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.
- 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.
In attendance
- Richard Banks, Director of Health Informatics.
- Lea Fountain, 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).
2 members of staff and 1 Governor were in attendance.
Introduction
Welcome and apologies
Reference
Board public 25/05/01
Mrs Lavery welcomed all attendees to the meeting and to Maria Clark, Non-Executive Director, at her first board meeting. Apologies for absence were noted from Sarah Fulton Tindall, Non-Executive Director.
Quoracy
Reference
Board public 25/05/02
Mrs Lavery declared the meeting was quorate.
Declarations of interest
Reference
Board public 25/05/03
Mrs Lavery presented the declarations of interest report which outlined that there were changes to the register declared since the last meeting that included the removal of interests relating to Professor Janusz Jankowski and the addition of Maria Clark to the register.
Clarifications relating to Ms Blake and Ms Clark declarations of interest were noted and would be included in the paper at future meetings. 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 27 March 2025
Reference
Board public 25/05/04
The board approved the minutes of the meeting held on the 27 March 2025 as an accurate record.
Matters arising and follow-up action log
Reference
Board public 25/05/05
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 out of area placement (OOAP) risk share (open action board public 24/09/21), Mr Lewis advised that although a funding agreement had been reached with South Yorkshire, the position with Humber and North Yorkshire (NEY) Integrated Care Board (ICB) was unlikely to achieve the same position within this financial year despite considerable efforts. Work would continue to reach an agreement and Mr Lewis envisaged this could be achieved by December (to enact the following financial year). It was noted a detailed update on out of area placements would be presented later in the meeting. A quality and safety impact assessment statement (QSIA) and equity impact assessment (EIA) in respect of the capital investment plan for the out of area placement would be undertaken in June, and a risk had been registered on the risk register with responsibility of the action transferred to Mr Lewis and Mr Chillery.
Board Assurance Committee reports to the board of directors
Report from the Quality Committee (QC)
Reference
Board public 25/05/06
Dr Falk presented the paper and gave the key highlights.
The committee meeting format had been refreshed creating a new structure aligned to the quality and safety plan, with focus on four domains of quality, safety, experience and the patient safety incident response framework (PSIRF). The committee would aim to avoid duplications and have streamlined processes. An evaluation of the new meeting format would be undertaken within the next twelve months to review its effectiveness.
Concerns had formally been raised relating to the failure to receive medicines management reports on two occasions, as well as at the quality and safety group. Dr Falk acknowledged the work pressures faced by the committee and reporting authors, with the need for interim updates to ensure no significant issues or concerns were missed. Mr Lewis stated he was aware of the concerns raised and that an interim update was expected by 13 June. Dr Sinclair provided an update following recent meetings of the medicines management committee and medicines optimisation group. There had been isolated incidents relating to medicines management with action plans underway to address those. Dr Sinclair acknowledged the importance of medicines management reporting and work was underway to address the issue of non reporting.
The board received and noted the report from the Quality Committee.
Action
Dr Diarmid Sinclair
Report from the Audit Committee
Ms Gillatt presented the paper and gave key highlights to the board. There were no matters of concern or areas to escalate to the board.
Internal audit progress was positively received, noting strong performance with three reports issued including two rated as significant assurance (mandatory and statutory training (MAST) and Promises 3, 4 and 5).
The interim head of internal audit opinion 2024 to 2025 gave an indicative opinion of moderate assurance. This was an improvement compared to the previous year. The final opinion would be received in June 2025.
Preparations were underway and on track regarding the preparation and audit of the annual report and accounts 2024 to 2025. Ms Gillatt recognised the importance for completing these prior to required submission in June 2025. It was noted that after further discussion, there was no need for accounts to be restated or prior year adjustments made in respect of the St John’s hospice building.
The external audit planning was underway, and no change in key risks relating to accounts. There had been positive developments of the risk management and embedding good practice across the organisation. The Audit Committee would continue to have governance and oversight of clinical audit, and to ensure the committee did not duplicate the work of the Quality Committee.
Regarding the counter fraud, bribery and corruption progress, Mr Mohammed advised the counter fraud functional standard return had been finalised and would be prepared for approval and submission within the next week.
The Charitable Funds and Flourish audits were due to be completed and submitted by the end of June. Mr Mohammed advised work was underway to close down significant risk areas. Both exercises were on track.
Mr Lewis referred to the clinical audit programme developed the previous year and the positive progress achieved, and agreed to seek clarification around the approach and prioritisation of the clinical audit work.
The board received and noted the report from the Audit Committee.
Reference
Board public 25/05/07
Report from the Mental Health Act (MHA) Committee
Dr Falk, on behalf of Ms Fulton Tindall, presented the paper and highlighted key points. Dr Falk commended the chairing which Ms Fulton Tindall provided.
With respect to the key indicators for seclusion within the integrated quality performance report (IQPR) Dr Sinclair explained the timeframes for medical reviews of patients in seclusion, noting the target had been met in respect of patients in seclusion waiting to be reviewed within five hours. Dr Sinclair acknowledged the compliance rate for independent reviews beyond eight hours was significantly below the desired level, advising there were various workstreams underway to address the issue including potential policy changes and discussions at senior doctors’ meetings. Mr Lewis emphasised the need for the clinical leadership executive (CLE) to see the outcome of this work by the end of June.
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 25/05/08
Ms Blake presented the paper and highlighted key points.
The Freedom to Speak Up (FTSU) update highlighted the need to continue building trust, responding to colleagues concerns, how issues raised were taken seriously by the organisation and preventative action taken. It was noted a Freedom to Speak Up report would be presented separately later on the agenda.
Staff survey results gave a 56% response rate. Key areas had been identified for directorates to focus and understand the concerns raised within the survey, and addressing the ‘other discrimination’.
The consultant vacancy position target reported within the integrated quality performance report had seen positive improvement following a significant period below the desired target. 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 25/05/09
Mr Vallance presented the paper and highlighted key points.
The volunteers recruitment journey continued to make good progress against the trajectory set to meet the target within promise 3. The committee would expect an update to ensure this was having a positive impact across services for both patients and volunteers.
Work continued to produce comprehensive health inequalities data to be reported from July 2025. It was noted this linked to the strategic delivery risk 2 (SO2), the revised integrated quality performance report and associated Health Inequality measurements and indicators. Mr Lewis stated there would be three key steps to successful achievement as outlined within his chief executive report.
Flourish financial performance showed improvement, and the committee were reassured by the financial position noting the reduction in deficit. Thanks were given to those colleagues who had supported the progress made.
Mr Chillery referred to the volunteer journey and a positive note this provided a volunteer to career pathway. Mr Chillery shared a few examples where volunteers had successfully secured paid employment within the organisation following their experiences as volunteers.
The board received and noted the report from the Public Health, Patient Involvement and Partnerships Committee.
Report from the Finance, Digital and Estates (FDE) Committee
Reference
Board public 25/05/10
Mrs Vickers presented the paper and highlighted key points.
With regard to estates, the organisation had been successful in securing £1,800,000 of national capital programme funding to support the provision of a high dependency rehabilitation unit (HDU) and Phase 4 of the Great Oaks project.
At month 12 (2024 to 2025) the financial position was £512,000 surplus, better than plan, with all care groups and corporate directorates meeting their targets. The finance plan 2025 and 2026 was a balanced plan, recognising the additional recurrent funding required to arrive at that position. Future finance reporting would be provided by directorate (think directorate) with focus on achieving key saving schemes to achieve plan.
The cybersecurity update provided significant assurance against the processes in place and highlighted the importance of learning and staying updated following recent cyber incidents outside the NHS framework, in particular across the retail industry. Mr Banks explained the role and function of the South Yorkshire Cybersecurity Board, which the trust was a member of.
Mr Lewis referenced the finance plan, noting this was a balanced plan but questioned what effect the national pay award announcement, made since the Finance, Digital and Estates Committee met in April, would have. Mr Mohammed responded the additional cost (above current assumptions) would be £2,700,000. It remained unclear whether this gap would be funded by the system allocation. Mr Mohammed estimated a pay award funding gap of between £800,000 and £900,000. Mrs Lavery acknowledged the growing concerns at a national level across the public health sector following the pay awards announcements and potential financial shortfalls this could create. Mr Mohammed explained the system allocation would be reserved for the integrated care boards to resolve in regard to mental health and ambulance trusts.
The board received and noted the report from the Finance, Digital and Estates Committee.
Report from the Trust People Council (TPC)
Reference
Board public 25/05/11
Mrs Lavery presented the paper and highlighted the Trust People Council continued to grow in maturity.
There was a progressive debate around promise 26 and work to tackle the wider aspects of discrimination and promote inclusion.
The health and wellbeing vision had been refreshed and continued to be shaped. Consistent feedback was to get the fundamental basics right of what should be expected within the workplace. Mr Lewis felt it important for the board to be aware this meant staff having essentials to work such as a designated base point, office and kitchen facilities, debrief areas for community colleagues, flexibility and supportive remote working. Mr Chillery stated care group colleagues continued to seek clarity around remote working. Ms Holden responded that although the wider workforce had benefited since flexible remote working had been introduced it was acknowledged not all areas were, such as bed based areas.
In quarter 3 and 4 work would progress to address flexible working with a consistent approach seeking equity across the organisation. Ms Holden advised the need to operationally change the organisational workforce and reported an innovative pilot taking place in St John’s hospice. This had seen positive results whereby staff self-roster, giving them responsibility for the autonomy of shift cover arrangements. Dr Graham noted this work linked to a number of promises around workforce reflecting the diversity of our populations. This would require leaders to think differently and space would be built into learning half days and the learning and education group to explore this further.
Mr Gowland raised the reporting arrangements from the Trust People Council and board committees to the council of governors. It was important to ensure reporting was timely in order to keep Governors informed on key issues across the organisation. This would be discussed at the next council of governor meeting to be held in June.
The board received and noted the report from the Trust People Council.
Action
Phillip Gowland
Chief executive’s report
Reference
Board public 25/05/12
Mr Lewis drew attention to the five key items within his report.
The NHS reset and changes across the integrated care board roles and workforce continued to attract attention. This should not distract from the organisational strategic mission. Board members were reminded of the importance for staff and managers to hear the long-term commitments which the organisation has made, and to hear that they would not change as a result of the NHS reset.
In early May, the Care Quality Commission made an unannounced inspection of the acute mental health and psychiatric intensive care unit (PICU) services across Rotherham, Doncaster and North Lincolnshire. Formal feedback following the inspection was not yet available, albeit informal feedback was positively received noting that staff were welcoming and open to the Care Quality Commission inspection process across ward areas. Mr Lewis advised space would be created for the senior leadership team in July for reflective learning from the Care Quality Commission inspection.
The distinguished service awards (DSA), previously known as long service awards, had relaunched. Thanks were given to colleagues’ contributions towards the first celebration held in early May. There would be retrospective awards for the years 2022 and 2023 to close the gap. The awards differ as they respond on an individual level and are more generous and extensive in celebrating staff anniversaries.
All directorates had achieved budget sign-off. Mr Lewis was pleased to report that teams had embraced the budget sign-off exercise, but reported that a learning exercise would take place in July, amongst the senior leadership team, with a view on future budget setting rounds.
The poverty proofing 2024 to 2025 reports had been published on the public website. These build from the pilots undertaken and demonstrate a response towards the trust’s values and promises.
In response to Ms Fountain, Mr Lewis confirmed the organisation had made progress against promise 23 by investing in Rotherham with the South Yorkshire Housing Association (SYHA), creating the specialist mental health and housing support partnership. Work had commenced to create similar models in Doncaster and North Lincolnshire, developing pathways to care for patients closer to home. Mr Lewis explained a detailed briefing paper was shared at the clinical executive leadership (CLE) and agreed to share the paper for information. The board recognised this work aligned to the organisational strategy and promises, to be overseen via the Public Health, Patient Involvement and Partnerships (PHPIP) Committee.
Regarding the NHS reset with revised operating and financial model, Ms Blake expressed her concern that smaller third sector organisations may be negatively impacted, and questioned how the organisation could provide support. Mr Lewis confirmed the organisation had no part in any plans the integrated care board decide. Efforts were being made to understand the reset process and equity impact assessment documentation had been requested for further insight. Executive colleagues continued to work closely with the integrated care board to support, understand and consider its contribution to collaborative working in the future. The organisational values would remain, focus to tackle inequalities and working with partners. Other practical responses, collaborative bidding and opportunities may arise for the third sector through investment bids and the Your Hearts and Minds charity.
Dr Graham referred to the publication contained within the annex of the report. The guidance Leading for all: supporting trans and non-binary healthcare staff would be considered through the appropriate staff networks to understand what the changes, if any, mean with an organisational response to be produced towards the end of July.
The integrated care board blueprint provided a summary to help integrated care boards produce plans by the end of May to reduce their running costs by 50%, shifting integrated care boards towards strategic commissioners and delivering the 10-year plan. Mr Lewis understood staff consultations would begin in June but no details on future functions or roles were available with those discussions remained internal to the integrated care boards. The board noted the NHS 10- year plan was yet to be published. Mrs Lavery recognised the major transformational changes in delivering the NHS reset, with operational and financial challenges, and change in statutory responsibilities.
Mrs McDonough was pleased to see the establishment of a community leadership executive and queried how this would be developed. Mr Lewis confirmed throughout June a series of meetings would take place to create space, hear community and patient voices with support from executive colleagues. These would be used to influence and impact on decision-making (promise 5), in addition to the patient and governor representation within the organisational committee and sub meeting structure. Mr Chillery referenced the well led work to be discussed later in the meeting, noting the strengths and improvements made linked to partnerships and communities. This included hearing the voices and connecting with younger people.
Mr Lewis drew attention to the new patient safety incident response approach (PSIRF) policy, which updated the 2023 version. He sought approval highlighting the appendix providing a clear diagram of what was covered in all likelihood by each investigative process. He noted that this presentation had come via clinical executives, himself and Dr Falk working through ideas. He also highlighted the quarter 1 planned audit of practice, reporting quarter 2. A number of board members welcomed the clarity. Mr Lewis then noted the proposed adverse events process relating to resident doctors: he highlighted that this differed from the one proposed by the postgraduate medical director, after review at clinical leadership executive. Acknowledging the possibility of controversy, he nonetheless noted Dr Sinclair’s proposal and sought, and received the support of the board as the model would further protect trainees and patients. He confirmed that in 2026 and 2027 the operationalisation of these changes could be re-reviewed.
The board approved the revised patient safety incident response framework policy for the trust (a matter reserved for the board).
The board noted the first bi-monthly reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR) report.
The board received and noted the chief executive’s report and the forward actions it contained.
Action
- Toby Lewis.
- Toby Lewis and Dr Jude Graham.
Staff survey: areas of focus
Reference
Board public 25/05/13
Ms Holden presented the paper and gave key highlights.
Following the staff survey results presented to the board in March 2025, there were nine suggested areas of focus for improvement to be above average, building on the people promises and learning from other organisations. These areas of focus linked to the organisational strategy and promises to be delivered over the next three years.
The annual staff survey provided a detailed set of results across the trust (provided within the annex) but more importantly by directorates to understand the areas of success and the areas of focus. It was important to note the data could be broken down by protected characteristics and by staff groups.
The results were the first to be received at directorate level and had been shared with all directors and engagement commenced with colleagues. Each directorate had been asked to identify a small number (two or three) actions which they wish to focus on this year, and then in future years it would be teams within the directorates.
Ms Holden drew attention to people promise 5 we are always learning. Despite the investment in learning half days and ringfenced training budget in 2024, this was the lowest ranking from the staff survey results. The best performing result was people promise 6 we work flexibly, acknowledging there remained areas within directorates where this scored very low. In response to Mr Vallance, Ms Holden confirmed each directorate had details of each question and the response rates. However the national staff survey was a set survey questionnaire with set timeframes, with the ability to analyse and compare against 210 organisations.
It was recommended that the development and subsequent monitoring of the work was delegated to the People and Organisational Development Committee and Trust People Council. In addition, the workforce race equality standard (WRES) and workforce disability equality standard (WDES) data and the associated national submissions to be reviewed by the People and Organisational Development Committee in August, in advance of the national reporting deadline in October 2025.
The board discussed the value of learning from previous staff survey results, other organisations, and other sources such as staff feedback from peer reviews. Ms Holden explained other triangulated factors would be explored and whether there were any additional learning and areas to improve.
The board delegated the development and subsequent monitoring of the work to the People and Organisational Development Committee and Trust People Council.
The board delegated to the People and Organisational Development Committee the review and submission of the 2024 workforce race equality standard and workforce disability equality standard data.
The board received and noted the staff survey results and areas of focus, and recognised the work and commitment required to facilitate the suggested improvements across the nine areas.
James Hatfield joined at 11:40am.
Care Quality Commission readiness: safe, effective, caring and responsive
Reference
Board public 25/05/14
Mr Forsyth presented the paper which provided a summary of the current self-assessment in thirteen directorates against four domains safe, effective, caring and responsive.
The self-assessments were developed with a triangulated view against the Care Quality Commission domains based on data and intelligence through various safety and quality reporting and associated action plans (as part of the quality and safety plan, integrated quality performance report safety metrics and always measures). Each domain had been scrutinised and challenged through a triangulated process with each care group. The findings highlighted areas for improvement and part of a clear and honest self-assessment of each care groups positions. There was recognised need to address unwanted variation across the organisation ranging from how rosters were completed between wards, how care planning was personalised and produced through engagement with people and families, access and waiting times, and staff training and supervision.
Mr Forsyth welcomed the board to consider the self-assessment and each Care Quality Commission domain separately.
Safe required improvement across the organisation and this was consistent with the finding from the 2019 Care Quality Commission inspection, including safeguarding training compliance and the need for improvement in medication optimisation and safe systems.
Mr Forsyth reflected on the good practice identified in physical health rehabilitation service demonstrating a safe environment. Mr Lewis observed the number of services which had self-assessed as required improvement around safe system, pathways and transitions. This had been discussed during the recent care group delivery reviews. Mr Chillery reflected there was a lot of good practice evidenced but mindful there was transformational and improvement change occurring with the implementation of patient safety incident response framework and incident management, risk and audit system. Mr Chillery stated he would be concerned if the safe domain required improvement.
Effective assessed as required improvement across the organisation, focusing on consent processes and the need for standardisation across the organisation.
Caring assessed as good. The board recognised the strengths in the caring domain and the aspiration to achieve an outstanding rating. The Care Opinion roll out had added value and evidence upon listening to and responding to patient experience and feedback. Peer reviews on wards also recognise the quality of care provided was of a good standard. Good practice was demonstrated in the children’s care group of working with people who had neurodiverse needs. Improvement areas had been identified with communications and in the culture of care assessment baseline, with variations across directorates of ability to respond to diverse needs of people. In response to Mr Lewis, Mr Forsyth advised within the Care Quality Commission assessment framework, the caring domain did include workforce wellbeing and enablement, with some care group areas identified for improvement.
Responsive assessed as good, recognising strong pathways and relationships between services. Improvement areas were identified to improve and embed equity of access consistent use of clinical patient outcomes measures across services through Dialog+. Health inequalities data would support these areas.
Mr Vallance noted the underlying themes and areas which required improvement. Training and related supervision, safe and effective staffing, personalised care plans and long waiting times had all been a longstanding concern. In response Dr Falk stated as chair of the Quality Committee he was fully supportive of the draft self-assessment and methodology used, that it gave an honest reflection and detail of commonalities which required consistency and improvement.
The board noted the strands of improvement works underway to strengthen what worked well. There would be longer term pieces of work linked to transformation and change management processes, whilst continuing to develop a learning culture. Mr Forsyth confirmed a further report would be presented to board in July 2025.
The board received and noted the update and status report in respect of the Care Quality Commission safe, effective, caring and responsive questions.
Freedom to Speak Up (FTSU) update
Reference
Board public 25/05/15
James Hatfield introduced the paper and key highlights.
The biannual report provided an overview of Freedom to Speak Up key areas, the nature of concerns raised, emerging themes, the latest findings from the staff survey with actions for the Freedom to Speak Up guardian, and the learning and improvements that had been implemented as a direct result.
The NGO 2025 Freedom to Speak Up recruitment framework standardises how NHS trusts recruit and support Freedom to Speak Up guardians. Implementation was essential for a robust Freedom to Speak Up function, crucial for safety and quality of care. Visibility of the Freedom to Speak Up guardian continued to be strengthened and promoted across the organisation to develop trust amongst staff.
The Freedom to Speak Up data of colleagues going through the Freedom to Speak Up process was above the national average, with the top three themes had been civility, bullying, harassment, leadership and culture. James advised each concern could have multiple concern themes within it, they would be investigated and addressed within the care group leadership.
Ms Blake stated it was good to see that each concern was listened to and addressed, noting the actions taken and improvement of feedback mechanism for detriment for Freedom to Speak Up concerns. In response to Mrs McDonough, Ms Holden confirmed the staff survey results and actions for the Freedom to Speak Up guardian had been broken down by directorates and again by protected characteristics. Mr Lewis was pleased to see the good culture of Freedom to Speak Up, the visibility of the Freedom to Speak Up guardian and other functions such as Freedom to Speak Up champions and support in place for staff.
Mr Lewis noted the improvement in feedback on Freedom to Speak Up concerns, and recommended strengthening timescales to four weeks to give care groups and services ownership as well as manage concerns raised. James responded Freedom to Speak Up training and support would be provided to managers and the implementation of Radar would support that initiative with better data management.
Regarding the 96 Freedom to Speak Up concerns raised in 2024 to 2025, Mr Lewis queried whether there was a comparison of data with peer organisations. James responded there was comparable data which the People and Organisational Development Committee had oversight of.
In response to Dr Falk, James confirmed he had not seen evidence of vexatious reporting of people feeling they had been detrimentally effected as a result of raising Freedom to Speak Up concerns. In response to Ms Gillatt, James advised any concern related to patient safety would be investigated and addressed with the support of the chief nursing officer.
Dr Graham explained the Freedom to Speak Up champions network was diverse and Mr Chillery confirmed the Freedom to Speak Up guardian role was frequently connected to care groups, teams and the executive leadership, and continued to use opportunities in identifying and responding to staff concerns such as service or model change.
The board received and noted the Freedom to Speak Up update, noting the Trust People Council would continue to work on the trust culture. Board members were encouraged to champion speaking up through respective board committees and networks.
Action
Steve Forsyth and James Hatfield
James Hatfield left at 12:45am.
Plans for approval (quality and safety plan and equity and inclusion plan
Reference
Board public 25/05/16
Mr Lewis presented the paper and explained board members would be familiar with both draft plans which had been previously considered through different forums including board committees and time out. Both plans would require support from colleagues to implement the changes and chosen priorities for the organisation.
The equity and inclusion plan had been shared at the Public Health, Patient Involvement and Partnerships (PHPIP) Committee and acknowledged some wording would slightly change to reflect feedback received, but the majority of the plan presented would remain. The majority of the plan was framed around the promises and strategy, with focus around inequalities and tackling exclusion. Work had already been deployed and advanced, and the Public Health, Patient Involvement and Partnerships Committee would continue to have oversight of its delivery.
There were fundamental changes to the quality and safety plan (as noted under item board public 25/05/06). Dr Falk drew attention to “getting things done” and timetable of the work to be adopted through 2025 to 2026 and beyond. These key areas would remain of focus for the Quality Committee and inform future agendas. Dr Falk was fully supportive of the plan as Chair of the Quality Committee.
Mr Vallance confirmed the Public Health, Patient Involvement and Partnerships Committee had endorsed the equity and inclusion plan, and embedding work into practice was advancing. As chair, he fully supported the plan.
The board delegated to the Quality Committee approval of the final list of always measures.
The board received and approved the equity and inclusion plan and quality and safety plan. Delivery oversight of these plans would be given to their respective board committee, in line with their already agreed terms of reference.
Reference
Board public 25/05/17
Patient story: human trafficking and modern slavery, multiple trust services
Reference
Board public 25/05/18
Mrs Lavery welcomed Dr Graham to share a patient story about a person who had been subject to human trafficking and modern slavery, therefore had accessed both physical and mental health services. Support was offered to anyone who needed or was distressed by this agenda item. Dr Graham referred to material shared prior to the board meeting and proceeded to give a presentation via pre-recorded video.
The video highlighted the patient’s journey as a 14-year-old travelling across borders from their home country in Eritrea to Ethiopia, being captured by the military and subjected to torture. The story highlighted the multitude of offences associated with modern slavery and human trafficking, the impact of trauma with victims in the UK who had experiences and accessing physical health services (hepatitis, Tuberculosis and dietician services) and mental health services, and people who may also work with us.
The story emphasised the need for healthcare providers to be aware of the different ways healthcare is offered in other countries, and to make information accessible in different methods and languages. It was important to learn about peoples’ experiences and not make assumptions to better understand their needs, with reliance on social media or other sources. It highlighted that newcomers to the UK may not necessarily be aware of access to basic healthcare medicines like paracetamol were available via the pharmacy or supermarkets rather than visiting a doctor or hospital. The story highlighted that family and carer involvement could provide valuable insight and help improve a persons care.
Mrs Lavery and the board thanked members for taking the time to listen and watch the video, and noted the intended reflection time later on the agenda.
2024 and 2025 serious patient safety incidents learning update
Reference
Board public 25/05/19
Mr Forsyth presented the paper and gave key highlights.
Following the board in March 2025, there were eighteen patient safety incident investigations (PSIIs) to conclude. The report provided the outcomes and learning of all patient safety incidents occurring in the previous twelve months.
There were nine key areas of learning to take forward, and Mr Forsyth proceeded to draw the board’s attention to the significant issues from the patient safety incident investigations. Themes include communication issues, involvement of family and carers, record keeping and support for people in crisis. The model of learning would change as part of the patient safety incident response framework deployment, with a new 50-day standard put in place to enable faster learning and delivery of actions. Key learnings would be shared as part of delivery reviews.
In response to Mr Vallance, Mr Forsyth advised the learning from the patient safety incident investigations was in relation to both avoidable and unavoidable issues. With respect to unavoidable, there could be other contributory factors and complex comorbidities. Dr Falk recognised the importance of the primary care role of listening and signposting patients to relevant services who required mental health support or who were in crisis.
Mr Lewis was encouraged by the patient safety incident response framework process whereby learning from patient safety incident investigations and actions would be more precise with learning embedded into practice, stating the timely sharing of information was important and ensuring that lessons were implemented effectively. Mr Forsyth acknowledged there were areas in the organisation where mistakes could be avoidable with an example of medicines management in community services. In regard to ensuring learnt lessons being implemented effectively, this area would improve with the new 50-day standard to enable faster learning and audits to ensure actions were put in place with measures of success.
Mr Forsyth highlighted a number of consistent organisational changes made following patient safety incident investigations with policy changes and development of patient pathways, and summarised the learning model would continue to be embedded through deployment of the patient safety incident response framework policy, the safety and quality plan, the education and learning plan, learning half days and learning systems like Radar. There would be an audit of patient safety incident response framework to test out its deployment, Mr Forsyth stated this would include ensuring actions taken were embedded and sustained (discussed above board public 25/06/13).
The board discussed embedding learning from patient safety incident investigations and sustained changed. Mr Lewis recommended learning from patient safety incident investigations for peer teams and other partner organisations to be considered within the learning system, in order to minimise similar incidents occurring. Dr Graham responded that a learning matrix would be developed whereby themes identified from patient safety incident investigations would be shared across care groups and relevant teams. Mr Forsyth referred to peer reviews, whereby board members would be able to check and challenge learning and actions from patient safety incident investigations ensuring sustained changes had been made. Mr Forsyth agreed to share the nine key areas of learning with partner organisations.
In response to Ms Blake, it was noted the number of patient safety incident investigations resulting in mortality and suicide had not seen an increase compared to 2022 to 2023. The patient safety incident investigations were mostly middle-aged males who died via suicide and compared to last year the number had reduced. Mr Chillery recognised there was a system wide suicide prevention strategy across place to support services and partners.
Mrs Lavery summarised the role of the Quality Committee would continue to have oversight of the patient safety incident investigations, and the board would receive a biannual review of those where patients came to serious harm with outlined learning and response to the learnings.
The board received and noted the annual review of the serious harm to patients during 2024 and 2025 and outlined actions in response to the learnings.
Action
Steve Forsyth
Care Quality Commission readiness: well-led
Reference
Board public 25/05/20
Mr Gowland presented the paper and gave key highlights. Following the previous well led assessments provided in May and November 2024, the assessment focused on the well-led key question, a part of the overall Care Quality Commissions single assessment framework.
The report highlighted the good progress made against several pieces of work detailed within the assessment into 2025 to 2026, including the leadership development offer and promise 5. The report recognised further areas of improvement with future planned actions identified. External partners the good governance improvement (GGI) and internal audit had provided related feedback and assurances. Mr Gowland explained the report complimented the previous discussion relating to safe, effective, caring and responsive key Care Quality Commission questions (board public 25/05/15).
Key to the work underway was the development of the maturity matrix approach across the care groups in support of the well led framework, alongside ‘think directorate’.
Mr Gowland highlighted it was important to note that foundation trusts were strongly encouraged to undertake reviews of their leadership and governance using the well led framework. It was noted the trust had previously commissioned external partners the Office of Modern Governance and good governance improvement. During quarter 4, a formal, externally commissioned, well led review would take place. Mr Lewis requested a subset of leaders should be agreed to oversee this work.
The well led assessment would continue to progress, noting a further paper would be scheduled to come to the board in November 2025. Mr Vallance referred to the current assessment of the quality statement learning, improvement and innovation and identified future areas for improvement, noting there remained a gap. Dr Graham responded that solutions were being identified. The learning and education plan together with the learning model continued to be developed and triangulated with other factors such as patient safety incident response framework, Radar and the quality and safety plan. Mr Lewis referred to recommendation 3 within the good governance improvement report, and acknowledged there was appetite to take this forward through the leadership development offer and for us to be clear what people’s roles were in meetings. It was acknowledged the board would spend time at its next meeting to focus on learning and education.
The board received and noted the Care Quality Commission readiness well-led update and status report in respect of Care Quality Commission well led key question, noting the next steps planned, and a report would be provided to the board in November.
Action
Phillip Gowland
Reduction of inappropriate out of area placements (OAPs)
Reference
Board public 25/05/21
Mr Chillery presented the paper and gave key highlights, acknowledging the ethical, clinical, and financial case for reducing out of area placements.
The paper outlined the key steps required to reduce inappropriate out of area placements, the changes required, the scale and complexities of the programmes of work underway in preparation to reduce out of area placements from 1 July onwards.
The trust had previously agreed to take the financial ownership for South Yorkshire out of area placement, from the South Yorkshire integrated care board. There were opportunities identified but also potential barriers relating to large scale systemic change. The bed base focused on the five adult mental health wards across Doncaster Rotherham and North Lincolnshire. Enhancing and reconfiguring the community services to support the inpatient settings, so create opportunities to remain in the community would be key to the changes. Mr Chillery highlighted the 6 challenges which were interrelated and various workstreams underway to tackle those.
To meet demand, the trust would need to maintain the current 12 discharges per month and then an additional 4. This is then 16 weekly discharges (an additional 4.37 discharges). Mr Chillery advised there was a need for sustained investment, integrated working and significant change, with clear leadership. Mr Chillery reminded the Board a detailed quality and safety impact assessment and equity impact assessment would be developed (open action board public 24/09/21).
The board recognised the large scale change required and discussed the complexities and risks presented and acknowledged this may create workforce shortages and capability issues. It was important to note out of area placements were associated with poorer patient outcomes, and delayed recovery. The board recognised there may become increased risks within community settings as the organisation moves to caring for people with complex needs closer to home. It was noted the high-quality therapeutic care taskforce (HQTC) had been established to oversee the work on therapeutic patient care, safety and quality along with timely care. Engagement with colleagues and partners was planned in June to identify and collaboratively develop a consistent model and system of working. Mr Forsyth reinforced the proposed change would not override clinical decision-making but rather clinical curiosity and ensuring all aspects were considered, referencing the learning from out of area placements.
In response to Mr Vallance, Mr Chillery advised some elements of the programme may not succeed. It was unclear what the system appetite was and recognised some cases of disjointed governance amongst partners (NHS trusts, local authorities, Police).
The board received and noted the reduction of inappropriate out of area placements update, acknowledging the ethical, clinical and financial case for reducing out of area placement, along with the complexity of change. The board recognised the work required for three of our 13 directorates, associated senior leadership and executive teams.
Integrated quality performance report (IQPR)
Reference
Board public 25/05/22
Mr Lewis introduced the integrated quality performance report (IQPR) for April 2025.
There had been zero breaches for “over 24 hour in section 136”, a notable achievement. Improvements had been seen on out of area placement. Physical health services continued to perform well across and achievement of the referral to treatment (RTT) 18 week compliance.
From July there would be meaningful health inequalities data reported through the integrated quality performance report. Mr Banks drew the board’s attention to the integrated quality performance report health inequalities analysis proof of concept and visual design. The integrated quality performance report would provide a breakdown of measures against key health inequality elements of age, gender, ethnicity and deprivation. There would be potential to build on data with year on year comparison.
Mr Vallance noted the deterioration in neurodevelopmental services for people waiting for attention deficient hyperactivity disorder (ADHD) assessments when compared with the trajectories. Mr Lewis suggested the board spend time at the next meeting to understand the complexities in achieving the trajectory.
The board received and noted the Integrated Quality Performance Report.
Action
Richard Chillery
Promises and priorities scorecard
Reference
Board public 25/05/23
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.
Promise 21 relating to hyper local working and integrated neighbourhood teams now had a set of measures to achieve success. Work was underway with strategic leads to make progress in the next six months.
Some promises remained actively ongoing and it would be important to celebrate the work that had been achieved in getting close to delivery of those promises. Mr Lewis stated it was important to celebrate and help build on sustaining those achievements. The promises and priorities would be shared at the annual members meeting in July, Mrs McDonough advised an easy read version would be coproduced with People Focussed Group. Ms Fountain was pleased to hear about the celebration events and positive achievements.
The self-assessment would be presented to clinical leadership executive in June to discuss what is needed to achieve segment 1, 2, and 3 promises over the balance of the year.
The board received and noted the promises and priorities scorecard update on the work to date and expectations in 2025 and 2026.
Strategic delivery risks (SDRs)
Reference
Board public 25/05/24
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.
Following the positive response from internal audit where significant assurance was received on that new approach, the format had been revised to articulate the risk actions and link to the risk management framework via individual lead executives, committees and in conjunction with the Audit Committee chair or director of corporate assurance tri-annual reviews. Further refinement and clarity will be achieved in delivering mitigating and impactful action to these risks.
The trust’s strategy remained until 2028 with five strategic delivery risks. It was anticipated that the NHS’s 10-year plan would be published shortly, this would need to be carefully reflected on, including whether it materially impact on the trust’s strategy or its strategic delivery risks. Therefore, he would consider and confirm the ongoing strategic delivery risks during quarter 3 and present this to the board in September.
The board received and noted the strategy delivery risks report, noting the planned next steps to enhance reporting arrangements and the intended review of strategic delivery risks following the publication of the NHS 10-year plan.
Action
Phillip Gowland
Operational risk report
Reference
Board public 25/05/25
Mr Gowland presented the paper which highlighted the current position in relation to the extreme risks.
The board spent time in April at its time out to review risk appetite levels and to determine how it wanted to categorise risks. Mr Gowland drew the board’s attention to the risk management framework and refreshed risk appetite levels. These would strengthen the approach to risk oversight and management, the risk appetite was key to drive that process and improve consistency in risk assessment. The implementation of the new Radar system, from 1 July, would have overview of the risk register across 23 directorates.
Mr Gowland confirmed there would be opportunities through the risk management group to review live and tolerated risks against the refreshed risk appetite levels and check they were categorised and being managed correctly.
Mr Lewis explained the rationale for there being a low tolerance (as opposed to adverse tolerance) in regard to legal risks. This would allow for judgement and opportunities, perhaps within procurement, where an informed risk may well be beneficial to take.
In response to Mr Lewis, Mr Gowland confirmed the disengagement risk identified at the last board meeting had been considered by the risk management meeting. This was a live open risk with a risk score of 9 (high) with actions underway, referring to the update provided with the action log (board public 25/01/21b).
The board received and approved the updated risk management framework including the updated risk appetite levels.
The board received and noted the operational risk report update, including extreme risks.
Fit and proper person test (FPPT) annual declaration
Reference
Board public 25/05/26
Mr Gowland presented the paper and highlighted the process followed to undertake the test and the assurance received from internal audit regarding the process.
Mrs Lavery confirmed that, following the receipt and review of self-attestation statements and where applicable, the checks undertaken during recent appointments, she had deemed all members of the board met the requirements of the fit and proper person test.
The board received and noted the update that confirmed the progress and state of readiness for implementing the requirements of the fit and proper person test.
The board received and noted the statement from the chair that, following the receipt of self-attestation statements, she had deemed all members of the board to be fit and proper.
Papers for information
Infection, prevention and control (IPC) annual report
Reference
Board public 25/05/27
Mrs Lavery informed the board of the infection, prevention and control annual report presented for information, and noted the work undertaken in 2024 to 2025 that demonstrated the trust was meeting its statutory duties and the required national standards regarding infection, prevention and control.
The board received and noted the infection, prevention and control annual report for information.
Safeguarding annual report
Reference
Board public 25/05/28
Mrs Lavery informed the board of the safeguarding annual report presented for information, and noted the work undertaken in 2024 to 2025 including the work in response to the limited assurance report from internal audit.
The board received and noted the safeguarding annual report for information.
Supporting papers (previously present at committee)
Learning from deaths annual report
Reference
Board public 25/05/29
Mrs Lavery informed the board of the learning from deaths annual report presented for information, which had previously been presented at Quality Committee level for scrutiny and challenge.
The board received and noted the additional report for information.
Any other urgent business
Reference
Board public 25/05/30
There was no further business raised.
Any risks that the board wishes the risk management group (RMG) to consider
Reference
Board public 25/05/31
The board noted the out of area placement risk share would be considered by risk management group in July.
Public questions
Reference
Board public 25/05/32
There were no questions raised by members of the public.
Closing statement
Reference
Board public 25/05/33
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: July 29, 2025
Next review due: July 29, 2026
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