Minutes of the council of governors meeting public session
Wednesday 5 March 2025 at 3pm to 5pm.
The Council Chambers Doncaster and via Microsoft Teams.
Present
- Kath Lavery, Chair
- Joy Bullivant: public, Doncaster
- Joan Cox: patient or carer
- Jennie Gaul: staff, Physical Health Care Group
- Kym Gleeson: partner, Health Watch Rotherham
- Lee Golze: partner, City of Doncaster
- Prachi Goulding: staff, North Lincolnshire Care Group
- Hannah Hall: public, Rotherham
- Ann Llewellyn: patient or carer
- Chris Pope: public, North Lincolnshire
- Emma Price: partner, South Yorkshire Integrated Care Board
- Richard Rimmington: public, Doncaster
- Ian Spowart: patient or carer
- Debra Taylor: partner, voluntary sector
- Kamlesh Vatish: public, Rotherham
- Maureen Young: public, Doncaster
In-attendance
- Rachel Blake ,Non-Executive Director
- Richard Chillery, Chief Operating Officer
- Sarah Dean, Corporate Assurance Officer (minutes)
- Dr Richard Falk, Non-Executive Director
- Steve Forsyth, Chief Nurse
- Sarah Fulton Tindall, Non-Executive Director
- Kathryn Gillatt, Non-Executive Director
- Philip Gowland, Director of Corporate Assurance and Board Secretary
- Carlene Holden, Director of People and Organisational Development
- Janusz Jankowski, Non-Executive Director
- Toby Lewis, Chief Executive
- Jill Savoury, Deputy Director of Finance
- David Vallance, Non-Executive Director
- Pauline Vickers, Non-Executive Director
Public and staff
- Glyn Butcher, People Focus Group
- Pippa Harder, Stag Medical Centre
- Graham Keeton, People Focus Group
- Noma Makhanda, Professional Lead for Occupational Therapy and Deputy Chief Allied Health Professionals
- Samantha O’Brien, public
- Paula Rylatt, Head of Quality and Promises
Welcome
Reference
Council of governors: 01/03/25.
Kath Lavery, Chair, opened the meeting and welcomed all attendees.
Quoracy and apologies for absence
Reference
Council of governors: 2/03/25.
Kath declared that the meeting was quorate.
Apologies were received from Governors, Cllr Linda Beresford, Dr Dean Eggitt, Kevin Hodgkiss, Dr Michael Seneviratne, Champion Solesi and Victoria Stocks; and from Dr Diarmid Sinclair, Medical Director, Dr Jude Graham Director for Psychological Professionals, Izaaz Mohammed, Director of Finance and Estates, Richard Banks, Director of Health Informatics and Jo McDonough, Director of Strategic Development.
Declarations of interest
Reference
Council of governors: 3/03/25.
Members were reminded to check their declarations of interest and inform Philip Gowland if any updates were required. There were no changes to the declarations of interest and no further declarations were made in respect of the agenda items for this meeting.
The council of governor’s received the declarations of interest.
Minutes and actions of the previous meeting held on 4 December 2024
Reference
Council of governors: 4/03/25.
The council of governors approved the minutes of the previous meeting as an accurate record.
The council of governors reviewed the action log, updates were noted and the proposed to close actions agreed. There were no other matters arising.
Trust performance: committee reports from committee chairs and governor members
Reference
Council of governors: 5/03/25.
Governors attend as members of four of the committees. This aligns to promise five. The chairs were asked to give an overview of activities:
Finance Digital and Estates Committee
Pauline Vickers highlighted that with respect to estates, that fire safety remained an area of focus with a targeted approach for high-risk areas going forward through 2025. The committee received updates on capital plans and business cases previously approved, namely Waterdale in Doncaster and Elizabeth Quarter in North Lincolnshire, with lease agreements to be secured within the financial year. Finance performance at month 9 and 10 was considered and a key area within the delivery of savings plans was the reduction on agency spend and the filling of vacancies. The financial plans were as expected with an end of year deficit circa £340,000. There was slippage in the capital plans regarding Great Oaks which would move into next year’s plans, with other capital project plans being brought forward such as IT equipment. The capital budget for the next year was around £5,000,000. The committee were assured by the digital clinical coding audit, and the accuracy of the coding reported a very high standard.
In response to Maureen Young, Toby Lewis confirmed there were plans to refurbish Hazel and Hawthorne Wards within Tickhill Road Hospital. As Magnolia sits beside those wards, it would need to relocate and work was underway on a business proposition to look at acquired brain injury patients and their care across South Yorkshire. Toby advised discussions remained ongoing with South Yorkshire Integrated Care Board about what the future of those services would be, whilst working with the care group director who was responsible for the service on a potential interim move of Magnolia in early 2026. Toby summarised work was underway for all estates plans across Rotherham, Doncaster and North Lincolnshire, and Governors would receive further updates in the future.
Richard Rimmington provided feedback as a member of the committee, noting all reports were well written and easy to understand. Richard reflected on the discussions from the last committee regarding access to information and how information was shared with stakeholders and the public such as the estates plan communication.
Rachael Blake left the meeting at 3.20pm.
People and Organisational Development Committee
Pauline Vickers, on behalf of Rachael Blake, gave highlights from the last People and Organisational Development (POD) Committee. The new Supporting health, wellbeing and managing attendance policy would launch on 1 April 2025 to provide support to colleagues. The vacancy rate was reported at 3.3%, closing in to the target of 2.5%. The committee discussed the importance of filling vacancies and the various recruitment strategies in place, including apprentice open days and community health bus events. The turnover rate had slightly reduced to 10% and indicated a positive trend. The committee noted the importance of continuing efforts to retain staff and reduce turnover further. The Guardian safe working hours report highlighted new hybrid working arrangements and feedback on exceptions, such as late finishes and missed educational opportunities. The committee emphasised the importance of addressing those issues to ensure safe working hours for doctors.
Jo Cox stated she was pleased to hear the vacancy rate was closer to target and queried what plans were in place to reduce the vacancy rate. Carlene Holden explained she was confident the recruitment plans and offers in the system would achieve the target, working on some of those hard to recruit areas with different recruitment strategies such as recruitment and apprentice open days, expansion of nursing assistants and holding student qualification type events by taking the health bus into the community. Toby advised the organisation was focused to keep vacancies below 100 at any time (compared to 159 vacancies at present).
Richard Rimmington provided feedback as a member of the committee, noting at the last meeting that the number of Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) incidents had reduced in the last quarter and the reports were understandable and educating to him.
Public Health, Patient Involvement and Partnerships Committee
Dr Richard Falk, on behalf of Dave Vallance, stated a key highlight from the committee was the community involvement framework. The three poverty proofing pilots had been successful with work underway to understand how all services across the organisation could be poverty proofed such as in respect of transport and cost of travelling to appointments. Dr Falk highlighted the importance of issues faced across communities and the need to poverty proof services. Toby noted the community involvement framework involved partners, communities, the council of governors and therefore recommended this as an agenda item for a future meeting of the council of governors.
Quality Committee
Dr Falk highlighted the committee focused on five recommendations identified from the Greater Manchester Mental Health NHS Foundation Trust independent review as relevant to Rotherham, Doncaster and South Humber NHS Foundation Trust. A baseline position was presented of improvement works undertaken over the last year. It was noted that similar work was underway following the findings from the Care Quality Commission (CQC) rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT), its assertive outreach service and disengagement with services. The patient safety report was considered alongside the importance of ensuring learning from patient safety incidents was consistently embedded and sustained.
Jo Cox reflected it was positive to hear the good practice and culture of learning from patient safety incidents both internally and externally, recognising not all risks could be eliminated but rather minimised wherever possible.
Trust People Council
Kath Lavery, on behalf of Dave Vallance, highlighted the Trust People Council (TPC) discussions on flexible working and the importance of ensuring that staff were not bullied or discriminated against in the workplace. Staff governors were also welcomed at the Trust People Council for the first time. The real living wage would be paid from 1 April 2025. Toby welcomed anyone to contact him should they require further information and support relating to the real living wage.
2024 to 2025 annual report and associated matters
Reference
Council of governors: 6/03/25.
Kath Lavery highlighted the importance for the council of governors to take the opportunity to raise and make any recommended suggestions in advance of the finalisation of the documents during April and May, prior to its publication in July 2025. It was noted a public-facing, easy read version would also be produced. The report provided an annual summary of key materials as well as what was planned over the next year.
Toby Lewis highlighted the key themes for the annual report and subjects which would be reflected on. The importance of balancing positive and candid less positive information was emphasised. Key themes to draw out within the annual report would be the improved vacancy rates, staff survey results, financial performance overall and underlying deficit of £6,900,000, investments and savings plans, increased engagement and hearing the voices of patient and community with Care Opinion and involvement opportunities. Toby acknowledged there could be parts the communities that feel they are still not heard or engaged. Safety and quality governance would be a priority moving forward, with the development of new quality numeric measures. The roll-out of Dialog+ replaced the care programme approach and he anticipate this would also provide quality outcome data. The diversity of those working with us had positively changed with growth in peer support workers and volunteering across services. Although the work on addressing health inequalities was slightly behind what was expected, work would continue in respect of homelessness, rurality and veterans. Progress on the delivery of promises and priorities overall would be reflected on with People Focussed Group (PFG). Leadership arrangements had changed and would continue to do so, recognising the significance of clinical leadership to shape the services delivered across the organisation. Toby welcomed the council of governors to provide feedback on the suggested key themes to be included within the annual report and associated matters.
David Vallance questioned whether there would be an opportunity to reflect the context we work in. Noting that referrals continued to rise with respect to eating disorders and school nursing, the aging populations that are served, working with partners and government funds whilst balancing the wellness of people in communities. Toby suggested a discussion at a future Public Health, Patient Involvement and Partnerships Committee on this topic would usefully help how it was framed in the annual report.
Lee Golze also recommended a reflection on the significant changes in reform policies, the direct impact on how care was provided and services transformed in the communities for children, young people and adults in Doncaster.
In response to Ian Spowart, Toby advised an easy read version of the annual report would be produced for members of the public. In response to Maureen Young, Toby reiterated the board’s commitment to connect with partners including voluntary services, aiming to support people’s needs and to be holistic.
The Council of Governors received and noted the annual reporting and associated matters on 2024 to 2025, noting finalisation of these documents during April and May
Out of area placements (promise 19)
Reference
Council of governors: 7/03/25.
Richard Chillery gave a presentation and overview of promise 19 with plans to end out of area placements as part of supporting people to be cared for as close to home as safely possible. Work was underway to focus and improve bed management functions, admissions, discharges, lengths of stay, and care in the community. This also included complex cases and identify barriers to improve the quality and flow of inpatient care. A high-quality therapeutic inpatient taskforce was underway and meeting monthly, under the chairmanship of Toby Lewis.
In response to Maureen Young, Richard advised there had been collaborative improvements and investment across South Yorkshire in regard to the provision of section 136 under the Mental Health Act through an additional suite (in Sheffield) and the adoption and delivery of 24 hour (maximum use) metrics. Data showed the organisation was short, on average, of 22 inpatient adult mental health beds per day. There was capacity and demand improvement work underway to address and improve patient flow pathways, length of stays and the review of complex cases. The work would also provide opportunities working with our partners and systems, so people can return safely to home, as well as supporting the community offer and having the right safe space provision.
The council of governors was reminded that the board had previously agreed to take the financial risk for inappropriate out of area placements. Toby and Richard explained the admissions assessments and processes, with many admissions and decision-making made out of hours and during weekends, with many decisions made by services outside the organisation. This would be an important dynamic to work through and Toby anticipated incidents may rise and risk taking within the communities would require change over the coming years. There was no current process to discharge safely on weekends or out of hours, so there was need to change practice and culture, working with partners in order to ensure quality care was provided seven days a week.
In response to Lee, Richard clarified that a Doncaster resident admitted to a mental health inpatient unit in Rotherham would not be deemed as an inappropriate out of area placement.
Steve Forsyth referred to national enquiries and recommendations made relating to out of area and length of stay. Benchmarking data suggests the average length of stay was 32 days, Steve acknowledged there were opportunities to learn from those areas.
Debra Taylor referred to partnership working, stating there would be responsibility for local services to be part of this. There were some non-clinical charitable and voluntary specialist services available to provide wrap around care for families, building those local relationships with communities and bringing people back into area appropriate for their care and stable transition. Debra supported the need for culture change and putting trust in partners.
The council of governors received and noted the progress made against promise 19, and plans to end out of area placements.
Trust membership: a revised approach (promise 5)
Reference
Council of governors: 8/03/25.
Phillip Gowland presented the revised membership approach that, in line with promise 5, would systematically involve communities at every level of decision-making within the organisation. Three main parts for focus were current membership, the future of membership and what the offer was. Membership had been built across the organisation since becoming a Foundation Trust in 2007. There was a recognised need to create more opportunities amongst communities, grow involvement and collaboration with partners such as the People Focussed Group. Views had been sought and a survey undertaken regarding membership and awareness. Phil summarised the proposed membership offered three different levels of membership dependent upon individual’s appetite for involvement and engagement, each level offering the respective member an increasing benefit or reward for being a member.
Steve Forsyth stated the membership offer had to get people across communities interested, enthused and engaged, ensuring people representing the membership had connection with the council of governors. Steve reflected on the successful launch of the Trust People Council and engagement with members of the council of governors provided another level of engagement. Steve suggested that governors could engage with Care Opinion in order they could hear the voice of the public.
Ian referred to the gaps in membership between young people, older people, and people from an ethnic background, and was supportive for the need to refresh membership. Maureen queried what targets NHS trusts had in terms of number of members and whether there were any national statistics. Steve replied he was aware other organisations had achieved 10,000 members, but cautioned what was meaningful activity and what difference they had made. More engagement from a smaller number may be a better approach. Steve was also aware the organisation was capturing protected characteristics data when registering all members. Ann referred to older people and barriers of being disadvantaged due to technology. Steve responded there had been a successful volunteer recruitment in older people after the organisation wrote out to people with letters via post.
Jo Cox commented it was positive to see membership would have a refresh and she was aware there was a need to increase young people representatives. It was important to focus on incentives for younger people and what membership offered such as shadowing and learning opportunities to prepare them for entering employment.
The council of governors received and noted the revised approach to membership (promise 5) and noted the intention of providing further updates later in the year.
Trust update: regular reports
Reference
Council of governors: 9/03/25.
Chairs report
The council of governors received and noted the chairs report, there were no additional comments.
Chief executive’s report
The council of governors was made aware that the 2025 to 2026 national pay awards may not be fully funded, hence creating a cost pressure. The board had approved £6,000,000 in savings plans in January, with a further £4,000,000 of savings plans to be presented to the board in March.
Other committee reports (audit, Mental Health Act and remuneration)
The council of governors received and noted the report, there were no additional comments.
Governor activities
Reference
Council of governors: 10/03/25.
The council of governors received and noted the report, there were no additional comments.
Any other business
Reference
Council of governors: 11/03/25.
There was no other business.
Public questions
Reference
Council of governors: 12/03/25.
Graham gave thanks and recommended there was need to hear more people’s voices and those with lived experience.
Date, time, and venue of next meeting
Reference
Council of governors: 13/03/25.
Wednesday 11 June 2025 at 4:30pm.
Page last reviewed: September 02, 2025
Next review due: September 02, 2026
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