Present
- Kathryn Lavery, Chair.
- Rachael Blake, Non-Executive Director.
- Richard Chillery, Chief Operating Officer.
- Maria Clark, Non-Executive Director.
- Dr Richard Falk, Non-Executive Director.
- Steve Forsyth, Chief Nurse.
- Sarah Fulton Tindall, Non-Executive Director.
- Kathryn Gillatt, Non-Executive Director.
- Carlene Holden, Director of People and Organisational Development.
- Toby Lewis, Chief Executive.
- Dr Rumit Shah, Associate Non-Executive Director.
- Simon Sheppard, Director of Finance and Estates.
- Dr Diarmid Sinclair, Chief Medical Officer.
- Dave Vallance, Non-Executive Director.
- Pauline Vickers, Non-Executive Director.
In attendance
- Richard Banks, Director of Health Informatics.
- Dr Jude Graham, Director for Psychological Professions and Therapies.
- Philip Gowland, Director of Corporate Assurance, and Board Secretary.
- Jo McDonough, Director of Strategic Development.
- Shabir Pandor, NExT Director.
- Sarah Dean, Corporate Assurance Officer (minutes).
- Laura Brookshaw, 360 Assurance (observing).
- Lewis Swann, 360 Assurance (observing).
- Sheena Curnisky, The Value Circle (observing).
- Sheryl Scott, People Focused Group.
- Sam Butcher, Nurse Director, Physical Health and Neurodiversity Care Group.
- Mickey Delahunty, Unplanned and Specialist Nursing.
- Kathryn Bebb, Matron, Community and Long Term Conditions.
Welcome and apologies
Reference
Board public: 26/01/01.
Mrs Lavery welcomed all attendees to the meeting, in particular to Dr Shah and Mr Sheppard at their first meeting. There were no apologies. Mrs Lavery advised there was a minor change to the agenda, the patient story would be taken just before lunch. Mr Lewis took the opportunity to apologise to the board that the patient’s story was not presented by a patient. There were several reasons for this, and it was not a situation that was expected to occur again. He explained this at the outset because he did not want the staff who came to share what was a very interesting and valuable story to feel that their contribution was being diminished.
Quoracy
Reference
Board public: 26/01/02.
Mrs Lavery declared the meeting was quorate.
Declarations of interest
Reference
Board public: 26/01/03.
Mrs Lavery presented the declarations of interest report and confirmed there had been amendments to Mr Sheppard and Dr Shah declarations of interest to the register since the last meeting.
Acknowledged a minor amendment to Mr Forsyth and Dr Graham’s declaration was needed relating to fellowship of the Queen’s Institute of Community Nursing (QICN).
The board received and noted the changes to the declarations of interest report.
Standing items
Minutes of the previous board of directors meeting held on the 16 December 2025
Reference
Board public: 26/01/04.
The board approved the minutes of the meeting held on the 16 December 2025 as an accurate record.
Board public 25/12/06 remaining 2026 and 2027 clinical changes
Mr Lewis noted that, while the Child and adolescent mental health service (CAMHS) medical staffing proposal was referenced within the minutes, the private board minutes held on 8 January made it clear that the proposal was not being progressed (minute board public 26/01/07).
The board agreed that this clarification did not represent an inaccuracy within the minutes.
Matters arising and follow up action log
Reference
Board public: 26/01/05.
The board received the action log and noted the progress updates. All actions noted as “propose to close” were agreed.
Board public 25/11/23 promises and priorities scorecard
Mr Lewis advised he would expect this action to have progressed and not be overdue by May.
Board assurance committee reports to the board of directors
Quality Committee (QC)
Reference
Board public: 26/01/06.
Dr Falk presented the paper and gave the key highlights from the Quality Committee. Some services in Rotherham were noted as remaining an outlier across several metrics but this was noted for awareness rather than escalation, with related issues being progressed elsewhere on the agenda.
In relation to the Patient Safety Incident Response Framework (PSIRF) final internal audit report, it was noted that the audit provided moderate assurance, reflecting its timing shortly after agreement of the refreshed Patient Safety Incident Response Framework approach. It was considered that a later audit may have resulted in significant assurance.
Mr Forsyth stated confidence in future assurance was attributed to the embedding of the refreshed Patient Safety Incident Response Framework and the Radar system, which had strengthened the recording, triangulation and sharing of learning from after action reviews, multidisciplinary team discussions and SWARM huddles.
It was noted that Radar prevented closure of reviews until learning was evidenced and shared, with oversight provided through the Quality Committee and alignment to both the organisational quality and safety and education and learning plan.
The improvement in complaints was highlighted as a significant positive. Dr Falk noted that it was not the volume but the learning and actions from complaints that should be our focus.
In relation to promise 22 (seven day working), Dr Shah noted that assurance could not be gained at a single point in time. Mr Lewis explained that an audit to establish a baseline position was due to be completed by March, led by Steve Forsyth. It was noted that following receipt of the baseline audit and review, a decision would be required over the summer 2026 about what changes would realistically be delivered between now and 2028.
Mr Chillery, as strategic delivery risk 3 owner, emphasised that rapid or isolated implementation could pose workforce risks and that any decision would need to be taken at system level rather than by the trust alone. It was also noted that monitoring had commenced in relation to urgent care elements of the relevant promise, with progress expected to become clearer over the coming months.
The appointment of the community development director was highlighted as a key enabler of strategic change through neighbourhood working. It was recognised that inpatient discharge was heavily dependent on the strength and shape of the community offer, and that changes to community service models would need to mature over the coming months to support safe and sustainable discharge arrangements.
The board received and noted the report from the quality committee.
Audit Committee (AC)
Reference
Board public: 26/01/07.
Ms Gillatt presented the paper and provided key escalations from the Audit Committee.
Positive progress was noted in internal work to manage audit recommendations and risk reviews, with improvements observed duringthe month and a more dynamic approach evident.
Good progress was also reported across the counter fraud function and increased training and awareness, Ms Gillatt noted this fostered a safer environment for raising concerns.
Ms Gillatt commended the collaborative approach to audit work across committees, with this described as strengthening ownership, accountability and progress.
The board received and noted the report from the audit committee.
Mental Health Act Committee (MHAC)
Reference
Board public: 26/01/08.
Ms Fulton Tindall presented the paper and highlighted key points from the Mental Health Act Committee.
Two areas of concern were highlighted. Firstly, the continued lower compliance in Rotherham services related to consent to treatment, particularly section 132 rights, which remained persistently lower than other areas. Improvement work was underway and expected to deliver improvement by March, Ms Fulton Tindall emphasised that this remained an issue the board should continue to note. The second area related to compliance with level 3 Mental Health Act and reducing restrictive interventions (RRI) training, where progress had been limited despite ongoing enforcement actions. It was noted that the forthcoming training needs analysis included specific actions to strengthen delivery: with Ms Holden having provided assurance to the committee about the quarter 1 2026 consequences regime.
Section 132 rights had shown improvement previously but was now more variable, and further work was ongoing. Regarding section 136 suites, it was noted that assessment within 24 hours continued at 100% however, suites had been closed on 14 occasions during the period due to operational reasons. While this represented a spike, it was acknowledged that closures were linked to capacity management and, in some cases, supported avoidance of out of area placements. Ms Fulton Tindall suggested future reporting to include additional narrative to support understanding of resource and capacity decisions, with continued monitoring through routine reporting.
Ms Fulton Tindall reported progress in the committee’s developmental focus, particularly in relation to blanket restrictions. Following presentations and papers received, work was underway to develop a clearer trust wide approach and expectations, which was viewed positively. Mr Lewis noted that further work on reducing restrictive interventions would be considered at the next meeting, supported by improved data on repeated medication use and restraint. He noted that the role of ward advocates would be in place by April 2026: one year on from the board’s decision.
The board received and noted the report from the Mental Health Act Committee.
People and Organisational Development Committee (PODC)
Reference
Board public: 26/01/09.
Ms Blake presented the paper and gave key highlights from the People and Organisational Development Committee. The ongoing contribution and constructive challenge from Governors was recognised as shaping discussion and helping to maintain a clear focus on patient delivery. Ms Blake highlighted the staff survey where a reduced response rate was acknowledged in line with national trends.
The People and Organisational Development Committee would later consider how survey results fed into people priorities and understanding at care group and directorate level.
The last People and Organisational Development Committee had focused on developing a stronger understanding of data, with agreement reached on a set of top ten measures to support sharper focus. Future meetings would consider three measures at a time to enable deeper analysis and formulation of recommendations to the board. The People and Organisational Development Committee also covered internal audit recommendations with continued focus on Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) and violence and aggression against staff.
Positive impact from implementation of the real Living Wage was highlighted and welcomed. Ms Blake noted the constructive discussion on the training needs analysis and recognised the range of development opportunities available to staff, and the contribution these made to delivery of holistic patient care.
Resident doctors’ industrial action in December was explored, with assurance provided that services continued safely with all shifts covered through contingency arrangements. Dr Sinclair acknowledged that some additional costs were incurred through on call provision. Mr Sheppard confirmed £200,000 subsequent national funding was received to support industrial action costs and would be reflected in future financial reporting.
In response to Mr Sheppard’s question regarding the staff survey response rate of 49.3% per cent, Ms Holden explained that overall participation was lower than in previous years, reflecting a national trend and survey fatigue. She reported no significant outliers were identified, with a fair spread of responses across clinical services, although corporate areas continued to respond at higher rates. It was noted that analysis would enable review of responses by staff group to ensure appropriate breadth. The interest of consultant medical staff in the survey was welcomed.
Mr Lewis suggested that future reporting in people and organisational development of the agreed top ten workforce measures should be clearly aligned to the people and teams plan priorities of attract, belong and cultivate (the ABC approach) to support collective focus and assurance. Ms Blake committed to this request.
The board received and noted the report from the people and organisational development committee.
Public Health, Patient Involvement and Partnerships Committee (PHPIP)
Reference
Board public: 26/01/10.
Mr Vallance presented the paper and highlighted key points from the Public Health, Patient Involvement and Partnerships Committee.
Good progress was noted in relation to veterans’ services and the adult eating disorders collaborative. An area identified for continued attention was the alignment between the RDaSH 5 priorities and the equity and inclusion plan.
While clarity on data and targets was in place, mixed early outcomes were reported, which were recognised as understandable at this stage and emphasised the need to sharpen focus on health inequalities to ensure anticipated benefits were realised.
Promise 15 relating to neighbourhood working was highlighted due to its national significance. Local progress was noted through two pilot sites in Rotherham and Doncaster, alongside improvements in physical health within community teams. It was acknowledged that this work was still developing, and it was agreed to return to this in quarter 1 when additional management capacity was available.
Mr Vallance noted further information was included in the board agenda pack to provide context on the national position. The Public Health, Patient Involvement and Partnerships Committee agreed an action that further work was required to ensure clarity and consistency in the use of the term global majority, as inconsistent usage had caused some confusion during previous discussions.
Dr Shah referred to the veterans work and noted that a patient he was known to had expressed willingness to contribute to a board patient story in the future, should this be appropriate for consideration.
The board received and noted the report from the public health, patient involvement and partnerships committee.
Finance, Digital and Estates Committee (FDE)
Reference
Board public: 26/01/11.
Mrs Vickers presented the paper and highlighted key points from the Finance, Digital and Estates Committee.
The Finance, Digital and Estates Committee considered three key areas of financial risk and opportunity. The year to date position and forecast continued to forecast break even.
Risks relating to the high dependency rehabilitation unit (HDU) income and deficit funding position were noted, with assurance provided that the position remained in line with expectations.
Progress on the Waterdale lease was noted, with executive oversight in place and previous board discussions referenced.
The position on the trust procurement function and proposed merger with Sheffield Health Partnership University NHS Foundation Trust (SHPU NHS FT) was noted, with further clarity on timing expected following consideration by the SHPU NHS FT board.
Mr Sheppard reported that the month 9 position continued to forecast a year end break even, despite the loss of £609,000 quarter 4 deficit support due to system performance. He confirmed that an additional £3,400,000 capital allocation had been secured for the Waterdale scheme.
An internal audit update would go to the audit committee on 4 February, with actions expected to be completed by March and a focus on using the findings to support service improvement.
Mrs Lavery highlighted recent visits to capital development sites, including Phoenix and Great Oaks, and welcomed both the progress and positive staff engagement. Thanks were recorded to colleagues providing interim cover in finance and estates, and the opening of the new neurodiversity centre in Bentley was noted positively.
The board received and noted the report from the finance, digital and estates committee.
Trust People Council (TPC)
Reference
Board public: 26/01/12.
Mr Vallance presented the paper and also gave a verbal update following the Trust People Council discussion held the previous day.
It was noted that the session focused on culture through open conversation rather than formal papers, and that outputs would be
shared with those unable to attend. Mr Vallance commended the design and facilitation of the session and reflected on the power of conversation, storytelling, and active listening in supporting cultural change. He highlighted the quality of staff governance, scrutiny, and respectful challenge, alongside the value of diverse perspectives.
It was acknowledged that cultural change required sustained effort across multiple forums, particularly during a period of significant service change, and Mr Lewis agreed the Trust People Council demonstrated effective, balanced collaboration.
The board received and noted the report from the Trust People Council.
Chief executive’s report
Reference
Board public: 26/01/13.
Mr Lewis drew attention to the key items within his report.
Recent media coverage in the Financial Times highlighted the four week wait achievement, and Mr Lewis reflected on the importance of continuing to recognise successes alongside ongoing organisational change. He emphasised that leaders had a responsibility to acknowledge positive achievements with staff, particularly during challenging periods, as failure to do so risked overshadowing staff morale.
Experiences shared at Trust People Council highlighted the emotional impact on staff supporting colleagues through change and the need to balance challenge with recognition of progress. Mr Lewis noted this was an important reminder of celebrating success.
The board was reminded of the Supreme Court Judgment in July 2025, which related to a specific legal case on the meaning of “sex” and had at times been misrepresented. It was noted that, in response to increased external interest following a recent discrimination case in Darlington, several organisational policies had been amended or temporarily withdrawn, pending the publication of delayed national guidance. Mr Lewis explained what has been done when and why.
An appropriate balance in managing long term sickness over the next six months was required, recognising that sickness levels remained higher than desired but that compassionate support for staff was essential.
Mr Lewis noted encouraging grip on long term sickness through care group reviews and HR sickness clinics, with corporate directorates expected to show similar focus by the end of February. He emphasised that improvement would be gradual and confirmed that external agencies would be engaged to support conversations with staff on long term sickness during the period of organisational change.
Job planning should remain a collective priority and Mr Lewis emphasised its foundational importance to delivering organisational change in quarter 1. Progress had been made on job planning for band 7 nurses, allied health professionals and psychological professionals, and senior medics, but it was stressed that coherent job plans needed to be in place.
Mr Lewis clarified that implementation groups were not responsible for undertaking job planning, and that subject to Audit Committee agreement, detailed audits would be included in the next audit programme to assure the quality and validity of job plans.
Dr Graham noted that several proposed improvements, including neurodiversity, wheelchair services and estates, were dependent on commissioning decisions and partnership behaviours within an unsettled system.
Mr Lewis advised that work was progressing to standardise neurodiversity services and funding arrangements across South Yorkshire, with relevant proposals under consideration by the integrated care board, although wider challenges around mental health funding were acknowledged.
He noted cautious optimism regarding changes to wheelchair service contracting to achieve more sustainable funding, and reported encouraging early discussions on Rotherham estates, while recognising that further work and resolution were required.
Dr Sinclair reported the successful clearance of the Driver and Vehicle Licensing Agency (DVLA) assessment backlog in Rotherham memory waits, highlighting this as a strong example of effective multidisciplinary team working and positive patient impact.
He updated the board on national British Medical Association job planning discussions, including proposed changes to the clinical and non clinical split from 75:25 to 70:30, which remained under negotiation.
Mr Lewis emphasised that job plans provide role clarity, support productivity and ensure senior clinicians focus most of their time on complex patient care, with supervision, research and education forming an essential but smaller component of up to 25 percent.
In response to Dr Shah, he confirmed that approval rates were currently low, as expected following the policy agreement in November and the wider rollout across senior roles, with comprehensive coverage targeted for July and ongoing engagement with the regional office in place.
Dr Falk noted the report’s reference to frank conversations with staff about the impact of artificial intelligence (AI) and digital technologies. Mr Lewis emphasised the importance of transparency as artificial intelligence capability developed, particularly in screening, triage and administration, and in preparing for changes in ways of working by 2027. He highlighted that reducing administrative burden was key to increasing patient contact time and that efficiencies gained through technology would support increased clinical activity in some specialties.
Ms Holden asked whether the achievement of the four week wait was consistently understood across the organisation, and Mr Lewis noted progress through care group delivery reviews while explaining that further work was required on related processes such as unallocated patients and administrative clearance; once these were stabilised, it was agreed that strengthening staff understanding and pride in the achievement would be important.
Ms Holden also reflected that work on digital and AI enabled tools, including ambient voice technology, had been deliberately phased, with the administrative review deferred to allow time to build digital literacy and meet training needs, supported by open conversations with staff about future changes in ways of working.
Mr Forsyth highlighted the importance of understanding the implications of the Mental Health Act Bill, as outlined in the appendix, and its relevance to the training needs analysis. Mr Lewis noted previous briefings to the integrated care board by Dr Graham and Dr Sinclair on the legislative impact, but agreed this context now needed to be reiterated. He confirmed that the Bill was one of several factors contributing to the £3,900,000 gap between the trust and commissioners, which continued to be raised to support wider system understanding.
Ms Clark raised concerns about supporting staff on long term sickness where aspects of trust policy or practice were professionally challenging.
Mr Lewis noted the need for clearer distinction between sickness absence due to ill health and absence linked to consultation or organisational change, adding that such behaviours might increase in the coming weeks.
Ms Holden shared an example of a nurse declining redeployment, unrelated to organisational change, illustrating how sickness policies could be used in response to workforce management decisions.
Mr Banks discussed board oversight of ambient voice technology as it moved beyond evaluation, noting previous review arrangements. It was confirmed that decisions were expected by March including procurement, with opportunities for further board involvement if required.
The board received and noted the chief executive’s report and the forward actions it contained, and noted the progress being made towards 12 February 2026 revised national plan submission.
Learning from prevention of future deaths (PFD) reports
Reference
Board public: 26/01/14.
Dr Sinclair presented the paper and gave an overview of prevention of future death (PFD), including the circumstances in which coroners issue regulation 28 reports, both nationally and locally, and their publication on the national judiciary database.
A thematic review of 180 mental health related prevention of future deaths (January 2023 to December 2025) showed recurring national themes, which aligned with those identified in the trust’s own prevention of future deaths, with no unique local issues identified. National areas of concern aligned with work already underway, including transitions between inpatient and community services and between primary and secondary care.
Work through high-quality therapeutic care (HQTC), improvements to discharge processes and changes to multidisciplinary team structures were noted. Challenges linked to out of area placements were acknowledged, and reducing such admissions was recognised as important to supporting safe discharges.
National suicide prevention guidance on risk assessment was highlighted, including the move away from global low, medium and high risk stratification, with trust policies being updated accordingly.
The two prevention of future deaths issued to other agencies but involving trust patients were noted. Improvements in communication and information sharing were highlighted, including shared clinical systems with primary care and prescribing visibility, alongside the introduction of Dialog+ and single care plans. Learning from incidents was being embedded through the Patient Safety Incident Response Framework (PSIRF), and policies had been tested with clinical services prior to approval.
Mrs Lavery emphasised the importance of board visibility of prevention of future deaths. Dr Falk confirmed that routine reporting was provided to the quality committee and reflected on recent local and national benchmarking following the Greater Manchester review, highlighting the need for the board to remain sighted and assured given the national significance of these issues. Ms Gillatt emphasised the importance of ongoing board oversight, including mid-year assurance where required.
In response to her query on the timescales between prevention of future deaths and completion of actions, Mr Lewis noted that detailed chronologies had been presented to the board on three occasions and confirmed he was happy to provide further detail outside the meeting if required.
Ms Blake sought further understanding of actions relating to prevention of future deaths and how learning from incidents was embedded for new starters and sustained through organisational culture, linking this to the people and learning plan and learning half days. She referenced national recommendations and the importance of strengthening advocacy within and beyond the trust.
Mrs Lavery agreed that a dedicated session to explore these issues further would be planned, including engagement and disengagement, information sharing and consent, with Dr Sinclair and relevant clinical leaders invited to contribute.
Mr Lewis emphasised that the report was a trust initiated piece of work, not a mandated requirement. He highlighted its significance, given the breadth of cases considered, and welcomed further informal board or non-executive director (NED) discussions to fully explore its findings. He noted that similar issues were likely to recur, reinforcing the importance of understanding the learning. Mr Lewis also drew attention to paragraph 9.1 as a key area of focus, stressing the importance of ensuring trust policies were clear, accessible and implementable, and that staff understanding of policies was a fundamental part of the organisation’s cultural shift.
Mr Forsyth welcomed the paper and noted the importance of understanding the wider context of coroners’ inquests and post Covid delays. It was recognised that avoiding out of area admissions, including through decisions such as the closure of section 136 suites, could reduce avoidable harm and improve patient safety despite increased local service pressures.
Mrs McDonough discussed eating disorders and acknowledged that a number of challenging cases had highlighted wider system issues, which had driven the work of the joint committee. The investment in the medical emergencies in eating disorders (MEED) pathway was welcomed as a positive step to better support patients admitted to acute trusts. Mrs McDonough sought assurance that the expected commitments from acute trusts would be delivered, and Mr Lewis advised that responses from all three trusts had been positive, although further work over the coming weeks was required to ensure expectations were clearly understood. It was confirmed that planned investment from both the trust and the integrated care board (ICB) remained in place for the next year, and the board noted the wider national gaps in planning for eating disorders and dementia, which continued to be raised at regional level.
The board received and noted the national themes arising from prevention of future deaths reports including continuity of care, risk assessment, staffing, communication, learning and implementation of policies.
The board noted that the trust is actively progressing actions plans for prevention of future deaths that have been issued to the trust and has systems in place to review national prevention of future deaths to proactively take action within the trust. The board noted the intention to repeat this analysis looking at prevention of future deaths that have been issued again in quarter 4 in 2026 to 2027.
Dr Shah left the meeting at 11:35am.
Training needs analysis (TNA) 2026 to 2027
Reference
Board public: 26/01/15.
Ms Holden presented the paper and gave key highlights.
The training needs analysis had been developed through a trust wide approach covering all 23 directorates. It was noted that the analysis used a pyramid model to address organisational, team and individual needs and that it informed the prioritisation of training and investment for the forthcoming year.
Ms Holden stated the workforce was the organisation’s most valuable asset and that ongoing development was essential to avoid a static workforce.
Although the trust received multiple funding streams, training was managed through a single collective budget while maintaining the integrity of those streams, enabling alignment with organisational priorities including promise 24 and the expansion of the educational offer.
Previously the trust managed a single collective training budget and that this new approach aimed to address historical misconceptions about separate funding pots.
Ms Holden acknowledged a shift from traditional training models towards a broader focus on workplace development, including digital literacy, artificial intelligence, leadership development, mental health and physical health skills, particularly for inpatient colleagues. It was noted that the trust had made significant investment in training, including an additional £75,000 to further increase the availability of training.
Existing barriers including the timing of training requests and the operational challenges of releasing staff to attend training was
highlighted. Ms Holden emphasised the importance of inclusivity and equity, noting the need to ensure all staff groups had fair access to development opportunities, with a particular focus on multi-professional leadership and alignment with trust strategy. Equality, diversity and inclusion data would be used to monitor access to training and associated outcomes.
Mrs Lavery reaffirmed that the training budget was a protected and essential investment for the trust. It was emphasised that the focus was on equitable allocation and clear justification of training priorities, to ensure that investment was fair, transparent and aligned with organisational needs. Mr Sheppard noted that based on experience across a number of trusts, the training needs analysis was considered to be highly impressive, comprehensive, thorough and inclusive. He had observed through care group delivery reviews that the training needs analysis was well understood and fully owned by care groups, and welcomed the recognition of the quality of the work undertaken.
Dr Graham welcomed the development of a strong, well aligned training and learning infrastructure, noting positive momentum and an increased organisational focus on learning. The structured approach was recognised as supporting forward workforce planning and addressing wider organisational needs beyond statutory requirements.
Mr Lewis highlighted clear directorate ownership but noted remaining barriers, including historic assumptions about separate budgets, challenges coordinating cross directorate training, late requests in previous years and difficulties in releasing staff. Ms Holden confirmed actions were underway to address these through a single budget, earlier planning and improved communication, though further cultural change was needed.
Dr Graham explained that the NHS England traditional funding model does not always reflect modern expectations of being well led and safe.
The trust shift toward multi-professional leadership and development was supporting collaborative practice, expanded roles such as non medical prescribing and integrated working across disciplines. She confirmed the training needs analysis approach strengthened safety, effectiveness and organisational leadership.
Ms Blake emphasised that equality data (workforce disability equality standard (WDES), workforce race equality standard (WRES)) was used to ensure equitable access to training. She welcomed the single training budget as supporting fairness, consistency and alignment with trust strategy, noting expected benefits for staff and the organisation.
The board received and noted the training needs analysis represents a step change in approach, addressing known frailties in process from previous years and providing a robust, inclusive and transparent evidence base for investment in learning and development.
The board considered the new training which is being commissioned in 2026 to 2027, and recognised the improvements made in response to learning from previous years.
The board noted the revised approach for a small number of mandatory and statutory training (MAST) courses and the management of compliance.
Care Quality Commission readiness self assessment
Reference
Board public: 26/01/16.
Mr Forsyth presented the paper and gave key highlights. The Care Quality Commission readiness and self assessment had been built during the previous 12 month. Over 350 pieces of evidence had been collected and stored in an accessible vault, supporting a culture of continuous Care Quality Commission readiness. Peer reviews, including participation from non executive directors and governors, were used to test and validate the evidence, ensuring multi professional scrutiny.
Progress was noted across the domains of safe, effective, caring and responsive, with 66 quality statements improving from “requires improvement” to “good”, while 12 remained rated as “requires improvement”. Safe overall remained rated as “requires improvement”, with effective, caring and responsive showing improvement. Across directorates, 20 domain level improvements were reported, with a small number remaining static, particularly within responsive and safe domains. Mr Forsyth summarised the significant progress made, recognised the remaining areas requiring improvement and agreed the need to focus on consolidation, closing outstanding gaps and agreeing the process for reviewing evidence files between March and June, with a further update to be brought back to the board.
Board members welcomed increased rigour and improved articulation of ratings. Questions were raised about how patient experience feedback had informed the assessment, confidence in the consistent use of Dialog+, and the balance between subjective and objective evidence. Further assurance was sought on the robustness of evidence testing and the role of external challenge. Improvements within Rotherham services were acknowledged, with the caveat that this required recalibration of earlier assumptions. Mr Forsyth confirmed Care Opinion feedback had informed changes, especially in community services, and that Dialog+ remained a key improvement area. Peer reviews and readiness meetings were strengthening multi‑professional scrutiny. It was recognised that self assessments provide a point‑in‑time view and that performance may fluctuate, reinforcing the focus on continuous readiness.
The board noted strong triangulation of assurance through peer reviews, care group delivery reviews and comparative data, while acknowledging vulnerability to Care Quality Commission’s assessment of staff experience during periods of change. Members requested clearer improvement plans for areas rated requires improvement. Mr Lewis acknowledged the significant work undertaken and highlighted the need for collective board engagement with the evidence. He sought clarification on how the trust’s internal assessment aligned with the Care Quality Commission framework, noting that while he was persuaded that community health services for adults had improved to good, he was less assured that community based mental health services for working age adults were at the same level and asked for clarification on this position.
Mr Forsyth advised that the trust had made a significant transition in publishing waiting lists and emphasised the importance of communicating this clearly to both the public and staff. He noted that celebrating progress was important, while recognising that Care Quality Commission would primarily test staff experience on the ground. He advised that assurance would be strengthened through the quarter 1 forward plan, with non executive directors and executives testing evidence directly through site visits and staff engagement. He further outlined that sustainability was being supported through wider organisational learning, including policy improvements, learning from incidents and structured education and learning initiatives, reinforcing that Care Quality Commission readiness was a continuous process rather than a one off exercise. Mr Forsyth acknowledged that some services had moved from “outstanding” to “good”, while others had improved from “requires improvement”, highlighting significant progress in physical health services. In relation to community mental health services, he noted improvements in access, effectiveness and responsiveness, while acknowledging ongoing work required in areas such as Dialog+, and confirmed that the current assessment was based on available evidence and performance metrics.
Mr Lewis tested assurance in relation to areas rated as “requires improvement”, particularly within community based mental health services, noting concerns about unallocated patients, care planning and waiting lists. It was clarified that these issues were reflected within specific domains that remained rated as “requires improvement” despite overall progress. The board recognised the subjectivity of ratings and the risk that particular weaknesses could disproportionately influence Care Quality Commission judgements.
The board agreed that assurance would be strengthened through continued peer reviews, Care Quality Commission readiness meetings and direct engagement with frontline practice. It was agreed that part of the April board development session would be used to scrutinise the evidence repository and that the process for inspecting evidence between March and June would be confirmed. A further Care Quality Commission self assessment would be presented to the board in July.
The board received, noted and discussed whether there were any unmentioned or under discussed items that the board considers have to be addressed in the self-assessment. The board agreed at its time out session in April to confirm a process for inspecting evidence files between March 2026 and June 2026, returning to re-examine the self assessment in lieu of that in July 2026.
Neurodiversity waits update
Reference
Board public: 26/01/17.
Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Lewis.
Dr Sinclair noted the national context and Care Quality Commission self‑assessment findings, highlighting progress but outstanding work on care planning, risk and safety. Concern was raised about waits of up to two years, and assurance sought on service safety and responsiveness. Ms Clark requested further analysis of attention deficit hyperactivity disorder (ADHD) did not attend (DNA) rates, including causes, equality impacts and potential mitigations. She queried the size and profile of the waiting list, whether this reflected national trends, and sought assurance on risks associated with separating services, given co‑occurring conditions.
Mr Vallance supported the proposed approach and asked for clarity on support available pre‑ and post‑diagnosis, including talking therapies, and whether this aligned with national expectations. He highlighted the need for constructive support during long waits.
Mr Lewis noted uncertainty around how the Care Quality Commission will assess neurodiversity services and advised this should be clarified with the Care Quality Commission. He acknowledged inconsistencies between narrative and documentation on waiting times and advised caution in overstating support offers, reflecting patient feedback. He noted the absence of a funded backlog plan for adults and limited integrated care board engagement, though proposals continue to be developed. Did not attend (DNA) issues were discussed, with actions underway to improve transparency on likely waits and to segment waiting lists (assessment, diagnosis and treatment). A sustainable assessment rate is planned by April 2026.
Mrs Vickers highlighted ongoing lack of backlog funding, integrated care board limitations and borough‑level differences, stressing the need for clear patient communication. Mr Lewis advised work was underway to reduce reliance on right‑to‑choose providers through a fair tariff, with limited current integrated care board interest. He confirmed progress by the care group and noted national review activity.
Dr Falk highlighted risks that increased capacity may further increase demand and raised concerns regarding shared‑care and private prescribing. Mr Lewis noted delays were largely dependent on integrated care board decisions. He referenced progress in North Lincolnshire, with integrated care board investment from 1 April intended to address the unsafe prescribing gap for young people, with a small funding gap remaining. A three year agreement and tariff model were being finalised.
The board received and noted the neurodiversity waits update report, and acknowledged work across the integrated care board’s providers to try to develop a level “paying” field for neurodiversity tariffs and quality standards. The board noted the outlined route-map on prescribing wait harms in North Lincolnshire and considered the progress summarised on adult neurodiversity since October.
The board recognised the lack of a backlog plan and funding for adult neurodiversity waiters, and request the Risk Management Group to review neurodiversity risks mindful of this paper at its next meeting.
Action
Phillip Gowland
Financial plan 2026 and 2027 to 2028 and 2029
Reference
Board public: 26/01/18.
Mr Sheppard presented and gave key highlights.
The 2026 to 2027 financial plan was reconfirmed to be a break even plan which had been submitted to NHS England in December, alongside the requirement to submit a 3 year plan in February 2026. The board were reminded that the underlying deficit was expected to be £6,300,000 at year end, a significant improvement from £16,000,000 in 2023, with an underlying break even position projected for the following year. National assumptions on pay and inflation had been applied, generating an efficiency requirement of £5,100,000, and the overall cost improvement programme (CIP) requirement for 2026 to 2027 was confirmed to be £10,000,000 to address the deficit and cost pressures.
Contract discussions with partners in Humber and North Yorkshire (HNY) integrated care board were progressing positively, with broad agreement reached, and most South Yorkshire (SY) Integrated Care Board contract variations had moved in the trust’s favour. Final issues were expected to be resolved shortly. Mr Sheppard highlighted that the directorate budget setting process was on track for completion in mid February.
Forward projections indicated that the required cost improvement programme and income growth and margin for the two subsequent years would fall to £7,600,000, reflecting the benefit of improving the underlying position. Mr Sheppard acknowledged the significant work undertaken by all colleagues involved to progress the financial plan and contract negotiations.
Mrs Vickers welcomed the progress and thanked the team for setting out the developing long‑term plan. She noted that £3,600,000 remained held centrally by the integrated care board and asked about confidence in securing this funding, as well as whether the long‑term plan reflected any future estates benefits. Mr Sheppard confirmed that estate changes were expected to support the medium‑term position, though further work was needed before values could be included. He noted that the executive team had discussed themes for future years, recognising the organisation could not continue making small, isolated reductions. This strategic work would inform the medium‑term financial plan, though the timing of benefits remained uncertain; however, they would support the £5,300,000 cost improvement programme.
Mr Lewis highlighted concerns regarding the mental health investment standard, noting that South Yorkshire’s allocation would have been £7,600,000 but that the integrated care board planned to spend around £5,000,000 on its own services, leaving no investment for three years to deliver national mental health commitments. He stressed that the standard should be treated as a minimum, not a ceiling, and that allocating two thirds centrally was unacceptable and required local resolution. He also noted that the 2025 to 2026 financial plan contained at least £1,000,000 of unanticipated costs, some unforeseeable and others reflecting process weaknesses, and emphasised the need to reduce this margin for error in future planning. Certain income assumptions had previously been overlooked but were now corrected for 2026 to 2027. Mr Lewis drew attention to points 9 and 10 of the paper on the proposed clinical leadership executive investment fund approach, confirming board consideration would precede clinical leadership executive discussion and that no Mental Health Optimal Staffing Tool (MHOST) issues were identified for 2026 to 2027. With bids totalling £6,800,000 across around 50 proposals, Mrs Lavery stressed the importance of prioritising older adult admission avoidance and aligning investment with poverty and inequalities priorities.
Ms Gillatt noted that the analysis clearly highlighted remaining issues and asked about risks to delivery. Mr Sheppard expressed overall confidence, acknowledging that while cost improvement programme delivery remained a risk, the workforce schemes and supporting processes were strong and ahead of many organisations, with the main unresolved issue being discussions with the Southy Yorkshire Integrated Care Board, which might need to return to the private board. Mr Vallance highlighted the tension between holding more than 200 vacancies, which generated underspend, and the intention to reduce this to around 100. Mr Lewis confirmed plans to begin addressing this from late May, explaining that reconciliation issues between finance and human resources systems had disrupted vacancy control in 2025 to 2026 and were being reviewed through internal assurance. He emphasised that ensuring the accuracy of underlying budget detail was the priority and confirmed that full vacancy management would resume in May, with the aim of returning to a fully staffed position.
The board received and noted the Financial Plan 2026 and 2027 to 2028 and 29, and the cost improvement target of £10,000,000 in 2026 to 2027 and £5,300,000 in 2027 to 2028 and 2028 to 2029. The board considered the latest income position regarding South Yorkshire Integrated Care board and Humber and North Yorkshire Integrated Care board. The board recognised the 2025 and 2026 exit underlying position and the movement to a breakeven underlying position in 2026 and 2027.
The board delegated authority for the final submission to the chief executive and chair of the Finance, Digital and Estate Committee, and the submission of a break-even Income and Expenditure plan for 2026 to 2027, 2027 to 2028 and 2028 to 2029.
Promise 2 carers plan: forward look to 2026 and 2027
Reference
Board public: 26/01/19.
Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Forsyth.
Ms Blake noted the progress and asked whether the plan included support for staff who were also carers, including access to the Carers Federation and other resources to help them self serve. Dr Falk highlighted the risk of increasing demand on local authorities and asked where this risk was captured on the risk register and how it was being monitored should demand exceed local authority capacity. Mr Forsyth confirmed that local authority representatives attended the Staff Carers Network and that increased use of local authority services was expected and welcomed. He noted that the Doncaster wellbeing service had cleared a backlog of untriaged carers and was developing joint protocols so assessment responsibilities could be shared between the local authority and NHS continuing healthcare, with some primary care networks already signposting carers early for support.
Mr Forsyth reported that staff carer identification had increased from fewer than 50 in April 2024 to more than 150, with an estimated total of around 250 once all carers were identified, and confirmed that work was ongoing to understand their profile and reach under represented groups. He noted that the Doncaster wellbeing team had shared details of the early support offered before formal assessments, and that joint work with the local authority and partners would continue, with similar activity taking place in North Lincolnshire and Rotherham. Mr Chillery observed that some managers were still unsure how to support staff with caring responsibilities despite the new structures. Mr Forsyth advised that manager training already covered flexible working and carer support and highlighted the wellbeing passport as an important tool for prompting open conversations in personal development reviews (PDRs) and supervision, noting that some staff remained reluctant to disclose caring duties during organisational change and that managers should continue to use the passport to promote consistent practice.
Mr Lewis drew attention to paragraph 6.4 regarding a carer support function. It was confirmed that this would not be funded through the bids process and that resources would instead be drawn from existing central teams. Mr Forsyth reminded the board of the carers’ network first anniversary event on 17 March at St Catherine’s House, and board representation was welcomed.
The board received and noted the promise 2 carers plan: forward look to 2026 and 2027, recognised the work to be done from April to embed this work and the wider always measure within all 13 directorates. The board discussed whether the delivery chain is sufficiently understood to create a coherent plan by which to ensure the required behavioural change.
Well-led: externally commissioned developmental review
Reference
Board public: 26/01/20.
Mr Gowland presented the paper and a brief update on the commissioned well‑led review.
Since the last meeting, Mr Gowland and Mrs Vickers had completed the procurement process and appointed The Value Circle. The team had begun work, including an opening meeting with the chair and chief executive and an initial data request. Board and committee observations started today and would continue over the coming months, alongside a programme of individual interviews to be arranged within the next week.
The board received and noted the update on the well-led externally commissioned developmental review paper, and noted the contract award and the commencement of the external review by The Value Circle in line with the timeline. The board would participate within the review through the interview and observational processes being deployed by The Value Circle.
Kathryn, Sheryl, Mickey and Sam joined the meeting at 11:15am
Story to board
Reference
Board public: 26/01/21.
Mrs Lavery welcomed Kathryn, Sheryl, Mickey and Sam, who would present the patient feedback on behalf of Matty who had benefited from partnership work between the People Focused Group and Doncaster physical health unplanned community and long term conditions services.
Kathryn, Sheryl, Mickey and Sam presented the story of Matty, a patient with complex needs, and illustrated the importance of flexible, relationship based outreach and the collaborative efforts of the team to provide wound care and support outside traditional settings. Sheryl described her long term involvement with Matty, highlighting the difficulties in engaging him with traditional services due to his complex circumstances and the need for creative approaches to maintain contact and provide care. Mickey recounted the team’s decision to provide wound care directly on the streets, adapting their approach to Matty’s needs and overcoming barriers such as his reluctance to attend appointments and the severity of his untreated leg ulcer. Kathryn, Sheryl, Mickey and Sam emphasised the importance of building trust through consistent relationships, flexibility in service delivery, and understanding the patient’s priorities, which enabled Matty to accept care and spread the word to others in similar situations.
Mr Lewis noted that practical barriers such as smells, dogs or drinking cans could make people feel unwelcome and limit access to services, and Mickey added that waiting increased anxiety and often caused people to leave, highlighting the value of flexible approaches such as later appointments and using community sites like the Duke Street building. Dr Graham stressed the importance of hearing directly from those the service supported, many of whom were highly disadvantaged, explaining that some avoided coming indoors due to rules, other people present or the hospital environment, and that meeting people where they were helped reduce these barriers. She emphasised the importance of familiarity, trust and supporting people regardless of whether they wished to change their circumstances, while acknowledging the emotional strain on staff.
Dr Falk praised the team and asked whether engaging with people in difficult settings risked breaching policies; it was explained that staff focused on safe, appropriate practice using experience, teamwork and established procedures rather than checking every rule. Ms Blake welcomed the progress and partner recognition of the team’s work with those most excluded from services, stressing the need for greater kindness across the community and the importance of embedding this early‑intervention approach more widely. Sheryl added that supporting people facing multiple addictions and challenging circumstances required flexibility, compassion and a non judgemental, practical approach. Dr Falk thanked Sheryl and commended the team’s rapid response to an urgent case of someone at risk of death on the street, contrasting their swift action with the delays common in traditional routes. Mrs McDonough agreed, describing the response as exceptional compared with the usual obstacles encountered when seeking support for people on the streets.
Mrs Lavery and the board thanked members for taking the time to listen to the patient story and noted the intended reflection time later on the agenda.
Operating performance, governance and risk management
Integrated quality performance report (IQPR)
Reference
Board public: 26/01/22.
Mr Chillery introduced the integrated quality performance report (IQPR) for January 2026 review (data as at 31 December 2025).
Section 136 hours analysis noted the recent spike and subsequent reduction in Section 136 hours under the Mental Health Act, noting that December saw a decrease to 97 hours, with 24 hours attributed to planned suite closures, 10 hours to clinically appropriate extensions, and 47 hours related to Section 140, including 14 hours for cleaning. This would continued to be monitored to address excessive cleaning times.
Performance remained strong. The trust continued to meet its referral to treatment (RTT) 18 week targets and access standards for children and adults, though talking therapies access remained below target despite improvements in reliable recovery, with further planning to address national performance drives targets set as part of the planning round.
Quality indicators showed progress, including meeting the new 12 hour falls metric for the first time, although Malnutrition Universal Screening Tool (MUST) compliance and safer staffing remained concerns. The safer staffing figure of 88% reflected rostering issues rather than unsafe shifts, prompting questions about the accuracy of the metric versus actual ward experience, leading to a decision to revise integrated quality performance report reporting from April to better reflect real conditions.
Financial risks remained, including pressures linked to the high dependency unit (HDU). Workforce discussions highlighted high sickness levels at 6.59%, with long term absence making up two thirds of cases and stress and anxiety accounting for 42% of absences. Managers were working closely with staff, and projections for reducing sickness were realistic, though achieving 4.1% over the planning cycle would be challenging. Ms Holden explained the challenges, including a north-south divide in sickness rates and a significant proportion of absences due to stress and anxiety. The team is working with managers to better understand and address long term sickness, with ongoing efforts to support staff through organisational change. Mr Lewis noted this subject would return to the board in May.
Following discussion, the board agreed to change the integrated quality performance report from April to focus on the number of shifts not rated green, rather than calculated percentages, to better align reported data with ward realities. Further conversations would occur outside the meeting to finalise this approach.
Action
Steve Forsyth and Richard Chillery.
The board received and noted the integrated quality performance report.
Promise 5: making it real
Reference
Board public: 26/01/23.
Mr Lewis presented the paper and highlighted its importance in supporting the trust’s commitment to nurturing the power of communities.
Mr Lewis emphasised the need to maintain a realistic and self critical approach, recognising progress while acknowledging areas where further development was required, particularly in relation to the membership offer. He highlighted reflective work on accessibility and ways of working, alongside the Community Involvement Framework, with a shift towards 80% of engagement occurring in community spaces rather than within the organisation.
Discussion focused on how progress against the Community Involvement Framework would be evidenced over time, with emphasis on presence, accessibility, trust and meaningful participation rather than solely quantitative measures. Mr Lewis discussed the forthcoming establishment of the Community Leadership Executive, replacing the “shadow clinical leadership executive” label, would formally launch in March, with its identity to be shaped by its members. He highlighted the importance of language, identity and power sharing in supporting authentic community engagement and practical steps to nurture community involvement.
Mr Lewis proposed that the board hold a dedicated time out session in June to revisit its shared understanding of power, alongside the community involvement framework, particularly in light of recent changes in board membership. Mr Vallance supported the proposal and, reflecting feedback from the Trust People Council, agreed that now was an appropriate time to deepen collective understanding of power sharing and organisational culture.
Action
Toby Lewis.
Ms Blake noted that the community leadership approach represented a positive shift in power dynamics and should avoid tokenism. Mr Lewis agreed, emphasising that success should be demonstrated through lived experience and trust, and that engagement must be embedded across the organisation by empowering local leaders rather than holding it centrally. Dr Graham highlighted the need for a broader understanding of accessibility, stressing that meaningful inclusion required people to be heard, valued and supported as equals, with diversity recognised, trauma informed approaches adopted and practical factors such as timing and location considered to widen participation. Mr Lewis added that as the work matured, the emphasis should move toward learning and continuous improvement rather than pass or fail assessment, informed by wider public sector experience and coproduction.
The board received and noted the paper on promise 5 making it real and considered what it wished to do differently in 2026 to 2027 to support the promise. The board recognised the establishment of the Communities Leadership Executive, and agreed to explore how we would know if our community involvement framework was being delivered at a dedicated time out session in June.
Promises and priorities scorecard
Reference
Board public: 26/01/24.
Mr Lewis presented the promises and priorities scorecard and emphasised the importance of reaffirming the agreed pecking order of priorities, particularly in the context of ongoing national policy announcements.
The pecking order which had previously been agreed by the board remained an important tool to support leaders in making clear and consistent decisions. Mr Lewis highlighted several developments expected to support future progress in the coming weeks, including full evaluation of existing weekend provision (promise 22), and the planned switch off of care programme approach (CPA) in April will assist with the consistent use of Dialog+ (promise 16).
Attention was drawn to a number of success measures that had remained in the lower tier for a sustained period. While acknowledging the complexity and scale of these areas, Mr Lewis stressed the importance of setting an ambition to improve performance in these measures over the next six months, rather than accepting persistent underperformance.
Mr Vallance welcomed the honest assessment of progress and noted that the scorecard gave a clear view of both achievements and ongoing challenges. Mr Lewis highlighted the need for renewed collective leadership focus following recent organisational change. It was noted that several lower performing measures related to centralised functions, challenging assumptions about where complexity lay within the organisation. Mr Lewis emphasised the importance of maintaining clarity on priorities, recognising that difficult choices would continue to be required, and asked the board to agree the recommendations in the paper, including continued focus in the first half of 2026 to 2027 on sustaining progress against promise 14.
The board received and noted the latest self assessment provided, augmented by the narrative within the promises and priorities Scorecard. The board acknowledged the effort across 23 directorates to deliver 28 Ppromises by the end of 2028, and recognised continued focus in the first half of 2026 on both parts of Promise 14.
Strategy delivery risks
Reference
Board public: 26/01/25.
Mr Gowland presented the paper and highlighted the improved format following feedback from 360 Assurance, which aimed to increase clarity and strengthen the links between assurances, actions and areas requiring further work.
The five strategic delivery risks (SDRs) had been subject to ongoing committee oversight over recent months with a continued need for clearer and more precise measures of progress, improved tracking, stronger evidence of risk mitigation, and careful management of expectations in relation to multi year delivery trajectories. Mr Gowland noted that strategic delivery risks were referenced across several reports and discussions during the board meeting, including the Community Involvement Framework, the availability and use of data, and the importance of robust data to support decision making. Links were also made to neighbourhood and primary care, including the use of GP insights and shared records.
A consistent theme emerged around leadership development, workforce planning and capability, including training needs analysis, the people plan, leadership development and induction, and staff survey feedback on how supported staff felt. Mr Gowland highlighted that these represented the five key areas which, if not addressed, would prevent delivery of the trust’s strategy.
Mr Lewis emphasised the need for clearer indicators of progress, including quantifying the number of leaders required to meet defined competency levels. Mrs McDonough highlighted progress in understanding and addressing risks related to diversity and community engagement, noting the use of ongoing roadshows to support clinical directorates in interpreting their data. In response to both points, Mr Gowland agreed to seek assurance from executive leads on the achievability of the March deadlines, to clarify any risks of not meeting targets, and to ensure that the strategic delivery risk evidence was updated to reflect the actions described.
The board received and noted the strategic delivery risk report.
Operational risk report
Reference
Board public: 26/01/26.
Mr Gowland presented the report and gave key highlights.
The processes for moderation and scrutiny of risks continued to improve through the Risk Management Group (RMG), with increased focus on engagement with risk leads, the quality of risk descriptions, and the effectiveness of mitigating actions and controls. It was noted that increased attention was being given to areas with few or no recorded risks, alongside analysis of risk coverage across directorates and teams, following feedback from care group delivery reviews. This was described as demonstrating a more mature, organisation wide approach to risk management, with the most significant risks highlighted within the paper and prioritised by the Risk Management Group.
Mr Vallance raised concern about the ligature risk at Great Oaks, particularly relating to doors and bedrooms (RSK 103), and questioned why the issue remained unresolved. Mr Forsyth explained that this was a longstanding risk being managed through the wider refurbishment programme, confirming that all anti‑ligature doors had now been replaced, with remaining alarm work scheduled. Mr Lewis also clarified the position on the Windermere door installation (RSK 476), noting that work was underway to determine what was required to complete installation in July. Mr Chillery asked whether risks should be stepped down during redevelopment, and it was confirmed that risks would remain in place until works were fully completed. Mr Lewis suggested considering whether there was a link between areas not reporting risks, incident reporting levels, and staff engagement with Radar. It was noted that around one thousand staff had not previously accessed Radar, with an expectation that all staff would do so by 31 March. The board received and noted the operational risk report.
The board noted the revised reporting thresholds based on risk appetite and the planned work to address the extended number of risks that are currently outside of appetite and tolerance.
Supporting papers (previously presented at committee)
Mortality report
Reference
Board public: 26/01/27.
Mrs Lavery informed the board of the mortality report for information which was presented as a supporting paper that had previously been presented at quality committee level for scrutiny and challenge.
The board received and noted the mortality report for information.
Closing items
Any other urgent business
Reference
Board public: 26/01/28.
There was no further business raised.
Any risks that the board wishes the Risk Management Group to consider
Reference
Board public: 26/01/29.
In relation to the board’s earlier discussion on children and young people’s (CYP) neurodiversity waiting lists, Mrs Vickers raised whether the issue had been considered by the Risk Management Group. Mr Lewis noted that, although referenced earlier in the meeting, this risk was not prominent on the risk register, raising concerns about risk calibration. He advised despite an identified solution for children and young person prescribing in North Lincolnshire expected by June, the issue was considered a current risk following prolonged non resolution, and it was agreed that the Risk Management Group would review it.
Public questions
Reference
Board public: 26/01/30.
There were no public questions.
Closing statement
Reference
Board public: 26/01/31.
The chair resolved:
“That because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, the public and press would be excluded from the remainder of the meeting, which would conclude in private.”
Next meeting Thursday 26 March 2026 at 10am, Legacy Conference Centre, Doncaster.
Page last reviewed: March 31, 2026
Next review due: March 31, 2027
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