Board of directors minutes July 2025

Minutes of the council of governors meeting public session
Thursday 24 July 2025 at 10am at the Enterprise suite, The Arc, 2 Lichfield Avenue, Scunthorpe, DN17 1QL.

Present

• Kath Lavery, Chair.
• 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.
• Izaaz Mohammed, Director of Finance and Estates.
• Dr Diarmid Sinclair, Chief Medical Officer.
• Pauline Vickers, Non-Executive Director.

In-attendance

• Richard Banks, Director of Health Informatics.
• Lea Fountain, NeXT Director.
• Philip Gowland, Director of Corporate Assurance and board secretary.
• Sarah Dean, Corporate Assurance Officer (minutes).
• Cheryl Gowland, Primary Care Strategic Lead.
• Emma Stables, Senior Clinical Nurse Specialist, Infection Prevention and Control.
• 2 members of staff and 1 governor were in attendance.

Welcome and apologies

Reference

Board public: 25/07/01.

Mrs Lavery welcomed all attendees to the meeting. Apologies for absence were noted from Rachael Blake and Dave Vallance, Non Executive Directors, Dr Jude Graham, Director for Psychological Professions and Therapies and Jo McDonough, Director of Strategic Development.

Quoracy

Reference

Board public: 25/07/02.

Mrs Lavery declared the meeting was quorate.

Declarations of interest

Reference

Board public: 25/07/03.

Mrs Lavery presented the declarations of interest report which outlined that there were changes to the register declared since the last meeting that included the additional declarations for Maria Clark and the removal and an additional declaration for Rachael Blake.

Clarification relating to Ms Clark declarations of interest were noted.

The board received and noted the changes to the Declarations of Interest Report.

Staff story

Reference

Board public: 25/07/04.

Mrs Lavery welcomed Emma Stables, supported by Cheryl Gowland, to share her own experience of being a carer whilst working within the organisation, and the challenges she had faced managing her work and life balance. Mrs Lavery referred to material shared prior to the board meeting. Support was offered to anyone who needed or was distressed by the agenda item.

Emma talked about the care she provides to several family members and shared some photographs of her family to provide some context to the people she referred to. Emma spoke about how she managed the caring responsibilities with other family members whilst they maintained professional caring roles themselves. Emma spoke about the increased support required as their loved ones grew older or at times when they suffered a deterioration in health and the additional challenges then of attending medical appointments and fitting that in within the working day. Sadly, Emma’s son passed away three years ago from pneumonia and sepsis and Emma spoke briefly about her bereavement and the impact this had on her work life.

Emma highlighted the fact that sometimes staff were expected to take annual leave to support loved ones that they are caring for appointments, when leave was often even more important for carers to provide some much needed respite and to avoid taking periods of sickness. Emma felt that due to her increasing caring responsibilities the better option for her was to reduce her hours at work, rather than asking for time off at challenging times. Emma acknowledged that was not an option for everyone. Emma felt fortunate that in her role as a clinical specialist there was an option to work more flexibly around her caring responsibilities but realised that this was less of an option for patient-facing, ward-based clinical staff.

Emma talked about the importance of the Carers Network and the support for colleagues who had additional caring responsibilities outside of the workplace. It was acknowledged most members were admin or specialist role colleagues, not ward based colleagues, and further engagement work continued to reach out and promote the Carers Network.

Mr Lewis reflected on the outpour of love which came from Emma’s story. Mr Chillery stated the story highlighted how caring responsibilities affected lots of people and need to recognise as an employer to create flexibility and right roles to be able to lessen the stress and burden on colleagues. Mrs Lavery stated the matter was raised at the recent Trust People Council and how ward based staff could be supported.

Mr Forsyth recognised the supportive team in which Emma was part of, and was aware ward based colleagues often changed roles in non ward environments to fit around their caring responsibilities. There would be intention to discuss later on the agenda on the carers delivery plan and how staff would be supported with caring responsibilities.

Ms Holden questioned whether there was anything retrospectively different which could have supported Emma further. Emma confirmed compassion, caring and understanding of colleagues personal circumstances needed to be taken account. When Emma’s son passed away she received a standard letter from her manager which did not feel supportive or understanding even though Emma had a very supportive and compassionate manager. Ms Holden acknowledged the negative impact Emma experienced and responded the bereavement policy had since changed where colleagues would be entitled to up to two months leave under the circumstances, which is separate to sickness absence.

Mrs Lavery and the board thanked members for taking the time to listen to Emma’s story and noted the intended reflection time later on the agenda.

Standing items

Minutes of the previous board of directors meeting held on the 29 May 2025

Reference

Board public: 25/07/05.

The board approved the minutes of the meeting held on the 29 May 2025 as an accurate record subject to wording amendment requested by Mr Lewis under board public 25/05/13 (chief executive report).

Matters arising and follow up action log

Reference

Board public: 25/07/06.

There were no other matters arising from the minutes. The board received the action log and noted the progress updates. All actions noted as “propose to close” were agreed.

Board Assurance Committee reports to the board of directors

Report from the Quality Committee (QC)

Reference

Board public: 25/07/07.

Dr Falk presented the paper and gave the key highlights.

There was a concerning observation arisen and a theme from other committees for education on substance misuse management for people with comorbidity.

There may be opportunity to incorporate substance misuse education into learning half days. There was no use of agency staff during April and May to support inpatient safe staffing and fill rates had been maintained at acceptable levels.

The quality safety impact assessment (QSIA) highlighted the themes and impacts from the savings programme, and the committee were assured a structured approach was being taken to assess and monitor quality and safety. A retrospective audit of QSIAs would be undertaken to ensure all schemes had been appropriately assessed. Ms Holden advised there would be a retrospective review of directorate budget sign off which may reflect the QSIA process and any learning would be shared.

The committee were provided with an overview of work to deliver promise 16 relating to personalised care and move to the use of patient reported outcome measures (PROMs). The work highlighted the areas for focus and importance of training and organisational culture change.

A refined set of “always measures” (AMs) would be implemented as part of the foundational elements of the Quality and Safety Plan and linked to strategic objectives. The always measures would be reviewed and adjusted based on feedback and implementation outcomes.

The board received and noted the report from the Quality Committee.

Report from the Audit Committee

Reference

Board public: 25/07/08.

Ms Gillatt presented the paper and confirmed there were no matters of concern or areas to escalate to the board.

Good progress and positive team working was noted regarding the annual report and accounts for 2024 to 2025.

The head of internal audit opinion had given significant assurance, an improvement from limited assurance in the previous year.

An overview of the procurement arrangements and future plans to improve the function was highlighted, and timeline for an alternative delivery model. The review would include single quote waiver process and policy to ensure they were relevant and best practice.

The board received and noted the report from the Audit Committee.

Report from the Mental Health Act (MHA) Committee

Reference

Board public: 25/07/09.

Ms Fulton Tindall presented the paper and highlighted key points.

The Mental Health Act (MHA) compliance during April and May showed there were 288 detentions, 1 of which was unlawful.

There had been positive improvements made regarding training compliance for reducing restrictive interventions, the section 136 assessments undertaken within timeframe, and reduction in the number of Mental Health Act incidents. Ms Holden stated it was good to see training compliance rates continued to improve across all areas and confirmed there had been great effort from the learning and development team to address culture and support colleagues to improve compliance.

There had been a refresh of the annual Mental Health Act equalities report with focus on ethnicity, and whether people were disproportionately detained under the Mental Health Act compared to the population. Analysis indicated detention rates for the black community were higher than the white community, this reflected the national picture. Mr Forsyth stated it was a significant concern to note that many people detained would also experience the criminal justice system. Mr Lewis confirmed work was underway to better understand those findings.

Issues remained relating to seclusion for a patient to have an independent consultant review within 5 hours particularly during weekends. A robust action plan was being developed with Dr Sinclair to improve compliance and job planning reviews.

Dr Falk noted there had been 1 unlawful Mental Health Act detention and questioned whether there had been any specific learning from that. Dr Sinclair advised the detention was made by an external consultant and work was underway with local authority partners on receipting of patients with appropriate completed MHA paperwork.

With regards to blanket restrictions, Mr Lewis highlighted the changes implied were substantial changes to process, policy and governance arrangements, and would expect to conclude by the end of September.

The board received and noted the report from the Mental Health Act Committee.

Report from the People and Organisational Development (POD) Committee

Reference

Board public: 25/07/10.

Mrs Vickers, on behalf of Ms Blake, presented the paper and highlighted key points.

There would be new exception reporting on the guardian of safe working hours which would be implemented from September.

Racist incidents had seen an increase, potentially due to the implementation of Radar that provided more accurate detail whether staff felt the incident was racial or discriminatory. Consultation had been made with The Race Equality and Cultural Heritage (REaCH) network. Mr Chillery stated it was good to see data was being shared with networks and triangulated to understand qualitative information.

The people and teams plan continued to progress with good progress on a self rostering pilot at the hospice as part of the future flexible working arrangements. Consideration for acute areas was needed and how flexible working could be managed, this was also being explored with the carers and women’s network, noting the theme from the trust people council.

Mr Lewis explained the chief executive officers report also provided further detail on seven-point action plan in response to part of promise 25 on anti-racism and wider discrimination, noting there would be an audit of the Appropriate Behaviour Policy in practice.

The board received and noted the report from the People and Organisational Development Committee.

Report from the Public Health, Patient Involvement and Partnerships (PHPIP) Committee

Reference

Board public: 25/07/11.

Dr Falk, on behalf of Mr Vallance, presented the paper and highlighted key points.

He confirmed there were 286 active volunteers (target is 350 by October) and noted challenges faced including cultural barriers, uptake and retention of volunteers.

Positive progress had been made against delivery of the research and innovation plan and promise 28. The trust was successful to host the regional ethnic minority research inclusion network and Dr Kellett from the Rotherham care group had become a professor, a positive step towards enhancement that would attract staff to research.

A self assessment was undertaken in 3 areas against the patient, carers, race equality framework (PCREF).

Partnership working continued to be strengthened, noting internal audit significant assurance on partnership governance arrangements and development of a partnership scorecard.

The development of health inequalities reportable data continued to be refined and verified against delivery of a number of promises.

Mr Lewis referenced the first fundamental Aspire partnership report which showed strong performance from the alcohol and drug service.

The board received and noted the report from the Public Health, Patient Involvement and Partnerships Committee.

Report from the Finance, Digital and Estates (FDE) Committee

Reference

Board public: 25/07/12.

Mrs Vickers presented the paper and highlighted key points.

At month 2, there was a £597,000 deficit (better than plan). The delivery of the out of area placement (OOAP) savings target would take effect from 1 July and was key to delivering the 2025 to 2026 financial plan. At month 2, there were nine directorates not compliant with their respective budgets and remedial action had been taken to support them. Mr Lewis advised he was satisfied those areas which had deviated from financial plans would be resolved, and confirmed budget delegation would be removed in respect of two care groups by the end of July until they were in a financially stable position and this would be hoped by end of October.

The medium term financial plan had been refreshed to include assumptions and level of cost improvement programmes (CIP) required to be delivered to reach an underlying balance. Whilst the plan assumed a £1,000,000 shortfall for the pay awards, this could be higher once funding arrangements were known in August.

An overview of the procurement arrangements and future plans for an alternative delivery model were noted as above (item board public 25/07/08).

The information quality work programme was a positive highlight and demonstrated a structured process was in place to address data quality.

The data security and protection toolkit (DSPT) final submission had been completed since the last committee. Mr Banks confirmed the DSPT 360 assurance audit report had also been completed with all achievements being met.

Mr Chillery referred to the key assumptions related to achieving the out of area placement target and delivery of promise 19, and confirmed it was a fluctuating position with 8 people who were out of area.

The board received and noted the report from the Finance, Digital and Estates Committee.

Remuneration Committee

Reference

Board public: 25/07/13.

Mrs Lavery presented the paper and highlighted key points.

The national arrangements for very senior manager (VSM) colleagues terms and conditions framework had been revised. The new framework would no longer include claw back arrangements for the chief executive’s salary. The committee accepted the recommended national VSM pay award for 2024 to 2025.

The board received and noted the report from the Remuneration Committee.

Report from the Trust People Council (TPC)

Reference

Board public: 25/07/14.

Mrs Lavery presented the paper and highlighted key points.

Feedback from the carers network and disability and wellbeing network (DAWN) was shared related to reasonable adjustments, flexible and remote working. These would be explored further to understand the barriers and parameters as noted earlier (item board public 25/07/10).

The engagement, culture and feedback from members was positively received with real debate and many contributions.

Dr Falk referenced the further work with managers to understand barriers to flexible working as well as kindness. The board discussed compassionate leadership and cultural change and acknowledged it was an area of ongoing development. Mr Lewis referred to the Trust People Council (TPC) to have an equal and diverse range of staff voices including those on behalf of trade unions, noting a British Medical Association (BMA) representative had positively contributed to the TPC.

The board received and noted the report from the Trust People Council.

Chief executive’s report

Reference

Board public: 25/07/15.

Mr Lewis drew attention to the key items within his report.

The board were asked to approve the refreshed Green Plan 2025 to 2028 which was previously supported at the Public Health, Patient Involvement and Partnerships (PHPIP) Committee. The updated plan outlined the strategic approach to reducing the carbon footprint of services and estates to align with the NHS ambition to achieve net zero. Mr Lewis reminded members the subject would be discussed at the next Board time out session relating to abolition of energy related grant schemes and potential joint venture proposal.

The new NHS Oversight Framework had been developed to support system performance and improvement, noting the organisation was rated as a 3. This continued to be an evolving situation and Mr Lewis stated that core scores would have given a rating of 2 (better).

The Care Quality Commission (CQC) had confirmed it no longer held ratings at a Trust level (previously rated as required improvement), and the outcome of recent acute visits was to follow shortly.

The annual members meeting (AMM) was held in July alongside the first children and young peoples AMM, with considerations to explore, following feedback from young people and their carers.

There would be an audit of the seven point plan as part of promise 25 to address anti racism and discrimination (item board public 25/07/10). Good progress had been made against delivery of the plan, noting the changes made where complaints were investigated by someone from a global majority background. There would also be changes made to the interview panel process.

Waiting times would begin to be published on the website from the end of July. This work had been coproduced in partnership with local GP colleagues to provide transparency and reduce pressures. Mr Forsyth noted Care Opinion was a mechanism for direct patient feedback and response relating to waiting times. This would give real time qualitative feedback from patients on the experience of waiting for an appointment across all service areas – both positive and negative.

There were no specific matters to escalate from the clinical leadership executive (CLE) but Mr Lewis drew attention to the items explored during June and July as well as those to consider in August and September.

There were five Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) reportable incidents during quarter 1.

The NHS 10 year plan had been published with focus on neighbourhood health, and the board would spend time in its August time out to consider further.

Regarding the children and young peoples annual members meeting, Mr Mohammed reflected on board members creating space to develop and enhance relevant and appropriate skills and knowledge, and stated he welcomed the planned future board time out session to spend dedicated time with children’s services.

In response to Dr Falk and implementation of the NHS 10 year plan, Mr Lewis confirmed engagement with the primary care networks had commenced and partnerships continued to be developed with primary care and GP partners. Coproduction work would be required to consider clear and effective neighbourhood working and outcomes. Mr Chillery noted the importance of partnership working to include voluntary and community services as well as primary care partners.

Ms Clark noted waiting times would be published and raised a concern whether this could be distressing for some patients. Mr Lewis responded as part of promise 14 and deadline of April 2026, there had been significant investment and work to reduce waiting times which would be measured in weeks. Mr Lewis confirmed this work, alongside work across the South Yorkshire Integrated Care Board would be brought back to the Board in September.

In response to Ms Gillatt query relating to the green plan, Mr Lewis advised environmental measurements and qualitative descriptions were reported within the trust annual report.

The board supported submission of the trust’s update green plan.

The board received and noted the chief executive’s report and the forward actions it contained.

Action

Toby Lewis.

Older People’s Quality Indicators paper

Reference

Board public: 25/07/16.

Dr Sinclair presented the paper and gave key highlights.

Following the closure of an older adult ward in Rotherham earlier in the year, the board had made the decision to move from a traditional function to a mixed functional and organic older adult ward. Although this model was a minority position nationally, it had successfully been implemented across Doncaster and North Lincolnshire. There would be different patient environments, designs and staffing make ups to consider as part of the model. The board were reminded that a regulation 28 notice was issued in September 2024 following concerns about the lack of crisis team provision for people aged over 65. The new arrangements for over 65s who required crisis support came into effect at the end of last year.

There was a need to implement and track meaningful mental health quality indicators for older adults, to monitor the impact of the changes made, be able to benchmark older people services against the working age services to identify differences in care and outcomes, and develop towards data informed services.

The quality indicators had been split broadly into two categories for inpatient and community, and Dr Sinclair drew attention to the domains created to measure against accessibility, effectiveness, safety, patient experience and Care Quality Commission self assessment ratings.

Mrs Lavery referred to the board’s previous discussions and decision relating to older peoples services, and the importance of having the quality indicators to be able to evidence and assure the changes made were effective and safe. In response to Dr Falk, Dr Sinclair advised the quality indicators would have a wide remit of safety and care domains to be able to assure the changes in model had not caused harm.

The board discussed the development of the data, monitoring and escalation arrangements. Mr Lewis explained an assessment would be taken, with monitoring to become part of the high quality therapeutic care taskforce (HQTC), safety and quality plans and delivery reviews, with any concerns for escalation to the quality committee. A formal review of the older peoples quality indicators would be undertaken in September 2026, to allow time to develop and implement service development. Dr Falk expressed his interest to become part of those developments.

Mr Chillery referenced the inpatient quality indicators proposed, and suggested there may be disproportionate compared to community quality indicators noting that the majority of patient care was provided in the community. Dr Sinclair agreed to explore developing the community quality indicators further.

Ms Gillatt referred to disengagement and safe care. Mr Lewis noted there was intended time to discuss the subject during its private meeting. There was a substantial programme of work for safe care planning in community mental health services underway linked to promises and recommendations, and next steps would be provided to the board at its meeting in September.

The board discussed other measures to consider as quality indicators, and Dr Sinclair agreed to explore people measures such as turnover and mandatory and statutory training (MAST).

Mr Chillery advised the older peoples mental health services in North Lincolnshire were trialling virtual ward and would be opportunity to test and apply those quality indicators.

The board received and noted the older people’s quality indicators paper.

The board supported the quality indicators as a current baseline, with the intention to compare the indicators against other relevant providers (noting the intent to also make comparison to working age services). The quality indicators would continue to be refined, and a progress report would be provided to the Board at its next meeting in September.

Action

Dr Diarmid Sinclair.

Promise 24: Education at the trust

Reference

Board public: 25/07/17.

Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Ms Holden to respond. Mr Lewis recognised the educational journey to support and upskill the workforce and leadership teams over the year.

Mrs Lavery noted the improvement made in utilising the apprenticeship levy, and acknowledged further plans to continue with focus on supporting local partners. Mr Mohammed referred to levels of apprenticeships and equity of workforce, with the shift to support lower level qualifications rather than senior and higher paid colleagues.

Ms Gillatt explained the Audit Committee had oversight of educational governance, both internally and externally, and welcomed the paper as additional oversight and assurance of educational investment, resources and its effectiveness. Mrs Vickers reflected on earlier discussions on flexible working and how this needed to be integrated with educational plans. Ms Clark highlighted the importance of raising awareness of educational opportunities, noting from a recent inpatient peer review conversation there were some colleagues who were not aware.

Ms Holden responded the educational plan had been on an improvement journey during the previous year, with twelve key areas of focus to reflect, learn from and implement changes. Ms Holden agreed there would also be cultural change with managers in the learning space.

A training needs analysis review had been undertaken which had been refined and revised approach embedded. The organisation had not exceeded the apprentice levy, but this was improving and had seen an improvement in mandatory and statutory training (MAST) training since creating learning half days with focus on compliance. Managers had more understanding and increased ownership on individuals whether they were compliant or not. The development of training dashboards for managers was readily available and would include placements and specialisms, and in September there would be focus on education dashboards at delivery reviews.

There were two national changes that would support the apprentice spend related to functional skills requirements and shorter courses. Discussions had commenced with volunteers and community partners to enable learning spaces and educational spend opportunities. There had been changes in clinical roles career pathways such as allied health professionals (AHP) able to access the apprentice levy. There had also been a shift in continuing professional development (CPD) allocation which had historically been ringfenced for nursing and allied health professionals. Ms Holden advised the paper was also taken with the learning update which detailed the learning structure and the four pillars of learning for individual and systemic learning and education.

The board received and noted the update in respect promise 24 and education at the trust, aligned with promise 9.

Learning update

Reference

Board public: 25/07/18.

Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Lewis.

Mr Gowland questioned the change needed in some corporate teams, and whether this was large scale change. Mrs Lavery acknowledged the positive action taken to protect time for learning with the creation of half learning days. Mr Chillery referred to what had been learnt so far and supported the approach of progressing using plan, do, study, act (PDSA) cycles to constantly learn and improve. Ms Holden referred to the positive outcomes and important insight it provided which could be adopted in other areas for development.

Mr Lewis responded the paper focused on two areas since the education and learning plan was launched. The first was to understand what had been learnt so far, and secondly how learning was triangulated and shared. Mr Lewis drew attention to learning half days, what had been learned from feedback, the challenges faced and areas for development. There would be rolled out during quarter 2 and 3 with an adjusted model of learning for 24 hour community and inpatient services.

The learning model would continue to be implemented and changed to be able to support triangulated learning, how that would be communicated in an accessible way and embed as good practice.

The board received and noted the learning update paper.

Productivity at the trust

Reference

Board public: 25/07/19.

Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Mohammed.

Mrs Lavery stated the paper was clearly articulated and queried how productivity would be sustained across the organisation. Dr Falk supported the method of measurement of productivity and having clear understood definitions of productivity which would focus on high quality care for patients. Mrs Vickers agreed and referenced learning from cost improvements and ability to benchmark against internal performance to inform and measure productivity.

Regarding unpicking block contracts, Dr Sinclair acknowledged the potential this would create towards productivity improvements. Mr Chillery stated national guidance on productivity was in its infancy, and the trust had already made progress in creating the methodology and definition of productivity relevant to the organisation.

The board noted the programme of work would be developed to make productivity improvements in each care group. Case studies would be created to demonstrate how productivity had impacted following changes made.

Mr Mohammed confirmed pilots had commenced in Rotherham and physical health teams, and initial results had shown an improvement in engagement across teams as well as productivity. Data was available through dashboards to support productivity and provide insights. Mr Mohammed referred to national productivity tools, and the organisation continued to engage with peer organisations and wider networks. The trust was able to benchmark national cost collection information and performed well compared to nationally. Mr Mohammed reminded colleagues a £4,800,000 target for productivity improvements was included in the 2025 to 2026 financial plan, with the 2026 to 2027 plan likely to include cash releasing savings stemming from this work.

Mrs Lavery noted the ambition to achieve promise 14 (4 week wait) was the primary driver towards delivery of productivity improvements, and acknowledged the progress made in creating a method for embedding the productivity improvement requirements into the existing delivery work.

The board received and noted the update in respect of productivity at the trust. A further update on delivery of productivity work would be presented to the board in January 2026.

Action

Izaaz Mohammad.

Promise 2: carers delivery plan

Reference

Board public: 25/07/20.

Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Forsyth.

With regards to the success measures of the carers delivery plan and in particular measure 4, to identify all age carers that use services, Mr Lewis questioned whether there was a clear understanding of why carer assessments were not completed. Dr Falk recognised the plan resonated with the always measures (AMs) and delivering personalised care, as part of the overall quality and safety plan, with work underway to produce clear guidelines for all staff to show the process of recognising and signposting for carers assessments.

Ms Fulton Tindall noted the low number of staff who were declared as carers, and what plans were to identify and better support carers in the workforce for the future whilst reflecting on an ageing population that would continue to grow. Regarding national statistics of people providing unpaid care and following feedback from the children and young peoples annual members meeting, Ms Holden questioned whether carers felt integral to the decision making process and how young people in services were also recognised as carer providers. Mr Forsyth agreed to explore how young people in services providing caring responsibilities were being recognised.

Mr Forsyth responded that there was a mixed and complex situation to recognising and supporting carers from both patient and staff perspectives. Factors to consider included cultures, aging populations, and consultation with those of lived experienced had took place. The carer delivery plan had since been strengthened with focus on carer support, how the voices of parents, carers, family and friends and staff with caring responsibilities would be listened to and be involved. There were good areas of carer engagement to learn particular from children and young people services.

Mr Forsyth noted several workstreams would support delivery of the carers plan such as always measures and delivery of personalised care (discussed under item board public 25/07/07). The measures of success would continue to be monitored and other methods of feedback considered to enhance carer support.

The board received and noted the promise 2 carers delivery plan, and an update on its implementation would be provided to the board in November.

Action

Steve Forsyth.

Promise 14: delivering a 4 week wait for all referrals

Reference

Board public: 25/07/21.

Mr Chillery presented the paper, which provided a progress update on the management of waiting lists.

A trajectory had been set detailing the number of services anticipated to meet the four week waiting time by October 2025, December 2025, and March 2026. The trajectories were essential to deliver against promise 14’s to deliver a four week maximum wait for all referrals from April 2026. Mr Chillery highlighted it was important to note that sustained or sudden increase in referral volumes or unforeseen changes, such as sickness in small teams may impact projections, this had already been seen in a small number of services including podiatry. Mr Chillery advised there were some pathways at higher risk for achievement due to the scale of improvement work required regarding community mental health teams and learning disabilities services in Doncaster. An update on the neurodiversity position for adults and children would be provided to the board in September.

Significant work had been undertaken to ensure visibility of clinical pathways to provide visibility and detailed focus to waiting lists. The focus has been a focus on referral waiting lists and further work is ongoing with a small number of secondary waits, to enable targeted support and intervention. There was planned time to discuss with the clinical leadership executive (CLE) in August regarding secondary waits for some therapy pathways. In response to Ms Clark, Mr Lewis confirmed there was no intention to publish secondary waits but we would want to ensure visibility and action on these waiting lists.

Mrs Lavery gave thanks for the open and honest report, and acknowledged the enormous work that had been produced to date on addressing wait times and overall, a positive picture. Ms Fulton Tindall stated it provided an honest insight on waiting times.

Regarding waits, Dr Falk queried whether this had impacted on the podiatry service. Mr Chillery replied that the care group had recognised the podiatry service could struggle to meet trajectory should demands be sustained. This was due to the significant increase in referrals following a health promotion work undertaken the previous quarter 3, rather than secondary waits. Mr Chillery explained although the service had responded quickly to the change, an investment bid may be required should the demand be sustained.

Mr Lewis summarised there was ongoing effort in data and performance collection, alongside demand and supply, for services to be able to make decisions about offering appointments inside a week of referral.

Mrs Lavery noted the timetable of delivery outlined within the report, and recognised the identified non-compliant services and timetable for further review. Work would continue to define secondary waits, recognising that the commitment made by the board must be the one which patients experience.

The board received and noted the update relating to promise 14 to deliver a 4 week wait for all referrals.

Action

Richard Chillery.

Care Quality Commission readiness: our next steps

Reference

Board public: 25/07/22.

Mr Forsyth presented the paper and gave key highlights.

The Care Quality Commission (CQC) readiness programme continued to progress following the board’s review of the CQC self assessment across the four domains of safe, caring, effective and responsive. The aim would be to achieve and sustain “good” rating across all domains, with ambition to achieve “outstanding” by 2026. Mr Forsyth explained the next steps planned and areas of focus.

Quality peer reviews would be extended across community areas in addition to inpatient areas. A time to show (share and shine) event would be hosted to help services showcase the work they were doing to improve services and learn. Care group and directorate evidence folders would be checked and challenged for consistency.

Mr Forsyth drew attention to the key milestones which remained between July and November to be able to achieve a “good” rating. It was noted a delivery plan had been shared with directorates with focus areas which required improvement. Mr Lewis confirmed scrutiny would be undertaken at care group delivery reviews, and Mr Forsyth would reflect on how the process supported services to generate positive and reflective scrutiny and challenge.

In response to Mr Mohammed and from feedback in care group delivery reviews, Mr Forsyth advised evidence folders would be built upon, standarised and become consistent, with digital solutions to support services and ensure benchmarking against the CQC four domains. Mr Forsyth explained staff engagement and communications would continue to be promoted, noting the support in place of staff booklets and as it being part of staff inductions.

Mrs Lavery summarised the proposed action plans and timescales proposed for delivery, and confirmed the board were content with those.

The board received and noted the Care Quality Commission readiness paper and next steps.

Plans for approval:

Reference

Board public: 25/07/23.

People and teams plan

Ms Holden introduced the people and teams plan, emphasising its importance for the organisation. The plan focused on team and leadership development at all levels, aiming to harness the energy of leaders to drive sustainable changes.

Ms Holden highlighted the need to measure success through 10 key metrics for each directorate, which would help track progress and ensure that the plan was effectively enabling changes within the organisation. The focus areas in the plan included employees, students, and bank workers. Ms Holden explained governance arrangements and oversight of the plan would be through the Clinical Leadership Executive People and Teams Group, People and Organisational Development Committee, and board, and a crucial role to drive the plan forward to ensure successful implementation.

Digital enabling plan

Mr Banks introduced the digital enabling plan, and highlighted its focus on data availability and quality. The plan aimed to improve how data was used to facilitate interactions with patients and staff.

The plan included specific success measures that would be monitored through the Clinical Leadership Executive Digital Transformation Group starting in August. These measures would help track the progress and effectiveness of the plan. In response to Mrs Vickers, Mr Banks advised the plan was strongly aligned with the NHS 10 year plan. The plan’s key strengths included digital inclusion, human-centred design, data and intelligence, and partnerships. These areas aligned with the NHS priorities and demonstrated the plan’s maturity and innovation.

Mr Banks acknowledged the link between the future digital plans and projects and the trust’s future capital plan for 2026 to 2028 and the input he would make to that broader process.

The board received and approved the people and teams plan and digital enabling plan. Delivery oversight of these plans would be given to their respective board committee from quarter 2, in line with their already agreed terms of reference.

Integrated Quality Performance Report (IQPR)

Reference

Board public: 25/07/24.

Mr Chillery introduced the Integrated Quality Performance Report (IQPR) for June 2025.

There had been a slight increase in sickness absence versus target, with recent benchmarking data showing that sickness levels benchmarked high compared to other similar trusts. The 5.5% vacancy figure reflected the increase in establishment linked to significant changes in community rehabilitation services and also the development of the high dependency unit.

Improvements had been seen in the access rates to talking therapies and children and young people services, although both were still below target. There remained a focused improvement plan on achieving the target for severe mental illness (SMI) annual health checks, including register consolidation and the introduction of blood test machines for key services.

Although racist incidents had seen a drop in reporting, this had been identified as an area of underreporting due to the implementation of Radar system.

The financial position was £38,000 better than plan at month 2. During June there were 7 out of area placements (OOAPs) (compared to 25 last year) and Mr Chillery recognised that position had increased to 8 at present although significant effort and change continued to reduce the number of out of area placements.

The board received and noted the Integrated Quality Performance Report.

Health inequalities review of Integrated Performance and Quality Report (IQPR)

Reference

Board public: 25/07/25.

Mr Lewis, on behalf of Mrs McDonough, presented the paper which provided an analysis of the Integrated Performance and Quality Report (IQPR) data through a health inequalities lens.

The analysis focused on four protected characteristics of ethnicity, deprivation, age and gender, and highlighted a significant number of services do not fully reflect the communities that they serve in relation to at least one protected characteristic.

It was proposed that the Clinical Leadership Executive Equity and Inclusion Group would review the data, to better understand local need of patients with different protected characteristics. It would also need to understand any variances in provision versus community population, and consider how to provide targeted, culturally appropriate services.

Mr Lewis gave thanks to the health informatics team for their efforts in producing the health inequalities data pack (as part of agenda pack B).

Dr Falk recommended to streamline and refine the report, with future focus on significant health inequalities data so not to be distracted on less significant numbers or percentages. Mr Lewis acknowledged the health inequalities data would continue to be developed and refined to have meaningful data.

The board received and noted the health inequalities review of the Integrated Performance and Quality Report, and supported the next steps contained within the paper.

Promises and priorities scorecard

Reference

Board public: 25/07/26.

Mr Lewis presented the paper which highlighted the progress made on the specific promises and the need to focus on delivery in the coming year. Of particular note were the number of plans assessed as “red” and “amber red” on likelihood of delivery.

There were clusters of plans that although different in their measures and plans, had common themes and were key to delivery of promises. An example was promise 9. The board would receive a progress update against delivery of promise 1 (peer support) in September.

There was real commitment from all care groups to deliver promise 3 (volunteers), noting validation of data was ongoing and confidence of what was required to be able to deliver to expand volunteer numbers and increase diversity was growing.

Mrs Lavery referred to promise 22 and highlighted the importance of a seven day service for patient care, noting that the current service levels differ significantly between weekdays and weekends. Mr Lewis acknowledged the challenges and advised a gap analysis would be undertaken over the coming months to help identify the necessary steps and resources required for implementation. This would consider the feasibility, resource requirements, and potential impact on staff and patients.

The board received and noted the promises and priorities scorecard update on the work to date and expectations in 2025 to 2026.

Board and Committee reporting August 2025 to March 2026

Reference

Board public: 25/07/27.

Mr Gowland presented the paper.

The forward plans had been developed for board and its committees, and Mr Gowland highlighted the importance of consistent oversight and planning.

There was need to ensure that all committees were aligned, that any additional topics were regularly covered, to ensure that they were working towards common goals and addressing relevant topics effectively. Mr Gowland confirmed the key focus for the committees would be on four roles of statutory compliance, plan delivery, partnership duties and matters delegated by the board.

There was intent to continue a thematic focus for future board meetings, noting July’s theme of education. A programme to create a rolling update would be introduced to ensure that attention was always four or five meetings in advance, to include the Audit Committee.

The board discussed the benefits of having a rolling update in advance so that members could collaborate, what key topics may have been missed, overlooked or duplicated, and confirmed its support to receive the update in advance.

Mr Gowland confirmed that emergency preparedness, resilience and response (September 25) and cyber security (March 2026) would be included to the forward plans.

The board received and noted the board and committee reporting arrangements for the remainder of the financial year.

Strategic delivery risks (SDRs)

Reference

Board public: 25/07/28.

Mr Gowland presented the report, reminding the board of the revised approach taken within the last year to strategic risk management with enhanced reporting and oversight through its committees.

The strategic delivery risks (SDRs) continued to be strengthened and understating what gaps remained, with regular engagement with executive leads, as well as tri-annual reviews with Ms Gillatt as the Audit Committee Chair and Mr Gowland.

There would be intention to review the strategic delivery risks in light of the NHS 10-year plan, the output from that would be presented at the next meeting. Mr Lewis cautioned some plans and targets for delivery may shift following this review.

The board received and noted the Strategy Delivery Risks Report, noting the planned next steps to further refine and enhance plans to mitigate those risks and the intended review of strategic delivery risks following the publication of the NHS 10 year Plan.

Operational Risk Report

Reference

Board public: 25/07/29.

Mr Gowland presented the paper which highlighted the current position in relation to the extreme risks. There had been a shift in operational risk management with the use of risk appetite statements and implementation of the new radar system. The change aimed to improve the identification and management of risks.

The use of risk appetite statements helped define the level of risk the organisation was willing to accept. The approach would ensure that risks were managed within acceptable limits.

The new Radar system was being used to track and manage risks more effectively, and provided a comprehensive view of risks and helped develop clear mitigation plans. Mr Gowland emphasised the need to address risks that were outside of the defined appetite. Clear mitigation plans were required to manage these risks and ensure they would not impact the organisation’s objectives.

A total of five risks were previously reported to the board as extreme. Following the recent recalibration of risk scores across the organisation, three of these risks now sat outside of appetite levels but remained within tolerance limits, which indicated they were managed but still required close monitoring. There were two risks which remained outside of tolerance levels pending further mitigation or resolution.

Scrutiny would be undertaken through the Risk Management Group (RMG), noting the higher number that remained outside tolerance and required focused attention. In response to Mr Lewis’s question about categorisation, Mr Gowland confirmed that the RMG would review all as part of its next meeting to ensure they were appropriate.

The board received and noted the Operational Risk Report update, including extreme risks. The board noted the updated risk appetite levels and the planned work to address the extended number of risks that were currently outside of appetite and tolerance.

Supporting papers (previously presented at committee)

Supporting papers

Reference

Board public: 25/07/30.

Mrs Lavery informed the board of the following additional reports for information which were presented as supporting papers that had previously been presented at committee level for scrutiny and challenge:

• Accountable Officer for Controlled Drugs Annual Report 2024 to 2025
• Health, Safety and Security Annual Report 2024 to 2025
• Mortality Report
• Guardian of Safe Working Hours Report

The board received and noted the additional reports for information.

Any other urgent business

Reference

Board public: 25/07/31.

There was no further business raised.

Any risks that the board wishes the Risk Management Group (RMG) to consider

Reference

Board public: 25/07/32.

• Independent review of seclusion and work ongoing to conclude and is this captured in our risk register.
• Net zero and ability to record carbon, and whether the organisation was able to accurately record its carbon position.

Public questions

Reference

Board public: 25/07/32.

Mr Lewis addressed a public question that was raised at the annual members meeting (AMM) about dairy allergies, emphasising the importance of ensuring patient safety and proper communication about dietary restrictions. Mr Forsyth noted this was in response to a patient who had an extreme allergy to dairy whose life was at risk should they come into contact. The patient complained they could not get staff to understand he could not have food with dairy product or indeed certain clinical and medical interventions which included dairy. Mr Forsyth confirmed all food menus did have an alternative non dairy option available, the food was cooked from fresh and frozen, and was able to account for allergies.

Dr Sinclair agreed to provide an update relating to staff awareness for alternative dairy free medication.

Action

Dr Diarmid Sinclair.

Chairs closing statement

Reference

Board public: 25/07/34.

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.

Page last reviewed: November 06, 2025
Next review due: November 06, 2026

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