Annual report and accounts summary April 2023 to March 2024

Contents

The performance report overview and supplementary information is provided below.

A full copy of this annual report and accounts is available (and any previous years required) from the Corporate Assurance team by contacting rdash.corporate-assurance@nhs.net.

Overview of performance

This section provides an introduction to the annual report from the chief executive and chair. It describes the trust and highlights some of the major achievements in the year, the risks we have faced and provides some facts and figures about the Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH).

Chair’s introduction

It’s been a very exciting and successful year for RDaSH despite the pressures nationally on the NHS.

In the last financial year, we have successfully completed a restructure with our senior managers, and Toby, our chief executive, and I have completed just over a year in our job roles. As a board of directors we’ve completed board development sessions, helping the board mature, and we can see results from this work already.

I’d like to pay tribute to a range of people in this annual report. Firstly, to our governors, who have set objectives for the board. They have also worked with us and been incredibly enthusiastic about our new clinical and organisational strategy from 2023 to 2028 and our 28 promises. I’d like to thank Jo Cox, our Lead Governor, for the time she gives and her energy and passion.

Justin Shanahan, one of our Non-Executive Directors and our Audit committee chair has recently bid us farewell and I want to thank him for his dedication to our trust and for the contributions he has made over the last seven years. I also want to thank Kathy Gillatt, who will take on the audit role going forward. Sheila Lloyd, our Deputy Chief Executive and Director of Nursing and Allied Health Professionals also retired. Such a loss for RDaSH and I also thank her for her duty and dedication to our trust. I’m so pleased we have recruited Steve Forsyth to the chief nurse role. Steve is also the UK’s first male chief nurse who comes from a South Asian background. We have also welcomed Richard Chillery as our new chief operating officer recently too. It’s brilliant they have both chosen to work with us.

It’s great to see that as our colleagues naturally leave us, we are able to replace them with equally good people. As other senior staff leave us in the coming year to go to pastures new, it gives me great assurance knowing that people see working here as a great place to come to work, whether on the board of directors or in our services.

I also want to stress how I value our board members who have been with the trust for many years. It’s that mixture of experience and new recruits that makes our board a very stimulating place.

The last financial year has seen us start to embed and develop our relationship with the communities we serve. We’ve still much more to do, but I’d like to thank the People Focused Group (PFG) in Doncaster, the S62 and the Stag and Rose Court Patient Participation Group, both in Rotherham, for their energy, support and commitment to our direction of travel.

Our relationships in South Yorkshire and North Lincolnshire with our two integrated care boards (ICBs) are also maturing. In South Yorkshire we are playing a big partnership role in the South Yorkshire Mental Health, Learning Disability and Autism Provider Collaborative. This system work is starting to grow and mature and I’m so pleased that RDaSH is committed to playing our part.

I’m so looking forward to the coming year. The 2023, 2024 financial year was one of planning and restructure and the coming year will be a year of making what we want to happen, happen! It was a tough year, but we have worked through it together. Now we are ready to deliver our 28 promises and it’s great to see colleagues fired up about these and I’m looking forward to working together to develop and deliver them. The coming year is so exciting, and all of this work has been done to improve our offer to our patients and the communities we serve.

We won’t be resting on our laurels, we have a lot of exciting work to move forward and we’re in a great place to do this.

With best wishes,

Kathryn Lavery, Chair 11 July 2024.

Chief executive introduction

Thank you for taking the time to read our annual report, along with, I hope, our quality account. These are the nationally mandated reports we are required to provide in a prescribed format. In addition, we have issued a more narrative description of the financial year of April 2023 to March 2024 and the year ahead, and some Easy Read material to go with that.

In reporting year, we are proud to have co-produced and launched our five year strategy, and within that the very recognisable 28 promises that we have made about our future. What matters most about those promises is that they help us to shift the balance of power in local healthcare decisively towards the local NHS responding to the needs of our communities. That does not always mean providing a health service, it may mean investing in a local voluntary sector group. During the last year we have had the opportunity to do that with S62 in Rotherham and with the People Focus Group across our neighbourhoods. In 2024 as we expand peer support worker numbers at the trust, we will grow our voluntary sector partnerships further.

We made some big changes to services during the last year. Assertive outreach in Rotherham expanded its hours and saw many more people, and we were able to close some inpatient rehabilitation beds as a result. We have totally transformed how dementia care is delivered in the community in Doncaster, based on feedback organised by Healthwatch: our new partnership with The Alzheimer’s Society is intended to better respond to both carers and patients. And in North Lincolnshire, this year has seen a transformation, working with local GP practices and with MIND, in access to physical health checks for local people with a serious mental illness.

In national and local media, NHS finances and waiting times dominate discussion. We report a deficit at year-end, but one significantly better than the original approved plan. That reflects the success of clinical leaders and many others in reshaping how we spend money. More of each pound is being spent on patient care. In the reporting year, for the first time since the pandemic, the trust has met some of the national access standards, or targets (see operational performance section on pages 17 to 22). Our promises are very ambitious, seeking a maximum wait of no more than four weeks from April 2026. This summer we expect to deliver that for all children’s services except neurodiversity diagnosis, and a significant investment to address unacceptable waits for those services will see waits reduce markedly during 2024.

It is important to be honest that not everything works well or works for the best every time. I am very grateful to those who have voiced complaints or spoken up in other ways. I hope we can evidence not simply that we have listened, but that changes have happened as a result. New communication handover arrangements in Crisis services are one example of that, arising from serious incidents. Our changes to what was once called “disengagement” from services come directly from the tragic death of a local resident.

The trust is changing how we are managed and how we lead. During the reporting year we have restructured our organisation. This of course introduced a period of uncertainty, including for partners, and perhaps patients too. I very much hope now there is clarity, aided by our new website designed with patients, about whom to contact and who can help. As we introduce a product called Patient Opinion in the summer of 2024, we will certainly be more open to feedback in real-time.

Mavis is on the front cover of our strategy. That is because of her feedback on the benefits to her life and family from being looked after using our virtual care model. This service has been very successful in Doncaster over the last year, and the trust is determined to expand that idea, in line with promises 13 and 20 of our strategy and introduce similar ideas into our mental health services.

The trust’s board and leadership is determined to be open to different influences and voices in how we work. I am grateful for governors for their time and advice, and to those local people who are members or volunteers with us. You make a difference. Our staff networks are developing, this year has seen our new women’s network, and we have colleagues who act as champions for a range of important initiatives including freedom to speak up and our environmental work. Health Education England have lauded the work done at RDaSH over the past two or three years to improve placements and education. Our research excellence is also regionally acknowledged. It is really important to those who work in our organisation, and to those we serve and care for, that these influences continue and are grown. We cannot deliver any of our promises unless we become fully staffed, with consistent teams learning together.

Toby Lewis, Chief Executive 11 July 2024.

Annual governance statement

Scope of responsibility

As accounting officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum.

The purpose of the system of internal control

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Rotherham Doncaster and South Humber NHS Foundation Trust, to evaluate the likelihood of those risks being realised, and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Rotherham Doncaster and South Humber NHS Foundation Trust for the year ended 31 March 2024 and up to the date of approval of the annual report and accounts.

Capacity to handle risk

As the accountable officer, I am accountable for ensuring that the trust can discharge its legal duty for all aspects of risk. I have overall responsibility for the management of risk and for maintaining a sound system of internal control.

Leadership arrangements for risk management are detailed in the trust’s risk management framework and further supported by the board assurance framework and individual job descriptions. The risk management framework, refreshed as the year closed, outlines our approach to risk and the accountability arrangements including the responsibilities of the board and its committees, clinical leadership executive and its groups, especially the newly formed risk management group, executive directors and all staff. Active leadership from all managers at all levels to ensure effective risk management is a fundamental part of an integrated approach to quality, corporate and clinical governance, performance management and assurance.

The director of corporate assurance, board secretary has delegated responsibility for the trust’s board assurance framework and for ensuring the implementation of the risk management framework within services. All executive directors have responsibility to identify and manage risk within their specific areas of control in line with the management and accountability arrangements in the trust.

The Audit committee monitors and oversees both the internal control issues and the processes for risk management. Both Internal and external auditors attend the Audit committee.

The management of strategic and operational risk is detailed in the revised and refreshed board approved risk management framework, which also contains the agreed trust risk appetite statement “The trust recognises that its long-term sustainability depends on the delivery of its strategic objectives and, its relationships with its communities, including service users and families, the public and partners. Patient and staff safety is paramount and as such the trust will not accept risk that materially provide a negative impact on quality and governance. The trust acknowledges the challenging business environment in which it operates and has a greater appetite to take considered risks in terms of the impact to achieve innovation and excellence”.

The trust ensures that staff are equipped to manage risk in a variety of ways and at different levels of strategic and operational function. All policies are available to staff via the trust’s website and undergo an equality impact assessment and is part of the approval process along with consultation. All operational risks are recorded in the risk module within Ulysses. During April 2023 to March 2024, the number of risks recorded has significantly increased as a result of a concerted effort to raise the profile of risk management across the trust. Key decision-making is also now rooted within a risk-based process: including the management of financial choices to reduce or increase budgets, and to allocate capital. Risk module training and general risk training is provided to identified risk leads, and this is being significantly increased in the year April 2024 to March 2025: risk registers, mitigations and concerns are addressed directly with the executive in bi-monthly delivery reviews.

The trust learns from a range of sources including patient and staff feedback and the outcomes of reported incidents and innovations. The trust has established an education and learning group, as part of its new decision-making structure, which will undertake a stocktake on the “what and who” are undertaking learning, and develop a trust wide approach around the 4 pillars of learning:

• learning to know
• learning to do
• learning to live together
• learning to be

During the year April 2024 to March 2025, we will continue to review the approach and systems by which we learn internally to consider innovations for learning, and measurement of impact, including the introduction of mandated learning half days across the trust from September, a major endeavour which will significantly increase the capacity to spread learning inside the organisation in every team, clinical and non-clinical.

The risk and control framework

The trust considers risk management to be an intrinsic part of its governance and quality frameworks that enhances strategic planning and prioritisation, assists in achieving objectives and strengthens the ability to be agile to respond to the challenges that we face. Risk management is an essential and integral part of planning and decision-making so that the trust can meet its objectives successfully, improve service delivery and achieving value for money.

The risk management framework explains how risks are identified, evaluated, scored and monitored within the organisation. The trust has in place a risk scoring matrix, which is used to evaluate all risks. Once agreed, operational risks are included in the relevant risk registers. Up to December 2023 were monitored by the relevant board committee in accordance with allocated theme associated with the BAF. Oversight and management of operational risk moved to the risk management group (a decision-making group of CLE) in January 2024 when the group was established as part of the new operating model. This monthly group, chaired by the chief nurse, directly advises the clinical leadership executive and provides significantly enhanced visibility of risk, and a more direct route to mitigate it. We would expect risks identified at “12” to “15” to grow, and risk velocity to increase markedly.

The trust manages its most significant current and future potential strategic risks to the achievement of our strategic objectives through the board assurance framework that provides a structure for the effective and focused management of the principal risks. Risks are assessed by using a 5 by 5 risk matrix where the total score is an indicator as to seriousness of the risk. Each risk is allocated an executive director lead and a lead committee of the board. Following the new trust strategy in July 2023, the board asked that for an interim period the reporting of risk against the prior BAF was moved to a by exception model, which occurred, pending approval of a revised BAF in March 2024 and May 2024. Regular review and update of each risk and the associated action continued throughout the year. I am satisfied that board members have been fully involved with BAF related risks throughout the year, and I cannot concur with the concerns speculated on by the head of internal audit opinion, as they have not manifested themselves, and I am satisfied that had risks arisen, our approach fully provided for them to be addressed. The most labile strategic risk in the April 2023 to March 2024 BAF related to finance, and the trust’s in year and underlying financial position has substantially improved over the period.

During 2023, 2024 it should be recognised that:

• the risk management framework has been fully revised
• risk reporting has been changed and risks identified have grown, and their source diversified
• the BAF has been developed across the board, whilst the extant BAF has been suitably monitored

There remains further work to do to ensure that risks manifesting themselves through other sources of concern, including incident reporting, and primary care alerts, are recognised and moved into risk registers even where local teams overlook this. This work will occur in 2024.

The trust has also developed a range of guidelines, policies and procedures to assist managers in the assessment, control and investigation of risks. These procedures set out the levels of risk and identify where in the organisation each should be managed. The key policies and procedures are:

• incident reporting policy
• learning from deaths policy the right thing to do
• being open policy (incorporating and duty of candour)
• clinical risk assessment and management policy
• listening and responding to concerns and complaints policy
• freedom to speak up policy, raising concerns (whistleblowing) policy

The trust is registered with the Care Quality Commission (CQC) with no conditions applied and the statement of purpose is regularly updated and changes reported to the CQC.

The trust is committed to supporting patient safety by ensuring information is accessible, its integrity is protected against loss or damage, and confidentiality is maintained. The trust recognises that information handling represents a corporate risk in that failures to protect information properly, or to use it appropriately, can have a damaging impact on the safety of our patients and the reputation of the organisational.

Information risk management is monitored via our information risk management framework. As part of this, information risks are clearly recognised, and the appropriate controls implemented through the risk management framework. The senior information risk owner (SIRO) is responsible for overseeing the development and implementation of the information risk management framework. The SIRO is supported in this by the Information Governance (IG) team and by the information asset owners (IAO) within each business area. IAO’s are responsible for managing information risks to the assets within their control.

Quality of data is overseen by the Information quality work programme, which audits and kite marks key performance metrics set by the trust as part of its floor to board assurance and reported via the integrated quality and performance report. Metrics assessed and kite marked are reported to FDE each quarter. More broadly the Performance team and the data support officers who are embedded in operational services undertake regular data quality samples of the performance data reported both internally and externally.

NHS Foundation Trust licence condition compliance

As an NHS Foundation Trust, the trust is required by its licence to apply relevant principles, systems and standards of good corporate governance (FT4). To discharge this requirement the trust has a board of directors and committee structure with responsibilities set out in formal terms of reference. The board and its committees have associated reporting lines, performance and risk management systems. Each committee is chaired by a non-executive director and has an associated executive team member as its executive lead. The work plans of the committees are reviewed annually with the Terms of reference.

A self-assessment of compliance against the trust’s licence is undertaken by the director of corporate assurance and reviewed by the board of directors. The board of directors has not identified any principal risks to compliance with provider licence condition FT4 and is satisfied with the timeliness and accuracy of information to assess risks to compliance with the provider licence and degree of rigour of oversight it has over performance.

The trust also has a comprehensive programme of internal audit in place aligned to key areas of potential financial and operational risk. This will increasingly be examined, set, and managed alongside our clinical audit programme, as we look to work on an integrated basis.

Stakeholder relations

The trust recognises the importance of working in partnership with others including statutory organisations, voluntary sector and communities. During the year April 2023 to March 2024 we have reviewed our key partnerships with stakeholders in Rotherham, Doncaster and North Lincolnshire and across the two integrated care systems that we work in. A new approach to managing stakeholder relations and partnerships has been developed which will involve executive directors taking a relationship manager role with each key partner in the year April 2024 to March 2025. The trust has adapted its governance structures to establish a new board committee which focuses on our partnerships and will assess the effectiveness and quality of our partnership working on a regular basis. Feedback from partners bodies has been overwhelmingly positive about the changes made, and the improved visibility of the organisation as an effective partner.

The trust has a social enterprise called “Flourish”. Flourish was formed in 2014 and is a wholly owned subsidiary of the trust. It is incorporated as a community interest company and is registered with Companies House. Flourish currently trades and provides vocational pathways across 3 business areas from St. Catherine’s House, Woodfield Park in Doncaster. The trust is represented at the directors meetings by the director of corporate assurance. He maintains oversight over the delivery of Flourish’s strategy, financial plans, business continuity, risk management and operational performance, reporting through a board committee.

The trust is also the April 2023 to March 2024 lead provider for the South Yorkshire Adult Eating Disorder Provider Collaborative. This includes commissioning beds from Independent Sector Providers that is supported by financial and quality oversight: this is delivered through a joint agreement with other providers in South Yorkshire. Funding is provided via NHS England’s Specialist Commissioning team. The purpose is to provide the highest quality eating disorder care that is person centred, supports recovery, is responsive and is delivered as close to home as possible. By doing this we are reducing the need of people to need care in hospital and support people to lead successful lives supported in their local community.

The trust has a range of patient and public involvement activities and consultation with its communities and empowering them. There are many examples of this. We work with our voluntary and charity sectors to deliver our Aspire drug and alcohol services. This includes a strong peer support model. In Rotherham we have invested fully in community resources to support individuals beyond traditional service boundaries. Local community groups were micro-commissioned and funded according to the needs of our service users and were provided in communities across Rotherham. This included peer support, befriending, activity and exercise.

The People Focused Group (PFG) working in the voluntary sector are our patient participation partner and together we engage with many parts of our communities to work with them on designing and delivering services. This work is across the whole RDaSH geography.

PFG deliver services for people experiencing a mental health crisis by providing the Safe Space service in Doncaster. The service is delivered by a large network of peer support workers and provides much needed care to our communities. Peer support workers in reach into trust wards, and the strategy commits to growing this work.

Close working with voluntary sector partners who provide support for those living with dementia has been at the centre of our approach to ensuring the best experience for patients and carers. This includes setting up an advisory panel who set their own terms of references and areas of focus. Our recently established partnership with the Alzheimer’s Society will also enable us to focus more on working with our communities on an equal footing.

The trust has commissioned or supported a number of initiatives in conjunction with the voluntary community and social enterprise sector during April 2023 to March 2024. Over £623k has been invested in this regard and have included giving support to the following organisations:

• the People’s Focus Group for work across all areas in respect of community, inpatient and waiting list initiatives as well as community development and lived experience
• S62 Rotherham for community development work
• MIND, Helping Hands and Mindful Activities in respect of winter pressures
• Citizen’s Advice Bureau and Voluntary Action Rotherham in respect of Community Mental Health team transformation (experts by experience)
• Rotherham Rise, GROW and Rotherham alcohol and drug services (ADS) in respect of the trauma resilience service

Safer staffing and workforce development

The trust continue to invest heavily in the health and wellbeing of our colleagues and is focusing more on our commitment to be a compassionate and inclusive organisation, which has a restorative just and learning culture and where the trust is an employer of choice. We have been successful in our international recruitment across a number of staff groups, and we are looking at new role and developing our colleagues to excel in their roles and the patient care they deliver.

E-Rostering is used to monitor clinical staffing levels primarily in our clinical services. The national electronic staff record (ESR) is utilised to manage budgeted establishments and actual establishments and provide detailed information in relation to skill mix, vacancies, and turnover. ESR is also utilised for monitoring professional registration, statutory employment checks, statutory and mandatory training compliance, and professional development review compliance. In addition, the trust has an in-house staff portal which is utilised to monitor clinical and managerial supervision compliance and the trust and each directorate is provided with data from all of these systems on a monthly basis to ensure compliance is monitored and actioned. This year we launched the staff app to provide colleagues with a choice as to what information they access, how they access it and when they access it.

The numbers of our colleagues on our wards are monitored and managed operationally through the chief operating officer and the care group structures. The safe staffing requirements are determined and monitored by the chief nurse and locally at place level by locality care group nurse directors. Staffing levels are published on our website. Safe staff reporting is a requirement for health trusts and has been published the data in line with national requirements set by NHS England.

In the period of April 2023 to March 2024 we have undertaken a stock take of our current safer staffing framework. Our recently appointed chief nursing officer has set a direction of exciting operational, tactical, and strategic plans to take forward the trust on a journey to workforce excellence. This includes governance, controls and mechanisms to ensure oversight of staffing issues on a daily, weekly, monthly, bi-annual and annual basis. This will include changing to forward-view reporting including our fill rates, quality indicators and clinical narrative so our local communities are fully informed of our staffing position. We are implementing exciting digital innovations as enablers to support productivity through e-roster optimisation. All with the ambition to ensure there is a visibility of staffing levels across the trust, and that we are safe and compliant with the National Quality Board (NQB) workforce safeguards in delivering outstanding care to those who are in receipt of our services. All delivered with the context of a workforce plan which is relevant and considers the backdrop of the national and global workforce context including staffing shortages. This will include a flexible and efficient bank offer in partnership with NHS Professionals. We will take forward plans to be a local market leader, with a local, regional and national innovative recruitment plan and a retention plan which is meaningful to our staff at the point of care with quality outcomes which demonstrates impact.

There is a dedicated people plan steering group that meets to progress focused work streams, identify areas of improvement and change, and also work upon interventions to ensure a more sustainable workforce.

Key focus areas over the past year have been the enhancement of nursing career pathways assisted by a number of colleagues who have completed their training programmes, such trainee nurse associates, nursing associates, nurse top up programmes and the newly introduced CAP roles. We have further increased our apprenticeship levy spend and we have a clear commitment by 2025 to utilise our full levy allocation, whilst supporting local recruitment. Trajectories to recruit to all roles within our trust are being set alongside our budgets in the year April 2023 to March 2024. Unambiguously recruiting to our funded roles is the basis for the trust’s Operating Plan April 2024 to March 2025 and to significantly reduce our agency spend.

Compliance statements

The foundation trust is fully compliant with the registration requirements of the Care Quality Commission.

The foundation trust has published on its website an up-to-date register of interests, including gifts and hospitality, for decision-making staff (as defined by the trust with reference to the guidance) within the past twelve months as required by the managing conflicts of interest in the NHS guidance.

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the scheme are in accordance with the scheme rules.

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.

The foundation trust has undertaken risk assessments on the effects of climate change and severe weather and has developed a green plan following the guidance of the Greener NHS programme. The trust ensures that its obligations under the Climate Change Act and the adaptation reporting requirements are complied with.

Review of economy, efficiency and effectiveness of the use of resources

The Finance, Digital and Estates committee (FDEC) and ultimately the board of directors ensures through a series of robust review mechanisms, that the use of resources is planned in an efficient and effective manner, and that our financial position is monitored and scrutinised. They oversee the monthly position against the approved financial plan for the year though their primary focus is underlying financial viability on a multi-year basis.

I have responsibility for ensuring that the resources used in the day-to-day operational activities of the trust are done so in an economic, efficient and effective manner. This is discharged through two formal systems. A sub-group of the clinical leadership executive oversees financial performance. Every month by rotation our care groups and each corporate directorate undertake a delivery review, where alongside safety, workforce and wider delivery matters, financial control is discussed, and relevant actions taken. In the year April 2023 to March 2024 every single care group met its budgetary obligations, despite a 5% cost improvement programme. This is testimony to local control and has benefitted too from central and corporate support.

In addition to the monthly budgetary control system, the trust ensures economy, efficiency and effectiveness as well as value for money through the implementation of a suite of effective and consistently applied financial controls, effective tendering procedures and procurement practices, robust establishment controls and continuous service improvement and modernisation programmes. Our standing financial instructions have been reviewed and revisited in-year through the board.

We have a bi-monthly Audit committee that includes reports from internal and external audit. The auditors provide their respective views to the committee on our overall governance and control processes. FDEC and the Audit committee are two of the eight committees put in place by the board of directors as part of its governance structure. For further details on the structure and the attendance of directors at meetings of the board. The annual assessment of compliance statement with the corporate governance code is provided in the annual report.

Information governance

The trust has a nominated senior information risk officer (SIRO) at executive level who has been nominated responsibility for information risk. The data protection officer (DPO), overseas data protection compliance throughout the trust and provides independent advice to the trust.

Information governance incidents are monitored through the Information governance group (chaired by the SIRO) on a monthly basis. During the year April 2023 to March 2024 there have been 543 incidents reported (515 incidents were reported in the year April 2022 to March 2023) of which 4 required notifications to the information commissioner via data security and protection toolkit (during the year April 2022 to March 2023 there were two incidents). Details for the incident are summarised below.

1. April 2023, audits were undertaken within the trust’s electronic staff record (ESR) regarding a staff member who was working their notice within the workforce department. Evidence was found of inappropriate access to three staff members tax information. Further investigation has found evidence of pay slips being sent to the staff members personal email account on two occasions. Recommendations provided but no further action taken by the Information Commissioner’s Office (ICO).
2. October 2023, a member of staff from a different organisation (contract, information sharing agreement et cetera in place) has inappropriately accessed the medical records of approximately two patients. No action taken, ICO happy with actions taken by RDaSH and other organisation.
3. October 2023, staff member sent a person’s copies of identification in error to the incorrect person. No action taken by ICO.
4. March 2024, It was identified that student nurse on placement with trust had been inputting patient names into CHAT GPT to utilise the AI forum to create written documentation for both course material and patient record keeping. Recommendations provided but no further action taken.

Data quality and governance

The trust has published a data quality policy, management information guide and quality assurance and performance Framework flow chart, these three documents support the coproduction of reports through development to sign off, which includes data quality testing. The management information guide also set out ongoing responsibilities for the oversight and escalation of data quality. In addition, the data quality group (monthly meeting) is a forum for data quality issues to be escalated, explored and corrected. The data quality group reports into the digital transformation group which subsequently reports to the clinical leadership executive (CLE).

In terms of elective waits, the trusts access and waiting times policy outlines the services for which it applies the principles of referral to treatment (RTT). In year we identified some discrepancies within the application of that policy and a revised approach to waiting list management was discussed with the board. It has been applied effective 1 April 2024.

The Information Quality team audit and kite mark the waits in scope of national RTTs which are also monitored internally through the IQPR.

Review of effectiveness

As accounting officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me.

My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the board and its committees. The Audit committee provides the board of directors with an independent and objective view of arrangements for internal control and risk management within the trust and ensure that the internal audit service complies with mandatory auditing standards. It approves the annual audit plans for internal and external audit services, receives regular progress reports and ensures that recommendations arising from audits are actioned proportionately.

It will be apparent that I disagree with, and reject, the views offered by both the head of internal audit and within the external audit value for money opinion. This is highly unusual. I set out the detail here of that disagreement, before, more importantly explaining the strengths and weaknesses of the trust’s controls which have informed my opinion.

Both external and internal auditors have confirmed that, to the extent that it is within their responsibilities, they have identified no additional, or significant, risks or consequences arising from the claimed gaps in control. Moreover, data within this annual report on the organisation’s safety, workforce, finance, and operating performance shows improvement from prior years.

The issues identified by the auditors have occurred in prior years when different, less limited, opinions have been offered and, for the reasons I outline below, I am assured that the underlying functions, arrangements, and outcomes have not deteriorated and, in some instances, positively reflect the hard work undertaken by my staff. The Auditors’ note that the BAF issue is a new and transitional one and highlight that the timeliness of audit recommendation responses has been an ongoing concern for some time (notwithstanding extremely good performance in the year April 2022 to March 2023).

Turning to the specific concerns raised by the auditors.

The external audit opinion draws on the head of internal audit opinion, is concerned by a lack of documentation over the interim approach the BAF, and take a view, with which I disagree, over progress with the finance development plan. I am satisfied, as is the Audit committee with progress on the latter. The chair, audit committee and I are content with the interim BAF arrangements in place.

The internal audit opinion relies on three views:

• firstly that the board made a mistake in choosing to change the BAF approach and manage the BAF in-year in a different way
• secondly that 85% internal audit recommendations completed represents a limited level of performance because only 60% occurred on time
• thirdly that the huge increase in identified risks within the trust is not indicative of improved approaches to risk management because the risk management framework was not agreed at the board until January 2024 (though the new approach to risk has been deployed from June 2024). I consider that 85% represents reasonable practice, that the BAF management has been situationally suitable, and that the approach to risk is objectively better than in any year at the trust since the onset of the pandemic

It is important that the above comments are not read defensively. The trust has significant weaknesses in systems, and these are outlined here openly. They are not the weaknesses highlighted within audits. Moreover, whilst very positive about our staff survey performance, especially at a time of change, we do not believe that a rating of Requires Improvement is acceptable.

April 2023 to March 2024 has been a year of transition. The full board took the view that prior systems of control lacked for data and for delivery mindset. The operating model introduced in mid-year, with assistance from two separate external advisors, has not simply replaced prior systems, but introduced new systems and processes to address the deficits highlighted. This has necessarily led us, and in every case in a planned and known way, to give less emphasis to certain processes, whilst addressing more important consequential matters. There remain gaps and deficits which I outlined in the prior year’s annual governance statement and rediscuss below.

The work of internal audit is monitored via the Audit committee, from which further assurances, through their objective and independent view of the system of internal control, have been received. Plans to address any weaknesses identified through these audits are subject to regular follow up by the Corporate Assurance team and are overseen by the Audit committee. Based on the work undertaken during April 2023 to March 2024 the Head of Internal Audit has stated in their head of internal audit opinion of limited assurance as detailed below.

I am providing an opinion of limited assurance that there are weaknesses in the design and, or inconsistent application of the framework of governance, risk management and control that could result in failure to achieve the organisation’s objectives.

• Strategic risk management and board assurance framework (BAF), I am providing an opinion of limited assurance. Since the appointment of a new chief executive in March 2023, the trust has undergone a significant programme of change including the launch of a new strategy, a revised operating model and a restructure of its care groups. During this time, the board took the decision to report BAF risks by exception whilst new arrangements were put in place, including the development of a new BAF to support strategic delivery which remains in progress. As a result of the reduced level of reporting, we were unable to sufficiently evidence the review and management of strategic risk during April 2023 to March 2024.
• Internal audit outturn, I am providing an opinion of moderate assurance for this element. Of the 11 assurance opinion reports issued since our April 2022 to March 2023 opinion, four provided limited assurance and three provided moderate assurance.
• Implementation of internal audit actions, I am providing an opinion of limited assurance for the implementation of actions. The trust implemented 60% of its actions in accordance with agreed timescales. At the time of concluding my opinion, one high risk and eight medium risk actions were overdue. A further high-risk action was implemented beyond the original due date.

My opinion takes into account third party assurances received by the organisation.

External Audit report to the trust on the findings from their audit work, in particular their audit of the financial statements and the trust’s arrangement for the secure economy, efficiency and effectiveness in its use of resources. For April 2023 to March 2024 an unmodified audit opinion has been issued in respect of the financial statements but with specific weaknesses identified in respect of the trust’s arrangements for securing economy, efficiency and effectiveness in its use of resources.

During April 2023 to March 2024 the Quality committee approved the annual audit plan for clinical audit services, received regular progress reports on outcomes and around the implementation rates for actions arising from the recommendations made. Going forward this role will be undertaken by the Audit committee to enable a broader oversight of the delivery of clinical audits alongside the internal audit programme.

In the year April 2023 to March 2024, I identified four areas of underlying system weakness, whilst accepting that they were not significant internal control issues and therefore do not require a disclosure statement. I report on progress since and comment on new limitations which we will look to address in the future.

Data for care

Our data quality remains well governed, and there is clearly with our IQPR, improved data visibility not only within the board, but across the organisation. The timeliness and immediacy of this data needs to further improve, and the safety plan identified in our quality account as a priority for April 2024 to March 2025 will rely on that improvement for its effectiveness. The trust has further work to do, impeded by personnel changes in the year April 2023 to March 2024, to finalise its top-level scorecard of safety and quality indicators.

Financial improvement

Delivery on both revenue and capital in year, and most importantly the substantially improved distributed and delegated leadership of each, suggests real transformation on this matter in year. We have for our main cost, pay, better oversight going into the year April 2024 to March 2025, and this gives us confidence on delivery of the agency gains which underpin our CIP. Our non-pay controls are strong, but information sharing associated with medicine and non-pay spend will need to improve further.

Data about staffed teams

It has taken a lot of work to improve this, and that work has come to fruition in quarter 4 of the year. At a very local level there is good grip of hiring decisions and wider line management. Aggregation of data and its use to plan workforce reform has taken time to systematise. The significant changes made in practice suggest that we are now using this data well to make decisions. The transfer to NHS Professionals will further enhance this work as we have a flexible working partner in place. Benchmarking work continues, and intelligence on our supervision, appraisal, placement and educational models informs my positive view of our capability for the two years ahead, including implementation of the national workforce plan.

Delivery capability

We have entirely restructured our frontline management, and much of our corporate management during the year. We are investing to support those leaders and finding a balance between internal expertise and new recruits where skill gaps exist. External advisors make clear the progress and difference seen, but recognise as I do, the fragility of change. We are working better with place partners but have more work to do to support primary care partners. I am satisfied that our delivery skills are improving, as evidenced by the trust meeting three of the national access standards in the year April 2023 to March 2024, a step forward from past practice.

These four issues remain a focus in 2024, 2025. Two other issues will be crucial to supporting our strategy, and therefore our control of risk at a strategic level, and trust as a day-to-day level:

• our ability to translate into practice our commitment to work with patients, carers and communities in co-production. This is not an add-on to our governance but at its heart. This will be difficult to do, and the board is very aware that it may require us to change transitional practice, systems and language to make these collaborations effective. Processes including those of audit and regulation will need to be wisely managed mindful of that ambition
• our culture must adapt yet retain the longstanding strengths valued in our excellent staff survey results. That adaptation will include challenges the weaknesses in that and other data, notably in relation to discrimination and racism. Our intent to deliver must not overlook the diverse needs of employees, managers, and partners. The new BAF focuses hard on cultural alignment as a key risk for the future. Managing culture, curating it, and shaping it is a capability we will need to work to deliver

The trust’s oversight of operational delivery and financial obligations has been improved during the year April 2023 to March 2024. I have confidence that a similar trajectory of transformation is in place for safety and quality and people and teams. The choice to focus on these matters in the year April 2024 to March 2025 does not indicate secondary importance, but rather the need to have key capabilities in place so that improvement can be secured and can endure.

I note that the two additional issues identified here are threaded through the approved board assurance framework risks for 2024 to 2027, which are cultural in nature and focus on our partnership working, consistent with a system-first NHS. These are:

1. cultural competence, if our “changed ways of working” with the diverse population (including among excluded communities) are not delivered by 2027, because of the leadership’s inability to identify, communicate and engage then it will lead to a loss of confidence locally and likely non-delivery of strategic objective one
2. data for insights, if we do not execute plans to consistently create, use and respond to data inside our services (and with others) because our leaders lack the time, skills, or diligence to see through specific changes or are distracted by “wider system” priorities then this will lead to a lack of precision in how the trust reshapes services
3. joined up care, if we cannot agree with local GPs and the wider primary care leadership how to coordinate care at primary health care team, primary care network, or neighbourhood level because there is not the mutual skill to change, or confidence to experiment by both parties, or funding models are restrictive, then we cannot deliver our new community offer with the effectiveness that our strategy requires and shared care will not be achieved and patients will suffer harm
4. patient-first working models, if seven-day working and other bed-based service alterations are not implemented fully because of resistance, inflexibility, or affordability, with colleagues able to move elsewhere (where such difficulties are not occurring) then we will continue to place patients out of area and see severe stress and burnout; and increased turnover, among our own employees
5. leadership capability, if we do not achieve the step-up in institutional and system capability to deliver multiple time-bound simultaneous changes with impact by 2027, because we do not develop and practice the skill sets required to make change occur, then the trust’s strategy will not achieve what it has promised, and we will face reorganisation, frustration, and turnover among employees

The board has confidently retired the prior BAF risks in January to March 2024 having concluded that they are no longer the most relevant risks to the trust’s work or delivery of the new strategy. Indeed, those previous BAF risks are largely situational, replicative of other NHS Trusts, and do not describe material issues impacting patient care at RDaSH.

Conclusion

I confirm that the trust has an adequate and effective system of internal control, and any specific internal control issues are being addressed through robust actions. We are revising wholly our approach to the issues highlighted by internal audit, with oversight from the audit committee chair and me, and I am confident that performance on the specific issues they identify will improve during 2024. Matters raised by the external audit opinion will be formally considered at the Audit committee on 7 August, and management will be directed by their conclusions whether changes are needed in response.

There are no significant internal control issues identified during the period from 1 April 2023 to 31 March 2024 that require disclosure in this statement.

Toby Lewis, Chief Executive, 11 July 2024.

Our services

The trust is registered with the CQC to provide safe care that is responsive and effective and as such provides a range of health and social care services across three localities through a Care Group model in Rotherham, Doncaster, North Lincolnshire.

A review of the trust’s governance structure was undertaken during the year in terms of the meeting and care group leadership structures. Implementation commenced in November 2023 with a revised care group model:

• children’s care group providing a range of services for children, young people and families including children’s mental health across the 3 localities, Doncaster, North Lincolnshire and Rotherham
• physical health and neurodiversity care group providing inpatient and community physical health services to the communities of Doncaster and attention deficit hyperactivity disorder (ADHD) across Doncaster, North Lincolnshire and Rotherham
• Doncaster mental health and learning disabilities care group providing adult mental health services, older peoples mental health services, drug and alcohol services, forensic services to the communities of in addition, community learning disability services are provided across Doncaster, North Lincolnshire and Rotherham
• North Lincolnshire adult mental health and Talking Therapies care group providing adult mental health services, older peoples mental health services to the communities of North Lincolnshire. In addition, Talking Therapies services are provided across Doncaster, North Lincolnshire and Rotherham
• Rotherham adult mental health care group providing adult mental health services, older peoples mental health services to the communities of Rotherham

About Rotherham Doncaster and South Humber NHS Foundation Trust

The trust was originally formed in October 1999 and in 2002, took on responsibility for the delivery of mental health services in Rotherham. On 1 August 2007, the trust was authorised to operate as an NHS Foundation Trust under the NHS Act 2006.

On 1 October 2010, the transfer of tier 2 primary mental health child and adolescent mental health services (CAMHS) from Doncaster Council (DMBC) and tier 3 CAMHS from Doncaster and Bassetlaw Hospitals NHS Foundation Trust (DBH) to the trust took place.

Also in 2010, the trust integrated with Doncaster community healthcare and Rotherham community health services under the transforming community services programme. The trust was renamed Rotherham Doncaster and South Humber NHS Foundation Trust (formerly known as Rotherham Doncaster and South Humber Mental Health NHS Foundation Trust) to reflect the range of services provided.

The trust is the appointed lead provider for the adult eating disorder provider collaborative within the South Yorkshire ICS and as such has commissioning responsibilities in respect of the adult eating disorder service across the whole of South Yorkshire.

The trust provides a range of health and social care services across three localities, Rotherham, Doncaster, North Lincolnshire serving a population of over 740,400. The trust operates from over 100 community and inpatient sites, employs 3,450 (whole time equivalent) staff and has an annual income of approximately £225million.

Trust strategy

During the year the trust launched its new clinical and organisational strategy, following an extended period of consultation with stakeholders. This new five year clinical and organisational strategy, running through to 2028, sets out our ambition and is framed around five objectives:

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

The five objectives are underpinned by 28 promises made to our community to be achieved during the lifetime of the clinical and organisational strategy. This sets out what we stand for in terms of values and behaviours and the promises that we are making to our patients, people and communities about how we will behave for example to be an antiracist organisation.

This clinical and organisational strategy was written following significant engagement with and contributions from communities, patients, governors, partners and our own people. It shapes the trust’s priorities and ways of working over the next five years, ensuring alignment to our vision.

The clinical and organisational strategy and associated promises are outlined for delivery through eight plans. The eight plans are:

• quality and safety
• equity and inclusion
• people and teams
• learning and education
• finance
• estates and sustainability
• research and innovation
• digital

These eight plans are being developed and are expected to be finalised by June 2024.

There was no significant change to our operating environment in the reporting year. The trust continues to improve its work with others to make sure various plans and pathways for patients are “joined up”. The trust works with others where it means that the trust can achieve better, more effective, and more efficient patient care (whether that’s at a system or place level). This includes working in collaboration with other providers.

Health inequalities

The trust is committed to reducing the health inequalities in our communities. Our work to address health inequalities is ingrained in a range of promises made in our clinical and organisational strategy 2023 to 2028. The trust has developed an equity and involvement plan to target in key areas and has formed a new board subcommittee which focuses on public health and patient involvement. Some of the activity in the period of April 2023 to March 2024 has included:

• working with primary care to increase the level of annual health checks for people with a severe mental illness (promise 7)
• reviewing access and waiting times for diverse communities to our services using a “Core20PLUS” lens to understand if inappropriate variations in access exist. We have used this information in our Talking Therapies service as a pilot to target activity at under-served communities, for example, older people (promise 7)
• working with partners on a programme to support homeless people in Doncaster with their health needs (promise 9)
• outreach work with the Gypsy, Roma and Traveler community to aid better access to health services (promise 9)
• working with the deaf or hard of hearing community to identify and address barriers to accessing services (promise 8)
• profiling of schools the trust works in, so that interventions and support of children and young people receiving school nursing are better tailored to their needs (promise 17)
• introducing a new trust website that better meets accessibility standards
• creating information in the top languages spoken across our communities
• profiling all of our services using the Core20PLUS approach

We continue to develop the work programme as part of delivering our promises:

• programme of poverty proofing all our services due to commence in June 2024 (promise 6)
• our current and future contribution to the 10 health improvements identified for children, young people and adults in the Core20PLUS5 programme (promise 7)
• implement the patient and carers race equality framework (promise 7)
• implement specific recruitment and apprenticeship offers for refuges, citizens with learning disabilities, care leavers and those from other excluded communities (promise 9)
• work with partners to map prison discharge pathway to ensure our services can meet their health needs (promise 10)
• establish a homeless health team (promise 10)
• ensuring we deliver the NHS commitment to veterans and their families (promise 11)
• deliver integrated neighbourhood teams (promise 15)

Whilst the trust has started reporting information by ethnicity and deprived neighbourhoods, this is not yet systematic nor consistent and we will improve this during 2024. Also, we need to improve the analysis of data to better understand any discrimination or inequality in service offer, access and health outcomes.

Working with our integrated care boards

Integrated care boards (ICBs) are statutory bodies that are responsible for planning and funding most NHS services in the area. They are responsible for developing a plan in collaboration with NHS trusts and foundation trusts and other system partners for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the defined area. The trust works across two ICBs, South Yorkshire and Humber and North Yorkshire respectively. In developing its clinical and organisational strategy and promises, the trust took into account the ambitions and aspirations in the forward plans of the two ICBs that it works with setting out how they will meet the health needs of their population. The table below gives a simple explanation of how the ICB’s forward plans are complimented by the strategic plan of the trust and in more detail through the promises to our community we have made.

Trust 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.

South Yorkshire joint forward plan objectives

• Reducing health inequalities and creating a prevention first NHS.
• Improving access, quality and transforming care.
• Maximising the use of digital, data and technology and research and innovation.
• Making best use of our collective resources.
• Working in partnership and collaboration.
• Supporting and developing our entire workforce.

Humber and North Yorkshire joint forward plan objectives (priorities for North Lincolnshire)

• Mental health and wellbeing will thread through all that we do, across all ages.
• Innovation will be supported including digital tools that enable individuals to maximise health and wellbeing.
• Asset based community development will identify and work with the strengths of our communities to level up North Lincolnshire.
• The health inequalities gap will reduce across our wards.
• Healthy life expectancy will improve.
• Access to health and care takes account of rural challenges.
• The integrated practice model will be person centred.
• People with long term conditions will experience proportionately good health.
• There will be a single workforce strategy covering leadership and management, recruitment and retention, reward and recognition, career pathways and talent development.

The trust works with the ICBs, at a system and place level, to develop performance and operational priorities, workforce development, capital programmes, and finances.

Our approach is also aligned with the Health and Social Care Act which places a legal duty to have regard towards the wider effect of our decisions which the ICBs also have a legal duty towards. This is to make sure we better meet a triple aim of:

• health and wellbeing of our population
• quality of services provided
• efficiency and sustainability in the use of resources

Summary of principal risks

The trust has a comprehensive risk management framework in place which enables informed management decisions in the identification, assessment, treatment and monitoring of risk. The trust defines risk as the chance of something happening that will have an impact on business objectives, and this can be in terms of both threats and opportunities.

The trust’s board assurance framework (BAF) provides a structure for the effective and focused management of the principal risks in meeting the trust’s key objectives. It enables the identification of the controls and assurances that exist in relation to the trust’s key objectives and the identification of significant risks.

All risks included on the BAF have an executive director lead who has reviewed these risks and the associated actions in place on a regular basis to progress mitigation. The strategic risks in place during the reporting year were:

• if the trust fails to recruit and retain skilled staff for groups where there are shortages then this will impact on the delivery of safe services for our patients
• if the trust does not have quality leadership to embed compassionate care and a high performing culture, then the right care will not be delivered
• if the trust does not achieve the planned budgeted deficit in year and does not return to a budgeted breakeven position over the longer term, then it will impact on the long-term sustainability of the trust and its ability to deliver services
• if we do not work in partnership at system and place, then the trust will fail to meet its duty to collaborate and, or deliver integrated care for the benefit of our communities
• if the trust does not develop, approve and deliver the clinical and organisational strategy, then this may impact on patient safety, patient experience, clinical effectiveness and regulatory compliance
• if we do not have a robust governance process in place, then this may lead to the trust being ineffective, inefficient and may compromise the well-led status of the organisation
• if a significant destabilising event occurs then the delivery of services, financial performance and wellbeing of staff may be impacted

As the year concluded, the board was undertaking its review of the board assurance framework to align the strategic risks with the clinical and operational strategy and the potential to impact on delivery of the strategic objectives.

Overall performance of the trust in the period of April 2023 to March 2024

NHS England’s indicator regarding the NHS Oversight Framework segmentation (1 to 4 with 1 equalling maximum autonomy) has the trust scored as a level 2 for the period of April 2023 to March 2024. This is the same level for the previous period of April 2022 to March 2023.

CQC overall rating (either inadequate, requires improvement, good or outstanding) has the trust rated as “requires improvement” for the period of April 2023 to March 2024. This is the same rating for the previous period of April 2022 to March 2023 as there has been no inspection of the trust since 2020 when this rating was provided.

The group deficit was £2.3million for period of April 2023 to March 2024, this included a reversal on valuation of impairments and other technical items that are removed from the trust’s control total for NHS England’s monitoring purposes. The trust deficit for operational performance purposes was £3.5m compared to a planned deficit of £6.2million.

National targets relevant to mental health and community services were partially compliant (4 out of 6 targets achieved) for period of April 2023 to March 2024. The trust was partially compliant (5 out of 7 targets achieved) for the period of April 2022 to March 2023. Further detail is summarised below.

• The number of referrals to and within the trust with suspected first episode psychosis or at “risk mental state” that start a NICE, recommended package care package in the reporting period within 2 weeks of referral had a target of 60% for the period of April 2023 to March 2024 and the trust achieved 97%. For the period of April 2022 to March 2023 the trust achieved 92%.
• Discharges followed up within 72 hours had a target of 80% for the period of April 2023 to March 2024 and the trust achieved 96%. For the period of April 2022 to March 2023 the trust achieved 90%.
• Children and young people eating disorder waiting time, urgent (within 1 week) had a target of 95% for the period of April 2023 to March 2024 and the trust achieved 100%. For the period of April 2022 to March 2023 the trust achieved 100%.
• Children and young people eating disorder waiting time, routine (within 4 weeks) had a target of 95% for the period of April 2023 to March 2024 and the trust achieved 95%. For the period of April 2022 to March 2023 the trust achieved 95%.
• Number of adults and older adults (aged 18 and over) receiving two or more contacts with community mental health teams (LTP01) had a target of 8,533 for the period of April 2023 to March 2024 and achieved 9,403. This measure was not applicable for the period April 2022 to March 2023.
• Improving access to psychological therapies access (LTP02a) had a full year target of 22,860 and achieved 17,034. For the period of April 2022 to March 2023 the trust achieved 15,468.
• Improving access to psychological therapies access (LTP02b) had a quarter 4 target of 5,921 and achieved 4,045. For the period of April 2022 to March 2023 the trust achieved 3,837.
• Perinatal and maternal metal health access (LTP 03) target for the period of April 2023 to March 2024 of 617 and achieved 742. For the period of April 2022 to March 2023 the trust achieved 545.
• Children and young people access target (LTP04) for the period of April 2023 to March 2024 of 9,830 and achieved 9,858. For the period of April 2022 to March 2023 the trust achieved 9,039.
• Inappropriate out of area bed days had a quarter 4 (LTP05) target of 305, however the trust recorded 2,484. This measure was not applicable for the period April 2022 to March 2023.
• Virtual ward available beds target (LTP06) for the period of April 2023 to March 2024 was 60 and the trust achieved 60. This measure was not applicable for the period April 2022 to March 2023.

Going concern

After making enquiries, the directors have a reasonable expectation that the services provided by the NHS Foundation Trust will continue to be provided by the public sector for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual.

Significant events since year end and overseas operations

There have been no important events since the end of the financial year affecting the trust, nor is there any overseas operations to report against.

Trust’s directors remuneration for period of April 2023 to March 2024

Page last reviewed: December 23, 2024
Next review due: December 23, 2025

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