Board of directors minutes March 2025

Minutes of the board of directors meeting on Thursday 27 March 2025, 9:30am at:

CAST theatre
Waterdale
Doncaster
DN1 3BU

Present

• Kathryn Lavery, Chair.
• Rachael Blake, Non-Executive Director
• Richard Chillery, Chief Operating Officer.
• Sarah Fulton-Tindall, Non-Executive Director.
• Steve Forsyth, Chief Nurse.
• 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.
• Dave Vallance, Non-Executive Director.
• Pauline Vickers, Non-Executive Director.
• Dr Janusz Jankowski (virtually attended), Non-Executive Director.

In-attendance

• Richard Banks, Director of Health Informatics.
• Lea Fountain (virtually attended) NeXT Director.
• Philip Gowland, Director of Corporate Assurance and Board Secretary.
• Dr Jude Graham, Director for Psychological Professions and Therapies.
• Jo McDonough, Director of Strategic Development.
• Sarah Dean, Corporate Assurance Officer (minutes).
• Emily Andrews, staff story.
• Melanie Mitchell, staff story.
• 7 members of staff and 4 governors were in attendance.

Introduction

Welcome and apologies

Reference

Board public 25/03/01

Mrs Lavery welcomed all attendees to the meeting. Apologies for absence were noted from Dr Richard Falk.

Mrs Lavery noted that with additional financial discussion required, she had agreed to defer discussion of agenda item 24, the enabling and delivery plans, to the board timeout. She drew attention to the day-before issue of an addendum to agenda Item 16, 2025 to 2026 financial plan, with paper copies available. This addendum recognised negotiations with the integrated care board (ICB) over the past 48 hours which had resulted in a recommended balanced plan, albeit with elevated risk associated with the high dependency unit (HDU) dependency.

Quoracy

Reference

Board public 25/03/02

Mrs Lavery declared the meeting was quorate.

Declarations of interest

Reference

Board public 25/03/03

Mrs Lavery presented the declarations of Interest report which outlined that there were changes to the register declared since the last meeting relating to Mr Mohammed and Mr Forsyth.

The board received and noted the changes to the declarations of interest report.

Staff story

Staff story: adult neurodiversity service

Reference

Board public 25/03/04

Mrs Lavery welcomed Emily and Melanie to the meeting to share their story and experience of working in the adult neurodiversity service.

Emily and Melanie shared they were both attention deficit hyperactivity disorder (ADHD) practitioners. Emily was new to the team and new to prescribing, whereas Melanie had worked within the team for the past year. Emily acknowledged the organisation had made commitments and investment into the service to address ADHD assessment and waiting times.

Emily and Melanie highlighted the importance of reducing waiting lists for assessment and provide high quality care. The ADHD referral point had changed including the role of band 5 staff in triaging and managing referrals, which helped the management of referrals with thorough assessment and gathering of information to provide personalised care for patients, accurate diagnoses and appropriate treatment plans. They highlighted the importance of patient safety, including managing complex cases and ensuring patients receiving the right level of care and support.

The challenges the team had faced included managing large caseloads, prescribing and medicines management with regular follow up, the mental and emotional toll on colleagues, and need for better health, safety and wellbeing support such as fit for purpose staff base. Emily and Melanie shared examples of how medication had positively impacted patients’ lives. The Attention Deficit Hyperactivity Disorder team would be exploring non-pharmacological interventions, such as psychosocial support, to complement medication and provide holistic care for patients.

Mr Lewis reflected the sheer sense of responsibilities the team were carrying to address waiting times, and questioned how the organisation could support the team to balance that burden. Dr Graham offered the team support, and acknowledged the service was high paced and makes a real impact on those with lived experience. Mr Lewis reflected on the point there was no base for the whole team and noted this would change as part of estate transformation plans, funded in the capital plan for 2025 and 2026.

Ms Blake queried whether there were peer support and voluntary sectors which could provide additional support. Melanie advised there were not many voluntary services which specialised in autism however the service did link in with the local voluntary autism service.

Mr Chillery highlighted the challenges the ADHD team faced and was important to hear, acknowledging it was not always cognisant of how many cases were being managed in the community. Mr Chillery explained managing ward environments were challenging when on the ward, but recognised community was different and not always able to hand over cases when taking annual leave. Mr Forsyth agreed the burden of responsibilities and period of care when handing over was very different in the community compared to inpatient ward care.

Mrs Lavery and the board thanked Emily and Melanie for taking the time to speak about their experiences and noted the intended reflection time later on the agenda.

Standing items

Minutes of the previous board of directors meeting held on the 30 January 2025

Reference

Board public 25/03/05

The board approved the minutes of the meeting held on the 30 January 2025 as an accurate record.

Matters arising and follow-up action log

Reference

Board public 25/03/06

Mr Lewis referenced the backlog of structured judgement reviews (SJR) discussed at the last meeting (item board public 25/01/07). From 31 March 2025, additional resource was in place to address the backlog of SJRs. He reminded the board that from, 1 April 2025 SJRs would work differently and would only be undertaken in certain circumstances aligned to our patient safety incident response framework (PSIRF) approach.

The outcome of the good governance improvement (GGI) review, discussed at the last meeting (item board public 25/01/06) had been received and would be shared with board members in the forthcoming well-led paper.

Mr Forsyth referred to the previous minute regarding promise 3 (item board public 25/01/18) and confirmed it accurately recorded his contribution to the discussion but clarified that the current position with respect to volunteers was that there were 220 volunteers, with a further 80 offers pending (offers made in writing to individuals).

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.

With reference to closed action board public 24/09/19, Mrs Lavery advised she had met with Ms Fulton-Tindall to discuss the role of board security champion, noting a job description had been identified.

Mr Forsyth reported the commencement of a full reaudit and recovery plan into the next quarter of Mental Capacity Act (MCA). This work needed to beyond a focus on training compliance.

In relation to open action board public 24/09/25, Mr Chillery advised pathways for mental health (OP08d) had made significant improvement towards achieving the 92% target and would continue to be reported via the integrated quality performance report (IQPR). The board agreed to close this action.

Mr Lewis recommended the consideration by the Risk Management Group, of a risk of disengagement, noting the trust had received a Regulation 28 regarding disengagement (open action board public 25/01/21b).

Action

Phillip Gowland

Board Assurance Committee reports to the board of directors

Report from the Quality Committee (QC)

Reference

Board public 25/03/07

Mr Vallance, on behalf of Dr Falk, presented the paper and gave the key highlights.

The annual safe staffing declaration provided assurance the organisation was compliant with national standards (in patient areas only). The committee took assurance of the direction of travel for the safe staffing workstreams. Mr Lewis reminded the board that the staffing establishments for 2025 to 2026 had been set and would not change unless there was a clear egregious difference and professional judgement to patient safety that required a revisit. In regard to the MHOST acuity tool (recommended tool for use for mental health bed-based services) this was a supportive tool, but it was made clear that clinical professional judgement would take precedent. MHOST in 2025 and 2026 would influence workforce planning, as MHOST in 2024 and 2025 had. Steve Forsyth confirmed that that was the intention and supported this.

Progress had been made against health, safety and security plans including violence prevention and reduction standard (VPR). The Committee felt clarification was required around the future reporting arrangements for the health and safety plan, to avoid duplication of work between committees (the Quality Committee and Finance, Digital and Estates Committee).

The committee noted the recovery plans to address backlogs in respect of structured judgement reviews and complaints.

The digital programme for safe quality care was positively received and highlighted the importance of data quality in patient care.

Mr Vallance wished to record the committee’s appreciation to Dr Jankowski for his contribution whilst a member of the committee.

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

Report from the Audit Committee

Reference

Board public 25/03/08

Ms Gillatt presented the paper and highlighted three points to the board.

The counter fraud, bribery and corruption work was on target to deliver the plan with no matters of concern to report.

Internal audit had issued three audit reports since the last meeting (strategic delivery risk management, significant assurance; estates helpdesk implementation, limited assurance; and policy management framework, moderate assurance). Follow-up work on audit actions remained strong with continued oversight and progress through audit action leads. The interim head of internal audit opinion was likely to be moderate and this would be received at the next committee meeting in April.

The final accounts timetable and plan was noted, including the recent interim audit work. Ms Gillatt highlighted the emerging issues relating to the treatment of St John’s hospice within the balance sheet (donated assets). Work was underway to resolve this matter and dependent upon the outcome a prior year adjustment or representation of the accounts may be necessary. Mr Mohammed advised this work would not impact on his ability to make the necessary submissions for 2024 to 2025 accounts in line with the timetable. Responding to a question from Mr Lewis, he noted that any prior year adjustment implications would be discussed with the accountable officer in coming days, should they prove necessary. Mr Mohammed provided positive feedback from his meetings with the external auditors Deloitte, noting the interim audit so far had gone well.

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

Action

Izaaz Mohammed

Report from the Mental Health Act (MHA) Committee

Reference

Board public 25/03/09

Ms Fulton-Tindall presented the paper and highlighted key points.

There had been two Care Quality Commission Mental Health Act inspection visits which had identified a consistent theme around personalised care planning. This had also been identified as part of the annual Mental Health Act performance reporting. A review of personalised care planning was underway to provide clarity of what constituted a personalised care plan. Mental Health Act seclusion remained a challenge particularly the accurate recording of the seclusion on the electronic patient record system.

Positive progress had been made against sustaining Mental Health Act level 3 training compliance. Further improvements had also been made in Mental Health Act reporting in relation to correctly recording consent to treatment and section 132 rights.

The committee positively received a Mental Health Act patient and carer feedback report, this would be built on as part of the delivery of promise 4.

Mr Chillery referred to care group delivery reviews, advising the care groups were requested to review what their future training needs analysis would be over the next year including care planning. Ms Holden advised support was being provided to improve training compliance with focus across Mental Health Act level 3 and reducing restrictive interventions. There were 52 staff non-compliant with training (including some exceptions such as long term sickness). Additional courses were available to those staff during March, April and May 2025. She understood that only 2 individual remained unaccounted for.

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 25/03/10

Mrs Vickers presented the paper and highlighted key points.

Sickness absence had slightly increased to 6.28%. A task and finish group would be undertaking a deep dive review and a revised policy (supporting health, wellbeing and managing attendance policy) would be launched in April 2025. This had been widely discussed within clinical leadership executive group.

The vacancy position was closing in to target of 3.3% (less than 100 vacancies) with efforts continuing to manage turnover and improve the vacancy rate to 2.5% for 2025 to 2026.

Following the emergency closure of Brambles ward in Rotherham, a meeting took place with the Deanery to discuss the impact of clinical service re-design on education and training. Ms Holden provided feedback from that meeting, stating there were in total seven resident doctors who were impacted by the ward closure. The seven resident doctors had since reported positive training experiences from working in a blended approach across the communities as a result of the closure of the Brambles ward. Mr Lewis noted the importance of the Deanery’s formal guidance in relation to junior doctor placements and training programme but also drew attention to the informal nature of the visit, which was not a quality escalation. A formal response by the end of May would be submitted by himself and Dr Sinclair.

The leadership development offer (LDO) launched in January with cohort one; a second cohort would commence from April 2025 and again this included several community partners.

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 25/03/11

Mr Vallance presented the paper. Regarding eating disorders, it was noted the Ellern Mede unit at Moorgate was closed with the relocation (with the patients’ full agreement) of long term patients to London, noting there had since been improved patient outcomes.

The strategic delivery risk (SDR3) focus was on building relationships with primary care, highlighting the importance of engagement and raising awareness of the services available across the organisation amongst staff and with primary care.

The Poverty Proofing workstream (promise 6) had collaborated with the Citizens Advice Bureau. This would provide money and debt advice for patients and staff. Ms Holden added the hardship grant was also available for staff. Funding of £35,000 from the investment fund was agreed to support some patients in relation to transport costs.

Health inequalities data highlighted there were higher did not attend (DNA) rates in deprived areas across Rotherham which stood at 42%. Work was underway to reduce this. Health inequalities data would be included in the integrated performance and quality report and presented to the board on a regular basis.

Mrs McDonough referred to the eating disorders collaborative and clarified the extra package of care had reduced significantly. However that did not bring any funds back into the organisation and was not a financial gain.

Dr Graham commented it was a real investment to help people travel to appointments, triangulating with the fact that vacancies were being filled, so people could be seen and attend appointments. Mrs Lavery reflected the organisation was making changes which would make a real difference to communities such as support for travel to appointments. Mr Lewis explained the transport support protocol would have to provide people with the funds in advance to use for transport and not putting people out of pocket, rather than the traditional way of claiming back travel expenditure.

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

Action

Toby Lewis and Rachael Blake

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

Reference

Board public 25/03/12

Mrs Vickers presented the paper and highlighted estates compliance remained an area of focus, in particular fire safety although it was an improving picture. It was noted fire assessments were due to be completed by the end of March 2025 and external specialist support was being provided. A sustainable, forward plan was in place in relation to fire safety compliance.

Regarding the estates enabling plan, there would be further exploration for potential funding solutions including land disposal, system capital allocation, national programmes, and off-balance sheet schemes. Mrs Vickers extended the offer to board members to discuss the estates enabling plan funding options.

The draft finance plan 2025 to 2026 was received, noting work would continue to develop the finance plan and it would be discussed later on the board’s agenda.

The clinical coding audit report provided assurance there was a robust process in place and to a high standard. The report positively highlighted the achievement of quality in clinical coding undertaken across the organisation.

Mr Lewis noted it was encouraging that each group was confident in delivering its financial plan this year. Mr Mohammed explained there had been a lot of focus, scrutiny and increased grip on directorate level review of budgets, controlled spend and non-recurrent funds, and budgets would be signed off on the basis of all 23 directorates for the first time.

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

Report from the Remuneration Committee

Reference

Board public 25/03/13

Mrs Lavery presented the paper and highlighted the discussions. Mr Lewis suggested increasing confidence that a new very senior manager (VSM) pay framework would be published soon, and that it would be received at a future meeting of the committee.

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

Chief executive’s report

Reference

Board public 25/03/14

Mr Lewis drew attention to the key items within his report and one item which was not contained in his report in relation to the recent Government changes affecting carers and disability allowances. Mr Lewis recognised the changing welfare landscape ahead and reminded the board of the organisation’s commitments and delivery of promises (examples such as Real Living Wage and Poverty Proofing) and suggested that the board should continue to consider whether these were proportionate response to the challenge communities now face.

The new interim general practice (GP) contract was worth noting. The conclusion to the dispute should allow the trust to move forward with shared care agreements. Conversely the lower priority for annual health checks was noted.

Future medical education and placements would be reviewed, considering the positive reflections from the Deanery. The structure of the medical education leadership would also be strategically strengthened to create a team support of education for future resident doctors. The most important step within those changes would be embedding the team within the chief medical officer’s directorate, with Diarmid Sinclair holding the accountability. Mr Lewis noted there would be potential changes to the curriculum specifically the Sheffield School of Psychiatry to approach all age services. The potential changes in education arrangements could support the Neighbourhood Health workstream for community-based services, which would look to re-introduce “generalism” in care models which have moved for some time towards sub-specialisation.

The first community geriatrician was due to join the organisation as part of bringing together the wider specialist physical and mental health services. This important role and change would support how the organisation worked with system partners to support older adults. Discussions with the integrated care board remain ongoing to fund a second community geriatrician, potentially through winter 2025 to 2026.

Following the board’s discussion on violence and on reducing restrictive intervention practices in November 2024, the implementation of a reducing restrictive intervention advocacy role in each ward team would be undertaken during Q1. This work would be led by care group senior nurses and overseen through the High Quality Therapeutic Care (HQTC) Taskforce. The reducing restrictive intervention training would also be enhanced. Mr Lewis advised there would likely be a change in the ward behavioural landscape from July when out of area placements would cease, recognising the importance of having the reducing restrictive intervention advocate roles in place from quarter 2.

Mr Lewis noted the board would seek to confirm in May, for the staff survey, as it had done for Care Quality Commission ratings, what the organisational aim truly would be over the period to 2028.

Action

Carlene Holden

In response to Dr Graham, Mr Lewis stated he believed the recent government announcements may cause some interruption of relationships and to potential national programmes of work, but did not foresee delays with any organisational plans. Mr Lewis cautioned that the board would need to remain mindful and aware of these changes and that there may be implications from provider led arrangements and commissioning, this could in turn present both risk and opportunities. Mr Lewis had arranged to meet with senior leaders next week in direct response to the government “reset” and the potential implications for the organisation and other non NHS clinical services across Rotherham, Doncaster and North Lincolnshire. Mr Lewis reminded the board a new NHS 10-year plan was due to being published in June 2025.

In regard to “think directorate”, Mr Vallance noted the Quality Committee received the clinical audit and effectiveness report and queried whether this would provide encouragement for directorates to understand clinical effectiveness. Mr Lewis agreed and advised the directorates continued a development journey and data flow and quality measures for directorates would continue to develop, including the DIALOG+ tool deployment to be delivered during 2025.

Mr Chillery referred to potential impacts around section 117, case management of specialist placements, and continuing healthcare checklist assessments. Although it was too soon to identify any risks, Mr Chillery advised they would continue to be monitored and related to the risk register should that be necessary.

In response to Mrs Gillatt, Mr Lewis advised there would be no change at present to the Standing Financial Instructions or Schemes of Delegation arising from the “think directorate” development works. Regarding any change in model and potential operational or strategic risks, he anticipated the biannual risk appetite review would be undertaken at the board time out in April.

In regard to “think directorate” and whether clinical research would be considered for directorates’ quality measures, Mr Lewis stated the research and innovation plan did include certain academic research outside the organisation specifically in management leadership disciplines that would support the organisational strategic plan and promises. A recent case from the children’s care group delivery review discussed innovative changes to service they were leading on which involved creating a culture of clinical research and experiments. Mr Lewis highlighted it was important to have the balance of locally led clinical research and strategic plans.

Ms Fulton-Tindall referred to the government “reset”, noting public funding would be changing and questioned how likely this would impact on delivery of promise 23 (investment in residential care). Mr Lewis replied that he believed this would be an opportunity to expand work across place. This work had already commenced in Doncaster with commitment to divert NHS resource into the public health budget, and the ability to offer social care services via Flourish (community interest company). Mr Mohammed referred to supporting system partners with estate challenges and the potential to develop new models of working. Mr Lewis responded that conversations would continue to create triangulated relationships with care homes, hospitals and primary care, and build on delivering promise 23.

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

Action

Phillip Gowland

2024 and 2025 serious patient safety incidents: learning

Reference

Board public 25/03/15

Mr Forsyth presented the paper. All patient safety incidents were responded to with immediate learning discussed at the time of the incident, including significant learning from serious incidents. All reviews form part of the patient safety incident response framework (PSIRF) and learning from those serious incidents identified the theme to improve data quality such as patient records and care plans.

Following restructure within the nursing and facilities directorate, there was a clear remedial action plan in place to conclude those serious incident reviews which had exceeded six months to complete.

Mr Vallance sought clarity on what the report was seeking to tell us, as many of the patient safety incident investigations were not yet completed from 2024 and 2025. Ms Fulton-Tindall also questioned whether the paper set out learning or symptoms from case review. Mr Lewis suggested that what was needed was the learning, the forward measure and an understanding for these most serious of patient safety incidents about when and how we would know change had occurred.

Mr Forsyth acknowledged that the paper did not contain that material and emphasised the scale of work to be done in forthcoming weeks to address these concerns. Mrs Lavery suggested that the paper needed to be resubmitted in May, with the wider detail included and work completed. She welcomed the openness of the discussion and emphasised that the board must carry in its mind clarity about the patient safety incident investigations we have each year.

Mr Forsyth emphasised there were initial learnings from implementing the new standards of the patient safety incident response framework to take forward to provide further assurance and demonstrate learning from incidents. An example would be the learnings and significant sustained changes made following a serious incident and regulation 28 around ageless service response to crisis out of hours. Those changes would pre-empt or stop a further similar incident from occurring again within the organisation.

In response to Mrs Gillatt and Ms Blake, Mr Forsyth explained the patient safety incident response framework management processes and expectations, highlighting the role of daily safety huddles and regular meetings with matrons to review serious incidents. It was noted some investigations could involve multiple organisations, have exceptions to timescales such as legal and criminal investigations, and have systemwide learnings and change.

Mr Forsyth advised the scrutiny and oversight of patient safety incidents would continue to be reported through the Quality Committee and Quality and Safety Group. The oversight of patient safety incidents and the learning model would be presented to board annually.

Mr Lewis requested a learning report was presented to the Quality Committee and board in May with focus on the most serious patient safety incidents during the previous 12 months, and what lessons have been learnt as a result of those incidents (as part of the one-year anniversary of educational learning).

The board received and noted the lessons learned from patient safety incidents concluded year to date. The board noted the intention to include 12 months work for 2024 and 2025 quality account and outlined actions in response to the learnings. The board would receive an annual review of the serious harm to patients.

Action

Steve Forsyth

Promise 26

Reference

Board public 25/03/16

Promise 26

Ms Holden presented the paper which provided an update following the previous discussion at board in September 2024. Ms Holden reminded the board that delivery of promise 26 was much broader than anti racism but rather all elements of discrimination and promoting inclusion.

The 2024 staff survey results were highlighted, recognising the support provided following the national summer riots. There had been some positive improvements from staff experiences of discrimination of racism, but recognition that further work was required. The initial 10 point action plan had been further refined with consultation taking place with wider colleagues and networks. The plan would continue to focus on key areas identified by colleagues and would continuously be reviewed whether success or not. Ms Holden referred to the suggested areas of focus for each network, noting the success measures and work which would be undertaken.

Ms Fulton-Tindall stated it was positive to see the networks within the organisation taking forward the initial 10 point plan, and recommended an area of focus could be older people discrimination, noting the discussion by the board at its timeout in February. Ms Holden agreed to explore older people discrimination to understand the “other” discrimination reported via the 2024 staff survey and shape the trust response.

Ms Holden agreed to share the initial 10 point plan with governors.

Mrs Vickers stated she supported the approach for the organisation’s networks to drive forward the 10 point plan, noting that disability discrimination had increased compared to 2023 staff survey. Ms Holden confirmed work was underway to explore the staff survey results to understand what additional support was required for colleagues and line managers, noting there had been significant investment through a reasonable adjustments budget. Ms McDonough declared she was the executive sponsor of the disability network (DAWN) and aware that a higher proportion of colleagues declare in the staff survey their disability, compared to what is declared on their electronic staff record. It was important to educate and raise staff awareness, promoting reasonable adjustments, providing peer support, training and wider cultural support, whilst balancing the complexities and relationships between individual needs of colleagues and line managers (and not one size fits all approach).

In response to Mr Mohammed, Ms Holden advised there were various network and engagement events and the People Pulse Survey continued to roll out on a quarterly basis, which would provide an additional form of feedback and sense check whether the 10 point plan had any impact on reducing discrimination. Dr Graham reflected there were other promises which would also support promise 26 and bring an element of diversity of people with protected characteristics such as those with lived experience and providing peer support workers.

Mr Banks reflected on reverse mentoring which board members had undertaken in previous years. The learning from those programmes included individuals felt not responded to with reasonable adjustments and being able to contribute to the workforce in a full time capacity, putting pressure on performance and meeting targets. Mr Banks stated this did raise the risk of losing the right people in the right roles, and why it was important to identify and support those individuals.

The board received and noted the promise 26 update and ongoing workstreams and commitments, noting the staff survey results associated with promise 26.

Action

Carlene Holden

Older people’s services: proposed changes in 2025 and 2026

Reference

Board public 25/03/17

Mrs Lavery introduced the paper, highlighting this would be an important decision for the board to take in respect of the older people’s services proposed changes. Mrs Lavery summarised the rationale for the change paper being presented to board, explaining that there is a recommendation to make a choice to move to a mixed provision across trust, which is a model other trusts have adopted, but is a less frequently adopted model of care both regionally and nationally. In addition one option would overturn the submitted financial plan.

Dr Graham introduced the paper and detailed the changes required in older people services with the associated rationale. Previous concerns had been raised in relation to the provision and consistency of older people’s inpatient services and medical staffing. This had been brought into focus following the recent emergency closure of Brambles ward in Rotherham. An intense but extensive process of engagement around options had taken place since January, and those details were appended to the paper itself. Dr Graham recognised the amount of engagement and expertise provided both internally and externally to create the paper and preferred recommendation, noting there was not one single model that was advocated nationally, and therefore the organisation would be able to make an operational choice.

The recommendation and proposal would be option two, a three-site mixed ward model for older people’s service with an enhanced community care provision. The recommendation would support the organisational strategy and objectives to provide care closer to home to those people served. Clear quality indicators had been produced which would monitor any effect of change, these included patient safety, staff and carer experience. She noted that if those could not be met by 2026 then a revised cross site specialised model may need to be considered, and that that is reflected in the recommendations.

Dr Graham reassured the board that since the emergency closure of Brambles ward in December, data had been closely monitored daily such as patient safety incidents, patient flow and bed occupancy. The data showed that there had been no older adult out of area placements in this time, and there remained six older adult beds available at the time of presenting this paper to the board. These factors further support the proposed option as a model of care for older people to support people to be cared for as close to home as possible.

Mrs Lavery stated clinical expert opinion was sought from board members not in attendance, and summarised Dr Falk’s opinion that distinct older peoples inpatient care was not financially sustainable. The idea of subjecting patients and their carers at such a vulnerable time in their lives was something to be avoided if at all possible. Dr Falk was aware of the trauma caused to patients when requiring transfer from care homes to inpatient care. Dr Falk supported the proposal of a mixed model of care and reassured that quality markers were being applied to the proposed mixed model with review later in 2026.

Mrs Lavery summarised Dr Jankowski’s opinion that he was in support of the proposal, noting funding was likely to become even more difficult from 2026. Having out of area care was not great unless superior expertise was given, stating there needs to be a more homogeneous model of care across the organisation and supporting partnerships.

Dr Sinclair noted the mixed model of care in place for North Lincolnshire and Doncaster residents had been successful. From experience the organisation can adapt good practice in Rotherham with the correct environmental changes and close monitoring of quality indicators in place, and recognised the longer term benefits and short term expectations or risks.

Mr Forsyth referred to the monitoring of quality and safety indicators. Data to date had not shown any increase in patient harm incidents and those incidents reported were either low level or no harm.

Ms Blake stated she understood the proposal and recommendation made and confirmed her support to the principle of providing patient care closer to home noting this would also support the current climate and recent government decisions. Ms Blake asked if Dr Graham could elaborate on the engagement that had been undertaken. Dr Graham responded that there had been consultation with internal and external experts who had experience of using a mixed model of care, as well as those who had not had experience of a mixed model of care, between January to March 2025, in addition there had been contact with local care partner providers. Mr Vallance referred to South West Yorkshire NHS Foundation Trust who undertook public consultation, noting this was due to change in location and deemed to be significant. Mr Vallance stated he felt reassured the organisation would not be required to undertake a wider consultation on the older adult service proposal.

Mr Vallance referred to the next steps of the recommendation, any environmental changes for consideration and staff skills mix required to support the model of care. Regarding the environment, Mr Forsyth explained there would need to be environmental adjustments to best support the mixed ward population considering Royal College of Psychiatry guidance. Dr Graham referred to gender balance, and stated that the current ward also meets the national standard required for single sex accommodation, as all bedrooms are single occupancy with en suite, and the direct care staff have the ability to concertina the ward should it become necessary.

Mr Chillery referred to the emergency closure of Brambles ward and emphasised this was not premeditated, and a joint decision carefully made with the senior operational colleagues. Mr Chillery noted that the care group nurse director along with the Rotherham care group leadership team continued to engage with staff during the interim closure of Brambles ward.

Mrs Lavery asked Mr Lewis to summarise the recommendation and reflect on the discussion. He acknowledged with gratitude all colleagues who had contributed and expressed their views on this subject, recognising the multiple opportunities to hear the diversity of clinical perspectives. He highlighted the need for a balanced approach to decision-making between service areas and suggested the development of an older person’s financial precept, to reassure ourselves from 2025 to 2028 that, for example these services were not being disproportionately cut over a three-year cycle. Mr Lewis discussed the plan to invest in community-based services for older adults across three geographies, aiming to enhance local care and reduce the need for out of area placements. The decision to adopt a blended localist model involved collaboration across geographies to share expertise and resources. Should the blended localist model not work within eighteen months to two years, the decision would be revisited, and a more specialist model would be considered.

The board received and noted the older peoples service paper, noting the change in service model outlined in the preferred option.

The board acknowledged the move to mixed provision was the less common option nationally and regionally.

The board approved the recommendations made and agreed to reconsider the success of the change against the cited key performance indicators and other measures of impact in March 2026. The board acknowledged any move to a separate specialist bed-based model would likely be contingent on statutory consultation.

Trust bed base: forward look to 2028

Reference

Board public 25/03/18

Mr Chillery presented the paper and explained the focus was primarily the adult mental health inpatient provision. Mr Chillery acknowledged there had been two purposeful ward closures during the last two years, with enhanced community support in assertive outreach services. The decision just made confirmed a third change.

Extensive work was required to address the complexities of bed modelling, admissions, length of stay occupancy rate and discharge rates. Three modelling scenarios were included in the appendix. Mr Chillery advised scenario two, bed model demonstrated a reduced length of stay. If successful, while ambitious this would then meet current adult mental health demand.

Mr Chillery therefore confirmed that he felt that it was possible to agree that there would, as the paper outlined, be no further ward closures in adult mental health for at least the period of the trust strategy (to 2028) Mr Chillery advised work continued to focus on reducing out of area placements which interlinked with the high quality therapeutic care taskforce programme of work. He advised of the complexities of reducing length of stay in mental health provision. To meet demand, the discharge rate needed to increase approximately by three patients per week across the five adult mental health wards. This goal was considered achievable but required significant effort and coordination. The key change agent would be clinical decision-making on the wards. The patient flow team would continue to work with community teams and local authorities across place, considering safer alternatives to admissions and working consistently to address 7 day working admission and discharges. There remained concern regarding medical vacancies and leadership gaps in order to achieve sustainable change.

Integrating community services with ward practices was discussed as a critical factor in improving patient flow. This involved ensuring that community caseworkers were actively involved in the discharge planning process.

It was noted the organisation would be investing in “local” specialist inpatient facilities such as a high dependency unit (HDU) to address reinvestment in mental health services.

At a later date a paper addressing the issues related to length of stay and discharge rates would be presented to the board to provide further insights and strategies to improve these metrics.

The board received and noted the trust bed base forward look to 2028, and acknowledged there would be no further ward closures in adult mental health for at least the period of the trust strategy. The national policy imperatives to reduce length of stays in acute mental health and there continued to be significant work towards reducing length of stays. The board would continue to receive regular tracking data against occupancy, bed days and average length of stay (potentially integrated performance and quality report).

2025 and 2026 financial plan (including investment fund bids)

Reference

Board public 25/03/19

Mr Mohammed presented the paper including the addendum circulated prior to the meeting, copies of which were tabled during the meeting.

The revised financial plan included in the paper and addendum was a balanced plan. It was confirmed the organisation had secured £3,800,000 of new, recurrent funds from the system to achieve this balanced plan, with confirmation from the integrated care board of additional funding flowing from October 2025 for the provision of a high dependency rehabilitation unit.

Critical to meeting the financial plan was the successful delivery of savings plans, delivering the out of area plan (£3,000,000 savings) and workforce plans (including sustaining our 2024 and 2025 elimination of agency use). Mr Mohammed highlighted the need to reduce out of area placements as the key variable, recognising that if at mid-year this was not achieved then items from his private paper may need to be accelerated.

Mr Mohammed highlighted the alignment of the financial plan to the NHS England oversight framework, with progress updates provided against each measure to reflect the submission of a balanced plan.

The organisational workforce had increased by 21% since the pandemic and work was underway to understand how much of this was linked to previous financial investments and plans, as against incremental changes pre-2023.

Mr Lewis highlighted the lack of contingency in the financial plan and the importance of timely and effective implementation of the plan, meaning any delays or failures in meeting the savings targets could have significant financial risk. Mr Lewis stated it was crucial the target to reduce out of area placements by two thirds be achieved in the last three quarters of the year. He thanked colleagues for the hard work to achieve corporate savings at an extended level, drawing attention to the bias of savings schemes over the past two years in that regard.

Mrs Lavery provided her thanks on behalf of the board to Mr Mohammed and Mr Lewis for their contributions over recent days, and acknowledged the effort made with stakeholders and system partners to producing the financial plans and settle outstanding financial matters. Mrs Vickers confirmed her full support to the financial plans and as Chair of the Finance, Digital and Estates Committee recognised the challenges faced across the financial system, noting the financial plan provided clear focus for financial delivery.

In response to Ms Gillatt, Mr Mohammed stated the cash balances remained at approximately £35,000,000. As the financial plan remained balanced, the organisation did not require any cash support.

Regarding the plans to reduce out of area placements, Mr Chillery noted that a plan in this regard would come to the board in May. He remained cautious about the scale and speed of change needed.

The board received and noted the 2025 and 2026 financial plan, recognising the continued effort to settle outstanding financial matters with system partners and reliance of full year delivery savings plans. The board recognised the challenges across the national financial landscape and “difficult choices” may be required to move the organisation to an underlying balance in 2026 and 2027.

Health and safety update including ligature risk assessment review

Reference

Board public 25/03/20

Mr Forsyth presented the paper and provided a progress summary against key actions undertaken to address health and safety concerns previously discussed at board, including a ligature risk assessment review.

There had been an area of focus and improvement undertaken over the last six months to address health and safety. All fire safety risk assessments were scheduled to be completed by the end of March 2025. Ongoing fire safety improvement works would be addressed within the capital plans.

There was a clear ligature risk assessment work plan in place. This included a review of the ligature risk assessment policy and national guidance. Work continued to replace the remaining anti ligature doors in mental health inpatient areas. Estates work was planned to install anti-climb fencing to address safety and risks identified within the garden spaces at Swallownest Court, Rotherham.

Mr Lewis confirmed there was limited contingency funds for any potential material large scale ligature remediation that sat outside the agreed capital plans, emphasising the need for cost effective solution for additional identified health and safety programmes of work. In response, Mr Forsyth stated the ligature policy was updated in December to reflect guidance, with the complete review of all identified ligature risks according to the new Care Quality Commission framework. There was a clear view of what ligature risks remain and mitigation in place to manage those areas.

Mr Forsyth acknowledged that while significant progress had been made, there were still ongoing challenges in managing ligature risks stating, although no area could be ligature free, the importance of identifying and reducing ligatures remained a key area of focus. The ligature risk assessment work plan would provide continuous monitoring and review of dynamic environmental ligature risks, both fixed and non-fixed ligature assessments, alongside the learning from incidents with immediate remedial actions where necessary to maintain safety standards.

Mr Lewis acknowledged, although there was a minor works programme in place which supported £150,000 per quarter across the organisation, this was a competitive space (not solely to address health and safety work programmes), was clinically led and prioritised by risk rating. Mr Lewis reminded the Board the minor works programme was not a contingency for any large-scale ligature remedial work not already identified within the capital plans. Mr Forsyth highlighted there was a very clear process in place in identifying health and safety contraventions to manage those within that current budget, with the commitment and investment by the organisation on the replacement anti ligature door programme.

The board received and noted the health and safety update including ligature risk assessment review. The board recognised the work completed since October 2024, noting there remain no major capital dependent ligature or other safety steps.

Apprentice levy

Reference

Board public 25/03/21

Apprentice Levy

Ms Holden presented the paper highlighting the work undertaken to exceed the apprentice levy spend by 2025 and delivery of promise 9.

The recruitment process had been revised to include apprentice first to support lower banded colleagues and improve career opportunities. The apprenticeship levy would nationally be replaced by a skills and growth levy. It was hoped the new levy would address the different apprenticeship offers and provide more opportunity to exceed the apprentice levy spend.

Ms Holden described the plans underway to develop the four structured access programmes for vulnerable groups and success measures, stating the People and Organisational Development Committee would continue to have oversight of the progress made to exceed the apprentice levy and delivery of promise 9 during quarter 1 and quarter 2.

Current forecast stood at 73% of utilising the apprentice levy in 2024 to 2025, with the levy budget for 2025 to 2026 expected to be higher due to the reduced staff turnover and annual national pay award. Plans had been identified to fully spend the levy during 2025 to 2026 by widening the participation to apprenticeships and offer of continuous professional development training or non-credited training. Some levy funds would be transferred to support voluntary community partners across systems and delivery of programmes relevant to promise 9. Plans were in place to address clinical expansion and workforce planning, maximising the levy and training expenditure. Additionally, the performance development review and appraisal approach would support staff development and a positive impact on the apprentice levy.

Mrs Lavery reflected on the recent government announcements around welfare and financial changes and recognised the workforce opportunities would encourage and support communities in entering employment and utilising the apprenticeship levy.

Mrs Vickers referred to the positive changes to come as part of the apprentice levy and queried whether apprenticeship opportunities would be part of career conversations during the appraisal process. Ms Holden stated it was important to discuss career opportunities during appraisals including potential apprenticeship opportunities. In response to the apprentice levy spend, Ms Holden explained current spend was 73% with the remainder 27% to be carried over into the next financial year rather than returned to the Treasury. Dr Graham recognised the positive national changes to the apprentice levy and apprentice opportunities this would create.

The Board received and noted the apprentice levy update report.

2024 and 2025 reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR)

Reference

Board public 25/03/22

Mr Forsyth presented the paper and highlighted the nine RIDDOR incidents reported in the period April 2024 to March 2025.

Analysis and learning of the reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR) incidents showed there was no commonality or specific theme year on year, with numbers remaining static. Learning was being addressed within the organisation and shared during patient safety huddles as well as via the health and safety forum. Mr Forsyth shared examples of learning from falls such as addressing staff who were not compliant with uniform dress code and footwear in clinical areas and trip hazards. A trial was also underway with People Safe regarding lone working devices, this would help identify when a person had fallen and alert People Safe.

Ms Fulton-Tindall noted the number of assaults on staff and questioned what preventative action had been taken. Mr Forsyth explained work continued to enhance lone working arrangements and to further support the improved reporting culture and response to violence and aggression to staff. Changes were being made to the RRI training and disengagement training.

Mr Lewis asked whether the authors had full confidence in the reporting process, and Ms Holden confirmed that she did not. Mr Lewis highlighted there were two road traffic incidents occurred within the reporting period that were not contained within the RIDDOR report. Mr Lewis proposed to add to his Chief Executive’s report details of RIDDOR incidents to enhance transparency and ensure the Board were regularly updated on safety incidents and actions taken throughout 2025 and 2026.

The board received and noted the RIDDOR report during the period April 2024 to March 2025, noting near real time reporting of RIDDOR incidents would feature as an annex in future chief executive officer reports.

Action

Toby Lewis

Our enabling and delivery plans

Reference

Board public 25/03/23

The board noted the item would be deferred to a future meeting and would be discussed at board time out in April.

Operating performance, governance and risk management

Operational risk report: extreme risks or high impact to low likelihood risks

Reference

Board public 25/03/24

Mr Gowland presented the paper which highlighted the current position in relation to the extreme risks. There were six extreme risks on the register. At the last board meeting, a total of six extreme risks was reported, one risk had since been de-escalated while another new risk had been escalated to extreme status.

Previously reported extreme risks included the management of out of area placements and neurodiversity waiting times as discussed earlier. The report also identified risks which had high impact but low likelihood. Mr Gowland explained the importance of the board to have continued oversight.

Mrs Vickers referred to the delivery of promise 19 ending out of area placements and asked whether there were associated financial risks. In response, Mr Lewis confirmed the saving target for ending out of area placements was not presently identified as a risk.

Regarding the newly identified extreme risk (DCGMH 6/23), Mr Lewis noted this was a longstanding risk relating to medical staffing gap of an older people’s consultant (OPMH) within the Doncaster Adult Mental Health Care Group. Mr Lewis requested the Risk Management Group review whether the risk description and score was appropriate due to the medical staffing gap being low and whether this could result in patients coming to harm.

In response to Mr Lewis, Mr Forsyth confirmed the high impact and low likelihood risk around ligature alarms (NLCG 11/23) solely related to Laurel Ward, with plans in place to install as part of phase 3 and phase 4 of the capital plans.

The board received and noted the operational risk report update, including extreme risks and risks identified as high impact with low likelihood.

Action

Steve Forsyth

Strategic delivery risks (SDR) 2024 and 2025: year end report

Reference

Board public 25/03/25

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.

Significant assurance was received from internal audit on the refreshed approach to strategic risk management. It was noted some recommendations were made to further enhance formatting to clearly demonstrate the link between strategic risk controls and respective assurances. Work would continue to progress the five strategy delivery risks through executive leads and with respective committees.

Mrs Lavery acknowledged the revised strategy delivery risk approach had progressed throughout the year and that it was positive to see the significant assurance received from internal audit. Mrs Gillatt questioned the confidence of reaching strategy delivery risk targets and whether reassessment was required. Mr Gowland answered this work would be pivotal during  quarter 1 and acknowledged the development of the strategy delivery risks would include more specifics on assurances, current scoring, target assessments and measures in place. Mr Gowland referred to the proposed future reporting arrangements, and explained it would allow for progress to be made in the intervening periods but provide the right focus for board and its committees regarding strategy delivery risks.

The board received and noted the strategy delivery risks 2024 and 2025 report, noting significant assurance from internal audit and the planned next steps to enhance reporting arrangements.

Integrated quality performance report (IQPR)

Reference

Board public 25/03/26

Mr Chillery introduced the Integrated Quality Performance Report (IQPR) for February 2025, and stated he anticipated seven of the “top 10” would be delivered at the end of year target.

There had been significant improvements (reduction) in section 136 breaches and seclusion rates. Mr Chillery advised challenges remained in meeting some performance metrics, and particularly the attention deficit hyperactivity disorder trajectory remained higher than target with work underway to address sustained progress with a revised trajectory. Although the number of ligature incidents had increased, analysis showed this was related to three specific patients. Mr Mohammed confirmed the year end forecast was a surplus of circa £544,000 (FIN03).

Mr Lewis acknowledged some indicators may start to rise before they reach target, an example was the ending of out of area placements may result in higher demand of seclusion suites.

The board received and noted the integrated quality performance report.

Promises and priorities scorecard

Reference

Board public 25/03/27

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. It was noted progress on promises and success measures would feature in the trust’s annual report.

The scorecard provided an assessment of work already completed as well as key priorities to move towards delivery into 2025 to 2026 and beyond. The promises had been considered by the clinical leadership executive (CLE) and segmented to show the work required over the coming months. Mr Lewis recognised the real effort that had taken place to achieve delivery of some of the promises to date, as well as those which continued to be progressed. Quick mobilisation would be required over the coming months of some promises, noting the need for better communication and understanding among staff the importance of focusing on key priorities and learning from successful initiatives.

The board reflected on the promises and scorecard. Mr Lewis informed that progress had been made for strategic objectives one and five and advised the promise measures and models continue to be progressed and tested to seek assurance. Communication of the promises and priorities would continue with leadership teams through the leadership development offer.

In preparation for the annual members meeting, Mr Lewis agreed to explore how community feedback could be captured and shared with community partners within the event.

The board supported the current state assessments outlined for success measures and noted the critical success factors for early 2025 to 2026 improvement outlined. The board recognised the segmentation of promises’ relative priority agreed with clinical leadership executive group and would continue to focus board time on testing the depth and pace of change required.

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

Action

Toby Lewis

Supporting papers (previously presented at committees)

Supporting papers

Reference

Board public 25/03/28

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:

• annual safe staffing declaration 2024 an 2025
• eliminating mixed sex accommodation annual declaration
• mortality report
• guardian of safe working hours report

Mr Lewis noted the safe staffing declaration was solely in relation to inpatient care. A separate piece of work was underway to review community safe staffing via the Quality Committee.

The board received and noted the additional reports for information.

Any other urgent business

Reference

Board public 25/03/29

There was no further business raised.

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

Reference

Board public 25/03/30

The board recommended the following:

• disengagement (linked to previous regulation 28 and open action board public 25/01/21b)
• financial plan 2025 to 2026 critically required timely delivery for all capital improvement plans
• mixed sex accommodation, although national guidance stated the organisation was compliant, Mr Lewis recommended consideration should be given to any other associated risks with mixed sex accommodation

Action

Steve Forsyth and Phillip Gowland

Public questions

Reference

Board public 25/03/31

There were no questions raised by members of the public.

Closing statement

Reference

Board public 25/03/32

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: June 16, 2025
Next review due: June 16, 2026

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