Board of directors minutes May 2026 – Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)

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.
Dr Andrew Heighton, Deputy Chief Medical Officer.
Carlene Holden, Director of People and Organisational Development.
Toby Lewis, Chief Executive.
Simon Sheppard, Director of Finance and Estates.
Dave Vallance, Non-Executive Director.
Pauline Vickers, Non-Executive Director.

In attendance

Dr Jude Graham, Director for Psychological Professions and Therapies.
Jo McDonough, Director of Strategic Development.
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).
Gary Cox, veteran for the patient story.
James Hatfield. Freedom to Speak Up Guardian.
3 members of staff.
1 governor.
1 member of the public.

Welcome and apologies

Reference

Board public: 26/05/01.

Mrs Lavery welcomed all attendees to the meeting. Apologies were noted from Dr Diarmid Sinclair, Chief Medical Officer. Mrs Lavery noted that there were items on the agenda to be managed through a question led format to support focused discussion and efficient use of time. Feedback on the meeting and any subsequent questions were welcomed, with any public questions to be addressed at the conclusion of the public meeting. Mrs Lavery emphasised the strong and explicit focus on organisational culture, reflecting its importance across multiple agenda items.

Quoracy

Reference

Board public: 26/05/02.

Mrs Lavery noted the meeting was quorate.

Declarations of interest

Reference

Board public: 26/05/03.

Mrs Lavery presented the declarations of interest report and confirmed there had been amendments to the register since the last meeting in respect of Kath Lavery, Rachael Blake, Maria Clark, Kathy Gillatt and Pauline Vickers. 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 26 March 2026

Reference

Board public: 26/05/04.

The board approved the minutes of the meeting held on the 26 March 2026 as an accurate record.

Matters arising and follow-up action log

Reference

Board public: 26/05/05.

The board received the action log and noted the progress updates. All seven actions noted as “propose to close” were agreed, and noted that six remaining actions would be addressed at the July meeting.

Future adult attention deficit hyperactivity disorder (ADHD) and adult autism services

With reference to closed action board public 26/03/13, Mr Lewis advised a further discussion would take place at the next board of directors in July 2026 which may include proposals regarding how the adult autism service goes forward. Members of the board were encouraged to discuss concerns in this regard with either himself, Dr Graham or Mr Chillery prior to the next meeting.

Estate enabling plan

In response to a query from Mr Lewis regarding capacity and capability to deliver the estate enabling plan, Mr Sheppard advised that additional resource had been secured to support development of the business case. Project management support from an external organisation was expected to be confirmed by the end of the following week, ensuring sufficient capacity and capability ahead of the July board meeting. Internal teams, including strategy, estates and finance, were also contributing to the work.

Workplace violence and aggression

With reference to closed actions board public 26/03/17 and board public 26/03/28, Mr Forsyth noted that board feedback had been welcomed, particularly the request to strengthen and expand the recommendations, and confirmed further progress had since been made.

Firstly the recommendations were discussed at the Risk Management Group (RMG) in early May.

Where it was agreed that psychological professional leads would work to ensure a consistent response to incidents across all care groups, including strengthened immediate and follow-up debrief arrangements, with progress to be reported back.
Oversight of incident reporting through the Radar system was enhanced to improve executive visibility of violence and aggression incidents and ensure timely and visible action, addressing staff survey feedback.
Work, led through high-quality therapeutic care (HQTC), focused on developing more neuro specific and trauma informed environments, including physical and sensory improvements to support calmer therapeutic settings.
There was also an increased focus on therapeutic activity within inpatient wards with a broader and more patient led programme to support violence reduction.

Mr Lewis referred to meaningful debriefs for colleagues, and Dr Graham added that debrief processes had reflected both immediate and more reflective approaches, supported by the Trauma and Resilience team, with specific attention given to incidents involving racism through dedicated oversight arrangements.

The board received and noted the update related to workplace violence and aggression and four actions Mr Forsyth had oversight of.

Board assurance committee reports to the board of directors

Mrs Lavery introduced a revised approach to this non-executive led section of the meeting and asked for the discussion to initially focus on the four escalated matters from within the committee reports to board.

Quality Committee (QC)

Reference

Board public: 26/05/06.

Lithium prescribing and monitoring

Dr Heighton advised that the main issue had been a lack of clarity around shared care arrangements. A recent internal review found good compliance, with no patients identified as unmonitored. The remaining gap was the development of a comprehensive register shared with primary care. Most patients, including those under shared care, continued to receive monitoring through secondary care.

Dr Falk noted that the risk had been escalated through the Quality Committee due to limited progress, but further discussion had confirmed this reflected system complexity rather than a failure in monitoring. The risk on the register had remained escalated longer than necessary. Challenges were identified with primary care blood monitoring, where GPs retain responsibility for results, and clearer arrangements were considered to enable testing in primary care with results actioned by secondary care. Dr Heighton noted that patients on lithium should have appropriate records and many were included on the sever mental illness (SMI) register, and this would provide additional safeguards.

The issue was recognised as wider than lithium prescribing and relevant to broader system improvements in result sharing and clinical responsibility. Mr Lewis advised that related shared care discussions were ongoing and would inform this work. Dr Shah highlighted the need to consider the issue within South Yorkshire medicines optimisation forums to ensure system oversight, which Mr Lewis agreed would be picked up with Dr Crichton.

Safe staffing annual report and establishment review

The board had received the 2025 and 2026 safe staffing annual report and establishment review following detailed scrutiny by the committee that included the triangulation of workforce, quality, and safety data. This included acuity-based staffing information, roster and fill rate metrics, incident reporting, workforce indicators, and quality outcomes, as detailed in agenda pack B. Mr Forsyth advised the Quality Committee confirmed that there were no escalated concerns arising from the review, the trust had met National Quality Board (NQB) standards for safe staffing, and safe staffing governance arrangements were robust and effective, with appropriate oversight and mitigation of risks. The Quality Committee therefore recommended that the board note the strong position in relation to safer staffing across the trust, and approve the annual safe staffing declaration, based on the comprehensive data set presented. The board agreed the positive assurance provided by the Quality Committee.

Action

Toby Lewis

Mental Health Act Committee (MHAC)

Reference

Board public: 26/05/07.

Ms Holden provided an update on Mental Health Act and reducing restrictive interventions (RRI) training compliance, noting that 421 colleagues (across the trust and all competencies) had outstanding elements as at year end. Individuals had been written to with a deadline of 1 June to achieve compliance, with further follow-up planned where this had not been met. It was confirmed that sufficient training capacity was in place, with the main challenge being releasing colleagues and attendance.

It was acknowledged that further work was required to validate the accuracy of mandatory and statutory training requirements (MAST), particularly for reducing restrictive interventions training, to ensure they were proportionate and role appropriate. A review was underway, led through the Education and Learning governance structure, with a report to be presented to its next meeting. Ms Holden confirmed that progress was being made, with improvements already evident following recent validation work. The focus remained on core mandatory training, ensuring requirements were proportionate, relevant and aligned to roles.

Mr Sheppard added that this exercise had been undertaken with the estate team and had proved efficient, effective and valuable. Mr Lewis emphasised the importance of enabling colleagues to challenge training requirements where these seem inappropriate and of maintaining a proportionate and manageable programme. Dr Graham added that although training requirements continued to be reviewed against national guidance, mandatory and statutory training requirements needed to remain sensible and appropriate to role. Mrs Lavery advised this would also apply for non-executive director training requirements.

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

Public Health, Patient Involvement and Partnerships Committee (PHPIP)

Reference

Board public: 26/06/10.

Ms Blake reported that progress against inequalities related to promise 8, 9 and 10 remained slow and would be addressed through risk registers and delivery reviews. There was emphasis on the need for sustained focus, noting that gaps were not closing and required new approaches to access services, including stronger system working, community engagement and collaboration with the voluntary sector to improve access for underrepresented groups. Ms Blake understood this would be discussed further later in the agenda.

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

Trust People Council (TPC)

Reference

Board public: 26/07/10.

Mrs Lavery noted that the Trust People Council had identified a key risk in relation to organisational culture, which would be considered later on the agenda.

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

Mrs Lavery then invited board members to raise any questions on other issues within the reports. Dr Falk commended the revised process of reporting escalated matters from committees to the board, noting it worked well to have a question led format with executive responses. It was also recognised that this approach allowed for more detailed narrative within reports (more than one page), which was helpful and effective in sharing connection between committees.

People and Organisational Development Committee (PODC)

Reference

Board public: 26/08/10.

Ms Clark noted reference made of the impact to nationally determined Clinical Excellence Awards and potential reputational risk. Concern was raised that the term “trust control” could imply a lack of influence when the trust can influence this and support female colleagues to apply. Mrs Lavery declared her interest as Chair of the Advisory Committee on Clinical Impact Awards (ACCIA) Yorkshire and Humber Panel.

Ms Holden clarified the wording was not intended in that way, while recognising the concern as valid. The findings, including awards outcomes, would inform supportive employment actions, with further analysis by directorate planned to identify patterns, set targets, and drive improvement. Mrs Lavery added that national work in this area would also be shared as information arose.

Ms Clark raised concern about a spike in reported racial incidents in Rotherham, questioning whether this reflected increased racism or improved reporting and support. Mr Lewis advised the spike in data was largely attributed to two patients involved in multiple incidents. Mr Lewis drew attention to the antiracism work on Mulberry ward, with plans to extend this to Rotherham wards over the next four to five months. Whilst the data reflected specific cases, there was concern about possible underreporting in Rotherham, alongside a welcomed recognition that awareness and reporting may be improving.

Mr Lewis referred to the work to address gender pay gap, noting significant progress in reducing it to around 1%, while recognising it had not been fully closed and what the next steps would entail. Ms Fulton Tindall advised further analysis was planned before agreeing next steps, and Ms Holden explained this would include reviewing the impact of the real living wage and Agenda for Change pay awards, post change management workforce and remaining pay protection cases, noting for the first time analysis would be undertaken at directorate level to identify any hotspots and address the 1% gender pay gap. This would inform more targeted actions and future Board discussions. Dr Graham highlighted the importance of addressing occupational segregation, particularly increasing opportunities for women in underrepresented workforce areas through targeted recruitment and apprenticeships.

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

Audit Committee (AC)

Reference

Board public: 26/09/10.

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

Finance, Digital and Estates Committee (FDE)

Reference

Board public: 26/05/12.

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

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.

Operating performance, governance and risk management

Mrs Lavery advised the meeting moved to a section of the agenda that had traditionally been taken at the end, but was now brought forward in recognition of its importance as core board business.

Strategic delivery risks (SDRs)

Reference

Board public: 26/05/13.

Mr Gowland presented the paper.

Strategic delivery risks remained central to the Trust’s work of risk mitigation, noting the recent triannual meetings with executive leads and Mr Gowland outlined changes in lead responsibilities following the retirement of Mr Banks. Timescales for risk mitigation had been revised, recognising that while significant progress had been made, further work was still required and the end point had not yet been reached. Ongoing internal development work with leaders and colleagues was highlighted, alongside external dependencies, particularly with system partners and primary care colleagues, which were critical to progress, especially regarding seven day working. A comprehensive update on each risk was included in the paper.

Mr Gowland addressed whether additional strategic risks should be included, particularly finance, and advised against this given the trust’s going concern position and robust finance plans being in place, confirming that focus should remain on the existing five strategic delivery risks (SDRs). The board was asked to confirm that these five strategic delivery risks remained relevant for 2026 and 2027 unless material changes arose.

Mr Vallance queried whether the capability of the middle management group (known as the 555) represented a more significant organisational risk, given their role in leading teams and embedding change. It was suggested this could be greater in magnitude than existing risks and may warrant increased board focus. Mr Lewis responded that this should sit within strategic delivery risk 5 (leadership capability), with further strengthening of content rather than adding a new risk. It was agreed strategic delivery risk 5 may require refinement.

Mr Sheppard supported not adding a standalone finance strategic risk but questioned whether a top 10 risks tier was missing between strategic and operational levels, noting potential inconsistency in identifying risks to delivering the 2026 to 2027 financial plan. Mr Gowland did not support creating an additional tier, stating risks should already be clearly articulated within the existing register. He emphasised better presentation of risks within and outside tolerance, and that “top risks” should be reflected through existing operational risk reporting. Mr Lewis noted a potential behavioural gap in ownership of corporate risks, and on behalf of the executive group agreed to review the risk register to ensure it captured key risks and was easy to interpret.

Action

Philip Gowland.

Mrs McDonough supported retaining the five strategic delivery risks, noting concerns about progress against strategic delivery risk 1 and that the December 2026 target appeared ambitious and may require review. Mr Forsyth sought assurance that mitigations for strategic delivery risk 2 and 3 were progressing at pace and that plans were resilient to external factors.

Ms Fulton Tindall noted that, while not requiring a new strategic risk, leadership development alongside the change programme presented challenges around capacity, engagement, and consistency, and required continued board focus. Ms Gillatt highlighted that while some risks were progressing well, others were constrained by complexity and external factors. She encouraged a more focused approach, including decluttering, prioritisation, and root cause analysis. Ms Blake added that health inequalities should be more explicitly reflected within risk descriptions. Mr Chillery supported further focus on strategic delivery risk 5 and questioned whether identical scoring across all strategic delivery risks limited effective differentiation.

Mr Gowland thanked members and acknowledged the need to ensure all relevant elements were captured within strategic delivery risk 5, to involve a broader range of contributors, and to strengthen delivery plan resilience. He also noted the need to review risk scoring and refresh actions to support progress.

The board received and noted the strategic delivery risk report, and confirmed the strategic delivery risks were relevant for the remainder of the 2026 and 2027 year.

Operational risk report

Reference

Board public: 26/05/14.

Mrs Lavery invited questions for Mr Gowland.

Mr Lewis welcomed the report but raised two concerns firstly the specific estates issue of a door not closing correctly on Sandpiper Ward (RSK 547), and secondly the confusion regarding lack of a reliable method for monitoring disengagement (RSK 044), given the amount of work contributed to implement an existing policy and data driven reporting being built linked to disengagement.

Dr Falk noted the report was helpful but questioned whether the organisation was focusing on the most important risks. He suggested that once risks were identified as out of tolerance, the red or amber colour distinction may be unnecessary and potentially misleading, and proposed this be reviewed. Ms Gillatt encouraged that future reports more clearly draw out the key themes and “so what” implications, providing greater clarity on the impact of the work described.

Responding to Mr Lewis, Mr Forsyth advised that the estates risk regarding the door had not been clearly articulated until review at the Risk Management Group, after which it was promptly resolved within two weeks. Mr Forsyth clarified that the disengagement risk reflected previously unidentified gaps, including patients being discharged from crisis without being seen, and noted that while a policy had been approved, implementation remained variable and required further assurance. Mr Lewis stated, although the clarification was helpful he recommended that a position statement be brought to the next Board to clarify progress in the operationalisation of the policy and identifying where key risks sat.

Action

Dr Diarmid Sinclair

The board received and noted the Operational Risk Report.

Integrated quality performance report

Reference

Board public: 26/05/15.

Mr Chillery introduced the integrated quality performance report (IQPR) for May 2026 review (data as at 30 April 2026).

The integrated quality performance report would undergo change in light of national guidance and metrics still evolving. Mr Chillery provided context on the challenges of reducing length of stay, emphasising this was a complex issue without quick solutions. This was discussed by board members.

Progress was highlighted in significantly reducing the number of out of area placements, improving ward flow and partnership working, but acknowledged further work was required across the pathway, particularly at the point of admission and discharge. He noted that improvements in out of area placements may have increased the complexity of remaining patients, impacting on length of stay. Actions underway included reviews of patients with stays over 32 days, recognising the complexity of multi-agency discharge arrangements, and earlier engagement with housing and social care partners. Some progress was noted in embedding multidisciplinary teams and high-quality therapeutic care (HQTC) improvement work across wards, but still needed further embedding with imminent work in community services which may lead to support admission avoidance. Social housing remained a key constraint. Mr Chillery cautioned that improvements would take time and may have unintended impacts, and emphasised a balanced and realistic approach, while recognising the efforts of colleagues working in challenging environments.

Mr Lewis noted that the introduction of increased personal accountability for length of stay had strengthened oversight, led by responsible clinicians. However, this had generated discomfort among some clinical colleagues, who could feel scrutinised, despite the approach being implemented supportively and developmentally. The intention was to intervene earlier in admissions to prevent delays. It was recognised that length of stay reduction was critical to maintaining low out of area placements, though this required sustained effort and systemwide flow improvements. Variations across services were acknowledged, alongside the importance of analysing data more meaningfully, including use of data by diagnosis to better understand performance.

Dr Graham outlined key factors influencing length of stay, including strengthened clinical oversight through weekly executive review and escalation processes for complex cases. Analysing length of stay by diagnostic group provided more meaningful insights, despite added complexity from multiple diagnoses and local factors. She highlighted the impact of workforce and service factors, including seven day working and weekend delays, and emphasised the need for joint working between inpatient and community services. Dr Graham also noted wider system and cultural challenges, including shifting models of care, patient expectations, and potential workforce impacts, with increased accountability possibly leading to some staff turnover.

Dr Heighton emphasised the importance of the full patient pathway, noting that continuity between inpatient and community interventions could affect length of stay. He highlighted the impact of complex long stay patients on flow, staff wellbeing, and incident pressures, and impact on crisis team’s capacity to support admission avoidance and timely discharge. Mr Forsyth noted that length of stay was influenced by multiple factors, including clinical decisions such as one to one observations and section 17 leave outcomes, highlighted that legal frameworks under the Mental Health Act, including section 3 and other longer sections, could inherently extend length of stay.

Ms Blake highlighted the importance of social housing and its impact on mental health, and queried current work in this area. Mr Chillery advised that work was ongoing on a case by case basis with local partners, though strategic work remained limited due to housing challenges in the wider system. Mr Pandor highlighted the tension between reducing length of stay and ensuring safe community support, and queried variation between localities, including a three-week difference between Doncaster and Rotherham. Mr Lewis clarified that the focus was on reducing restrictive care rather than cost, with no change to the bed base. He noted that variation was a systemic issue and outlined plans for targeted improvement, acknowledging that meaningful change would take time.

The board received and noted the integrated quality performance report, the continued delivery of promise 14 in respect of planned care and further improvements in out of area placements. The Board recognised that without length of stay reductions, notably in Rotherham, we cannot meet our agreed aims for inpatient care quality improvement.

Promises and priorities scorecard

Reference

Board public: 26/05/16.

Mrs Lavery invited questions for Mr Lewis.

Dr Falk queried whether limited improvement in access to talking therapies for older adults, recorded as unknown, may be linked to GP awareness of available capacity. Mr Forsyth highlighted trade-offs between priorities and sought assurance that overall strategic objectives would still be achieved.

Mr Lewis responded that low referral rates, rather than capacity, were limiting access to talking therapies for older adults. He highlighted ongoing work to increase awareness, noting this reflected a wider national issue despite strong outcomes for those who access the service. In response to Mr Forsyth, it was acknowledged that assurance could not be fully given, noting the need to prioritise and accept trade-offs between delivery areas. Mr Lewis highlighted work to better distinguish between what was effective, ineffective, or uncertain, particularly in relation to health inequalities. It was recognised some areas, including promise 12, required further focus and resourcing, and that progress may be slower than expected. However, there remained ongoing work to map activity, improve visibility, and drive progress through focused oversight, with continued emphasis on board committee scrutiny and prioritisation.

The board received and noted the promises and priorities scorecard, and the work done to ensure rhythm and focus on the mid-table success measures. The board recognised it had time scheduled twice in 2026 to ensure collective effort on promise 26, and the need for board committees to focus on promises 16 (Quality Committee), 24 (Education and Learning Committee) and 28 (Public Health, Patient Involvement and Partnerships Committee (PHPIP)).

Organisational change quality and safety indicators

Reference

Board public: 26/05/17.

Mr Forsyth presented the paper and gave key highlights.

The report was the first presentation following the change management process, with further reporting expected in July including full quarter 1 (Q1) data. It was highlighted that some data gaps reflected a lack of historical baselines rather than absence of activity, and that indicators to date appeared stable with minimal variation. It was emphasised that early variation should prompt inquiry rather than concern. No patient harm had been identified at this stage, though some workforce challenges were noted within one scheme relating to unplanned nursing care.

Mr Forsyth invited any questions. Mrs Vickers queried whether unplanned nursing care, including weekend staffing gaps, represented an emerging risk requiring further monitoring. Ms Blake welcomed the early report, noted improving data maturity, and queried whether high did not attend (DNA) rates in North Lincolnshire talking therapies were typical or linked to recent changes.

Mr Forsyth reported that mitigations were in place to maintain safe staffing during unplanned absence, including flexible team responses and prioritisation of urgent patient needs such as pain relief and end of life care, which has resulted in some delays to planned care. No patient harm had been identified. Mr Chillery added that whilst risks were being managed, further time was required to embed the model, understand underlying causes, and gather staff feedback. Ms Holden advised early feedback indicated some staff concerns and a small number of short term absences, mainly among Band 5 colleagues. Proactive support and return to work processes were in place, with close monitoring to prevent escalation. A short term increase in absence was anticipated as the model embedded, with ongoing management oversight and engagement to address emerging issues.

Regarding did not attend rates in North Lincolnshire, Mr Forsyth advised that System Connect and patient led bookings had increased did not attend (DNA) rates, as patients may not be to able attend within four weeks, creating a misleading performance signal. Mr Chillery noted current patterns reflected system embedding, and Dr Graham confirmed digital access was supporting, not worsening, attendance, in line with national trends. A further update would be presented to the board in July. The board received and noted the organisational change key performance indicators report, and that no significant adverse trends had been observed in the initial two months of quality and safety impact assessment (QSIA) monitoring (April 2026 to May 2026), indicating no immediate intervention was required before the end of quarter 1.

The board recognised that robust monitoring mechanisms were in place, with clear governance and escalation processes, and that any future sustained adverse trend (signal) would trigger prompt action. Early data should be interpreted with caution, as several new indicators lack historical baselines and some fields are still undergoing validation.

Chief executive’s report

Reference

Board public: 26/05/18.

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

The establishment of the Community Leadership Executive (CoLE) was celebrated which brought together sixteen voluntary sector organisations to work alongside the trust’s management. Mr Lewis noted this was a significant development and acknowledged that realising its full potential would require a shift in approach, including sharing influence and embracing alternative perspectives. Overall, this was seen as a positive opportunity in the medium term.

Attention was drawn to recruitment and learning from the recent change management process indicated that devolved recruitment arrangements had created inconsistencies and inefficiencies. A move towards more centralised recruitment for certain roles would therefore continue, despite some managerial resistance, to improve equity and reduce vacancies. It was noted that achieving full establishment (that is, less than 100 vacancies) was unlikely before late November or early December.

The Akeso report referred to in his paper, focused on aligning partners such as the integrated care board and Doncaster and Bassetlaw Hospitals, providing a quantified assessment of opportunity and included consideration of different patient flows and experiences across the system. It was emphasised that the work of this third party would be important in informing the forthcoming estate full business case, with investment expected to focus on patient benefit.

An initial neurodiversity waiting time scorecard was presented within the annex. Whilst still work in progress, concerns were raised regarding the coherence of current management arrangements. As advised earlier, a more detailed discussion would take place at the next meeting in July. Some positive progress was noted, particularly increased uptake of digital offers among children waiting over two years, given our commitment to a child and young people maximum wait of 104 weeks by October 2026.

They’re remained ongoing uncertainty regarding national operating measure indicators, with data definition for the current year still outstanding. It was anticipated these would be published shortly, although quarter 1 performance may be reported before full clarity was available.

Mr Lewis also informed of delays in contract finalisation with the integrated care boards, despite repeated efforts. A further deadline had been set. Concerns were raised regarding proposals for providers to assume demand risk in certain areas, which would not be supported in relation to neurodiversity given legacy under-commissioning which the national prevalence study may contribute to tackling.

Finally, issues relating to Talking Therapies access data were discussed. Mr Lewis noted that the reported increase in waits may reflect either previous data inaccuracies or a loss of process control. Remedial actions would include restating the access policy and reinforcing disengagement processes to ensure waiting times were reported appropriately and capacity was managed effectively. Mr Chillery noted that, in relation to Talking Therapies, the figure of 200 was under review as it may not reflect accurate data. An update would be provided, with a fuller discussion to return to the board in July as previously outlined.

In response to Dr Falk’s query, Mr Lewis clarified that perceived resistance to Dialog plus reflected maintenance of existing care planning approaches rather than opposition to the new. Transitioning to a single, standardised model remained a practical challenge, particularly where patient contact was infrequent. He acknowledged that consistent care planning had not yet been fully embedded across the trust. Mr Vallance noted this reflected longstanding issues seen in areas such as risk assessment, transitions, and documentation. Mr Lewis advised that, while some progress had been made, consistency remained difficult to achieve. Always measures and increased oversight were identified as key improvement mechanisms, alongside a shift towards real time action to address noncompliance. It was emphasised that consistent care planning was a fundamental requirement requiring clear and sustained organisational focus across 2026.

Ms Clark raised concerns regarding recruitment panels and sickness. The reference to parental leave alongside sickness absence in particular noted the potential perception and impact on colleagues. Mr Lewis clarified that the intention was to reflect the overall strain on services from staff absence, where both factors pertained. In relation to mandatory ethnically diverse interview panels, it was noted that initial feedback had been more positive than anticipated, although some challenges were expected as implementation progressed. Mr Lewis acknowledged that perceptions of tokenism may arise, particularly among global majority colleagues, while some resistance was anticipated more broadly. The importance of maintaining focus on improving equity and progression at senior levels was emphasised.

Positive feedback was given on the Community Leadership Executive visual materials, and it was requested that progress against its ambitions be reported regularly (quarterly), supported by clear metrics.

The board received and noted the chief executive’s report and the forward actions it contained, and noted the uncertainty over our quarter 1 “segmentation” outcome with NHS NEY.

Energy feasibility study: route to full business case

Reference

Board public: 26/05/19.

Mrs McDonough presented the paper and reminded of the ambient loop presentation at a previous Board time out session.

The trust was committed to reducing its carbon footprint, with current emissions of approximately 2,500 tonnes, of which around 1,200 tonnes related to gas usage at the Tickhill Road site in Doncaster. A range of green energy options had been appraised, with no single solution being without drawbacks. Ground source heat pumps using an ambient loop had been identified as the preferred option, offering the greatest reduction in carbon emissions (removing gas related emissions at the site) alongside lower ongoing energy and maintenance costs, despite requiring significant upfront capital investment.

The approach would need to be considered alongside wider estate improvements, including upgrades to insulation and glazing, and the inclusion of solar energy where appropriate, to maximise energy efficiency. The proposal was noted to be interdependent with the wider estate enabling plan, particularly given the potential future control of energy source via energy centre on the Tickhill Road site. While installation would involve some disruption, it was considered the most effective option in balancing sustainability outcomes and deliverability. Mrs McDonough invited members of the Board to consider the proposal and raise any questions.

Members of the board expressed strong support for the proposed solution and the outcome of the options appraisal. Ms Gillatt queried the anticipated payback period, noting the importance of understanding the scale and timeframe of return on investment. Mr Pandor sought clarification on the relationship between the proposed works and the wider estate development, including whether implementation would be phased to minimise disruption. Mrs Vickers questioned the scheme’s interdependencies with the estate enabling plan, including the assumptions required to progress and the potential availability of national funding to support delivery.

Mrs McDonough advised that payback details were not yet available and would be confirmed in the full business case, including both financial and carbon benefits. However, she did note that there would not be a full financial pay-back, the pay-back for this will be measured in carbon emissions saved. She confirmed the programme could progress alongside the estate plan, subject to clarity on the retained estate, and noted the solution was scalable. Previous bids for national funding had been unsuccessful due to oversubscription but further opportunities and funding options, including external investment, would continue to be explored.

Mr Lewis raised a query regarding current energy expenditure and the anticipated revenue savings, alongside clarification of the cost differential between the preferred option and the air source heat pump alternative. Mr Sheppard advised that annual gas expenditure was approximately £700,000 and electricity approximately £1,300,000, with the proposed solution expected to significantly reduce this, alongside further savings from improved electricity efficiency. Mrs McDonough highlighted that, while the air source option (not preferred) presented a lower upfront cost, it would require more frequent replacement and maintenance, whereas the preferred ambient loop solution offered greater longevity and higher long term savings. It was noted detailed financial analysis, including payback and revenue comparisons, would be provided in the full business case.

Ms Holden queried the impact of installation disruption on patient flow and activity. Mrs McDonough advised that, while works would be significant, disruption would be minimised, with limited impact on ward occupancy. Some decanting may be required for window upgrades, and works would be delivered in phases to maintain service continuity.

Mr Forsyth noted that the full business case would set out return on investment assumptions, including energy price variability and capital costs. He highlighted additional benefits, including potential income from energy generation and increased land resale value. Mr Forsyth drew attention to risk 468, noting it currently reflected uncertainty regarding funding availability and access, and that this would need to be addressed.

Dr Heighton queried the patient safety implications, particularly in relation to water heating requirements. Mrs McDonough advised that additional heating via electrical heat pumps would be required to achieve necessary temperatures (for hot water and Legionella control), with systems operating per building. It was noted that the solution would also provide a cooling function, supporting colleagues and patient comfort during periods of high temperatures.

The board received and noted the energy feasibility study: route to full business case paper, and noted the option appraisal undertaken to identify a preferred approach to reducing carbon emission from gas.

The board had considered the options appraisal outcome alongside costs and benefits, recognised the focus on Tickhill Road site initially, and noted work commenced to attract external investment in the capital required.

The board decided that ambient loop was the preferred approach on Tickhill Road site.

Mr Gary Cox joined the meeting at 12:40pm.

Sickness absence

Reference

Board public: 26/05/20.

Ms Holden presented the paper and highlighted some key ideas.

Sickness absence remained higher than comparator organisations, despite similar levels of deprivation, indicating further improvement was required. Sickness absence clinics had been reintroduced and would continue, with a focus on reducing long term absence, which had increased. Data showed a significant proportion of the workforce had little or no absence, with around a quarter of employees accounting for higher levels.

The importance of manager capability, timely interventions, and effective return to work discussions was emphasised. Additional support measures, including improved engagement with colleagues during absence and partnership working with external organisations, were outlined to support earlier returns. Ms Holden advised reducing sickness absence would require sustained focus and would support improvements in patient care, workforce stability, and reduced reliance on bank staffing.

Mr Lewis welcomed the paper, highlighting key improvement measures including sickness absence clinics, internal redeployment to enable faster return, and occupational health pathways. He emphasised a more proactive approach to managing cases unlikely to resolve and the need for timely human resources processes where these overlapped with long term absence. Mr Sheppard noted the scale of absence, equating to over 200 colleagues off daily, and highlighted that reducing long term absence would return significant capacity, with benefits comparable to a 1% capital investment plan (CIP) and improvements to patient care and team resilience.

Ms Clark queried differentiation between work and non work related causes of anxiety, stress and depression, and the impact of external waiting times, particularly for musculoskeletal (MSK) services. She also raised concerns around presenteeism, including infection control risks and alignment with flexible working. Dr Falk emphasised preventative action and engagement with GPs on fit notes, noting forthcoming national changes and capacity concerns. Mr Forsyth queried links between long term sickness and increased turnover, and whether further action was required. Ms Fulton Tindall highlighted the importance of wellbeing and personal responsibility, querying whether expectations on sickness and attendance could be strengthened through recruitment and organisational culture. Mr Chillery queried whether stress levels reflected contextual factors specific to mental health and community services, given that peer trusts were typically higher than acute sites, and whether additional targeted support was required.

Ms Holden responded and acknowledged inconsistent practice remained in managing long term sickness, with some managers delaying action despite clear occupational health advice. Work was underway to address this and promote more timely, appropriate decision-making. Links between long term sickness and human resource processes were recognised, with actions in place to improve the timeliness of investigations, including exploring centralised and outsourced approaches. Data on sickness absence causes was available but limited by inconsistent coding of secondary reasons which makes it difficult to separate stress, anxiety and depression into work, personal related. Or both. Support for musculoskeletal conditions was available via occupational health, although access to surgical interventions remained dependent on external and acute services. Presenteeism was acknowledged as a concern, with measures in place to support flexible working and protect vulnerable colleagues and patients. Greater use of occupational health advice and engagement with GPs was identified as an area for improvement. A small link between long term sickness and turnover was noted. The importance of staff wellbeing, personal responsibility, and strengthening organisational expectations was emphasised, alongside addressing cultural factors within mental health services.

Mr Lewis summarised that the paper constituted the board’s agreed sickness absence plan and formed the trust’s response to the relevant regional compliance requirement.

The board received and noted the sickness absence paper, and noted the focus on long term sickness for the first twelve months and the suggested 1.5% reduction. The board had considered whether any wider support could be offered, and recognised the focussed work in this area and the wider workstreams which were being considered and implemented.

The board delegated the review and scrutiny of the approach and delivery to the People and Organisational Development Committee.

2025 to 2026 serious patient safety incidents: learning update

Reference

Board public: 26/05/21.

Mr Forsyth presented the paper and gave key highlights.

The patient safety incident learning update was part of an ongoing series rather than a one off review, supporting sustained focus on learning and improvement. It was reported that progress had been made in areas including referral and access, with no further incidents relating to missed referrals, and improvements in risk assessment practices, with no new incidents citing risk failures. Early improvements were noted in physical health management, prescribing practices, and crisis response, although these were not yet consistently embedded. Further improvement was required in documentation, particularly timely and contemporaneous record keeping, as well as family involvement in care planning and transitions and discharge processes. It was noted that the implementation of always measures would support sustained improvement.

Mr Lewis welcomed the report but noted limited assurance on transitions of care and discharge planning safeguards and documentation, and sought clarity on safer staffing huddle decision-making and when robust data would be available. It was advised that further work was required to define and measure transition safeguards. Documentation monitoring would begin in quarter 1, while assurance on medical documentation remained limited. Implementation of ambient voice technology was expected to improve timeliness and data availability. Ms Blake acknowledged the importance of staff engagement with carers and families, noting that while improvements had been made, consistency remained an issue and further work was required in line with promise 2 and always measures.

Ms Holden queried the status of action plan 884 (male with serious fracture) and the challenges in finalising it. The summary of key learnings highlighted the reliance on training, emphasising that training alone would not deliver sustained improvement. Ms Holden asked what additional measures were in place alongside training. Mr Vallance questioned whether sufficient time and resources were in place for frontline teams to deliver the required improvements, highlighting the risk of continued underperformance if underlying conditions were not addressed.

Regarding the challenges in finalising the action plan 884, Mr Forsyth explained that while the investigation had concluded, finalisation of the action plan had been delayed due to an ongoing police investigation and the need to confirm whether the injury was directly related to the incident. In relation to training, it was acknowledged that improvement required a broader approach, including system and information technology (IT) developments, improved access to equipment, and protected learning time. These measures aimed to support consistent practice and embed learning alongside training, including learning half days, with a continued focus on key themes to strengthen organisational consistency.

Mr Lewis drew the chair’s attention to the report recommendations. The board accepted the second recommendation but considered the first overly reassuring. It was agreed to amend the recommendation to reflect clearer timelines and measurable progress, particularly for documentation and transition safeguards, and the recommendations were approved as amended.

The board received and noted the 2025 and 2026 serious patient safety incidents learning update report, the progress outlined and the areas of ongoing risk or challenge where work remained outstanding which, when complete, would provide stronger evidence that the identified safety actions from 2024 and 2025 and the 2025 and 2026 patient safety incident investigations (PSIIs) had been delivered or were on track, and that the trust patient safety learning approach was aligned with national expectations.

The board recognised the ongoing areas of risk highlighted, notably the need for further improvement in clinical documentation standards and consistent family and carer involvement, and the importance of sustained focus to ensure these improvements are fully embedded, and residual safety risks are mitigated.

Story to board

Patient story

Reference

Board public: 26/05/22.

Mrs Lavery welcomed Mr Gary Cox, a veteran, who was in attendance to share his experiences of accessing services.

Mr Cox shared his lived experience of accessing services following a significant post traumatic stress disorder (PTSD) episode triggered by traumatic events in his community. He described initial difficulties accessing support, particularly with remote and telephone based services, and highlighted gaps in provision for complex veteran needs. Mr Cox spoke positively about the response from the Crisis team and Tickhill Road Hospital, emphasising the timely, compassionate and family‑centred approach, which he described as lifesaving. He highlighted the importance of face to face support and coordinated care, including the effective transition to OP Courage, where ongoing treatment had supported his recovery.

Members of the board reflected on Mr Cox’s experiences and noted both the areas for improvement, particularly awareness of services and accessibility, and examples of excellent practice, including partnership working and continuity of care, and thanked Mr Cox for sharing his experience. Mrs Lavery noted the intended reflection time later on the agenda in the private board.

Mr Gary Cox left the meeting at 1:20pm.

Well led: externally commissioned developmental review

Reference

Board public: 26/05/23.

Mrs Lavery invited feedback and questions for Mr Gowland, noting this built on reports previously presented to the board, and a further discussion would take place in the private session.

Mr Lewis, Mrs Vickers and Mr Pandor reflected that overall the review felt balanced, appropriately highlighting both strengths and areas for improvement, although some recommendations were considered low level. It was noted that similar challenges were evident across the wider public sector, reflecting broader system complexity. Mr Forsyth referred to the importance of ensuring recommendations were followed through effectively, with clear arrangements to demonstrate impact and learning over time. Mr Lewis noted that, ahead of the next report, clarity would be required on which actions would be progressed and which would not. It was further suggested that consideration be given to how decisions not to proceed would be reviewed over time to ensure continued assurance and learning.

Mr Gowland agreed this should be treated as a continuous improvement process and Mrs Lavery acknowledged the significant contribution of colleagues in delivering the report. Mr Sheppard noted the report provided some strong assurance ahead of Care Quality Commission (CQC) inspection and should be used as a tool to support ongoing improvement. Mr Chillery cautioned against any perceived complacency, emphasising the need to remain alert to further improvement opportunities. Mr Gowland highlighted the importance of ongoing cultural development and stressed that implementation of recommendations should be seen as part of continuous improvement rather than a definitive end point.

The board received and noted the Well led externally commissioned developmental review report from The Value Circle (TVC) acknowledging the conclusions and recommendations it contains. The board had considered any informal feedback on our preparedness and readiness for a well led assessment from The Value Circle in the private session of the board.

The board noted the intention for a management response report to be presented to the board of directors in July 2026, that will respond to the The Value Circle report recommendations and that will describe the actions to be taken in respect of the related provider capability assessment framework.

Culture work

Reference

Board public: 26/05/24.

Mr Lewis introduced the report, noting that it linked to previous agenda items discussed earlier in the meeting.

While progress had been made, the trust had not yet achieved anyone’s desired culture, with differing views across the organisation on whether we needed to go forward, or indeed back to the future. Mr Lewis emphasised the importance of recognising both achievements and areas for development, and outlined initial proposals for a wider cultural development or reset programme to commence in early autumn. This would focus on strengthening both accountability and care across the organisation.

Particular focus was given to the concepts of high support and high challenge, noting that while expectations around accountability were clearer, further work was required to define and embed high care in practice. Engagement with staff and leaders would be critical in shaping this work. It was noted that the pace of development would be deliberate to ensure meaningful and sustainable change, with leadership capability and capacity identified as key enablers of cultural improvement.

Dr Graham welcomed the paper, emphasising the need to maintain context by balancing incident learning with recognition of positive patient experience and organisational strengths. She noted the importance of avoiding overly negative narratives, acknowledged the value of past achievements, and highlighted the need for this work to be clearly distinct from previous cultural initiatives before the lifetime of this board team. Mr Vallance highlighted the need to balance high support and high challenge, emphasising that sustainable improvement requires setting clear expectations alongside ensuring the right conditions and support are in place for staff to deliver. Mrs McDonough noted real comparative strengths in the current culture but recognised concerns that staff perceived reduced compassion. She also emphasised the need to balance high support and high challenge, addressing reluctance to challenge and ensuring staff felt valued through consistent people management practices with effective professional develop reviews (PDRs) and clear objectives.

Ms Fulton Tindall reflected on the need to clearly define and embed the language of high support and high challenge. Mr Chillery noted a perceived shift away from a staff centric culture and highlighted a potential disconnect between strategic intent and staff experience, with a risk that delivery could be seen as metric driven. The importance of continued listening to address this gap was emphasised.

Mr Forsyth recognised the cultural development work as a continuous journey rather than a time limited initiative, with consideration given to how progress would be sustained alongside ongoing operational and financial pressures. Mrs Lavery acknowledged the wider national NHS context, with the need for the organisation to adapt its culture to current system demands, while recognising that this may not always be visible or understood by staff.

Mr Lewis highlighted the importance of strengthening basic employment conditions, demonstrating consistent listening behaviours, and identifying internal advocates to support change was highlighted. Mrs Lavery recognised this as a key priority area for the board and agreed that further detailed work, including clarity on risks, mitigations, and measures of success, would be brought back over the summer.

The board received and noted the culture work report, the planned actions and the associated timescales which provide co-production opportunities across the organisation. The board had opportunity to comment on the planned actions and refine the planned work or terms of reference prior to the co-production.

The board agreed a further paper would be presented in July 2026 to enhance the proposals, leading then to a delivery plan before September launch.

Action

Toby Lewis.

Staff survey

Reference

Board public: 26/05/25.

Mrs Lavery invited feedback and questions for Ms Holden.

Mr Lewis sought clarification on the potential scope of collaboration with Navigo, noting its relevance to forthcoming discussions with NEY and requesting an overview of the intended direction.

Dr Graham reflected that this represented only one aspect of how the organisation listens to staff, noting the importance of recognising that different channels, including anonymous feedback, encourage different types of engagement and insight. Mrs Vickers queried whether any key themes or unexpected findings had emerged from the staff survey results.

Ms Holden advised, in response to Mr Lewis, that initial engagement with Navigo would focus on understanding their approach and learning from their experience, rather than adopting a predetermined model. Regarding Dr Graham’s comment, Ms Holden acknowledged that staff survey feedback represented only one element of listening but remained important as it covers all colleagues and due to benchmarking, noting low response rates in other engagement routes. It was emphasised that, despite this, feedback highlighted perceptions that patient care was not always seen as the top priority, which required further exploration. In response to Mrs Vickers question, Ms Holden noted some unexpected findings, including more positive feedback from corporate services than anticipated and continued positive responses regarding flexible working, despite variation across service areas and in particular inpatient areas.

Mr Vallance emphasised that the identified priorities required visible leadership, with the board and executive modelling expected behaviours. Ms Holden confirmed this would be reflected across related work, highlighting the need to strengthen feedback loops and ensure staff concerns were addressed. Mr Lewis confirmed that a separate staff survey action plan would not be developed, with findings instead informing a broader cultural development programme focused on underlying issues.

Ms Blake queried whether engagement reached all colleagues and highlighted a disconnect between organisational messaging, staff experience, and patient feedback. Ms Holden acknowledged that staff survey engagement did not yet reach all colleagues as demonstrated via our response rate.

Mr Lewis noted the number of recommendations and sought clarity on decision-making. It was agreed that the People and Organisation Development Committee would have a role in monitoring progress, but it was emphasised that overall accountability should remain with the board and that the wording of the recommendation should be adjusted accordingly.

The board received and noted the staff survey results and the suggested areas of focus.

The board had considered the nine staff survey areas and whether we should focus our attention on other areas to those suggested, the two-year suggested improvement journey and the two areas of focus for this year.

The board recognised the work and commitment required to facilitate the suggested improvements.

The board confirmed its overall accountability for responding to the outcomes of the staff survey, but delegated the subsequent monitoring of the work to the People and Organisational Development Committee and Trust People Council.

In addition, the board of directors delegated to the People and Organisational Development Committee the review and submission of the workforce race equality standard (WRES) and workforce disability equality standard (WDES) data.

Freedom To Speak Up bi-annual update

Reference

Board public: 26/05/26.

Mrs Lavery invited questions for Mr Hatfield and Mr Forsyth.

Mr Lewis asked what further actions could be taken to improve staff confidence in Freedom to Speak Up arrangements and encourage greater willingness to raise concerns. Ms Blake reinforced this, querying how feedback loops could be strengthened to ensure staff felt concerns were taken seriously and acted upon.

Ms Holden queried what could be learned from comparator organisations and how best practice could inform improvement. Dr Graham asked whether reduced confidence reflected a shift in how staff were raising concerns and how different feedback channels could be better understood and aligned.

Mr Lewis also queried how data could be further disaggregated, including to provide insight into neurodiverse staff. Mr Pandor asked how outcomes of concerns were communicated back to individuals and how assurance could be provided that feedback was meaningfully closed.

In response, Mr Hatfield advised that further work was required to understand areas of low reporting and confidence, with targeted engagement planned, including use of Freedom to Speak Up champions. It was noted that feedback mechanisms were in place, with around 82% of respondents indicating they would raise concerns again, although this did not capture all staff. The importance of strengthening visibility of outcomes and closing the feedback loop was emphasised.

Mr Forsyth acknowledged that triangulation with wider workforce and patient data would be strengthened, and further work would be undertaken to improve understanding of specific groups, including neurodiverse staff.

Action

Steve Forsyth.

The board received and noted the Freedom To Speak Up bi-annual update, including the content of this report as a confidence on the trust’s Freedom to Speak Up arrangements and oversight, including the trends, themes and comparisons presented.

The board considered the key findings and data, notably the trends in concerns raised and the benchmarking against peers, and discussed any implications for sustaining and strengthening the trust’s speak up culture. The board recognised the key findings and data, notably the trends in concerns raised and the benchmarking against peers, and discussed any implications for sustaining and strengthening the trust’s speak-up culture.

The board agreed to continue supporting and championing the Freedom to Speak Up forward plan and associated improvement actions (as outlined in the paper’s appendices), including visible leadership support for Freedom to Speak Up, reinforcing that no detriment would be tolerated for speaking up, and promoting the new initiatives to further embed a safe, responsive speak-up culture.

Older adults indicators

Reference

Board public: 26/05/27.

Dr Heighton, on behalf of Dr Sinclair, presented the report.

An update on the review of the move to a mixed older adults ward model in Rotherham reported that no evidence had been identified to suggest the change had resulted in patient harm. Whilst some incidents had been examined, including those relating to physical health deterioration and other concerns, these had not been attributed to the model itself. Instead, issues were noted regarding medical input and ward support, potentially linked to broader service factors rather than the ward configuration. Further analysis, including comparative outcomes for patients with dementia and non-organic conditions, would be brought back to the board in July.

Action

Dr Dairmid Sinclair.

Dr Falk welcomed the report, noting it provided assurance that no patient harm had been identified. A query was raised regarding the use of the term “good enough care” in the introduction, which was acknowledged as historic wording and potentially misleading. Ms Blake suggested that future reports could include more qualitative feedback from staff to complement patient and carer information. Clarification was sought on follow-up actions relating to specific incidents, with Mr Lewis responding that findings from the independent review would inform appropriate action.

Dr Graham welcomed the report, noting it was based on patient experience and supported a consistent, inclusive care model. She highlighted the challenges in distinguishing between organic and functional conditions and noted that staff perspectives may have evolved following implementation. Dr Heighton noted increasing dual training across specialties and highlighted improvements in staff training, including enhanced immediate life support (ILS) training and planned bite sized physical health sessions for resident doctors from August.

Mr Forsyth highlighted challenges in benchmarking older adult wards, stressing the need for better comparators and further learning. Concerns were raised about attributing serious incidents to physical health decline within an isolated model, given wider system factors and prevalence across services. Staffing and medical cover were seen as more likely contributors than ward design. Mr Lewis noted the report provided assurance on the current model, with no evidence for change, and emphasised that any further idea of relocation would need overwhelmingly strong evidence which he felt was not currently present: as such the proposed third recommendation in the paper was not supported by the board.

The board received and noted the older adults indicators report, and noted the data around the performance of our inpatient and community teams.

The board agreed the mixed model of functional and organic older adult wards was safe to be retained, and asked for a further paper on dementia to be considered over the summer.

Board and committee work plans

Reference

Board public: 26/05/28.

Mr Gowland presented the paper.

The proposed work plan for the board and its committees for 2026–2027 was presented for approval. It set out focused, prioritised agendas aligned to committee terms of reference, reflecting key components within the terms of reference. The approach strengthened tracking of rescheduled and delegated actions, improved clarity on forward agendas, and maintained a clear focus on partnerships and delivery oversight. Work plans were intended to demonstrate tangible progress rather than fragmented activity, providing transparency on priorities and timelines while retaining flexibility for emerging issues.

In response to Mr Vallance’s observation, Mr Lewis and Mr Gowland would review the work plans to ensure they fully reflected the intended scope of committees and in particular the delivery of the relevant plans. Any further commentary from Mr Vallance would be welcomed after the meeting.

Action

Philip Gowland.

Mr Vallance noted that broader strategic themes, particularly prevention between hospital and community, and digital transformation, were not clearly reflected in the work plans and suggested these be considered at board level, potentially through an autumn development session.

Mr Chillery queried why promise 22 was referenced within the quality committee work plan. It was explained other promises sat outside committee work plans and reported to the board, with promise 22 specifically highlighted as it was not sufficiently covered within the quality and safety plan and it required a clear forum for discussion.

The board received, noted and approved the work schedules for the board of directors and committees for the remainder of the financial year.

Fit and proper person test

Reference

Board public: 26/05/29.

Mrs Lavery presented the paper as read and 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 concluding statement from the chair that, following the receipt and review of self attestation statements and where applicable, the checks undertaken during recent appointments, she has deemed all members of the board to meet the requirements of the fit and proper person test.

Supporting papers (previously presented at committee)

Establishment review paper for safer staffing and annual declaration report and mortality report (January and February 2026)

Reference

Board public: 26/05/30.

Mrs Lavery informed the board of the mortality report and the establishment review paper for safer staffing and annual declaration 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 establishment review paper for safer staffing and annual declaration report for information.

Closing items

Any other urgent business

Reference

Board public: 26/05/31.

There was no further business raised.

Any risks that the board wishes the Risk Management Group to consider

Reference

Board public: 26/05/32.

In relation to the staff survey results, Mr Lewis advised that a review would be undertaken to identify any emerging risks that were not currently captured on the risk register, and to ensure these were considered by the Risk Management Group as appropriate.

Action

Steve Forsyth

Public questions

Reference

Board public: 26/05/33.

There were no public questions.

Closing statement

Reference

Board public: 26/05/34.

The Chair resolved

“That because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, the public and press would be excluded from the remainder of the meeting, which would conclude in private.”

Next meeting at 9:30am, Thursday 30 July 2026, Barton upon Humber

Page last reviewed: August 05, 2026
Next review due: August 05, 2027

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