Contents
- Introduction
- Staff story
- Standing items
- Board assurance committees
- Key matters for decision or assurance
- Routine reports
- Supporting papers (previously presented at committees)
Minutes of the board of directors meeting on Thursday 28 November 2024, 10am at:
The Centre
Brinsworth Lane
Brinsworth
Rotherham
S60 5BU
Present
- Kathryn Lavery, Chair
- Richard Chillery, Chief Operating Officer.
- Dr Richard Falk, Non-Executive Director
- Sarah Fulton-Tindall, Non-Executive Director.
- Steve Forsyth, Chief Nurse.
- Kathryn Gillatt, Non-Executive Director
- Carlene Holden, Director of People and Organisational Development.
- Dawn Leese, Non-Executive Director.
- Toby Lewis, Chief Executive.
- Izaaz Mohammed, Director of Finance and Estates.
- Dr Diarmid Sinclair, Interim Medical Director.
- Dave Vallence, Non-Executive Director.
- Pauline Vickers (virtually attended), 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.
- Jyoti Mehan, NeXT Director.
- Jo McDonough, Director of Strategic Development.
- Laura Brookshaw, 360 Assurance.
- Jo Cox (virtually attended), Lead Governor.
- Sarah Dean, Corporate Assurance Officer (minutes).
- Ann Llewellyn (virtually attended), Governor
- Ian Spowart (virtually attended), Governor.
- Nick Skinner, Staff Story
- Dr Stephen Kellett, Staff Story
- 4 members of the public
Introduction
Welcome and apologies
Reference
Mrs Lavery welcomed all attendees to the meeting. Apologies for absence were noted from Non-Executive Directors Rachael Blake and Dr Janusz Jankowski.
Mrs Lavery gave thanks to Mrs Leese for her work and contributions as non-executive director for the past eight years, as well as senior independent director (SID) and Chair of Quality Committee (QC), noting this was her final board of directors meeting. Mr Vallance will succeed Dawn as SID, and Dr Falk as Chair of QC.
Quoracy
Reference
Mrs Lavery declared the meeting was quorate.
Declarations of interest
Reference
Mrs Lavery presented the declarations of interest report which outlined the changes to the register since the last meeting. These related to Mrs Vickers’ new interest, Director of Marsh and Vickers Coaching Limited, and Mr Gowland, whose wife was employed within the trust as primary care strategic lead.
A new declaration of interest was noted for Mr Forsyth regarding his Fellowship of the Queens Nursing Institute (QNI).
The board received and noted the changes to the declarations of interest report.
Staff story
Reducing Restrictive Interventions (RRI) project
Reference
Mrs Lavery welcomed Nick and Stephen to the meeting who were invited to share the outcomes of a controlled RRI pilot project undertaken in the Rotherham adult mental health care group to improve patient safety through organisational culture on the psychiatric intensive care unit (Kingfisher).
Nick had worked within the organisation for a number of years and spoke about his first experiences of restraint on the wards, which he felt were chaotic and unorganised with the patient left feeling frightened and frustrated with no subsequent support. Nick was now the trust’s RRI training lead and highlighted the opportunity he had to work directly with the Kingfisher ward as part of the RRI pilot project to assess how the training was reflected and implemented on the wards. Nick witnessed a culture that needed to change from restraint being the first option. Nick spent time with a member of staff on the ward as an RRI advocate, to bridge the gap between training and reality, and to effectively implement the training as part of day-to-day practice. This was successful in terms of openness and transparency, improvements were made in terms of incident reporting with a positive change in culture on the ward.
Stephen worked on Kingfisher as a consultant psychologist and in the Grounded Research team, he spoke about the use of restraint being difficult for patients and staff and the importance of ensuring there was a culture where restraint was an occasional necessity. In terms of evidencing change, there were 2 stages to the pilot project, the first being to understand what predicts restraint using a regression analysis, the analysis highlighted staff variables which led to the culture change project and the RRI advocate role to support and coach staff before, during and post restraint. This work was supported by a reflective practice group which was facilitated on the ward on a weekly basis.
The controlled pilot project commenced in September 2021 and the data was reviewed for 19 months pre-intervention and 19 months post intervention against a control ward to assess the impact of the project. A comparison exercise was then undertaken with another control ward pre-intervention which highlighted the positive impact of the RRI Advocate, the use of full restraint had reduced by 50%, seclusion was being used less frequently, and a reduction in the use of rapid tranquillisation.
Stephen noted that the evidence would be published nationally, including within the British Medical Journal and with other trusts to share evidence and learning around the use of the RRI advocate role to ensure safe practice and a change in culture to reduce the use of restraint.
Mr Lewis referred to the upcoming funding decision on this work, he was interested in Stephen and Nick’s reflection in terms of deployment and rolling out the project trustwide, he suggested a separate discussion to think through the critical success factors to move this forward. Stephen supported each ward having an RRI advocate that could ensure safe practice, associated learning and to support a culture change.
Mr Forsyth referred to the regression model which was utilised in his previous trust and the collaborative approach to RRI in a psychiatric intensive care unit (PICU). The data was reviewed in hours using a traffic light system which was reduced and sustained to zero. Mr Lewis clarified that there would be a further discussion at the clinical leadership executive (CLE) in February 2025.
Dr Graham suggested reviewing the number of people with attachment issues to assess whether it prolonged the issue.
Mrs Lavery and the board thanked Nick and Stephen for taking the time to speak about the RRI project and experiences and noted the intended reflection time later on the agenda.
Stephen and Nick left the meeting at 10:25am.
Standing items
Minutes of the previous board of directors meeting held on 26 September 2024
Reference
The board approved the minutes of the meeting held on 26 September 2024 as an accurate record, subject to a minor wording amendment requested by Ms Fulton Tindall under 24/09/19 (Biannual report of the board’s security champion)
Matters arising and follow-up action log
Reference
There were no matters arising from the minutes.
The board received the action log and noted the progress updates. All actions noted as “propose to close” were agreed.
Board assurance committee report to the board of directors
Report from the Quality Committee (QC)
Reference
Dr Falk presented the paper and noted the conversation in the Committee regarding Rotherham Care Group and the patient safety report. Mr Chillery referred to the care group’s delivery review that took place this week when never events and safe staffing levels were rated as good for Rotherham. He noted that the delivery reviews provided an opportunity for additional check and challenge. Mr Lewis clarified that there was no intention to intervene with the care group in the next 10 weeks, the Voice Scorecard as taken to Trust People Council (TPC) would provide some softer intelligence in terms of feedback. Work was ongoing to develop a management escalation process with agreed parameters for intervention, by January 2025.
Dr Falk highlighted the discussion held in regard to agency staffing and the importance of not becoming complacent, the plan was to liaise with services with previous high agency use to gain their perspective and track any unintended consequences.
The board received and noted the report from the Quality Committee.
Action
Report from the Audit Committee
Reference
Ms Gillatt presented the paper and referred to the key points of discussion, all of which were demonstrating good progress. She noted the response to the external audit recommendations and the low-level areas that the trust was proposing not to progress with.
The Risk Management Framework report was positively received and demonstrated the robust management and oversight of risk.
A progress update was received in respect of research governance and a similar piece on education governance would follow at the next meeting.
The board received and noted the report from the Audit Committee.
Report from the Mental Health Act (MHA) Committee
Reference
Ms Fulton Tindall presented the paper, highlighting that the committee was pleased to note the successful trust associate managers (TAM) recruitment process.
There were 277 detentions within the trust during quarter 2 and challenges remained in respect of documentation compliance, consent to treatment on admission and section 132 rights. The committee noted that the trust had acted unlawfully within some of these compliance areas.
Ms Fulton Tindall highlighted the positive impact of the new weekly urgent metrics review which contributed to improvements seen in consent to treatment and section 132 rights.
The board received and noted the report from the Mental Health Act Committee.
Report from the People and Organisational Development (POD) Committee
Reference
Mr Vallance on behalf of Ms Blake presented the paper and referred to the key areas.
The committee supported the acceptable behaviour policy.
In regard to the workforce disability equality standard (WDES), Mr Vallance recognised the similar pattern of deterioration to the WRES data in terms of bullying, harassment and abuse by managers and colleagues. This was taken to the Trust People Council for further discussion and work continues to develop a robust action plan.
Freedom to speak up (FTSU), the committee noted the issue around detriment and the standard operating procedure (SOP) that was being developed to address this. James Hatfield (FTSU Guardian) would be providing a FTSU presentation to the new governors to enhance their understanding.
Mr Lewis noted the intent to progress with FTSU SOP and have it in place by the end of December 2024 with a robust process to manage this going forward.
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
Mr Vallance presented the paper, highlighting the open and transparent presentation from Mrs McDonough regarding the concerns on meeting the delivery measures for promise 8. Further data and understanding of commitment was required to mobilise the organisation for the RDaSH 5.
An update on school readiness (promise 17) was received which proposed what the trust would do differently and posed questions around capability and next steps in terms of innovation.
Mr Lewis clarified that the board would consider the 8 supporting plans at January’s meeting, noting research and innovation maybe delayed, but that it would be further consideration of this during quarter 4.
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
Mrs Vickers presented the paper highlighting the key risk around the financial deficit position, linked to the potential shortfall in the funding of the pay award. She referred to the board’s agreement in September (at M7) to submit an updated forecast to NHS England if the shortfall in allocations materialised. Mr Mohammed noted that discussions, including Mr Lewis and ICB partners remained ongoing.
Fire safety compliance remained a key area of focus and was currently partially compliant. The committee requested a further update at the next meeting around the fire safety door inspection programme of work.
The committee approved the conclusion of the procurement arrangements for the electronic patient record (TPP). Mr Banks confirmed the procurement documentation exchange was almost complete.
Mr Lewis requested for the underlying financial position to be presented at future meetings to enable the board to focus on this. Mr Mohammed confirmed that this would be reflected within future reports.
The board received and noted the report from the Finance, Digital and Estates Committee.
Action
Report from the Trust People Council (TPC), including Terms of Reference
Reference
On behalf of Mrs Vickers, Ms Fulton-Tindall presented the paper highlighting the work to rebase trustwide vacancy factors as part of 2024 to 2025 planning was complete. Monthly monitoring continued to ensure a consistent approach was taken across all areas.
The NHSE investigation and intervention report found the trust had strong controls with respect to agency spend. The trust was working across South Yorkshire providers to share best practice and review rostering controls.
Mr Lewis clarified that the delivery of the cost improvement programmes (CIPs) was on track. Mr Mohammed noted he was confident schemes had now been identified to deliver the Savings Plan in full.
The board received and noted the report from the Finance, Digital and Estates Committee. Mr Vallance presented the report which included Trust People Council Terms of Reference for the board’s approval.
In response to Dr Falk’s query regarding the quorum, Mr Lewis agreed to amend the wording to ensure it was clear that board members must not form the majority of the quorum.
The group received the initial voice scorecard which sought to bring together key people data, such as vacancies, with feedback data drawn from FTSU, incidents, and staff survey. Further refinements were planned to the scorecard and this would be utilised in future committee and board meetings.
Mrs Leese expressed her support for the voice scorecard which provided an ability to see the associated staff and patient data. Mr Lewis noted that time was spent at the last delivery reviews to review the first phase results of Care Opinion, this would be a focus at the board timeout in February 2025. There was a particular focus on ensuring the data was being utilised at all levels of the organisation, initial feedback from teams was so far optimistic and positive with specific recognition to Stuart Green (Patient Experience and Involvement Lead) for driving this work forward.
Mr Chillery expressed the importance of recognising where data is missing and ensuring everybody’s voices were equally heard.
The board received and noted the report from the Trust People Council.
The board approved the terms of reference for the Trust People Council.
Action
Chief Executive’s report
Reference
Mr Lewis drew attention to the key items within his report.
The report detailed the current vacancies, Mr Lewis was enthused that approximately 90 new members of staff had joined the organisation over the last 2 rounds of induction.
Positive progress was being made in regard to flu vaccinations and the goal to reach 3000 vaccinations. The trust was in a high position nationally and had exceeded last year’s numbers.
Mr Lewis attended the last Quality Committee to provide an update on regulation 28 reports issued to the trust. He reminded colleagues of the report issued to NHS England in relation to the Medical Emergencies in Eating Disorders (MEED) guidance, a paper would be presented from the South Yorkshire Mental Health, Learning Disability and Autism (MHLDA) Provider Collaborative to the ICB in January 2025 to formally delegate the national guidance or address the substantial non-compliance.
The most recent regulation 28 letter issued to the trust, which the board had previously been sighted on, was in relation to the death through suicide of a patient in Rotherham older peoples services. Mr Lewis noted that a response had been issued to the coroner and revised guidance had been issued to staff within crisis services to amend the age parameters that most likely two thirds of services had worked with previously. He clarified the responsibility of management to ensure that the age parameters were clear.
With reference to the regulation 28 issued around mental health disengagement, the actions would be implemented, however the intended progress hadn’t been made to date. The trust had taken the opportunity to assess the approach in other areas, given it was a national issue.
Mr Lewis noted the work in relation to the case of Annette, who sadly passed away 10 years ago. He confirmed that the Coroner had recorded that the trust was contributory negligent to her early death. It was agreed to refresh the action log and re-energise the work signed off by the board in 2021, with a particular focus on how patients with learning disabilities are viewed they are being cared for within other services.
Mr Lewis referred to the successful position on the transfer to NHS Professionals, meetings continue with partners and the initial data suggested that the majority of the 600 shifts were being filled. There would be a further evaluation undertaken during quarter 1 2025 to 2026.
There were approximately 180 volunteers currently in roles across the trust with an aim to have 250 by April 2025. Mr Lewis noted that teams were taking on volunteers who hadn’t previously been engaged and they were embracing volunteers.
Ms Fulton Tindall was pleased to see the work ongoing around ensuring high therapeutic quality care and suggested for the board to receive a further update given the importance and the amount of change involved. Mr Lewis noted the discussions held with executive colleagues on the importance of implementing this work and the support for the wards required throughout the year to get it right.
Mr Chillery referred to the achievement with NHS Professionals and the ambition to achieve zero agency use by the end of the year, he linked this with the discussion held at the last Quality Committee around remaining curious and the review of persistent lines of enquiry to understand any unintended consequences. There remained a risk on the risk register in relation to speech and language therapy, and he noted that this was a specialised area that NHSP couldn’t necessarily provide.
Ms Fountain made reference to the medication provision for people diagnosed with ADHD and sought further understanding around the reduction by about 30 appointments per month. Mr Lewis clarified that this was currently affecting the ability to maintain the trajectory. The adult improvement plan, to achieve 4-week waits in 2026, was on trajectory, as well as Doncaster children’s services. North Lincolnshire wasn’t currently on trajectory, Rotherham had doubled activity over the last 3 months which was encouraging, however the trajectory was more challenging. The revised guidance on medication provision had been considered by the CLE and the trust was compliant. The board noted the creation of the Rotherham primary care shared care agreement which would go live in January 2025 and the work required with Rotherham General Practitioners (GP) to support the use of medication that was available nationally.
With reference to 1.1 and 1.2 within the report, Ms Holden noted the benefits of discussing the positive feedback from Care Opinion at the last care group delivery reviews, and seeing this being recognised as part of the newly introduced local rewards scheme. Mr Lewis felt that the implementation of Care Opinion would provide real insight and afford the opportunity to preserve and share good practice, as well as identifying the aspects that required change or improvement.
The board received and noted the chief executive’s report and the forward actions it contained.
Key matters for decision or assurance
Care Quality Commission readiness: Well-led
Reference
Mr Gowland presented the report and reminded the board of the approach to well-led agreed in May 2024. Good Governance Improvement (GGI) would be returning in quarter 4 to provide their input on related work.
The paper set out the Well-Led key questions and the current position of the evidenced-based assessment undertaken with a RAG rating, in line with the CQC assessment framework. The assessment was developed with input from a number of colleagues across the trust and work would continue to collate the necessary evidence over the coming months.
He noted the use of Care Opinion and the voice scorecard, both referred to earlier in the meeting, as important pieces of evidence and felt that the initial overall assessment was balanced, positive and reflective of the work undertaken on the trust’s new operating model. The launch of the new leadership development offer (LDO) would further enhance the ability to provide relevant evidence. Mr Gowland suggested providing further update on progress in March 2025.
Mrs Lavery found the report helpful, particularly the appendices which provided a view of where the evidence would be collated from.
Dr Falk queried if the quality statement criteria and definitions was based on the CQC framework, Mr Gowland confirmed that the template had been completed in line with the CQC framework.
Mrs McDonough drew attention to the changes made since the paper was last reviewed and the importance of considering the associated impact. She felt that better linkages could be made within the report, such as the diversity mix of FTSU versus the feedback from the WRES and WDES, and further information included within the sustainability section. Mr Gowland noted the reference within the Shared Direction and Culture around stakeholder feedback and the demographic data being collected and analysed.
Mr Gowland welcomed other feedback provided that linked to the way in which the assessment reflected a ward to board, collective understanding and how the respective “voices” from right across the trust would need to be included. Further, that the assessment should develop to include all relevant sources of assurance and triangulation between them, opportunities for learning and that the associated timescales (to become “green”) needed to be realistic. Developing a common understanding of the assessment would be important for the board and others and Mr Gowland reiterated his intention to bring a further update to the board in March 2025.
Mr Lewis was keen to be sighted on the parameters of the next GGI review and supported the positive or negative assurance construct. He then commented on the CQC methodology and the real insight required into the broader view of the indicators and the associated evidence.
The board received and noted the update and status report in respect of the Well-Led key question, the next steps and planned reporting schedule.
Action
Sexual safety charter: Action and results
Reference
Dr Graham presented the report which provided an update on the work associated with sexual safety and the sexual safety charter in the trust.
She reminded colleagues that the board signed up to the sexual safety charter during quarter 3 of 2023 to 2024 and outlined the work undertaken in terms of the baseline assessment and with the national workstreams to develop a consistent policy and training for organisations – this was released at the end of October 2024.
Further work was required to improve this area and reference was made to the staff story and that some restraint incidents did relate to sexual safety. The 8-step plan was detailed in the report which was linked to the NHS England findings.
In response to Mrs McDonough, Dr Graham advised that the team had liaised with the staff networks and the baseline data collection found that only females were reporting sexual safety incidents over the last 5 years. The planned work included reaching out to males to understand why the reporting wasn’t higher. This had been a topic of discussion within the Women’s Network and work was ongoing with public health colleagues around sexual safety.
Dr Graham informed colleagues that the majority of the incident reports received were from staff of a black minority, this was subsequently discussed at the REACH network and with the spiritual care team to understand further.
Mr Mohammed considered how new staff joining the trust were informed around areas such as sexual safety. Dr Graham and Ms Holden were working on this as part of the leadership development offer and the National Directors Network.
Mr Lewis referred to the 149 incidents regarding patients to staff and questioned the realistic aims to address this. Dr Graham noted the zero-tolerance initiative and that this would be unachievable given the circumstances. However, proactively preventing sexual abuse in the workplace and ensuring people were supported to speak up was the aim. Dr Graham noted that some staff had left the organisation due to the experience they had in terms of sexual abuse, which was predominately within inpatient settings.
Ms Holden noted the feedback in the staff survey relating to patient to staff incidents and significant work required, 1 in 4 women and 1 in 18 men had been sexually abused, this equated to 849 women and 37 men within RDaSH, however the IR1 system did not demonstrate those numbers. She considered if the approach to tackle racist incidents could be replicated in respect of sexual safety.
Dr Sinclair questioned if there was a robust methodology to incorporate students and trainees and felt that this was an underreported area. Dr Graham advised that a robust reporting mechanism for people such as volunteers and students was required, however these were factored in as part of the national process.
Mrs Lavery summarised the discussion and a further update would be provided to a future meeting.
The board received and noted the ongoing workstreams associated with sexual safety and the sexual safety charter.
An overview of research activity in the trust
Reference
Dr Sinclair presented the paper which provided an overview of research activity in the trust and how the priorities within the Research and Innovation Plan were beginning to be addressed. The paper also considered the barriers within clinical services to enable the building of research and development capacity and capability.
The Grounded Research team had embarked on a project using the Self-Assessment of Organisational Readiness (SORT) tool, this was currently being trialled within the children’s care group with potential to identify the learning and apply to other areas across the trust if successful.
Dr Falk spoke about the importance of research and that patients wanted to be involved. He encouraged further development of research within the trust, noting the income it could generate, the positive reputation and benefits in terms of recruitment and attracting new starters.
Dr Falk then referred the Grants and Expressions of Interest (EOI) and queried one of the key reasons declining EOIs being studies were mainly looking for PIC sites, he recognised the opportunity for the trust to become a PIC site to GP research.
Mr Lewis provided a RAG rated response to three aspects of the paper with the consistent delivery of portfolio targets year on year representing a “green” achievement and he congratulated the team on that success. The “amber” related to the need for work as an executive team to develop research trust-wide and move the trust towards being more “research-ready”. He then referred to essentially his “red” area and the six priorities presented in appendix 1, which was an honest presentation of the current state in his view. With a couple of exceptions, he felt there was further work required to refine and enhance some of the workstreams in Q4.
Dr Sinclair explained that the trust was in discussions with a research company that undertook psychedelic research, the company were exploring the lease of one of the trust’s buildings in Doncaster to conduct studies. The current models of using psychedelic drugs was in association with assisting therapy, with the appropriate dose. If this aspect of research wasn’t undertaken, the likelihood of this being rolled out with a timeframe for patients being able to access would be small. Mr Lewis clarified that a decision would be made in the next 6 weeks and clinical colleagues had expressed their material interest.
Mrs McDonough noted the work required to agree the focus for research fundraising, as part of the trust’s charity. Patients and communities were interested in research and would feel motivated to donate to that purpose if the reasoning was clarified. Mrs McDonough, Mrs Vickers and Dr Sinclair agreed to explore this further outside the meeting.
Mr Vallance expressed that research was part of everybody’s job role and considered the work required to enable capacity and capability to implement this across the organisation. Dr Sinclair discussed the multiple ways to enable dedicated time for staff to be involved in research.
Mr Chillery referred to discussions held regarding staff and need to support our communities to be involved in research, he mentioned the newly developed research facility in Sheffield for children.
Dr Graham noted that sessions were available as part of the learning half days for all staff to gain a further insight and understanding into research and patient ambassadors were involved in the research team. She expressed the importance of helping staff have the identity of being a researcher.
Mrs Lavery advised that the governors were equally interested in research as staff and community representatives.
Mr Lewis noted the need to recognise the excellence of Grounded Research could be an inhibiter as well as an enabler. Work was required over the next 6 months to change that.
Ms Fulton Tindall suggested including the values of research in job descriptions, Dr Sinclair provided an example where a member of staff accepted a job at RDaSH with research being the deciding factor.
A further update would be provided to the board in due course.
The board received and noted the overview of progress in research in the trust over the last 6 months.
Productivity at RDaSH 2025 to 2026
Reference
Mr Mohammed presented the paper which provided an overview of the early findings from the Akeso productivity review commissioned by the South Yorkshire Mental Health, Learning Disability and Autism Provider Collaborative in September 2024.
The review included identifying the potential productivity gains in Older Adult Inpatient Services, Community Mental Health teams (CMHT) and Children and Young People Services (CYP). Productivity improvements of £3.8m were identified for RDaSH which were detailed within the paper, some of which were aligned to existing workstreams. Data quality was highlighted as a barrier to this work and was driving a number of the variances.
Mr Vallance recognised the link to the value for money assessment and felt that an internal arrangements should be in place to determine if value for money was being provided, with consideration as to how this linked with productivity. Mr Mohammed agreed that the two elements should be aligned.
Dr Falk raised concerns in respect of the RDaSH geography and the work required with primary care to improve the referral process from primary care into CMHTs and ensure all patients are allocated a service. Mr Lewis requested a further update on this work within the next 6 months.
Mrs Leese considered how this information was shared with clinicians and productivity reports were a great opportunity to explore further improvements with clinicians.
Mrs Vickers supported the paper and recognised the joint working opportunity through the Finance, Digital and Estates Committee and the Quality Committee.
Mr Gowland drew attention to the inappropriate referrals from primary care and questioned if there were other external influences to address that would support with the trust’s productivity. Mr Mohammed advised that other external influences would be included within the pilot.
Mr Lewis pointed out the relevance of DIALOG+ to this work and the purposive nature of how we change clinical time, he agreed to further explore the connectivity between the two workstreams.
Mr Lewis then noted the importance of ensuring time was the currency of this work and the focus on clinical time spent with complex patients.
The board received and noted the progress of the Akeso review and the potential productivity gain identified of up to £3.8m within RDaSH, noting the other productivity work streams the trust intended to take forward, including how the work will be delivered.
Action
Promises 6, 7 and 8: Accelerating delivery
Reference
Mrs McDonough presented the report which explored the barriers to making progress with promises 6, 7 and 8 and the ways to accelerate delivery.
In terms of promise 6, Poverty proof all services by December 2025, the trust had worked a partner organisation, Children’s North East, to undertake the 3 pilots in North Lincolnshire CAMHS, Podiatry in Doncaster and Early Intervention in Psychosis in Rotherham. The pilots were a success and the teams were positively engaged and feedback was being sourced from patients and the communities. The draft report received for the podiatry pilot identified opportunities for reducing the impact of poverty on people’s ability to access services, including the challenges with regular travel to access care and treatment.
Promise 7, Work had been undertaken to identify all of the Core20Plus5 measures and those that were relevant to RDaSH services. The associated challenges related to the data and information that existed for patient cohorts within our care and primary care. Work was ongoing to resolve this to ensure it was clear which patients fell under the learning disability (LD) service and serious mental illness (SMI) service, for each area. There was a risk of not meeting the December 2024 target for achieving 95% coverage for health checks for those patients with an SMI or LD.
Promise 8, this promise builds on the Core20plus5 measures by focusing more on people with autism, a learning disability or a mental illness, 4 out of 5 areas had been identified to date where we want to reduce inequity. The challenge was identifying the key actions to lead to change and subsequently address the issues. Mrs McDonough and Mr Lewis would be meeting with the 4 areas to address the challenges, some which was around capacity and capability.
Mr Chillery referred to promise 7 and SMI, work was ongoing to meet the RDaSH lists by December 2024 and discussions had been held with the ICB on the wider system work. Mr Lewis emphasised the work required to receive an aggregated view of all SMI and LD patients.
With reference to promise 6, Ms Fountain sought to further understand the barriers for people attending appointments. Mrs McDonough advised that some of the barriers were financial, but others were the availability of appointments, transport and location. The key actions were to support people with these challenges, such as flexibility of appointments, moving services closer to people and transport.
Mr Gowland linked this to the strategic delivery risks and recognised the need to ensure leaders had the ability and capacity to have those conversations.
Mr Chillery noted the targeted work required to understand what we class as DNA and disengagement for deprived areas, and the link to previous discussions regarding productivity.
Mr Lewis recognised the need for further discussion on the approach to poverty proofing and the associated programme of work, and emphasised the need for impactful work and change and not just commenting on inequalities.
Mrs McDonough invited board members and governors to become part of the poverty proofing programme.
The board received and noted the assessment of work undertaken and learning to date for promises 6, 7 and 8.
Baby friendly status
Reference
Dr Graham presented the paper which provided an update on the work and workstreams associated with being a ‘Baby Friendly’ organisation, and the UNICEF Baby Friendly Initiative (BFI).
Dr Graham was the Baby Friendly Guardian for the trust and explained the reason why this work was required, which included the negative advertisements around breastfeeding women and the lack of appropriate facilities being available. She noted that in some local communities that breastfeeding rates were low.
In terms of delivery focus, the trust’s baby friendly services were in North Lincolnshire and Doncaster. Dr Graham highlighted that the UNICEF Baby Friendly Initiative (BFI) were recommending the gold accreditation for North Lincolnshire, the final results would be received next week.
Work was ongoing with the Doncaster team to prepare its application to “go for Gold” too. Actions were in place to improve the workplace “baby friendly offer”.
Mr Lewis asked if the board could provide any useful support to this work, Dr Graham noted the responsibilities from leadership perspective in terms of knowledge and openness, the ability to have active discussions with parents and carers.
Mr Chillery acknowledged the praise received for the work undertaken by Dr Graham, and the importance of considering school readiness.
Ms Holden linked the discussion to Strategic Delivery Risk 5 and the capacity and capability to develop leaders. The staff survey data identified good results in terms of flexibility working, however deeper dives highlighted that some managers decline flexible working requests, and there was a need to further understand this data.
It was suggested that a breastfeeding mum would attend the board for a future patient story.
The board received and noted the content of the report and the ongoing workstreams.
The chair on behalf of board gave a presentation to Mrs Leese. Mrs Leese left the meeting at 1:30pm.
Routine reports
Operational risk reports
Reference
Mr Gowland presented the report which highlighted the current extreme risks and the high impact and low likelihood risks.
There were currently 4 extreme live risks and work continued with the accountable directors to review the risks with monthly scrutiny via the risk management group.
In line with the Risk Management Framework, it was important for the board to be sighted on the high impact and low likelihood risks and work was ongoing to ensure these risks were represented on the risk registers. In terms of high impact and low likelihood, Mrs Lavery referred to the recent water supply issues in Doncaster and the risk of this re-occurring and the associated impact. Mrs Lavery then discussed the risk of flooding being on the risk register, Mr Gowland agreed that this would be considered as a high impact and low likelihood risk.
Mr Lewis noted the expectation for all departments to work through their high impact and low likelihood risks by March 2025, Mr Gowland advised the Head of Risk Management was driving this forward and more work would be done to effectively identify these risks.
Mr Lewis referred to the ligature risk update due at the board in March 2025 which linked to 3 of the risks highlighted within the paper.
In regard to HI 4/23 around the discontinuation of support for Windows 10 in October 2025, Mr Banks clarified that the mitigation was part of a current Replacement Programme.
Mr Mohammed referred to RCG 12/24 regarding the replacement of the Thymatron machines used in the Rotherham ECT, he advised that the procurement process had been finalised, and the replacement machines would arrive within the next few weeks.
Ms Gillatt considered the management of key system risks, recognising those against the trust’s portfolio. Mr Gowland was engaged with his counterpart at the South Yorkshire ICB who shared their risk register and Board Assurance Framework, an element of this would be introduced as part of the Risk Management Group work around the broader understanding of system risks. Mr Banks referred the South Yorkshire ICB Cybersecurity Forum, noting that some risks were generic across health organisations but being responded to with differing mitigations. The group provided a good opportunity for supporting and learning from each other.
The board received and noted the operational risk report update.
Strategy delivery risks 2024 to 2025: Q3 report
Reference
Mr Gowland presented the report which focused on SDR 2 and 5, both of which were subject to review at the respective Committee’s in October 2024.
The paper highlighted the latest position for both risks and noted the revisions in the format to respond to previous commentary to provide clarity where action had been taken, this was now highlighted in bold text.
Given the nature of the strategic risks, Mr Gowland noted that progress may be slower than the mitigation of operational risks and referred to pivotal work required to mitigate the strategic risks.
Ms Holden referred to SDR 5 and the leadership development offer, noting that there was engagement with community colleagues to develop the programme. The staff survey closed on the 29 November 2024 and the results would provide related data for this risk.
In terms of SDR 2, Mr Banks highlighted the opportunity presented through using the learning half days to delivery training and offer support to staff, for both known areas and areas that had emerged through the digital needs survey. Mr Lewis clarified that SDR2 was focused on precise data quality.
Mr Lewis noted that the learning development offer would contain an assessment of individuals capabilities and quantified measures would be identified from the first 6 months. Ms Holden noted that a tool would be rolled out to feed into the wider evaluation of the programme.
Mrs McDonough referred to the delivery of social value and felt that there wasn’t enough knowledge and understanding within the organisation and considered if this could be factored into the leadership development offer.
The board received and noted the strategy delivery risks 2024 to 2025 report, noting the planned next steps to enhance reporting.
Integrated quality performance report (IQPR)
Reference
Mr Chillery introduced the integrated quality performance report (IQPR) for October 2024.
With reference to the top 10 areas of delivery, a strong position was reported for adult access services, perinatal, dementia, adult ADHD, virtual ward and talking therapies.
Children and young people (CYP) access remained below the target by 179 children, there was a plan in plan to achieve this by the end of December 2024. Section 136 breaches had improved during November 2024 and this continued to be a key focus area.
In terms of safe staffing, there was a decline in safe staffing numbers during October, Mr Forsyth reported the closure of Emerald Lodge had contributed to this and following review, this was now an improving picture.
Mr Mohammed provided an update on the financial performance, the position at the end of October 2024 was a deficit of £152k, this was £154k adverse compared to the revised plan. The biggest influence on this included the pay award income accrual of £386k, a change forecast had been submitted to the South Yorkshire ICB. The trust was on track to deliver the plan this year, with the exception of the pay award.
In terms of the delivery of revenue, Mr Lewis advised that this would require 3 of the 6 care groups to deliver their budget, and 3 to deliver better than budget, the final numbers would be confirmed next week.
Mr Lewis noted the progress with the capital expenditure plan and confirmed that following a meeting with Mr Mohammed and the Head of Estates, that schemes (IT related) had been brought forward from 2025 to 2026 to recover the current year position. Mr Lewis was now confident that the 2024 to 2025 plan would be achieved.
The board received and noted the integrated quality performance report.
Promises and priorities scorecard
Reference
Mr Lewis presented the paper highlighting that the board received and supported the format at the last meeting.
Mr Lewis reiterated the focus on eliminating the plan ‘reds’ going into Q1 2025 to 2026 and was confident that there was an emerging and coherent plan for the majority of those areas. Further work was required to develop a comprehensive plan for promise 2, this would be a focus area at the Executive Group team away day.
Promises 2, 9, 13 and 25 were specifically highlighted in the paper as challenging areas of delivery.
Mrs McDonough referred to promise 27 (achieving net zero) and the anticipated difficulties with moving from red to amber. The current options for achieving this were significant in terms of infrastructure and associated costs. Mr Lewis agreed with the difficulties in delivery, but noted however that it was possible to build a coherent plan that would achieve delivery.
In response to Ms Gillatt, Mr Lewis confirmed that the emerging estate ideas would achieve approximately 20% of the net zero and carbon emissions target. There was a need to replace the power system and options for this were being looked into, including potential support from the Government.
The board received and noted the promises and priorities scorecard update on the work to date and expectations in 2025 to 2026.
Supporting papers (previously presented at committees)
Supporting papers
Reference
Mrs Lavery informed the board of the following additional reports for information which were presented as supporting papers that had previously been presented at committee level for scrutiny and challenge:
- mortality 6 monthly report
- workforce race equality standard (WRES) and workforce disability equality standard (WDES) annual report 2024
- guardian of safe working hours
- freedom to speak up (FTSU) biannual update
Mr Lewis referred to the discussion held at the last Quality Committee regarding the backlog of Structured Judgement Reviews (SJR) and the importance of distinguishing this between understanding the reasons people had died in RDaSH care versus the wider learning around mortality. Dr Falk discussed that the learning from deaths policy was dependent on the completion of SJRs, and therefore partial assurance had been taken. Dr Graham clarified that the trust was sighted on all deaths through the incident reporting system reviewed through the daily incident meetings and the mortality operational group.
The board received and noted the additional reports for information.
Any other urgent business
Reference
There was no further business raised.
Any risks that the board wishes the risk management group to consider
Reference
Mr Lewis requested for the three SMI lists to be included in the risk register if not already covered, Mr Chillery agreed to clarify.
Action
Public questions
Reference
There were no questions raised by members of the public.
Final note
Reference
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: April 02, 2025
Next review due: April 02, 2026
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