Board of directors minutes January 2024

Contents

1. Introduction
2. Patient or staff story
3. Standing items
4. Board assurance committees
5. Operating performance, governance, and risk management
6. Supporting papers (previously presented at committees)

Minutes of the board of directors meeting, held in public on Thursday 25 January 2024, 10am to 1:30pm, at:

Baths hall
Doncaster road
Scunthorpe
DN15 7RG

Present

• Kathryn Lavery, Chair
• Richard Chillery, Chief Operating Officer
• Ian Currell, Executive Finance Director
• Sarah Fulton Tindall, Non-Executive Director
• Kathryn Gillatt, Non-Executive Director
• Dawn Leese, Non-Executive Director
• Toby Lewis, Chief Executive
• Sheila Lloyd, Deputy Chief Executive and Executive Director of Nursing and AHP
• Nicola McIntosh, Director for People and Organisational Development
• Dr Graeme Tosh, Medical Director
• Dave Vallance, Non-Executive Director
• Pauline Vickers, Non-Executive Director

In-attendance

• Richard Banks, Director of Health Informatics
• Philip Gowland, Director of Corporate Assurance and Board Secretary
• Dr Judith Graham, Director of Therapies
• Joanne McDonough, Director of Strategic Development
• Lea Fountain, NeXT Director
• Jyoti Mehan, NeXT Director

5 members of staff and 3 governors joined to observe.

Introduction

Welcome and apologies

Reference

Board public 24/01/01 and board public 24/01/02.

Mrs Lavery welcomed the attendees to the meeting.

Apologies for absence were received and noted from Mr Shannahan and Dr Jankowski.

Quoracy

Reference

Board public 24/01/03.

Mrs Lavery declared the meeting was quorate.

Declarations of interest

Reference

Board public 24/01/04.

Mrs Lavery presented the declarations of interest report which outlined the changes to the register since the last meeting relating to Mr Chillery, Dr Jankowski and Ms Fulton-Tindall.

The board received and noted the changes to the declarations of interest report.

Patient or staff story

Staff story, integrated neighbourhood teams

Reference

Board public 24/01/05.

Mrs Lavery welcomed Ms Treen, Ms Jubber and Mr Bennett to present the staff story on integrated neighbourhood teams (INT). The presentation provided an overview of their contribution to joined up working and the community offer as part of South Scunthorpe INT.

The presenters highlighted their role and remit within the INT covering the wider strategic framework at ground level, the experience of working at the community service level and what this could look like in terms of transformation. The current status of community mental health transformation and integrated working or collaboration was outlined in both primary care at Place and across the wider system.

The next steps for integrated working directly aligned with the promises was to progress a pilot on population serious mental illness (SMI) diagnosis, to break down historical barriers in engaging with services. Professionals from across the social care system regularly meet to provide support the entering referral pathway and prevent delays to treatment.

The Board reflected on the benefits of this hyper local working. Mr Lewis highlighted the need to focus on practical care changes for the over 500 residents with SMI. He expressed a desire to make sure the trust delivered on this specific change, if necessary at the expense of ‘system working’ on a broader more policy orientated sense.

Standing items

Minutes of the previous board of directors meeting held on 23 November 2023

Reference

Board public 24/01/06.

The Board approved the minutes of the meeting held on 23 November 2023 as an accurate record subject to minor amendments from Ms Fulton Tindall (minute refence board public 23/11/17):

“Ms Fulton Tindall asked members to also note an endemic issue within some trusts of older age defining patients, which can impact on expectations for their treatment, and queried whether attitudes to older people also needed identifying to raise awareness and recognition in this regard.”

Matters arising and follow-up action log

Reference

Board public 24/01/07.

There were no matters arising from the minutes.

The board received the action log and noted the progress updates. All actions noted as “propose to close” were agreed apart from action board public 24/01/2022 regarding NHS professionals which was to remain an open action.

Action

NMc.

Gender pay gap

The board revisited the prior paper on the gender pay gap. There was no support to progress affirmative action steps to close the gap. There was agreement to take all other relevant steps, and to provide three monthly monitoring data to the people and OD Committee of the board. A significant debate took place over the significance of responsibilities to narrow the gap on employment benefits, which was the largest single driver for our residual GPG. Dr Graham stressed the gendered nature of these benefits and resisted suggestions that it should be set aside.

Chair’s matters

Reference

Board public 24/01/08.

Mrs Lavery provided a verbal update of activities and engagements since the last meeting. She highlighted the success of the annual awards ceremony that took place in November. Mrs Lavery referred to the visits to services in December undertaken with Mr Lewis to express Christmas wishes and deliver small tokens of appreciation, and to her visit to St John’s Hospice.

The peer review on Magnolia ward had gone well, and board members were encouraged to take part in these.

A meeting was held with the lead Governor Jo Cox with work ongoing with Mr Gowland on constituency changes and meeting arrangements, pending the upcoming council of governors.

As the non-executive lead for equality and diversity she had participated in the South Yorkshire Equality, Diversity and Inclusion (EDI) group and Mrs Lavery also noted her attendance at the trust’s anti-racism alliance group. She noted that there remained a significant amount of work to be done to achieve the promise of becoming an anti-racist organisation, but she and many others were determined that this promise would be met.

On behalf of the Board, Mrs Lavery expressed her thanks for Mrs Lloyd’s contributions at the trust and in the wider NHS, on the occasion of her imminent retirement.

Board assurance committees

Report from the Audit Committee

Reference

Board public 24/01/09.

Mrs Leese presented the report in Mr Shannahan’s absence. She highlighted:

• the number of deferments to the internal audit plan
• the limited assurance opinion in the procurement audit
• the board assurance framework (BAF) refresh expected by March 2024 (separate agenda item today)
• the resultant potential of a limited or moderate assurance in the head of internal audit opinion (HOIAO)

Mr Lewis responded to the concerns over deferment, which he had separately discussed with Mr Shannahan and the trust chair. These related to specific patient experience or safety audits where Q1 (first quarter) activity would provide a more useful prompt to action, given bandwidth issues in the department. He highlighted that nothing in the procurement audit was an immediate or pressing priority, notably when compared to other work that function needed to undertake in respect of our promises. Mrs Gillat noted this item would come to the next Audit Committee.

He asked that the report from the committee was reworded as it could be taken to imply that the board had not current BAF, which is not true. This amendment was agreed.

The board received and noted the report from the Audit Committee.

Report from the People and Organisational Development Committee

Reference

Board public 24/01/10.

Mr Vallance presented the report and highlighted a decrease in turnover rate, that mandatory and statutory training (MAST) compliance was at 90%, and there were no extreme risks reported.

The guardian of safe working hours (GoSWH) report had been highlighted in respect of elevated reporting levels from trainees. Dr Tosh confirmed the concerns raised had been addressed through medical staffing and the provision of admin support.

Mr Vallance contrasted the learning and education plan seen by the Committee, which was fully developed, with the more outline people and teams plan. It was acknowledged by executive members that significant focus on the people and teams plan was needed by May.

The board received and noted the report from the People and Organisational Development Committee.

Report from Finance, Performance and Informatics Committee

Reference

Board public 24/01/11.

Mrs Vickers presented the report, which was the final one from the committee in its current form.

Mrs Vickers advised that the committee had increased confidence in the forecast year end position (the current deficit of £4.3m against a planned deficit of £6.15m).

There was significant progress with the delivery of the savings target with £7.42m achieved at month 9 (£9.4m planned by 31 March 2024). This success was acknowledged, albeit there remained ongoing challenges and having reviewed the programme of work, whilst assured about the process, the committee had asked for additional information in respect of three key areas.

She highlighted that there remains a failure to deliver the planned reduction in agency staffing. This is a significant opportunity for the year ahead, but lessons need to be learned from the failure to deliver in 23/24.

Mrs Vickers highlighted a minor amendment required on the paper with reference to the expenditure controls issued by the ICB. The trust would respond to not comply with, as currently stated, as two deviations from the proposal had been agreed by the CLE and noted in FPIC.

The board received and noted the report from the Finance Performance and Informatics Committee.

Report from the Public Health Patient Involvement and Partnerships Committee

Reference

Board public 24/01/12.

Mr Vallance presented the report from the first Public Health Patient Involvement and Partnerships (PHPIP) Committee in Mr Shannahan’s absence and gave focus to two areas.

• The Doncaster fairness and wellbeing commission report had been discussed, enabled by the acting director of public health. The committee had discussed how to align our work the recommendations of the commission, and Mr Lewis had agreed to outline in May how this would be done.
• Work on promise 6 “poverty proofing” had been procured to identify and address barriers for those in poverty accessing our services.

Committee members reminded the board that the research and innovation plan was a key part of the work of the PHPIP Committee.

The board received and noted the report from the Public Health Patient Involvement and Partnerships Committee.

Report from Quality Committee

Reference

Board public 24/01/13.

Mrs Leese presented the report from the Quality Committee and gave focus to three areas.

Compliance with resuscitation standards were still not in place. This longstanding issue was a concern in itself, and a symptom of wider non-compliance. Mr Lewis acknowledged the persistent failure of the management to grip this issue and resolve it. He would offer an oral update at the next board meeting.

The malnutrition universal screening tool (MUST) assessment data indicated non-compliance. A deep dive review was ongoing, and an initial snapshot audit had identified improvement opportunities. Dr Graham was leading work with the care groups to address data and delivery issues.

Racist incidents had increased. There had been discussion at the board previously around compliance and organisational tolerance levels. Mr Lewis drew attention to his recent video log, and noted work he would take forward to identify with local police forces what steps they would in practice take when hate crime reports were made from mental health inpatient wards.

Ms Fulton Tindall asked about serious incident reporting and the learning that arises. Mrs Lloyd suggested that although the immediate work to improve had already taken place, further changes were planned which also included the pre-empting and addressing of any potential questions from the coroner and family.

The board received and noted the report from the Quality Committee.

Action

TL.

Chief executive’s report

Reference

Board public 24/01/14.

Mr Lewis drew attention to four items within his report, which included his usual annex on governors’ priorities as well as a strike impact analysis.

• He was concerned that, notwithstanding work on eating disorders in community and specialist settings, the existing liaison arrangements with district general hospitals, fell short of safe standards. He had agreed with the Board of the collaborative that the trust would take forward discussions with TRH and, or DBTH. He had also highlighted his concerns to the chief nurse and medical director of the South Yorkshire ICB.
• As noted by FPIC, agency spend reduction had fallen short of intention. Upcoming internal guidance would change the trust’s authorisation model for 2024/2025, to sharply reduce non-medical agency staffing and eliminate use of long-term agency employees. He acknowledged this would lead to some unhappiness at the disruption of established working relationships.
• 2024/25 ICB financial planning discussions were ongoing with Chairs and CEOs. The national position was extremely challenging; however, the board’s leadership role was not to expose frontline teams or leaders to unwarranted pressure, but to manage demands and expectations choice fully.
• During Q3 (third quarter) the trust had continued to invest in local communities, for example with section 62, and had also provided continued support to PFG to establish a community of practice among local VCSE or peer led groups across RDASH.

He invited Mrs Lloyd to provide a summary of the 2-day health services safety investigations body (HSSIB). She drew attention to positive feedback on the trust’s patient flow methodology and the openness of staff on risk and safety. Staff quotes would be included in the final report. HSSIB had requested an opportunity to revisit the trust at a future date.

The board received and noted the chief executive’s report and the forward actions it contained.

Emergency preparedness, resilience and response (EPRR) update report

Reference

Board public 24/01/15.

Mr Chillery presented the EPRR update report and highlighted the key issues arising. In line with a prior report from September 2023, there were increased requirements and a resultant reduction in compliance against the core standards: a “hard reset” had been applied nationally, and benchmarking results showed the trust’s compliance of 21% (as against 17% on average for trusts in South Yorkshire).

He was satisfied that a clear plan of improvement action was in place and drew attention to the priorities outlined in the report.

Members discussed the immediate risk, as well as the organisational effort required. There was a consensus that business continuity planning and evacuation arrangements were a priority. Mr Lewis sought, and received, confirmation that the focus would be on actual changes to improve risk management as distinct from policy updating to improve the rating. Mr Chillery noted that an ICB check and challenge collaboration meeting has been scheduled for 1 March 2024.

Mrs Lavery summarised the discussion and asked for a report in July, rather than the proposed September.

The board received the EPRR update report and agreed as amended the recommendations contained in the report.

Operational risk report (operational and strategic) as at January 2024 including risk management framework

Reference

Board public 24/01/16.

Mr Gowland presented the operational risk report (operational and strategic) as at January 2024 and highlighted there were no extreme operational risks. The BAF was still in place and included within today’s report, however a refresh was underway.

Mr Gowland presented the revised risk management framework which outlined the process for the management of risk in the organisation. He drew attention to the significant change in approach and commented on the upswing in risk focus visible across the trust.

Mr Vallance referred to the section in the framework around the chief executive’s responsibility for communicating and embedded the necessary values and behaviours to support the appropriate risk culture. Mr Gowland noted the training regime intended from June with key leaders.

Mrs Leese challenged the framework’s lack of clear measures of effectiveness and suggested that the document needed material amendment. Mr Gowland was asked to review the monitoring arrangements and ensure that they were comprehensive and clearly articulated how the trust and its board would be sure that the framework was being followed and was effective.

Mr Lewis queried whether high impact or low likelihood risks were specifically referred to in the framework and it was agreed that this would be checked. He asked that during 24/25 a specific analysis of this framing was brought to the board. Post meeting note, reference to these risks was included as an area to be reviewed by the risk management group.

The board received and noted the operational risk report (operational and strategic).

The board approved the risk management framework subject to receiving and agreeing a revised monitoring section at the March 2024 board.

CQC Preparedness briefing, caring

Reference

Board public 24/01/17

Mrs Lloyd presented the CQC preparedness briefing on caring. She highlighted the trust’s ambition to be “outstanding” on caring. This had been agreed with the board and members recognised the stretch required.

The current informal assessment might suggest that the trust was at “good” based on previous audits, peer reviews, 15-step work, and feedback from CQC and Mental Health Act (MHA) investigators.

The recommendations in the report provided some potential further improvements that could be taken forward. Members held a discussion on how the organisation could demonstrate caring and collective accountability against a background of tired staff, racist incidents and the level of current vacancies. It was recognised that the challenge was to support exceptional behaviours as outstanding caring actions, whilst needing to try to systematise good practice.

Mrs Lavery questioned how the board would know how we were going and wondered whether KPIs might help. A detailed discussion took place, which included considering the current data available highlighted in the report. Mr Lewis disagreed that for this ambition a dataset was the key step, recognising that the interventions were cultural. He agreed to discuss further how the desire for visibility of progress could best be achieved, drawing attention to timeout visit times planned six times a year over the coming months.

The board agreed the recommendations in the CQC preparedness briefing, caring.

Action

KL/TL.

Operating model and new ways of working including board committee terms of reference and standing financial instructions

Reference

Board public 24/01/18.

The chair informed members the report on the operating model and new ways of working would be discussed in the private board session in the interests of time and other agenda items.

Operating performance, governance, and risk management

Integrated Quality Performance Report (IQPR) December 2023 including Finance Report M9

Reference

Board public 24/01/19.

Mr Lewis noted that the current format would continue, recognising that Mr Banks would review the data items included at the start of the coming year. He felt that operationally the use of the IQPR was maturing with informed discussions taking place regularly at the Clinical Leadership Executive (CLE) and the Delivery Reviews.

He introduced Mr Chillery to discuss the key data items. He highlighted progress with the virtual ward; he confirmed the perinatal CYP target achievement was on track and that there was a significant amount of work underway regarding data validation and quality for CMHT.

Mr Lewis requested work to ensure Children and Young People (CYP) and Community Mental Health teams (CMHT) hit their markers as both were time bound (31 March 2024). He stressed the significance of delivery, which Mr Chillery acknowledged.

Mr Currell advised that from May the finance data would be reported to the board via the IQPR only, with a revised and detailed report through FDE. This would bring finance into parity with other data items at the board. This was welcomed by members.

The year end forecast position ranged from a deficit of £4.3m to £3.5m and included a £3.5m system support income reduction from South Yorkshire ICB to help reduce the system planning gap.

All corporate and care groups were forecast to achieve their budgets. This is a transformation from twelve months previously where central “top-ups” had been used to balance local positions.

Mr Currell noted that he had been asked at the prior meeting about liquidity and a review carried out since had confirmed that the reported cash position was accurate. However, it was being compared to a cash plan set regionally which was no longer accurate. He proposed to consider this further within the Finance, Digital and Estates Committee.

The board receive and noted the integrated quality performance report (IQPR) December 2023 including finance report M9.

Action

RC.

Eliminating out of area placements (OAP) target and health based place of safety (section 136 suites) usage review

Reference

Board public 24/01/20.

Mr Chillery presented the related reports on out of area placement and health-based place of safety (section 136). He highlighted reducing numbers of OOAP and the pressure created by section 136 suites which were closed on average 25% of the time.

The issues and reasons for the medium-term increase in the out of area placements were due to two broad reasons. The lack of specialist provision for learning disability and secure rehab within the region; and the spread of flow through community resource to support people in community and manage risk and system anxiety requiring an extension of the community work.

Members discussed the geographical factors impacting service provision and considered other related matters including the potential increase in the use of section 140. Dr Tosh noted that that practice was not uniform across South Yorkshire.

Mrs Lloyd added that clinical pathways would give a solution to achieve a safe and therapeutic bed base however where special beds were not used appropriately this required the provider collaborative to ensure all providers improved their systems to help the overall position. Flow needed to be clinically led with resulting care pathways, gatekeeping and rules of the collaborative looking at engagement of the system. Mr Chillery informed members of initial actions that are to be completed, with ambitions on more complex issues to be brought back to Board in the future.

Mrs Leese welcomed the report, the detail and discussion. She highlighted the refreshing candour of the position. Mr Vallance wondered what specific actions might be taken to improve matters.

Mr Chillery noted the work being done in Rotherham to reduce OOAP. He highlighted discussions with place leaders in North Lincolnshire on section 136 availability. But he drew attention to our reliance on the behaviour of others. Members agreed to the recommended strategic oversight through Mr Lewis as lead chief executive of the collaborative to galvanise the whole system, mindful of promise 19 in which the trust board has committed to eliminating OOAP by the end of 2024.

The board noted the recommendations from the eliminating out of area placements (OAP) target and health based place of safety (section 136 suites) usage review reports.

Break for lunch

Break taken at 1:30pm.

Strategic objective 5

Reference

Board public 24/01/21.

Mrs McDonough introduced a new routine report, this time focusing on the fifth objective. The aim of the paper was to stimulate discussion on the “hardest parts” of the objective. Within this report she noted the wider infrastructure challenges of the green promise on climate adaptation and the challenges posed by anti-racism.

Mrs Gillatt questioned whether action plans for each promise existed and felt that the board should discuss this further. Mr Lewis noted that this work was part of the operating model agreed by the board in September, but highlighted, as an example that approval of the strategy was to his mind agreement that the real living wage would be adopted. Work would take place through 2024 to that end and the paper helpfully set out the dilemmas arising from that.

The board received and noted the report on strategic objective 5.

NHS professionals update and proposal

Reference

Board public 24/01/22

Ms McIntosh presented the proposal to move the trust’s bank to NHS professional (NHSP). She acknowledged that this discussion, whilst it had been ongoing over two years, may require more than one conversation. She highlighted the potential benefits to a mental health and community trust, recognising that NHSP was dominant in the acute sector.

Mrs Lloyd supported the proposal, highlighting the benefits to safe staffing and reduced agency. She felt that the proposal should now move forward.

Mrs Lavery voiced concerns about experiences in other trusts. She enquired what assurance we had about our own and NHSP’s implementation capability. Ms McIntosh reflected on positive reports from peers. Mrs Lavery raised a view that the trust might provide its own, and queried how surpluses from NHSP were spent.

There was an extensive discussion about the merits of the case, the clarity or otherwise of the dissent, and how the Board might move forward. Mr Vallance drew attention to prior assent and suggested that the chief executive should indicate a decision. Mr Lewis noted both his queries and support, but disagreed that this was a management decision, highlighted the significance of TUPE transfer of so many colleagues. Ms McIntosh expressed some frustration about the ask, and the further delay implied. Mr Lewis asked whether the transfer was an exclusive arrangement or whether risk could be reduced if NHSP did not deliver in a given domain. It was agreed to explore this further. Mrs Leese voiced concerns about the risk of implementation, and members agreed that this was a key issue: if the proposal proceeded, we need to have the bandwidth to do it well.

Mrs Lavery summarised the discussion and agreed to a proposal to revisit the item at the next meeting. Ms McIntosh questioned what was needed next time. On invitation, Mr Lewis suggested that the new paper needed to consider:

• a brief appraisal of alternatives to NHSP
• confirmation of support from MHLDA CEO partners
• agreed terms of trade with NHSP, jointly accepted by the CEO and director of finance
• a risk and risk mitigation plan for the first six months of transfer

The board agreed to consider a further proposal subject to the completion of the criteria noted above.

Action

NM/TL/IC.

Supporting papers (previously presented at committees)

Supporting papers

Reference

Board public 24/01/23.

Mrs Lavery informed the board of the following additional reports for information which were presented as supporting papers that had previously been presented at committee level for scrutiny and challenge:

• mortality quarterly report (September and October 2023 data)
• guardian of safe working hours report (June to September 2023 data)

The board received and noted the additional reports for information.

Any other urgent business

Reference

Board public 24/01/24.

There was no further urgent business raised today.

Chair’s summary (actions, decisions, and new risks)

Reference

Board public 24/01/25.

Mrs Lavery gave a brief overview of discussions from the meeting in particular the staff story on the work of integrated neighbourhood teams, gender pay gap, risk reporting, CQC report on caring, and places of safety which linked to the CQC caring item. She noted that the NHSP item and proposed risk management framework would return to the next meeting for further scrutiny.

Public questions

Reference

Board public 24/01/26.

There were no questions raised by members of the public.

Other

Reference

Board public 24/01/27.

The chair resolved “that because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, the public and press would be excluded from the remainder of the meeting, which would conclude in private”.

Next meeting

Thursday 28 March 2024 at 10am at:

CAST Theatre
Civic Quarter
College Rd
Doncaster DN1 3JH

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

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