Annual quality account April 2024 to March 2024

Copies of previous year’s annual quality account are available from the Corporate Assurance team by emailing rdash.corporate-assurance@nhs.net.

Contents

1 Statement on quality from the chief executive

Thank you for reading our latest quality account.

In the year April 2023 to March 2024, perhaps the most important contribution we have made to improving safety and quality is a really simple one. We have reintroduced “Hello My Name Is” as a campaign, a motif, and an obligation across our organisation. Since December 2023, based on feedback from patients and carers, everyone who works, studies or volunteers in our trust is expected to wear a simple introductory yellow badge, letting colleagues, patients and visitors know who they are and how they wish to be known.

Most services in our trust are rated by our regulators as “good” or “outstanding”. But some are “requires improvement”. A rating from 2019 that we want to change. I am satisfied that in the last year we have improved, but not yet by enough. We have real work to do on our consistency of care, making sure personalised care plans are in place for all. That is why our safety plan in 2024 matters so much. In each service we will have routine standards, met each shift, each day, each week. As we compare the quality of our care, we will seek Royal College accreditation for all our mental health services over the coming two years.

This quality account is more open about error, and about what we have learnt from our complaints and serious incidents than in prior years. Though in the year April 2023 to March 2024, we made a start with PSIRF, in the year ahead we need to make the very best of that new national regime. Tackling health inequalities is central to quality as well, and it is obvious from our 28 promises how committed the board and organisation, as a whole, are to that mission: we have identified five areas of particular focus (the RDaSH 5) and we will poverty proof all the services this trust provides, becoming the first NHS organisation to take that measure on this scale.

I would draw your attention to the comments of our partners. Nothing we deliver is done alone. In particular, we partner with the voluntary sector locally and with local GP practices and community pharmacies to deliver care and continuity.

In the year ahead, the board is determined to tackle unacceptable waits for children and adults with ADHD diagnoses and to deliver our four-week wait promise, due in 2026, during 2024 in children’s services. In the year April 2023 to March 2024, we introduced our twenty four seven CAMHS service with cover site wide: my congratulations to those involved, it has been a long haul, but we have succeeded.

If when you read this account, you feel we have missed or misstated something, please let me know. The essence of quality is honesty and the trust that that creates.

As chief executive of the trust, I confirm that to the best of my knowledge the information provided within this quality report is accurate.

Toby Lewis, Chief Executive, May 2024.

2 Required reporting

2.1 Our priorities for improvement

The strategy and how we work to deliver it, are framed around our five objectives. Those are to:

• nurture partnerships with patients and citizens to support good health
• create equity of access, employment, and experience to address differences in outcome
• extend our community offer, in each of, and between, physical, mental health, learning disability, autism and addiction services
• deliver high quality and therapeutic bed based care on our own sites and in other settings
• help to deliver social value with local communities through outstanding partnerships with neighbouring local organisations

Continuous quality improvement is at the heart of everything we do and we aim to provide the insight, tools, support and expertise to ensure that the care delivered by Rotherham Doncaster and South Humber NHS Foundation Trust reflects the three pillars of safety and quality:

• patient safety
• patient experience
• clinical effectiveness

A revised trust long term strategy was published in September 2023, with safety and quality at its core. This is supported by a specific plan to address new safety and quality priorities for the trust.

The five objectives are supported by 28 promises, which underpin our plans for the future (see annex 3).

2.1.1 Priorities for improvement the year April 2023 to March 2024 and our progress against these

In the year April 2023 to March 2024, we continued to address the ambitions and commitments identified in the safety and quality delivery strategy and made significant achievements, as detailed in below. Under each priority we have also included a short reflection regarding learning and change.

2.1.1.1 What is our priority?

To improve the experience of care and the opportunities for involvement across all care groups and corporate departments

2.1.1.1.2 What did we expect to achieve?

• Quarter 1 and 2, we will launch a coproduced experience plan (patient experience and involvement plan) that will include the 5 key pledges for improvement.
• Quarter 1 and 2, we will establish a programme plan and governance structure for the implementation of projects and activities that deliver each of the pledges and several “we will” statements within each pledge. The plan will be led by a triple leadership framework: staff, patients and community.
• Quarter 1 and 2, we will develop patient experience feedback volunteer role descriptions for inpatient and community services, and launch local recruitment drives, in support of the Tendable system roll out, and other systems for patient feedback.
• Quarter 1 to 4, we will work with the South Yorkshire Integrated Care Partnership Strategy, to develop a coproduction framework for South Yorkshire
• Quarter 1 to 4, we will provide leadership support to the South Yorkshire MHLDA Provider Collaborative to embed involvement and coproduction within the provider priorities.

2.1.1.1.3 What have we achieved?

• We have completed a significant amount of work in terms of enhancing our patient, community and citizen engagement over the past year. We have not only linked through key voluntary, community and social enterprise (VCSE) partners in terms of mental health, physical health and learning disabilities support, but we have also conducted purposeful and targeted work with communities and community organisations that are often marginalised, including veterans’ groups, community faith groups, LGBTQ+ community groups and traveller community groups.
• This purposeful work, and related outcomes, have helped contribute to, and form the foundation of our clinical and organisational strategy for the organisation, with the key elements of each pledge now featuring within the 28 promises, each of which is governed through the clinical leadership executive and the 10 subgroups.
• We have developed patient experience feedback volunteers and have people recruited and ready to start in role.
• We are enhancing the ways we use digital interventions in the way we work, this includes the use of “Tendable” which is a digital audit system and also via the use of digital feedback forums (for example, Care Opinion).
• The South Yorkshire Integrated Care Partnership Strategy is developing a “working with people and communities” strategy, currently out for consultation, and this includes the principles of coproduction.
• The people focused group, in partnership with the trust wide peer forum, and the experts by experience alliance (associated with the RDaSH Change and Transformation team) are working effectively together to consider how we best coproduce with people and communities to develop services. This is central to promise 5 in our strategy: where patients will form part of our decision-making at every level, usually through our work in communities.

2.1.1.1.4 What have we learned?

In working beyond our traditional boundaries, and with a more diverse range of communities, we have learned how to improve the experience of care for the wider community rather than just focused upon learning from and engaging people who are happy to provide feedback and attend standard feedback sessions provided.

2.1.1.1.5 What changes have we made?

In our effort to listen differently we have made a number of changes, and our learning has informed our engagement plan moving forward. Two examples of changes made are:

• we have progressed a digital engagement pilot which has generated and has demonstrated an 8% improvement in feedback, learning from this pilot is informing our role out across the trust
• through discussions with different communities, we have identified additional groups that are provided on evenings and weekends, we have changed the working times of our experience team in order to engage at the times that communities wish to

2.1.1.2 What is our priority?

To implement a trust wide quality accreditation process and ensure that “CQC readiness” is “business as usual”.

2.1.1.2.1 What did we expect to achieve?

• Each care group and team will undertake our internal accreditation process which mirrors the CQC assessment framework.
• Each area will have a peer review but also undertake a self-assessment.
• Action plans will be produced, monitored and supported if there are any shortfalls.

2.1.1.2.1 What did we achieve?

• Accreditation is part of a longer term aim as CQC readiness becomes business as usual. We chose in year to focus on peer reviews rather than accreditation.
• Peer reviews in all inpatient areas have been completed. This has been an invaluable method of providing both insight into quality and safety of our services and organisational learning. Learning has been gained by both the wards being reviewed and the review team themselves. Teams consisted of trust staff (clinical and non-clinical), executive and non-executive directors, the FTSU guardian, and trust governors, some of whom have lived experience. From 2024, all our reviews now include patients and carers.
• Action plans from peer reviews ensured that any issues identified were acted on and resolved. A full end of year evaluation took place, including feedback from the wards and review team members and was wholly positive. As a result, the inpatient reviews will be repeated in the year April 2024 to March 2025 but with the addition of a pilot (and subsequent development) of reviews outside the hours of 9am to 5pm, Monday to Friday to mirror the 24-hour nature of the services provided by wards.
• A self-assessment process for community teams has been launched and trialled.

2.1.1.2.2 What have we learned?

In our peer reviews, we have learned a number of things from our patients, staff and partners. These have related to the experience of our estate, the training needs we have and also in terms of the experience of the care provided. Each peer review has a learning log, with actions, and follow-ups. We also cross-reference learning when we have had peer reviews in similar services.

2.1.1.2.3 What changes have we made?

We have made small and large changes as a result of our peer review processes. Two examples of small changes are:

• environmental repairs to the inside and outsides of buildings
• changes in signage and notice board content

Examples of larger changes have been:

• the improvement and expansion of safety huddles
• safety pod expansion and process review

When changes are made, they are not only made in the areas where the peer reviews have occurred but then checked in terms of all other similar trust settings.

2.1.1.3 What is our priority?

To improve our complaints process.

2.1.1.3.1 What did we expect to achieve?

• The complaints and investigation team are to be realigned to the care groups in order to promote and embed the new complaints standards.
• There will be monitoring of the complaints recovery plan to include response times, training and action plans that may be required where care falls below the standard that is expected.
• Through early in the year April 2023 to March 2024 work will be undertaken to ensure that ethnicity and gender information is collected more thoroughly for the patient (whether they are the complainant) and an analysis of the gender and ethnicity of patients, complainants as against our treated population and as against the resident population.

2.1.1.3.2 What did we achieve?

• A review was undertaken of the complaints and investigation teams. A new model was developed and agreed by staff.
• On 1 April 2024, the two functions split into a separate Complaints team and an Investigations team.
• During March 2024, a review was undertaken of the friends and family test, Your Opinion Counts and the patient advice and liaison service (PALS). The review proposed that the three functions moved from the complaints team to the Patient Experience team, building on the trust’s approach to capturing patient feedback. The transfer was completed on 1 April 2024.
• Throughout the year, we have a standard complaints procedure which has been followed. To improve this process, and aligned with the progress of PSIRF, we have reviewed the trust complaints procedure and launched an improved model in January 2024.
• Complaints training was commissioned and delivered on 20 February and 18 March 2024
• Ethnicity and gender have been captured as part of the complaints process. During quarter 1 the year April 2024 to March 2025, this will be mapped against our patient population and against the resident population.

2.1.1.3.3 What have we learned?

Our complaints are often unique, however, at times, there are similar factors in multiple complaints. In changing our approach and enabling a more responsive model, we are more able to coordinate learning and identify cross cutting themes.

2.1.1.3.4 What changes have we made?

We have made changes in individual services as a result of complaints:

• we have altered how referrals are triaged in our hospice
• we have changed the information we provide to families waiting to be seen in neurodiversity services
• we are finalising new policies on how to support children during family breakdowns
• we have made changes to our smoking policy and food offer arising from feedback
• most importantly, we are changing our disengagement policy to move to an engagement approach, which we will audit and revisit again in the year April 2024 to March 2025

2.1.1.4 What is our priority?

To fully implement the Patient Safety Incident Response Framework (PSIRF)

2.1.1.4.1 What did we expect to achieve?

• In Q2 we will agree our incident priorities and identify appropriate learning response tools based on our patient safety data analysis, within RDaSH, integrated care boards (ICB) and our regulatory partners. These priorities will be included in our patient safety incident response Plan (PSIRP) and will outline areas where we will undertake patient safety incident investigations (PSII).
• In Q2 and Q3 we will continue to engage with colleagues, patients, families, carers and the wider public as to our incident priorities, our approach to learning response tools and how we will engage those affected by incidents and identify how we will measure effective engagement and satisfaction.
• In Q2, we will launch the PSIRF training programme to allow for further insight and develop expertise in systems approach to patient safety incident investigations which will allow us to maximise learning.
• In Q2, we will develop our PSIRP based on our patient safety incident profile, outlining our governance processes for signing off PSII, identify learning and support and share this across the organisation, working with our ICB.
• In Autumn Q3, we will launch PSIRF and LFPSE across the trust. We will continue to embed and measure implementation of PSIRF in Q3 and Q4, making any changes as they arise based on our feedback and measurables.

2.1.1.4.2 What did we achieve?

• All preparation work was undertaken, and the trust PSIRF policy and plan was developed. The trust has started to progress with learning from patient safety events (LFPSE) on 1 August 2023.
• A PSIRF workshop as held as part of the board development programme in October 2023. The PSIRF plan was subsequently approved by the integrated care board (ICB) and trust board in November 2023, with a full launch of PSIRF trust wide on 3 January 2024.
• PSIRF training has been accessed through the healthcare safety investigation branch (HSIB) and all investigators have completed this training. Further training is required for others in the trust, which will be our focus in quarter 1 and Q2 the year April 2024 to March 2025. Through this, the trust will roll out internal training for the incident response tools.
• We now have a daily incident meeting, which means that we can be more responsive in terms of sharing our learning and also analysing actions. This is supplemented by a weekly incident “round up”, which allow us to reflect and triangulate the learning across the week.
• Leadership circles and safety huddles let us learn locally and then share across trust and nationally, if appropriate. We have Schwartz rounds and post incident reflective groups, which support us to process learning and relationship dynamics in a “safe space” environment.

2.1.1.4.3 What have we learned?

Although we have commenced our PSIRF journey and had some positive effect in terms of our daily incident meetings and risk triangulation, we have not progressed in all areas we would have liked during the first four months of 2024.

We have made contact with other organisations who have progressed PSIRF to understand and learn from their journey and compare with ours. This has helped us identify gaps, which are then linked with our actions intended for our April 2024 to March 2025 plan.

We have also learned that there are inhibiting factors regarding risk reporting linked with the accessibility of the risk system, and in response to this learning we are now completing a review and consideration of our risk reporting system to enable the use of handheld devices and apps, which will help mitigate against the factors identified.

2.1.1.4.4 What changes have we made?

We have made a number of changes in terms of progressing with our PSIRF journey, a few of these changes include:

• the production and circulation of daily incident reports, which include all incidents in the past 24 hours
• the progress of daily incident meetings in which our clinical and backbone services work together to both respond to and also analysis any themes and trends in terms of incidents on a daily and weekly basis; this analysis then contributes to preventative work
• the publication of focused clinical learning briefs that are shared with the entire organisation. These briefs are linked, at times, with our incidents but also can be linked to national learning (for example, from national medication alerts)
• we have sourced bespoke training for our investigators, which enables a modernised approach to fact finding and investigation aligned with PSRIF
• we have increased our coproduction work with patients, families and staff in terms of establishing the parameters for reviews and investigations and also agreeing supportive timelines and updates

2.1.1.5 What is our priority?

To continue to improve the effectiveness of clinical audit within the trust.

2.1.1.5.1 What did we expect to achieve?

• A proposed clinical audit calendar is being agreed with the care groups. This will include mandated national audits.
• Clinical audit is central to our quality improvement and care standards. Actions will be monitored and supported should any audits fall below the expected quality standards.

2.1.1.5.2 What did we achieve?

• The audit framework has continued to drive forward the audit activity in the organisation throughout the year April 2023 to March 2024, providing the structure for clinical audit activity within the trust. The proposed trust wide forward clinical audit programme for the year April 2024 to March 2025, has been presented and discussed with care group leads, quality committee and audit committee and the final forward programme will be aligned to the safety and quality plan.
• All audits have been conducted appropriately as planned. Where an audit has identified that a recovery plan is needed, support has been given to operational services by the Clinical Effectiveness team. Where required, audits have been conducted to show recovery effectiveness; this is included in the annual clinical effectiveness audit report which is monitored through Quality committee.
• We also engage in an internal 360 audit programme, as well as a number of service and professionally focused NHS Benchmarking exercises, all of which help us to consider our organisational intelligence and organisational learning.

2.1.1.5.3 What have we learned?

Our internal and clinical audit programmes help us to continually learn, both in terms of aspects of our delivery that are running well and aspects that require improvement.

Within the changes in our strategic model and operating model, we have enacted learning related to leadership behaviours regarding clinical outcomes and audit. We aim to expand this work within our April 2024 to March 2025 education and learning plan.

2.1.1.5.4 What changes have we made?

A number of changes have been made in terms of improving where audits have shown shortfalls. As well as this, our audits have also resulted in other changes, and example of change is:

• Quick reference guides developed, linked with a number of our clinical policies, including infection control and prevention, to ease staff use.

2.1.1.6 What is our priority?

Health and safety.

2.1.1.6.1 What did we expect to achieve?

A health and safety calendar of audits is being developed and agreed with the care groups.

2.1.1.6.2 What did we achieve?

There was a reinitiation of the Tendable application across the trust in September 2023. As part of this work, there was a focus on the audits and schedules that are currently a requirement:

• daily environmental checklist
• twice weekly kitchen refrigerator temperature monitoring recording
• daily fire manual daily Inspections
• twice weekly running of infrequently used water outlets
• daily security check

A programme of inspections is scheduled to cover inpatient and community services. Including:

• health and safety inspection
• security risk assessment
• ligature risk assessment
• lone worker evaluation and device management

All audits have been completed and are on track. All audits are in place as per policy. Inspections, audits are coordinated based on availability of care group employees to support and coordinate actions. There is a central log within the Health and Safety team of inspections dates and actions that are monitored by the team.

2.1.1.6.3 What have we learned?

In our checks, we have learned more about our environments and how the occupancy and acuity we are seeing, particularly in our inpatient settings, is changing the risk dynamic in terms of our environment.

2.1.1.6.4 What changes have we made?

An example of changes underway relates to our inpatient doors, regarding their accessibility, fitment and risk assessments. This has resulted in some immediate change, and also informed our capital spending plan for April 2024 to March 2025.

2.1.1.7 What is our priority?

To use data and triangulation of data to support quality improvements.

2.1.1.7.1 What did we expect to achieve?

Quality improvement metrics will be agreed and will be monitored against.

2.1.1.7.2 What did we achieve?

We have made a number of changes in terms of our data maturity over the past year. Actions in this area have ranged from the use of personal electronic devices to the progress of systems which help us view our data in a different way using SPC charts rather than single points, which helps us with trend analysis.

As well as the systems we use, we have also continued our quality improvement training, which has helped train our staff to consider the data available to them in different ways. Whether this is 1-to-1 patient observation data, case load data or data in terms of health profiles.

2.1.1.7.3 What have we learned?

We are on a journey in terms of our use of data, and we have learned that equal focus upon the mechanics required (including devices and storage) are as important as our focus upon the dynamics (including our staff awareness and training) in order to achieve effective implementation.

Our digital supporting plan is being coproduced, encompassing both of these aspects.

2.1.1.7.4 What changes have we made?

We have developed and launched our integrated quality performance report (IQPR) provides high board level quality metric data and is now running as business as usual. There is a run chart produced and narrative alongside any anomaly.

We also produce bimonthly safety reports which support our organisational learning and are reviewed in our Quality committee. In terms of a future focus, FTSU information will be included alongside of our patient safety data in this report to support better triangulation of risk.

During April 2024 to March 2025, we expect to launch our safety plan indicators: driving towards “always events” in care pathways across community and mental health services.

2.1.1.8 What is our priority?

To move from minimum safe staffing to optimal staffing on inpatient units and in community services.

2.1.1.8.1 What did we expect to achieve?

• Fully implement mental health optimal screening tool (MHOST) across all services.
• Undertake analysis and provide evidence to support that inpatient flow has been improved.
• Provide evidence of where and when minimum staffing has moved to optimal staffing

2.1.1.8.2 What did we achieve?

Our current position meets core standards for the national safe staffing declaration requirements. We have a coherent policy which is adhered to and there are escalations aligned with the policy when required. Most importantly, operationally staffing is adjusted to meet need on a shift by shift basis.

However, there are areas of improvement we aim to see:

• we have issues with data use and compliance levels specifically in our PICUs. However, we have no evidence of significant harm in terms of these data or compliance issues
• although our ward level analysis is conducted on a daily and weekly basis, our trust wide reporting does not yet include weekly data, but this is an intention for year April 2024 to March 2025 and there will be monthly oversight provided via the CNO and CEO in terms of this improvement
• our safe staffing report also does not yet analyse bank and agency percentage of shift fill rates. This issue is managed at a local level support by the Nursing and Quality team. Data visibility on this matter will improve early in the year April 2024 to March 2025

2.1.1.9 What is our priority?

The trust is fully engaged with the national inpatient quality standards programme.

2.1.1.9.1 What did we expect to achieve?

• We will be able to evidence where inpatient services have met the national standards.
• We will evidence a reduction in the number of out of are placements.
• We will evidence improved patient experience

2.1.1.9.2 What did we achieve?

Since the pandemic the acuity and occupancy levels in our inpatient services have increased. We have engaged with our ICB and national partners in terms of making improvements to our inpatient services in partnership. However, we remain challenged in this area, which is reflected in our occupancy levels, our out of areas placement levels and also our length of stay.

The focus on improving inpatient care means that a very senior group of board leaders are currently meeting fortnightly to coordinate change efforts.

2.1.1.9.3 What have we learned?

Our focused work has considered three aspects, patient pathways, partnership working and also workforce.

Whilst we know we have positive pathways in terms of the needs of many of the people accessing our services, we also have learned that people who present who have differing needs (in terms of neurodevelopmental needs for example) experience our inpatient services in different ways which is a challenge for recovery.

Our learning in terms of partnership working is related to people who experience longer than average lengths of stay linked with different levels of community provision across our footprints. This has meant that we have focused our efforts in terms of changes such as the development and enhancements of virtual ward provision, but we have also worked with VCSE partners in terms of crisis and out of hours mental health support.

2.1.1.9.4 What changes have we made and are we planning?

We have made a number of changes, two examples are:

• the expansion of assertive outreach community care provision from a 9 to 5, Monday to Friday services, to a 7 day per week service to better support patient needs and outcomes.
• the trust has been successful in selection for the NHS England “culture of care” national programme, to which we are signed up. We commenced this programme at the end of Quarter 4, 2024, and Saiqa Akhtar is our Senior Quality Improvement Advisor, NCCMH, Royal College of Psychiatrists. The executive leads for this programme are the chief nursing officer and the director for psychological professionals and therapies.

We are looking forward to receiving additional improvement expertise and coaching form the national team to progress this work.

2.1.2 Serious incidents

See also section 2.3 table 14 for reporting against core indicators regarding patient safety incidents.

2.1.2.1 Serious incidents (SI) reported

Of the total number of incidents reported in the year April 2023 to March 2024, 46 serious incident and patient safety incident investigations were reported in the year April 2023 to March 2024, this is equal to the number reported from the previous year. Of the 46, 33 were reported under the serious incident framework (up to 31 December 2023) and 13 were reported under the patient safety incident response framework (from 1 January 2024).

2.1.2.2 Categories of serious incidents

The majority of serious incidents fall under the category of “apparent, actual, suspected self-inflicted harm meeting SI criteria”. Actions taken to address this includes:

• deep dives are undertaken where clusters or themes arise
• the trust is part of the South Yorkshire and North Yorkshire ICBs and attend the suicide prevention groups
• the trust are part of the learning panels delivered in place bases and led by public health this allows locality based learning
• an environmental risk in clinical areas exists to monitor environment safety
• mortality structured judgement reviews are undertaken at the mortality operational group
• data is included in the monthly report to the mortality surveillance group and in the patient safety report

2.1.2.3 Learning from serious incidents

• Whilst the trust has robust processes to monitor out of area placements. Continuity of care is key to support our patients. It has been identified that not all out of area placements are engaging with our services. RDaSH have taken proactive steps to ensure the community teams engage without of area patients at the earliest opportunity. This ensures that community services are engaged in discussions about leave and discharge planning to ensure that patients can be supported when returning home.
• Communication between teams remains key. The learning from an investigation and an inquest has been, whilst verbal communication was in place when changing from night to day shifts, written documentation is now completed on shift change within crisis services to ensure that there is a point of reference to check on progress and actions.
• Deaths by suicide remains a major public health challenge nationally. Identifying and targeting risk factors for suicide mortality is a key approach to prevention. Risks relating to chronic pain and long term conditions has been recognised nationally and across the integrated care boards. This is a key area for the NHS South Yorkshire ICB who held an event in 2023 focusing on this topic. Key findings from this investigation will be shared in the South Yorkshire ICB meeting as points of wider learning.

2.1.3 Quality and safety priorities for the year April 2024 to March 2025

The safety and quality priorities for the year April 2024 to March 2025 and how we will achieve this programme are detailed below.

2.1.3.1 What is our priority?

Deliver on our promises under strategic objective 1, with a focus on promise 4 to put patient feedback at the heart of how care is delivered in the trust, encouraging all staff to shape services around individuals’ diverse needs

2.1.3.1.1 How will achieve this?

• We will maximise the impact of use of SMS and digital to gather feedback, building on our work in Talking Therapies during the year April 2023 to March 2024.
• We will introduce, develop and evaluate Care Opinion as our main mechanism for gathering feedback from people in our communities’ using services: this will ensure much faster and wider visibility for our employees of feedback from their patients.
• Each quarter, the clinical leadership executive will discuss and act on a summary of feedback gathered through these methods.
• In early 2025, patient feedback will become a key measure within organisational management of its directorates within the delivery review process.

2.1.3.2 What is our priority?

We publish our quality and safety plan which will set out a series of safety measures, as always events, designed to improve the consistency of our care

2.1.3.2.1 How will achieve this?

• The safety plan’s successful implementation will demonstrate improvements in key measures of psychiatric and physical care, including timely rights compliance, consenting, MUST assessments and VTE screening.
• The safety plan work will also see us improve the pace of assessment in community pathways, especially where urgent referrals have been made.
• Our quality plan implementation will see improvements initially in three areas:
  • ARMS services as part of EIP
  • work to improve toilet training among CYP teams’ client groups
  • improved speed of wound healing in district nursing services

2.1.3.3 What is our priority?

We will implement improvements to deliver a good rating under the CQC framework, including our work on culture of care within mental health inpatient settings.

2.1.3.3.1 How will achieve this?

• We will deploy our inpatient improvement plan in year, using external expertise to assess our progress, whilst working with the collaborative to ensure that we have learnt from local partners.
• We will implement our safe staffing reporting improvement measures, reducing use of temporary staffing, staff sickness, and filling vacancies in the organisation.
• We will ensure all inpatients have a personalised care plan.

2.1.3.4 What is our priority?

We will make progress to deliver promises 14 and 19 within our strategy.

2.1.3.4.1 How will achieve this?

• We will identify the route to meet our March 2026 four-week wait guarantee, making initial progress in CAMHS, community nursing services, and memory clinics.
• Waiting times for children and adult neurodiversity services will reduce significantly.
• We will work to deliver our aim of no inappropriate out of area placements: with an initial intent to hold consistently, below 15, the number of patients away from their local area for care.

2.1.4 Measuring and reporting of the priorities for improvement

A review of the governance structure was undertaken, and the trust moved to the following structure in year.

Council of governors:

• board of directors:
  • committees:
    • Finance, Digital and Estates committee
    • Quality committee
    • People and Organisational Development committee
    • Mental Health Act committee
    • Charitable Funds committee
    • Audit committee
    • Renumeration committee
    • Public Health, Patient Involvement and Partnerships committee
  • clinical leadership executive:
    • risk management group
    • operational management group
    • people and teams group
    • education and learning group
    • quality and safety group
    • finance group
    • digital transformation group
    • estate and sustainability group
    • research and innovation group
    • equity and inclusion group

Care group and corporate services bi-monthly delivery reviews.

The reviewing, monitoring and measuring of quality has been reported to trust board through the trust’s governance structures (via the Quality committee and the Mental Health Act committee) by various reporting methodologies including:

• quality dashboard reports
• board assurance framework (BAF) by exception from July 2023
• Quality Committee summary report to board
• CQC MHA update reports
• internal audit reports
• quality peer reviews

2.1.4.1 Board assurance framework (BAF)

The board assurance framework (BAF) provides the board of directors with assurance that appropriate arrangements are established regarding the effectiveness of controls relating to the strategic risks faced by the trust. These are the controls that have been put in place to mitigate the trust’s exposure to risk in the achievement of its strategic objectives.

The BAF in place during the year April 2023 to March 2024 contained seven strategic risks, two of which related to quality:

• SR 5, If the trust does not develop, approve and deliver the clinical strategy, then this may impact on patient safety, patient experience, clinical effectiveness and regulatory compliance
• SR 7, If a significant destabilising event occurs then the delivery of services, financial performance and wellbeing of staff may be impacted

Quality related operational risks are captured on the nursing and quality, operations or care group risk registers and an overview was presented to the Quality committee on a regular scheduled basis until December 2023. From January 2024 a new risk management group was established, its key remit is the management of operational risk. Any extreme rated risks (scored at 15 or more) have a director assigned as the risk lead for review and update and they are reported and monitored by the board of directors. During the year April 2023 to March 2024 there were no extreme risks identified.

2.1.4.2 Quality committee summary report to board

The chair of the Quality committee is a non-executive director and senior independent director of the trust and presents a Quality committee summary report (including highlights and escalation of any issues and matters relating to quality) to the public board of directors’ meeting. This meeting is bimonthly.

2.1.4.3 Quality dashboard reports

The quality dashboards provide assurance internally to care group assurance meetings and externally to the Integrated care board on the following areas:

2.1.4.4 Monthly

Patient safety:

• incident reporting
• duty of candour
• serious incidents
• suicides
• complaints
• patient advice and liaison service (PALS)
• Your Opinion Counts
• friends and family test
• MP letters
• safeguarding adults
• safeguarding children
• infection prevention and control
• falls, high risk areas
• pressure ulcers
• reducing restrictive interventions
• medicines management
• non-medical prescribing (NMP)

2.1.4.5 Quarterly

Clinical effectiveness:

• deprivation of liberty standards
• reducing restrictive interventions training compliance
• blanket restrictions
• NICE guidance
• clinical audit

In addition, “quality of care” metrics are also reported as part of the trust’s Integrated performance dashboard. These have been updated in the year April 2023 to March 2024.

2.1.4.6 Care Quality Commission (CQC) inspection

The trust’s last CQC well led inspection took place in November 2019 and the inspection report was published on 21 February 2020. The trust received an overall rating of requires improvement, with ratings of good in the domains of caring and responsive and a rating of requires improvement in the domain of safe, effective and well led. The inspection report can be accessed via the Care Quality Commission.

CQC identified 33 must do actions and 44 should do actions as a result of their inspection and all of these actions have now been closed. Regular updates have provided to CQC during the year April 2022 to March 2023 through routine engagement with them.

The trust’s ratings overall and at service level are identified in the figures below, along with comparative rating from the previous inspections. Where there are no comparative arrows, the core service was not inspected during the most recent inspection and therefore the rating remains the same.

During the year April 2022 to March 2023, CQC continued to prioritise inspections of trusts on a risk based approach. As CQC were assured of the trust’s safety and quality, they did not deem a further inspection to be a priority during the year April 2022 to March 2023. CQC receives assurance via their own reporting mechanisms, from information provided by the trust and through CQC’s routine engagement with the trust.

2.1.4.7 Trust overall rating February 2020

2.1.4.7.1 Ratings for whole trust

2.1.4.7.2 Ratings for the combined trust

2.1.4.8 Service level ratings comparative with previous inspection results

2.1.4.8.1 Ratings for mental health services

2.1.4.8.2 Rating for community services

2.1.4.8.3 Rating for adult social care services

The trust no longer has services at Station Road and Travis Gardens.

2.1.4.9 Internal audit reports

During the year April 2023 to March 2024, 360 Assurance (the trust’s internal audit service) has reported the following four Internal audits to Audit committee relating to quality:

• complaints, received in May 2023 with limited assurance
• CQC action Plan, received in July 2023 with significant assurance
• savings programme, received in November 2023 with significant assurance
• 18 weeks referral to treatment, received in January 2024 with limited assurance

Significant assurance, as a result of this audit engagement we have concluded that, except for the specific weaknesses identified by our audit in the areas examined, the risk management activities and controls are suitably designed, and were operating with sufficient effectiveness, to provide reasonable assurance that the control environment was effectively managed during the period under review.

Limited assurance, as a result of this audit engagement we have concluded that, in the areas examined, the risk management activities and controls are not suitably designed, or were not operating with sufficient effectiveness, to provide reasonable assurance that the control environment was effectively managed during the period under review.

The following arrangements are in place for all internal audit (360 Assurance) reports providing internal assurance:

• The audits are reported through the trust’s governance structures, for example, Quality committee, Finance, Digital and Estates committee, People and Organisational Development committee and Audit committee.
• There is an action plan in place for each audit where recommendations have been made from the audit results. These action plans have a responsible executive director and agreed time scales for completion.
• A process for monitoring and follow-up of all audit actions is in place with actions leads and through the scheduled meetings with the executive directors.

2.2 Statements of assurance from the board

2.2.1 Freedom to Speak Up (FTSU)

As a trust we have undertaken a significant amount of work to embed measures which enable and empower staff to speak up about issues that concern them, considering equality, diversity and inclusion. Work led by the Freedom to Speak Up (FTSU) guardian team over the last seven years has focussed on developing partnerships with front line staff, managers, board members and other partner organisations, with a view to enhance patient safety and staff wellbeing through a strong FTSU culture.

The trust has established several routes that staff can take to speak up about issues that concern them which have been adapted over the last year to accommodate remote working. We used digital routes through which staff can raise issues via Microsoft Teams and Zoom, and continued to support face to face meetings where social distancing and infection prevention measures could be used. There are established routes where staff can raise concerns by speaking up to line managers and clinical leads and, where this is not possible, staff can raise with the FTSU team, staff side representatives, safeguarding team, spiritual support and the health, wellbeing, and security support team. There is also an option to anonymously “speak up” using a button on the staff intranet or they can contact a FTSU Champion via text, email, or contact through social media. This collective approach has been critical in offering a diverse range of opportunities for staff to raise issues and ensure that they are offered support during the pandemic.

This year April 2023 to March 2024 shows an increased number of concerns up to 98 for the last financial year compared to 59 in the year April 2022 to March 2023. It is believed that the cultural interventions from the Organisational Development (OD) team, the increased support from the FTSU champions, safety huddles in 16 settings across the organisation and staff using the line manager route to raise concerns is helping to make speaking up what we do at RDaSH. We continue to promote the FTSU pathway and the learning from concerns raised is shared with individuals, at care group level and in the safety and quality group. There has been a 66% increase in the number of concerns raised to the guardian in the year April 2023 to March 2024. This could be attributed to the increase in freedom to speak up champions and also the increased visibility of the guardian in forward facing the service.

Throughout the last 12 months, we have continued to grow our FTSU Champions from across all core services. Currently we have 58 FTSU champions trained champions and 38 colleagues who have expressed an interest in becoming a FTSU champion. There has been particular focus on increasing the champions within inpatient settings given the concerns arising from the panorama and dispatches documentaries in 2022 as well the recent shocking revelation from the Countess of Chester Hospital Case regarding mortality rates. Once the new champions have been trained, they will be invited to our regular champions meetings, their contact information will be advertised on leaflets and posters and promotional materials. Regular and targeted communications will be channelled through daily briefings, Intranet, online and in person events and display boards across the organisation. We are still recruiting more to cover areas across the organisation where reporting is low or non-existent. FTSU training provided the champions with tools and skills to have conversations to encourage civility and respect amongst colleagues. Work is being undertaken by the guardian and the Improvement and Culture team around civility and respect and some training packages are being piloted in clinical areas with a view to rolling this out through the trust. The trust supports the message that “speaking up” encompasses matters that might be referred to as “raising concerns”, “complaining”, “raising a grievance”, “raising concerns about bullying” or “whistleblowing”.

In terms of our FTSU, team we have a NED responsible for FTSU who regularly meets with our FTSU guardian in terms of case analysis and reflection. Our CEO and our senior executive responsible for FTSU also meet regularly with the FTSU guardian.

2.2.1.1 Targeted Freedom to Speak Up (FTSU) engagement and induction

Work has continued to take place regarding increasing FTSU communication and enhanced induction for new starters including the international nurses. Information on speaking up is shared in trust publications.

The guardian continues to deliver induction engagement sessions to the Internationally educated workforce speaking about the importance of the FTSU agenda.

2.2.1.2 Board of directors

As a trust we have completed the national guardian’s FTSU reflection and planning tool. This has also had specific focus within our board development sessions in terms of coproduction. Our outcome and action plan has been shared with ICB partners, linked with across organisational learning.

2.2.1.3 Freedom to Speak Up, progress

All our people can access the new FTSU e-learning on the electronic staff record (ESR), The first module, “Speak Up”, is for all workers; the second module, “Listen Up”, is for managers and anyone that supervises people. This module focuses on listening and understanding the barriers to speaking up. The final module, “follow-up” is now available and is for senior leaders to support the role of Freedom to Speak Up as part of the strategic vision for organisations and system. We would like to explore this module with the board of directors as part of their development alongside completion of the reflective planning tool for FTSU.

2.2.1.4 Schwartz Rounds and team time

The rounds have been facilitated to support individuals to tell their stories and they promote “speaking up” about experiences in the health care sector. There is a high demand for bespoke Schwartz rounds in clinical areas.

The guardian is in the process of completing the Schwartz round facilitator training and is now able to deliver Schwartz round as a facilitator throughout the trust (the training should be completed by quarter 2, 2024).

2.2.1.5 Leadership support circles now known as cultivating compassion circles (3Cs)

These are interactive one-hour sessions that occur monthly via teams comprising ten themes, where we can share and thrive together. Safe spaces where people of all levels share their experiences and are heard. The guardian takes a collaborative role in delivering the sessions alongside colleagues from organisational development.

2.2.1.6 Speaking Up and staff diversity networks

The RDaSH FTSU guardian continues to attend virtual meetings for all the staff networks, being visible and creating safe psychological spaces for colleagues to discuss their concerns. The role of FTSU guardian is seen as a vital mechanism to ensure that people can continue to care for patients safely and to support staff wellbeing.

2.2.1.7 Safety culture at the trust

The Antiracism Alliance continues the journey towards the organisation becoming an antiracism organisation as per promise 26 of the clinical and organisational strategy. Antiracism work at RDaSH continues to be delivered in a systematic and structured way following the antiracism framework as advocated by NHS England and the Northwest framework; and aligns with the trust’s REaCH (race equality and cultural heritage) staff network. The Antiracism alliance meets bimonthly and has the chief executive as the executive sponsor who is overseeing and guiding on this work. It has attendance and representation from operational colleagues to senior managers either with or without lived experience. We have developed an action plan that has been shared within the alliance and the work allocated to fully implement the framework. The aim is that we eradicate racism and discrimination from our organisation and work towards requesting recognition and accreditation from the North West BAME (black, asian and minority ethnic) assembly.

2.2.1.8 Widening cultures via communities of Freedom to Speak Up practice

Our RDaSH FTSU approach is to ensure that we are fully linked into several networks to benefit from a collective approach to “speaking up”. The FTSU guardian attends regional FTSU guardian meetings and accesses peer support regularly that has been put in place. The national guardian’s office has psychological sessions and webinars to support guardians, it is recognised that FTSU guardians need support to continue to be fully effective within their organisational role.

2.2.1.9 Visibility of the guardian

The guardian has focused on increasing visibility through the organisation and visits each care groups once every 4 to 6 weeks to help develop trust within the staff group and to help spread the word of what FTSU does. Some other action the guardian has taken are below:

• present at each staff diversity network
• present in all quality peer reviews
• expanded champion’s network
• shadowing opportunities with the guardian
• substantive FTSU guardian now in place from Feb 2024
• confidentiality is maintained throughout the process with oversight from the guardian
• confidentiality is discussed withy champion in the FTSU champions network
• peer network with other guardians in the region

2.2.1.10 Freedom to speak up month October 2023 (breaking barriers)

During freedom to speak up month in October 2023, the guardian based himself in a different locality each week, to make himself available to discuss with staff the importance of speaking up and for staff to approach the guardian to discuss any concerns they had regarding the places they work in.

Information was distributed every week in October via the trust’s daily comms, with senior leaders throughout the organisation promoting the importance and value of speaking up.

Adopting and implementing FTSU in this way has yielded several benefits for patients, staff, and joint working. Key achievements over the year April 2023 to March 2024 have been:

• civility and respect training session being delivered throughout the organisation with the guardian helping to deliver session alongside colleagues from organisational development
• recruitment of more FTSU champions. This has been addressed and training has been delivered to the new volunteers
• development of Anti Racism Alliance partially due to FTSU concern raised
• connecting and meeting with other neighbouring trust leads on FTSU has enabled learning and good practice to be shared and processes embedded to systematically improve patient care internally and with our external colleagues
• guardian meetings and peer support has been enhanced and informal education sessions and skills sharing has been undertaken to develop and share good practice with our partners
• implementation of FTSU mangers form to formalise timescales for resolution of concerns and how learning will be imbedded within the service
• the trust is exploring making speak up, listen up and follow-up training mandatory
• guardian attending all quality peer reviews in inpatient settings
• completion of new FTSU Policy in line with recommendation from the National Guardian Office (NGO)
• completion of FTSU reflective planning tool with board member involvement

2.2.2 Staffing in the adult and older adult community mental health services

In the year April 2023 to March 2024, we embarked on year three of the community mental health transformation programme.

The community mental health transformation has had significant further investment in expanding the primary care workforce, since the year April 2020 to March 2021 the mental health workforce has expanded, the additional investment in the year April 2023 to March 2024 allowed a further 12.37 WTE posts to be recruited meaning across three years, 63 additional roles have enhanced our community mental health provision aimed at heavily supporting the “right care, right time, first time” approach to mental health and emphasising “no wrong door”. The roles include therapeutic, clinical, and non-clinical roles working in partnership with primary care.

The move towards personalised care and introduction of Dialog+ has been embedded across all transformed community mental health services in the year April 2023 to March 2024 starting with a roll-out across all primary care hubs and early intervention services with a focus on the whole system mobilising the new approach throughout the period of April 2024 to March 2025.

We have further invested in our VCSE partners and developed roles with a focus on coproduction and the introduction of an expert by experience coordinator and mental health alliance has flourished in the year April 2023 to March 2024.

A robust programme evaluation has taken place during Quarter 4, 2024, which has led to a transitional plan for the year April 2024 to March 2025, which will oversee the monitoring of five core metrics to embed impact of the newly transformed models and impact of additional workforce over the first year of full implementation.

There were also nonrecurrent monies invested in memory services, Rotherham. This nonrecurrent investment took the form of an additional two band 6 nurses and an additional two band 4 assistant psychologists, all fixed term. This additional investment, supported with addressing waiting times, from a costed capacity and demand point of view, however, further work will need to take place to ensure how increasing demand will be meet in future years.

In this period, Doncaster Place ICB commissioned several services via the Doncaster Alliance for which RDaSH provided both pre-diagnostic and post-diagnostic dementia care. The ICB gave notice on the Dementia Alliance contract and when the new contract was put out to Tender this was in two parts, the pre-diagnostic and the post-diagnostic. The decision taken by RDaSH was to only bid for the post-diagnostic service which we were successful in being awarded.

2.2.3 Learning disability improvement standards benchmarking

NHS Improvement have developed four standards that trusts need to meet; doing so identifies them as delivering high quality services for people with learning disabilities, autism or both.

The trust is partially meeting these standards.

With regard to learning disabilities, the trust takes part in the annual benchmarking of our learning disability services, we hold a trust wide quality circle meeting attended by multi professionals and are part of the learning disability quality effectiveness group.

The national team for benchmarking has announced that the learning disability standard benchmarking will not continue in the year April 2024 to March 2025. As a result, the trust learning disability directorate and the senior leadership team will explore options to agree standards to internally monitor and measure against.

The four standards concern:

2.2.3.1 Respecting and protecting rights

Annette’s charter remains a live document across the trust. This has been reviewed, working in collaboration with Annette’s family. The revised charter will be relaunched in 2024, ensuring this is cascade widely across our primary care sectors partners.

The trust has a monthly learning disability forum, known as the Quality Circle. This is attended by a number of key professionals ensuring we have a collective voice and ensuring that we are making continuous service improvements for people with learning disabilities.

2.2.3.2 Inclusion and engagement

The Doncaster Learning Disability team have a health co facilitator, who works a minimum of 2 days per month within the Health Action team. They are an active member of the team and support the wider learning disability community with training, advocacy and being the voice of people with learning disabilities.

A peer support worker also works in the Rotherham services to support inclusion and engagement.

2.2.3.3 Workforce

Level 3, 4 and 5 positive behavioural support courses are provided for staff to ensure the existing workforce develops their skill base within this area to meet the referral demand.

In 2024, the learning disability directorate will complete a targeted piece of work looking at the workforce to ensure that we have staff fit for the future and a sustainable model, including nurturing our students, trainee nurse associates, apprentices, and peer support workers.

2.2.3.4 Specialist learning disability services

• The positive behaviour support pathway is established in Rotherham and work is underway in Doncaster and North Lincolnshire.
• The sensory pathway is being developed for the Learning disability and or autism spectrum disorder (ASD) population.
• The Allied Health Professional team are developing a new posture pathway and OTAGO classes which involve exercises which are designed to help build up strength and improve balance in order to help prevent falls.
• Each area of the trust holds the learning disability dynamic support register on behalf of the integrated care board (ICB). This ensures we have effective and full oversight of all the people, who are currently in hospital, or are at risk of being admitted to a hospital. Holding the register allows us to work with our partners to avoid admission wherever possible.
• The community learning disability teams will focus on the trust’s promise 7 in achieving 95% of health checks for people with learning disabilities working in partnership with our primary care colleagues.

The learning disability and forensic directorate are developing a work plan for the year April 2024 to March 2025 that will focus on a number of key areas such as:

• developing a dementia pathway for people with a learning disability
• transition pathway from children’s to adults’ services for people with a learning disability
• STOMP (stopping over medication of people with a learning disability, autism or both with psychotropic medicines)
• LeDeR, focusing on the learning from the annual learning form deaths report and reviewing the recommendations

The work plan will focus on standardising the pathways irradiating inequities within the services.

The trust is reviewing both its learning disability and its autism services against these standards and has submitted data for national benchmarking annually over a 6-year period. The trust is currently awaiting the latest benchmarking outputs to be released (covering the year April 2022 to March 2023) but a draft is available to review and an action plan, to address any non-compliance against the standards, is being progressed.

A work stream is actively reviewing audits around transitions and the STOMP agenda. Further work steams have been developed to undertake targeted work in relation to training staff in the role of learning disability ambassador’s and reviewing how we receive feedback, concerns and complaints and embedding “Ask Listen Do”.

2.2.4 Response to national concerns regarding the care of patients with a learning disability and or autism

We are taking part in the inpatient mental health transformation programme with South Yorkshire Integrated care board provider collaborative and Humber and North Yorkshire, which is a response to last year’s national concerns regarding the care of patients with a learning disability and or autism. We will be able to report back on the progress and outcome of this in the year April 2024 to March 2025.

2.2.5 Review of services

During the year April 2023 to March 2024, Rotherham Doncaster and South Humber NHS Foundation Trust provided and or subcontracted 63 relevant health services.

Rotherham Doncaster and South Humber NHS Foundation Trust have reviewed all the data available to them on the quality of care in all 63 of these relevant health services.

The income generated by the relevant health services reviewed in the year April 2023 to March 2024 represents 100% of the total income generated from the provision of relevant health services by Rotherham Doncaster and South Humber NHS Foundation Trust for the year April 2023 to March 2024.

Further details of the services provided and subcontracted by Rotherham Doncaster and South Humber NHS Foundation Trust are provided on Rotherham Doncaster and South Humber NHS Foundation Trust’s services page.

2.2.6 Clinical audit

2.2.6.1 Trust (local) clinical audits

The audit framework has continued to drive forward the audit activity in the organisation throughout the year April 2023 to March 2024, providing the structure for clinical audit activity within the trust. The proposed trust wide forward clinical audit programme for in the year April 2024 to March 2025, has been presented and discussed with care group leads, quality committee and audit committee and the final forward programme will be aligned to the safety and quality plan.

The reports of 15 local clinical audits and 5 national audits were reviewed by Rotherham Doncaster and South Humber NHS Foundation trust in the year April 2023 to March 2024. The chart below shows the outcome ratings from these 20 clinical audits.

The table below shows a comparison of clinical audit outcomes from the years April 2022 to March 2023 and April 2023 to March 2024.

At the end of the year April 2023 to March 2024 the status of the key audits on the Programme were as follows:

The results of each audit are analysed and reported by the Clinical Effectiveness team and shared through either the care groups quality meetings through their audit leads or the associated trust wide assurance groups or steering groups. Action plans are developed collectively in each case and progress against these actions are tracked centrally by the Audit team and reported through to the assurance meetings.

2.2.6.2 Audit actions (local and national)

• Of the 15 local clinical audits completed, action plans were developed to improve the quality of healthcare provided, generating a total of 37 actions. 53% of the agreed actions have been completed and 47% are not yet due.
• 5 national audits had action plans developed to improve the quality of healthcare provided, generating a total of 5 actions. 40% of the agreed actions have been completed with 20% not yet due.

In October 2023, the Clinical Effectiveness team set up a monthly mental health centralised audit action group with representatives that included the care group directors of nursing and matrons. This was to support audit activity, agree actions to improve the quality of healthcare provided in relation to the key audits, and proactively address overdue actions from clinical audit. Since the restructuring of roles and responsibilities within care groups, we are seeing an uptake of involvement.

The main themes, as a result of the learning, that have occurred from clinical audit activity, have been changes to the design of aspects of the SystmOne electronic patient record, updates and amendments to clinical policy, and education at ward or service level by the clinical leaders in those areas, where gaps were identified in employee’s knowledge and understanding.

The trust clinical effectiveness lead can be contacted in relation to clinical audit reports, local and national (where available), and local activity linked to the responsive rolling programme based on care group or service priorities.

2.2.7 Clinical research

The number of patients receiving relevant health services, provided or subcontracted by Rotherham Doncaster and South Humber NHS Foundation Trust in the year April 2023 to March 2024, that were recruited during that period to participate in research approved by a research ethics committee and on the National Institute of Health Research (NIHR) portfolio, was 1,638 against an increased target of 900 participants in the NIHR portfolio studies.

2.2.7.1 Rotherham, Doncaster and South Humber NHS Foundation Trust performance against other partner organisations across Yorkshire and Humber region

With more open portfolio studies than the trust has ever seen before (20 compared with 16 at this time last year), the trust is ranked 11 out of 24 partner organisations. Compared with other mental health trusts, the trust is performing well above its peers in terms of recruitment to complex, interventional studies.

The Grounded Research (GR) team is based in a fully functioning, dedicated community clinical research facility (CRF), within the existing NHS trust infrastructure. The facility comprises clinical areas, bespoke pharmacy (for dispensing clinical trial medication) and a dedicated laboratory (to process research bio samples). It was set up with support from the Yorkshire and Humber Clinical Research Network (CRN) to respond to the research needs of the COVID-19 pandemic. The CRF was designed with input from all parts of the local community and within weeks of opening the team operated national and international vaccine trials. The GR team was named research team of the year for 2022 by the National Institute for Health and Care Research (NIHR) Clinical Research Network.

GR has successfully engaged with clinical research organisations (CROs) who place pharmaceutical industry sponsored and funded studies in UK NHS sites. We have formulated strategic partnerships with PAREXEL, IQVIA and PPD to ensure we are internationally recognised as a site of choice for both mental health, COVID-19 clinical trials, with an intention to build the pipeline of physical health commercial clinical trials. In the past year we have seen one commercial study in COVID-19 vaccinations successfully close, another COVID-19 vaccine study which is still in the follow-up phase and a mental health psilocybin study in the set-up phase. We hope to win further commercial clinical trial contracts in the year April 2024 to March 2025.

Between November 2022 and March 2023 GR undertook a workforce quality accreditation (WQA) process with an external company, the International Accrediting Organisation for Clinical Research (IAOCR). The team was awarded gold award status, the first clinical site to be awarded the accreditation at this level. An in depth, three month WQA assessment process reviewed the RDaSH GR team’s workforce processes, culture and development to ensure a competent and efficient “workforce of excellence”. The robust and independent assessment confirmed a highly impressive and dedicated team operating at global best practice standards, positioning the trust as both an employer of choice and clinical trial partner of choice.

GR participated in the assessment and certification process because it wanted to:

• provide reassurance to patients, sponsors, CROs, and staff that it is working to the workforce best practice standards
• ensure safe and effective delivery of clinical trials
• increase confidence and capability across the team, through ensuring competency based development and established staff wellbeing processes are embedded at the core of the organisation
• ensure a “right first time” and “quality built in” workforce ecosystem that is essential to reducing risk and ensuring compliance with International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and Good Clinical Practice (GCP)

The GR team is undertaking the WQA renewal process in April and May 2024 and later in the summer plan to initiate a more in depth accreditation process offered by the IAOCR team named global clinical site accreditation (GCSA). The GCSA certification encompasses WQA revalidation (to bronze level only) in addition to other domains to assess us against global clinical site standards:

1. patient engagement
2. feasibility
3. study start up and initiation
4. study management, operations and close down
5. research and development (R and D) commercial strategy
6. governance

GR has sponsored, led and delivered on several national NIHR funded studies over the past year. In partnership with the University of Sheffield Clinical Trial Research Unit (CTRU) and an industry partner MindLife, it has begun the setup of the StratCare-2 trial, which will evaluate the clinical and cost effectiveness of AI driven stratified care for depression. Working with the same industry partner we have secured funding for the UpLift-X project from Innovate UK, to investigate if remote group psychotherapy can be conducted at scale using an improved, modularised Unified Protocol. GR has continued collaboration with the national Centre for Mental Health to better understand the causes, triggers and course modifiers of disease pathogenesis in mental disorders and has begun discussions with the Dementia Platform UK team to become part of the trial delivery framework, which aims to Integrating the research environment to accelerate the discovery of new drugs for dementia.

Every year, the NIHR Clinical Research Network asks thousands of research participants to share their experiences of taking part in research. The participant in research experience survey (PRES) aims to put participant experience at the heart of research delivery, helping to improve the way research studies are designed and delivered, now and in the future. GR has collected PRES in all of its studies, gathering 94 responses against a target of 136 (increased from last year from 32), as of February 2024. The information received brought to light many positives from various participants, as well as suggestions on how to improve experiences for those wanting to participate in research in the future.

As GR moves into the year April 2024 to March 2025 it is exploring ways to assist in the development of the trust’s research and innovation (R and I) plan, delivery of promise 28 and the trust’s key performance indicators to measure the success of research and innovation across the organisation and beyond.

2.2.8 Commissioning for quality and innovation (CQUIN)

The CQUIN scheme this year includes core clinical priority areas, where improvement is expected across the year April 2023 to March 2024. NHS England and NHS Improvement have suggested that the indicators focus on specific evidence based improvements, rather than on complicated change programmes. The CQUINs are nationally set at the beginning of the financial year to work towards improving quality across services throughout the 12 months. The trust is required to ensure all reasonable endeavours are made to achieve the indicators within the CQUIN Scheme for the year April 2023 to March 2024 to drive improvements in the areas identified with the aim of improving the quality of the NHS services and outcomes for patients.

This scheme sets out 15 national CQUINs, six of which CQUINs are applicable to Rotherham Doncaster and South Humber NHS Foundation Trust:

2.2.8.1 Commissioning for quality and innovations (CQUINs)

• CQUIN 01, staff flu vaccinations, target was 75% to 80%
• CQUIN 12, assessment and documentation of pressure ulcer risk, target was 70% to 85%
• CQUIN 13, assessment, diagnosis and treatment of lower leg wounds, target was 25% to 50%
• CQUIN 14, malnutrition screening in the community, target was 70% to 90%
• CQUIN 15:
  • routine outcome monitoring in community mental health services, target was, paired overall of 20% to 50%, paired PROMs 2% to 10%
  • routine outcome monitoring in CYP and community perinatal mental health services, target was 20% to 50%
• CQUIN 17, reducing the need for the use of restrictive practices in adult and older adult inpatient settings, target was 75% to 90%

Further details of the National CQUIN Schemes for the year April 2023 to March 2024 are available electronically via the NHS England web page at NHS England (opens in new window).

2.2.9 Care Quality Commission (CQC) registration

Rotherham Doncaster and South Humber NHS Foundation Trust is required to register with the Care Quality Commission (CQC) and its current registration status is for the following regulated activities:

• accommodation for persons who require nursing or personal care
• assessment or medical treatment for persons detained under the Mental Health Act 1983
• diagnostic and screening procedures
• family planning
• personal care
• transport services, triage and medical advice provided remotely
• treatment of disease, disorder, or injury

In regard to Rotherham Doncaster and South Humber NHS Foundation Trust’s CQC registration, during the year April 2023 to March 2024 reporting period:

• no enforcement action was taken by CQC against Rotherham Doncaster and South Humber NHS Foundation Trust
• Rotherham Doncaster and South Humber NHS Foundation Trust have not participated in any special reviews or investigations by the CQC during the reporting period

Rotherham Doncaster and South Humber NHS Foundation Trust has the following conditions on registration, applied against the “accommodation for persons who require nursing or personal care” activity:

• the registered provider must not treat persons under 18 years of age at the location Danescourt
• the registered provider may not use the enhanced care accommodation at Danescourt
• the registered provider must only accommodate a maximum of 5 service users at Danescourt

2.2.10 Data quality

2.2.10.1 Hospital episode statistics

Rotherham Doncaster and South Humber NHS Foundation Trust submitted records during the year April 2023 to March 2024 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics, which are included in the latest published data.

The percentage of records in the published data included:

• the patient’s valid NHS number was 100% for admitted patient care (not applicable for outpatient care and for accident and emergency care)
• the patient’s valid general medical practice code was 100% for admitted patient care (not applicable for outpatient care and for accident and emergency care)

2.2.10.2 Data security

The national NHS Digital data security and protection toolkit reports whether standards have or have not been met from NHS Provider submissions. Rotherham Doncaster and South Humber NHS Foundation Trust achieved “standards met” for the year April 2022 to March 2023 and expect to achieve “standard met” for the year April 2023 to March 2024 final submission in June 2024.

2.2.10.3 Payment by results

Rotherham Doncaster and South Humber NHS Foundation Trust is paid on a block basis for the services it delivers and is therefore not subject to any payment by results coding reporting.

2.2.10.4 Data quality

Data quality and accuracy is governed through the trust’s annual data quality improvement programme, reporting a quarterly position to the Finance Performance and Information committee (FPIC) and more recently the finance, Digital and Estates committee (FDEC) on progress and position. This programme provides key focus on measures linked to the integrated quality performance report and accompanying information management guide, CQUIN and big 6.

The trust chief nursing information officer provides clinical leadership to translate and drive data quality needs into improved clinical recording accuracy and practice, whilst also understanding needs for improved quality of care delivery and efficiency. This is supported through a monthly data quality group.

Subject to both internal and external validation, the trust is committed to continuously improving the board assurance framework position for data quality and related quality of care outcomes.

The quality of our services will continue to be increasingly defined at an operational level through the clinical leadership executive (CLE) and operational management group (OMG), by care groups and directorates, with patient, carer and stakeholder involvement, with due regard to appropriate organisational governance arrangements and oversight by the board of directors.

There is an approved clinical audit policy which describes the trust’s approach and arrangements and an approved clinical audit programme. The clinical audit function is used appropriately to focus on risks, as well as on nationally identified issues. Progress against the clinical audit programme and the outcomes of audits are reported to the care groups.

The trust data quality policy provides assurance on the approach to data quality as a trust, aligning to the trust information governance and management framework, national data standards and legal commitments and obligations. The policy and framework drive a clear directive for trust wide data quality ownership, accountability, and action to ensure continuous data quality, whilst recognising the importance of accuracy for patient care and safety.

2.2.11 Learning from deaths

The trust Learning from Deaths: the right thing to do policy sets out the trust’s expectation on how it processes, responds to, and learns from deaths of patients where we are the main provider of care to that person. There is no national guidance as to what constitutes a ‘death within scope’ in a trust’s activities. It is something to be determined by an individual organisation. The trust has specific guidance within the policy to determine what is a “death within scope”. The trust continues to consider on a case by case basis if an out-of-scope death requires further review.

Within the trust, all deaths of patients who have a learning disability are highlighted and automatically subjected to at least a structured judgement review as well as scrutiny from the national LeDeR (learning disabilities mortality review) process.

The trust has a mortality surveillance group (MSG) in place which is chaired by the executive medical director, and this meets bimonthly. In line with the terms or reference, the group has oversight of all trust deaths including all expected and unexpected deaths, homicides, domestic homicides of patients currently in receipt of trust care and receives information relating to any child deaths.

The trust has a mortality operational group (MOG) in line with the requirements from the learning from deaths policy. The group is chaired by a consultant psychiatrist with dedicated time for mortality as part of their job role. This meets on a weekly basis with additional meetings held as and when required to ensure that reported deaths are considered in a timely manner. The aim of the group is to review the mortality information of all deaths that have occurred within the organisation that are within scope, determine if a structured judgement review (SJR) is required or not and to escalate any deaths to the Patient Safety team where concerns are identified and where a serious incident investigation, PSII may be required.

All deaths are reported onto a dedicated mortality module within the Ulysses Safeguard reporting system. The module has several components including the template for the completion of SJRs and ensures that all mortality processes are within a single system.

The structured judgement reviews for deaths are conducted by trained reviewers who have undergone formal training to undertake the reviews and are senior clinicians within the organisation.

The learning from deaths policy reflects current practice and has associated key performance indicators that are reported to the MSG. Terms of reference of monitoring groups are in place.

2.2.11.1 Mortality data

During the year April 2023 to March 2024, there were 593 deaths reported on the Rotherham, Doncaster, and South Humber NHS Foundation Trust mortality Ulysses system. This is down by 111 compared to the year April 2022 to March 2023.

This figure relates to deaths of patients from 1 April 2023 to 31 March 2024, who had contact with the trust within 6 months prior to death.

Of the 593 deaths the following occurred per quarter of that reporting period:

• 123 in quarter 1 (April to June 2023)
• 138 in quarter 2 (July to September 2023)
• 158 in quarter 3 (October to December 2023)
• 174 in quarter 4 (January to March 2024)

The trust works with 8 other mental health trusts in the North of England Alliance. Since the introduction of the new mortality reporting process, the trust has been reporting numbers of deaths which are in line with our partner organisations.

Of all deaths reviewed in MOG, 10% were subjected to structured judgement review.

Understanding the data around the deaths of our service users is a vital part of our commitment to learning from all deaths. For deaths resulting in reviews, the trust seeks to identify if the death was due to a problem in care. The process also seeks to identify where a high standard of care was delivered and if there were areas of learning.

From the structured judgement reviews completed to date, no deaths have been found to be due to a problem in care.

The structured judgement reviews undertaken have identified the following areas of good practice:

• good communication between agencies
• care plans reflective of needs
• recovery focused
• recognition of relapse and prompt interventions
• good physical health monitoring
• good dysphagia care and SALT intervention
• evidence of least restrictive practice
• good pharmacy support and interventions
• escalation of concerns to consultant psychiatrist when indicated

The structured judgement reviews also identified areas of learning for the trust:

• inadequate documentation, completion, content, frequency of reviews
• care plans not always completed or in line with assessments
• communication
• lack of clarity around referral completion
• carer stress recognition and interventions
• documentation of formal capacity assessments
• updating of FACE risk assessment was not robust at times

Learning from Inquests:

• the management of multi-disciplinary team meetings in crisis home treatment now run by team managers and senior clinicians
• all staff in the HomeFirst service have been made aware of the React to red and documentation circulated to all professional groups in the service including AHPs who had not been included in awareness or training previously
• we identified that letters sent to patients who were waiting for gateway assessments didn’t contain details of the Crisis team. Letters have now been amended not only to include details of the crisis team but also to include details of wrap around support including safe space, Andy’s Man Club and other organisations.

As part of the work of the mortality surveillance group during the year April 2023 to March 2024, the trust has:

• undertaken several deep dives and reviews including an annual review of drug and alcohol related deaths in Doncaster
• annual review of learning disability deaths
• the trust are part of the work being undertaken by Doncaster Public health looking at deaths of people were homeless
• undertaken a review of several deaths in older people’s and undertook a comparison across the trust footprint. This looked at a range of demographics and compared to data from the Office of National Statistics
• undertook bespoke locality reviews of deaths
• undertook an initial deep dive review of a number of unexpected deaths
• learning from other organisations

The mortality surveillance group will undertake the following areas of work in the year April 2024 to March 2025:

• further work on ensuring feedback from structured judgement reviews is being provided to clinical teams to ensure local action as needed
• annual mortality report
• annual review of drug and alcohol deaths in Doncaster
• annual review of learning disability deaths
• place based reviews will be undertaken to allow further learning within the localities

2.3 Reporting against core indicators

The trust is required to provide performance data against a core set of indicators using data made available to the trust by NHS Digital. Guidance from NHS England (opens in new window) specifies the following indicators must be reported on in trust quality accounts.

The percentage of patients receiving a follow-up within 72 hours of discharge had a target of 60% for April 2023 to March 2024

This indicator is not included within the NHS Digital mental health community teams activity submission and therefore not part of national comparable data.

The Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data is as described and has taken the following actions to improve the quality of the data against these indicators, and so the quality of its services, in the forthcoming year (April 2023 to March 2024):

Regular checks of the raw data for accuracy (prior to submission) are carried out by the trust’s Performance team.

This indicator is not included within the NHS Digital mental health community teams activity submission and therefore not part of national comparable data.

The Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data is as described and has taken the following actions to improve the quality of the data against these indicators, and so the quality of its services, in the forthcoming year (April 2023 to March 2024):

• regular checks of the raw data for accuracy (prior to submission) are carried out by the trust’s performance team

Source: CQC Mental Health Community Services Survey 2023 (opens in new window).

The mental health community survey is an independently administered national survey of patients receiving mental health care in community settings. The survey is comprehensive and provides valuable quantitative data to facilitate comparison with other trusts and benchmark our services numerically against a range of indicators. The survey for RDaSH in 2023 contacted 1250 service users, of which 265 completed the survey.

The results for specific questions are categorised depending on whether they are better, worse or about the same compared with other trusts. For RDaSH the breakdown was as follows:

• in 33 questions, RDaSH was “about the same”
• in 0 questions, were RDaSH was “better than expected”
• in 2 questions, RDaSH was “worse than expected”

The two worse than expected questions related to feedback. They highlighted that only 17% of people using RDaSH mental health services in the last 12 months were asked to give feedback. Traditionally, as a trust, we have used a lot of paper based feedback gathering methodologies for instance: Your Opinion Counts (YOC) and friends and family test (FFT). The trust is currently exploring new ways to gain feedback. One successful, 9-month trial that saw a 12% (2,500 patients) feedback rate in 2023 was a SMS feedback service for Talking Therapies.

To improve the gathering of feedback trust wide, the services of Care Opinion are currently (April) been explored as a potential option to enable this. Care Opinion is an independent online platform where people can leave their thoughts and feedback. Designated staff from the relevant service can then leave response to the feedback or concern.

Source: NHS England (data only published annually in September each year) RDaSH Ulysses incident reporting system.

National Reporting and Learning System (NRLS April 2021 to March 2022 published October 2022 (opens in new window). Further date not currently available.

NHSE September 2023 update: “We have paused the annual publishing of this data while we consider future publications in line with the current introduction of Learn from Patient Safety Events (LFPSE) (opens in new window) service to replace the NRLS”.

The link below can be used to see this information:

• organisation patient safety incident reports (opens in new window)

The Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data is as described for the following reasons:

The Rotherham Doncaster and South Humber NHS Foundation Trust continues to encourage reporting of incidents. The implementation of the patient safety incident response framework (PSIRF) and the introduction of learning from patient safety events (LFPSE) has encouraged and improved the reporting of patient safety incidents across the trust. The trust has implemented a daily incident meeting attended by all care groups and staff across the trust, improving how we learn from and responds to incidents. Increased incident reporting enables identification of themes and trends, and so maintain the quality of services. By creating a culture of openness and a restorative just culture staff will feel able and confident to report incidents without fear of reprisal.

3 Other information

This section provides an overview of the quality of care delivered by Rotherham Doncaster and South Humber NHS Foundation Trust. These indicators are in line with national strategies, priorities and requirements and with the quality priorities and strategic ambitions of the trust. The following is a summary of the key indicators for each of the three quality domains of patient safety, clinical effectiveness, and patient experience.

3.1 Patient safety

3.1.1 Patient safety incident response framework (PSIRF)

• During the year April 2023 to March 2024, the trust undertook data analysis and preparation work to support the PSIRF process. The trust PSIRF policy and plan was developed.
• The trust went live with Learning from patient safety events (LFPSE) in August 2023.
• A PSIRF workshop as held as part of the board development programme in October 2023. The PSIRF plan was subsequently approved by the integrated care board (ICB) and trust board in November 2023.
• The trust formally launched PSIRF trust wide on 2 January 2024.
• PSIRF training has been accessed through the Healthcare Safety Investigation Branch (HSIB). All Investigators have completed the PSIRF HSIB approved training.
• In October 2023, the trust established a daily incident meeting attended by all care groups.
• A weekly safety huddle was established which includes directors of nursing, matrons and representatives of specific services including safeguarding, pharmacy. This reviews the key incidents from the week and confirms next steps and actions required. The meeting identifies and discusses any pattens or themes observed.
• Services and care groups have begun to utilise the PSIRF incident response tools.
• The trust replaced the serious incident review group with the patient safety incident response review group. Membership includes ICB representatives.
• Learning is cascaded through the clinical learning brief.

3.1.1.1 Next steps

In quarter 1 and 2 of the year April 2024 to March 2025 the trust will roll our internal training for the incident response tools.

We will review the PSIRF process and plan in quarter 4, in the year April 2024 to March 2025.

3.1.2 Safeguarding

Living a life that is free from harm and abuse is a fundamental human right of every person and an essential requirement for health and wellbeing. Healthcare staff are often working with patients, who for a range of reasons, may be less able to protect themselves from neglect, harm or abuse.

The responsibility to safeguard adults and children and promote their welfare is more comprehensive than protection. To be effective, this requires staff members to recognise their individual responsibility to safeguard and promote the welfare of children and adults who are vulnerable as well as the commitment of trust management to support them in this.

This includes ensuring staff have access to appropriate training, advice, support and supervision in relation to Section 11 of the Children Act (2004), Care Act (2014), Mental Capacity Act (2005, 2019), and the Prevention of Terrorism Act (2005). These acts place a duty on key people and bodies, including NHS trusts, to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children and adults with care and support needs. “Working Together to Safeguard Children, 2023” sets out how organisations and individuals should work together to undertake their duties to safeguard and promote the welfare of children and young people in accordance with the Children Acts 1989 and 2004.

The trust believes that everyone has a responsibility to promote the welfare of children, young people, and adults, to keep them safe and to practice in a way that protects them. We give equal priority to keep all children, young people, and adults safe regardless of their age, disability, gender reassignment, race, religion or belief, sex or sexual orientation.

The trust has a suite of comprehensive safeguarding policies which contain information and guidance, including how to raise concerns if staff are worried about a child, young person, or adult at risk.

Recruitment practices and retention of a safe and expert workforce is vital. In addition, those who would harm a child, young person or adult at risk are discouraged from joining the organisation through safe recruitment processes.

The trust has a person in position of trust policy in place to manage allegations made against a member of staff and safeguard individuals.

3.1.2.1 Governance and accountability

The safeguarding team is made up of a diverse and multi-professional team who provide expert advice, support, supervision, and training to all trust employees to fulfil their safeguarding responsibilities and duties on a wide range of safeguarding issues. The team prides itself on ensuring that the person at risk of or suffering neglect, harm or abuse always remains in our “line of sight”, and that we “hear their voice” and they remain at the centre of all we do.

The safeguarding leadership and governance structures are well established. The chief nursing officer is the executive Lead for Safeguarding. The deputy chief nursing officer supports the chief nursing officer with the executive role. The nurse consultant provides strategic direction for both adult and children’s safeguarding, and the named nurses, professionals and lead professionals provide expert advice, guidance, and leadership.

The safeguarding assurance group (SAG) provides challenge and assurance about the safeguarding arrangements within the trust. The safeguarding team works with many partner agencies and contributes to local multi-agency safeguarding children partnerships, safeguarding adults boards and subgroups across the footprint. The trust provides external assurance through a variety of methods including section 11 audits, self-assessments and contractual standards required by the integrated care boards.

3.1.2.2 Safeguarding clinical effectiveness activity

The following section summarises the outcomes of safeguarding clinical effectiveness activity and assurance during April 2023 to March 2024.

3.1.2.3 Referrals into children’s social care

• Scrutiny: Safeguarding assurance group.
• Summary: Scrutiny of children’s safeguarding referrals.
• Outcome: Good.
• Actions: Embed the requirement for an IR1 to be completed following a referral.

3.1.2.4 Safeguarding training evaluation

• Scrutiny: Safeguarding assurance group.
• Summary: To provide assurance that the safeguarding team are delivering effective and appropriate subject based training sessions for colleagues working across the trust.
• Outcome: Outstanding.
• Actions: To continue to analyse feedback following delivery of training.

3.1.2.4 Domestic abuse

• Scrutiny: Safeguarding assurance group.
• Summary: To ensure that staff have an understanding of what domestic abuse is and that they respond appropriately, take relevant action to reports of such abuse.
• Outcome: Routine enquiry to be included in domestic abuse training. Ensure all assessment templates have an ability to record routine enquiry for domestic abuse. To explore whether domestic abuse to be included in the FACE risk assessment.

3.1.2.5 Training

The delivery of safeguarding training remains a key priority for our safeguarding team, with the requirement that all staff are provided with the appropriate level of training commensurate to their role as defined in the Intercollegiate documents: Safeguarding Children and Young People: Roles and Competences for Healthcare Staff (2018), Looked After Children: Roles and Competences for Healthcare Staff (2020) and Adult Safeguarding: Roles and Competencies for Healthcare staff (2019).

The aim of the safeguarding training is to ensure that every member of staff is aware of their safeguarding responsibilities, recognises abuse and knows what to do about it, as the minimum requirement. All training delivered by the team meets national standards as described in the Intercollegiate documents.

The trust contributes to the delivery of multi-agency training programme developed by the local safeguarding children’s partnerships and safeguarding adults boards. This includes the graded care profile 2 training in Rotherham and Doncaster.

As a provider of NHS care we are required to have mechanisms in place to train staff to understand the risk of radicalisation. Mandatory prevent training in line with NHSE Prevent Training and Competencies Framework is accessed by our staff via eLearning.

The domestic abuse policy has been reviewed and updated to include supporting staff who are experiencing domestic abuse. In addition, a domestic abuse level 2 training package has been developed and delivery of this package commenced in January 2023.

The table below shows trust compliance with safeguarding training as of March 2024 and compares data to the previous year. There has been improvement in adults level 3, children’s level 3 and domestic abuse level 2 compliancy with rating now amber rather than the red of last year. Prevent Level 1 and 2 has seen a slight decrease falling just under the target but prevent level 3 has seen a slight increase and is now over the target.

The table below identifies the number of specific training courses delivered in April 2023 to March 2024 and the number of participants that attended. This evidences that the trust offers a variety of level 3 training and the safeguarding training audit evidence that it is well received by staff.

3.1.2.6 Safeguarding supervision

Safeguarding supervision is fundamental in supporting practitioners in delivering high quality care, providing risk analysis and individual actions plans. Safeguarding supervision is mandatory for all staff working with children and families. The trust uses a cascade model for facilitating safeguarding supervision and supervisors act as a visible champion of safeguarding within their own service areas to provide a link between their colleagues and the safeguarding team.

Joint safeguarding children and adult group supervision sessions have been combined across all three localities across the trust, with sessions held weekly for greater accessibility. The sessions are facilitated by a Named Nurse and lead professional from children and adult safeguarding to ensure the “Think Family” model is embedded in practice. Supervisors are encouraged to bring case discussion and positive feedback is being received.

The safeguarding team facilitates quarterly safeguarding forums. Each forum has a different theme and a guest speaker. Topics this year have included counterterrorism, refugees and honour based abuse.

3.1.2.7 Multi-agency working

The trust is fully committed to multi-agency working and ensuring that effective safeguarding arrangements are in place across each of the three locality areas the trust operates in. This is achieved by:

Membership of Doncaster Safeguarding Children Partnership, Doncaster Safeguarding Adult Board and subgroups of both:

• membership of Rotherham Safeguarding Children Partnership and Rotherham Safeguarding Adult Board and subgroups of both
• membership of North Lincolnshire Safeguarding Children Partnership and North Lincolnshire Safeguarding Adult Board and subgroups of both

The trust remains committed to active involvement in local statutory multi-agency reviews including domestic homicide reviews, safeguarding adult reviews, child safeguarding practice reviews and learning lesson reviews. Any learning is disseminated across the trust.

The trust publishes an annual safeguarding report that outlines the collaboration with local safeguarding children partnerships and safeguarding adult boards alongside the trust’s safeguarding priorities.

3.1.3 Infection prevention and control (IPC)

Our vision is that no person is harmed by a preventable infection. The trust continues to make substantial progress towards achieving the trust’s key priorities. We have a continued commitment to promoting best practice in infection prevention and control and maintaining low incidents of healthcare associated infections within the trust.

The IPC clinical nurse specialists work together to provide leadership, advice, and support to ensure compliance with the Health and Social Care Act (2008). Learning is facilitated across the trust through training, education and learning lessons from incident reports.

National guidance and initiatives have been key drivers for elements of our annual work programme, and this evolving work stream will continue into the year April 2023 to March 2024.

Infection prevention and control is the responsibility of everyone, and success is achieved when everyone works together.

3.1.3.1 Key achievements of April 2023 to March 2024

• Continued low rates of healthcare associated infections (HCAIs).
• Ongoing outbreak management and support to colleagues and patients.
• IPC conference held in September and attended by approximately 100 participants from a wide variety of clinical backgrounds within the trust, with a large representation being IPC link champions from across all care groups. Also in attendance were a range of regional and PLACE colleagues. Presentations were around a diverse range of topics.
• Work across the trust to remind staff of the importance of being bare below the elbows (BBE) to facilitate effective hand hygiene. Partnership working with patients on Amber Lodge has resulted in a video of their views on the importance of hand hygiene which was voiced over by colleagues.
• Incorporation of the National IPC manual with a range of quick guides to support colleagues in managing specific organisms and procedures.
• Completion of the inpatient audit programme with all 19 wards being audited using the Tendable platform with positive results.
• Dedicated link champions supporting their peers and colleagues to deliver safe care.
• Completion of a sharps safety audit by an external company, to support safety, training and compliance with legislation. This showed significant improvement from the previous audit.
• The visible and proactive approach of the IPC team.

3.1.3.2 Governance

Safe, effective IPC remains a top priority for the trust. It acknowledges that avoidable infections can be devastating for patients and their families and can have a detrimental impact on patient care delivery.

The chief executive holds ultimate responsibility for providing effective IPC arrangements, with the chief nurse, director of infection prevention and control (DIPC) holding the portfolio for IPC.

The deputy chief nurse is responsible for the operational leadership of IPC provision with the nurse consultant for safeguarding providing direct line management of the IPC team.

The care group nurse directors are responsible for the operational delivery of IPC in all care groups and are supported by the deputy director of nursing and nurse consultant for safeguarding.

IPC reports are received by trust board via the safety and quality operational group and Quality committee.

3.1.3.3 Healthcare associated infections

Source: Local reporting system, cases as defined by Health Protection Agency guidelines.

3.1.3.4 Outbreaks of infection

• There have been 3 outbreaks of norovirus, diarrhoea and vomiting.
• There have been 0 outbreaks of influenza trust wide.
• There have been 24 outbreaks of COVID-19 across the trust.

Managing COVID-19 outbreaks remained the most challenging work stream in the year April 2023 to March 2024 due to there being limited restrictions outside a healthcare setting.

The IPC team provided support and guidance daily to affected inpatient areas utilising clinical area visits, telephone updates and emails.

The outbreaks were managed internally with outbreak meetings held if required and any actions fed back through the IPC Operational Group.

Measles guidance and flowcharts have been distributed to the care groups, patient immunity status is being reviewed on admission and patients will be offered MMR vaccination if there is no documented evidence of immunity or if they are non-immune, HR are currently working on guidance to collate colleague immunity status and the offer of MMR vaccination from OH. The EPRR core standard is around FFP3 access and there are currently fit testers in all localities with each care group formulating their own fit testing plans and there are further sessions planned for more fit testers across the organisation.

3.1.3.5 Link champions

IPC link champions support patient safety strategies through the dissemination of IPC knowledge and best practice in their clinical areas, there are approximately 81 IPC link champions across the trust covering all care groups.

The IPC link champions are encouraged to provide information at ward and clinic level using information boards. A wide range of information is displayed and disseminated to patients, visitors and colleagues. Link champions are encouraged to change the board content on a quarterly basis and to consider any seasonal or current IPC issues such as influenza, norovirus, food poisoning etc.

Six link champions have undertaken the Florence Nightingale Foundation course “Developing health care support workers to be infection prevention control champions”. The purpose of the course is to develop nursing, midwifery and allied health professional leadership identity, capacity and capability to influence organisational and patient outcomes at a local, systems, national and international level of healthcare delivery.

Further dates have been published and sent out to all link champions and service managers and matrons to share with their teams.

3.1.3.6 Audits

The IPC team have utilised the Tendable mobile app and web portal system to audit practice and staff knowledge of procedures in the trust IPC manual. The audit tool provides the reports, analytics and insights to improve performance and compliance. All 18 inpatient areas were audited:

• one area was rated red for the sharps audit, with five areas rated amber. The main areas of concern were around the assembly and use of sharps containers, and contamination injury management
• seven areas were rated amber for the infection prevention and control audit. Key concerns were around out of date consumables, knowledge gaps around patient management, segregation of storeroom contents and management of patient equipment

3.1.3.7 Mandatory training

Standard precautions training:

• level 1 is for all non-clinical staff and is required every three years
• level 2 is for all clinical staff and is required annually

The training is completed by eLearning and compliance is monitored monthly. A paper based version of the training is available for staff groups unable to access eLearning. This has been utilised primarily by staff from the estates and facilities department with limited access to IT. For these groups of staff, the knowledge and learning post training is assessed by the individual’s line manager.

3.1.4 Pressure ulcers

All trust acquired category 3 and 4 pressure ulcers are reviewed by a multidisciplinary internal team of experts. The root cause and any lapses in care are established, themes and trends and learning are identified and are cascaded to the multi-professional pressure ulcer harm reduction group (PUHRG).

During the year April 2023 to March 2024 partnership working with Yorkshire Ambulance Service (YAS) was strengthened and a trial of the wound responsive action pack and training for YAS staff was rolled out. Two hundred packs in total have been distributed with the aim of being “if you see, treat and refer on”. An evaluation of the impact of those receiving care via the use of the packs is currently underway.

In the year April 2024 to March 2025, it is anticipated that the PUHRG will be further improved with the addition of mental health and allied health professional representation. Links with Doncaster and Bassetlaw Hospitals NHS Foundation Trust are also being strengthened.

3.2 Clinical effectiveness

3.2.1 Clinical policies

Clear, comprehensive, and up-to-date policy documents, that can be easily located and understood by everyone are a crucial element of a safe, effective and caring organisation.

The clinical policies review and approval group (CPRAG) provides assurance to the board that:

• the trust has a robust framework for the ratification of all clinical polices through a structured review and approval process
• in accordance with relevant legislation and guidance, the trust is fulfilling its statutory duty to have up to date, evidence based clinical policies in place
• appropriate consultation of clinical policies has taken place
• all clinical policies are reviewed, ratified, and reported in accordance with the trust’s procedural documents (development and management) policy
• scrutiny and challenge of all clinical policies content takes place to ensure they are fit for purpose in:
  • providing guidance and standards for staff in safe working practices
  • promoting standardisation in the provision of safe and effective care and the management of risk

There continues to be a strong focus from the Clinical Effectiveness team to lead task and finish groups to facilitate collaborative clinical policy reviews with key stakeholders such as subject-matter experts, clinical leads, and junior staff.

In response to feedback received and the progressive nature of the organisation, we continue to review and reduce where clinically indicated and safe to do so, both the number of clinical policies and the volume of information within policies.

A recent project has been successfully completed to review and refresh the infection prevention and control (IPC) manual. The end user now has access to 22 easy read quick guides with a link to the national IPC manual for further reading and reference. This has resulted in a reduction of 20 separate clinical procedural documents which were 214 pages in total. Positive feedback has been received and the outcomes from this pilot will be reviewed within the organisations’ leadership groups and committees to ascertain the appetite for further phases of work to follow based on this pilot. This also aligns to the trusts clinical and organisational strategy and patient safety incident response framework (PSIRF).

3.2.2 National Institute of Health and Care Excellence quality standards

The NICE guidance centralised process meeting provides the NICE leads the opportunity to meet monthly to discuss the recently published NICE guidance, discuss applicability to services and supports consistency across the trust. The group identify any guidance that requires a corporate review.

All guidance is reviewed, and a response recorded centrally within 28 days of publishing. In the year April 2023 to March 2024 190 pieces of NICE guidance were published. Seven7 pieces of guidance were assessed as being core to one or more services, 10 were assessed as being relevant to one or more services, 42 were assessed as being for information, 131 were assessed as being not applicable.

There was a total of 11 baseline assessments (national guidance or clinical guidance) completed with a further 15 in progress.

A piece of work has been undertaken to align the central database to the new structures and directorates within the care groups.

The new trust clinical strategy promotes the use of NICE quality standards (where applicable and available) to underpin evidence based practice and use as a tool to measure and improve the quality of care provided. This will continue to be a key area of focus for the year April 2024 to March 2025 to support measures within clinical audit activity.

3.2.3 Guidance identified as core

3.2.3.1 CG185 Bipolar disorder, assessment and management

Care group:

• physical health and neurodiversity
• Doncaster mental health and learning disabilities
• North Lincolnshire mental health and Talking Therapies

Services:

• inpatient physical health rehab
• older people’s mental health
• adult mental health
• forensic services
• drug and alcohol service
• learning disabilities

3.2.3.2 HTE10 KardiaMobile 6L for measuring cardiac QT interval in adults having antipsychotic medication

Care group:

• North Lincolnshire mental health and Talking Therapies

Services:

• learning disabilities
• older people’s mental health
• adult mental health

3.2.3.3 NG158 Venous thromboembolic diseases, diagnosis management and thrombophilia testing

Care group:

• Rotherham adult mental health

Services:

• older people’s mental health
• adult mental health

3.2.3.4 QS11 Alcohol use disorders, diagnosis and management

Care group:

• Rotherham adult mental health

Services:

• older People’s mental health
• adult mental health
• learning disabilities

3.2.3.5 Transition from children’s to adults’ services

Care group:

• physical health and neurodiversity
• North Lincolnshire mental health and Talking Therapies

Services:

• community nursing
• long term conditions
• specialist palliative care
• learning disabilities
• older people’s mental health

3.2.3.6 QS211 Epilepsies in children, young people and adults

Care group:

• children’s
• physical health and neurodiversity

Services:

• CAMHS and CYPF
• long term conditions

3.2.3.7 QS8 Depression in adults

Care group:

• North Lincolnshire mental health and Talking Therapies
• Rotherham adult mental health

Services:

• learning disabilities
• older people’s mental health
• adult mental health

3.2.4 Guidance identified as relevant

3.2.4.1 CG185 Bipolar disorder, assessment and management

Care group:

• Doncaster mental health and learning disabilities
• pharmacy

Services:

• learning disabilities

3.2.4.2 HTE15 Virtual reality technologies for treating agoraphobia or agoraphobic avoidance: early value assessment

Care group:

• North Lincolnshire mental health and Talking Therapies

Services:

• learning disabilities
• older people’s mental health
• adult mental health

3.2.4.3 HTE9 Digitally enabled therapies for adults with anxiety disorders: early value assessment

Care group:

• North Lincolnshire mental health and Talking Therapies

Services:

• learning disabilities

3.2.4.4 MIB324 Flow transcranial direct current stimulation for treating depression

Care group:

• North Lincolnshire mental health and Talking Therapies

Services:

• learning disabilities
• older people’s mental health
• adult mental health

3.2.4.5 NG33 Tuberculosis

Care group:

• children’s

Services:

• CAMHS and CYPF

3.2.4.6 QS11 Alcohol use disorders: diagnosis and management

Care group:

• Doncaster mental health and learning disabilities

Services:

• drug and alcohol service

3.2.4.7 QS140 Transition from children’s to adults’ services

Care group:

• Doncaster mental health and learning disabilities
• Rotherham adult mental health

Services:

• adult mental health
• learning disabilities
• older people’s mental health

3.2.4.8 QS211 Epilepsies in children, young people and adults

Care group:

• Rotherham adult mental health

Services:

• learning disabilities

3.2.4.9 QS74 head injury

Care group:

• Rotherham adult mental health

Services:

• learning disabilities

3.2.4.10 QS8 Depression

Care group:

• pharmacy

Services:

• not applicable

3.2.5 Completed baseline assessments with an outcome of fully implemented

3.2.5.1 CG189 Obesity, identification, assessment and management

Care group:

• children’s

Summary:

• baseline assessment completed by children’s care group., all recommendations are met

3.2.5.2 NG216 Social work with adults experiencing complex needs

Care group:

• trust wide

Summary:

• baseline not completed as it was deemed to be too generic, reviewed by social work practice lead with plan in place to present recommendations widely

3.2.6 Completed baseline assessments with an outcome of partially implemented

3.2.6.1 NG225 Self-harm: assessment, management and preventing recurrence

Care group:

• trust wide

Summary:

• a baseline assessment was completed 2023 which identified a number of gaps in terms of meeting the recommendations from NG225. A working group was established to review and update the trust’s self-harm policy and align it to NG225. This work stream was completed in February 2024, with the updated policy now published. The outcome remains partially implemented as no audit has been undertaken to measure compliance with the recommendations and policy

3.2.6.2 CG103 Delirium: prevention, diagnosis and management in hospital and long term care

Care group:

• North Lincolnshire mental health and talking therapies

Summary:

• a baseline assessment has been completed where it has been identified that some recommendations are not currently met. Further work is required to evidence how we do meet recommendations and to develop an action plan where recommendations are not met

3.2.6.3 NG227 Advocacy services for adults with health and social care needs

Care group:

• trust wide

Summary:

• a baseline assessment has been completed where it has been identified that some recommendations are not currently met, action plan has been developed and actions are being progressed

3.2.6.3 NG222 Depression in adults: treatment and management

Care group:

• trust wide

Summary:

• a baseline assessment has been completed where it has been identified that some recommendations are not currently met, action plan has been completed; however, input is required from psychological professionals around 5 recommendations

3.2.3 QUIT programme

Throughout April 2023 to March 2024 the QUIT team have continued to provide services to patients and staff members who want to stop smoking. The trust exceeded their performance target, set by the integrated care board, to increase the number of patients identified as a smoker and to provide them with NRT within 72 hours. The team achieved 60% compliance, compared to 46.5% compliance in the previous year.

Over the last 12 months, 78 patients have reached a 4 week quit, and 58 patients reached a 12 week quit. This success continues in the staff offer with 13 staff reaching a 4 week quit and a further 22 staff reaching a 12 week quit.

The QUIT team continue to submit a full data set to the integrated care board and NHS England to evidence the positive work being undertaken. Requirements for data submissions continues to grow as the service expands. The QUIT team are working with Rotherham Council to provide access to the swop to stop scheme for all RDaSH staff and patients, which will provide a free 12-week starter kit plus ongoing behavioural support from the QUIT teams tobacco treatment advisors.

The QUIT team show commitment and dedication to maintaining smokefree environments across all trust sites via positive role modelling and by providing training, advice and guidance to colleagues. The team have recently started a quality improvement project in conjunction with the Royal College of Psychiatry. This aims to increase the number of patients in mental health inpatient units receiving smoking cessation treatment.

3.2.4 Non-medical prescribing

The trust has a significant number of prescribers consisting of Community Prescribers and Independent Prescribers. To ensure good governance, accountability and assurance a number of measures are taken. Policies are reviewed, processes improved and systems to monitor competency of those approved to prescribe are robust. Oversight of this is supported by using a digital portal which is overseen by the nursing and quality directorate.

3.2.5 Professional nurse advocate

Professional nurse advocacy (PNA) is a professional clinical leadership role introduced post pandemic by the chief Nurse and NHS England and Improvement to introduce a framework for providing restorative clinical supervision for nurses using the A-EQUIP (advocating and educating for quality improvement) model.

The PNA role guides staff through a continuous development process that builds personal and professional nursing leadership and increases contribution to quality improvement. The PNA provides restorative clinical supervision which delivers elements of psychological support and develop holistic resilience and emotional wellbeing for nurses. The aim of restorative supervision is to address the emotional needs of staff while providing “thinking space” which reduces stress and burnout and in turn improves staff retention.

During the year April 2023 to March 2024:

• a PNA ambassador was established in each care group, the ambition is to have one PNA per team; the trust currently has 14 qualified PNAs and seven in training
• PNA council bimonthly meetings held (for all qualified and in training PNAs)
• communities of practice were established regionally and all trust PNAs are invited to attend to share learning across the region

3.3 Patient experience

3.3.1 Community mental health survey

The mental health community survey is an independently administered national survey of patients receiving mental health care in community settings. The survey is comprehensive and provides valuable quantitative data to facilitate comparison with other trusts and benchmark our services numerically against a range of indicators. The results are provided to the trust as a whole trust and it is not possible to break this down by geographical area.

RDaSH took part in the survey in 2023, with 266 patients providing feedback. For each scored question in the survey, the individual (standardised) responses are converted into an average score between 1 and 10. A score of 10 for a question represents the best possible response and a score of 0 the worst. The higher the score for each question, the better the trust is performing.

There are 40 questions in the mental health survey which cover 13 important areas, this being:

• section one, support whilst waiting
• section two, the mental health team
• section three, planning care
• section four, involvement in care
• section five, medication
• section six, Talking Therapies
• section seven, crisis care support
• section eight, crisis Care access
• section nine, support with others
• section ten, support in accessing care
• section eleven, respect dignity and compassion
• section twelve, overall experience
• section thirteen, feedback

Overall results were encouraging, with most scores for the trust sitting in the intermediate range with a score of between 6 and 6.9 (out of 10). This is comparable with the previous year’s results with the trust also falling within this range in the year April 2022 to March 2023.

Table 20 shows the bottom five scores in relation to the national average. The single lowest scoring question (Q40) clearly highlights the importance of the community mental health survey and the importance of work that has already been stared in our trust in relation to gaining feedback.

The survey highlighted that only 17% of people who responded to the survey and had used RDaSH mental health services in the last 12 months were asked to give feedback.

Traditionally as a trust, we have used a lot of paper based methods for gathering patient feedback, for instance Your Opinion Counts (YOC) and friends and family test (FFT). The trust is currently exploring new ways to gain feedback. An example of this is a 9-month trial in 2023 of SMS (text message) feedback for patients using the Talking Therapies services. 2500 patients were surveyed during the trial which resulted in a 12% response rate.

During the period of the trial, the SMS texting service outperformed “Your Opinion Counts” by 120%. Due to this success, a wider SMS feedback system is currently in the process of being launched. The SMS feedback texting service will include trust wide questions (including the friends and family test) questions and four or five service specific questions. All feedback will be visible through the trust’s internal reporting mechanisms for the service areas and for assurance meetings. The person filling in the SMS feedback will also be asked if you wish to get involved in engagement or volunteering. There are currently 15 services that have shown interest in taking up this SMS service. The SMS service will also include a link to Care Opinion.

Care Opinion is an independent online platform where people can leave their thoughts, feedback, compliments, and informal complaints. Designated staff from the relevant services can subsequently leave response to the feedback or concern on Care Opinion. We have agreed an initial two-year contract with Care Opinion. The trust PALS team will provide oversight to the process. This along with the SMS feedback service will eventually replace the current Your Opinion Counts (YOC).

Both Care Opinion and the SMS feedback services will be launched on 1 May 2024.

There are other questions where the trust did not meet the national average standard and a common theme involved getting services and support from mental health services around work, finances, and physical health needs. RDaSH’s average scores in terms of financial advice have declined over the last four years in line with the national scores for this question. The table below illustrates this.

As the table shows, there has been 15.9% drop in people receiving any advice on finances. This drop is also reflected in the national picture.

We continue to take part in the national survey each year, and will therefore be able to track progress, and the impact of our new approaches been taken by the patient experience team.

3.3.2 Complaints

In the year April 2023 to March 2024, a total of 70 new complaints were received. This is a decrease of three (4.11%) in the year April 2023 to March 2024. The table below shows the number of complaints received by month trust wide in the year April 2023 to March 2024 compared to the year April 2022 to March 2023.

Adult mental health remains the area with the highest percentage of new complaints received during the year, reflecting the volume of activity in that area.

Most trust services have received less than three complaints across the year. The services receiving more than three complaints in the period are illustrated below:

Doncaster community mental health services had the highest number of complaints with 13 received. There were seven complaints about child and adolescent mental health service (CAMHS), primarily Rotherham and Doncaster services. There is a national problem with the neurodevelopment pathway with long delays in awaiting assessments, but it is acknowledged that the CAMHS Service in Rotherham in particular is experiencing a long length of time for neurodevelopmental assessments to be undertaken.

Four complaints were for Cusworth ward, an acute adult mental health ward. Inpatient wards, however, provide care for patients with higher acuity and additional challenges in terms of complexity.

Across the trust, thematically there is a wide variation of categories, with the highest proportion of complaints relating to patient care, see chart below.

In the patient care category, when the complaints are broken down further, the most prevalent category is “care needs not adequately met”, followed by ‘inadequate support provided’’ which together accounted for 26 individual complaints in the period. See table below.

An initial analysis was undertaken of date for ethnicity and age. Whilst this was present for some complaints, it had not been routinely collected. Complainants are asked to complete a diversity and ethnicity form as part of the investigation process, but responses to this remain variable.

During the year April 2024 to March 2025, we will explore different methods to obtain the data to allow a more robust analysis in relation to demographics. Home postcodes will also be collated. We will then undertake an analysis against our patient population and against the resident population.

3.3.2.1 What have we learned?

We have focussed upon complaints on both an individual and a thematic basis. We have earned from each complaint made, whether about an individuals care and treatment, the experience of a care setting or pathway, or an aligned learning about partnership working.

Where learning has occurred involving several agencies, we have connected with “place” and system partners to share learning and reflection.

A specific example of learning from complaints has included, we have had learning in terms carer support and communication, specifically where people have transitioned from one care setting to another (for example, inpatient to community teams). We have used this learning to inform listening events and engagement with others to check whether issues are unique or experienced by a wider group of people. This has then informed changes in practice and coworking with VCSE carer focused organisations.

3.3.2.2 What changes have we made?

In our effort to listen and learn differently from complaints we have made several changes, and our learning has informed our safety, quality and organisational learning plans for the next year.

An example of change made is a review of appointment attendance information and letters, resulting in key changes to ensure communication is more ‘trauma informed’ and supportive of patients who may be experiencing different difficulties and life events that mean attendance to regular appointments with services. This has been a specific learning point in regard to our Talking Therapies services but has had transferable change in terms of our community mental health settings.

Other examples can be provided on request.

3.3.3 Patient advice liaison service (PALS)

The number of new PALS concerns received by the trust in total this year has followed a similar trajectory to complaints received, with an initial increase followed by a decrease to approximately previous levels. The overall number received has increased from last year’s total of 613, by 82 enquiries, to 695. However, 27% of these related to concerns about other organisations and providers which are signposted elsewhere.

The PALS team follow-up on queries at the end of the process to check whether the concern has been resolved, any further signposting required and next steps. The outcomes from the PALS contacts at the end of the process is illustrated in the table below. This demonstrates an effective investigation process, with the vast majority of concerns raised via this route resolved satisfactorily, and just 19 (3%) being escalated to formal complaints for the year. This is same as in the previous year.

3.3.4 Your Opinion Counts

Your Opinion Counts continues to be the trust’s primary source of direct experience feedback from patients, families, and carers. It is also the primary means of collecting our responses to the Friends and Family Test question.

The number of forms received overall in the year April 2023 to March 2024 has decreased by 301 (20%) from 1490 in the year April 2022 to March 2023 to 1189 in the year April 2023 to March 2024. The trust is currently reviewing the process of receiving and monitoring the YOCs to improve the efficacy of the feedback.

It has not been possible to separate the data for Doncaster mental and physical health care groups prior to January 2024 as the system supporting this data could not provide this. Further changes to the care group structures were made in January 2024 and the system was realigned at this point.

Adult mental health (AMH), learning disabilities (LD), physical health (PH).

3.3.5 Compliments

The number of compliments recorded by the trust has increased from the year April 2022 to March 2023 by 69% (total of 628 in the year April 2022 to March 2023 and 1058 in the year April 2023 to March 2024). This is mainly due to an increase by the children’s care group reporting of their compliments, for which their reporting has increased by almost 246% in the year April 2023 to March 2024.

North Lincolnshire adult mental health and Talking Therapies care group has seen a drop in recorded compliments by 62% and Rotherham adults mental health care group saw a drop of 80%.

It has not been possible to separate the data for Doncaster mental and physical health care groups prior to January 2024 as the system supporting this data could not provide this. Further changes to the care group structures were made in January 2024 and the system was realigned at this point. However, overall Doncaster care groups recorded comparatively similar numbers of compliments (351 in the year April 2022 to March 2023 and 355 in the year April 2023 to March 2024).

This system is reliant on staff recording compliments. This will be reviewed during the year April 2024 to March 2025.

4 Annexes

4.1 Annex 1 Statements clinical commissioning boards, local Healthwatch organisation and overview and scrutiny committees, and governors

Statements were received from:

• NHS South Yorkshire Integrated Care Board, Doncaster and Rotherham Place
• Humber and North Yorkshire Integrated Care Board
• Doncaster Health and Adult Social Care Scrutiny Panel
• North Lincolnshire Council Integration and Performance Scrutiny Panel
• Healthwatch Doncaster
• Healthwatch North Lincolnshire
• Healthwatch Rotherham
• RDASH Council of Governors
• Rotherham Health Select Commission

Due to the all out elections taking place, the Rotherham Health Select Commission were unable to provide comments on the draft quality account.

4.1.1 South Yorkshire Integrated Care Board (ICB): Doncaster and Rotherham PLACE

Doncaster and Rotherham PLACE Integrated Care Board (ICB) welcomes the opportunity to read and provide feedback to the Rotherham Doncaster and South Humber NHS Foundation Trust’s (RDASH) document “Annual quality report the year April 2023 to March 2024”.

The year April 2023 to March 2024 has seen the trust progress against their ambitions and commitments in their safety and quality delivery strategy. This focusses on experience of care and involvement in care, CQC readiness being embedded as daily regimes, that their complaints team is realigned to support new standards, full implementation of the PSIRF framework, improving clinical effectiveness and health and safety as well as triangulating data to support quality improvements. The trust continue to work on improving staffing to optimal levels and being fully engaged in the national inpatient quality standards programme.

The trust has been working on their board assurance Framework and the governance processes that support effectiveness and risk mitigation. In addition, the trust has reviewed and implemented new leadership and care group structures. The quality dashboards provide assurance of reporting processes and clearly identify that the ICB is included for external assurance. The ICB are keen to continue to support and will continue to use the clinical quality review group as a mechanism for this to continue.

The ICB are pleased to understand the significant work that’s taken place to embed measures which enable and empower staff to speak up about issues that concern them, considering equality, diversity and inclusion. Work led by the Freedom to Speak Up (FTSU) guardian team should continue to develop partnerships with front line staff, managers, board members and partner organisations therefore enhancing patient safety and staff wellbeing. The past year has seen an increase in the number of concerns reported and champions are supporting the process.

During the year April 2023 to March 2024 the trust undertook data analysis and preparation work to support the PSIRF process. Additionally, the trust went live with learning from patient safety events (LFPSE) and their PSIRF policy and plan was developed and signed off by the ICB which was formally launched trust wide on 2 January 2024. Training has been accessed through the healthcare safety investigation branch (HSIB). To support patient safety weekly safety huddles have been established which includes senior leadership team and support services such as safeguarding and pharmacy. The ICB is supporting the trust to finalise quality assurance of investigations via the old serious incident framework and the learning that is embedded and sits with the trust’s patient safety incident investigation meeting.

Safeguarding clinical effectiveness activity has identified good outcomes and training remains a key priority to meet expected safeguarding training standards. Safeguarding continues to be central to all work streams and RDASH are clear on the shared responsibilities and joint working with partner agencies. Commitment to ensuring the duties and principles of safeguarding children, young people, and adults. Keeping people safe features heavily in the work plans moving forward.

Pressure Ulcers continue to be reviewed and learning shared via their harm reduction group. It was positive to understand the work that has taken place to support local Ambulance staff with training and utilising a wound responsiveness action pack tool kit. Enhancing the reduction group with mental health and allied health professional should support parity of esteem and strengthen links with the local acute hospital to reduce pressure ulcer occurrence and deterioration.

The involvement of patients and carers and their experience has continued to be a focus for the trust and involvement in national and local experience processes is showing intermediate scores which the trust is using to support learning and improvement. The launch of online and digital platforms to understand patient feedback in 2024 should support data collection of experience measures.

The ICB (Doncaster and Rotherham Place) would like to take this opportunity to reiterate our commitment to working with and supporting the trust’s continued quality improvement journey.

Andrew Russell, NHS SY ICB Director of Nursing (Doncaster and Rotherham Place), 20 May 2024.

4.1.2 Humber and North Yorkshire Integrated Care Board (ICB)

Humber and North Yorkshire Integrated Care Board (HNYICB) welcomes the opportunity to provide comment on the RDaSH quality report for the year April 2023 to March 2024. Firstly, the HNYICB would like to take this opportunity to thank all staff across Rotherham, Doncaster and South Humber NHS Foundation Trust for their hard work and dedication throughout the last year.

We recognise the significant challenges in the recovery journey for service delivery, no longer solely a consequence of the COVID-19 pandemic, but further impacted by continued high demand and the significant financial constraints facing all in the health and care sector.

The ICB wish to congratulate RDaSH on continuing to drive quality improvement, ensuring it is at the heart of everything they do and indeed RDaSH have been an integral partner in the North Lincolnshire Place integration agenda, known as “making it real”, that was launched in May 2023.

Since the appointment of Toby Lewis little over a year ago, there has been a comprehensive overhaul of structures across the organisation and has seen the trust launch its new five-year strategy (2023 to 2028). This strategy outlines the trust’s clear ambitions, the intent to nurture the power within the communities that they serve, as well as the recognition of all staff being their most important asset. The emphasis within the delivery of the ambitions is to improve the health and care for local people and supporting people and teams to thrive at work. The ICB welcome this as it also reflects their own ambitions of ‘start well, live well, age well and die well’.

It is pleasing to note that significant work and progress has been made against the ambitions outlined by Toby last year, such as improving the experience of care by harnessing the power of the lived experience, enhancing public and patient involvement as well as strengthening the volunteering offer. These feature as integral to the new five-year strategy.

Additionally, the ICB wishes to acknowledge some key achievements from the quality report:

• the launch of a coproduced lived experience plan, which has been merged within the clinical and organisational strategy
• the commitment in working with all relevant agencies to address the reduction in placing individuals out of area, and indeed repatriating individuals as relevant
• ongoing commitment to improving the safety culture, including the roll-out of Schwartz rounds and continuing to grow Freedom To Speak Up champions
• developing a trust wide accreditation programme to ensure that “CQC readiness” is business as usual. This is building upon the improvements seen in order to satisfy the CQC findings of the inspection that took place in 2019 with the report published in February 2021. The assurances seen by CQC in relation to the trust, combined with the routine engagement from CQC with the trust has meant that they have not yet deemed a further inspection to be a priority
• working at pace to fully implement the patient safety incident response framework (PSIRF) and being able to go live with learning from patient safety events (LFPSE) in August 2023. Further work is planned with the Organisational Development team to further enhance the “just and restorative culture” work. This will complement the extensive work that has been undertaken by the trust to embed such as the Freedom to Speak Up (FTSU), cultivating compassions circles and visibility of the guardian

Whilst the HNY ICB acknowledges the progress and improvement made by the trust during the year April 2023 to March 2024 there remain some areas of challenge.

The ICB acknowledges the ongoing collaborative work in relation to “out of area” placements and the repatriation agenda, however, there needs to be a sustained commitment from all system partners in developing a sustainable position that makes an “out of area”, placement an exception, thus demonstrating our intention in striving to provide the best possible outcomes and experience for the communities we serve.

As identified within the previous quality account reports, workforce issues remain a particular area of concern and as such remain relevant as an area of focus and support from the North Lincolnshire Health and Care Partnership Place (NLHCP). HNY ICB recognise that challenges with workforce are a national issue. Work undertaken by the trust to improve this position has been outlined within previous quality accounts and it is pleasing to note that the trust continue to have the ambition to move from minimum safe staffing to optimal staffing on inpatient units and community services.

To conclude, the HNY ICB recognise the trust’s achievements outlined within this quality account and through the North Lincolnshire Health and Care Partnership Place will continue to work closely with RDaSH as key system partners supporting their continued improvement journey.

Rachel Stanton, Deputy Director of Nursing and Quality (North Lincolnshire Health and Care Partnership), 14 May 2024.

4.1.3 Doncaster City Council health scrutiny panel

The RDASH draft annual quality accounts were provided to the panel for consultation, it was received, and no comments were provided.

Chair of the scrutiny panel, 14 May 2024.

4.1.4 North Lincolnshire Council health, integration and performance scrutiny panel

North Lincolnshire Council’s Health, Integration and Performance Scrutiny Panel welcomes the trust’s annual quality account, and supports the aims and priorities outlined within.

We look forward to meeting with trust representatives throughout the forthcoming year to discuss both the Account and the performance of local services.

Cllr David Robinson, Chairman (North Lincolnshire Council Health, Integration and Performance Scrutiny Panel), 13 May 2024.

4.1.5 Healthwatch Doncaster

Last year RDaSH recognised the importance of patient voice and we thank you for that. On reflection of this year’s report, we can see that you have now fully embedded patient voice within the organisation, placing it at the very heart of everything you do where it can make real difference and drive service delivery and change when needed. These are clearly illustrated within the first five promises as part of the RDaSH 28 promises, this shows a stronger commitment to the people you support, the communities around you and the professionals you work with. Furthermore, you’ve recognised the effectiveness of community involvement by committing to increasing the number of volunteers your organisation will recruit and support.

We are also pleased to see that you are working with a Doncaster community based partner the People Focused Group, gaining the real lived experience feedback from people who access all of RDaSH’s services, they truly are the experts who will be able to share what is good about a service and where improvements need to be made.

It’s encouraging that as an organisation you’ve recognised that there are limitations to the current insights and feedback process and that there’s been a low response rate. Addressing the paper system used previously and embracing potential digital solutions, such as SMS messaging and utilising the Care Opinion website platform will hopefully provide more initiative ways of capturing feedback, increasing responses and targeting areas of improvement in a more timely manner.

We’ve received excelled feedback relating to the Virtual Wards service, it really works for the patient as they are able to enjoy the comforts of their own home while still receiving the clinical support needed and have a pathway back in to hospital if needed. The service also offers great continuity of care which is rated highly to the cohort of patients this service is provided for.

The “Freedom To Speak Up” movement within the RDaSH culture is refreshing and a workplace culture which sits incredibly well with our ethos at Healthwatch Doncaster. The increase of 66% in the number of concerns raised by staff demonstrates that people are being listened to and the effectiveness of the FTSU culture and the great work the FTSU champions are achieving across RDaSH services. The commitment to further increase the number of FTSU champions manifest an ever growing positive culture of people being listened to and having their views heard.

The 28 promises outline a real responsibility towards tackling health inequalities, supporting people who are usually under served and least heard, whilst tackling discrimination. We look forward to seeing the progress made over the coming months.

At Healthwatch Doncaster we believe everyone has a story tell, all you have to do is listen. RDaSH you are taking the time to listen and learn from patients, carers, staff and other people connected to your services. Thank you for understanding the power of voice.

Fran Joel, Chief Operating Officer (Healthwatch Doncaster), 12 May 2024.

4.1.6 Healthwatch North Lincolnshire

Healthwatch North Lincolnshire welcomes the opportunity comment on Quality Account for Rotherham, Doncaster and South Humber NHS Foundation Trust. We recognise that the quality account report is a useful tool in ensuring that NHS healthcare providers are accountable to patients and the public about the quality of service they provide. The following is the response from Healthwatch North Lincolnshire.

This quality account illustrates aspects of the trust’s performance during the year April 2023 to March 2024. Overall, the trust has shown commitment to improving performance across all areas. However, the report appears to be incomplete, as there is no information in relation to progress against the patient safety, specifically development of the PSIRP and the launch of the PSIRF and FPSE across the trust. The account was also lacking the statement from the chief executive, which is important to set the scene and add context to the rest of the account.

The account content is detailed and clearly shows development against improvement priorities since the previous version, in particular the development of the LIVED experience plan and the recruitment of patient experience volunteers across the trust.

However, as commented in previous responses to the account, Healthwatch North Lincolnshire are disappointed that the information is not clearly separated by locality, which makes it difficult to provide a response on behalf of North Lincolnshire residents specifically.

Healthwatch North Lincolnshire welcome the new approach to ensuring coproduction is embedded within the trust and look forward to seeing progress on the “peoples promise” in the coming months. It would be important to ensure that the trust consider the equality and diversity of those who are involved in co production activities, including ensuring a good geographical coverage.

Healthwatch would like to request that future quality accounts are written in a more accessible way or have an accessible version available that contains definitions of acronyms contained within the report.

Carrie Duran, Head of Health and Care Programmes (Hull CVS Signed on behalf of Healthwatch North Lincolnshire), 13 May 2024.

4.1.7 Healthwatch Rotherham

Thank you for sharing this report with us. We would like to take this opportunity to thank staff at the trust who have been working hard through a turbulent year to improve services since the last CQC inspection, which we know the trust were disappointed by.

It’s positive to read the progress made against this year’s objectives, as quite a few of these are working behind the scenes with staff and driving a more transparent culture at RDaSH. Especially about staff safety in their place of work, all staff should feel they are in a safe environment regardless of their role and have all aspects of their wellbeing promoted. Cultural change is pivotal to patient experiences, which is being supported and promoted through the Schwartz rounds to encourage staff to voice their concerns knowing they are free from reprove. The increase of 66% in the number of concerns raised by staff is further evidence that the change in the culture at RDaSH is taking effect.

Healthwatch Rotherham understands the value of people who are experts by experience. To highlight how a service can do better and involve people who use the services to codesign services that are fit for the future. We were pleased to be commissioned during this year to captcha some of these experiences to drive improvements within RDaSH. These experiences were helped to create the Action plan to support patients to have a positive experience and therefore a positive health outcome. We are reassured that RDaSH had also found, that the complaints procedures do not support patients or patient’s families to express dissatisfaction with their care in all cases.

We welcome RDaSH to work alongside us to provide solutions to iron out any common issues faced within the patient experience, to meet the person’s needs with their voice about their care at the heart of their service. For people to receive the right person, right care and preventing any avoidable delay in their treatment, ultimately leading to better health outcomes for Rotherham people.

Healthwatch Rotherham feels that some fantastic progress has been made against the 28 promises during this year and we recognise that for all promises to be actioned and implemented this will take some considerable time and funding. We look forward to working with RDaSH further to support patients voices to heard by the RDaSH service over the next twelve months.

Kym Gleeson, Healthwatch Manager, 14 May 2024.

4.1.8 Rotherham Doncaster and South Humber NHS Foundation Trust, council of governors statement for the year April 2023 to March 2024

The council of governors is pleased to have the opportunity to comment on the quality report for the year April 2023 to March 2024.

A range of governor engagement activities during the year April 2023 to March 2024 have allowed for more face to face activities to be attended and more opportunities for the council of governors to be involved with initiatives to promote and be aware of quality services within the trust. Listed below are brief details of some of the ways that governors have been included and been involved.

Governors identified and agreed three priorities in the year April 2023 to March 2024 including volunteering, health promotion and engagement, all of which have close ties to elements of the trust’s clinical and organisational strategy. Updates on progress have been provided at each council of governors meeting (strategic objective 1, promises 3 and 5).

The council of governors received update reports at its meetings that included specific updates on this quality objective and the work of the Quality committee. This section is presented to the council of governors by the chair of the Quality committee (Dawn Leese, Non-Executive director). During the meeting governors provide feedback and ask questions in respect of the information provided, seeking where necessary additional explanation and or confirmation to hold the non-executive directors to account and also demonstrating a keen interest in areas of work that will benefit the patients, service users, carers and staff of the trust (strategic objective 1, promises 1, 3, 4 and 5).

In 2023 a number of governors have attended (virtually) and observed the bimonthly Quality committee and had first-hand opportunity to see the committee undertake its business and to hear and observe the challenge, support and discussion between members of the committee and to see the progress made throughout the year. In 2024 there will be an opportunity for governors to be a member of the committee (strategic objective 1, promise 5).

Safety and quality priorities include the requirement for each area to have a peer review. Governors have participated in peer reviews throughout the year. Governors, alongside colleagues from the board of directors has attended reviews and had the opportunity to meet staff and patients and to see and hear first hand about the quality of service they have received, and the challenges faced by staff and their success in delivering care to those in need (strategic objective 1, promise 4).

A number of governors have attended (virtually and face to face) and observed the meetings of the board of directors held in public. This has also provided a valuable opportunity to see the wider business of the board but also to see the input to the board from the Quality committee. Governors have engaged by asking questions relating to quality matters. This relates to quality priority “to improve the experience of care and the opportunities for involvement across all care groups and corporate departments” (strategic objective 1, promise 5).

The council of governors supports the content of the report as an open and honest reflection of the trust’s position, in line with that presented to the Quality committee and board of directors.

The council of governors is committed to working closely with the board of directors, staff, service users, carers and public over the coming year to support the delivery of the quality priorities contained within the trust’s clinical and organisational strategy and the achievement of the objectives and promises it contains.

The council of governors identified three focus areas in the year April 2023 to March 2024 including volunteering, patient and public engagement and health promotion and it would like to continue to work closely on these areas with the trust in the year April 2024 to March 2025.

The council of governors welcomes and looks forward to continuing and enhancing its work, with support from the trust, to more effectively hold the non-executive directors to account for the performance of the board of directors. This includes active discussions between governors who work with, and through, non-executive directors and learn from the good practice of other NHS trusts.

Council of governors, 5 June 2024.

4.2 Annex 2 Statement of directors’ responsibilities for the quality report

The directors are required under the Health Act 2009 and the National Health Service (quality accounts) regulations to prepare quality accounts for each financial year.

NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report.

In preparing the quality report, directors are required to take steps to satisfy themselves that:

• the content of the quality report meets the requirements set out in the NHS foundation trust annual reporting manual the year April 2023 to March 2024 and supporting guidance
• the content of the quality report is not inconsistent with internal and external sources of information including:
  board minutes and papers for the period April 2023 to March 2024
• papers relating to quality reported to the board over the period April 2023 to March 2024
• feedback from commissioners:
  • NHS South Yorkshire Integrated Care Board, Doncaster and Rotherham Place, 20 May 2024
  • Humber and North Yorkshire Integrated Care Board, 14 May 2024
  • Feedback from Council of Governors, 5 June 2024
  • feedback from Doncaster Healthwatch organisation, 12 May 2024
  • feedback from North Lincolnshire Healthwatch organisation, 13 May 2024
  • feedback from Overview and Scrutiny Committee:
    • Doncaster Health and Adult Social Care Scrutiny Panel, 14 May 2024
    • North Lincolnshire Health Scrutiny Panel, 13 May 2024
    • Rotherham Local Authority Health Select Commission Unable to provide
• the trust’s complaints report the year April 2023 to March 2024 published under regulation 18 of the local authority social services and NHS Complaints Regulations 2009
• the latest national community mental health patient survey 2023
• the latest national staff survey 2023
• the head of internal audit’s annual opinion of the trust’s control environment (interim opinion 3 April 2024 final opinion to be received by Audit committee 5 June 2024)
• the quality report presents a balanced picture of the NHS Foundation Trust’s performance over the period covered
• the content of the report illustrates the ongoing improvements since the CQC Inspection report dated 21 February 2020
• the performance information reported in the quality report is reliable and accurate
• there are proper internal controls over the collection and reporting of the measures of performance included in the quality report, and these controls are subject to review to confirm that they are working effectively in practice
• the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and
• the quality report has been prepared in accordance with NHS Improvement’s annual reporting manual and supporting guidance (which incorporates the quality accounts regulations) as well as the standards to support data quality for the preparation of the quality report.

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the quality report.

By order of the board.

Toby Lewis, Chief Executive, June 2024.

Kathryn Lavery, Chairman, June 2024.

4.3 Annex 3 Trust objectives and 28 promises

Our 5 objectives:

• nurture partnerships with patients and citizens to support good health
• create equity of access, employment, and experience to address differences in outcome
• extend our community offer, in each of and between physical, mental health, learning disability, autism and addiction services
• deliver high quality and therapeutic bed based care on our own sites and in other settings
• help to deliver social value with local communities through outstanding partnerships with neighbouring local organisations

4.3.1 Our 28 promises

4.3.1.2 Promises 1 to 5

Nurture partnerships with patients and citizens to support good health.

1. Employ peer support workers at the heart of every service that we offer by 2027.
2. Support unpaid carers in our communities and among our staff, developing the resilience of neighbourhoods to improve healthy life expectancy.
3. Work with over 350 volunteers by 2025 to go the extra mile in the quality of care that we offer.
4. Put patient feedback at the heart of how care is delivered in the trust, encouraging all staff to shape services around individuals’ diverse needs.
5. From 2024, systematically involve our communities at every level of decision-making in our trust throughout the year, extending our membership offer and delivering the annual priorities set by our staff and public governors.

4.3.1.3 Promises 6 to 12

Create equity of access, employment and experience to address differences in outcome.

6. Poverty proof all our services by 2025 to tackle discrimination, including through digital exclusion.
7. Deliver all ten health improvements made in the Core20PLUS5 programme to address healthcare inequalities among children and adults: achieving 95% coverage of health checks for citizens with serious mental illness and those with learning disabilities from 2024.
8. Research, create and deliver five impactful changes to inequalities faced by our population in accessing and benefitting from our autism, learning disability and mental health services as part of our wider drive to tackle inequality (the RDaSH 5).
9. Consistently exceed our apprentice levy requirements from 2025, and implement from 2024 specific tailored programmes of employment access focused on refugees, citizens with learning disabilities, care leavers and those from other excluded communities.
10. Be recognised by 2027 as an outstanding provider of inclusion health care, implementing national institute for health and care excellence (NICE) and NHS England (NHSE) guidance in full, in support of local Gypsy, Roma and travellers (GRT), sex workers, prisoners, people experiencing homelessness and misusing substances, and forced migrants.
11. Deliver in full the NHS commitment to veterans and those within our service communities, recognising the specific needs many have, especially for access to suitable mental health and trauma response services.
12. Work with community organisations and primary care teams to better recognise and respond to the specific needs of the rural communities and villages that we serve.

4.3.1.4 Promises 13 to 17

Extend our community offer, in each of and between physical, mental health, learning disability, autism and addiction services.

13. Substantially increase our home first ethos which seeks to integrate physical and mental health provision to support residents to live well in their household, children’s home or care home, including older adults.
14. Assess people referred urgently inside 48 hours from 2025 (or under four where required) and deliver a four-week maximum wait for all referrals from April 2026, maximising the use of technology and digital innovation to support our transformation.
15. Support the delivery of effective integrated neighbourhood teams within each of our places in 2024 as part of our wider effort to deliver parity of esteem between physical and mental health needs.
16. Focus on collating, assessing and comparing the outcomes that our services deliver, which matter to local people, and investing in improving those outcomes year on year.
17. Embed our child and psychological health teams alongside schools, early years and nursery providers to help tackle poor educational and school readiness and structural inequalities.

4.3.1.5 Promises 18 to 23

Help deliver social value with local communities through outstanding partnerships with neighbouring local organisations.

18. From 2023 invest, support and research the best models of therapeutic multi-disciplinary inpatient care, increasingly involving those with lived experience and expert carers in supporting our patients’ recovery.
19. End out of area placements in 2024, as part of supporting people to be cared for as close to home as is safely possible.
20. Deliver virtual care models in our mental and physical health services by 2025, providing a high quality alternative to prolonged admission.
21. Actively support local primary care networks and voluntary sector representatives to improve the coordination of care provided to local residents, developing services on a hyper local basis.
22. Develop consistent seven day a week service models across our intermediate care, mental health wards and hospice models from 2025 in order to improve quality of care.
23. Invest in residential care projects and programmes that support long term care outside our wards, specifically supporting expansion of community forensic, step down and step up services.

4.3.1.6 Promises 24 to 28

Deliver high quality and therapeutic bed based care on our own sites and in other settings.

24. Expand and improve our educational offer at undergraduate and postgraduate level, as part of supporting existing and new roles within services and teams while delivering the NHS long term workforce plan.
25. Achieve living wage accreditation by 2025, whilst transitioning significantly more of our spend to local suppliers in our communities.
26. Become an antiracist organisation by 2025, as part of a wider commitment to fighting discrimination and positively promoting inclusion.
27. Deliver the NHS green plan and match commitments made by our local authorities to achieve net zero, whilst adapting our service models to climate change.
28. Extend the scale and reach of our research work every year, creating partnerships with industry and universities that bring investment and employment to our local community.

4.4 Annex 4 Glossary of terms and definitions

This section aims to explain some of the terms used in the quality accounts. It is not an exhaustive list but hopefully will help to clarify the meaning of the NHS jargon used in these pages.

Page last reviewed: November 18, 2024
Next review due: November 18, 2025

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