Contents
- Introduction
- Patient or staff story
- Standing items
- Board assurance committees
- Operating performance, governance, and risk management
- Supporting papers (previously presented at committees)
Minutes of the board of directors meeting on Thursday 25 July 2024, 10am at:
Scunthorpe United Football Club
Glandord Park
Scunthorpe
DN15 8TD
Present
- Kathryn Lavery, Chair.
- Clare Almond, Interim Deputy Director of People and Organisational Development.
- 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
- Dr Janusz Jankowski (virtually attended), Non-Executive Director.
- Dawn Leese, Non-Executive Director.
- Toby Lewis, Chief Executive.
- Izaaz Mohammed, Director of Finance and Estates.
- Dr Graeme Tosh, Medical Director.
- Dave Vallance (virtually attended), Non-Executive Director.
- Pauline Vickers, Non-Executive Director.
In-attendance
- Richard Banks, Director of Health Informatics.
- 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.
- Lea Fountain, NeXT Director.
- Laura Brookshaw, 360 Assurance.
- Lisa Connor (virtually attended), Corporate Nurse Director.
- Sarah Dean, Corporate Assurance Officer (minutes).
- Dr Andrew Heighton, Medical Director, North Lincs Adult Mental Health and Talking Therapies Care Group.
- Iona Johnson, Care Group Director, North Lincs Adult Mental Health and Talking Therapies Care Group
- Ian Spowart (virtually attended), Governor.
- Philip, Staff Story.
Introduction
Welcome and apologies
Reference
Mrs Lavery welcomed all attendees to the meeting. Apologies for absence were noted from Carlene Holden, Director of People and OD and Rachael Blake, Non-Executive Director.
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. Whilst there is already a record of Ms Gillatt’s work with NHS Business Services Authority (NHSBSA), for complete openness and transparency Ms Gillatt has declared that NHSBSA makes payments related to NHS Training Grants and bursaries to individuals, and has been commissioned to develop a system for medical examiners to use when reporting deaths and the Medical Examiner’s Office.
The board received and noted the changes to the Declarations of Interest report.
Patient or staff story
Reference
Staff story, apprenticeships
Mrs Lavery welcomed Philip to the meeting who was invited to share his story and apprenticeship experience.
Philip gave thanks to the board for inviting him to hear his story. He provided details of his early career and the circumstances that led him to consider and secure a bank role in Doncaster adult mental health. He noted as he progressed, he took an opportunity in 2018 to start an apprentice journey through the Trainee Nurse Associate (TNA) Foundation Degree Apprenticeship Programme. Within a variety of placements, he developed a passion for rehabilitation and in particular he reflected on how much he enjoyed his work on Magnolia Lodge to acute mental health or general nursing. Progress and development continued through a Qualified Nurse Associate (QNA) role on Magnolia, securing a trust GEM Award on the way and he has since gone on to undertake the registered nurse degree apprenticeship programme and qualify as a registered general nurse (RGN) (March 2024). Most recently Philip noted he was awarded the South Yorkshire (SY) apprenticeship of the year award in health and social care and was applying for a band 5 development post on the ward.
Philip responded to a number of questions from the board, noting within his responses the importance of support both at home and at work to apprentices, to better place them to succeed. This support maybe emotional support but also dedicated time and opportunity to complete studies alongside working in his role. Financial support to make courses and opportunities possible was also very much appreciated and Philip was pleased to hear about the trust’s commitment to the full use of the apprenticeship levy. He noted that since joining 10 years ago, he had always felt supported by management and leadership teams, any issues he came across were dealt with quickly and was encouraged to further develop his roles within the trust.
Dr Tosh referred to Philip’s skillset, being a qualified nurse as well as a chef, and the importance of nutrition and invited Philip to consider being involved with the Grounded Research team and the nutrition research on the ward. Philip confirmed he would be interested to be involved, and was aware of some of the research studies being undertaken in Doncaster. Dr Tosh agreed to share details outside of today’s meeting.
Dr Graham referred to the trust’s expansion of its education offer and was interested to hear from people with lived experience of carers, and how the education offer could encourage more people to bring that lived experience to experts in education as well. Philip suggested any experience can be pulled from anywhere and by anyone, whether volunteering or lived experience of caring for people at home and the community and encouraged employers to support and empower people to progress through an apprenticeship course. Mrs Lavery and the board thanked Philip for taking the time to speak about his experience and noted the intended reflection time later on the agenda.
Standing items
Minutes of the previous board of directors meeting held on 30 May 2024
Reference
The board approved the minutes of the meeting held on 30 May 2024 as an accurate record, subject to a minor wording amendment (page 13 Minute Item 24/05/20 reference to Mr Falk to change to Dr Falk).
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.
Mr Lewis referred to
Reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR) information (closed action board public 24/03/13) and requested RIDDOR was included on the board’s work plan (bi-annual reporting).
Action
Board assurance committees
Report from the Finance, Digital and Estates (FDE) Committee
Reference
Mrs Vickers presented the paper highlighting 3 main areas under the remit of the Committee.
There had been focus on the performance of the finance and savings plans previously approved by board, as well as scrutiny of mitigating risks against the savings plan. The finance plan showed a planned deficit of £3.6m. There were five areas of risk including a cost pressure of £1.1m in respect of energy inflation. Plans to mitigate energy inflation were being developed and form part of the trust’s savings plan. Mr Lewis clarified there had been an estimated £1.1m increase in energy costs and that additional funds, totalling £800k, had been budgeted for to offset this. The mitigating actions continue to help manage the £300k financial risk.
The committee were content that audit recommendations were being responded to appropriately and noted that the work on the IQPR received significant assurance in relation to its functionality and being fit for purpose.
Business cases received and approved were in respect of Great Oaks and Waterdale (Doncaster) and the committee would be kept informed of progress via future capital reports.
Great Oaks, capital phases 1 and 2 were noted in respect of improving staff and patient areas and it was agreed by the committee to proceed with Phase 3 and 4 in respect of the creation of two additional bedrooms, a crisis assessment centre and other associated work including office space.
Waterdale, the relocation of children’s services into a central space in Doncaster City Centre was to proceed subject to completion of the impact assessment.
Mr Banks reflected on the data security and protection toolkit (DSPT) audit recommendation and confirmed the completion of the 2023/2024 DSPT submission against all assertions was completed by the 28 June 2024 deadline.
Ms Gillatt was content that audit recommendations and actions identified within the Committee’s remit were being reviewed and scrutinised. In regard to business cases, Ms Gillatt questioned whether any could be considered being funded elsewhere such as charitable funds. Mr Lewis confirmed that option was available normally, but in respect of the business cases received for Great Oaks and Waterdale neither was appropriate. Mrs Vickers explained a process was being developed similar, to capital bidding, where larger applications that meet charity criteria with a clear link to the strategy were identified to be funded through charitable funds.
Mr Gowland referred to the energy inflation and mitigating action underway, noting this was currently an extreme risk to be presented in further detail to the board later on the agenda (see board public 24/07/25).
The board received and noted the report from the Finance, Digital and Estates Committee.
Report from the Public Health, Patient Involvement and Partnerships (PHPIP) Committee
Reference
Mrs Leese presented the paper, highlighting the progress with the development of both the research and innovation plan and equity and inclusion plan. She also noted that work was underway in respect of promise 5 and the aim to involve our communities’.
Support had been provided by the committee at the meeting to the appointment of three new directors for Flourish. Subsequent to this, Mrs Lavery confirmed the board’s approval of the appointments.
Work continued to mobilise and start shaping delivery against promise 8 (the Rotherham, Doncaster and South Humber NHS Trust (RDaSH) 5) in identifying 5 key areas to have an impactful change in terms of inequalities, 3 areas were already in progress (physical health checks, dementia, older peoples Talking Therapies).
The committee focused on health inequalities for Gypsy Roma Traveller (GRT) communities and working with our partners. An update would be received at its next meeting following discussions and dialogue between the trust with South Yorkshire integrated care board on funding, investment, research and GP registration criteria. Mr Lewis recognised the partnership and research opportunities with community leaders particularly in Doncaster, as well as raising cultural awareness amongst staff. In raising this awareness Mr Gowland referenced the link to the strategic delivery risks and how, the current shortfall in cultural capability was referenced. He noted the need to support staff to complete their individual roles and through such as the new leadership development offer and revised induction, those staff would have greater cultural awareness of the trust and the communities it serves.
The board received and noted the report from the Public Health, Patient Involvement and Partnerships Committee.
Report from the People and Organisational Development (POD) Committee
Reference
On behalf of Mr Vallance, Ms Fulton-Tindall presented the paper and highlighted the focus on the retention rate. Consultant vacancy rates remained static but she noted two new recruits would be joining the trust in the coming months. Recruitment to post was beyond expected timescales primarily due to slow returns on disclosure and barring service (DBS) checks and candidates taking time to decide between multiple offers. Work remained ongoing with care groups to address this and drive up performance against recruitment targets.
The recommendations and actions identified following the appraisals audit resulted in the audit opinion being given as moderate assurance. Work was underway to implement the agreed actions in response, specifically in relation to performance management development and the overarching training needs analysis for the trust’s workforce.
There had been an improvement in the gender pay gap, with local benchmarking undertaken as a comparator. Dr Graham added there remained a large amount of work to do in order to fully address the gender pay gap, and that she would be inviting male managers to explore this matter further.
RIDDOR information would be captured in future through the IQPR.
Ms Fulton-Tindall advised the administrative support for the guardian of safe working hours (GoSWH) had previously been raised as an issue and there had been an agreement that this would now be put in place. Dr Tosh advised that there had been an increase in Doncaster of breaches and inappropriate on-calls. Following review, it was noted less than 5% of call-outs were inappropriate, and Dr Tosh felt this was an acceptable level. Mr Lewis highlighted the change and implementation of the new rota design and related numerations.
The board noted Ms Blake would take the role of chair of the committee from Mr Vallance at the next meeting.
The board received and noted the report from the People and Organisational Development Committee.
Report from the Mental Health Act (MHA) Committee
Reference
Ms Fulton Tindall presented the paper, highlighting an area of concern in relation to Mental Health Act compliance and performance. During quarter 1 there were 130 detentions representing 110 people and the concerns related to detention admissions paperwork, recording of consent to treatment, section 132 rights and section 17 leave.
Level 3 and reducing restrictive interventions training remains challenging. The committee identified a theme throughout the reports received which continued to identify issues with incorrect receipt, scrutiny and recording. Work was underway to address the concerns and issues identified, and this would be challenged at forthcoming delivery reviews.
Mental Health Act (MHA) compliance would have a future emphasis and focus on key areas, to resolve the over 24-hour length of stay in the trust’s section 136 suites, and to ensure the trust was working multi professionally on its seclusion arrangements. Patient feedback would be reported bi-annually.
Mrs Leese was pleased to note the committee’s future areas of focus on compliance and greater understanding of MHA data, as well as being challenged in delivery reviews. Mr Chillery referred to the MHA breaches and the potential impact of out of area placements (OOAP), and acknowledged work was underway to “smarten” these measures.
The board received and noted the report from the Mental Health Act Committee.
Report from the Quality Committee (QC)
Reference
Mrs Leese presented the paper and highlighted the safe staffing reporting arrangements were enhanced with daily oversight having been implemented. The safeguarding annual report provided assurance that the trust was meeting its statutory requirements.
Resuscitation compliance remained a concern, in particular resuscitation equipment audits and level 3 training. Mr Lewis recognised the slight improvements made in terms of audit compliance, but there remained further work to address and sustain overall compliance.
The MCA annual report did not provide assurance and identified gaps in respect of data compliance, performance and risks. Mr Lewis noted the Quality Committee action (September 2024 Quality Committee) requesting for an assessment of current performance, compliance data, the associated gaps, level of risk and recovery plan. Mr Lewis recommended that this was presented to QC in quarter 3 to quarter 4.
There remained concern in relation to complaints management with a new process under review and a recovery plan to be developed. Mr Lewis stated that at present there were 51 open complaints and a recovery plan was in place to resolve and respond to these complaints.
The committee received the draft quality and safety plan, with further comments to be provided for consideration.
Dr Graham referred to the development of future patient experience reports to include the feedback received via the new platform, Care Opinion. In response to Mrs McDonough, Dr Graham advised of the advantages of moving to Care Opinion that included its enhanced functionality, with it having easy read and different languages meaning it would be more accessible to the public and would still be used for people who were digitally excluded through our service champions. Mr Lewis reflected that this was an important development in how the trust received and shared real time patient feedback to identify themes, and by December 2024 the sharing of patient feedback would be in place for inclusion at the delivery reviews.
The board received and noted the report from the Quality Committee.
Action
Report from the Audit Committee
Reference
Mrs Gillatt presented the paper and confirmed that the trust’s Annual Report and Accounts 2023/2024 were signed as complete on 11 July 2024. The reports were not available to the public at the trust’s Annual Members Meeting on 20 July 2024 as they were waiting to be laid before Parliament prior to publication.
There had been improved progress regarding audit recommendations with increased oversight on outstanding actions and delivery through the trust’s governance structure, including the committees.
The committee was not assured in relation to the report it received relating to the Standing Financial Instructions, in particular about the waivers applied to the quotation or tender process. Mr Mohammed advised there had been improvements made in proactive planning for procurement processes but that this remained a focus area of work for his team.
The board received and noted the report from the Audit Committee.
Chief Executive’s report
Reference
Mr Lewis drew attention to the key items within his report. Mr Lewis apologised for the incorrect statement within his cover sheet, and confirmed there, “would be no new further new initiatives or areas of focus during quarter 2…”.
There has been strong conversations held within the clinical leadership executive (CLE) regarding the wider issues in older people’s services and how to address the inequalities and support an aging population. The CLE recognised the journey to develop staff knowledge on the balance between an aging population, the general skills required to care for those people and the small number of people who will require refined expert specialist skills. This ambition had been subject to national publications but had not yet found practical application, Mr Lewis advised this needed to be considered as part of the workforce and training needs plans, and to confirm how it would find practical application.
The children’s care group remained fully focused on the maximum 4-week wait to receive specialist intervention and support (CAMHS) for young people with mental health needs (excluding looked after children and neurodiversity). Progress had been made on the wait list backlog since the board last met, and Mr Lewis stated he would expect to achieve the agreed position by end of July or August 2024. Mr Lewis highlighted that other CAMHS services, locally and nationally, had far longer waits.
Mr Lewis acknowledged that there remained secondary waits for those receiving medication in children and adult neurodiversity services. Mr Lewis advised an update to the board would be provided in September confirming the removal of the backlog of medication waits in neurodiversity and a sustainable go forward position. Mr Lewis recognised the considerable work to be undertaken on the renewed autism work to ensure people in our services were supported in the appropriate manner.
The Mental Health Learning Disabilities and Autism (MHLDA) Collaborative board had approved an analysis of Medical Emergencies in Eating Disorders (MEED) guidance compliance for liaison provision for eating disorders care to ensure collective efforts were effective and well structured across partners. Steps were being taken to change services as part of the new eating disorders collaborative. Mr Lewis advised it was important that the board remained sighted on this collaboration.
The changes in the use of agency staff has gone live and provided a real insight to better working in teams. Initial enthusiasm remained positive with teams looking at identifying resource solutions to sustain financial and savings plans. Mr Lewis would expect to see reductions on agency expenditure, as currently trajected by October 2024, being achieved.
The inaugural meeting of the trust People Council was held on 24 July 2024 with key focus to continue on institutional cultures. A report from the council would come to the next board meeting. Mrs Leese noted the concerns previously raised from the patient story at the board’s last meeting regarding neurodiversity secondary waits was being listened to, as well as action taken to address the issues.
Mrs Leese stated this linked to promise 4 and one way of putting patient feedback at the heart of how care was delivered. Mr Lewis highlighted the importance of improving waiting times for people accessing services, of learning from patient feedback and of how this is shared and embedded with leaders.
Mr Gowland suggested that those people who present their staff and patient stories were provided with reflections and feedback, including what learning and improvements were identified, as well as what changes have the trust made as a result.
Mr Lewis referred to the financial plan to release £500k of costs in-year by reducing the bed base through the closure of Emerald Lodge community rehab facility during October 2024. The estate asset itself would need to be repurposed and he was confident that this could be done either within trust needs or working with partners. Mr Lewis was satisfied that the trust was taking the right step and that it would bring clinical benefits. No staff redundancies would be made, with redeployment arrangements in place. A detailed paper would be provided to a future board.
Mrs Leese commented that it was extremely useful to be transparent including financial reinvestments or change to how services were delivered. Mr Chillery advised engagement with staff and unions had already commenced with early communications outlining the vision for service improvement and patient outcomes. Ms Almond stated the staff side chair was fully supportive of the plans.
The board received and noted the chief executive’s report and the forward actions it contained.
Action
Change in responsible officer
Reference
Dr Tosh presented the paper which included a request for the board’s approval in the transition the role of Responsible Officer from Dr Sunil Mehta, Deputy Medical Director, to Dr Diarmid Sinclair, Deputy Medical Director, from the 1 September 2024.
The board approved the transition of the responsible officer to Dr Diarmid Sinclair, Deputy Medical Director, from the 1 September 2024.
Trust response to the independent culture review of the Nursing and Midwifery Council (NMC)
Reference
Mr Forsyth presented the paper that represented the trust wide response to the nursing and wider professionals workforce following the culture review of the Nursing and Midwifery Council (NMC). Mr Forsyth expressed his personal disappointment and concerns following the investigations into the NMC that found key cultural findings, many of which were longstanding, consisting of a dangerous toxic culture that featured racism, discrimination and bullying. There was a failure in senior leadership to face the challenges within the NMC. Mr Forsyth has independently written to the Health Secretary asking for action. The investigation found fundamental issues including the backlog of NMC Fitness to Practice (FtP) cases (circa 6,000), that was resulting in serious impact on those people who had been referred under the FtP process. It was distressing to learn people that had been subject to the NMC FtP process had died by suicide.
To support the trust workforce, there was the need to demonstrate compassionate leadership and ensure clarity from the trust that bullying and racism were unacceptable, and that colleagues were encouraged and were free to speak up. The trust would review those currently under or recently concluded FtP investigation and offer compassionate support to them during this period of unease.
Mrs Leese was supportive of the recommendations and commented that the findings had been part of discussions within the Quality Committee. Mrs Leese acknowledged there were wider implications including trauma for those people who were in the FtP process and the length of time taken for decision-making. Dr Tosh was aware of similar processes within the General Medical Council and it was acknowledged that the outcome of the findings would likely impact on wider regulatory bodies and professional groups.
Mr Lewis confirmed he was fully supportive of the recommendations made and understood the current Freedom to Speak Up (FTSU) position, stating he would wish to understand any barriers should they arise in raising the profile of FTSU and increasing FTSU champions. Recommendations made in the report were to be taken forward through the People and Organisational Development (POD) Committee (linked to Promise 26).
Dr Falk referred to Mr Forsyth letter to the Health Secretary and recommended the board support a trust response. Mr Lewis and Mrs Lavery agreed that they would write a trust response to express their disquiet into the independent culture review of the NMC.
The board received the trust response to the independent culture review of the Nursing and Midwifery Council (NMC) and agreed the recommendations included in the report, noting the action for a trust response to be formulated and sent.
Action
Strategy delivery risks 2024/2025 quarter 1 report
Reference
Mr Gowland presented the report noting that the board had previously received and considered the strategic delivery risks (SDR) in May and since then the risks had been further refined.
He noted work remained ongoing to manage the risks and that the current SDR report now presented initial risk scores and target risk scores, specific actions, controls and respective leads for mitigating actions. Actions would impact on the risks and future reporting would present details of where and why risk scores reduced.
There were areas of commonality within the five risks such as leadership, culture awareness, and capability. Mr Gowland cautioned as the SDR were major risks, they will take time and energy in mobilisation and delivery. The SDR will be reported and scheduled through the board’s assurance committees, Finance, Digital and Estates (FDE), PHPIP, People and Organisational Development (POD) Committee and Quality Committee (QC). In response to Mr Lewis, Mr Forsyth explained the leadership offer with respect to strategic objective 1 (SO1) was linked to the delivery of promise 26 and that he would expect the delivery timeframes to be aligned.
In response to Mr Mohammed, Mr Forsyth explained the first point of focus would be with leaders and new starters, with other work then broadening the offer across the trust. Ms Almond added there were supplements to support and embed existing mechanisms in recruitment and leadership development, such as talent management and supervisory programmes. In response to Mrs Fulton-Tindall, Ms Almond advised the recruitment process of new starters was part of a values based recruitment approach, capturing people for both their skills and values.
Mrs Leese noted the QC would be sighted on the SDR in September 2024, and acknowledged the SDR was subject to further development including impactful measures.
In response to Ms Gillatt, Mr Banks referred to data availability strategic objective 2 (SO2) and explained the challenges faced as well as the work that had progressed to mitigate against the risk.
Mr Lewis referred to strategic objective 3 (SO3) and advised he was meeting with Primary Care partners to build on mutual understandings.
Mr Chillery referred to strategic objective 4 (SO4), and the need to fully understand the current position of seven-day services to create a baseline. A key example, that would have a significant impact, would be discharges, which were only currently delivered during working hours, 5 days per week. The ability of partners to support seven-day services such as housing and social work would also be noted.
The board received and noted the progress with the development of the mitigating plans for the five strategic delivery risks and the planned next steps and the commencement of new monitoring arrangements via Audit Committee chair meetings, board committees and at the board of directors.
The board supported the individual risk scores assigned to each SDR and the target score and associated time scales (for risk mitigation).
Learning half days (LHD) introduction and pilot learning
Reference
Dr Graham presented the report and highlighted the key aims of the learning half days (LHD) as part of the learning and educational plan and delivery of promise 24 of the trust’s strategy.
Evaluation from the pilot held in North Lincolnshire highlighted both successes and challenges. Wider implementation work would require consideration during the next 2 years to align with strategic ambitions. Next steps include trust wide implementation from September 2024, the prototype approach and learning from the pilot would inform mobilisation for the other 21 directorates in the trust. There would be sessions that were beneficial for across trust or directorate attendance. Future considerations would include increased partnership working, greater inclusivity for staff who work shifts, and enablement of learning cycles.
In response to Ms Fountain, Dr Graham advised Shwartz Rounds were reflective sessions on experiences, they were emotive and facilitated around particular models and themes. These would be expanded on what people wish to discuss including antiracism.
From a care group perspective, Dr Heighton explained the challenges from the pilot included supporting people and why learning applies to everyone in all roles across all services. Since introducing the protected time to learn, Dr Heighton reported that there had been a number of different learning opportunities and the uptake had increased amongst staff.
Dr Graham advised the protected time to learn would be introduced, and the expectation was that all directorates adopt this approach starting in September 2024. Workforce policies and processes would reflect the support required for the mandating of learning. In response to Ms Mehan, Dr Graham advised learning sessions would be beneficial for across trust or directorate, as well as building a library of learning for people who were unable to attend on the day. All learning would be considered for next session planning, with evaluation of learning topics and the offer of repeated sessions. Mr Lewis recognised that Learning Half Days could have some content from Executive leadership, but the majority of those agendas would be driven by local leaders across the workforce.
The board supported the introduction of Learning Half Days, recognising the commitment to education and learning leadership highlighted within the paper.
Placements in each profession
Reference
Mr Forsyth presented the paper and highlighted the trust’s placement landscape was complex, ranging from formal placements through to work experience and volunteering. It was important to consider the service delivered and quality impact that placements brought, alongside supporting the delivery of the trust’s strategy and its promises. The trust currently works with professional bodies in terms of regulation and funding, and has formal placement agreements across nursing, allied health professions, social work, psychological professionals, medical and pharmacy. Mr Forsyth stated there were considerations to be made on how the trust attracted a wider placement landscape whilst retaining the quality of those placements, and how it would encourage young people and others from inside local communities to take up those placements.
The board requested the recommendations made in the report were considered by the People and Organisational Development (POD) Committee.
The board received and noted the placement landscape report, noting the obligations of the trust regarding commissioned and non-commissioned training.
Action
Learning and education plan
Reference
Dr Graham presented and explained the report was presented to enable an understanding of what education and learning meant in respect of the trust strategy and to provide clear and measurable actions for change. There was specific focus upon promises 9 and 24 as well as a summary of what would constitute success in the future.
Despite the new government’s plan to reform the apprenticeship levy, the trust’s commitment would remain the same and there was no intention to change promise 9 and its delivery.
The board received and noted the learning and education plan, and the work being done to develop a coherent plan for the trust.
Learning from deaths
Reference
Mrs Lavery highlighted that it would be the last board meeting attended by Dr Tosh who would be leaving the trust and thanked him for his contribution and work over the twelve years at the trust.
Dr Tosh presented the report and highlighted the importance of learning from deaths in the trust and the tragic case which led to the national agenda on improving this. The report outlined the processes through which every death was reviewed and seek to learn from these where possible and if appropriate spread that learning across the trust (and beyond). In relation to mortality, individual clinicians were supported to be inquisitive and to learn, corporately there was a need to identify lessons to be learnt and take appropriate action.
Dr Tosh referred to the importance of the work of the mortality operational group (MOG) in analysing 593 deaths in our care during 2023/2024, 62 of which were escalated to structured judgement reviews (SJR). The paper supplements the board’s focus on learning and education, and provided detail on the mortality governance pathway and processes in place of how we implement and evidence learning where we identify potential for improvement.
A new statutory medical examiner system would be rolled out nationally to provide independent scrutiny of deaths and to give bereaved people a voice. From 9 September 2024 all deaths in any inpatient health setting that were not investigated by a coroner would be reviewed by NHS medical examiners. The trust was already active with the local medical examiners’ process and it appeared to be working well. Dr Tosh advised the trust learning from deaths policy will be amended to include the application of the medical examiner process.
Learning from deaths continued to be disseminated across care groups as well as clinical learning briefs. Dr Tosh referred to the improving and recommissioning our incident reporting system will be made more user friendly to those reporting or reviewing a death.
Mrs Leese advised the Quality Committee had regular oversight of mortality, and highlighted the importance of the board being sighted on mortality and learning from deaths, and recognised the learning and benefits to the improvement work that has been produced across the trust.
Dr Falk noted the mortality governance arrangements and processes in place, stating primary care also have responsibilities in shared care cases as well as the trust. Dr Tosh explained that whether a death was in scope or out of scope, each notification of death was subject to the same scrutiny, review and reporting.
The board received and noted the learning from deaths report, recognising the mortality governance arrangements in place and importance to seek to learn from these.
Clinical and operational strategy, strategic objective 3 (SO3)
Reference
Mrs McDonough presented the paper and highlighted the progress made to extend the community offer in physical, mental health, learning disability, autism and addiction services.
There were 5 promises which sit within strategic objective 3 (SO3) and there were complexities and difficulties anticipated with the aim to shift care into communities from the current bed based services; to provide more integrated care to our community patients with partners, especially primary care; and to meet the challenging target to reduce the time that patients wait for care to 48 hours for urgent care and 4 weeks for routine care. Successful delivery of the objective would include working with local communities, education, primary care partners and other partnerships.
Dr Falk referring to promise 15, recognised the development across Scunthorpe South and engagement with primary care and other partners. Mrs Johnson explained the model of integrated neighbourhood working and how engagement and progression was being produced in a staged but impactful way. This work included reviewing health inequalities data and identifying which areas need to be targeted and prioritised.
The board noted the intentions to develop similar joint working opportunities in Rotherham and Doncaster. The board received and noted the clinical and operational strategy focused on strategic objective 3.
Operating performance, governance, and risk management
Emergency preparedness, resilience and response (EPRR) biannual update
Reference
Mr Chillery presented the paper and reminded the board of the position reported in January 2024, where a “hard reset” had been applied nationally, and benchmarking results showed the trust’s compliance of 21% (as against 17% on average for trusts in South Yorkshire). The trust had developed a 2-year programme of work to achieve compliance by September 2025. The focus for year 1 was 3 core pieces of work, and the aim to report 60% compliance in October 2024 for the annual trust emergency preparedness, resilience and response core standard submission.
Key areas of focus included in improvement plans were business continuity and exercises based on those plans, temporary shelter and evacuation plans, and development of the training programme for on call colleagues, both tactical and strategic level training. Training exercises had already taken place to test readiness and responsiveness to incidents, and learning had been disseminated through the trust’s emergency preparedness, resilience and response group.
In response to Mrs Lavery, Mr Chillery confirmed that the trust was part of the regional planning committees which was a requirement to meeting the emergency preparedness, resilience and response core standards. The board received and noted the emergency preparedness, resilience and response biannual update
Integrated Quality Performance Report (IQPR)
Reference
Mr Chillery presented the Integrated Quality Performance Report (IQPR) reporting the position in June 2024 against operational performance, quality, workforce and finance data.
The trust continued to focus delivery on 10 key metrics on the understanding that all performance was a priority. There remained a number of key performance metrics where there were areas for development and action. The clinical leadership executive (CLE) and individual leaders were deeply engaged with the accuracy and meaning of the core data. A review of that data and items in the IQPR had been largely completed, but there was further work to develop quality and safety data.
Mr Chillery highlighted that the Mental Health Act section 136 metric went live from 1 July and would be reportable from August 2024. In addition, the metric in relation to Community Mental Health team (CMHT) access continued to double run as it transitions across metrics.
Talking Therapies access and out of area placements (OOAP) metrics continued not to achieve their targets. In terms of metrics on plan to achieve target, Mr Chillery confirmed these were CMHT transformed access, perinatal services, children and young people access and the ADHD adults. In regard to dementia, although not a trust target and reported through primary care, the national target was set at 66% which was achieved in South Yorkshire, however North Lincolnshire was under target at 55%. This was being explored further by Mr Chillery with Mrs Johnson.
The trajectory for sever mental illness (SMI) health checks was on track to be achieved, and currently achieved in Doncaster and North Lincolnshire.
Mr Lewis noted the financial position and overspend in relation to the agency expenditure as referenced in his chief executive officer report. There remained a savings gap target to be identified through full year effects of prior savings schemes and additional income opportunities in year.
The board received and noted the Integrated Quality Performance Report.
Operational risk report, extreme risks
Reference
Mr Gowland presented the report and highlighted the trust’s current extreme risks. There were 8 extreme risks which were all subject to regular review by the respective risk owner and monthly scrutiny via the risk management group.
Themes were now visible associated with eating disorders and OOAP, long waits for neurodiversity diagnosis and care. Mr Gowland advised that the risk registers were being explored in respect of how they connect to system based registers, for example ICBs and partners. Mr Gowland advised risk training has been commissioned through NHS Providers to support risk leads, the first session of which was in early August.
Mr Lewis referred to the current extreme risks and sought clarity in future reports of the actions being taken and the planned and actual reduction in the risk scores. In particular risks relating to OOAP, eating disorders and autism related to waiting times. Mr Chillery advised in relation to neurodiversity, this had been shared with clinical leadership executive (CLE) and there was a trajectory on waiting times with the expectation that improvement would start to be seen from September 2024.
The board received and noted the Operational Risk Report, extreme risks update.
Risk management framework (RMF) annual report
Reference
Mr Gowland presented the annual report and highlighted the RMF provides an overview of the work undertaken during 2023/2024 in respect of strategic and operational risk. The board were reminded of the improvement work undertaken in raising the profile of risk management. This had resulted in a significant increase in number of risks on the registers, enabling the production and use of a more comprehensive risk profile. Risk had become a specific point of reference within decision-making processes.
At 2023/2024 year end, the registers contained 237 open risks, a three-fold increase on the position at the end of the previous year. Mrs Lavery commented that it was encouraging to see the positive results from raising the profile of risk management. In response to Ms Gillatt, Mr Gowland advised the role and responsibility of the risk management group was to ensure the risk management framework was implemented effectively and to oversee work to mitigate risks, as well as identifying cross trust risks (themes). Longstanding risks were scrutinised and challenged with risk owners.
The board received and noted the Risk Management Framework Annual Report, and took assurance on the delivery against the framework and that the trust has in place robust arrangements for risk management acknowledging that there was further scope for development.
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:
- Accountable Officer for Controlled Drugs Annual Report 2023/2024
- Safeguarding Annual Report 2023/2024
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
There was no further business raised.
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: November 15, 2024
Next review due: November 15, 2025
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