Present
- Kathryn Lavery, Chair.
- Rachael Blake, Non Executive Director.
- Richard Chillery, Chief Operating Officer.
- Maria Clark, Non Executive Director.
- Dr Richard Falk, Non Executive Director.
- Steve Forsyth, Chief Nurse.
- Sarah Fulton Tindall, Non Executive Director.
- Kathryn Gillatt, Non Executive Director.
- Carlene Holden, Director of People and Organisational Development.
- Toby Lewis, Chief Executive.
- Simon Sheppard, Director of Finance and Estates.
- Dr Diarmid Sinclair, Chief Medical Officer.
- Dave Vallance, Non Executive Director.
- Pauline Vickers, Non Executive Director.
In attendance
- Richard Banks, Director of Health Informatics.
- Dr Jude Graham, Director for Psychological Professions and Therapies.
- Philip Gowland, Director of Corporate Assurance and Board Secretary.
- Shabir Pandor, NExT Director.
- Dr Rumit Shah, Associate Non Executive Director.
- Sarah Dean, Corporate Assurance Officer (minutes).
- Jocelyn Flower, Social Worker, for the staff story.
- 3 members of staff.
- 2 governors.
- 2 members of public.
Welcome and apologies
Reference
Board public: 26/03/01.
Welcome and Apologies Mrs Lavery welcomed all attendees to the meeting. Apologies were noted from Mrs McDonough, Director of Strategic Development.
Mrs Lavery noted two public questions had been received from Glyn Butcher on behalf of People Focussed Group (PFG) and that the chief executive would respond to these through the high-quality therapeutic care (HQTC) item later in the meeting.
Mrs Lavery explained that from the next meeting in May, the board’s start time would be 9:30 am and after minutes, action log and committee reports the board would consider risk (both operational and strategic), the integrated quality performance report (IQPR) and promises papers, and then before lunch, the chief executive’s report, the patient or staff story and one substantial item, before completing the agenda after lunch. The overall meeting time would still end at 4 pm.
Mrs Lavery noted that, after 26 years of service, this meeting marked Mr Banks’s final attendance at the board, and affirmed the board’s appreciation for his very significant contribution over that time.
Quoracy
Reference
Board public: 26/03/02.
Mrs Lavery noted the meeting was quorate.
Declarations of interest
Reference
Board public: 26/03/03.
Mrs Lavery presented the declarations of interest report and confirmed there had been amendments to Mr Pandor’s and Ms Blake’s declarations of interest to the register since the last meeting.
Ms Gillatt informed the board that she had accepted a role as an independent member of the audit committee for Cafcass (under the Ministry of Justice umbrella).
The board received and noted the changes to the declarations of interest report.
Standing items
Minutes of the previous board of directors meeting held on the 29 January 2026
Reference
Board public: 26/03/04.
The board approved the minutes of the meeting held on the 29 January 2026 as an accurate record.
Matters arising and follow-up action log
Reference
Board public: 26/03/05.
Reducing restrictive interventions (RRI)
Advocates Mr Lewis queried whether the commitment to have reducing restrictive interventions advocates in place by April was realistic, noting the issue had been ongoing for since March 2025. Mr Forsyth acknowledged the delays but confirmed that recruitment and preparations were now sufficiently advanced to expect advocates to be operational by the end of June 2026.
The board received the action log and noted the progress updates. All actions noted as “propose to close” were agreed.
Action
Steve Forsyth
Board assurance committee reports to the board of directors
Quality Committee (QC)
Reference
Board public: 26/03/06.
Dr Falk presented the paper and gave the key highlights from the Quality Committee.
The Quality Committee had provided support on two matters, firstly for the key performance indicators (KPIs) relating to post proposal service redesign, which was aligned with items later on the agenda; and secondly for the planned inclusion of therapeutic activities within the safe staffing reporting in recognition of their clinical importance and their tendency to be dropped in periods of pressure.
Dr Falk addressed three areas of concern:
- the potential data burden associated with the new key performance indicator (KPI) framework, although substantial reassurance had been received at Quality Committee from Dr Graham and Mr Forsyth
- Radar task volume and the number of tasks generated risked creating reminders that staff might begin to ignore
- pressure ulcers, which had surfaced significantly the previous year and continued to require monitoring
Regarding Radar task burden, Mr Lewis expressed concern that constant reminders risked desensitising staff, and he asked that the issue be taken through the action log for further refinement within the delivery review process.
The board received and noted the report from the Quality Committee.
Action
Toby Lewis
Audit Committee (AC)
Reference
Board public: 26/03/07.
Ms Gillatt presented the paper which contained no escalations to the board.
She explained that the internal audit programme had demonstrated strong progress with the implementation of recommendations particularly positive. There were no accounting policy issues requiring immediate escalation, and the clinical coding audit review had shown strong performance. Ms Gillatt explained ongoing work to improve transparency around single source waivers and financial instruction compliance. Ms Gillatt noted the moderate assurance rating for the safe staffing audit and the commentary regarding the differential between inpatient and community based staffing in the audit.
Regarding the safe staffing audit, Mr Lewis emphasised that the trust would not be developing an independent community staffing tool because no such tool existed nationally and doing so was not feasible or standard practice. The action plan behind the audit would be amended, and Mr Forsyth would take responsibility for this update. Dr Graham reflected on national context on the widespread absence of community acuity tools, noting that work was underway across several organisations to develop a national approach.
The board received and noted the report from the Audit Committee.
Action
Steve Forsyth
Mental Health Act Committee (MHAC)
Reference
Board public: 26/03/08.
Ms Fulton Tindall presented the paper and highlighted key points from the Mental Health Act Committee.
The Mental Health Act Committee noted ongoing concerns about the decline in reducing restrictive interventions (RRI) and Mental Health Act level 3 training compliance, which in January were 75% and 76.3% respectively. The Committee noted that the personal consequences approach for non-compliance for mandatory training had been adopted.
Progress on reducing restrictive interventions and blanket restrictions work was welcomed, with further updates expected at the next meeting. The committee also noted the early stages of the revised Mental Health Act implementation programme, including February work on detention changes planned for 2027 within the wider 10-year programme, and recognised associated resource and expectation pressures.
It was confirmed that Ms Clark would take over as chair of the Mental Health Act Committee from its next meeting.
The board received and noted the report from the Mental Health Act Committee.
People and Organisational Development Committee (PODC)
Reference
Board public: 26/03/09.
Mr Vallance, on behalf of Ms Blake, presented the paper and gave key highlights from the People and Organisational Development Committee.
Staff safety including violence and aggression would be received later on the agenda. Mr Lewis noted that actions cited within the report had since been resolved. The appointment of the resident doctor lead role was recognised, which forms part of the national 10-point plan.
Responding to Ms Gillatt query related to mandatory training, Mr Lewis reminded the board that the trust’s approach differed from most NHS organisations which counted each individual training component, with the trust instead required staff to complete all required training to be considered compliant. Letters would be issued to all staff not fully compliant as at 30 April, and formal consequences for those without a credible plan would follow in June. He acknowledged that certain training categories, including Mental Health Act level 3, reducing restrictive interventions training and immediate life support, had been longstanding areas of weakness and that the shift to a more stringent compliance model was essential for safety.
The board received and noted the report from the People and Organisational Development Committee.
Public Health, Patient Involvement and Partnerships Committee (PHPIP)
Reference
Board public: 26/03/10.
Mr Vallance presented the paper to be taken as read, and highlighted there were no matters for escalation from the Public Health, Patient Involvement and Partnerships Committee.
The board received and noted the report from the Public Health, Patient Involvement and Partnerships Committee.
Finance, Digital and Estates Committee (FDE)
Reference
Board public: 26/03/11.
Finance, Digital and Estates Committee (FDE) Mrs Vickers presented the paper and highlighted key points from the Finance, Digital and Estates Committee. The estate plan was noted to be presented later on the agenda.
The trust remained on course to meet its financial obligations and Mrs Vickers highlighted the month 11 surplus position of £654,000.
Negotiations regarding 2026 and 2027 income continued, and progress had been made in digital investments, information governance and clinical coding. Thanks were given to Mr Banks for his contribution to compliance improvements prior to his forthcoming departure.
Mr Lewis sought clarification regarding a figure in the report referring to a reduction in underlying deficit from £16,000,000 to £6,000,000. Mr Sheppard agreed that the update was erroneous, clarifying that the underlying deficit was expected to be £6,300,000 at year end (31 March 2026), a significant improvement from £16,000,000 in 2023, with an underlying break even position projected for the following year (2026 to 2027), and agreed that the report would be amended for accuracy.
Post meeting note: report subsequently amended.
Mr Sheppard updated the board on the confirmation and receipt of deficit support funding in quarter 4 and explained that although cash had been received, it was not available for general expenditure. He also confirmed that capital departmental expenditure limit (CDEL) cover was in place for the Waterdale development prior to contract signature.
The board received and noted the report from the Finance, Digital and Estates Committee.
Dr Falk reflected on the committee highlights reports presented. Mrs Lavery agreed to review the format with Mr Lewis outside the meeting and to consider improvements to committee reporting, escalation, and access to committee minutes, to support greater insight, cross referencing and informal communication.
Action
Kathryn Lavery
Post meeting note: the format of board out-briefs has been amended to ensure only escalations are orally presented to the board, allowing more time for questions.
In addition, the non- executive meeting will be used to ensure cross committee discussion between chairs. Any board member can ask to have sight of papers and minutes from any meeting.
Remuneration Committee (RemCo)
Reference
Board public: 26/03/12.
Mrs Lavery presented the paper and highlighted key points from the committee.
The board received and noted the report from the Remuneration Committee.
Chief executive’s report
Reference
Board public: 26/03/13.
Mr Lewis drew attention to the key items within his report. The trust’s position within the National Oversight Framework remained stable (2, with a financial override to 3) but the future of the national process lacked clarity and predictability. Mr Lewis cautioned that the absence of clear national metrics from April 2026 made future segmentation difficult to anticipate, and impossible to be confident plans were consistent with a segment 1 or 2 rating, which was our agreed aim.
He noted good progress with work to reshape older adult care in Doncaster and development of the proposal for the frailty centre of excellence (Pond Project), into the summer. Work continued to align local stakeholders despite varying priorities and organisational changes at Doncaster Royal Infirmary.
There would soon be a relaunch of Lio (previously known as Oxevision) training in light of new national guidance, emphasising the consent processes in inpatient mental health settings. Mr Lewis noted that while Lio remained controversial and subject to national scrutiny, the trust remained committed to its safe and ethical use.
Mr Lewis drew the board’s attention to Palantir, noting that some organisations, including the British Medical Association (BMA), had appealed for a pause in the migration of providers onto the Federated Data Platform. He assured the board that Palantir usage within the trust was limited to non-patient data, and a specific governance arrangement had been instituted for any proposed expansion.
The Communities’ Leadership Executive (CoLE) recruitment process was taking place, with strong engagement across Rotherham, Doncaster and North Lincolnshire. There had been 34 applicants, and interviews were scheduled for the following week. Membership of the expected 16-person executive would be confirmed, with informal meetings planned for April and formal commencement from May.
Dr Graham asked whether wider system level barriers risked undermining the trust’s ability to deliver, citing the Secretary of State for Health’s announcement on new recovery programmes for underperforming trusts. Mr Lewis confirmed the trust remained high performing but highlighted the Mental Health Investment Standard and associated funding flows as continuing system challenges, while noting the intended introduction of pass-through activity in community physical health contracts as a positive step. Mr Banks asked about the impact of North Lincolnshire and Goole (NLAG), and Hull NHS trusts entering special measures, and Mr Lewis explained that given their merged model, the situation was unusual but reinforced the need for strong engagement with North Lincolnshire and Goole, particularly for the crisis centre and children’s neurodiversity services.
In relation to Lio, and in response to Ms Clark’s question on whether consent was the only area of concern, Mr Lewis explained that although national debate had raised ethical questions about continuous monitoring, the trust had already determined that Lio would be used as a harm reduction tool. The priority was now to strengthen consent processes and ensure that monitoring was withdrawn promptly when consent was removed. Dr Graham noted that research and evidence supported this approach, demonstrating that assistive technologies could reduce bias and enhance both staff and patient confidence.
Mr Vallance and Ms Blake referred to annex 8, noting that although the 5-year pattern was acknowledged, we should all wish to understand why there was such variance between longer standing and more recently hired employees. Mr Lewis clarified that the five-year reference was intended to avoid assuming the results were solely a consequence of change management, as directorate level data showed both improvements and declines. Further analysis would return in May alongside culture related work.
Responding to Ms Gillatt, Mr Lewis confirmed that the main forward financial risks remained the high dependency rehabilitation unit (HDRU), energy costs and the community pharmacy scheme, as described in his private chief executive officer report. Mr Lewis highlighted wider system pressures, including significant savings requirements across integrated care boards and in particular South Yorkshire’s £130,000,000 challenge, which included a substantial unresolved gap, and reiterated that the Trust had declined to submit a plan with unidentified savings, unlike neighbouring organisations. He noted that although the integrated care board faced uncertainty, 3 year allocations still indicated growth for community and mental health services, dependent on acute care changes being delivered. He did not consider the trust at greater financial risk than the previous year, though flexibility had reduced due to energy pressures, high dependency rehabilitation unit requirements and reliance on non recurrent savings. Mrs Vickers confirmed that the Finance, Digital and Estates Committee would continue close monitoring.
With respect to neurodiversity, Mr Lewis reported two positive developments with £1,200,000 secured for children and young people’s services in North Lincolnshire, with communications to affected families planned for May and clinical work due to begin in July. He also highlighted improved adult assessment performance from April. He noted, however, that medication backlogs remained a significant concern, particularly for children and young people, where an earlier issue had been resolved only for a further problem to emerge.
Given the prior board discussions, he acknowledged that this was unacceptable and confirmed that contingency funding would be used to clear the backlog, with work underway to prevent recurrence. Mr Lewis also confirmed priority pathways for young people transitioning to adult services and noted the medium-term aspiration for a dedicated transitional team.
The board discussed governance in identifying and escalating risks, including underestimation of likelihood scores, and noted a neurodiversity waits and volumes scorecard would feature in future reports throughout 2026 to 2027. Attention was drawn to the research evidence cited in the annex to the report, which sought to challenge the ‘overdiagnosis’ commentary. Options to strengthen capacity, including collaboration with community pharmacies for stable adult patients, were being explored. Mr Lewis noted that 6,000 adults remained on the waiting list, and that a decision needed to be made in quarter 1 over the future of the autism pathway.
Action
Toby Lewis
The board received and noted the chief executive’s report and the forward actions it contained, and noted the progress being made in tackling unacceptable wait times for neurodiversity care.
Promise 14: delivering a 4 week wait for all referrals
Reference
Board public: 26/03/14.
Mr Chillery presented the paper and acknowledged the significant achievement in delivering a 4 week wait.
The organisation’s operational focus had already begun to shift from solely meeting the 4 week wait for all referrals to embedding the 1 week turnaround standard, which required services to notify patients of their proposed appointment within 7 days of referral. Mr Chillery described the 1 week standard as crucial not only for operational flow but for patient experience, noting the quality benefits for patients and reductions in complaints, explaining that patients often needed time before confirming their first appointment. Mr Chillery advised there were around 40 patients still required scheduling before the end of March, with arrangements in place for early April, and outlined the development of SystemConnect to further enhance patient communication and pre booking options.
There was emphasis on the need to sustain performance through continued central oversight due to the fragility of smaller teams and impact of staff sickness, with the next priority focused on validating and reducing secondary waits. Dr Graham noted the strong engagement of clinical teams embracing the 4 week waits, the potential of productivity and reducing did not attend (DNA) and was not brought (WNBs), reduction in complaints about waiting times and positive feedback from GPs alongside other wider system benefits, and referenced ongoing work on demand and capacity, including potential investment bids such as podiatry. Dr Sinclair referred to the work around disengagement, confirming that evidence of timely assessments and associated care planning would be essential to ensure the 4 week standard remained meaningful.
Responding to Ms Blake, Mr Chillery confirmed that the podiatry service had not met the 4 week standard due to a 100% increase in referrals, and explained that although investment had been secured and recruitment was under way, the new posts would not take effect until the summer. He advised that a detailed trajectory would be provided once the additional staff were in place.
Action
Richard Chillery
The board received and noted the report and the considerable progress in delivery of access waits to 4 weeks, the next steps for 2026 to 2027, particularly in relation to secondary waits and explored any risks that may impact on supply and demand. A report would return to the board in July.
Trust-wide learning from patient safety and experience reports (April 2025 to March 2026)
Reference
Board public: 26/03/15.
Mr Forsyth presented the paper and gave key highlights.
The report outlined triangulated organisational learning, patient safety and the ongoing development of the trust’s learning culture during the period. The introduction and embedding of Radar had markedly improved the trust’s ability to capture, analyse and act on safety related intelligence, supporting transparency, follow through and shared accountability. Mr Forsyth noted that nearly 8,500 incidents had been recorded, over 2,000 learning responses completed and more than 150 good care events identified, demonstrating positive practice and strengthening staff confidence in reporting.
Incident reporting had increased, including a peak in November, and Mr Forsyth stressed that this should be interpreted as a sign of greater openness and a maturing safety culture rather than a deterioration in care. He highlighted several tangible improvements arising from learning workstreams, including sustained 100% compliance with falls assessments in quarter 3 and significant estates improvements, with over 300 environmental issues resolved following peer review ward visits. Connected improvements were noted, referencing promise 14 and the impact of reducing wait times for assessment and treatment.
Dr Graham and Ms Gillatt reflected on how learning was becoming more embedded in everyday practice and questioned whether the organisation had reached a point where learning was shaping behaviours and service design from the outset rather than relying on retrospective corrective actions. They noted positive indications, including improvements linked to recent leadership development programmes and the active bystander training, which had strengthened staff awareness of values based behaviours. Mr Forsyth agreed that fostering a proactive learning mindset would be essential to sustaining progress.
Mr Lewis highlighted the need for further improvement in the timeliness and quality of incident closures on Radar. Mr Forsyth reported that learning responses were taking between 8 and 25 days to upload and that more than 300 tasks remained open, reflecting increased reporting volumes and slower closure rates in some directorates. He confirmed that this would be monitored monthly by the Patient Safety Oversight Group. Mr Lewis emphasised the importance of ensuring that tasks were closed with meaningful learning rather than under operational pressure.
Further discussion highlighted the importance of communication with patients and carers. Mr Vallance noted that many complaints and care opinion themes related not only to clinical issues but to communication, clarity of expectations and the emotional impact of waiting, and encouraged a more patient centred approach to communication design. Ms Blake added that effective communication also supported wider system benefits by reducing anxiety, improving engagement and preventing repeated contacts across services.
In response to Ms Gillatt’s question on how learning was being supported through leadership development, Mr Forsyth referred to work with the Virginia Mason Institute to strengthen problem solving, reflective practice and the use of improvement methodologies. Mr Chillery added that senior leaders were participating in learning sets examining waiting list risks, medication review pathways and early warning triggers, demonstrating that learning was now shaping wider operational practice. Mrs Lavery invited members to review Care Opinion to gain further insight in how patient feedback was being received and responded to.
The board received and noted the key themes and learning from the trust-wide review of patient safety and experience report, and recognised the progress made in embedding PSIRF, the improving reporting culture and responding to patient feedback.
HQTC taskforce closure report
Reference
Board public: 26/03/16.
Dr Graham and Mr Lewis presented the paper and gave key highlights.
The high-quality therapeutic care (HQTC) inpatient taskforce had brought together multi professional staff, social care partners and people with lived experience in a way not previously achieved in the trust. Dr Graham explained that this breadth of involvement was central to shaping outcomes that reflected clinical expertise, therapeutic practice and the perspectives of those who had received inpatient care. The taskforce had delivered measurable improvements, including strengthened therapeutic activity, increased engagement in care planning and more consistent multidisciplinary team processes, alongside qualitative improvements in patient and carer experience. Although focused on mental health wards, learning had been shared across physical health and substance misuse services, with autism and sensory friendly developments already adopted in the neurorehabilitation unit.
Dr Graham added that the work had created the foundations for more precision based care, with clearer alignment between diagnosis, expected length of stay and discharge planning, while maintaining clinical autonomy in complex presentations.
Mr Lewis emphasised the transformative impact of lived experience involvement and confirmed that the next phase of community redesign would include a lived experience co-chair.
He highlighted the significant cultural shift involved in moving to multi professional leadership teams on wards, replacing the traditional model where ward managers held primary responsibility. Leadership would now be shared across professions, supported by training. He confirmed that consistent daily 2pm multidisciplinary teams were essential to the model and that while most wards were compliant, a small number required improved reliability.
Responding to questions raised in advance of the meeting by Glyn Butcher, Mr Lewis confirmed that the final wards would adopt the 2pm multidisciplinary team structure the following week and that alternative care planning approaches for patients for whom Dialog+ was unsuitable, including those with dementia, would be completed in early April, with implementation in May and June. He drew attention to the next step actions in the paper and stressed the need to maintain momentum as the programme moved from the taskforce phase to sustained operational delivery.
Dr Falk and Ms Fulton Tindall welcomed the shift to interdisciplinary working, with professions contributing to a shared therapeutic approach rather than task orientated. Dr Graham highlighted the need for careful application of diagnosis led models, noting that presentations such as acute stress reactions could evolve. Mr Chillery stressed the importance of strengthening discipline around the purpose of admission, noting that successful inpatient transformation required consistent decision making across system partners and that some avoidable admissions continued to be driven by wider system pressures, making collaborative work with commissioners and acute trusts essential.
Mr Lewis advised that the board should focus on its strategic role, particularly oversight of diagnosis-led, length of stay work throughout 2026, which would become the primary area for scrutiny in the coming months. Mrs Lavery noted the maturity and scale of the work and recognised that the time taken reflected the complexity of inpatient care and the depth of cultural change required. The board expressed strong support for the direction of travel and agreed that further reports would be brought back as the next phase progressed.
The board received and noted the high-quality therapeutic care taskforce closure report, and recognised the work done by colleagues to try and bring consistency to inpatient adult and older adult mental healthcare since February 2025. The board acknowledged the current state assessment which indicates more work to do over coming months, and accepted the forward governance outlined and agree to receive a further report in November.
Workplace violence and aggression: staff safety and incident trends (April 2025 to March 2026)
Reference
Board public: 26/03/17.
Mr Forsyth presented the paper on workplace violence and aggression.
The paper highlighted the seriousness and frequency of incidents across the trust. Mr Forsyth illustrated the scale of the issue, noting that the equivalent of every person in the room would have been assaulted within the past week, with around 1,000 assaults recorded each year, predominantly in inpatient mental health services. Although many incidents were categorised as low or no harm, staff reported significant psychological impact and a tendency to normalise aggression as part of the job in high risk settings. An 18% reduction in harm between quarters 1 and 2 was noted but interpreted with caution. Mr Forsyth emphasised the need for sustained improvement aligned to the quality and safety plan, the people plan and the education and learning plan, and highlighted risks associated with skill mix, lone working and inconsistent risk assessment in physical health and community services.
Mrs Vickers stressed the importance of actively offering support, as staff who normalised aggression were often the least likely to seek psychological help. Dr Graham outlined existing post incident processes, including immediate operational debriefs, the post incident learning loop and psychologically informed group sessions, while noting the need for greater consistency across teams.
With respect to community services and lone working, Mr Chillery reported that around a quarter of violent incidents occurred in patients’ homes and that double staffed visits did not reliably reduce risk and could, in some cases, escalate it. He confirmed the procurement of additional lone worker devices and strengthened pre visit risk assessments, particularly in physical health and overnight community nursing, and noted that district nursing teams operated with 3 staff at night to provide flexible support. Mr Forsyth added that there was no evidence linking reduced out of area placements to rises in inpatient violence and that recent peaks were associated with a small number of highly unwell patients.
Ms Blake raised questions about staff support, board visibility and consequences for perpetrators, suggesting that the “no harm” category should be reconsidered given the impact of racial or verbal abuse. Mr Vallance highlighted the need to recognise the effect on family members concerned about staff safety.
The board discussed whether current recommendations were sufficient and the importance of reinforcing a culture where violence was not treated as an accepted part of the job. Mrs Lavery referenced learning from ambulance services, including structured decompression, team debriefing and targeted psychological support, and encouraged further cross service learning. Mr Forsyth acknowledged that the 4 recommendations in the paper addressed only part of the challenge and emphasised the need for alignment across the trust’s quality and safety, people, and learning plans, alongside the high-quality therapeutic care programme. In responding to Mr Lewis’ question he agreed to reflect on the impact of the discussion held before finalising the action plan. The update on this would be considered a matter arising at the next board meeting.
The board received and noted the workplace violence and aggression report across the trust and had opportunity to consider the impact on staff wellbeing and operational delivery.
Action
Steve Forsyth
The board recognised the progress made and the areas requiring further action. The proposed recommendations would be refined to strengthen prevention, support, and governance.
Jocelyn Flower joined the meeting at 1pm.
Story to board
Reference
Board public: 26/03/18.
Mrs Lavery welcomed Jocelyn Flower, known as Joss, a social worker who worked across high dependency rehabilitation unit (HDRU) and Amber Lodge in Doncaster, who gave her story on social working. Joss joined in 2006 and explained her career journey across Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) and her time at Wathwood Hospital and described the values of social work and colleagues experiences of practising within an NHS Trust.
Joss highlighted the value of multidisciplinary teams, lived experience, peer support, partnership with voluntary organisations and listening closely to families and carers. She spoke passionately about social work as a vocation rooted in trauma awareness and advocacy, noting that social workers were often overlooked within multidisciplinary teams despite their important role in supporting people whose lives had been shaped by significant adversity. She described her work with individuals with learning disabilities, those discharged after long secure stays and those with limited family networks, emphasising the need to see people beyond diagnostic labels and to maintain a focus on identity, humanity and recovery. She encouraged greater integration of social work within multidisciplinary teams and explained how shadowing across professions helped build understanding of roles. Increased social work presence on wards was helping to rebalance responsibilities previously carried by medics, and she described the distinct expertise social workers bring in advocacy, safeguarding, cultural understanding and community connection.
Mr Chillery and colleagues agreed that social work should be recognised as a core part of multidisciplinary teams rather than an adjunct to a medical model. Dr Shah noted inconsistent social work input into primary care multidisciplinary teams, despite its importance for people with dementia and those living in care homes. Joss advised that capacity within the trust had grown and that previous pilots placing social workers in primary care had produced strong results but required sustained investment. The board acknowledged the importance of strengthening interdisciplinary working, ensuring that social work skills were fully utilised and continuing to build a culture where all professional voices were equally valued. Mrs Lavery and the board thanked her for a powerful and insightful presentation, and noted the intended reflection time later on the agenda.
Jocelyn Flower left the meeting at 1:30pm.
Next steps on community mental health services for adults
Reference
Board public: 26/03/19.
Mr Lewis noted that this paper was a follow on from the discussion held in September. Risk and complexity in community mental health services remained high and the paper therefore focused on next steps, including plans to mobilise a fully participatory, patient involved transformation programme.
He noted persistent issues with care planning, with too few patients having active, up to date plans and limited uptake of Dialog+. He also highlighted longstanding problems with caseload management and outflow, with many patients remaining on caseloads for extended periods, reducing capacity and sustainability.
Mr Lewis observed that the board had not previously examined community mental health performance in detailed operational terms and that team leaders were often more familiar with accreditation measures than with core metrics such as caseload size, activity, engagement and throughput. Annex A within the report set out basic operational information to be provided to teams, creating a baseline and enabling leaders to work to clearer parameters from quarter 2.
Mr Lewis noted clear links between this work and the organisational change programme, given the overlap in affected teams. He reiterated concerns raised in September that current community arrangements did not yet meet an acceptable standard and encouraged reflection on how this aligned with recent Care Quality Commission (CQC) self‑assessments rating community services as “good”, including what “good enough” should mean in practice. He concluded that, as demonstrated by the significant progress on 4 week waits, community teams could achieve rapid improvement with the right support. While optimistic, he stressed that current evidence did not show consistent delivery of high quality care planning and that substantial further work was needed as the improvement programme began.
Mr Vallance noted that the paper set out a clear direction for community mental health work, with further detail on outcomes to be developed as the programme progressed. Dr Graham welcomed the inclusion of an enabling workstream to ensure community roles were designed as high quality and achievable from the outset. Mr Forsyth asked how the programme would strengthen the no wrong door approach, given the absence of new funding for neighbourhood mental health teams and the need for clearer referral thresholds. Mr Lewis agreed that supporting teams to define what made their roles manageable would be valuable and could be incorporated into the programme. He noted that pressures varied by locality, with North Lincolnshire lacking wider system infrastructure and therefore placing greater demands on trust teams. He reported improving relationships with the local authority and opportunities for greater involvement in the work. He cautioned that national investment was often directed at creating new services rather than strengthening core teams, which risked adding structures without resolving underlying pressures. A key decision in the coming year would be whether some additional teams should be consolidated into larger, more sustainable community mental health teams.
Mr Lewis stressed the need for central oversight of thresholds and referral criteria, as teams currently applied inconsistent parameters. This would support a more reliable no wrong door approach and reduce inappropriate rejections.
He proposed that the board receive an early update in July on pathway development, followed by a fuller assessment in January 2027. Dialog+ care plan coverage should also form part of ongoing oversight, as current levels did not meet an acceptable standard of care. The board endorsed this approach. Dr Shah noted that work had already begun with primary care, including co designed referral forms in Doncaster South aimed at reducing rejection rates.
The board agreed to receive a further progress update in July and a detailed position in January.
Action
Toby Lewis
The board received and noted the next steps on community mental health services for adults, and the focus on ensuring that all patients have a timely and up to date DIALOG+ based care plan.
The board recognised the step up in accountability outlined within the paper, and had opportunity to consider how best the Board as a whole may be sighted on progress during 2026 to 2027.
Estate plan: route to full business case (FBC)
Reference
Board public: 26/03/20.
Mr Sheppard presented the paper: the board was asked to note and approve the estate plan as the basis for progressing to a full business case in July, with a separate energy options business case scheduled for May. The plan covered all geographical areas, with Rotherham identified as the immediate priority, in the context of past concluding investments in North Lincolnshire, and more complex plans for the Tickhill Road site. This included advancing the Riverside option to replicate the Elizabeth Quarter and Waterdale facilities and retaining neighbourhood locations wherever possible. Detailed work in Rotherham would continue through April and May.
For the Tickhill Road site, Mr Sheppard stressed the need to stabilise the design early, as the full business case would be extensive and could not be repeatedly amended. Effective change control would therefore be essential. He highlighted the financial overview and confirmed that the Finance, Digital and Estates Committee would scrutinise the detail between April and June. He also noted the alignment between the estates and digital plans, including the U-curve capital investment profile.
Mr Sheppard advised that the trust did not have the internal capacity to deliver a programme of this scale and would commission external specialist support through formal procurement, with funding already included in the 2026 to 2027 capital plan. Mr Lewis emphasised that the board must be confident in both digital investment and advisory capacity, as the Trust could not afford to progress major estate changes only to revisit them later.
Mr Vallance asked whether potential redevelopment of the St John’s site might affect the business case. Mr Lewis confirmed that the hospice would remain in place and the current planned future footprint had been designed to protect its position. Any wider redevelopment options would be considered only once a development partner was secured and would not alter the present case. In response to Ms Gillatt, it was noted that retained land allowed scope for future expansion and that future proofing would be addressed through detailed clinical and operational engagement, including recent work on future capacity assumptions. Mr Sheppard confirmed that best case and worst case scenarios, risks and benefits would be fully reflected in the full business case. He also addressed concerns about digital cost volatility, noting that some replacements were essential due to expiring contracts and operational risk, and early procurement using recent capital funding provided some protection against market fluctuations.
The board discussed land disposal, noting that significant land would be sold to fund the redevelopment. Mr Lewis confirmed that only land no longer required would be sold and the proceeds used to fund the new estate. The trust would not control future use of sold land beyond planning conditions, and regulatory approval would require demonstrating that the trust could replenish its cash position over time. The board acknowledged that the programme would not deliver like for like replacements and would require service redesign supported by specialist expertise.
The board received and noted the estate plan and route to full business case (FBC), and noted the forthcoming paper on site energy options due May 2026. The board had opportunity to consider the key questions cited and note the full business case content list outlined, and recognised the focus on Rotherham options over the next 8 weeks.
The board delegated pre scrutiny of the financial estimates to the Finance, Digital and Estate Committee, noted the budgeted engagement of advisors and capacity in quarter 1, and accepted the paper as suitable outline business case calibre sufficient to proceed to next stage.
Organisational change go live
Reference
Board public: 26/03/21.
Mr Lewis introduced this paper which reflected on the quarter 4 change programme and sought board assent to proceed to implementation. Mr Lewis advised that redeployment processes and trial periods would continue into April, and that early indications remained consistent with the estimates shared with the board in January.
The programme had proceeded to plan and that implementation now represented the most challenging phase, as responsibility would transfer from the senior design group to operational teams, some of whom had not been fully involved in earlier design work. Training and development had therefore been prioritised to support leaders through the transition.
Mr Lewis confirmed that the steering group would continue to oversee delivery until the end of April, after which the programme would move into business as usual monitoring. He emphasised the need for close tracking of quality key performance indicators (KPIs) throughout the year to identify any early issues requiring adjustment. Work was underway to ensure managers had reliable and timely data to support decision making.
Mr Lewis noted key clinical risks relating transition of patients between key workers, which were being closely managed.
In response to questions from Mr Vallance, Mr Lewis clarified the productivity expectations, explaining the distinction between the overall organisational requirement and team specific levels agreed in December. He noted that some variation across localities would need to be levelled, particularly in North Lincolnshire, but confirmed that all expectations were within safe and achievable margins based on extensive data triangulation.
Mr Sheppard welcomed the comprehensive approach to monitoring, noting it would support organisational learning and strengthen readiness for future changes to activity based funding models. Mr Chillery highlighted the importance of sustaining engagement, recognising that the programme had been undertaken with care but that staff nonetheless experienced uncertainty. He also noted the value of moving ahead at pace, respecting staff feedback that they were ready to implement the new structures.
Mr Vallance noted the “above and beyond” approach outlined, which was far more extensive in terms of safety governance than he had experienced previously at the trust. The board noted the ongoing efforts to achieve redeployment where that can be delivered in a timely manner, and recognised the key performance indicators being adopted to track safety risks. The board endorsed the recommendations to proceed now with scheme implementation to largely conclude in quarter 1.
Capital plan 2026 to 2028
Reference
Board public: 26/03/22.
Capital plan 2026 to 2028 Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Sheppard, to consider the capital plan for approval noting its alignment with the previously agreed revenue plan and the estate plan.
In response to Mr Lewis’s question of why planned capital expenditure exceeded the allocation, Mr Sheppard explained that the NHS operates a “use it or lose it” capital regime, and programmes often underspend due to unavoidable delays. Setting a plan slightly above the allocation ensures the trust can fully utilise available funding and respond quickly if additional national capital becomes available later in the year. The proposed plan exceeded the allocation by £1,300,000, which is consistent with national guidance and previous board practice. Expenditure would be monitored monthly and adjusted later in the year if necessary to avoid overspend. Mr Lewis agreed this was a prudent and well managed approach.
The board received, noted and approved the capital plan for 2026 to 2027.
Operating performance, governance and risk management
Strategic delivery risks (SDRs)
Reference
Board public: 26/03/23.
Strategic delivery risks (SDRs) Mr Gowland presented the paper and gave key highlights.
A concerted effort with executive leads would be undertaken to ensure all relevant information relating to the highlighted strategic delivery risks were appropriately reflected in the scores from May. Mr Gowland observed that several actions were likely to extend beyond the stated dates, not due to failure but because they had only recently been initiated and further work was required for inclusion in the next iteration.
Progress had been made against the objectives, and the risks continued to represent the most significant threats to delivery of the organisational strategy. Mr Gowland noted the discussions throughout the meeting had reflected all of the principal risks, with specific reference made to staff development activity, high-quality therapeutic care discussions, and leadership matters. Data and the organisation’s use of data were identified as a substantial theme of earlier papers demonstrating they lay at the heart of board business.
Mr Gowland referred to the increasing volume of data now available and triangulation of data sources, including comparisons with staff surveys and incident trends. It was acknowledged that work remained to be done to strengthen the organisation’s ability to operate in a data led manner, although progress had been noted. Mr Gowland highlighted the appointment of the community development director as a positive step in managing the risks relating to neighbourhoods and primary care. It was noted that forthcoming survey results and the evaluation of leadership development offer (LDO) would support the organisation in responding to risks relating to staff experience and readiness for change. Progress was considered steady due to the scale and complexity of the risks, however none of the risks were believed to be escalating.
Mr Lewis reflected on recent discussions through the clinical leadership executive and high-quality therapeutic care meetings concerning 7 day working, including discussions on what activity should be delivered independently and what should be undertaken collaboratively with partners. He emphasised active management of the risks was evident across the organisation, and that the concept of strategic risk could be difficult for staff to interpret unless it was clearly connected to active management and operational use.
Mr Chillery noted that some strategic delivery risks were complex and that expectations and timescales might require adjustment to set realistic expectations, recognising they did not operate at the same pace as operational risks.
Mr Gowland reflected that the target risks and timescales might benefit from refresh, as earlier assumptions regarding delivery pace had proved optimistic. It was also suggested that certain developments had not yet been fully incorporated into the register and that the May refresh would provide an opportunity to demonstrate progress with clearer milestones to support expectation management (open action board public 25/05/24).
Mr Lewis confirmed that responsibility for risk scoring rested with the Executive lead. Mrs Lavery acknowledged the debate regarding the refresh of the strategic risk register, and agreed to receive an updated position on each strategic risk at the next meeting.
The board received and noted the strategic delivery risk report.
Operational risk report
Reference
Board public: 26/03/24.
Mr Gowland presented the report, noting the continuation of the revised approach to operational risk reporting.
The risks that remained outside the agreed tolerance threshold were highlighted and required increased attention. Although the report provided details and authorship, Mr Gowland noted that work on risks linked to organisational change remained important, particularly in relation to change management processes. He recognised the need to stay alert to additional risks arising from such change and to ensure alignment with ongoing key performance indicator work. The Risk Management Group (RMG) intended to continue monitoring these matters and to ensure they were clearly reflected in future reports.
Mr Vallance drew attention to staffing risks, noting significant pressures, including a vacancy rate of around 6.5%. He asked whether risks would reduce as posts were filled. Ms Holden explained that the position varied, as some risks related to sickness absence hotspots while others resulted from changes within the service portfolio. She noted that several risks needed refreshing to ensure accuracy, particularly in respect of dates and tolerance status. Dr Falk queried specific risks, including those linked to prescribing, which appeared to fall within tolerance. Mr Gowland suggested that current categorisation influenced how risk levels were assessed and that some subjectivity remained. He agreed that refining categorisation would support more accurate assessment and ensure risks were aligned with appetite and tolerance levels.
Mr Lewis referred to RSK‑038 (lithium prescribing and monitoring) and confirmed that Dr Sinclair would provide a briefing at the next Quality Committee meeting, given earlier discussions with clinical leads and the complexity of the issue in practice. Ms Blake raised the length of risk resolution timescales, noting that some extended beyond 6 months, and suggested that clearer explanation of the differences between short delays and significantly longer timelines would be helpful. Mr Gowland agreed to note the revised reporting thresholds based on the organisation’s risk appetite and the planned work to address the volume of risks outside tolerance. Mr Lewis emphasised the need for clearer actions, mitigation progress and expected timescales, noting that narrative updates should go beyond restating the risk and should confirm what had been done, what remained outstanding and the anticipated timeframe for resolution, some delays were acceptable but significantly extended ones required closer review. Mr Gowland explained the Risk Management Group (RMG) would continue to oversee those risks outside tolerance.
Action
Dr Diamid Sinclair
The board received and noted the operational risk report. The board noted the revised reporting thresholds based on risk appetite and the planned work to address the extended number of risks that are currently outside of appetite and tolerance.
Integrated quality performance report
Reference
Board public: 26/03/25.
Mr Chillery introduced the integrated quality performance report (IQPR) for March 2026 review (data as at 28 February 2026).
The non-urgent care 2 hour standard was accurate, but discrepancies arose once submitted externally. The matter had been raised with NHS England so the differences in data could be resolved, although a response was expected to take at least two weeks. Mr Chillery expected this issue to be addressed further at the next meeting with NHS England.
Performance appeared to show unused virtual ward capacity, although in reality the trust had cleared beds early to support system partners over the weekend, and that performance overall remained consistently strong. Mr Chillery clarified section 136 was already a priority throughout the current year and into the next financial year. He added that achieving zero was unlikely, as some section 140 cases would continue to arise and not all were attributable to the trust. Mr Chillery stressed that improvements in length of stay were essential to reducing unnecessary section 140 use and that ward capacity and flow were central to this. were planned to support maintenance work. The section 136 suite remained a priority, supported by work to improve length of stay.
In response to Dr Falk’s question about whether all places of safety could be excluded before applying section 140, Mr Forsyth explained that section 136 suites were the designated places of safety. Although the law allowed other locations, such as a child’s placement, this was not common practice nationally. Mr Lewis agreed that section 140 had increasingly been used to expedite admissions, which was inappropriate, and stressed the need to ensure correct use of the provision. He reiterated the aim to improve length of stay and reduce section 136 over-stay hours: our success had been a key system achievement which should not be sacrificed.
Mr Forsyth noted that issues raised at the previous board regarding the presentation of safer staffing data had now been resolved, with the narrative clearly explaining the red and green elements.
The board received and noted the integrated quality performance report, and recognised that separate board and chief executive officer level oversight of neurodiversity delivery would apply from April 2026, acknowledging the slower than necessary improvement position.
Promises and priorities scorecard
Reference
Board public: 26/03/26.
Mrs Lavery invited questions for Mr Lewis.
With reference to the statement on the cover sheet (in bold) regarding the “lowest third” Ms Blake asked whether certain measures were inherently difficult or had simply lacked resource. Mr Lewis explained that some issues were complex but moving toward solutions, while others, such as developing a homeless apprenticeship scheme, had stalled due to limited capacity. He noted that most measures in the middle third were achievable with collective effort, and that focusing on them would improve delivery while allowing the Board to identify and prioritise the genuinely difficult areas.
Dr Falk supported this approach and asked whether all promises carried equal weight. Mr Lewis confirmed they did, although the success measures varied in complexity. He agreed that the executive team would focus over the next 4 months on shifting the middle group, with the board retaining 2 years to address the most challenging items.
Mr Vallance raised concerns about sustainability, noting overreliance on senior executives to resolve issues that should sit within the wider organisation. He highlighted limitations within the 555 line managers capability framework and the need for more consistent and resilient processes. Mr Lewis agreed and clarified that bespoke services had proven harder to implement than standardised approaches. He confirmed the need to build capability so progress did not depend on executive intervention. Mrs Lavery supported adopting a more structured approach, separating the middle and lower groups to improve focus, while noting that progress this year had been slower than planned.
The board received and noted the latest self assessment provided and work being done to make sense of urgent care, relevant to promises 14 and 22. The board had considered how it could stimulate impact on promises 8, 10, 11 and 12, and recognised the focused effort needed on quarter 1 on elements of promise 9.
Supporting papers (previously presented at committee)
Mortality report and the guardian of safe working hours report
Reference
Board public: 26/03/27.
Mrs Lavery informed the board of the mortality report and the guardian of safe working hours report for information which was presented as a supporting paper that had both previously been presented at committee level for scrutiny and challenge.
The board received and noted the mortality report and guardian of safe working hours report for information.
Closing items
Any other urgent business
Reference
Board public: 26/03/28.
There was no further business raised.
Any risks that the board wishes the Risk Management Group to consider
Reference
Board public: 26/01/29.
Mr Lewis referred to the forthcoming reflection Mr Forsyth had agreed to undertake on workforce violence and aggression, and asked that Risk Management Group should take account of the points raised and whether any risks to consider.
Action
Steve Forsyth
Public questions
Reference
Board public: 26/01/30.
Mrs Lavery confirmed two public questions had previously been addressed (item board public 26/03/16).
There were no further public questions.
Closing statement
Reference
Board public: 26/01/31.
The chair resolved:
“That because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, the public and press would be excluded from the remainder of the meeting, which would conclude in private.”
Next meeting at 10am Thursday 28 May 2026, Riverside, Rotherham.
Page last reviewed: June 02, 2026
Next review due: June 02, 2027
Problem with this page?
Please tell us about any problems you have found with this web page.