in each place locality are a great approach to volunteer recruitment: we then need to be much faster in converting people into roles on the ground.
• Working with volunteers is new to many services and colleagues, who also need support to onboard people and establish new ways of working.
• Working alongside community organisations can avoid a ‘contest’ for volunteers; many of our volunteers also offer their time to partner organisations.

2.2.3 What is next?

• By October 2025, we intend to reach our standard of having 350 volunteers in the organisation, which requires an expansion of roles in North Lincolnshire and Rotherham.
• We will evaluate the experience and impact of volunteering as more clinical services include these roles within their teams.
• We will ensure that we listen to volunteers as a rich source of feedback and a “fresh pair of eyes” on the quality of care we offer.

2.3 Trust led reviews of quality

2.3.1 Results of our peer review process

Quality peer reviews are an essential part of how we both assure ourselves of the quality and safety of our inpatient areas and how we learn from each other. It means that we have been able to provide support where needed in a variety of ways, whether that means speeding up an estates repair or providing additional specialist advice to staff. This is now our second year of undertaking the quality peer reviews and this year we have introduced out-of-hours reviews to complement the in-hours reviews, along with securing the expertise and independence of our colleagues from People Focused Group (PFG) to our review teams. This has provided a hugely valuable source of feedback from a patient perspective.

2.3.1.1 What have we achieved?

All inpatient wards, both within mental and physical health, have had an in-hours review and we are halfway through the process of visiting out of hours reviews. By March 2025, all 16 inpatient areas had an in-hours review and 7 out of hours reviews have taken place.

The peer reviews focus on core standards, aligned to Care Quality Commission domains, and visited teams receive a detailed report of observations and are encouraged to provide clear actions for change as a result.

2.3.1.2 What have we learnt?

We have found some areas of good practice that are consistent across our wards:

• staff embody our values and there is strong evidence of staff being caring, empathetic and responsive to patients. Staff are visible and accessible to patients on wards. This has been reported by patients as well as being witnessed by the review teams
• staff are generally confident in resolving patient concerns and complaints themselves but know how to escalate if necessary
• safety huddles, as a means of reviewing and learning from incidents in an open and transparent way, are valued by staff and effective. Staff have shown a good knowledge of how to report incidents

However, there were also consistent areas in which we find a need for improvement:

• the voices of patients are not always evident in care plans, even where patients have said that they have been involved in writing them. Sometimes, care plans are generic and not personalised. Not all patients had been offered or received a copy of their care plan
• risk plans are not always updated frequently enough
• activities available to patients, particularly in evenings and at weekends, are insufficient
• staff on several wards reported that they did not feel that staffing numbers necessarily reflected the acuity of the ward; qualified staff in particular felt they were not always able to take breaks

These feedback themes, the positive and areas for improvement, are also reflected in our initial culture of care assessment within mental health wards, undertaken in February and March 2025. In our report into quality in twelve months’ time the action taken as part of this work will be discussed. The trust has used the national methodology for Culture of Care but has incorporated patient and carer views into our process, consistent with the trust’s promise 5 approach to co-production.

2.3.1.3 What is next?

• Work is ongoing to improve record keeping ensuring that the patient voice is clear in the care plans and that risk assessments are consistently updated.
• We are reviewing how activities are provided and how volunteers can play an active part in this area.
• There are plans in place now to move the recording of the quality reviews onto the new risk, quality and compliance system, Radar. This will make the process more efficient and provide teams with nearer to real time results.
• We will now shift and expand our peer reviews into our community services throughout April 2025 to March 2026, including children’s services.

2.3.2 Patient reported outcome measures: DIALOG+

We have undertaken substantial preparatory work to meet promise 16: focus on collating, assessing and comparing the outcomes that our services deliver, which matter to local people, and investing in improving those outcomes, year on year. This work will be the basis for our Quality Improvement work over the period to 2028.

2.3.2.1 What has been achieved?

• The introduction of patient reported outcome measures (PROMs) including Dialog+ training will be completed by December 2025. The reporting of patient outcome measures from the implementation of these changes is increasingly visible within the trust. This data is live for teams to use in service and with patients to demonstrate the impact clinical interventions have on patients personalised goals and care plans.
• The focus of work in 2025 and 2026 will be on ensuring that trained colleagues use the approach to its fullest potential. Dr Jude Graham, the trust’s director of psychological professions and therapies is championing this work over the coming twelve months. The outcome measures will enable services to monitor patient satisfaction scores on specific elements of life and ensure consistency in holistic care, evidencing that the interventions used are right for patients, regardless of the service they are accessing.

2.3.2.2 What has been learnt?

• There is real commitment to replacing the care programme approach (CPA) with the new system, and a desire to learn among our teams.
• We need to provide more active support to translating that training into practice and to support individual teams to adopt the methodology.
• More support is needed to ensure that the most inclusive view is taken of patient’s needs and circumstances, including the role of carers.

2.3.2.3 What is next?

• The programme to ensure take-up and best use will be resourced through the trust’s Change and Improvement team in the coming twelve months, with clinical oversight as described.
• The development of quality outcome measures across other services not covered by the DIALOG initiative will be jointly led through clinical members of the executive in readiness for the year April 2026 to March 2027.
• The leadership of the trust more widely will spend time reflecting on how best to use outcome measures as a route to quality improvement: in contrast to more traditional key performance indicators where persistent improvement is often expected.

2.3.3 Changes made as a result of our clinical audit programme

The trust’s board is clear that clinical audit work has to have the same primacy and priority as other forms of audit, such as internal and external audit. There is more work to do to achieve this aim, but a revised Clinical Audit Plan for 2024 and 2025 has seen progress. The current governance of that work is under review, to support arrangements whereby Clinical Effectiveness team meet monthly with representatives that includes the care group directors of nursing and matrons. This supports audit activity, agrees actions to improve the quality of healthcare provided in relation to key audits, and proactively addresses actions.

The main levers, as a result of the learning, are threefold:

• changes to the design of aspects of the SystmOne electronic patient record,
• updates and amendments to clinical policy
• education at service level by the clinical leaders

Examples of learning from specific audits are shown below.

2.3.3.1 Audit: health care record keeping baseline (physical health and neurodiversity only)

Actions and learning:

• trust Mental Capacity Act lead to deliver a bespoke training session that covers the required actions from both this audit and the 360 assurance audit, session to be available on the induction for new and existing members of staff
• changes to wording templates on SystmOne to simplify recording of consent and to record the format of how patient wishes to receive letters
• team leads asked to ensure that record keeping is captured as part of ongoing supervision

2.3.3.2 Audit: management of a secluded or segregated patient policy re-audit

Actions and learning:

• care groups to ensure individuals understanding and knowledge is in line with the code of practice
• visual display board outside seclusion to prompt staff when reviews are due or staff allocated each shift to co-ordinate the seclusion episode and ensure timely reviews are undertaken
• re-issue checklist to all in patient areas and care groups, for completion following each period of seclusion. For submission to the Local Mental Health and learning Disabilities (MHL) Monitoring Group for oversight and escalation to both care groups and Mental Health and learning Disabilities Operational Group
• review the seclusion visualisation to incorporate the reason why a search was not undertaken prior to the patient being secluded

2.3.3.3 Audit: national audit of inpatient falls (NAIF)

Actions and learning:

• creation of a post falls SystmOne template
• all patients will have a lying and standing blood pressure measurement taken following a fall resulting in femoral fracture, this will be completed as part of the multi-factorial risk assessment (MFRA) review process and recorded within SystmOne
• staff who complete a delirium or cognitive assessment will record the date and time of the assessment within SystmOne, if this assessment is not deemed applicable this must also be documented
• staff attending to the fallen patient will record the manual handling method used to move the patient within SystmOne and on the IR1
• staff attending to the fallen patient will record the date and time of the transfer to the acute hospital in SystmOne and on the IR1 for reference
• all falls resulting in femoral fracture will be discussed at the incident review meeting

2.3.4 Learning from deaths

The Mortality Oversight Group (MOG) meets on a weekly basis and all deaths recorded by the trust are reviewed in this group.

As per the patient safety incident response framework process, a decision is then made as to how the deaths will be reviewed, with only the most serious resulting in full patient safety incident investigation (PSII). Those requiring investigation but not full PSII are undertaken as a structured judgement review (SJR). All remaining deaths are reviewed within the relevant care group.

Unless deemed appropriate for a PSII, all deaths of patients with a learning disability result in a structured judgement review.

During the period April 2024 to March 2025, there were 608 deaths reported on the Rotherham, Doncaster, and South Humber NHS Foundation Trust mortality Ulysses system.

The majority of deaths were not deemed to require a structured judgement review, but in addition to the completed structured judgement reviews above, the trust has a further ninety such reviews to complete (a backlog) by August. Over the period reported in the table below no structured judgement review has resulted in serious adverse findings about the care offered by the trust.

There have however been a number of recommended areas for focused action, either to share good practice or to take additional action to address weaknesses of process.

2.3.4.1 Strengths identified

• Good physical health monitoring particularly around patients prescribed antipsychotic medications.
• Timely documentation in care records.
• Good dysphagia (swallowing problems) care plans and appropriate reviews with risk assessments updated to reflect changes.
• Timely communication with other professionals to address identified issues and supportive of patients’ needs.
• Good multidisciplinary team and person-centred approach to patient care.
• Good timely and responsive assessments following initial referral for people with learning disabilities.

2.3.4.2 Areas for improvement

• Documentation of capacity using appropriate form available on the electronic patient record. Staff have been reminded to use the standard trust forms to record capacity status and best interest decisions. Additional learning has also been provided through learning half days.
• Risk assessments not always reflective of most up-to-date care plans. Staff have had educational sessions on risk assessment and team manager’s having been reviewing documentation.
• Lack of documentation of carer or family involvement. There have been education sessions on consent to share information.
• Hospital passports or traffic light documents for people with learning difficulties not being updated and added to the electronic patient record to reflect changes in health or social circumstances. Information about hospital passports has been cascaded throughout the learning disabilities service.
• Entries added to patient records being ambiguous of involvement from professionals and not identifying purpose of the contact. Training has been provided on accurate record keeping.

2.3.5 Learning from incidents

The table below sets out the incidents reports in the trust during the past year. Of these 19 are patient safety incident investigations (PSIIs), within which some relate to potentially permanent harm.

The board has twice reviewed the learning and actions arising from those harms, with one report yet to be completed owing to the involvement of multiple partners and agencies and the use of independent investigatory resources.

Most patient safety incident investigations reported do relate to the adult mental health directorates within the trust, and within that suspected suicide. Whilst suicide associated with the trust’s service offer or patients in our care is consistent, sadly, with similar sized services and prior years, the organisation remains committed to taking all steps possible to support preventive action and to work with households and with our own staff affected.

As outlined in this report, the trust continues to refine its approach to patient safety incident response framework, and that work will be undertaken mindful of the patient, carer, race equality framework (PCREF). Incident reporting analysis in line with protected characteristics of undertaken, as is protected characteristics analysis for use of the Mental Health Act. In this latter regard the trust displays some similar patterning to other providers, having a slightly higher rate of detention for black citizens, whilst the wider black and minority ethnic data analysis is proportionate to local census data.

Nine themes are identified as common learning across the patient safety incident investigations discussed within the board as follows:

1. communication both internally and externally.
2. our standards of record keeping falling below the required standard
3. that our care plans were not in these instances personalised and did not reflect the person’s needs
4. it certainly felt significant to the author, that we did not hear our family and carers, when we did, that did not always translate into the care we should have delivered. Certainly, it was not recorded as it should have been as relating to theme 2
5. we let down the people who were waiting to see mental health services and in at least one of our accident and emergency departments
6. our work with people who disengage with our service needs a cultural shift and the policy change has been a starter for this
7. our risk assessments need to be better at formulating the contextual risk and aligning that with other personal factors and stressors such as physical health deterioration
8. our physical health offer and intervention must improve for people experiencing an acute relapse of their mental health
9. our support to people who are in crisis, whether in the community or in seclusion needs to be timely, multi professionally led and always consistently applied. Communication and their rights must be shared with the person we are caring for, irrespective of gender, race, religion or where they are located

In July 2025, the board will receive a report on learning within the organisation, in its annual learning and education focused board meeting. We would expect to agree there additional actions and oversight to ensure that the changes agreed as part of patient safety incident investigation reports are truly embedded not only within the settings where the harm has arisen but across the organisation.

It is important to recognise changes made already as a result of patient safety incident investigation work, and those include:

2.3.6 Developing research

The trust achieved delivery of 1091 participants in National Institute of Health and care Research (NIHR) Portfolio trials. This number of recruits to portfolio trials was against a target of 900 in April 2024 to March 25. The trust has consistently exceeded its target for April 2024 to March 25 as it has done in previous years.

There is a diverse mix of recruitment to trials in Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) across a range of specialities and patient groups, with notable performance regionally in terms of Health Services Research. The IGLoO trial which focuses on returning staff to work after being off on long term sickness absence has been the largest contributor to this position.

Our emphasis remains on the ability to have a “research ready workforce” through development of Research and Innovation (R and I) capacity and capability. This is achieved via a range of projects such as the development of a number of groups as communities of research practice; the use of learning half days to promote training and development linked to research such as good clinical practice training; the use of validated tools for assessing readiness such as the state of organisational readiness (SORT) tool; and individual development programmes such as the principal investigator training programmes or the senior research leader programme.

As an organisation we have sought to measure the quality of our research systems and processes and be held to account in terms of the best standards globally. To that end we have proactively put ourselves through the inspection processes set out by the International Accrediting Organisation for Clinical Research (IAOCR) at two levels. One in relation to a site accreditation, and the second in relation to workforce accreditation. We have achieved gold standard in each category, which represents a very basis from which to develop our research work.

The trust has consistently championed patient and public engagement in the design and delivery of all of its research and innovation (R and I) work. As well as having a number of active public contributors helping us both on the ground in individual studies, as well as helping lead how research and innovation is deployed, we have sought to go further in relation to inclusion in research with a number of leading-edge examples. Two such examples are our Sponsorship of the PAMHOP trial with the University of York which focuses on the mental health of older prisoners, and our successful bid to host the Ethnic Minority Research Inclusion network (EMRI) network for the region.

The delivery of the forthcoming research and innovation plan will focus further attention on how we ensure that across the trust we implement successful trial outcomes, and adopt innovations at scale within the organisation. This is part of the work to achieve promise 28 in our strategy, which reflects the need to give patients from all backgrounds and traditions access to research-led care, and the opportunity to participate in research.

2.4 Key safety measures used for assessment during April 2024 to March 2025

The trust relies on data within an integrated quality performance report (IQPR) in its work to assess care quality. This report was first used in 2023. The explicit intention is to use more data, and more near live data, in monitoring safety. There is more work to do to ensure that these measures reflect the full range of services provided by the trust and support a focus on highest risk issues. The move to a directorate management model within the trust will help us to do this: “think directorate” is a focus for the year ahead.

In 2024 and 2025 the focus of effort has been on the following measures:

• number of patients aged over 16 years admitted with a completed venous thromboembolism (VTE) assessment: we achieved 94% compliance. Work is ongoing to develop the documentation processes around venous thromboembolism assessment but also ensure that the assessments are acted upon, and the appropriate prophylaxis is prescribed within the national guidance. We are concerned to ensure that where the responsible clinician is not medical or does not have prescribing rights, there is no delay to care for “physical” health needs
• number of wards reporting (in hours) fill rate for registered staff on nights or days above 90%: We achieved 90%, with a minimum of 1 registered nurse always present in charge of the shift
• number of absent patients without leave from low secure units: there are no recorded examples of this throughout the year
• number of detained patients absconding from acute adult and older people’s inpatient mental health units: no significant harm is recorded from the 25 incidents that occurred. That level is a reduction compared to April 23 to March 2024. Almost half such instances related to patients not returning from section 17 as planned, often for relatively short periods of time
• ligature incidents moderate or above all inpatient areas: 12% of ligature incidents were rated in this manner in the past year and this included several instances in recent months of the same patients repeatedly attempting to ligature. The trust has invested heavily to improving our environments, and is also rolling out reducing restrictive intervention (RRI) champions in each ward to seek to take a more proactive approach
• racist incidents against staff members: our aim was to increase reporting and whilst 46 examples were recorded, we suspect that in practice numbers and examples are higher. In 2024 we launched our appropriate behaviour policy, intended to take specific action against carers, visitors or patients where persistent racist or other discriminatory behaviour occurs. Our latest workforce race equality standard (WRES) data contained an increase in the proportion of colleagues reporting positive improvements. Whilst the results are showing positive signs of improvement, we recognise further work is required
• episodes of seclusion, an internal multi-disciplinary team within 5 hours: We recorded 62% against a target of 100%. The risk of our non-compliance with this safety target, continues to be highlighted on the risk register for each care group. The chief medical officer also writes to doctors who do not meet this standard to understand the reasons why this hasn’t been done
• inpatients have a completed malnutrition universal screening tool (MUST) assessment: our target was 100% achieved inside a time window, and the actual performance was 70%. During the second half of April 2024 to March 2025 there has been a substantial improvement owing to malnutrition universal screening tool being included in the admission checklist, alerts being added to inpatient records. Work to deliver this “always measure” will continue
• inpatients commenced with falls assessment within 72 hours: the target was 100%, the actual was 75%. The achievement on this parameter as of December 2024 was 92%, we are in April 2025 to March 2026 lowering the target to 12 hours, as we know our most vulnerable of patients will fall within 12 hours of their admission and hence the need to make this an “always measure” to improve the quality and safety of care our patients receive when coming to anyone of our inpatient wards

2.5 Major matters considered by our quality committee on behalf of the board

The Quality Committee works to support the board in its oversight of care quality at the trust. During April 2024 to March 2025, the committee is transitioning from involvement with a large number of operational issues into a focus on the quality and safety priorities agreed by the trust’s board in its three-year plan. During the past twelve months, the majority of the committee’s time has focused the following areas of enquiry and assurance.

2.5.1 Patient safety reports

These were received regularly and provide an overview of the key incidents, trends and learning dissemination. As is outlined elsewhere in this report this work will change markedly in April 2025 to March 2026.

2.5.2 Staffing

We supported our reduction and attempt to reduce agency usage to zero, by improving safer staffing compliance and transitioning to NHS Professionals as the only source to seek additional staffing, unless there was a direct risk to safety. Our review of our significant cultural and governance shift has seen no adverse impact on patient or service safety.

This work has included review of:

• safe staffing reports: inpatient and community settings providing ongoing oversight around our safer staffing levels, triangulating this against patient safety incidents, complaints, mandatory training compliance and sickness
• annual six-monthly safe staffing declarations: the committee approved these, reviewed compliance with national standards.
• the robustness of quality and safety impact assessment (QSIA) assessment, ensuring that our clinical reviews were robust and multi professional. Ongoing review of benefit realisation is monitored via the quality and safety impact assessment key performance indicators (KPIs) to alert to any concerns or areas to share more widely.

2.5.3 Focused work of improvement

The committee has sought to focus time and attention on complaints management. The remedial improvement work required intervention from the chief executive to address persistent failures to deliver. During quarter 4 (January to March 2025) significant improvements have been achieved, and the Nursing and Facilities directorate needs to sustain those improvements during April 2025 to March 26.

Resuscitation reporting and service was transferred over to nursing and facilities following a series of concerns with audit and compliance, a remedial action plan, external support and our skilled resuscitation lead returning from maternity leave has seen sustained improvements.

Risks associated with the backlog of structured judgement reviews has been monitored. Other areas discussed within our reporting compliance with learning from deaths policy and oversight of the received regulation 28 into the organisation in September 2024.

2.5.4 Patient safety incident response framework

Detailed work in quarter 3 and quarter 4 has focused on altering our initial approach to the patient safety incident response framework (PSIRF). The revised approach was agreed in May 2025 and reflected an overhaul of the governance flow and management of incidents. These changes should be assisted by the introduction of Radar, and internal audit will provide the committee and board with an independent view in quarter 2 in April 2025 to March 2026 of progress.

2.5.5 Learning from elsewhere

The quality committee has considered in detail lessons from the recent Greater Manchester and Nottinghamshire reviews, this has included benchmarking against the report into Greater Manchester and Nottinghamshire, assessing relevance and implementation of recommended actions. Whilst an interim view of the assertive outreach and out of area placement recommendations from Nottingham have been considered, until the trust has completed further work on the revised engagement policy it is premature for the board to consider the full range of residual risks associated with the learning from this enquiry.

2.6 Meeting our priorities in April 2024 to March 2025

2.6.1 Priority 1

2.6.1.1 What we said we aimed to achieve

• Maximise the impact of use of short message service (SMS) and digital to gather feedback.
• Introduce, develop and evaluate Care Opinion as our main mechanism for gathering feedback from people in our communities’ using services: this will ensure much faster and wider visibility for our employees of feedback from their patients.
• Each quarter, the clinical leadership executive will discuss and act on a summary of feedback gathered through these methods.
• In early 2025, patient feedback will become a key measure within organisational management of its directorates within the delivery review process.

2.6.1.2 What have we achieved?

• The use of SMS (text messages) has been rolled out across all Talking Therapies services and is now being used elsewhere.
• Care Opinion has been rolled out across all our services, with managers at team and service level responding directly to this feedback to provide a more personalised and timely response. iPads are being used in some areas to support gathering feedback and paper-based options are being retained.
• A cycle of analysing responses is in place, but there is further work to do to make this systematic at trust-wide level. The board, together with integrated care board leaders, reflected in February 2025 on lessons to date and opportunities for the future.

2.6.1.3 What have we learned?

• The support of very senior leaders, including the chief executive and chief nurse, at the outset enabled Care Opinion to be well received across the trust and to achieve roll out at this pace.
• Monitoring licences of care opinion have been made available to Healthwatch, integrated care boards and Care Quality Commission to support ongoing assessment of the trust, although anyone can publicly view all our stories on Care Opinion.
• Further work is being undertaken with uptake in older people mental health, forensics and learning disabilities services in order to be inclusive of these patient groups. The trust is liaising with similar trusts to learn from their experience, and this will be ongoing in 2025.

2.6.2 Priority 2

2.6.2.1 What we said we aimed to achieve

• The safety plan’s successful implementation will demonstrate improvements in key measures of psychiatric and physical care, including timely Mental Health Act (1983) rights compliance, consenting, malnutrition universal screening tool (MUST) assessments and venous thromboembolism (VTE) screening.
• The safety plan work will also see us improve the pace of assessment in community pathways, especially where urgent referrals have been made.
• Our quality plan implementation will see improvements initially in three areas: at risk mental state (ARMS) services as part of early intervention in psychosis (EIP), work to improve toilet training among children and young person’s teams’ client groups, and improved speed of wound healing in district nursing services.

2.6.2.2 What have we achieved?

• Work on improving the measures outlined, both in terms of safety and quality, has progressed: work on consent and Mental Health Act compliance is nearing completion.
• We have failed to publish or finalise our quality and safety plan in the year but it was agreed at the board in May 2025, significant work is now needed to deliver the first year of the plan and this is reflected in the objectives of senior leaders and in the priorities for 2025 and 2026 outlined in this report.

2.6.2.3 What have we learned?

• The architecture of quality and safety at the trust required complete renovation. Moving from an assurance mindset, often focused on audit and policies, to a data driven delivery mindset is a significant change.
• Delivering always measures (100% delivery) is a different matter than continuous improvement on a lower level key performance indicator (KPI).

2.6.3 Priority 3

2.6.3.1 What we said we aimed to achieve

• To deploy our inpatient improvement plan in year, using external expertise to assess our progress, whilst working with the collaborative to ensure that we continue to learn from local partners.
• To implement our safe staffing reporting improvement measures, reducing use of temporary staffing, staff sickness, and filling vacancies in the organisation.
• To ensure all inpatients have a personalised care plan.

2.6.3.2 What have we achieved?

• In February 2025 we launched our inpatient improvement work, described elsewhere in this report, which is intended to raise standards in our inpatient care.
• In February 2025 we began work on our self-assessment against the Care Quality Commission key lines of enquiry, to provide board oversight of whether the services we deliver are safe, caring, responsive and effective.
• We have created clear internal processes around Safer Staffing, including monthly review processes to provide oversight, challenge, and review of rostering periods.
• From October 2024, we transitioned to NHS Professionals (NHSP) for the provision of our bank workforce. By transitioning to this and with tight controls in relation to agency spends, we have not required agency nurses for over 7 months. Clear processes are in place to approve agency use, with a fundamental principle of ensuring patient safety if future agency workers were to be required.

We are part of the culture of care national programme; however, we are taking a personalised approach linked with our strategy as agreed with the National Culture of Care Director. We have worked with the national patient experience lead for culture of care, in terms of exploring a patient led version of the tool, and local patient experience partners to create a patient version. We have completed a baseline assessment for culture of care, with feedback from patients and staff in all areas including adult, older peoples and forensic services and are using the results as part of our high-quality therapeutic care taskforce work.

2.6.3.3 What have we learned?

• We have needed to step down other processes and work to re-prioritise to focus on the care improvement work outlined, including the to-be completed work to ensure that personalised care planning is in place.
• We knew that in April 2023 to March 24 there had been assurance gaps in relation to safer staffing, and implementation in April 2024 to March 2025 has required additional work. In April 2025 to March 2026 we will need to work to ensure that application of mental health optimal staffing tool (MHOST) supports multi-professional staffing assessment and that non-ward areas are also our focus.

2.6.4 Priority 4

2.6.4.1 What we said we aimed to achieve

• Identify the route to meet our March 2026 four week wait guarantee, making initial progress in child and adolescent mental health services (CAMHS), community nursing services, and memory clinics.
• Waiting times for children and adult neurodiversity services will reduce significantly.
• Work to deliver our aim of no inappropriate out of area placements.

2.6.4.2 What have we achieved?

• We have delivered promise 19 which looks to eliminate out of area placements, including first inappropriate out of area placements. We have focused on improving a number of areas. This has included establishing a complex clinically ready for discharge forum with all 3 local authorities in October 2024 and there has been a marked improvement in all 3 Places. We have prioritised work on the section 136 suites, with the successful introduction of a 24-hour metric which means suites remain open. We have relaunched the 3 monthly multiagency admissions and discharges events (MADE) in each care group facilitated by patient flow and attended by ward staff, local authority and integrated care board colleagues. This is an opportunity to discuss the trusts acute, older adult and paediatric intensive care unit (PICU) pathways from a system level to improve flow through the pathway and the experience of those who access our services.
• Progress has been made in all care groups regarding waiting times for routine referrals. This has supported a large piece of validation work to ensure that all waits recorded are validated. CAMHS services have been the forerunner for this work and have achieved a maximum 4-week wait in North Lincolnshire and Doncaster, except in cases of patient choice.
• Neurodevelopment services within children’s and Attention deficit hyperactivity disorder (ADHD) services in adults have received additional investment and are working towards trajectories to allow achievement of a 4-week wait in April 2026 to March 2027.
• Within promise 14 we gave a commitment to assess people referred urgently inside 48 hours from 2025 (or under four where required). This element of the promise is behind plan for achievement from 2025. Initial scoping has been conducted which has highlighted inconsistencies with referral categorisation across services, with 34 different definitions of urgent referrals being used across our services. Standardised urgent referral pathways trust-wide will be implemented, inclusive of all teams and service areas; the extension of operational hours to allow for 7 day per week triage and assessment and a full information system redesign.

Whilst delivery cited above is modest, the improvements in systems made during April 2024 to March 25 leave us well placed to succeed in April 2025 to March 2026. The operational plan for the organisation in that year relies on delivery of both promises, and the board is fully engaged with overseeing delivery, alongside the council of governors.

2.7 Implementing strategic objective 4

Including culture of care critical to the work of improving care is the organisation’s commitment to ensure that care within our wards is of sufficient therapeutic value. During April 2024 to March 2025, we have focused on listening to patients and to our own staff in understanding what works well currently and what needs to improve.

Within promises 18, 19, 20, 22 and 23 of our strategy are commitments to try to alter how we deliver care in order to improve our services. These are being taken forward mindful of national initiatives and reports which focus attention on inpatient mental health quality, drawing on lessons from enquiries, research, and feedback elsewhere.

The intention is that we move to seek to respond to the many and varied ideas by applying a consistent improvement methodology to ward-based care, which simultaneously encourages local innovation and seeks to apply consistent standards across our wards. We would expect that this will result in changes to how we work within our wards, the documentation that we use, and how we work with local authority partners, in particular.

In order to anchor our improvement work in a balanced suite of qualitative and quantitative measures we are working to ensure that we:

• meet standards consistent with Royal College of Psychiatrist accreditation
• deliver the core safety standards contained in our quality and safety plan
• improving our self-assessed delivery against the Culture of Care domains published nationally. These domains are:
  • lived experience: we value lived experience, including in paid roles, at all levels of design, delivery, governance and oversight
  • safety: people on our wards feel safe and cared for
  • relationships: high-quality, rights-based care starts with trusting relationships and the understanding that connecting with people is how we help everyone feel safe
  • staff support: we support all staff so that they can be present alongside people in their distress.
  • equality: we are inclusive and value difference; we take action to promote equity in access, treatment and outcomes
  • avoiding harm: we actively seek to avoid harm and traumatisation, and acknowledge harm when it occurs
  • needs led: we respect people’s own understanding of their distress
  • choice: nothing about me without me, we support the fundamental right for patients and (as appropriate) their support network to be engaged in all aspects of their care
  • environment: our inpatient spaces reflect the value we place on our people
  • things to do on the ward: we have a wide range of patient requested activities every day
  • therapeutic support: we offer people a range of therapy and support that gives them hope things can get better
  • transparency: we have open and honest conversations with patients and each other, and name the difficult things

As we continue this improvement work in 2025, we would expect to see improved occupancy rates within our wards; in simpler terms that beds would be available through week, with a reduction in both very long-stay patients awaiting complex support outside a clinical environment, and some increase in our ability to support patients in the community, recognising that admission may not be the best model of support.

During the last year, we opened our first supported housing initiative alongside the South Yorkshire Housing Association providing a rehabilitative environment through which to care for patients who might otherwise have remained in inpatient beds at the trust or elsewhere.

During the last year we also closed some inpatient capacity bringing services in Doncaster into line with the changes made in 2023 in Rotherham; with an expansion of community-based services being complemented by changes to remove low occupancy beds. The Emerald ward facility in Bentley will be repurposed as a neurodiversity care centre over the coming twelve months.

In March 2025, the board concluded work to consider the future of older adult inpatient care within the trust. The two wards within the Rotherham Woodlands unit have become one unit, supporting patients with both functional and organic needs, in line with our approach on both Scunthorpe and Doncaster. Reporting to the board of some ambitious quality indicators for older adult care will provide visible accountability as we seek to ensure that a locally based service can offer the outcome benefits of a more centralised specialist model seen in some other parts of NHS locally.

3 Quality and safety priorities for the year April 2025 to March 2026

In May 2025, the board approved a quality and safety plan for the coming three years. This outlines a framework of change within the organisation that builds on existing strengths but seeks to add pace and precision to our work to prevent harm and to improve quality.

3.1 Safety first

• We will meet core “always” standards consistently in new care episodes, and where relevant other ongoing safety standards consistent with the Care Quality Commission domain.
• We will apply agreed approaches to understanding, investigating, and improving our care when things go wrong, rooted in our patient safety incident response framework model.

3.2 Quality

• We will focus our efforts on meeting promise 16, with its commitment to outcome measures: this will be delivered in part through the Royal College of Physicians (RCP) accreditation and the implementation of DIALOG+.
• We will embed patient voice into our routine management and clinical process, protecting what patients tell us they value, and improving how we work to best meet diverse needs in our communities.

Bearing in mind that medium-term framework, we have a small number of immediate priorities.

This is a priority because, although the majority of trust provided services are rated good, not all are. In addition, the assessments made by the Care Quality Commission date from over five years ago, before the Covid-19 pandemic. We want to be confident that now all service meet core standards for safety, responsiveness, effectiveness, being well-led, and, in particular being, caring.

To deliver this priority we will:

• intensify work to understand evidence of service quality, including making a baseline assessment of all services by August 2025, we will then maintain a “live” rolling assessment of service quality reflecting on counter-evidence through our patient safety incident response and Radar frameworks
• work to support teams to learn from one another. For most elements of care, some services within the trust are consistently outstanding, the best of what the trust does, done consistently will achieve our aims
• continue to apply validated safer staffing tools where they exist, linked to professional judgement, ensuring that a multi-disciplinary view of staffing needs are prioritised
• make sure that patient and carer views of service quality are understood, acted upon on, and given priority within our “self” assessment as we look to build confidence and trust in our services

This is important because the plan is explicit about what matters most in quality and safety. Whilst we will maintain oversight and evidence of all reasonable metrics, measures and recommendations, we need to be focused in ensuring we deliver safety, for patients, volunteers, students and our employed staff, our colleagues.

To deliver this priority we will:

• implement delivery of a series of “always measures” as clear indicators of achievement in many of our care pathways, including all of our wards
• completely revisit and refresh the published quality and safety measures used in the management of the trust to ensure that they reflect the range of clinical care services provided across our 13 clinical directorates
• audit the effectiveness of our revised engagement policy and act on the results
• work to deploy the DIALOG+ tool outlined in this report in practice across relevant parts of our organisation
• audit use of our revised patient safety incident response framework policy and act on the lessons from that audit work

This is important because it is the part of our strategy that most directly addresses the quality of care we currently provide. Though not wholly in our control, because we work in partnership with local authorities, primary care, the police and others, it is our responsibility to be confident of the therapeutic value of what we provide. Long stays in hospital can often worsen someone’s health and can certainly isolate people from others. We want to become ‘one hospital on many sites’.

To deliver this priority we will:

• act to ensure that personalised care planning and high-quality dynamic risk assessment takes place, and that no patient is with us for more than 15 days without a validated plan for discharge and onward care
• ensure that our inpatient care environments are suitable for patients who have neurodiverse needs and that our care teams are well trained in supporting all of our patients
• tackle the use of inappropriate out of area placements and reduce them substantially over the coming twelve months
• continue to monitor unplanned readmissions and delays within emergency departments, sustaining our success in ensuring that health based places of safety are used no more than 24 hours for the care of our most vulnerable resident
• assess and publish during 2025 an analysis of quality and safety risks specific to our pattern of weekend working in key services

In April 2024 to March 2025 we achieved our highest ever number of vaccinations, and saw teams who had not vaccinated commonly, lean into this ambition. The NHS as a whole has low vaccination rates and our trust was an exception for the second successive year. We want to have a third year of sustained success ensuring that the 500 staff who did not opt out or get a vaccination are supported to choose widely this autumn.

To deliver this priority we will:

• ensure we have sufficient active vaccinators across all of our sites and services
• actively support the vaccination of part-time and flexi-working staff including bank workers
• work alongside GPs and others to reach housebound populations and to support those with learning disabilities who are at significant risk from flu
• champion vaccination as part of our wider preventive work and our wellbeing offer to our staff

This national measure, which includes patients, governors and others in assessing our services, is an important reassurance of the accessibility of our sites and departments to everyone in our community. In the last year our scores improved significantly. We wish to sustain those gains and go further, recognising that estate changes will take longer to achieve.

To deliver this priority we will:

• work with Healthwatch, People Focussed Group, and other key partners to ensure that our assessments have independent involvement and validity
• ensure that the outcome of the PLACE scores is widely discussed across our trust’s operating model and that all senior leaders are aware of the policy and practice changes needed, especially in relation to dementia suitability

The first five promises within our strategy reflect the importance of this priority. Promise 5 describes ongoing involvement by patients in every part of our decision-making.

Independent analysis suggests good progress has been made since 2023, but we know that there is more to do. In the year ahead we need to ensure that all local patients can contribute.

To deliver this priority we will:

• increase by 15% the scale of feedback received in the trust versus April 2024 to March 2025 baselines
• ensure that feedback is sought and received from a diverse range of backgrounds including those subject to Mental Health Act detention
• discuss and evaluate at Board level the impact of the voices and views of patients with learning disabilities in our service delivery model
• further develop our Youth Forums and young people led feedback system to make sure that the organisation is hearing the views of those using our services
• demonstrate that patient feedback at directorate level has resulted in meaningful change by 2026

These priorities, if delivered, will make a significant difference to service quality. They also evidently reflect learning from the year being reported here.

The board has a Quality Committee which takes a significant role in overseeing improvement. Operational assurance occurs through the delivery review cycle and through the clinical leadership executive, including its sub-groups like the quality and safety group.

In January 2026 we will discuss within the board of directors and in March in the council of governors delivery of the priorities above, which reflect and reinforce both established plans and our strategy’s promises.

The priorities here cannot be delivered by a small number of people. At their core they reflect a need to ensure that all leaders, managers and our wider staff teams, focus first on safety and are committed to consistent improvement of quality.

4 Annexes

4.1 Annex 1: Statements of required assurance

4.1.1 A1 Freedom to Speak Up

As a trust we have undertaken a significant amount of work to embed measures which enable and empower staff to speak up about issues that concern them, considering equality, diversity and inclusion. Work led by the Freedom to Speak Up (FTSU) guardian team over the last 8 years has focussed on developing partnerships with front line staff, managers, board members and other partner organisations, with a view to enhance patient safety and staff wellbeing through a strong Freedom to Speak Up culture.

There are established routes where staff can raise concerns by speaking up to line managers and clinical leads and, where this is not possible, staff can raise with the Freedom to Speak Up team, staff side representatives, safeguarding team, spiritual support and the health, wellbeing, and security support team. These concerns can range from quality of care, patient’s safety, bullying and harassment or anything related to their experience at work. There is also an option to anonymously “speak up” using a button on the staff intranet or they can contact a Freedom to Speak Up champion via text, email, or contact through social media. This collective approach has been critical in offering a diverse range of opportunities for staff to raise issues and ensure that they are offered support. The person raising the concern can choose how often they received updates and feedback and who this is from, for example the Freedom to Speak Up guardian or a particular senior leader.

At the point of closing the Freedom to Speak Up concern and at 3, 6 and 12-months post closure, the person raising the concerns is asked if there has been any detriment to them as a result of raising the concern. A standard operating procedure for addressing any reported negative impacts or detriments is in development and will be in place in 2025.

4.1.2 A2 clinical audit

4.1.2.1 Trust (local) clinical audits

The audit framework has continued to drive forward the audit activity in the organisation throughout the year April 2024 to March 2025, providing the structure for clinical audit activity within the trust. The proposed trust wide forward clinical audit programme for in the year April 2025 to March 2026, has been presented and discussed with care group leads, quality committee and audit committee and the final forward programme is aligned to the safety and quality plan.

The reports of 11 clinical audits and 10 national audits were reviewed by Rotherham Doncaster and South Humber NHS Foundation Trust in the year April 2024 to March 2025. The chart below shows the outcome ratings from these 21 clinical audits.

The reports of 11 local clinical audits and 10 national audits were reviewed by Rotherham Doncaster and South Humber NHS Foundation Trust in the year April 2024 to March 2025. The chart below shows the outcome ratings from these 21 clinical audits.

The tables below show a comparison of clinical audit outcomes from the years April 2023 to March 2024 and April 2024 to March 2025 and the current status of clinical audits.

The results of each audit are analysed and reported by the Clinical Effectiveness team and shared through the Care Groups Quality and business meetings through their audit leads and through the corporate governance of subgroups and Quality Committee.

Action plans are developed collectively in each case and progress against these actions are tracked centrally by the Clinical Audit team and reported through to the care group and corporate governance meetings.

4.1.2.2 Audit actions (local, key and national)

Of the 11 local and key clinical audits completed, action plans were developed to improve the safety and quality of healthcare provided, generating a total of 57 actions. 44 (77.2%) of the agreed actions have been completed.

6 national audits had action plans developed to improve the quality of healthcare provided, generating a total of 27 actions 22 (81.5%) of the agreed actions have been completed.

4.1.3 A3 Learning disability improvement standards benchmarking

NHS Improvement have developed four standards that trusts need to meet; doing so identifies them as delivering high quality services for people with learning disabilities, autism or both.

The trust is partially meeting these standards.

In relation to learning disabilities, the trust takes part in the annual benchmarking of our learning disability services, we hold a trust wide quality circle meeting attended by multi professionals and are part of the learning disability quality effectiveness group.

The national team for benchmarking has announced that the learning disability standard benchmarking will not continue in the year April 2024 to March 2025. As a result, the trust learning disability directorate and the senior leadership team will explore options to agree standards to internally monitor and measure against.

The four standards concern:

4.1.3.1 Respecting and protecting rights

Multiple reasonable adjustments for people with learning disabilities and, or people with autism are made across services, ensuring people have effective care and treatment plans that meet the person’s needs; this typically includes things like using modified communication, flexible appointment systems and modified triage assessments, and ensuring due regard to the content of hospital passports. We have implemented the vulnerable inpatient person (VIP) bags across two of our community services, supporting people who are admitted to the acute trust; this works in conjunction with promoting and embedding the hospital passport.

We have local representation at the learning disabilities mortality review (LeDeR) assurance panels and carry out local structured judgement reviews when people have died. This is triangulated back to shared learning through the clinical quality meetings.

As a trust, we have vigilant monitoring of any restrictions placed on a person with learning disabilities including deprivation of liberty. We have a dedicated lead for mental capacity and within the learning disabilities directorate, we have local representatives at the trust wide forum. Staff attend mandatory training.

4.1.3.2 Inclusion and engagement

The Doncaster Learning Disability team have a health co-facilitator who works a minimum of 2 days per month within the Health Action Team. They are an active member of the team and support the wider learning disability community with training, advocacy and being the voice of people with learning disabilities.

A peer support worker also works in the Rotherham services to support inclusion and engagement.

The directorate is attendees at all local learning disability partnership boards, engaging with families, carers and people with lived experience which enables us to improve our services.
Staff are actively engaged in local speak up groups whereby they offer and deliver training and education on any pertinent issues.

4.1.3.3 Workforce

In 2025, the learning disability directorate will complete a targeted piece of work looking at the workforce to ensure that we have staff fit for the future and a sustainable model, including nurturing our students, trainee nurse associates, apprentices, and peer support workers.

Staff are trained and routinely updated in how to deliver care to people with learning disabilities, autism, or both, who use our services, in a way that takes account of their rights, unique needs and health vulnerabilities. This is evidenced through the mandatory training, continued professional development and our half day learning sessions held monthly allows our services to participate and expand their knowledge.

The trust has a designated directorate trust wide for learning disabilities. The directorate provide induction, mentorship, supervision and appraisal that explores how people with learning disabilities, autism or both are being supported.

4.1.3.4 Specialist learning disability services

• The positive behaviour support pathway is established in Rotherham and work is underway in Doncaster and North Lincolnshire.
• The sensory pathway is being developed for the Learning Disability and or autism spectrum disorder (ASD) population.
• The Allied Health Professional team are developing a new posture pathway and Otago classes which involve exercises which are designed to help build up strength and improve balance in order to help prevent falls.
• The services have fostered good partner relationships with integrated care boards (ICB) and local authority (LA); we have representatives at the dynamic support register meetings (DSR) and attend relevant care and treatment reviews (CETRs).
• We have implemented a pathway for people who are admitted to our acute mental health wards to oversee and ensure effective discharge planning is established.
• The community learning disability teams are focussing on the trust’s promise 7 in achieving 95% of health checks for people with learning disabilities working in partnership with our primary care colleagues.
• As a directorate we have carried out a fully reviews of our stopping over medication of people with a learning disability and autistic people (STOMP) pathway; this includes listening to people with lived experience and making reasonable adjustments. Ensuring our staff are adequately trained and have the right skills.
• The trust has a dedicated reducing restrictive practice lead who the learning disability team link very closely to ensure we are practising in a least restrictive way.
• Dementia pathway established across the three community teams which is multidisciplinary led

The learning disability and forensic directorate are developing a work plan for the year April 2025 to March 2026 that will focus on a number of key areas

The work plan will focus on standardising the pathways irradiating inequities within the services.

The trust is reviewing both its learning disability and its autism services against these standards and has submitted data for national benchmarking annually over a 6-year period.

A work stream is actively reviewing audits pertinent to our service. Further work steams have been developed to undertake targeted work in relation to training staff in the role of learning disability ambassador’s and reviewing how we receive feedback, concerns and complaints and embedding “ask, listen, do”.

4.1.4 A4 review of services

During the year April 2024 to March 2025, Rotherham Doncaster and South Humber NHS Foundation Trust provided and or subcontracted 63 relevant health services.

Rotherham Doncaster and South Humber NHS Foundation Trust have reviewed all the data available to them on the quality of care in all 63 of these relevant health services.

The income generated by the relevant health services reviewed in the year April 2024 to March 2025 represents 100% of the total income generated from the provision of relevant health services by Rotherham Doncaster and South Humber NHS Foundation Trust for the year April 2024 to March 2025.

Further details of the services provided and subcontracted by Rotherham Doncaster and South Humber NHS Foundation Trust are provided on Rotherham Doncaster and South Humber NHS Foundation Trust’s services.

4.1.5 A5 clinical research

The number of patients receiving relevant health services, provided or subcontracted by Rotherham Doncaster and South Humber NHS Foundation Trust, staff and members of the community in the year April 2024 to March 2025, that were recruited during that period to participate in research approved by a NHS research ethics committee and the Health Research Authority and on the National Institute of Health and Care Research (NIHR) portfolio, was 1,062 against a target of 900 participants in the NIHR portfolio studies.

4.1.6 A6 commissioning for quality and innovation

NHS England paused the nationally mandated commissioning for quality and innovation (CQUIN) incentive scheme between April 2024 and March 2025.

4.1.7 A7 Care Quality Commission registration

Rotherham Doncaster and South Humber NHS Foundation Trust is required to register with the Care Quality Commission (CQC) and its current registration status is for the following regulated activities:

• accommodation for persons who require nursing or personal care
• assessment or medical treatment for persons detained under the Mental Health Act (1983)
• diagnostic and screening procedures
• family planning
• personal care
• transport services, triage and medical advice provided remotely
• treatment of disease, disorder, or injury

In regard to Rotherham Doncaster and South Humber NHS Foundation Trust’s Care Quality Commission registration, during the year April 2024 to March 2025 reporting period:

• no enforcement action was taken by Care Quality Commission against Rotherham Doncaster and South Humber NHS Foundation Trust
• Rotherham Doncaster and South Humber NHS Foundation Trust have not participated in any special reviews or investigations by the Care Quality Commission during the reporting period

Rotherham Doncaster and South Humber NHS Foundation Trust has the following conditions on registration, applied against the “accommodation for persons who require nursing or personal care” activity:

• the registered provider must not treat persons under 18 years of age at the location Danescourt
• the registered provider may not use the enhanced care accommodation at Danescourt
• the registered provider must only accommodate a maximum of 5 service users at Danescourt

4.1.8 A8 data quality: hospital episode statistics

Rotherham Doncaster and South Humber NHS Foundation Trust submitted records during the year April 2024 to March 2025 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics, which are included in the latest published data.

The percentage of records in the published data included:

• the patient’s valid NHS number was 100% for admitted patient care (not applicable for outpatient care and for accident and emergency care)
• the patient’s valid General Medical Practice Code was 100% for admitted patient care (not applicable for outpatient care and for accident and emergency care)

4.1.9 A9 data quality: data security

The national NHS Digital Data Security and Protection Toolkit reports whether standards “have” or “have not” been met from NHS Provider submissions. Rotherham Doncaster and South Humber NHS Foundation Trust achieved “standards met” for the year July 2023 to June 2024 and expect to achieve “standards met” for the year July 2024 to June 2025 with the final submission in June 2025.

4.1.10 A10 data quality: payment by results

Rotherham Doncaster and South Humber NHS Foundation Trust is paid on a block basis for the services it delivers and is therefore not subject to any payment by results coding reporting.

4.1.11 A11 data quality: the action taken to improve data quality

Data quality and accuracy is governed through the trust’s annual data quality improvement programme, reporting a quarterly position to the Finance, Digital and Estates Committee (FDEC) on progress and position. This programme provides key focus on measures linked to the integrated quality performance report and accompanying information management guide and other priority metrics.

The trust chief nursing information officer provides clinical leadership to translate and drive data quality needs into improved clinical recording accuracy and practice, whilst also understanding needs for improved quality of care delivery and efficiency. This is supported through a monthly Data Quality Group.

Subject to both internal and external validation, the trust is committed to continuously improving the strategic delivery risk framework position for data quality and related quality of care outcomes.

The quality of our services will continue to be increasingly defined at an operational level through the Clinical Leadership Executive (CLE) and Operational Management Group (OMG), by care groups and directorates, with patient, carer and stakeholder involvement, with due regard to appropriate organisational governance arrangements and oversight by the board of directors.

There is an approved clinical audit policy which describes the trust’s approach and arrangements and an approved clinical audit programme. The clinical audit function is used appropriately to focus on risks, as well as on nationally identified issues. Progress against the clinical audit programme and the outcomes of audits are reported to the care groups.

The trust data quality policy provides assurance on the approach to data quality as a trust, aligning to the trust information governance and management framework, national data standards and legal commitments and obligations. The policy and framework drive a clear directive for trust wide data quality ownership, accountability, and action to ensure continuous data quality, whilst recognising the importance of accuracy for patient care and safety.

The trust has introduced the concept of “data save lives” as a localised campaign linked to the national strategy. The local campaign has focused on data quality, electronic patient record (EPR) training and data consumption.

4.2 Annex 2: reporting against core indicators

The trust is required to provide performance data against a core set of indicators using data made available to the trust by NHS Digital.

The percentage of patients receiving a follow-up within 72 hours of discharge had a target of 60% for April 2024 to March 2025.

This indicator is not included within the NHS Digital mental health community teams activity submission and therefore not part of national comparable data.

The Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data is as described and has taken the following actions to improve the quality of the data against these indicators, and so the quality of its services, in the forthcoming year (April 2025 to March 2026): regular checks of the raw data for accuracy (prior to submission) are carried out by the trust’s Performance team.

This indicator is not included within the NHS Digital mental health community teams activity submission and therefore not part of national comparable data.

The Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data is as described and has taken the following actions to improve the quality of the data against these indicators, and so the quality of its services, in the forthcoming year (April 2024 to March 2025): regular checks of the raw data for accuracy (prior to submission) are carried out by the trust’s Performance team.

Source: Care Quality Commission Mental Health Community Services Survey 2024.

The Mental Health Community Survey is an independently administered national survey of patients receiving mental health care in community settings. The survey is comprehensive and provides valuable quantitative data to facilitate comparison with other trusts and benchmark our services numerically against a range of indicators. The survey for Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) in 2024 contacted 1232 service users, of which 245 completed the survey.

The results for specific questions are categorised depending on whether they are “better”, “worse” or “about the same” compared with other trusts. For RDaSH the breakdown was as follows:

• in 22 questions, RDaSH was “about the same”
• in 2 questions, were RDaSH was “somewhat better”
• in 8 questions, RDaSH were worse “better”
• in 3 questions, RDaSH were worse “much better”

The three “much better” questions were related to support while waiting, involvement in care and overall experience. In all sections RDaSH either remains on par with other trusts or has shown improvement. On the previous report it showed that there was a low intake of feedback which has improved to now be on par with other trusts.

This report clearly shows that the improvements and steps taken in the past year to improve the service provided by the trust have been successful in their implementation.

Source: NHS England (data only published annually in September each year) RDaSH Ulysses Incident Reporting System National Reporting and Learning System (NRLS) April 2021 to March 2022 published October 2022. Further date not currently available at NHS England Organisation patient safety incident reports.

The Rotherham Doncaster and South Humber NHS Foundation Trust continues to encourage reporting of incidents and has seen an increase in reporting between April 2024 to March 2025 of 8.6%. There was also a reduction in the patient safety incidents reporting severe harm and a significant reduction in the patient safety incidents resulting in death.

The implementation of the patient safety incident response framework (PSIRF) and the introduction of learn from patient safety events (LFPSE) has encouraged and improved the reporting of patient safety incidents across the trust. Increased incident reporting enables identification of themes and trends and so maintain the quality of services. By creating a culture of openness and a restorative just culture staff will feel able and confident to report incidents without fear of reprisal.

The first official patient safety statistics release of the learn from patient safety events (LFPSE) data has been published and will be further updated 15 May 2025 and will provide organisation level data. The public release of the Recorded Data Dashboard (RDD) is yet to be confirmed. Learn from patient safety events service replaces the National Reporting and Learning System.

From 1 May 2025, RDaSH incident and learning response data will be uploaded to the learn from patient safety events platform via the Radar risk management system.

The learn from patient safety events classifications and the psychological harm question, options and guidance will be reviewed during April 2025 to March 2026 and RDaSH has requested to take part in this review.

4.3 Annex 3: Current Care Quality Commission inspection ratings

The trust’s last Care Quality Commission well led inspection took place in November 2019 and the inspection report was published on 21 February 2020. The trust received an overall rating of “requires improvement”, with ratings of “good” in the domains of caring and responsive and a rating of “requires improvement” in the domain of safe, effective and well led.

The inspection report can be accessed via the Care Quality Commission inspection report.

The trust’s ratings overall and at service level are identified in the figures below, along with comparative rating from the previous inspections. Where there are no comparative arrows, the core service was not inspected during the most recent inspection and therefore the rating remains the same.

4.3.1 Trust overall rating February 2020

4.3.2 Service level ratings comparative with previous inspection results

The trust no longer has residential services at Station Road, Travis Gardens or 2 Jubilee Close.

4.4 Annex 4: statements from integrated care boards, local Healthwatch organisations and overview and scrutiny committees, and trust governors

Statements were received from:

• Rotherham Local Authority Health Select Commission
• Doncaster Local Authority Health and Adult Social Care Scrutiny Panel
• North Lincolnshire Council’s Health and Care Integration and Performance Scrutiny Panel
• HealthWatch Rotherham
• HealthWatch Doncaster
• Humber and North Yorkshire Integrated Care Board
• Rotherham Doncaster and South Humber NHS Foundation Trust Council of Governors

4.4.1 Statement of the Health Select Commission: Rotherham Metropolitan Borough Council

The Health Select Commission welcomed the opportunity to comment on Rotherham, Doncaster, and South Humber NHS Foundation Trust’s draft Quality Account for 2024 and 2025, despite receipt outside the statutory timescale, and look forward to working with Rotherham, Doncaster, and South Humber NHS Foundation Trust (RDaSH) during 2025 and 2026.

The commission were pleased to see emphasis on future improvements within RDaSH’s provision within the quality account and noted some positive steps towards improving engagement and inclusion, such as “Care Opinion”’ being rolled out across all services and are keen to understand how insights gained are used to identify areas of strength or weakness and harnessed to drive continual improvement. Members noted that some partners, for example, integrated care board (ICB) and Healthwatch had been provided with “monitoring accounts” and felt such access would benefit the commission if possible, as it may bridge the data or evidence gap members felt existed in parts of the quality account. Members were also pleased to see digital exclusion considered, with more traditional routes of dialogue maintained where appropriate. Similarly, work around uptake in older people with mental health forensics and learning disabilities services in order to be inclusive of those patient groups was pleasing, though members felt more context around the approach to and targeted outcomes of that work would add value.

Participation in the Culture of Care National Programme was also welcome, and members were keen to see the positive impact this may have on ensuring patient voice is reflected in care plans, the quality, accuracy and timeliness of record keeping and the sufficiency and timeliness of risk plans or assessments which the quality account noted as weaknesses or areas for improvement, particularly in the outcomes of peer reviews. In conjunction with the comments regarding staff perception that staffing levels did not reflect acuity and difficulties around taking breaks, this was a source of concern for Members; one they would be keen to explore in more detail through its public scrutiny function over the coming municipal year.

The intention to reduce child and adolescent mental health service (CAMHS) waiting times and waiting times for people seeking diagnoses and support with attention deficit hyperactivity disorder (ADHD) and autism was particularly welcome, as the Commission was aware of public concern regarding those areas. The waiting lists described both for adults and children are significant, with the lengthy waits and delayed diagnoses having the potential to impede or restrict development, life opportunities and quality of life not only for the patient, but for their families, carers and for those with whom they live, learn and work. The commission felt that the individual and cumulative consequences of failure to deliver reliable, timely services in these areas was significant and were keen to see work in this area prioritised. Members felt that more detail around how the intended reductions will be achieved would have been beneficial, and they would be keen to explore this in more detail with RDaSH, ideally through public scrutiny. Proposed work to expand peer reviews into community services throughout 2025 and 2026 including children’s services was therefore also very welcome.

Whilst the commission appreciated the vision and ethos behind the “always promises” referred to, Members were concerned that in most cases, performance fell significantly short in cases where 100% targets were applied and questioned whether this reflected a disconnect between the strategic aspiration and the reality of the operating environment for front line staff. Members welcomed stretching targets that drive continual improvement through delivery against fine margins, but were concerned that applying unrealistic targets may adversely affect staff morale and in turn, performance trajectory and ultimately patient experience and outcomes. Detail regarding how the “always promises” had been arrived at may offer reassurance in this area. A further example of this was that whilst the commission welcomed the amendment to the falls assessment target timescales from 72 hours to 12 hours based on data analysis alone, it was noted that performance against the existing timescale was 75%, calling into question operational capacity to deliver against the shorter timescale.

Members would welcome the opportunity to contribute to or comment on the publication of the Quality and Safety Plan 2025 to 2028, ideally before publication. The commission was also keen to understand performance against the previous plan, how learning from that had been used to inform the new plan and whether it had been co-produced.

Likewise, with respect to the implementation of strategic objective 4, members noted the expectation that this would result in changes to how RDaSH works with local authority partners. The commission would welcome the opportunity to be involved at an early stage to understand the implications for council services and assess the impact.

Members were interested to hear more about the trust’s approach to learning through “learning half days” and whether standing down face-to-face patient care had any adverse impact. Metrics surrounding the impact on waiting times, mandatory and statutory training uptake and improved patient experience feedback directly linked to training delivered may offer meaningful insights around this. Similarly, whilst members appreciated the financial operating environment within NHS services and therefore understood the desire to reduce agency spends, members were keen to see evidence that the approach outlined within the quality account represented no material change to the quality or safety of services provided since implementation.

Members were disappointed that four of six overall trust Care Quality Commission ratings were “requires improvement” or inadequate, particularly coupled with data which indicates declining performance in relation to post discharge follow-up, and a disproportionately low number of Patient safety incident investigations conducted considering the level and severity of incidents in children’s care compared to other care groups and were keen to advocate for children and ensure their voices and experiences were heard and learned from. An update in respect to the trust’s assessment of its current position may offer further reassurance.

As always, the Health Select Commission extends sincere thanks on behalf of the people of Rotherham to all at RDaSH for the hard work undertaken daily and continued commitment to improve their health and quality of life.

Councillor Eve Keenan, Chair, Health Select Commission, Rotherham Metropolitan Borough Council, 20 June 2025.

4.4.2 Doncaster Local Authority Health and Adult Social Care Scrutiny Panel

The Health and Adult Social Care Scrutiny Panel Members noted but made no comments on the document.

Christine Rothwell, City of Doncaster Council, Senior Governance Officer, 25 June 2025.

4.4.3 North Lincolnshire Council’s Health and Care Integration and Performance Scrutiny Panel

North Lincolnshire Council’s Health and Care Integration and Performance Scrutiny Panel welcomes the opportunity to comment on Rotherham, Doncaster and South Humber (RDaSH) NHS Trust’s 2024 to 2025 Quality Account. RDaSH is a key partner, providing critical services to residents of North Lincolnshire, and we have built a valuable and mutually respectful relationship over many years.

The scrutiny panel intends to invite senior trust representatives to a number of meetings throughout 2025 and 2026 to discuss the priorities and performance as outlined within the quality account document, as well as other issues of relevance.

The scrutiny panel welcomes many of the successes outlined within the quality account document, and we fully support the identified priorities and strategic objectives. Notably, we were delighted to see excellent performance in community mental health, clinical contacts, perinatal and maternal mental health, and the near end of the use of agency staff.

Naturally, we acknowledge that there are areas for further development throughout 2025 and 2026, and we share RDaSH’s desire to see improvements to access for talking therapies, annual health checks, and out-of-area placements.

Whilst we understand that the content of Quality Account documents is largely prescriptive, we feel that improvements to the use of data in the document could be made. Often, performance is reported, but without benchmarking data from other areas or over time, or the direction of trend. This leaves the reader without a full understanding about how the trust is performing. For example, there is a description of neurodevelopment waiting times, without the context of whether this is typical, higher or lower than would be expected, or which direction performance is going in. We would therefore respectfully ask the trust to consider this in future publications.

The Health and Care Integration and Performance Scrutiny Panel looks forward to continuing to work closely with RDaSH colleagues throughout the year in order to seek improvements to local services, on behalf of our residents.

Cllr J Kennedy, Chair, North Lincolnshire Council’s Health and Care Integration and Performance Scrutiny Panel, 26 June 2025.

4.4.4 HealthWatch Rotherham

At Healthwatch Rotherham, we welcome the trust’s clear commitment to placing patient voice at the heart of the care experience. The Quality Report for April 2024 to March 2025 demonstrates that local services are increasingly responsive, transparent, and engaged with the communities we serve.

We are encouraged by the trust’s efforts to listen to patients, evidenced by the widespread use of Care Opinion, where more than 35,000 views of patient stories underline a culture of openness and continuous improvement. The high percentage of positive messages, alongside constructive insights from those with critical feedback, reveals a thriving dialogue between patients, their families, and service providers. This active engagement empowers our community and helps shape better, more personalised care.

Healthwatch Rotherham is particularly pleased to see robust initiatives that bring the voices of local people into the planning of services. The implementation of learning half days, improved complaint management, and the integration of volunteer roles across services all contribute to establishing a service environment that is both compassionate and proactive. These measures not only address immediate patient needs but also set a solid foundation for enduring improvements across Rotherham’s healthcare landscape.

Additionally, the trust’s achievements in enhancing safety, through innovative technology, more stable staffing, and streamlined reporting systems such as Radar, speak to its commitment to safeguarding patient wellbeing. With improvements in areas like timely follow-up care and comprehensive risk assessments, there is clear evidence that quality care is becoming more accessible and equitable for all residents within our community.

In our view, the strategic emphasis on community partnership and the drive to involve local voices reflect a true dedication to co-production. When patients and carers are actively engaged in shaping their care services, not only are outcomes improved, but trust in the system is strengthened. We believe that these positive steps will pave the way for further progress in terms of both patient experience and service quality.

Healthwatch Rotherham looks forward to seeing further developments and sustained excellence in care delivery, and we commend the trust’s continued efforts to ensure that every individual’s experience is respected, heard, and acted upon.

While significant positive changes have been achieved, the report also highlights areas for further improvement. These include the need for more personalised care planning that consistently incorporates patient voices, more timely and effective responses to complaints, and further work to reduce waiting times, particularly for Attention deficit hyperactivity disorder (ADHD) and neurodevelopment assessments, and out-of-area placements. Additionally, enhancements in the frequency and clarity of risk assessments and documentation are necessary to maintain and improve patient safety further.

Kym Gleeson, HealthWatch Rotherham Manager, 25 June 2025.

4.4.5 HealthWatch Doncaster

Healthwatch Doncaster welcomes this year’s quality account from RDaSH and acknowledges the continued effort and progress made in embedding patient voice, learning culture, and service improvement across the organisation. The trust’s transparency in acknowledging challenges while taking clear steps toward change is commendable.

We are pleased to see the continued development of the 28 strategic promises, which provide a strong foundation for quality and safety. The growing use of Care Opinion to amplify patient voice and incorporate real-time feedback into service evaluation shows a genuine commitment to co-production. Positive patient stories across the child and adolescent mental health service (CAMHS), perinatal care, and community mental health reflect a culture of empathy, compassion, and professionalism among staff, which we consistently hear about in our own engagement work.

The ongoing success of the virtual wards is a real highlight, offering dignified, personalised care from home and reducing unnecessary hospital admissions. This innovation stands out as an example of patient-centred delivery and modern, flexible care that meets people where they are.

We also recognise the trust’s significant work in learning from incidents and deaths. The structured judgement reviews (SJRs), use of the patient safety incident response  framework, and weekly Mortality Oversight Group meetings all reflect a robust learning culture. We particularly welcome the trust’s plans to expand learning from serious incidents across the organisation to prevent recurrence and ensure consistent improvement.

The focus on improving inpatient experiences is another area of strength. Through involvement in the national Culture of Care programme, the use of patient-led assessment tools, and investment in personalised care planning, the trust demonstrates a commitment to therapeutic, respectful care. We encourage further embedding of these practices across all wards and sites, recognising the real difference this can make for patients and their families.

Healthwatch Doncaster supports the trust’s continued attention to equity and inclusion, particularly in relation to data on Mental Health Act detentions. Acknowledging disparities is a vital step, and we welcome the commitment to analyse protected characteristics and improve fairness in care delivery.

The trust’s rollout of the Radar system and shift to near real-time data for monitoring safety is a welcome advancement. Such digital tools can help drive faster responses, identify trends earlier, and support a more agile and transparent safety culture.

We also note the trust’s ambitious volunteer strategy under promise 3. With over 245 volunteers already in place and plans to expand further, this offers real potential to enhance service delivery and deepen community insight. We encourage the trust to build on this momentum by ensuring volunteers are also empowered as feedback-gatherers and representatives of lived experience.

We acknowledge the challenges that remain around access, particularly the long waiting times for ADHD and neurodevelopmental services. We are encouraged by the trust’s honest reflection on this issue and by the trajectory planning in place. We look forward to continued collaboration in ensuring these changes are shaped by those with lived experience.

As we reflect on the positive work described in this report, we offer a respectful challenge to continue broadening the reach of patient voice. The People Focused Group (PFG) provides invaluable insights, but relying on a small number of voices can unintentionally limit understanding. Every lived experience is unique, and true co-production must reflect the full diversity of our communities. We invite the trust to work with Healthwatch Doncaster and the wider voluntary, community, and social enterprise (VCSE) sector to strengthen engagement and ensure all voices are heard, especially those less frequently represented.

In conclusion, we commend RDaSH for its openness, dedication, and innovation. This quality account reflects not only a year of delivery but a clear sense of direction. We look forward to deepening our partnership and continuing to champion the voice of Doncaster residents in shaping safe, effective, and compassionate care.

Fran Joel, HealthWatch Doncaster, Chief Executive Officer, 26 June 2025.

4.4.6 Humber and North Yorkshire Integrated Care Board

Humber and North Yorkshire Integrated Care Board (HNY ICB) welcomes the opportunity to review and comment on the Rotherham Doncaster and South Humber NHS Foundation Trust’s (RDaSH) Quality Account for the 2024 and 2025 period.

We would like to extend our sincere thanks to all staff and representatives working for or on behalf of RDaSH for their continued dedication, hard work, and commitment to delivering high-quality services to patients across the region. Your efforts are deeply appreciated.

We recognise the trust’s continued commitment to learning and improvement, particularly the valuable insight gained through the complaints process, while recognising that 80% of patient stories were positive. The emphasis on early, open, and compassionate engagement with complainants is a significant step forward, and we are keen to see this approach embedded and sustained across services.

The quality account provides a comprehensive overview of the trust’s quality improvement activity, including learning from clinical audit, patient feedback, and staff experience. We are pleased to see the implementation of the patient safety incident response framework (PSIRF) and the trust’s active engagement with system partners to maximise learning opportunities.

We look forward to the publication and mobilisation of the trust’s quality and safety plan. This will be a key milestone in strengthening governance and delivering consistent, high-quality care across all services, aligning with the regulatory framework and ambition to achieving a “good” Care Quality Commission rating, while truly embedded patient voice throughout the service.

The quality account highlights a range of positive developments, including:

• the rollout of Care Opinion and increased transparency in patient feedback
• the introduction of learning half days and peer reviews to support a culture of reflection and improvement
• an increase in safety culture through higher incident reporting, and notable reduction in incidents resulting in severe harm or death
• progress in reducing agency staffing and improving workforce stability
• continued investment in digital systems and research, including Radar and the trust’s gold standard accreditation in clinical research

We are encouraged by the trust’s focus on embedding patient voice into service design and delivery, and we support the ongoing work to improve access and reduce waiting times. Additionally, we endorse the focus on improving inpatient safety, recognising the work of the therapeutic care task force to enhance the consistency of inpatient care.

Finally, we confirm that to the best of our knowledge, the quality account is a true and accurate reflection of the quality of care delivered by RDaSH, and that the data and information contained in the report is accurate.

Humber and North Yorkshire Integrated Care Board remains committed to working with RDaSH and all health and care partners to improve the quality and safety of services for our population, with the shared goal of improving patient experience and outcomes.

Deborah Lowe, Director of Nursing, Quality, Safety and Patient Experience, 30 June 2025.

4.4.7 Rotherham Doncaster and South Humber NHS Foundation Trust Council of Governors statement for the year April 2024 to March 2025

The council of governors is pleased to have the opportunity to comment on the quality report for the year April 2024 to March 2025.

A range of governor engagement activities during the year April 2024 to March 2025 have allowed for activities to be attended and more opportunities for the council of governors to be involved with initiatives to promote and be aware of quality services within the trust. Listed below are brief details of some of the ways that governors have been included and been involved.

Governors identified and agreed three priorities in the previous year and continued to support them in April 2024 to March 2025, these included volunteering, health promotion and engagement, all of which have close ties to elements of the trust’s clinical and organisational strategy. Updates on progress have been provided at each council of governors meeting alongside broader updates on the delivery of all promises.

The council of governors received update reports at its meetings that included specific updates on this quality objective and the work of the Quality Committee. This section is presented to the council of governors by the chair of the Quality Committee. During the meeting governors provide feedback and ask questions in respect of the information provided, seeking where necessary additional explanation and or confirmation to hold the non-executive directors to account and also demonstrating a keen interest in areas of work that will benefit the patients, service users, carers and staff of the trust. The council of governors has also received specific quality related presentations such as that regarding out of area placements in March 2025 (strategic objective 1, promises 1, 3, 4 and 5).

During the year governors have attended (virtually) as members of the bimonthly Quality committee and had first-hand opportunity to see the committee undertake its business and to hear and observe the challenge, support and discussion within the committee and to see the progress made throughout the year. (strategic objective 1, promise 5).

Safety and quality priorities include the requirement for each area to have a peer review. Governors have participated in peer reviews throughout the year. Governors, alongside colleagues from the board of directors has attended reviews and had the opportunity to meet staff and patients and to see and hear first hand about the quality of service they have received, and the challenges faced by staff and their success in delivering care to those in need (strategic objective 1, promise 4).

A number of governors have attended (virtually and face to face) and observed the meetings of the board of directors held in public. This has also provided a valuable opportunity to see the wider business of the board but also to see the input to the board from the Quality Committee. Governors have engaged by asking questions relating to quality matters. This relates to quality priority to improve the experience of care and the opportunities for involvement across all care groups and corporate departments (strategic objective 1, promise 5).

The council of governors supports the content of the report as an open and honest reflection of the trust’s position, in line with that presented to the Quality Committee and board of directors.

The council of governors continues to be committed to working closely with the board of directors, staff, service users, carers and public over the coming year to support the delivery of the quality priorities contained within the trust’s clinical and organisational strategy and the achievement of the objectives and promises it contains.

The council of governors welcomes and looks forward to continuing and enhancing its work, with support from the trust, to more effectively hold the non-executive directors to account for the performance of the board of directors. This includes active discussions between governors who work with, and through, non-executive directors and learn from the good practice of other NHS trusts.

Council of Governors, 23 June 2025.

4.5 Annex 5: statement of directors’ responsibilities for the quality report

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year.

NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report.

In preparing the quality report, directors are required to take steps to satisfy themselves that:

• the content of the quality report meets the requirements set out in the NHS foundation trust annual reporting manual the year April 2024 to March 2025 and supporting guidance.
• the content of the quality report is not inconsistent with internal and external sources of information including:
  • board minutes and papers for the period April 2024 to March 2025
  • papers relating to quality reported to the board over the period April 2024 to March 2025
  • feedback requested and received from:
    • NHS South Yorkshire Integrated Care Board: Doncaster and Rotherham Place, not received
    • Humber and North Yorkshire Integrated Care Board, 30 June 2025
    • Doncaster Healthwatch, 26 June 2025
    • Healthwatch North Lincolnshire, not received
    • Healthwatch Rotherham, 25 June 2025
    • Doncaster Local Authority Health and Adult Social Care Scrutiny
      Panel, 25 June 2025
    • North Lincolnshire Council’s Health and Care Integration and Performance Scrutiny Panel, 26 June 2025
    • Rotherham Local Authority Health Select Commission, 20 June 2025
    • Rotherham Doncaster and South Humber NHS Foundation Trust Council of Governors, 23 June 2025
  • the trust’s complaints report the year April 2024 to March 2025 published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009
  • the latest national community mental health patient survey 2024
  • the head of internal audit’s (HoIA) annual opinion of the trust’s control environment (final head of internal audit’s opinion received by the board of directors on 26 June 2025)
• the quality report presents a balanced picture of the NHS Foundation Trust’s performance over the period covered
• content of the report illustrates the ongoing improvements since the Care Quality Commission Inspection report dated 21 February 2020
• the performance information reported in the quality report is reliable and accurate
• there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice
• the data underpinning the measures of performance reported in the quality report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review
• the quality report has been prepared in accordance with NHS Improvement’s annual reporting manual and supporting guidance (which incorporates the quality accounts regulations) as well as the standards to support data quality for the preparation of the quality report

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the quality report.

By order of the board.

Toby Lewis, Chief Executive, June 2025.

Kathryn Lavery, Chair, June 2025.

4.6 Annex 6: glossary of terms and definitions

This section aims to explain some of the terms used in the quality accounts. It is not an exhaustive list but hopefully will help to clarify the meaning of the NHS jargon used in these pages.

Page last reviewed: July 03, 2025
Next review due: July 03, 2026

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