Annual quality account April 2025 to March 2026

---

Chief executive’s introduction

The quality account is presented differently this year. All of the statutory information is summarised in a series of annexes for accountability purposes.

But the main quality account report is in two sections:

• the actions we have taken based on feedback from our patients: this year that feedback is largely based on our ever-expanding work with Care Opinion; we also hear and act on feedback raised through complaints, which are described in our annual report, and we focus on the learning from both patient safety incident investigations (PSIIs) and prevention of future deaths reports from the coroner.
• the improvement work we have undertaken during the year to make patient care safer or to try to improve quality: we recognise that at a local service level, teams take steps to improve all the time, but our report focuses on major trust wide changes to enable better insight into service quality and risk, or to improve outcomes from our care

During 2025 the board approved our three-year quality and safety plan, which seeks to prioritise the work we will do to improve our services. It dovetails with the safety commitments at the heart of the strategic promises we made in 2023, as we aim to deliver care at home wherever possible and to improve the therapeutic quality of our specialist care. During times of change it is arguably, even more important that we use sources of insight, whether that is stories, or quantitative data, to understand when we fall short of the best quality and how we can address that.

For 2026 and 2027, the main reporting cycle of the trust’s management and board, our integrated quality performance report (IQPR), is being revamped to ensure that our quality indicators span services across all of our now 14 clinical directorates. At the same time, the centrepiece of the quality and safety plan is the introduction of always measures into services over coming months: these are 100% standards we will look to meet in time every time.

External inspection and regulation are an important additional element of a safety culture. A fresh pair of outside eyes can offer views and comparisons that are not seen locally. The Care Quality Commission works with the trust through its mental health act inspections, and through on-site service visits. Most trust services have not been inspected since 2020, but our inpatient wards for acute and intensive care were visited in 2025. Whilst inspectors praised improvements in leadership, they found that safety, responsiveness and effectiveness requires improvement. This view aligns with our own, which is why throughout the year under review, I have chaired a high-quality therapeutic care taskforce dedicated to trying to bring greater consistency to care within our mental health wards, including our older adult wards.

The board has been actively involved in scrutiny of service quality throughout the year. In addition to the work of the quality committee, the full board has intervened in a variety of service situations, including, though not limited to:

• the quality of inpatient care for older adults: in spring 2025 the trust aligned its Rotherham older adult service to the blended functional and organic model used in Doncaster and North Lincolnshire; the chief medical officer has provided a series of reports to assess the quality of what is offered, and that work will continue in 2026 with a focus on dementia care
• the potential impact of racism on quality of care: in October 2025 trust executives considered on open meetings with staff their experiences of the workplace, as we reviewed the progress of our acceptable behaviour policy; this work gives rise to continued concerns about patient-on-staff and staff-on-staff behaviours and explains why addressing this is one of five quality priorities for the year, in support of our promise 26
• continued very long waits for neurodiversity diagnosis: in September 2025 and January 2026, the board considered the route to shorter waits for young people and for adults within services; by October 2026 we expect to meet a maximum wait of two years for children’s services, still far too long but the shortest such waits locally
• concerns over the case management rigour within some parts of our community mental health service: implementation of DIALOG+ is detailed within the report, but beyond that the board has considered the lessons from a specific patient’s care, and from wider reviews of mental health provision in the community, including the Nottingham murders and ongoing enquiry.

It is important to acknowledge that the overwhelming feedback from patients about the care provided by the trust is extremely positive, and Care Opinion illustrates this very clearly. It is important that our desire to improve does not imperil what is valued by patients and by staff in what we do well. Indeed, our improvement journey could be explained as seeking to make the best of what we already do in Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) our consistent standard.

I would hope that the format for this year’s quality account is more engaging and inclusive, and we will continue to adapt our reporting year by year to provide a frank insight into our weaknesses and our strengths. Radical candour is very much the intention of our approach as we look to ensure that we invest time, skills, and where needed money, to improve what we do and outcomes communities experience.

Toby Lewis, Chief Executive
1 June 2026

---

Your voice matters: acting on what you have told us about care at the trust

As chief nurse, I’m committed to making sure the voices of our patients and their families are at the heart of everything we do. Over the past year we’ve made patient feedback a routine part of how this trust runs, from ward team meetings and directorate reviews to our clinical leadership executive and board discussions. We also listened through the independent Care Opinion website, which is a place where anyone can share their experience of health or care services to help make them better for everyone. Patients and families shared over 1,918 stories about the trust in the period 1 April 2025 to 31 March 2026 and these have been viewed more than 130,102 times. We responded to every single one, around 85% within a week, to show we listen and close the loop on feedback. Encouragingly, 86% of this feedback was positive, highlighting compassionate care and dedicated staff, while roughly 1 in 10 stories were moderately critical, giving us vital pointers on where we needed to do better. We welcome these critical voices, as they provide the building blocks for improvement.

One powerful example of feedback leading directly to action involved a young adult with a severe brain injury who had lost the ability to communicate. He used to rely on his mobile phone to express himself, but as his condition worsened this was no longer possible, leaving him unable to convey urgent needs, take part in a safeguarding process and police investigation, or receive support after a bereavement. When our staff saw this unmet need, they raised the issue through our “always measure 5” escalation route, which is our commitment to respond swiftly whenever an essential service or resource isn’t available for a patient. Recognising the serious risk of leaving him without a voice at such a critical time, we arranged a loaned iPad within 24 hours as an interim communication aid, bypassing the standard funding delays to meet his urgent need. This timely, compassionate decision meant the patient could participate fully in the safeguarding and legal processes, maintain contact with his family, and preserve his dignity and autonomy at an incredibly vulnerable moment. It also reduced distress for staff and removed barriers to safe practice, reinforcing their confidence that this organisation will act decisively and flexibly at the highest level when normal pathways aren’t enough to meet a patient’s needs. This case shows that when we truly listen and are prepared to adapt, we can translate feedback into immediate improvements in care.

I’m proud of how far we’ve come in embedding patient and family voices across our organisation, but we know we can and will go further. Looking ahead, in 2026 we’re launching a communities’ leadership executive to bring seldom-heard voices from the voluntary and community sector directly into our senior leadership. By welcoming these community partners to our leadership table, we’ll broaden our perspective and deepen our connection with the diverse communities we serve.

Importantly, listening is only the first step, we must act on what we hear and make sure those actions lead to real improvements. That’s why our board will, in May 2026, review the patient safety improvement actions (from patient safety incident investigations) it agreed in May 2025, to check we delivered on those promises and that they’ve made a difference. We’ll also follow-up with dedicated audits to test whether the changes we pledged in 2025 complaint responses have truly improved care as intended. This kind of follow-up and assurance holds us accountable for turning patient feedback into genuine change.

In summary, I want every patient and family member to know that your voice matter, not just in words, but in how we make decisions, set priorities, and ensure accountability from ward to board. We will continue to listen with compassion, act on what we learn, and prove that your feedback leads to better care for everyone. This is how we will keep earning your trust and continuously improving the services we provide.

Steve Forsyth, Chief Nurse
1 June 2026

You said, we did: impact

Care Opinion offers us almost 3,000 stories so far about care. It is our principal source of documented feedback. The vast majority of the stories shared offer positive reinforcement of the care teams have provided. It is important that feedback is not only lensed around change or improvement.

Twelve examples are showcased below of changes from this feedback: each has been or is being evaluated on an ongoing basis. We know that we have work to do to ensure that learning in one team or directorate is adopted where applicable across our services.

Physical health and neurodiversity (rehabilitation)

You said:

“The Tai Chi taster session was great, we’d love to do more of that because it really helps.”

We did: feedback from people attending cardiac rehabilitation and falls prevention sessions highlighted how beneficial a trial Tai Chi group had been. In response, the trust introduced Tai Chi as a regular weekly activity, commissioned a qualified instructor, and opened sessions to more patients across cardiac rehab and falls services from November 2025.

Impact: Tai Chi is now an established weekly part of rehabilitation, supporting improved balance, strength and confidence for people recovering from cardiac events or concerned about falls, directly reflecting what patients told us worked well for them.

Physical health and neurodiversity (adult attention deficit hyperactivity disorder service)

You said:

“As a nonverbal patient, I couldn’t use the intercom buzzer and could not get into my appointment.”

We did: we redesigned how people access the clinic following this feedback. A three-press door buzzer system was introduced so patients who cannot speak can alert staff without using the intercom. Clear signage explains the system and staff respond immediately when the signal is used.

Impact: people who are non-speaking or have communication difficulties can now access appointments independently and with dignity, removing a barrier that had previously prevented attendance.

Children’s Care Group (therapy access)

You said:

“We waited months for my daughter’s therapy, it was very stressful.”

We did: children’s therapy capacity was increased and a waiting time improvement plan introduced. Additional clinics were opened and pathways reviewed, so referrals moved more quickly into assessment and treatment.

Impact: by late 2025, nearly all children were being seen within four weeks rather than waiting many months, significantly reducing stress and anxiety for children and families.

Children’s Care Group (personalised support and transitions)

You said:

“The 1 to 1 sessions were amazing, but transition to adult services was disappointing.”

We did: in response to positive feedback about individual therapy, access to 1 to 1 support was expanded for children who find group work difficult. Separately, transition planning between child and adolescent mental health service (CAMHS) and adult mental health services was strengthened through earlier identification, clearer clinical ownership and improved information sharing.

Impact: children benefit from better engagement and clearer goals during personalised therapy, while young people moving into adult services experience smoother transitions with fewer gaps in care and reduced disengagement at a critical time.

Rotherham adult mental health (acute care)

You said:

“Being sent far from home made me feel isolated and slowed my recovery.”

We did: the trust opened new local facilities, including a step-down unit in Rotherham and a specialist rehabilitation unit in Doncaster, and improved trust wide bed management. This enabled the trust to stop using out of area acute placements.

Impact: acute mental health patients are now treated closer to home, maintaining contact with family and support networks. There are zero out of area acute placements out of hours, helping reduce isolation and support recovery.

Rotherham adult mental health (inpatient wards)

You said:

“Weekends on the ward were boring, there were no activities.”

We did: seven-day therapeutic activity programmes were introduced on all inpatient wards. Activities now run every day, including weekends, and include creative groups, gentle exercise, social activities and ward meetings.

Impact: patients have meaningful activity seven days a week, reducing boredom, improving mood and supporting recovery, with no longer a sharp drop-off in engagement at weekends.

North Lincolnshire mental health (community leave)

You said:

“Going out with staff in uniform made me feel singled out.”

We did: on Mulberry Ward, policy was changed, so staff wear plain clothes when accompanying people on section 17 community leave. This change was made directly following Care Opinion feedback.

Impact: patients feel less stigmatised and more confident when out in the community, and uptake of therapeutic leave has increased as people feel more comfortable leaving the ward.

North Lincolnshire mental health (community recovery)

You said:

“I wish I could talk to someone who’s been through this.”

We did: a peer support drop in group was established in Scunthorpe, co facilitated by people with lived experience of recovery. Sessions provide informal support, shared understanding and practical advice alongside clinical care.

Impact: patients report reduced isolation and greater confidence in their recovery, supported by connections with others who understand their experiences first hand.

Doncaster adult mental health (inpatient discharge)

You said:

“When I left the ward, I felt forgotten.”

We did: Doncaster inpatient services introduced routine follow-up phone calls for every patient after discharge. A clinician contacts patients shortly after they return home to check safety, wellbeing and access to ongoing support.

Impact: 100% of patients now receive post discharge follow-up, improving safety, reducing risk in the immediate post discharge period and helping people feel supported rather than abandoned.

Doncaster mental health (talking therapies)

You said:

“I waited far too long to get counselling.”

We did: extra clinics and evening sessions were introduced to tackle waiting lists. In Doncaster Talking Therapies, this resulted in a significant reduction in backlog, including a marked drop in waiting numbers within a short period.

Impact: shorter waiting times for counselling, with people now accessing therapy much sooner, supporting earlier intervention and reducing distress caused by long waits.

Trust wide (appointments and communications)

You said:

“The confirmation text didn’t explain what my appointment was for.”

We did: appointment text message templates were reviewed and rewritten to provide clearer information about the purpose of appointments and what to expect.

Impact: patients receive clearer, more reassuring information ahead of appointments, helping reduce anxiety and missed attendances.

Trust wide (therapeutic support and understanding)

You said:

“The support helped me understand my mental health better.”

We did: person centred and relational approaches were reinforced across services, focusing on shared understanding, collaboration and therapeutic relationships.

Impact: people report feeling more confident, better informed and more able to engage in their recovery, reflecting a stronger focus on understanding and partnership.

---

Our improvements: work in the last twelve months to build a safer trust

We have chosen to tell our improvement story through another twelve examples. As the introduction to this report explains much of the improvement work in healthcare is sight unseen. It happens inside teams, reflecting on what could be improved. As a trust that dedicates four hours each month across the whole organisation, we offer space and opportunity for that to happen, through our learning half days. With the launch in January 2026 of Learning Matters we have taken further steps to spread knowledge and insight between and across teams.

If you wish to find out more about any of these steps, please contact the Chief Nurse, Steve Forsyth, in the first instance. We welcome feedback on our changes, all of which remain to be further improved in the year ahead.

If there is a common thread to the improvements described, it is trying to work as one Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH), at scale, to leverage the talents and knowledge of people across the organisation. In doing that, we are making greater use than ever before of data in assessing service safety and quality. This does not overlook the importance of input measures, but it does begin to move us closer to the focus on outcomes, which is a feature of our strategy, at promise 16, and is the “north star” of our quality and safety plan.

Staff voice matters in patient safety. Our annual staff survey tells us that not enough people working in our organisation tell us that they believe safety is our top priority. The same survey explains that not everyone has confidence that speaking up or otherwise voicing concerns leads to change. As is outlined in our annual report, this feedback is taken very seriously, and the board is working with staff representatives to build the culture we need for the future.

The improvements we explore in this section of the report are:

• care planning, led by our work on DIALOG+
• short waiting times for assessment and care: promise 14
• learning from serious harms: patient safety incident investigations (PSIIs)
• focusing first on safety: our quality and safety plan 2025 to 2028
• open reporting of incidents and risks: introducing Radar in May 2025
• self-assessing care: Care Quality Commission quality statements process all directorates undertake
• tackling out of area placements: trying to deliver and sustain promise 19
• hearing patient voices: what works and needs to change: including Care Opinion
• hearing patient voices: lessons from what goes wrong: patient complaints
• ensuring everyone can be heard: focusing on interpreting service use
• beyond measurement: embedding safer staffing approaches into the trust
• improving the consistency of our care: inpatient mental health (high quality therapeutic care (HQTC))

Care planning, led by our work on DIALOG+

Documenting the care to be provided is important. It helps a team of professionals to coordinate their work, and it ensures that our patients, and their loved ones, understand and consent to care. Historically, within the trust, various care planning approaches have been used, and a large number of care planning templates and documents have developed. Despite this, we have not been assured that a written care plan is in place for the care of everyone that we look after.

For mental health services, we have committed to implement a care planning tool called DIALOG, or DIALOG+. This includes work with patients to agree that outcomes important to them. Deliberately a DIALOG+ care plan is owned by the patient and should be updated not duplicated in different care settings: so if someone is discharged from a ward, their DIALOG+ care plan travels with them into their community-based support.

In agreeing outcomes, we then analyse the work we do through what is called a paired outcome measure. That outcome measure will, from 2026, form part of how quality of care in mental health services is nationally assessed. In 2024, the clinical leadership executive agreed to implement the DIALOG+ model across all age mental health services. Nationally, not all trusts do so for children’s services. We have, because we recognise the importance in particular of transitional care (moving from children’s to adult services): transitional care is a top priority for our council of governors.

In March 2026 community service uptake was discussed by the board of directors, all patients within our early intervention psychosis and assertive outreach services have an active DIALOG+ in place.

Short waiting times for assessment and care: promise 14

Waiting for care is a time of anxiety, and sometimes of deterioration. The NHS more generally measures waiting times through an 18-week standard, from referral to treatment. But generally, this standard is not applied to community and mental health services, and never has: where it does apply, the trust has met the standard in all our services from April 2025 to March 2026 and expect to continue to do so.

In 2023 the trust’s board committed to a radical new approach of very short waits, to be delivered from April 2026. In the language of our strategy and promises, this is promise 14, which states:

“Assess people referred urgently inside 48 hours from 2025 (or under four where required) and deliver a four-week maximum wait for all referrals from April 2026: maximising the use of technology and digital innovation to support our transformation.”

In the last twelve months, and before, colleagues across the trust have worked to redesign how we provide care to meet this promise. It is clear we are now seeing more patients than ever before, and we have previously reported a 19% growth in our productivity.

There remain services where we have long wait, beyond this promise. With a 100% rise in referrals our foot health (podiatry) service in Doncaster does not meet the standard yet. We have invested almost £200,000 for the year ahead to grow staffing and change that position. In neurodiversity services waits for assessment, and in some cases for treatment commencement, remain far too long. We have invested almost £3,000,000 since 2023 to improve this position, taking on the Doncaster young peoples’ autism service in 2025, and doing the same for medication services in North Lincolnshire, with the new service due to start in July. We are working with commissioners to ensure that they too invest to meet the challenge posed by delays, which erode educational attainment and employment opportunities.

However, for the rest of our services, over seventy in total, we now meet our four-week promise. And expect to sustain that success in the months ahead. Increasingly appointments are issued inside one week, with patients having choice options about when they will see us. From June 2026 we will as standard text appointment reminders to patients, giving the opportunity to cancel or delay: aimed at reducing missed appointments.

These are the shortest waiting times in the NHS, right here in South Yorkshire and North Lincolnshire. This is something to be proud of and to cherish. We publicise it widely to make sure patients can tell us if they have been overlooked, and so that local GPs can rely on what we say.

After assessment and initial care some patients need specialist treatments. We are now tracking the waits for this and are aiming to deliver a wait of no more than 14 weeks: making an 18-week maximum wait in total, parity of esteem with services in acute hospitals.

Learning from serious harms: patient safety incident investigations (PSIIs)

In March 2025 we revisited our policy and approach to learning from incidents. The NHS as a whole changed its approach in the year April 2023 to March 2024 and moved to a model called the Patient Safety Investigations Review Framework (PSIRF). We want to be bold in our application of that model, thematically identifying trends in our data, and ensuring we act not only on the most serious harms but of early warning lower level concerns.

During the last year, our internal audit service independently evaluated how we have applied this model. That review provided moderate assurance. That is not as strong a rating as we would wish, and the audit is being re-taken in spring 2026 to see whether we have improved further.

In May 2025, our Chief Nurse, Steve Forsyth, presented a review of the most serious patient safety incidents to the board, meeting in public. Sixteen incidents were considered from the period April 2024 to March 2025: a further eight incidents have occurred in the twelve months since. Both the actions taken since, and the evidence of improvement, will be presented to the board in May 2026.

The themes from our most serious patient safety incidents are as follows:

• family involvement in care and planning including discharge planning
• physical health escalations, especially relating to transfer from acute adult general hospital ward to mental health ward
• clinical documentation, including long day entries
• assessment of mental health crisis, timeliness, planning, carers voice
• pre-leave risk assessment and post-leave risk assessment

Whilst much of the risk in care that we manage is within inpatient settings, and the patient safety incident investigations reflect that, we do need to consider how we work in community settings with complex patients seeking to find home care and least restrictive practice options. It is encouraging that harms are not being cited in these areas of practice suggesting, often, good risk management.

In January 2025, a patient in our care was involved in the death of his father. In January 2026, a hospital order was adjudicated in the courts following a trial by fact. During 2025 the trust commissioned an independent investigation into the care of this patient: it concluded that the immediate risk management at discharge and over the period of the fatality was appropriate. But made serious suggestions for improvements in our care, which have been, and continue to be actioned across our community-based services.

Focusing first on safety: our quality and safety plan 2025 to 2028

In 2024 and 2025 we spent time across the trust exploring what our priorities should be to enable safer care and better quality. Across our clinical leadership executive, and inside our directorates and care groups, a variety of ideas and options were considered. Teams started from different positions: some, like NHS Talking Therapies, had very structured national mandated guidance; other services did not and there was a need to develop standards and consider outcomes. It was important that the Board had a plan across all of our diverse services, mindful of a tendency to focus disproportionately on working age adult mental health services, and within that on inpatient care.

In May 2025 the final version of our quality and safety plan was agreed by the trust’s board of directors. There are important elements to this document which merit exploration:

• stories and qualitative data are privileged alongside hard data, consistent with our strategy’s emphasis on patient voices and insights
• we distinguish between safety and quality: the former are standard we always seek to achieve, whilst quality is an improvement journey
• mindful of the need to build trust among local patients and communities we have prioritised safety first, recognising that quality improvement will be our focus in 2027 and 2028, once we have secured consistent safety, always

Perhaps the best way to understand our quality and safety plan is through the simple matrix shown below.

Safety first: quality

• We will meet core always measures consistently in new care episodes and where relevant other ongoing safety standards consistent with the Care Quality Commission domain
• We will focus our efforts on meeting promise 16, with its commitment to outcome measures: this will be delivered in part through Royal College of Physician (RCP) accreditation and the implementation of DIALOG+
• We will apply agreed approaches to understanding, investigating, and improving our care when things go wrong, rooted in our Patient Safety Investigations Review Framework model
• 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

In governing the plan, the board’s Quality Committee has since April 2025 structured its agenda and meetings according to this matrix. Increasingly the delivery governance of the trust focuses in a similar manner on securing progress: in 2026 deployment of our always measures will be that focus, in both community and inpatient settings.

This will only succeed if it is a multi-professional endeavour. We have five always measures and these can only be achieved by teams working together, across professions and between shifts: nights and days, weekends and weekdays.

During 2026 we will look to embed these always measures across our services. The measures in outline are listed below:

1. we will always undertake a personalised care plan with you using a Patient Reported Outcome Measure (PROM). This will be commenced within the first 72hrs of your contact with any member of the multi-disciplinary trust team
2. we will always seek your consent with every contact and or intervention and record that you understand this. Including Gillick competence. Gillick competence is where children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment.
3. we will always ask you if you have a carer, family, friend or advocate that you want to be involved in your care, that person will be listened to, and we will always act on the information they share with us
4. your parent, carer will always be offered a carers assessment and reassessment at any point or change in your or their circumstances
5. any unavailable care or absence of support which is an identified need will be recorded, and alternatives will be offered to you

Open reporting of incidents and risks: introducing Radar in May 2025

An IT system is not an end in itself. Replacing the Ulysees system with Radar, after open public procurement, is an enabler to a wider change. Implemented in May 2025 the trust has implemented Radar (healthcare) across all our services. The legacy Ulysees data was carefully retained and managed as we exited the system. This enables us to have comparative data over time.

Everyone who works within the trust has access to Radar. Moreover, they are expected to access the system. From January 2026 we have begun addressing through employee supervision any staff members who have not accessed the system. This seeks to tackle the idea that staff are either “too senior” or “not clinical enough” to use it. Many of our facilities or estates colleagues have unique insights into safety in the trust.

Importantly, all elements of the Radar data system can be reported by team, by directorate, by group and at trust level. This means that the trust for the first time can analyse quality and safety information using the same units (or taxonomy) as its workforce, finance, and activity information.

Radar contains a variety of analytical and thematic tools to give visibility to information about the organisation’s performance. In particular, it enables us to consider:

• trends in increasing or recurring incidents
• tracking response times for incidents, complaints, patient advice and liaison service and freedom of information requests
• how we have responded to incidents and the learning captured
• the ability to link between multiple incidents and associated actions
• audit activity, including performance against the audit question-set, and progress against action plans to address identified improvement areas

Every trust employee now has access to incident report and to risk reporting. Not only can they themselves raise ideas, but they can also see what others have raised within their service. There is more work to do, likely through our learning half days, for employees across the trust to recognise that potential.

Management focus during 2025 has been on teams that are no or low reporters of incidents and risks. Having received significant assurance from our internal audit service for the maturity of our risk management system, we are insistent that we build depth to that system in every team. Service managers and matrons, especially, are held to account for low levels of reporting, conscious that healthcare contains harms and risks and those need to be surfaced and managed.

Our annual report contains a summation of the trust’s risks and control system. This work includes analysis of low likelihood and high impact risks, and our work on both information governance controls and business continuity and emergency preparedness, resilience and response (EPRR). The trust is the highest evaluated and rated emergency preparedness, resilience and response provider in NHS North East and Yorkshire.

Self-assessing care: Care Quality Commission quality statements process all directorates undertake

In the annex to this report, we outline the trust’s current ratings with the Care Quality Commission (CQC) and the history of those judgements. The regulatory approach of the Care Quality Commission continues to evolve. In 2024, the system moved to quality statements across the domains of well led, safety, caring, effective, and responsive. The board’s aim for the trust is for every service to be rated good: and for the trust to be rated outstanding in the caring domain. Currently our legacy ratings are requires improvement, with caring rated as good.

Teams across the trust have worked since early 2025 to self-assess our status against these quality statements. This work has sought to build evidence vaults against these standards, locally assessing what that evidence shows. Care group directors of nursing in particular have compared local evidence between groups and directorates to establish a standard of what we would expect: this has been presented to the board in May and July 2025, in January 2026, and then in April 2026.

Ratings for the well led domain are being refined through a separate process which has twice reported to the board during 2025, acknowledging that the Care Quality Commission has current working groups to alter and adapt this domain of their framework.

The Board recognises that unacceptable variations in care planning documentation, and wider concerns over timely documentation, represent the key issue to be addressed. This is a consistent theme of inspections and evaluations of the trust over many years, many formats, and many services. Tackling this is a foundational change, and both first improvement example (DIALOG+) and our twelfth (high quality therapeutic care) speak to this. We will retain a public facing self-assessment of all our services, drawing on our peer review programme and feedback from our students, volunteers, peers and partners: alongside Healthwatch led review processes.

Tackling out of area placements: trying to deliver and sustain promise 19

Treating patients outside their home area, whether in Rotherham, North Lincolnshire or Doncaster, can separate them from their households and loved ones, and pose a barrier to future community-based care. It is also expensive for the NHS because it is often care provided by a private company. In 2023 we set an ambition to end such placements in 2024: an ambition we did not deliver. However, in 2025 we have made huge progress. This reflects in particular our work to:

• clinically assess proposed out of area placements that take place out of hours, finding community and onsite alternatives that better manage risk. We have further work to do to make better use of crisis house alternatives
• revised approaches to leave beds and discharge management, recognising that we have far further to go to reduce our occupancy and length of stay

At the end of the year under review, all of the remaining out of area placed citizens are North Lincolnshire based. That is part recognises that between July 2025 and June 2026 we have been rebuilding the wards within that site: from June 1 we will be fully open once again.

There have been no out of area placements for Doncaster residents since September 2025, and none for Rotherham residents since January 2026.

In the NHS system, not everyone who is treated miles from home is counted as an out of area placement. But the trust promise does recognise that reality. What that means in practice is that:

• we look to place Rotherham residents in Rotherham beds, likewise for other places, repatriating patients to home place admission as rapidly as possible
• as part of our responsibility to work as a system, and through our involvement in the South Yorkshire collaborative, we are leading work to move home complex care placements.

Work on complex care placements began in 2025, with the opening of the Phoenix ward high dependency unit, based on Doncaster, serving patients across North Lincolnshire and South Yorkshire. This has a target inpatient length of stay of one year: caring for patients who in many cases have been placed in locked rehabilitation for several years.

In North Lincolnshire, we have emerging arrangements to address out of area care, but in July 2025 Humber and North Yorkshire Integrated Care Board invested in the trust to create a community-based complex rehabilitation team. This work is showing promise in changing the lives of the initial cohort of patients identified.

Hearing patient voices: what works and what needs to change: including Care Opinion

Care opinion is outlined as the basis for the first section of this report. The key learnings from our patients are not repeated here. It is also increasingly clear that this tool is embedded into the main management systems and models of the organisation.

The choice to use Care Opinion in late 2024 was informed by the experiences of some neighbouring providers in Nottinghamshire, but also by the extensive use of this in healthcare in Scotland and in Northern Ireland. The adoption within the trust has exceeded expectations to date, with staff winning national awards for the compassion of their responses. Patients tell us that they use the posts from other patients when considering our care. We have worked with the integrated care board chair and chief executive to consider how Care Opinion can become a more system-based resource: and can be at the heart of quality-of-care assessments made about services by commissioners.

We had success in early 2026 in growing use of the tool in some services where take up was initially lower. Our wards in Rotherham have led the way in doing this for informal and detained patients in mental health units. A variety of initiatives continue to grow use among young people using mental health services, mindful of the extensive use of Care Opinion in physical health services for children. The trust is aware of issues of digital exclusion, and has taken steps to address that, however, of age-identifiable posts using the tool, the clinical leadership executive notes the larger than expected use of the tool among older adults.

We rely on a range of approaches to gather patient feedback. Both our peer reviews and our stop for safety events seek and rely on feedback from patients. They also, during 2025 but not before, now include peer support workers within visiting teams. The trust welcomes ‘enter and view’ interventions from Healthwatch.

Under the guidance of the board’s dedicated Mental Health Act Committee, we have undertaken dedicated focus group work with patients who have been detained with us, and who entered our care via a health-based place of safety (section 136 suite). This work will be repeated in 2026. The results provide a contrasting focus to the legal compliance focus of the committee: with patient feedback focusing on stigma, rights, and property protection, as well as the better care needed for carers and loved ones. As the trust moves to implement the amended Mental Health Act, which received Royal Assent in 2026, these will be important areas of focus for us.

We welcome feedback on ways to hear from patients that we have overlooked. We anticipate that the communities’ leadership executive will assist us with this curious enquiry.

Hearing patient voices, lessons from what goes wrong: patient complaints

During the year April 2025 to March 2026, we received 188 formal complaints. Further details are provided in the annex to this report.

We have focused, but continue to focus, on five areas of improvement within our complaints process:

• achieving our local standard of thirty days for a response, except where a longer timeframe is agreed with a patient: our current performance is 45 days (a significant improvement on 2024 and 2023)
• ensuring that the complaints process is used by patients drawn from all groups of society and those we treat. We know that historically fewer complaints than expected had been received from black and Asian local residents; whilst our data is weaker, we suspect a similar under-representation applies to patients with central and Eastern European heritage
• reducing the re-opening of complaints, which we consider to be a mark of dissatisfaction with the adequacy of the response; we recognise that some complaints cannot be resolved to mutual satisfaction and support the work of the Ombudsman in such cases
• being entirely confident that changes promised in responding to complaints have happened in practice and been effective in tackling the root cause of concern. A more comprehensive analysis of this did not take place in 2025 owing to other pressures but will be prioritised in 2026
• supporting our staff where a complaint has been submitted: we recognise that this can have an impact of individuals, and whilst we are confident this does not affect future treatment or care, we want to ensure a just process of reflection with colleagues where complaints are submitted

We will use Learning Matters during 2026 to provide more transparent insights across our organisation into actions from complaints. We know that most complaints focus on how we communicate and whether what is said or shared is fully understood and then accepted. Within healthcare it is accepted that sometimes difficult conversations may not be heard best “in the moment” and we will use technology to try and help share with patients and their carers reinforcing information.

Ensuring everyone can be heard: focusing on interpreting service use

In October 2025, the trust commissioned a new principal supplier of interpreting services. This procurement was undertaken with partners across the area, as the NHS seeks to level up provision. Within the trust we took a decision, which we will persist with, in the year April 2026 to March 2027, to exclude the cost of interpreting services from budget limits that services have to live within. This decision reflects two factors:

• clarity that for reasons of safety we must be confident of mutual understanding of care and consent, and it is unethical to rely on family members or other routes to obtain interpreting
• having no baseline against which to set or agree fair budgets given legacy provision was sporadically used and there is a risk of reinforcing continued low use

The Equity and Inclusion Group of our clinical leadership executive continues to sponsor work across our organisation to increase the use of interpreting services, and to work with interpreters to provide additional support to them when they work with us. For example, translation work during a cognitive assessment, may require specific approaches or attributes. Consistent with our Promise 8 intent to ensure that dementia services are accessible to all within our local communities this is an area of focus.

Since the new supplier began work with us, we can confirm that:

• fill rates are good: when an interpreter is sought, they are invariably provided
• feedback from services on the quality of interpretation is positive

It is clear, under the prior service, and now, that we have some trust services which use far less, or indeed no interpreters. Given the population we serve, this seems improbable. During April, May and June 2026 we are working with those services to understand the barriers to use and to ensure that they take up the interpreting offer.

Interpreting is available across almost the full range of local languages. This includes British Sign Language. Of course, patterns of migration are labile, and we need to continue to identify overlooked languages and source supply at pace. Under our always measures, to be introduced in 2026 in full, unavailability of interpreting would be a breach of measure five if it cannot be safely mitigated.

The highest volume five languages presently taken up through interpreting services are:

• Slovak
• Polish
• Urdu
• Farsi
• Romanian

Beyond measurement: embedding safer staffing approaches into the trust

The term safer staffing could be taken to apply to all clinical professionals working to care for our patients. That interpretation is the intent of the trust, but it is not our, nor wider NHS practice. Put differently, quantified validated tools for the number of staff needed, linked an algorithm of need, is confined to inpatient settings and to nursing staff. Declarations of safer staffing compliance are confined to these areas.

The trust has been working for some years to approach staffing on a multi-professional basis. In 2023 we analysed our staffing position against peers where data was available and reported that position publicly. Of course, comparison to other providers is not a comparison to need but it can identify where we are an outlier for consideration and assessment.

In January 2026 we made an investment to address just such an outlier arrangement, with the addition of some allied health professional and some psychology roles within our mental health wards: with a primary focus on our Doncaster wards, Cusworth, Brodsworth, and Skellbroke. Appointments during 2025 had addressed historic gaps within our Amber Lodge forensic and learning disability service.

Each day we study and adapt our nursing staffing for inpatient and crisis services. During 2025 that work took place against the Mental Health Optimisation Staffing Tool derived staffing levels set for our wards. Analysis on that basis in November 2024 and November 2025 did not give rise to a need to change established staffing levels which are funded, with a 28% uplift to address rota leave, training and an anticipated level of sickness. The chief nurse has repeatedly confirmed to the board the sufficiency of staffed numbers. In year changes to our reporting systems (the integrated quality performance report) has been designed to ensure that we do not report false positives of missing staffing level where grade mix has been adjusted.

From April 2026 we have implemented a Care Hours tool (Safecare) which is intended to add a better layer of scrutiny and analysis to our work on nurse staffing. Drawing on near real time acuity assessments, this will allow us to reprioritise staffing between teams on a cross ward and cross site basis. This work will be combined with tightening of rota compliance within the trust, with rota lockdown to reduce last minute changes. A successful pilot of staff self-rostering within our St John’s Hospice service will be more widely used in services from October 2026.

In line with the commitment to high quality therapeutic care seven days a week, which is outlined below, Safecare will also capture data on which two or more daily activities did run, and any that did not. Safety cannot be separated from activities if we are to offer good care and a less restrictive ward environment.

Improving the consistency of our care: inpatient mental health (high quality therapeutic care)

Between February 2025 and March 2026, on behalf of the Board, a cross-section of clinical, patient, and executive leaders formed a taskforce (the high-quality therapeutic care taskforce) intended to co-design and implement significant changes to care delivery within the trust’s mental health wards. This directly included older and working age wards as well as psychiatric intensive care. Leaders within our forensic and physical health wards have adapted the conclusions of this work to their circumstances.

The closure report for the taskforce was reported to the public Board in March 2025: it described both the successes and learnings from the work and set out how the work will be taken forward at pace during the rest of 2026. In October 2026 all mental health wards in the trust will be considered by the Royal College of Psychiatrists for accreditation. If this is successful, Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) will become the first mental health provider to achieve this across all of its ward units.

Among the successes of the taskforce’s work have been, and continue to be:

• standardised seven day per week visiting hours across all our sites, welcoming carers and loved ones in the morning, afternoon, and evening.
• peer support workers being part of every ward, bringing additional support and lived experience to our care pathways: connecting inpatients to community resources in line with promise 1
• the introduction of therapeutic activities across 7 days of each week, with a much larger range of activities available to patients and ward teams (the weaknesses of past arrangements were the key finding from our Care Quality Commission inspection in summer 2025)
• standardisation of purposeful inpatient admission (PIPA) meetings each weekday in each ward to plan care and discharge
• the introduction of trust wide approaches to the management of leave beds, and to the discharge process on a day

Significant work has been undertaken but continues to:

• ensure multi-disciplinary meetings about and with patients take place daily across weekdays from 14.00, with a £150,000 investment to ensure the right technology is in place by June 2026 to support community teams’ participation
• support expected dates of discharge being set and managed to within five days of admission based on agreed trust wide criteria adjusted for risk factors
• intervene in care pathways where an initial and defined diagnosis has not been identified within 14 days of admission and or where a discharge date exceeds 35 days from admission (excluding Ministry of Justice patients)
• rationalise care planning documentation to frame most care activities within the parameters of the DIALOG+ care planning approach outlined earlier in this report

Our high quality therapeutic care has been underpinned by our work on culture of care. This was a national programme to define the quality of inpatient services based on learning from national enquiries and reviews into ward-based care weaknesses.

Our approach to this work has been more rooted than national guidance in the voices and feedback of our patients. Initial analysis was undertaken, led by assistant psychologists, in spring 2025, and this was repeated in March 2026. The themes identified continued work through 2026 include:

• ensuring that our work to make our ward suitable for patients who are neurodiverse or who have specific sensory needs is effective, and that the newly purchased equipment and training is effective in practice
• developing further the role of peer support within multi disciplinary teams (MDTs), using the outcomes frameworks developed for the board in late 2025
• introducing more defined ward leadership teams (our multi professional leadership teams, MPLTs) to ensure that our wards develop to their full potential, going above and beyond the consistency standards defined by the high quality therapeutic care

---

Annex

Annex 1: how we did with our quality priorities 1 April 2025 to 31 March 2026

In the quality accounts 2025, we identified 4 quality priorities for:

Achieving a Good rating under the Care Quality Commission framework

We said: we will implement improvements to achieve a good rating under the Care Quality Commission framework.

We did: during April 2025 to March 2026, RDaSH implemented a trust wide programme of work to improve performance against the Care Quality Commission framework. This included completing a full internal self assessment against all Care Quality Commission domains, identifying gaps, and implementing targeted improvement actions. Evidence libraries were established across all directorates to demonstrate compliance with Care Quality Commission quality statements. These were supported by structured peer reviews and mock inspections, enabling the trust to identify and address issues proactively.

Evidence:

• completion of trust wide self assessment against the Care Quality Commission assessment framework during 2025
• establishment of team and directorate level Care Quality Commission evidence libraries, reviewed through delivery reviews and escalated to board time out oversight
• implementation of peer review activity across inpatient wards, with findings and action plans reviewed through quality governance structures
• Care Quality Commission readiness activity, including internal review sessions and inspection preparation exercises during late 2025 and early 2026

Implementation of the first phase of the quality and safety plan

We said: we will implement the first phase of our agreed quality and safety plan.

We did: the trust launched its quality and safety plan in spring 2025. The first phase focused on patient safety, experience of care and equitable access. Key actions included embedding new patient safety systems, strengthening clinical assurance, improving access standards, and increasing responsiveness to patient feedback.

Evidence:

• formal approval and launch of the quality and safety plan in 2025
• implementation of new patient safety and incident management arrangements during the year April 2025 to March 2026
• delivery of access improvements, including achievement of the trust wide four week standard for core mental health services by October 2025
• elimination of out of area acute mental health placements (out of hours)

Improving consistency of inpatient care (strategic objective 4)

We said: we will improve the consistency of our inpatient care and deliver against the promises within strategic objective 4.

We did: the trust delivered a significant programme of work to improve the quality and consistency of inpatient mental health care during the year April 2025 to March 2026. The high-quality therapeutic care (HQTC) taskforce was used as the primary delivery vehicle to define and implement consistent ward practices. Standardised ward routines, multidisciplinary working arrangements and therapeutic timetables were developed and rolled out. Five trust wide “always measures” were agreed to ensure that core elements of care occurred reliably for every inpatient. These changes were developed across all adult mental health wards, reducing unwarranted variation and improving patient experience.

Evidence:

• establishment and operation of the high-quality therapeutic care taskforce throughout April 2025 to March 2026
• introduction of trust wide standard ward timetables and consistent multidisciplinary processes
• secured five “always measures”, including timely personalised care planning, consent, and carer involvement
• achievement of seven day therapeutic activity provision on all adult mental health wards
• audit and performance data demonstrating improved compliance with care planning and ward level standards by late 2025 and early 2026

Flu vaccination focus (April 2025 to March 2026)

We said: we will continue to focus overwhelmingly on flu vaccination for students, volunteers and staff, as well as selected patients.

We did: the trust delivered an intensive flu vaccination campaign throughout the April 2025 to March 2026 season, prioritising staff, students, volunteers and bank workers. Multiple delivery methods were used, including roving vaccinators with every level of nurse vaccinating including the chief nurse, workplace clinics and targeted communications. Senior leaders monitored uptake closely and introduced additional incentives and outreach where needed. The programme also included vaccination of selected patient groups, particularly inpatients and those being discharged to high risk settings.

Evidence:

• delivery of a trust wide flu vaccination campaign during autumn and winter April 2025 to March 2026
• vaccination of large numbers of staff, volunteers, students and bank workers within the first weeks of the campaign
• extension of flu vaccination to eligible inpatient groups as part of discharge and infection prevention planning
• ongoing monitoring of uptake data through workforce and infection prevention governance arrangements

Annex 2: our quality priorities for 1 April 2026 to 31 March 2027

Recognising that the trust’s board has adopted a multi-year quality and safety plan, we have nonetheless identified, as required, a specific annual list for focus in the year ahead.

Our quality priorities for 1 April 2026 to 31 March 2027 are as follows:

1. sustain focus on using patient’s feedback at service and directorate level to adapt and improve services
2. improve the rigour of the use of our Patient Safety Investigations Review Framework approach, ensuring that we can evidence genuine change resulting from patient safety incident investigations
3. tackle racism within our services as part of work to address inequalities and exclusion
4. implement our quality and safety plan, applying always measures to services during April 2026 to March 2027
5. increase the uptake of and learning from, paired outcome measures across all age services

Annex 3: learning from deaths

The trust is improving how it learns from deaths by making sure every death is carefully reviewed. Designated clinical practitioners look at each case to see if anything could have been done differently, and if needed, they carry out deeper investigations. This helps the trust understand what went wrong and what needs to change to keep people safer in the future. We have made some changes as a result of some of these investigations such as we now offer a crisis service to everyone no matter what their age is as before this was something that wasn’t available to over 65-year-olds.

The trust is also working to make care more joined up, especially when people move between services or leave hospital. We have changed when we run our inpatient meetings to ensure that community teams can be involved. We are also investing in having better technology such as videoconferencing to allow community teams, relatives and carers to come to meetings if they can’t make it in person. We have also put a lot of effort into trying to avoid sending patients out of area as it can be harder to provide joined up care if people are being treated away from home.

Another key change to make care joined up is having a care plan that will follow people from out of hospital into hospital and back out again. Sometimes the plan will need changing but our work giving people a single care plan that we produce with our patients should make it easier for everyone to know what the plans are.

The NHS introduced guidance on reducing suicide and we are busy doing work to implement these recommendations. A big part of this work is how we approach risk assessment. Instead of seeing risk as fixed, staff are now encouraged to keep reviewing it as things change as people are complex. We have been involved in some exciting pilots such as Rotherham Vista project that looks to provide support to people who have attempted suicide.

We don’t just look at our own deaths and learning. We regularly look at deaths and incidents that have happened outside the trust to see if there is anything for us to do to make sure that the same sorts of things don’t happen here.

Reviews of deaths

Doncaster mental health and learning disabilities includes learning disability deaths in all areas of the trust.

A structured judgement review (SJR), based on the methodology from the Royal College of Physicians, is a standardised, case note review process used to assess the quality of care in patients who have died. We use this process to look at the care of anyone that has died under the care of services who has a diagnosis of learning disability or is on the autistic spectrum following national guidance. We completed 23 of these reviews over the last year.

Patient safety incident investigations (PSIIs) are detailed investigations to identify whether problems in care contributed to the mortality, what happened, and how it can be prevented from happening again through learning and improvement. We undertake these in circumstances such as if a mental health patient dies on one of our wards or if it is felt that death may have arisen due to problems in care.

Annex 4: statements of required assurance

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 9 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 many strengths in our approach, but we discuss within the annual report, there is evidence of weakness that needs attention.

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, security support team and Radar. 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.

During this current financial year 1 April 2025 to 31 March 2026 there have been 101 concerns raised within the trust. The guardian continues to deliver training around civility in respect in conjunction with colleagues from the organisational development department to promote principles of speaking up as well as increasing visibility. We continue to promote the Freedom to Speak Up pathway and the learning from concerns raised is shared with individuals, at care group level and in the Quality and Safety Group.

April 2025 to March 26 quarterly pattern:

• quarter 1: 12
• quarter 2: 18
• quarter 3: 36
• quarter 4: 35

Clinical audit

National clinical audits and national confidential enquiries

The table below details the national clinical audits and confidential enquiries that the trust participated in during April 2025 to March 2026. The trust participated in all eligible audits. The National teams no longer stipulate an exact number of cases required.

Action that the trust has taken or intends to take as a result of these national audits or national confidential enquires

National Audit of Inpatient Falls (NAIF)

• Falls Leads to ensure older people receive a documented lying or standing blood pressure (BP) measurement completed in full on admission as part of the multifactorial falls risk assessment (MFRA). Any training needs are to be addressed for those staff who lack this clinical skill.
• Falls Leads to ensure that patients have a delirium assessment and where applicable a corresponding care plan which is completed in full on admission as part of the multifactorial falls risk assessment. Any training needs are to be addressed for those staff who lack this clinical skill.
• Patients who complain of pain following a fall must be offered analgesia and for this to be recorded in the clinical record
• All moderate harm and above falls will be subject to a swarm debrief within 5 working days or an after-action review (AAR) within 2 weeks if indicated
• Date and time of transfer to the acute hospital to be recorded in the post falls management section of the multifactorial falls risk assessment.

National Diabetes Footcare Audit (NDFA)

• 71.8% of patients with a severe ulcer are alive and ulcer free after 12 weeks.
• Where there are issues with referrals from other health professionals external to the trust, for example, GPs, the team to write to the referrer to advise.
• Where issues arise with referrals internal to the trust, the team hold a swarm huddle.

National Clinical Audit of Psychosis (NCAP), early intervention in psychosis (EIP): routine data extraction (CS)

Data specialist for the ongoing audit within the trust has been identified. This specialist will align SystmOne snomed codes to the trust’s Mental Health Services Data Set (MHSDS) to allow routine data collection (Snomed is systematized nomenclature of medicine clinical terms and is a structured clinical vocabulary for use in an electronic health record).

Prescribing Observatory for Mental Health topic 21b: The use of Melatonin

• Circulation of précis to Children’s Care Group and Doncaster Adult Mental Health and Learning Disabilities Care Group for action planning.
• Melatonin training package provided by the pharmacy team as part of learning half days. Package shared across care groups.

Prescribing Observatory for Mental Health UK topic 18c: Use of Clozapine

Medicines Optimisation Group reviewed the audit and circulated to care groups for action planning and further circulation.

Sentinel Stroke National Audit Programme (SSNAP) Audit:

6 trust admin team members now have access to the Sentinel Stroke National Audit Programme database to improve data entry, with clinician support if needed.

Prescribing Observatory for Mental Health topic 20c: Improving the quality of valproate prescribing in adult mental health services

• Audit report and précis sent to care groups and presented to care group Quality Meetings
• Valproate template reviewed and amended to include named clinicians to improve flow and compliance
• Process of linking prescribing through the SystmOne template reviewed with Humber Mental Health Trust.

Trust (local) clinical audits

The table below shows the local clinical audits undertaken during April 2025 to March 2026 and the outcome of these.

Where there was a need to improve compliance, the audits listed below required the support of an improvement cycle and plan, do, study, act (PDSA) cycles were utilised to implement changes in clinical practise leading to improvements.

The audits involved were:

• reducing restrictive interventions (PMVA) in Rotherham and Doncaster adult mental health inpatients
• healthcare record keeping in physical health: inpatient and community

Audit actions

Of the 14 local clinical audits completed by 31 March 2026, action plans were developed to improve the safety and quality of healthcare provided, generating a total of 72 actions. 51 (70.8%) of the agreed actions have been completed.

Examples of these actions are:

Health care record keeping re-audit

The full audit tool put onto Radar for monthly compliance monitoring by all Physical health care teams to monitor ongoing compliance.

Review of the health contribution to the Education Health Care Plan (EHCP)

• Golden Thread training delivered.
• Amendment to the special educational needs and disability (SEND) policy to include the Golden Thread training as well as the online training.

Neurodiversity attention deficit hyperactivity disorder quality improvement audit

• Patients who did not attend (DNA) face to face appointments or fail to give blood pressure, pulse, weight readings at telephone appointments to be discharged.
• If abnormal results, for example, high blood pressure or abnormal Electrocardiogram (ECG), the GP for the patient will be notified.

Reducing restrictive interventions (RRI) trust wide audit

• Reducing restrictive interventions lead and resuscitation officer carrying out weekly spot checks on documentation (NEWS2 and neuro observations) on mental health inpatient wards, with omissions brought to the attention of the ward leaders to act on.
• All areas have a positive behavioural support (PBS) lead, and all staff have completed positive behavioural support training.

Stopping over medication of people with a learning disability, autism or both with psychotropic medicines (STOMP) stopping over medication of people (baseline) audit

Care home training currently being delivered to North Lincolnshire. Future roll-out into the other localities.

Mental Capacity Act (2005)

• Mental Capacity Act (MCA) Champions identified in each team within the directorates.
• Development of link Multi professional Champion Mental Capacity Act Leads Network and Mental Capacity Act Champion Network meetings.
• Review of MCA1 and MCA2 templates in SystmOne following feedback from Care Group link champion network sessions.
• Development of Mental Capacity Act Standards for when to record on MCA1.
• Plan, do, study, act (PDSA) random selected dip samples (up to 5 NHS numbers) monthly by Mental Capacity Act Office.
• Review efficacy of Mental Capacity Act link Champion Network.
• The Mental Capacity Act re-audit is currently underway, and initial findings indicate a promising improvement to compliance.

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.

The four standards concern:

Respecting and protecting rights

Across services, multiple reasonable adjustments are made for people with learning disabilities and or autism to ensure care and treatment are tailored to individual needs. These adjustments include the use of adapted communication methods, flexible appointment systems, modified triage assessments, and appropriate consideration of information contained within hospital passports.

Vulnerable inpatient person (VIP) bags have been implemented across two community services to support individuals admitted to acute settings. This initiative complements the promotion and embedding of hospital passports to enhance continuity and quality of care.

The trust is represented locally at learning disabilities mortality review (LeDeR) assurance panels and undertakes structured judgement reviews following the death of individuals with learning disabilities. Learning from these reviews is triangulated and shared through clinical quality meetings to inform service improvement.

The trust maintains robust oversight of any restrictions placed on individuals with learning disabilities, including the use of deprivation of liberty safeguards. There is a dedicated lead for mental capacity, and within the learning disabilities directorate, representatives contribute to trust wide forums. Staff are also required to attend mandatory training to support safe, lawful, and person-centred practice.

Inclusion and engagement

The trust is committed to promoting inclusion and meaningful engagement for people with learning disabilities and or autism, ensuring their voices are central to service design, delivery, and evaluation.

People who use services, along with their families and carers, are supported to be actively involved in decisions about their care. This includes the use of accessible information, co-produced care planning, and opportunities to provide feedback on their experiences. The trust continues to promote the use of easy-read materials and adapted communication approaches to enable individuals to understand and contribute fully.

The learning disabilities and forensics directorate works collaboratively with experts by experience and carers to inform service development and improvement. Engagement forums and feedback mechanisms are in place to capture lived experience, and this insight is used to shape service delivery and drive quality improvement.

The trust also maintains links with partner organisations and community groups to support wider inclusion, reduce health inequalities, and improve access to services. Staff are supported through training and guidance to understand the importance of inclusive practice and to develop the skills required to engage effectively with people with learning disabilities and or autism.

Through these approaches, the trust aims to ensure that services are inclusive, responsive, and reflective of the needs and preferences of the people they support.

Workforce

In 2026, the learning disability directorate will finish 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.

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, autism or both with psychotropic medicines (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.

Review of services

During the year April 2025 to March 2026, Rotherham Doncaster and South Humber NHS Foundation Trust provided and or subcontracted 89 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 89 of these relevant health services.

The income generated by the relevant health services reviewed in the year April 2025 to March 2026 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 2025 to March 2026.

Further details of the services provided and subcontracted by Rotherham Doncaster and South Humber NHS Foundation Trust are provided our services section.

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 2025 to March 2026, 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 673 against a target of 900 participants in the National Institute of Health and Care Research portfolio studies, a large interventional trial, individual, group, leaders, organisation (IGLOo) closed in year 1 April 2024 to 31 March 2025 impacting on our recruitment figures in year. The National Institute of Health and Care Research Research Delivery Network set the arbitrary target of 900 as with previous years, despite the shift in portfolio activity.

Commissioning for quality and innovation (CQUIN)

The commissioning for quality and innovation (CQUIN) framework supports improvements in the quality of services and the creation of new, improved patterns of care. Please note the mandatory commissioning for quality and innovation framework scheme has been paused and has not applied in year.

Care Quality Commission (CQC) 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 (CQC) registration, during the year April 2025 to March 2026 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

Our work within the new Phoenix ward has been duly notified to the Care Quality Commission.

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.

Data quality: hospital episode statistics

Rotherham Doncaster and South Humber NHS Foundation Trust submitted records during the year April 2025 to March 2026 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)

Data quality: data security

The national NHS England Digital Data Security and Protection Toolkit reports whether standards have or have not been met from NHS Provider submissions. The trust achieved “standards met” for the year July 2024 to June 2025 and expect to achieve “standards met” for the year July 2025 to June 2026 with the final submission in June 2026.

Data quality: payment by results

Rotherham Doncaster and South Humber NHS Foundation Trust is paid on a block basis for the majority of services it delivers. 1.8% of income relates to elective recovery funding and is therefore subject to NHS Payment Scheme reporting.

Data quality: the action taken to improve data quality

Data quality and accuracy are governed through the trust’s annual data quality improvement programme, which reports quarterly to the Finance, Digital and Estates Committee (FDEC) on progress and current position. The programme focuses on key measures aligned to the integrated quality performance report, the accompanying information management guide, and other identified priority metrics.

Clinical leadership for data quality is provided by the chief nursing information officer (CNIO), who supports the translation of data quality requirements into improved clinical recording accuracy and practice. This role also ensures alignment with wider objectives for quality of care delivery and operational efficiency. The chief nursing information officer is supported by a monthly Data Quality Group, which provides oversight and coordination of improvement activity.

Subject to both internal and external validation processes, the trust is committed to the continuous improvement of its position particularly in relation to data quality and associated quality-of-care outcomes.

The quality of services is increasingly defined at an operational level through the clinical leadership executive (CLE). Care groups and directorates are responsible for delivery, supported by patient, carer, and stakeholder involvement, and operating within established organisational governance arrangements with oversight from the board of directors.

The trust has an approved clinical audit policy and an established clinical audit programme, which are used to focus on key risks and nationally identified priorities. Progress against the clinical audit programme, along with audit outcomes, is reported to care groups to support learning and service improvement.

The trust data quality policy provides assurance on the organisation’s approach to data quality, aligning with the trust’s information governance and information management framework, national data standards, and relevant legal obligations. The policy establishes clear trust wide ownership, accountability, and actions to support continuous improvement in data quality, recognising the critical importance of accurate data for patient care and safety. The trust has also introduced Data Saves Lives as a local campaign aligned to the national strategy. This initiative has focused on data quality, electronic patient record (EPR) training, and effective data use. During quarter 3 and quarter 4, the Information Quality team, working in collaboration with Performance, Reporting, and Finance teams, delivered “Data Saves Lives, why does data matter to me?” training as part of trust learning half day sessions. These two-hour sessions emphasised the importance of data quality and its impact across the NHS.

Annex 5: 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 2025 to March 2026.

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 2026 to March 2027) that 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 2026 to March 2027): that 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 2025.

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 the trust in 2025 contacted 1205 service users, of which 201 completed the survey, yielding a response rate of 16.7%.

The results for specific questions are categorised depending on whether they are better, worse or about the same compared with other trusts. For Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) the breakdown was as follows:

• in 15 questions, RDaSH was about the same as the national average
• in 5 questions, RDaSH was somewhat better as the national average
• in 12 questions, RDaSH was better as the national average
• in 1 question, RDaSH was much better as the national average

In comparison to other trusts, we continue to lead the way in patient experience of mental health services, performing much better than expected for two years. We have consistently performed better than expected with respect to the support we provide to access care and treatment, getting the help patients needed, and supporting patients to make informed decisions about the care they receive. We also performed better with respect to the support that we provide to patients to meet their needs and consideration of their wider life circumstances that impact mental health.

Source:

• NHS England (data only published annually in September each year)
• RDaSH Ulysses incident reporting system
• RDaSH Radar reporting system

The Rotherham Doncaster and South Humber NHS Foundation Trust continues to encourage reporting of incidents and has seen a decrease in reporting between April 2025 to March 2026 of 19.8% when compared to April 2024 to March 2025. There was a minor increase in the patient safety incidents reporting severe harm and a significant reduction in the patient safety incidents resulting in death.

The reduction in reported patient safety incidents for April 2025 to March 2026 is attributable to the implementation of the trust’s Radar incident reporting system in May 2025. The transition from the previous reporting system led to anticipated variations in reporting volumes during this period. The trust remains committed to fostering a culture of reporting and employs Patient Safety Investigations Review Framework proportionate, systems-based learning responses and commissioning patient safety incident investigations (PSII)

In accordance with the Patient Safety Investigations Review Framework, the trust applies proportionate, systems-based approaches to learning and initiates patient safety incident investigations (PSII) selectively, focusing on cases where meaningful improvements can be achieved. Consequently, the number of deaths investigated may be lower compared to the former serious incident framework, while rigorous mortality review, escalation, and learning processes continue to be upheld.

Annex 6: 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.

The trust had an inspection of acute wards for adults of working age and psychiatric intensive care units in May 2025 and the report was published in December 2025 (report dated (July 2025). The rating for these services is shown in the tables below but did not affect the overall rating of the trust. The report from this inspection can be found at the Care Quality Commission.

An action plan was developed to address the concerns raised by Care Quality Commission, but these actions had already been in train for some time. For instance, our high quality therapeutic care (HQTC) taskforce has progressed our work on activities being available 7 days a week, with this being expressed as a core offer, rather than an optional addition and going forward will be a key part of our daily staffing escalations.

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 2020 inspection and therefore the rating remains the same.

Ratings for whole trust February 2020

Service level ratings comparative with previous inspection results

Ratings for community services

Ratings for mental health services

Annex 7: statements from integrated care board, 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
• HealthWatch North Lincolnshire
• Humber and North Yorkshire Integrated Care Board
• Rotherham Doncaster and South Humber NHS Foundation Trust Council of Governors
• NHS South Yorkshire Integrated Care Board: Doncaster and Rotherham Place: not received

Rotherham Local Authority Health Select Commission

The Health Select Commission welcomes the opportunity to review the Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) Quality Account for 2025 to 2026. The Commission recognises the important role of quality accounts in providing transparency and assurance regarding the quality and safety of services and acknowledges that the trust has responded positively to feedback previously provided. The improved clarity of presentation, the increased use of plain English, and the stronger articulation of how feedback informs service improvement are welcomed and members consider this indicative of a culture of openness, learning, and responsiveness.

A strength is the emphasis on patient voice. The systematic use of feedback mechanisms, alongside clear “you said, we did” examples, provides assurance that lived experience is influencing service delivery. This could be further enhanced by including an additional column identifying next steps. The commission welcomes efforts to reach seldom-heard groups, including initiatives to bring voluntary and community sector voices into senior leadership discussions. Further clarity on how diverse communities are defined and supported, including how Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) engages with individuals with communication needs linked to disabilities or neurodivergence, would be helpful.

The commission noted several areas of positive progress including the elimination of out-of-area placements for Rotherham residents since January 2026, representing a marked improvement in continuity of care and reduction in inequality linked to travel, cost, and social isolation. The introduction of seven-day therapeutic activity programmes on inpatient mental health wards is also welcomed. The commission notes the expected benefits for patient wellbeing, but challenges the trust to consider what staff wellbeing and resilience benefits this might also bring.

Improvements in access are also acknowledged, including delivery of a four-week maximum waiting time across many services and notable reductions in waiting times for children’s therapies. The commission notes this reflects that focused effort can deliver meaningful change, however, it is concerned that similar progress has not yet been achieved in neurodiversity services and urges focus to address the continuing challenges in this area, where assessment and diagnosis waiting times remain unacceptably long. Such waits impact a significant number of Rotherham’s most vulnerable residents and have the potential for significant, long-term adverse impact on children, young people, and families. The commission considers that comparisons to poorer-performing areas do not provide sufficient assurance of progress and would welcome the trust defining targeted waiting times supported by an improvement given that this remains a concern. Members were keen to hear about progress in this area at a future Health Select Commission meeting.

The commission also highlights the need for greater transparency and evidence in several areas of the report. In particular, statements regarding service models, such as the blended functional and organic model for older adults’ inpatient care, require clearer explanation of both the approach and its benefits. Similarly, while the “you said, we did” framework is commended, the commission suggests that inclusion of next steps or ongoing actions would further strengthen understanding of continuous improvement.

In relation to care planning, the commission commends significant progress in inpatient settings but remains concerned that approximately half of community mental health patients do not yet have a DIALOG or equivalent care plan in place. The disparity between inpatient and community settings would benefit from further explanation. Likewise consistent data presentation, including both fixed values and percentages would enable clearer interpretation of impact.

The commission was concerned about workforce culture given that findings reflected not all staff believe safety is the organisation’s top priority, or that speaking up leads to change. Whilst the commission welcomes the increase in Freedom to Speak Up cases, which has seen significant increases over time, and the introduction of improved incident reporting systems, it appears that further work is required. Members were unclear from the report whether mechanisms supported reporting anonymity where required, which may prove critical to encouraging engagement in the face of uncertainty. The commission would welcome the same “you said, we did” approach for staff feedback to demonstrate how concerns raised lead to meaningful change. Members were keen to see more detailed analysis of the nature and scale of safety concerns, how these relate to issues such as workload, violence, clinical risk, or governance processes, and how improvement will be measured. They were likewise minded that consideration should also be given correlation between workforce concerns, sickness absence, recruitment, and retention.

The commission welcomes the trust’s inclusion of a self-assessment against Care Quality Commission (CQC) domains. This provides a useful indication of areas of improvement, stability, or decline where there have been significant periods between inspections. Linked to this, members noted concerns arising from clinical audit findings, including inadequate ratings in areas relating to the Mental Capacity Act and blanket restrictions in mental health services. Given the seriousness of these findings, members would welcome the opportunity to discuss the trust’s understanding of underlying causes and the actions being taken to address them at a future Health Select Commission meeting.

In relation to equality and health inequalities, the commission welcomes the trust’s acknowledgement of underrepresentation in complaints from Black, Asian, and Central and Eastern European communities. However, this highlights broader limitations in the use of data to understand how different groups experience services. The commission encourages a more systematic approach to disaggregated data, including factors such as ethnicity, deprivation, age, and communication needs, to ensure that improvement is equitable, and that hidden inequalities are identified and proactively addressed. Whilst members recognise that challenges are openly acknowledged within the report, they encourage stronger focus on measurable outcomes, clear timelines, and accountability to support demonstration of sustained improvement.

Members recognise that the trust has made meaningful progress and demonstrates clear commitment to learning and improvement, thanks the countless staff who work incredibly hard to deliver vital services to Rotherham residents and looks forward to supporting the trust through effective scrutiny, to continue to improve patient safety, experience and outcomes.

Councillor Eve Keenan, Chair
Health Select Commission
Rotherham Metropolitan Borough Council
22 May 2026

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, Senior Governance Officer
City of Doncaster Council
3 June 2026

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 2025 to 2026 Quality Account. Rotherham, Doncaster and South Humber NHS Foundation Trust is a key partner, providing vital 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 2026 to 2027 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 set out in annex 2. We also very much welcome the “you said, we did” section, which we believe sets out successes in a clear and easy to understand manner, and which helps to demonstrate the impact of responding to feedback and learning.

We do have some concerns with the outcomes of clinical audits as described on table 4, two of which are rated as inadequate, and five of which are requires improvement. We would welcome future discussions on this, including consideration of the relevant action plans.

For future reference, whilst we certainly welcome the section at annex 1 (how we did with our quality priorities), it would be useful to also see some high-level quantitative data in this section, in addition to descriptions of completed or planned work, or qualitative descriptions of evidence without inclusion of this data. Our view is that this would better explain how the trust has improved services, whilst also providing objective evidence that this has happened.

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

Councillor J Kennedy, Chair
North Lincolnshire Council’s Health and Care Integration and Performance Scrutiny Panel
4 June 2026

HealthWatch Doncaster and Healthwatch Rotherham (joint statement)

HealthWatch Doncaster and HealthWatch Rotherham welcome the opportunity to respond jointly to the Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) Quality Account for 2025 to 2026. We are grateful to the trust for sharing its draft account with us and for its continued commitment to transparency and openness in reporting. We would also like to acknowledge and thank the staff at RDaSH who work hard every day to deliver care to our communities.

Transparency and honest reporting

We particularly welcome the tone and approach of this year’s quality account. The chief executive’s introduction sets out a clear intent for radical candour, acknowledging areas of weakness alongside genuine improvement, and we believe this is exactly the right approach. A report that only celebrates success provides less assurance to the public than one that is honest about what remains to be done. The trust’s willingness to name ongoing concerns, including Care Quality Commission ratings, care planning documentation gaps, racism, long neurodiversity waits, and community mental health rigour, is both refreshing and necessary.

We are also pleased to see that the format of the account has changed to bring patient experience to the foreground, with the statutory annexes placed where they belong, as supporting evidence rather than the centrepiece. This is a meaningful shift in how the trust is presenting its relationship with the people it serves.

Patient voice and Care Opinion

We strongly welcome the trust’s commitment to embedding patient voice across its work. The use of Care Opinion as a principal feedback mechanism, with over 2,000 stories in the last twelve months and response rates of around 85% within a week, is impressive. The “you said, we did” examples in the report are meaningful, demonstrating tangible changes driven directly by feedback. This is the kind of accountability loop that HealthWatch organisations exist to promote.

We are, however, keen to understand more about how the trust is reaching those people who are not already engaged with its services. Care Opinion, by its nature, captures the experience of people who are motivated and able to share feedback. Those who are most marginalised, people with very severe mental illness, those without digital access, people who feel disempowered or disconnected from services, or those who have disengaged entirely, are often least likely to post on any feedback platform.

We therefore ask the trust to consider and report on

• What proportion of feedback through Care Opinion comes from people who are active participants in peer groups or are regularly engaged in services? People who attend peer support drop-ins, group activities, and recovery programmes are likely to report positively, and rightly so. But this may mean the platform disproportionately captures a more connected cohort.
• How is the trust capturing the experience of people who have left services, disengaged, or had a negative outcome? Unsatisfied patients are much less likely to volunteer feedback. The trust’s own acknowledgment that the majority of Care Opinion stories are positive (over 80%) is welcome, but it raises whether the platform has a selection effect toward those whose experience is broadly good.
• While the trust acknowledges digital exclusion, the report does not provide data on the scale of this issue or how it is being mitigated. We would welcome specific information: how many people are assisted to provide feedback through non-digital means? What is the trust doing to reach people for whom online platforms are not accessible, including those with learning disabilities, older adults in less digitally connected communities, and those whose first language is not English?
• We would like to challenge the trust to set explicit targets for reaching seldom-heard groups through its feedback mechanisms, and to report transparently on progress against those targets in next year’s account.

Carer involvement and always measure 3 and 4

We particularly welcome always measure 3 (asking every patient if they have a carer, family member, friend or advocate they wish to involve, and then acting on the information that person shares) and always measure 4 (offering carers an assessment and reassessment at any point or change in circumstances). These are commitments that carers and carer organisations have long asked for, and we are pleased to see them embedded as a 100% standard.

We have heard directly from people in our communities about their experiences as carers of Rotherham, Doncaster and South Humber NHS Foundation Trust service users. One carer has told us of a positive experience of collaboration in developing training materials to help staff recognise and support carers, which is encouraging. However, we have also heard from carers who feel their role is not consistently acknowledged in practice. In the words of one person who contacted HealthWatch Doncaster: carer status is not always proactively identified, and when it is mentioned, it does not always change the conversation.

We would ask the trust to report in the next quality account on the measurable implementation of always measures 3 and 4: how many patients were asked about carer involvement? Of those who identified a carer, how many carers were offered a formal assessment? We believe this data is essential to moving from a commitment on paper to a demonstrable change in experience for carers.

Waiting times and access

We recognise and welcome the significant progress the trust has made in reducing waiting times across the majority of its services, and the four-week standard being achieved across over seventy services is genuinely commendable. People in Doncaster and Rotherham told us for years that waits for mental health support were too long, and this progress matters.

However, we echo the concern raised by HealthWatch Rotherham about the continued impact of long waits in child and adolescent mental health services (CAMHS) and neurodiversity pathways. These are not abstract statistics. People who contact HealthWatch describe waits for neurodiversity assessment as life-altering, affecting children’s education, adults’ employment, and families’ wellbeing. We also note a specific concern raised directly with us about the podiatry service in Doncaster, where reduced clinical scope now means some people with diabetes who were previously offered routine foot care are no longer eligible for the same support, and face either long waits or a referral to private provision. We ask the trust to address this in its response and to consider how it communicates changes in service scope to patients.

We also received feedback about the practical experience of attending sites, including difficulties navigating the Tickhill Road site without clear directions, and concerns about the environment in some waiting areas. While these may appear minor, they reflect the experience of people coming into contact with services, often at a time of vulnerability. We would ask that the Trust considers how it attends to the basics of patient experience alongside its larger improvement programmes.

What we would like to see in future

Looking ahead, we would encourage the trust to:

• publish specific data on the reach of its patient feedback mechanisms, broken down by demographic group, including age, ethnicity, and mode of access (digital versus non-digital)
• report measurable outcomes against always measures 3 and 4, so that carer involvement moves from aspiration to demonstrable practice
• continue and strengthen its work on Nomad medication support, particularly for elderly patients and those with severe and enduring mental illness, where inconsistent pharmacy provision is causing concern
• provide a specific update on the podiatry service in Doncaster and how it is managing the impact of the change in clinical scope on patients who relied on routine diabetic foot care
• ensure that the communities’ leadership executive, due to launch in 2026, is genuinely co-produced with voluntary and community sector partners, and that its membership reflects the breadth and diversity of the communities Rotherham, Doncaster and South Humber NHS Foundation Trust serves

Our offer: enter and view visits

HealthWatch organisations have a statutory power to carry out Enter and View visits to health and social care services. We would not ordinarily use this power until a significant volume of concerns had been raised about a particular service. However, we recognise that the trust is actively seeking to improve, and we believe that an independent, patient-focused perspective can add value as part of that journey rather than only as a response to serious concern.

We are therefore making a proactive offer: HealthWatch Doncaster and HealthWatch Rotherham are prepared to carry out two enter and view visits during 2026 to 2027, to services identified jointly with Rotherham, Doncaster and South Humber NHS Foundation Trust. We would ask the trust to use its Care Opinion data, specifically the services which have received the highest volume of critical or moderately critical stories, to inform that conversation, and we invite the trust to share that analysis with us. The final choice of services would be agreed together, ensuring the visits are genuinely collaborative and constructive in intent.

Our enter and new reports will be published in the usual way, with findings shared with the trust, the relevant integrated care board, and the Care Quality Commission. We see this as an opportunity to bring an independent patient voice into services that are already committed to improvement, and to help the trust test whether the changes it is making are being felt by the people receiving care. We invite the trust to respond to this offer and to work with us to agree a programme and timeline before the end of summer 2026.

Conclusion

HealthWatch Doncaster and HealthWatch Rotherham are broadly encouraged by this quality account. The direction of travel is right: greater transparency, stronger patient voice, meaningful improvement work, and honest acknowledgement of what is still not good enough. We look forward to continuing to work alongside Rotherham, Doncaster and South Humber NHS Foundation Trust, and to seeing the commitments in this report translated into lived experience for the people we both exist to serve.

Fran Joel Kym Gleeson
HealthWatch Doncaster and HealthWatch Rotherham
4 June 2026

HealthWatch North Lincolnshire

HealthWatch North Lincolnshire welcomes the chance to comment on the quality account for the year April 2025 to March 2026.

The account contains a strong focus on how service user voice impacts upon service development and delivery with examples provided of how the trust has made changes as a result of feedback given via Care Opinion. The account also highlights the importance placed on learning from feedback with the trust dedicating four hours every month, across all the organisation, for reflection and improvement.

The quality accounts show that whilst the Care Quality Commission inspection of acute wards for working age and psychiatric intensive care units highlighted areas that require improvement it also shows the actions taken in response, including establishing the therapeutic care taskforce to try to provide a greater level of consistency in care for the mental health wards.

The quality account also shows the actions the board has taken over the past year in service scrutiny. Of note is the boards consideration of the long waits people are experiencing to receive a neurodiversity diagnosis; a subject that families have previously raised with HealthWatch North Lincolnshire. Whilst it is encouraging that waiting times should be decreased by October, two years waiting for a diagnosis is still going to create significant impact for those waiting. Putting in place more support pre-diagnosis would be beneficial.

The quality accounts shows that not enough staff within the organisation believe that safety is of top priority, as revealed in the trusts annual staff survey. The staff survey also highlighted that not all staff feel that highlighting issues will lead to change. However, it is positive that the trust recognises that this area needs serious attention and has tried to address this through the board working with staff representatives to improve organisational culture.

It was also encouraging to hear how the trust supports those with a learning disability and autism through reasonable adjustments that are put in place such as adapted communication methods and flexible appointment systems, The quality accounts also mention that engagement forums and feedback mechanisms are in place to help capture the lived experience.

In the report it states that the trust welcomes feedback from patients and we look forward to continuing to work with Rotherham, Doncaster and South Humber NHS Foundation Trust representatives to help highlight service user experience.

Jen Allen, Manager
HealthWatch North Lincolnshire
26 May 2026

Humber and North Yorkshire Integrated Care Board

The Humber and North Yorkshire Integrated Care Board (ICB) welcomes the opportunity to comment on Rotherham Doncaster and South Humber NHS Foundation Trust’s Quality Account for 2025 to 2026.

We wish to thank all staff for their continued dedication to the local population of North Lincolnshire, our partners and the wider health and care system.

We note the trust’s adoption of a new reporting style for its quality account, reflecting the embedding of learning, outcomes and patient voice more explicitly across its services.

We acknowledge the work in the implementing the first phase of this longer term 2025 to 2027 Quality and Safety Plan; seeing the introduction of five “always measures” and an ambition for Royal College of Psychiatrists accreditation across all mental health wards. The integrated care board looks on with interest to learn of how the trust’s 3-year quality and safety plan, 5 new quality priorities and existing 28 promises develop over the coming years. We commend the trust on the proactive approach in strengthening of its flu vaccination programme for staff, volunteers, students and eligible patients, with uptake monitoring and targeted outreach.

The integrated care board note the work being done to strengthen the patient voice, including the successful adoption of Care Opinion, and the inclusion of peer support workers in reviews and improvement work. The integrated care board were delighted to read and see the recognition that most Care Opinion feedback is positive. We also recognise significant progress in implementing the use of the DIALOG+ tool across all the trust’s mental health services, inpatient wards and community teams; improving communication and information sharing across services.

We commend the trust on the national clinical audits and local trust audit activity, noting the work in relation to post-audit action planning and connectivity to wider quality improvements. We particularly note the information set out in the Learning Disability Improvement Standards, benchmarking and the transparency within the account noting there is partial compliance.

Throughout, we recognise the approaches in empowering staff to speak up and are pleased to hear about how embedding Freedom to Speak Up team has strengthened the trust’s safety culture. We acknowledge the achievements within the Account, including the programme of self-assessment, incorporating peer reviews and the establishment of directorate level evidence libraries, this representing a more systematic approach to regulatory preparation.

The integrated care board would like to congratulate the trust’s continued focus on reducing out of area placements and the reopening of the Great Oaks site, also the work in respect of the neurodiversity pathway, with the new attention deficit hyperactivity disorder (ADHD) medication service planned to commence in July 2026. We acknowledge the work in developing the trust’s high quality therapeutic care programme and in delivering substantial progress across its mental health wards and the introducing of peer support workers.

We recognise the significant work undertaken by the trust during 2025 to 2026 and the progress made in improving safety, consistency of care and patient experience. We support the trust’s priorities for 2026 to 2027, which are appropriate, ambitious and aligned with its strategic direction. We will continue to work collaboratively to ensure high quality, safe and equitable care for the population of North Lincolnshire.

Humber and North Yorkshire Integrated Care Board confirm, to the best of our knowledge, the quality account is an accurate reflection of the quality of care delivered by Rotherham Doncaster and South Humber NHS Foundation Trust. The document demonstrating the Trust’s continued commitment to co production, quality improvement and the delivery of safe and effective care.

Deborah Lowe, Director and Nursing
Quality Assurance
5 June 2026

Rotherham Doncaster and South Humber NHS Foundation Trust Council of Governors

The council of governors is pleased to have the opportunity to comment on the quality report for the year April 2025 to March 2026.

A range of governor engagement activities during the year April 2025 to March 2026 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 have continued their interest in priority areas, volunteering, health promotion and engagement, which have close ties to elements of the trust’s clinical and organisational strategy and related Promises.

The council of governors received update reports at its meetings that included specific updates on 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 high quality therapeutic taskforce (HQTC), the use of Care Opinion as the primary source of patient feedback; poverty proofing of services; and transitional care arrangements between children’s and adult services.

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. It commends the work and progress made, particularly in the last 12 months towards the achievement of four week waits in services and to the reduction of out of area placements.

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
10 June 2026

4.8 Annex 8: 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 2025 to March 2026 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 2025 to March 2026
  • papers relating to quality reported to the board over the period April 2025 to March 2026
  • feedback requested and received from:
    • NHS South Yorkshire Integrated Care Board
    • Doncaster and Rotherham Place: not received
    • Humber and North Yorkshire Integrated Care Board, 5 June 2026
    • Doncaster Healthwatch, 4 June 2026
    • Healthwatch North Lincolnshire, 26 May 2026
    • Healthwatch Rotherham, 4 June 2026
    • Doncaster Local Authority Health and Adult Social
      Care Scrutiny Panel, 3 June 2026
    • North Lincolnshire Council’s Health and Care
      Integration and Performance Scrutiny Panel 4 June 2026
    • Rotherham Local Authority Health Select Commission, 22 May 2026
    • Rotherham, Doncaster and South Humber NHS Foundation Trust Council of Governors, 10 June 2026
  • the trust’s complaints report the year April 2025 to March 2026 published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations (2009)
  • the latest national community mental health patient survey ,2025
  • the head of internal audits (HoIA) annual opinion of the trust’s control environment (final head of internal audits opinion received by the board of directors on 25 June 2026)
• the quality report presents a balanced picture of the 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
Kathryn Lavery, Chair
June 2026 June 2026

4.9 Annex 9: glossary of terms and definitions

Page last reviewed: September 09, 2026
Next review due: September 09, 2027

Problem with this page?

Please tell us about any problems you have found with this web page.

Report a problem