Present
- Kathryn Lavery, Chair.
- Richard Chillery, Chief Operating Officer.
- Maria Clark, Non-Executive Director.
- Steve Forsyth, Chief Nurse.
- Sarah Fulton Tindall, Non-Executive Director.
- Kathryn Gillatt, Non-Executive Director.
- Carlene Holden, Director of People and Organisational Development.
- Toby Lewis, Chief Executive.
- Izaaz Mohammed, Director of Finance and Estates.
- Dr Diarmid Sinclair, Chief Medical Officer.
- Dave Vallance, Non-Executive Director.
In-attendance
- Richard Banks, Director of Health Informatics.
- Dr Richard Falk (attended virtually), Non-Executive Director.
- Lea Fountain, NeXT Director.
- Philip Gowland, Director of Corporate Assurance and Board Secretary.
- Dr Jude Graham, Director for Psychological Professions and Therapies.
- Jo McDonough, Director of Strategic Development.
- Sarah Dean, Corporate Assurance Officer (minutes)
- Nicola Bonser, Specialist Service Manager for Assertive Outreach team, Early Intervention in Psychosis team, Health and Wellbeing, Perinatal Mental Health team and Trauma and Resilience Service.
- 6 members of staff, 2 members of public and 4 Governors were in attendance.
Welcome and apologies
Reference
Board public: 25/09/01.
Mrs Lavery welcomed all attendees to the meeting. Apologies for absence were noted from Rachael Blake and Pauline Vickers, Non-Executive Directors.
Mrs Lavery acknowledged it was Ms Fountain’s last meeting as she had concluded her two years of the NExT Director programme. It was also Mr Mohammed’s final meeting before he commenced his new role with Manchester University Hospitals in late October. Thanks were given for their contributions and support to the board. Mrs Lavery commended Mr Mohammed and stated he had brought real change in both finance and estate functions to the organisation. He would be succeeded by Mr Simon Sheppherd who would join before the end of 2025. Mrs Jill Savoury, Deputy Director of Finance, would be acting up during that period.
Quoracy
Reference
Board public: 25/09/02.
Mrs Lavery declared the meeting was quorate.
Declarations of interest
Reference
Board public: 25/09/03.
Mrs Lavery presented the declarations of interest report and confirmed that there were no changes to the register since the last meeting.
The board received and noted the changes to the declarations of interest report.
Patient story
Reference
Board public: 25/09/04.
Mrs Lavery welcomed Nicola Bonser, who would present the patient feedback on behalf of Rowan who had benefited from the joint work with South Yorkshire Housing Association (SYHA) at Burns Court, Rotherham. Nicola advised that Rowan, although happy to share his story, did not want to attend or video record his patient feedback, and this had made him feel anxious. Rowan had spent several years under the care of the Early Intervention team (EIA). The team were able to put interventions in place to develop Rowan’s living skills and become independent, and through trauma informed support he was able to build a better family relationship. Nicola explained the new community rehabilitation pathway in Rotherham and processes in place with a step-down approach from inpatient care that included enhanced support from the Assertive Outreach team (AOT). The collaboration with SYHA had created a ten-bed supported accommodation provision. Nicola highlighted those collaborative efforts had resulted in a positive impact on patient outcomes. There were challenges where patients became unwell at admission and the model needed to be adapted to a more rehabilitation focused, Assertive Outreach team based community approach.
Nicola discussed how the Assertive Outreach and Early Intervention teams collaborated well and believed the success to this was the shared resource and provision to support people with complex mental health needs, and the ability to integrate in the community through the SYHA accommodation.
Mr Gowland stated it was good to hear the success of collaboration work and to hear the passion of the team. He asked whether there was scope and demand to replicate the model in other areas. Nicola explained previously SYHA had two buildings that provided accommodation for people with complex mental health needs. This was not necessarily a rehabilitation programme or pathway, it encompassed different mental health needs, not just those who suffered with a psychotic disorder. There was added benefit of the local authority able to refer patients into the service. This was previously successful and effective for patients but unfortunately due to funding SYHA closed the units which left a gap to support patients into the community. An opportunity arose following the closure of Goldcrest ward and the creation of the community rehabilitation pathway which the community teams embraced. The model had developed and taken time to ensure patients were cared for safely and were in the right place. Overall, the patient experience and outcomes had been positive.
Mr Lewis noted this project work supported promise 23, to invest in residential care projects and programmes that supported long term care outside inpatient wards. Although he anticipated the project was working well, Mr Lewis stated it was important to have a meaningful evaluation to ensure long term sustainability. Nicola highlighted the teams had been supported by Dr Mike Seneviratne with the use of patient rated outcome measures (PROMS) data, and to ensure DIALOG+ tool was used to improve care. Mr Lewis advised the new director of public health was very interested in the project, and there were plans to potentially expand the service.
In response to Dr Sinclair, Nicola explained patients felt independent and able to manage their care and treatment. The patients had been happy to be involved in the project and treated in the community, with some able to provide depots and clozapine whilst in accommodation rather than returning to wards. Mrs McDonough confirmed there were ongoing conversations with housing providers with plans to introduce similar community projects in Doncaster, and in North Lincolnshire, ensuring tenancy arrangements and funding were appropriately managed. Dr Graham acknowledged this was a national challenge and recognised the stigma which some people faced. Dr Graham highlighted the importance of holistic and recovery focused care required to support people in communities. Nicola agreed and explained there were patients who had been brought back under the rehabilitation step down model to be cared closer to home, from out-of-area (OOA) placements and locked rehabilitation, into housing accommodation in the community.
Mrs Lavery and the board thanked members for taking the time to listen to the patient story and noted the intended reflection time later on the agenda.
Nicola left the meeting.
Standing items
Previous board minutes
Reference
Board public: 25/09/05.
Minutes of the previous board of directors meeting held on the 24 July 2025.
The board approved the minutes of the meeting held on the 24 July 2025 as an accurate record subject to the following amendment.
Board public 24/07/04: staff carer story
To remove reference to Ms Fulton Tindall within paragraph five.
Board public 24/07/20: promise 2 carers delivery plan
To include “whilst reflecting on an ageing population that would continue to grow” within paragraph three.
Board public 24/07/33: public questions
To expand on Mr Foryth’s response regarding food menus having an alternative non-dairy option.
Matters arising and follow-up action log
Reference
Board public: 25/09/06.
Board public 25/01/21b disengagement risk. In response to Ms Fountain, Mr Lewis referred to a detailed update provided within the adult community services paper later on the agenda (contained within section 7.1 and 7.2 of the report) regarding the ongoing work, implementation and monitoring of the engagement and disengagement policy. In response to Ms Clark’s query relating to the language used to frame the policy, Mr Lewis advised the policy had been renamed following a specific conclusion from the prevention of learning from future deaths report, and the language was consistent with national policies. Dr Sinclair explained the policy applied to patients within mental health services but did not apply to physical health services. Mr Lewis advised the policy was subject to consultation through a patient lens with the People Focused Group (PFG) which may give opportunity to reflect and influence the language within the policy.
The board received the action log and noted the progress updates. All actions noted as “propose to close” were agreed.
There were two matters arising from the minutes.
Flourish Community Interest Company (CIC) Appointment of Director Mrs Lavery advised that the board reserved the power to appoint Directors to Flourish. Following a recent recruitment campaign it was recommended to appoint Mrs Kelly Milanese. The board approved the appointment of Mrs Milanese.
Patient safety incident response framework (PSIRF) policy, Mrs Lavery advised of the minor but important changes to an appendix of the PSIRF policy which was approved by the board previously. The board approved the amendments to the PSIRF policy appendix.
Board Assurance Committee reports to the board of directors
Report from the Finance, Digital and Estates (FDE) Committee
Reference
Board public: 25/09/07.
Ms Fulton Tindall, on behalf of Mrs Vickers, presented the paper and highlighted key points.
At month 3 there was a deficit of £716,000, better than planned and remaining ahead of plan at month 4. There had been £1,000,000 additional funding secured from the integrated care board to support appropriate out-of-area.
There was progress reported with the digital enabling plan. The challenges faced were the increased pace and complexity of reporting requirements, competing priorities and financial pressures. A pilot programme had been developed for the use of artificial intelligence in clinical settings and focussed on ambient voice technology. There were plans to assess and evaluate the impact on patient experience and effectiveness. Regarding cybersecurity, the organisation had the lowest cyber risk score across the region and continued to maintain a high standard.
The board received and noted the report from the Finance, Digital and Estates Committee.
Report from the People and Organisational Development (POD) Committee
Reference
Board public: 25/09/08.
Mr Vallance, on behalf of Ms Blake, presented the paper and highlighted key points.
The nursing and midwifery profile review band 4 to 9 concluded there was a potential financial risk due to potential changes leading to increased pay costs. Mr Lewis confirmed that there has been no evaluation received therefore no agreement made to date regarding implementation.
The workforce race equality standard (WRES) 2025 and workforce disability equality standard (WDES) 2025 both identified ongoing issues with bullying and harassment. There had been an increase in reporting of racist incidents, unfortunately continuing the story that the board were already sighted on.
The apprenticeship levy promise was on track to exceed its usage target for the year, which Mr Vallance commented was a real achievement in itself. Mr Lewis reflected on violence and aggression and noted the dissonance between the results of the recent internal audit (received significant assurance) and that of staff voices and experiences. Mr Lewis recommended Mr Forsyth and Ms Fulton Tindall created space to explore violence and aggression through the Mental Health Act (MHA) Committee.
Mrs McDonough referred to the WRES and WDES results, the support of the staff networks, and how support could be strengthened. Mr Lewis stated the Trust People Council (TPC) would seek to address or have at least a final hypothesis at its next meeting. Ms Holden explained the ongoing work of the Trust People Council where challenges and staff experiences had been voiced and acknowledged the need for further work on staff engagement, reasonable adjustments, sickness management and support through line managers.
The board received and noted the report from the People and Organisational Development Committee.
Action
Steve Forsyth.
Report from the Quality Committee (QC)
Reference
Board public: 25/09/09.
Mr Vallance, on behalf of Dr Falk, presented the paper and gave the key highlights.
The ligature report highlighted the importance of learning from incidents and national alerts to inform changes in practice, demonstrated from the learning from the death of a patient in 2022. Mr Forsyth explained the evidence of learning and sustained actions were accepted by the coroner, who accepted the recommendations and completed actions at the recent inquest and was satisfied learning had been embedded.
The Integrated quality performance report (IQPR) highlighted specific issues such as neurodiversity waiting times and meeting length of stay targets on wards. In response to Ms Gillatt, Mr Lewis confirmed the IQPR was received and scrutinised within the operating model that included care group delivery reviews, the clinical leadership executive (CLE) and other mechanisms.
Mr Lewis referred to the mortality report and confirmed the backlog of structured judgement reviews (SJRs) was on track to be concluded (cleared) by the end of November.
The board received and noted the report from the Quality Committee.
Report from the Mental Health Act (MHA) Committee
Reference
Board public: 25/09/10.
Ms Fulton Tindall presented the paper and highlighted key points.
There was a matter for concern related to the Rotherham adult mental health care group who remained an outlier in compliance. There had been a decline in consent to treatment on admission and section 132 rights, where the latter had not achieved over 79% compliance in the last 3 reports. The matter had been escalated to Dr Sinclair.
There were 316 detentions, 1 of which was unlawful. Consent to treatment on admission overall remained compliant at 92%, although this varied across geographies. Consent to psychiatric medication had fluctuated over the last few months.
There had been no section 136 suite closures during the reporting period, and all 83 patients detained under section 136 were assessed within 24 hours.
The North Lincolnshire adult mental health care group had been performing consistently over the last few reports at 100% in respect of consent to psychiatric medication and consent to treatment at both admission and 3 months.
Mr Lewis stated it was possible reporting of the closure of the section 136 suite and overstaying of the section 136 suite indicators had become transposed in the process of reporting.
Regarding the timely independent reviews being undertaken in seclusion, Dr Sinclair advised the process had been refined with doctors and the seclusion policy would be adjusted accordingly. This would take account of the process during the 5-day working week, out of hours and weekends, and how those independent reviews would be conducted across into 7-day working.
Mr Chillery referred to section 136 compliance, noting there were statutory 24-hour metrics as well as the organisation’s internal 24-hour metric. He suggested further understanding was required to ascertain any differences, and factor in whether the section 136 suite was physically closed at those admission points. Dr Sinclair confirmed the compliance report presented at the Mental Health Act Committee was broken down to show section 136 suite closures. Future reporting would be refined to ensure accurate reporting of section 136 suite closures and overstays, including providing a table with all relevant data items and metrics for committee and board clarity.
The board received and noted the report from the Mental Health Act Committee.
Action
Dr Diarmid Sinclair.
Report from the Public Health, Patient Involvement and Partnerships (PHPIP) Committee
Reference
Board public: 25/09/11.
Mr Vallance presented the paper and highlighted key points.
The NHS 10-year plan reflected on neighbourhood working, and part of the plans and promises to integrate services with partnerships to form neighbourhood working (promise 15). There were two pilots in Doncaster and Rotherham, and Mr Vallance explained the challenges faced.
There was need for clarity and precision in future neighbourhood plans, pilots, and patient outcomes to achieve, and noted further discussions were planned at the committee for January 2026.
There was good work underway on delivering promise 10, homelessness and inclusion health, with the establishment of a specialist homeless health team in Doncaster. Mr Vallance referred to the external review, research and insight it also provided.
He noted that the committee were able to track and monitor progress made on promises related to the equity and inclusion plan.
The board received and noted the report from the Public Health, Patient Involvement and Partnerships Committee.
Report from the Audit Committee
Reference
Board public: 25/09/12.
Ms Gillatt presented the paper and provided key highlights.
Regarding counter fraud, bribery and corruption, the risk assessment work had been significantly progressed with all fraud risks reassessed. Monthly training continued via half learning days.
The ISA260 report noted a total of 58 recommendations from the current year or that had been carried forward from previous years. In response to Mr Lewis, Mr Mohammed confirmed that only five remained open and that they were being addressed and programmed for 2025 to 2026 year end.
There had been good progress made regarding internal audit and noted there would be an internal audit on the risk management framework.
The board received and noted the report from the Audit Committee.
Chief executive’s report
Reference
Board public: 25/09/13.
Mr Lewis drew attention to the key items within his report.
The opening of the rehabilitation high dependency unit (HDU) (Phoenix) would take place in October. This was a strategic change and a new way of working for the organisation, which could lead to other opportunities in how care was provided closer to home.
A review of learning from complaints identified improvements related to wheelchair services. Mr Lewis described feedback from the recent care group delivery review and the ongoing efforts the directorate had made to improve wheelchair services, including user group participation, setting ambitious targets for assessment and delivery times, and acknowledged the need for continued improvement to meet the 4-week waiting time target.
There was significant focus on supporting approximately 460 colleagues in the approach and management of long-term sickness, particularly stress and depression related absence. The clinical leadership executive had plans for quarter 3 to explore those issues through directorates and individuals in the effort to support those on long term sickness being able to return to the workplace.
Recruitment was underway for the next director of postgraduate medical education to support medical education and the 10 point plan for resident doctors.
There were matters related to the private board of potential changes to procurement and estate management. Mr Lewis stressed those potential changes were not financially driven but aimed at service improvement. Mr Lewis drew attention to annexes 7 and 8, the position related to the procurement service transfer and extended timeline for estate maintenance supply change. The Finance, Digital and Estate Committee would be kept informed of progress.
Following the financial mid-year reviews, Mrs Lavery noted there were positive improvements in South Yorkshire Integrated Care Board funds at month 4 and 5. Mr Lewis advised regional reviews remained ongoing and cautioned optimism regarding quarter 3 and beyond.
Mr Vallance referred to the high proportion of long-term sickness absence and queried whether any could be caused by a contradictory factor. Mr Lewis anticipated there were points of comparison to what similar NHS organisations had, and not necessarily a consequence of terminal illness, and why it was important to undertake deep dive “clinics” in quarter 3 to explore those issues and remedies. Ms Holden referred to themes and trends of sickness absence and explained there was a deeper understanding of where efforts need to reduce sickness absence rates. Mr Chillery stated there were also known vulnerabilities and “hot spots” where work related stress and anxiety increased in areas impacted by service delivery change.
Ms Holden referred to the therapeutic activity programme across 7 days for mental health wards which would commence in October and questioned whether a similar programme would become available for physical health wards. Mr Lewis referred to the work led by the high quality therapeutic care taskforce (HQTC), and confirmed discussions were underway with the physical health and neurodiversity care group following the recent delivery review to explore how physical health teams could apply similarly.
In response to Ms Holden query related to promise 9, Mr Lewis advised the fifth pillar referenced the plans in 2026 to 2027 to introduce tailored access for people with learning disabilities.
Regarding promise 26 and discrimination, Mr Forsyth stated it was important and timely to discuss the acceptable behaviour policy and its use to support staff. There had been more challenges to its use and MP letters received regarding decisions made. Supportive messages, video logs and open meetings had been issued in response, and it was noted this item particularly would be discussed later on the agenda.
Mr Vallance observed that positive change had been undertaken that included the rehabilitation high dependency unit, the launch of therapeutic activities programme, the work across services to manage waiting lists and volunteer recruitment.
Mr Mohammed referred to the upward trend in learning from complaints and questioned whether there was an understanding of the demographics and if they were reflective of the communities served. Mr Lewis confirmed the data was available and referred to the health inequalities data report, he cautioned this was a limited time period to be able to reach any conclusions. Mr Lewis stated he was aware eastern, central European and Roma communities were far less represented in most data compared to the population.
Mrs McDonough stated it was good to see time had been taken to consider the issues arising following the supreme court judgement of the Equality Act.
Mr Lewis confirmed a review of environments was to be undertaken as well as revision of the trans equality policies, both legacy policies had been stood down. He advised should any issues become known during the absence of those policies, they would be dealt with personally and sensitively.
Mrs Lavery noted the changes to eating disorder care and improved service equity (set out in annex 5).
The board reconfirmed support for the changes in service provider proposed under annexes 7 and 8.
The board received and noted the chief Executive’s report and the forward actions it contained.
Emergency preparedness, resilience and response (EPRR) core standards draft submission
Reference
Board public: 25/09/14.
Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Chillery.
In response to Mr Lewis, Mr Chillery explained the reference to the organisation’s role with Doncaster Bassetlaw Teaching Hospital (DBTH) within the annex was in drafting and not legally binding but was good practice. A high-level agreement had been developed to outline commitment to assist during an event that would require DBTH to discharge up to 20% of its patients (an example would be a ward decant following a fire). The agreement would be key part of the evidence of collaboration for the core standard submission.
Mr Lewis noted the significant improvement in performance compared to the previous year. Mrs Lavery agreed and commended the hard work undertaken by the Emergency Preparedness, Resilience and Response (EPRR) team and others involved to have achieved those improvements.
Mr Gowland reflected on training, exercises, evacuation plans and learning from incidents. The essence of being able to respond in an emergency was to be prepared, and noted the good practice identified following recent incidents and use of lockdown. Mr Chillery explained significant change had been made following external learnings from the Manchester Arena attack and Grenfell Tower fire, with strengthened training, business continuity plans and leadership roles across care groups. There had been several successful tabletop evacuation exercises with plans to undertake a scenario evacuation exercise in the New Year.
The board received and noted the Emergency Preparedness, Resilience and Response (EPRR) Core Standards Draft Submission, the progress made to date, and the risks remaining to achieving full compliance. The board approved the EPRR draft submission and delegated to the chief operating officer such amendments as per review suggest necessary. A verbal update on the finalised outcome would be provided to the board in November.
Action
Richard Chillery.
Tackling waits in neurodiversity services
Reference
Board public: 25/09/15.
Mr Lewis presented the paper which followed from issues raised at the Quality Committee and wider discussion related to promise 14, the supply and demand of neurodiversity services and the confidence to meet four-week waits.
The service model and productivity for these services had been reviewed in an approach to reducing waiting times in neurodiversity services. Mr Lewis acknowledged the investments made to meet demand and tackle the backlogs. There were four areas of focus, and Mr Lewis proceeded to outline a plan over the next 15 month to improve productivity in neurodiversity services by redesign, setting clear expectations for assessment numbers, to change working patterns, and reallocating resources to address backlogs. There were key enablers and dependencies required to deliver those plans. Intensive work had taken place across three place-based children and young people (CYP) services, and the longstanding gap for adult services in Rotherham in relation to shared care was tackled.
Mr Lewis highlighted there was not a completed solution to the adult backlog and this would have continued attention amongst executive colleagues. Mr Lewis advised it was important the board were clear of the fast-paced actions required to deliver the supply model, and the need to make changes to roles and potentially to leadership structures. In quarter 4, there may be difficult choices for the board to form a view whether the adult neurodiversity service was sustainable or whether the service should cease.
Mrs Lavery acknowledged the commitment of the board and significant investment made in neurodiversity services during the previous 18 months, and noted the continued challenge faced to meet demand and meet four-week waits.
In response to Mr Vallance’s query related to investment and trajectory models, Mr Lewis explained changed models of practice had already been implemented with more accurate forecasting of service needs. He gave an example of adult services and by altering practices and workforce deployment, it could match demand and supply. Mr Lewis explained that some staff may need redeployment if unable to adapt to new working models, with a focus on reasonable adjustments but an emphasis on the need for consistent clinic-based work to achieve targets.
In response to Mrs Lavery, Mr Lewis explained there was commissioning issues, particularly in Humber and North Yorkshire, and efforts to transition prescribing responsibilities. There were continued negotiations to ensure service continuity and avoid secondary medication waiting lists.
In response to Mr Vallance, Mr Chillery advised there was a clear trajectory for children and young person services and explained the delivery model in place. He described the enormous effort made across adult services to address backlog issues and the confounding factors to consider. He described improvements in data collection and modelling to enable better understanding of the backlog and more accurate forecasting of service needs, with ongoing work to refine these processes. Mr Lewis stressed the need for daily clinical management and oversight of the work underway.
Dr Graham referred to the local and national context of neurodiversity services. In South Yorkshire, the Mental Health, Learning Disabilities and Autism Collaborative had worked with partners to develop a proposal for change which would be considered by the South Yorkshire Integrated Care Board. Dr Graham referred to patients seeking private care to reach speedier wait times but not necessarily the right assessment or treatment. She advised clinical directors across the collaborative were engaged in the effectiveness of neurodiversity services and shared recognition for the need of improvement and investment.
The board received and noted the update in respect of neurodiversity services, considered the issues raised, and problem analysis outlined, and recognised the suggested difficult choices cited notably in relation to clinical productivity.
The board delegated to the chief executive and colleagues the expedited actions outlined. An update would be provided to the board in November and January.
Action
Toby Lewis.
Audit Committee: work plan
Reference
Board public: 25/09/16.
Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Gowland.
There were no questions raised. Mrs Lavery acknowledged Ms Gillatt as Chair of the Audit Committee was fully sighted on the work plan alongside Mr Gowland.
The board received and noted the Audit Committee work plan for the remainder of the financial year.
Future of pharmacy services (wholly owned subsidiary)
Reference
Board public: 25/09/17.
Mr Mohammed presented the paper which followed from previous discussion at the private board meeting to develop the proposed option to establish a central pharmacy service.
The current pharmacy dispensing provision was externally outsourced from the private sector through Rowlands whose contract would end in April 2026, which provided opportunity to create a new pharmacy dispensing service.
The clinical, patient and service benefits of the proposed model of an in house pharmacy service were outlined. Mr Mohammed referred to the supply chain issue with the current provider and drew attention to the mobilisation plan. The likely delivery of a pharmacy dispense service would be through a subsidiary company, and no transferring to another employer (TUPE) from existing NHS staff was envisaged. The change would include the establishment of a central dispensary hub in Doncaster to enable reliable access to medicines, including for weekend discharges and community services.
In response to Mr Lewis, Mr Mohammed advised the mobilisation plan included the medicines dispensary element only of pharmacy provision. Dr Sinclair added this was separate to the role and service of pharmacy technicians who provided advice to services regarding patient medication. Mr Lewis recommended providing a measure of assurance to pharmacy colleagues, by writing to those in relation to future changes to pharmacy dispensing services.
Ms Holden supported the need to write to colleagues regarding the future change to pharmacy services. Regarding the creation of a subsidiary company, Ms Holden noted it would come with some equivalent benefits to NHS employment models, but not all. As part of promise 25, the organisation would commit to being a real living wage employer and would expect this to be adopted with any contracts through the accreditation process.
Mr Chillery questioned whether the mobilisation plan had been risk assessed and whether it could create a gap of provision of medicines. Mr Mohammed explained the mobilisation plan included a three-month crossover from February whilst the supply and dispensing model was finalised, most likely May 2026. Mr Lewis noted this would also include how to host new recruits in the intervening period. Mr Lewis agreed to provide the Board with an update regarding who would host the pharmacy service.
Dr Graham referred to patient experience and advised there may be an impact from the changes in pharmacy dispensary, which may create anxiety for some patients. Mr Mohammed confirmed, as part of the overall mobilisation plan, staff and patient communications would be developed.
The board received and noted the Future of Pharmacy Services paper, and the decision to cease external pharmacy services from 2026 to 2027. The board noted the clinical, patient and service benefits outlined of the proposed model. The board would be kept informed regarding who would host the pharmacy service.
Action
Toby Lewis.
Older peoples quality indicators
Reference
Board public: 25/09/18.
Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Dr Sinclair.
Mrs Lavery noted the quality indicators for older people’s services had been revised as recommended, with plans for both internal and national benchmarking.
Mr Vallance explained there was added value from staff feedback which could contribute to the quality indicators for older peoples services.
Mr Lewis noted that the March agreement divided itself between “merger key performance indicators (KPIs) for the ward” and good enough care measures for older adults. The judgement for the Board in 2026 needed to meet both. He was concerned to ensure that dementia or organic diagnosis patients had access to very good care and asked that both the measures and analysis reflected that specific concern.
Mr Chillery noted the quality indicators was an extensive list and questioned whether the indicators were readily available with baselines for measurement and future reporting. Mr Banks stated datasets had been developed and would be brought back to the board from November which would help inform the board on the quality of care.
Ms Holden referred to the outpatient indicators, and particularly the safety quality metrics. She recommended the quality metric for patients per staff ratio was changed to patients per whole time equivalent (WTE) and patient care hours (rather than headcount) to give an accurate metric.
Dr Sinclair responded he had also received a suggestion from Dr Falk who was concerned not all patient experience themes outside of incidents and complaints would be captured in the quality indicators. Dr Sinclair advised they would now include feedback from patient forums on the wards. Dr Sinclair agreed with Mr Vallance’s view that staff concerns and feedback would be a good quality indicator to include and agreed to take forward how this could be captured in a reliable way.
With regard to benchmarking and comparison, Dr Sinclair explained the indicators covered a range of quality measures, with data collection processes in place. There were plans to compare performance both internally over time and against national benchmarks where possible such as length of stay. Dr Sinclair explained a ‘cutting tool’ of the data would need to be developed to show whether a patient had a functional mental illness versus an organic presentation.
Mr Lewis stated it was important the data quality indicators would be developed by November 2025 and noted these were originally agreed by the board in March 2025, following the move to a merged ward model.
The board received and agreed the quality indicators for older peoples services, and the intention to compare the indicators against other relevant providers, noting the intent to also make comparison to working age services. Changes were however needed to focus on quality of care for dementia patients. Data would start to be shared with the board from November 2025.
Action
Dr Diarmid Sinclair.
Acceptable behaviour policy implementation
Reference
Board public: 25/09/19.
Mr Gowland presented the paper and highlighted the survey undertaken following implementation of the acceptable behaviour policy.
The survey reviewed the awareness, usage and effectiveness of the policy since it was launched 12 months ago. The policy was implemented following challenges of discrimination and how it would support people. Mr Gowland recognised that the environment in which the trust operated in continued to be a challenging one.
The results of the survey identified the need for further promotion of the policy, with plans to relaunch through several events, learning sessions and other mechanisms. Data suggested while incidents related to unacceptable behaviour had occurred, the policy had not been used as frequently as expected. The Radar functionality was being explored to improve reporting in order to prompt the incident reporter to consider the policy, and expectation for potential more use of this policy going forward.
Mrs Lavery acknowledged the video logs produced by the Clinical Leadership Executive (CLE) team and their messages in the fight against discrimination. Dr Graham referred to the increase in ethical challenges following decisions made from incidents of behaviour, and highlighted the importance of accessible policy materials, scenario-based training, and the inclusion of easy read summaries to ensure all staff understand and can apply the policy.
Mr Vallance noted the opportunity of learning following policy deployment and supported the timely review of its effectiveness and usage since policy implementation.
In response to Ms Fountain’s query related to cultural and ethical consideration, Dr Graham explained the need to balance the policy’s preventative and reactive aspects whilst addressing ethical considerations, and ensure the policy supported anti racism and psychological safety for staff and patients.
In response to Ms Clark, Mr Lewis agreed further reflection was required within the policy on the ability of staff to work in a safe and secure environment in community settings.
Mr Forsyth referred to the use of the policy and the use of red cards, the challenges faced and justifications regarding decisions made. There were also increased political drivers to consider. He recognised the cultural shift required in policy deployment and to have supportive mechanisms for staff to be able to continue to work in safe environments.
The board received and noted the outcome of the survey to assess the implementation of the acceptable behaviour policy. The board supported the planned actions to raise further the awareness and use of the policy, as appropriate, across the organisation.
Dr Falk joined the meeting at 1:20pm.
Our 8 plans: research and innovation
Reference
Board public: 25/09/20.
Dr Sinclair presented the paper and gave key highlights.
The updated research and innovation plan provided emphasis on capturing both large scale and small-scale innovations whilst fostering a culture of continued improvement. Dr Sinclair explained the plan broadened the definition of innovation to include small scale changes and systemic improvements, not just major research or clinical trials. The plan set out mechanisms to capture and evaluate those innovations.
The plan set out six big areas of focus for research and three areas specifically linked to innovative. They were aligned with the organisational strategy, its promises and the NHS 10-year plan. Mrs Lavery noted the health services research would become a priority research area.
Mrs McDonough reflected on discussions from the recent Public Health, Patient Involvement and Partnerships m(PHPIP) Committee, the need for ongoing cultural change and to encourage staff to report and evaluate innovations. It was acknowledged there could be failure points in some innovative plans which would become part of the process, but this was acceptable. There were plans for workshops and communications to reinforce that message and the upcoming leaders conference would dispel some of that. Dr Sinclair referred to the quality innovation (QI) poster project underway, and stated small innovative change can make practical improvement.
Mr Lewis explained the organisation was on a journey to develop innovation during the next few years with colleagues having started those quality innovation approaches through delivery reviews and clinical leadership executive. Mr Forsyth stated it was positive to reflect on promise 16 and how research elements linked to improve outcomes in mental health and physical health services.
Mr Lewis advised the plan made the position clear that innovation would be led by care group with support from others including the grounded research team.
The board received, noted and approved the research and innovation plan. The board recognised the research priority given to the big six and the change in approach to innovation that the plan implied.
Provider capability assessment
Reference
Board public: 25/09/21.
Mrs Lavery introduced the paper and explained this was a national requirement to be undertaken by 22 October 2025. Mrs Lavery highlighted it was important the assessment was accurate and complete, and that the board collectively agreed and supported the provider capability assessment.
Mr Gowland presented the paper and confirmed an initial draft assessment had been completed, with 15 out of 16 indicators rated green. There would be a national meeting the following week which would give more clarity to providers on how they were responding to the self-assessments. Mr Gowland suggested setting a deadline for 10 October for additional comments, before the chair, vice chair, chief executive, and director of corporate assurance met to sign off the final self-assessment, on behalf of the board of directors.
The draft self-assessment was aligned to other related documentation, assessment and assurances. In particular, the annual governance statement within the annual report 2024 to 2025, where it had been acknowledged there were areas for improvement linked to quality of care and the quality and safety plan. This criteria had been self-assessed at amber green. Mr Vallance supported the assessment and recognised work had been identified through delivery of the quality and safety plan.
In regard to indicator 9, Mr Lewis questioned the robustness of evidence to support the green rating and the ability of staff to express concerns as well as the reporting culture. Ms Holden referred to the improvements made to strengthen freedom to speak up, and the work planned to in response to the staff survey. It was acknowledged that whilst there were positive aspects, the board were aware that there continued to be areas which required improvement following staff feedback and reporting safety concerns. Mr Vallance and Mrs McDonough supported the initial assessment to change to amber green. Mr Gowland agreed to discuss the rating of the staff reporting culture indicator, and the robustness of evidence, with Ms Holden and Mr Lewis, with the possibility to reassess at amber green.
In response to Mr Lewis, Mr Gowland confirmed a well led assessment was planned to be undertaken in quarter 4. Mrs Lavery noted the Care Quality Commission well led criteria was subject to redefinition. Mr Lewis recommended for the well led assessment to proceed and cautioned a further commissioned well led review may be required subject to criteria change.
The board received and noted the changes to the regulatory environment including the new requirement to be assessed against a provider capability framework.
The board received, noted and reviewed the initial self-assessment presented in the paper against the provider capability framework.
The board delegated approval of the final self-assessment to the chair, vice chair, chief executive, and director of corporate assurance in order that the trust achieves the submission requirement deadline of 22 October 2025. The board would receive an update in November 2025 and any feedback received.
Action
Philip Gowland.
Medium term financial plan
Reference
Board public: 25/09/22.
Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Mohammed.
Mr Vallance questioned whether the tariff deflator and cost improvement programmes (CIP) delivery required were two separate downward numbers, or whether one became a consequence of the other.
Mrs McDonough queried the possible use of cash to capital spend, whether that was linked to the recent introduction of segmentation and league tables within the sector.
Ms Holden reflected on the cultural shift to manage the financial position. There had already been change across care groups and directorates in regard to the responsibilities and accountability of budget management and financial reporting, a position which would require to be sustained.
Regarding future planned growth funding and margin target by £3,300,000 in 2026 to 2027, and then £2,600,000 every year thereafter, which must be achieved to keep savings requirements. Mr Lewis requested more detail on how they would be achieved and recognised the cultural change in budget management which Ms Holden reflected on earlier. Mr Lewis acknowledged the assumption there would be an annual shortfall related to pay awards and asked Mr Mohammed to expand more on how that would be addressed.
Mr Mohammed responded the tariff deflator was in line with the national requirement and annual baselines to be delivered. The overall cost improvement programmes (CIP) delivery required was the figure that included the tariff deflator.
Responding to Mrs McDonough, Mr Mohammed advised there may be opportunities to utilise cash on capital spend and investments may arise, although there was no specific national guidance.
Mr Mohammed acknowledged Ms Holden’s reference to cultural change and budget management. He advised a directorate had its budget delegation removed whilst support and remedial action was provided, before returning the budget to the directorate. Mr Mohammed admitted some directorates were able to manage budgets better than others with continued development, upskilling and support in place for colleagues.
In response to Mr Lewis, Mr Mohammed explained the plan to achieve a balanced budget over three years, requiring cost improvements, marginal growth, and assumptions including national pay awards and funding. The plan included identifying £10,000,000 in savings for 2026 to 2027 and income growth to sustain financial balance. Mr Mohammed acknowledged the level of savings required was not sustainable and opportunities would have to be identified to achieve a balanced plan. The high dependency unit would be a sizeable investment and income, with potential to expand new services in future years. The key assumption for pay award presumed that would continue for next 4 years and were based on existing arrangements, which had been in place almost 4 years.
Mr Lewis drew the board’s attention to the £11,100,000 of growth and margin target over a 4-year period. He confirmed conversations would commence over the coming months related to future investments, income generation and service developments from 2026 to 2027 and beyond.
The board noted and discussed the key assumptions contained within the financial plan and noted the requirement to identify £10,000,000 of savings in 2026 to 2027, and the income growth needed to sustain underlying financial balance.
The board approved the medium-term financial plan, recognising routine reporting against these assumptions would then become part of how the Finance, Digital and Estates Committee operates.
2026 to 2027 savings programme
Reference
Board public: 25/09/23.
Mrs Lavery introduced the paper and acknowledged there may be colleagues observing with anxiety or interest to the issues. Mr Lewis had also set out in early September the forward financial ask in his video log for staff and partners.
Ms Holden explained, although there had been significant savings made in the last three year with delivery of cost improvement programmes (CIP) plans, there had been ongoing discussions regarding the need for significant savings over the next three years and route to financial stability and in view of the NHS financial reset and large-scale system change. Ms Holden recognised the challenges and anxieties this could create amongst colleagues and the need to ensure meaningful engagement and consultation through the changes. The process to develop detailed savings plans would commence during October, November and potentially early December, where executive colleagues and care group leaders would work together to develop saving schemes. Any schemes would likely begin in quarter 4 to give enough time to work through the detailed planning, staff engagement and consultation, and engagement with trade unions.
Dr Graham advised the savings schemes would be developed with clinical leadership colleagues and the board collectively and acknowledged they would be discussed in an open and honest way. Future plans required to be patient focused and would consider what services the organisation could deliver and which services could be delivered in partnership. Dr Graham stated this was a very different way of working which some colleagues may find difficult. Any consultation process would have to ensure people were psychologically safe as possible in a formalised way to reduce trauma.
Mr Lewis referred to the 2026 to 2027 savings programme schemes considered and agreed in July, and recognised one scheme, the removal of recruitment and retention premia (RRP) payments, would result in some staff being paid less from March 2027. Mr Lewis recognised it was conceptually difficult to understand the proposal that community teams may become smaller. It was also the case that there were a very large number of community teams working in different ways. It was the case that not every provision of community services was sustainable especially when the model had no income methodology and each may be impacted by the move to neighbourhood work. There was significant variability between the geographies and service provision across the communities, and there was need to get the right balance. Mr Lewis confirmed the key elements needed to have a fully worked up plan for each scheme by the end of November.
Regarding the backbone changes, Mr Lewis explained there was a material and historical backbone indicator since 2023 by opportunistically removing cost. What had been described was choices for the future function and although the potential schemes were not a definite list of options, he cautioned some may not proceed but could not be ruled out either.
Following a question received ahead of the meeting from a member of staff, Mr Lewis stated it was important to recognise communication with staff and trade union partners, to create safe and open spaces for discussion and allow colleagues to put forward thoughts and ideas. In response to the staff question, the board had committed through promise 25 to employ within the local community. Mr Lewis acknowledged indicators would include localism. Mrs Lavery agreed and that the organisation was an anchor institution and one of the largest employers across the geographies served. She stated the Board would work to offer meaningful employment opportunity to the communities and would work to minimise losses where possible. Mrs Lavery gave assurance that the board collectively understood its role and responsibility as an employer to the local communities.
Mrs Lavery gave her thanks to those colleagues who were tasked with these plans and its purpose, to ensure future services were offered in an effective and efficient way for communities, whilst offering value for money. Mrs Lavery reinforced it would be the board’s collective responsibility to have a fully worked up plan.
Mr Chillery raised concern as to what risks were anticipated in the delivery of the savings schemes. He asked what was meant by regular communications and how to ensure staff were aware of plans, and queried what indicators would be in place to monitor any impact on the delivery of promises.
Dr Sinclair stated, although some services would provide good care, the overall aim in change was to deliver safe and effective care.
In response to Mr Chillery, Mr Gowland referred to the strategic delivery risks and noted these may need to be reassessed should the board feel necessary there was a significant risk.
Mrs McDonough referred to the future changes to corporate functions and noted some functions would come to end with others redesigned. There would be choices made on what forms of work would stop.
Responding to Mr Chillery, Mr Mohammed referred to promise delivery and the associated risks. The key elements of the savings plan were required as part of the overall medium term financial plan. As part of that plan there was a commitment to invest £3,000,000 as part of promise delivery. Mr Mohammed emphasised the importance of tracking the impact on organisational promises and maintain a balance between disinvestment and reinvestment. Mr Mohammed reflected on learning from previous savings schemes, some were either partly or not delivered, and the risk of non-delivery of future schemes. Referring to capability and capacity, he suggested the provision of a project management office (PMO) function to ensure monitoring of any impacts to change and planned productivity.
Mr Lewis advised there were data tracking systems in place linked to the promises, with ability to track those consequences and adjustability in real time that would be used to mitigate against risk. Mr Lewis cautioned there may be emergent risks related to the level of staff moral and management bandwidth, rather than the actual delivery of saving schemes identified. Mr Lewis suggested there was risk in the management bandwidth to delivery and risk to recruitment.
In response to Mr Vallance in relation to preventative ill health, Mr Lewis stated the current provision could be described alternative rather than preventative, and that preventative thinking would have to be created and built in the following 3 years.
Dr Graham referred to Mr Chillery’s comments regarding risk and impact. She explained it would be necessary to undertake a pragmatic review of safety and efficiency to support service change by undertaking quality and safety impact assessments. Dr Graham noted the achievements made in terms of the pay awards, the National Living Wage, and Real Living Wage. The quality and safety impact assessment (QSIA) process would be part of ensuring lower paid clinical staff were not disadvantaged through change.
Regarding staff communications and in response to Mr Chillery and Ms Fountain, Mr Lewis recommended plans to improve communication with staff and line managers to include consistent and regular updates and position statements, with frequently asked questions and myth busting, and create safe spaces for discussion and response. Mr Lewis stated there were plans to involve leaders through those communication plans with the leadership development time. Mr Forsyth highlighted the importance to state the savings programme was fundamentally about the route to financial sustainability. The board supported the need for transparent and consistent messaging, especially through line managers.
Mr Lewis summarised in November the board would need to focus on what changes to workflow were needed as appose to what workforce changes were needed. Regarding implementation capability, Mr Lewis agreed to develop a temporary project management office (PMO) proposition to support this work in a centrally multi professionally led function. Mr Lewis stressed it was important the board was clear it could not rule out redundancies in the future.
The board would receive an update at its next meeting in November and acknowledged an additional Board meeting may be required prior to quarter 4.
The board received and noted the 2026 to 27 savings programme and noted the requirement in the long term financial model to identify £10,000,000 of savings and deliver £7,500,000 in year to achieve underlying financial balance.
The board noted and discussed the progress made to date in identifying the schemes and indicative values to meet the £10,000,000 target, and the planned work during quarter 3 and 4 required.
The board had discussed the key elements of work needed to have a fully worked up plan for each scheme by the end of quarter 3, including the delivery infrastructure to achieve the target savings.
Action
Toby Lewis.
Estate plan
Reference
Board public: 25/09/24.
Mr Mohammed presented the paper and highlighted the four areas of focus during the second half of the year.
The Rotherham estate options required engagement with external partners to look at alternative space and estate development. The estates funding model would need to be identified.
Mr Lewis noted the timeline for estate developments may coincide with staff consultations, job changes, and would require careful communication to manage perceptions and maintain trust.
In response to Ms Gillatt’s query on future capital works and cost management, Mr Mohammed referred to the indicative costs for estate repairs provided by Shared Agenda. He discussed recent capital investments and works undertaken at Swallownest Court, the need to reduce future repair costs through strategic estate investment, and the importance of balancing investment across different sites to ensure equity. Mr Lewis advised the hypothesis of the estate plan would be from 2028 there would be more capital available on digital transformation than what was required for estate. The estate plan would need to reflect remote working streams, with the expectation that these would support productivity and efficient use of space.
In response to Mr Gowland, Mr Mohammed described the work required to bring an outline business case for the estate plan by March, to include independent options appraisal, funding model development, and visual layouts for future site configurations.
The board received the estate plan and noted the areas of work outlined in the paper that need to be progressed over the second half of the year (H2) to bring an outline case before the board in March 2026.
Action
Toby Lewis.
Further update on community mental health services (adult)
Reference
Board public: 25/09/25.
Mr Lewis presented the paper which provided a further update on adult community mental health services.
Improvement work had been identified following a review of the quality of care in some community mental health services. Mr Lewis drew attention to the level of current insight amongst board members and how they could develop a shared knowledge base through which to support teams with improvement work in the year ahead. Mr Lewis recommended holding a structured discussion with board members in October time out.
Although there were a series of areas of good working practice in community teams, it was acknowledged there were other areas for improvement after an independent review of a specific patient’s care. Issues were identified such as baseline capabilities and care planning. Mr Lewis explained an improvement programme for community-based services would be developed and would return to the board in January and March to outline the approach.
Mr Vallance acknowledged the complexity of community mental health services and the difficulty in conceptualising pathways compared to inpatient services. There was an agreed consensus for better mapping and education to support informed decision-making.
Mr Chillery welcomed the paper and explained the infrastructure of data mapping required improvement across community mental health services, as they were less developed and brought challenge in case allocation.
Ms Fulton Tindall supported the need to better understand community services and for the board to create space to understand the complexities, pathways and modelling of services. Mr Lewis stated some of those community pathways required to be made more intuitive for both patients and for general practise. Mr Chillery reflected on the complexities of community care provision as well as services provided by partners. Mr Lewis stated it may also be the case that some community teams were retaining people in services and unclear what value was being added.
Regarding the assertive outreach services, Mr Lewis advised that commissioning patterns were different across the geographies. There were un-commissioned gaps across the North Yorkshire and Humber Integrated Care Board. The initial effort on the neighbourhood working pilots would be narrow and focused. The improvement journey would build on the neighbourhood work and would help support community mental health services. This would involve constructing a model with partners and be explicit what resource would be available.
Ms Gillatt stated she recognised there was no fixed model of community mental health provision and the organisation worked in a dynamic space. Mr Lewis explained that difficult change would be required and recognised firstly the need to understand the current state of community services and to document service provision more clearly. Dr Graham advised services were research informed with evidence-based interventions, and some could be flexible in how they were delivered.
The board received and noted the community mental health services (adult) update on thinking regarding improvements for patients and recognised the synergy between this work and wider neighbourhood working agenda. It agreed to utilise time at the forthcoming timeout to discuss its collective knowledge base.
Action
Toby Lewis.
Integrated quality performance report (IQPR)
Reference
Board public: 25/09/26.
Mr Chillery introduced the integrated quality performance report (IQPR) for August 2025.
Access to children’s services and referral to treatment (RTT) both physical and mental health remained strong performance. There had been significant improvement in performance related to section 136 (as discussed under item board public 25/09/10).
Mr Chillery advised it was important to note the metric for Talking Therapies had been adjusted by 12% to increase approximately 2,000 access contacts. The Talking Therapies service operating hours had been extended to improve access, but this may impact on the reliable improvement score.
The new metric length of stay was the average days inpatients spent in care. Although the baseline reported 123 days, Mr Chillery confirmed that figure had since reduced to 65 days and the target to achieve was 32 days. He cautioned the fluctuation in data linked to two patients who had been inpatients for some time and since discharged from the ward. A further metric had been included to measure the percentage of inpatients over 32 days length of stay, to better understand demand and capacity. Mr Chillery referred to the daily review of access to urgent community response service, with work underway whilst data validation was completed.
There had been an increase in ligature incidents. A deep dive showed they related to 2 patients with incidents of repeated self-harm, and supportive interventions were now in place.
The target for performance development reviews (PDRs) completed had continued to improve. The level of sickness was above target related to Rotherham care group, with support being provided to reduce sickness levels.
Mr Lewis noted the consistent achievement of the referral to treatment (RTT) target which was reportable both regionally and nationally.
The board received and noted the integrated quality performance report.
Health inequalities review of the integrated quality performance report (IQPR)
Reference
Board public: 25/09/27.
Mrs McDonough presented the paper which provided an analysis of the integrated quality performance report data through a health inequalities lens.
The data focused on year-to-date 2025 to 2026 and the overall conclusion was not significantly different to the data shown from 2024 to 2025. It showed not all services reflected the communities served and people with protected characteristics.
There was work underway to develop data and the recording of ethnicity to help understand whether some services were more restrictive than others or culturally appropriate.
In response to Ms Fountain, Mrs McDonough advised the comparison of data was internally compared to population data for Rotherham, Doncaster and North Lincolnshire.
Mr Forsyth referred to interpreter services and noted there had been an increase in usage, with the top five languages used were Polish, Slovak, Arabic, Romanian and Turkish. In response to Mr Vallance, Mrs McDonough explained the health inequalities data was presented to the Equity and Inclusion (E&I) Group for analysis to help build on the work required to deliver promises under the equality and inclusion plan. There was a disproportionate number of patients from ethnic minorities in some mental health services, as well as an increase in patients in services from deprived areas. Mrs McDonough explained the action underway to provide target, culturally appropriate services.
The board received and noted the health inequalities review of the integrated quality performance report and noted the comparison of the integrated quality performance report data to our local population, against four of the protected characteristics.
Strategic delivery risks (SDRs)
Reference
Board public: 25/09/28.
Mr Gowland presented the report and highlighted the key developments made.
The publication of the NHS 10-year plan would be considered alongside any further guidance before being able to confirm any changes to current strategic delivery risks and whether additional strategic delivery risks may be required. Mr Gowland noted the reference to neighbourhoods and 7-day working, matters which the organisation was working to address through its plans.
Progress had been made with respect to controls and assurances for each strategic delivery risk. Mr Gowland drew attention to the slight adjustment to the timeframes for achieving the target scores through 2025 to 2026.
Mr Lewis referred to the shifting of mitigation timescales and cautioned some controls would be harder to advance than others which may require more resource.
The board received and noted the update position for each strategic delivery risk and noted the intended review of strategic delivery risks following the full consideration of the NHS 10-year Plan and the expected additional guidance documentation.
Operational risk report
Reference
Board public: 25/09/29.
Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Gowland.
Mr Vallance noted the report was to ensure the board had oversight of operational risks which required escalation. Mr Gowland responded the Risk Management Group (RMG) reviewed those operational risks which sat outside of tolerance on a monthly basis. The Risk Management Group provided direct scrutiny, challenge and supportive action where required. The clinical leadership executive also received those operational risks outside of tolerance, and the board were required to be sighted on risks which sat outside of tolerance. The Risk Management Group role would continue to provide that additional scrutiny work with risk owners.
Mr Lewis requested future reporting to include mitigation timescales for when they would expect those risks to become tolerated.
The board received and noted the operational risk report and noted the revised reporting thresholds based on risk appetite and the planned work to address the extended number of risks that are currently outside of appetite and tolerance.
Action
Philip Gowland.
Promises and priorities scorecard
Reference
Board public: 25/09/30.
Mrs Lavery invited colleagues to take the paper as read and opened up for discussion and questions for Mr Lewis.
There were no questions raised. Mr Lewis drew attention to the league table, the key updates and measures for success, and how the work of the promises delivered would need to be sustained. Mr Lewis stated the importance of evaluation to identify any areas for improvement and sustainability.
The board received and noted the self-assessment provided, augmented by the narrative within the promises and priorities scorecard. The board noted the specific updates offered in the report itself, with a focus next time on promises 1 and 2. The board noted the celebrations held in July for promise 25 and intended in October for promise 3.
Supporting papers (previously presented at committee)
Supporting papers
Reference
Board public: 25/09/31.
Mrs Lavery informed the board of the mortality report for information which was presented as a supporting paper that had previously been presented at quality committee level for scrutiny and challenge.
The board received and noted the mortality report for information.
Any other urgent business
Reference
Board public: 25/09/32.
There was no further business raised.
Action
Philip Gowland.
Any risks that the board wishes the risk management group (RMG) to consider
Reference
Board public: 25/09/33.
To ensure risks related to racism and communication around the savings plan were adequately captured and monitored.
Action
Toby Lewis.
Public questions
Reference
Board public: 25/09/34.
In response to a public question on behalf of the People Focused Group (PFG) related to accessing neurodiversity services, people’s right to choose alternative providers, and the assurance of quality standards for external suppliers. Mr Lewis advised discussions were ongoing with South Yorkshire Integrated Care Board which would require all suppliers to meet quality standards and maintain separate waiting lists for diagnosis and treatment, aiming to address current gaps in service continuity.
Mr Lewis agreed to work with People Focussed Group and peer support workers to develop clear interim guidance for service users seeking neurodiversity services, ensuring they received accurate information about their options.
Closing statement
Reference
Board public: 25/09/35.
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: December 10, 2025
Next review due: December 10, 2026
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