Contents
- Introduction
- Patient story
- Standing items
- Board assurance committees
- Operating performance, governance and risk management
- Supporting papers (previously presented at committees)
Minutes of the board of directors meeting on Thursday 30 January 2025, 10am at:
Water’s edge
Barton
North Lincolnshire
Present
- Kathryn Lavery, Chair.
- Rachael Blake, Non-Executive Director
- Richard Chillery, Chief Operating Officer.
- Dr Richard Falk, Non-Executive Director.
- Sarah Fulton-Tindall, Non-Executive Director.
- Steve Forsyth, Chief Nurse.
- Kathryn Gillatt, Non-Executive Director.
- Carlene Holden, Director of People and Organisational Development.
- Toby Lewis, Chief Executive.
- Izaaz Mohammed, Director of Finance and Estates.
- Dr Diarmid Sinclair, Chief Medical Officer.
- Pauline Vickers, Non-Executive Director.
- Dr Janusz Jankowski (virtually attended), Non-Executive Director.
In-attendance
- Richard Banks, Director of Health Informatics.
- Jane Charlesworth, Head of Corporate Assurance.
- Lea Fountain, NeXT Director.
- Philip Gowland, Director of Corporate Assurance and Board Secretary.
- Dr Jude Graham, Director for Psychological Professions and Therapies.
- Jo McDonough, Director of Strategic Development.
- Ann Llewellyn (virtually attended), Governor.
- Chris Pope, Governor.
- Ian Spowart (virtually attended), Governor.
- Vicky Sinclair, Patient Story.
- Mr and Mrs Greenhalgh, Patient Story.
- 1 member of staff.
Introduction
Welcome and apologies
Reference
Board public 25/01/01
Mrs Lavery welcomed all attendees to the meeting. Apologies for absence were noted from Dave Vallance, Non-Executive Director and Jyoti Mehan, NeXT Director.
Quoracy
Reference
Board public 25/01/02
Mrs Lavery declared the meeting was quorate.
Declarations of interest
Reference
Board public 25/01/03
Mrs Lavery presented the declarations of interest report which outlined that there were no changes to the register since the last meeting.
It was noted that Dr Falk no longer provided medical consultancy advice to H I Weldricks Pharmacies and Rachael Blake was no longer a Trustee for South Yorkshire Community Foundation. Appropriate amendments would be made to the register.
The board received and noted the changes to the declarations of interest report.
Patient story
Learning disabilities
Reference
Board public 25/01/04
Mrs Lavery welcomed Vicky Sinclair (Primary Care Liaison Nurse) and Mr and Mrs Greenhalgh to the meeting to share their daughter’s story and experience of the care received.
Mrs Greenhalgh described her daughter and shared with the board the journey that she had supported her daughter through, including many challenges and involvement with multiple agencies.
She shared the more recent events that led to the greater involvement of and support from the Community Learning Disability team and other professionals.
The Community Learning Disability team, along with occupational therapists, physiotherapists, and social workers, provided extensive supported Amy and her family, helping them navigate her medical challenges and improve her quality of life. Amy’s family expressed gratitude for the coordinated care and support they received, particularly from Vicky, highlighting the importance of teamwork and communication among various professionals involved in Amy’s care. Amy went into respite at a care home in December 2023 and a decision was then made for her to live there permanently.
Mr Lewis thanked Mr and Mrs Greenhalgh for sharing their story and asked what worked so well in terms of the support provided by the teams. Mr Greenhalgh noted that the teams were consistently responsive and helpful, and highlighted the significant support received from Vicky and her coordination of Amy’s care.
Dr Graham questioned the support provided to Mr and Mrs Greenhalgh as carers, Mrs Greenhalgh referred to Vicky’s role in supporting the coordination of care and going above and beyond for Amy’s family, as well as the support provided from social services.
Mrs McDonough asked if Vicky was still involved in Amy’s care at the care home, Vicky advised that she visited Amy when visiting other patients. Since Amy’s diagnosis, work was ongoing in North Lincolnshire to develop a dementia pathway for patients with a learning disability with proactive monitoring and a post-diagnostic clinic. This was currently being piloted in North Lincolnshire Adult Mental Health and Talking Therapies Care Group.
Vicky advised that learning disability and best interest awareness workshops had been delivered to the Ambulance Service, Mr Lewis noted the work required to ensure this was also delivered to the Fire and Rescue Service.
Mrs Lavery and the Board thanked Mr and Mrs Greenhalgh and Vicky for taking the time to speak about their experiences and noted the intended reflection time later on the agenda.
Standing items
Reference
Board public 25/01/05
Minutes of the previous board of directors meeting held on the 28 November 2024.
The board approved the minutes of the meeting held on the 28 November 2024 as an accurate record, subject to a minor wording amendment requested by Dr Falk under board public 24/11/08.
Matters arising and follow-up action log
Reference
Board public 25/01/06
There were no matters arising from the minutes.
The board received the action log and noted the progress updates. All actions noted as “propose to close” were agreed.
Mr Lewis queried when the board would receive the outcome of the second good governance improvement (GGI) review. Mr Gowland advised that the GGI review and observation opportunities had commenced, the final report would be received during early March 2025.
The board supported Mr Lewis’ request to change the due date of the open action regarding Ligature Risk (board public 24/11/16), to March 2025.
Board Assurance Committee reports to the board of directors
Report from the Quality Committee (QC)
Reference
Board public 25/01/07
Dr Falk presented the paper and referred to the matter of concern regarding level 2 and 3 resuscitation training compliance remaining below target, this was a recurrent theme over a number of meetings.
The committee had discussed the need to understand the patterns of non-attendance and withdrawal from training. Dr Falk recognised the significant improvements made in terms of the other elements of resuscitation practice since the last report. The committee had received the RDaSH response to the Greater Manchester Mental Health NHS Foundation Trust Independent review, a further assessment would be undertaken during quarter 4.
The integrated quality performance report (IQPR) was discussed and there was reflection on the reporting arrangements and focus on the quality and safety quadrant as opposed to the overall IQPR, the committee felt that further guidance was required by the Board to agree the lens at respective committee’s. Mr Lewis clarified that the committee should be focusing on the quality and safety and performance quadrants of the IQPR.
In terms of mortality reporting, there would be a further update at the next meeting on the trajectory to address the backlog of structured judgement reviews.
Mr Lewis referred to the concerns around resuscitation training compliance and advised that this would be taken forward by the People and Organisational Development Committee as it was fundamentally based on the trust’s training arrangements.
Mr Lewis wished to discuss the CQC registration report and its stated assurance outside the meeting.
The board received and noted the report from the Quality Committee.
Report from the Audit Committee
Reference
Board public 25/01/08
Ms Gillatt presented the paper and noted the follow-up to internal audit actions was in a good position with 87% of the high and medium risks being closed on time and 91% of all risks being closed on time.
The committee received its first report on education governance and would further understand the different components and sources of assurance when it discussed the matter further in April’s meeting.
Ms Gillatt noted the proactive work ongoing to complete the year-end assessment against the counter fraud functional standard.
The board received and noted the report from the Audit Committee.
Report from the Mental Health Act (MHA) Committee
Reference
Board public 25/01/09
Ms Fulton-Tindall presented the paper and noted that there were 308 detentions during September and October 2024, all of which were lawful. The committee was pleased to receive the annual Mental Health Act (MHA) equalities report and it had been agreed to look again at the presentation of the data in order to better understand the main findings and align these with the key focus areas of the trust.
Mental Health Act level 3 training was a continued challenge in some areas of the trust, a further update would be received at the next meeting regarding the plans in place to address this.
There was fluctuation in compliance for section 132 rights, further work was required to ensure this was consistent across the trust.
There was a focus on ensuring the consultant review had been completed within 5 hours of a seclusion episode, this hadn’t happened in a number of cases. The committee was supportive of the approach to work with consultants and junior doctors to address process and communication issues that have been identified. Dr Sinclair advised that he had written to junior doctors to outline the expectations.
The board received and noted the report from the Mental Health Act Committee.
Report from the People and Organisational Development (POD) Committee
Reference
Board public 25/01/10
Ms Blake presented the paper and noted the positive discussion regarding the NHS Professionals implementation and the areas of good practice and wider learning. The gender pay gap had reduced to 4.45 which was a positive comparable from the 7.5 previously reported.
In terms of the guardian of safe working hours report, the committee was pleased to note that the rota design in Doncaster would be changed to a similar pattern used on Rotherham and North Lincolnshire starting from February 2025.
The staff incidents, violence and reporting of injuries, diseases and dangerous occurrences regulations report (RIDDOR) report was received and there was a particular focus on the sexual and racist incidents, the ways by which this would be addressed would be discussed in more detail at future meetings.
The board received and noted the report from the People and Organisational Development Committee.
Report from the Public Health, Patient Involvement and Partnerships (PHPIP) Committee
Reference
Board public 25/01/11
Dr Falk presented the paper and highlighted the emerging partnership with a clinical research organisation (CRO) and the positive discussion around poverty proofing and enthusiasm for the process. The draft community involvement framework was approved for further development.
Mr Lewis noted that the committee agreed on behalf of the board, the progression of the terms of the partnership with the CRO who specialised in psychedelic research.
The board received and noted the report from the Public Health, Patient Involvement and Partnerships Committee.
Report from the Finance, Digital and Estates (FDE) Committee
Reference
Board public 25/01/12
Mrs Vickers presented the paper, noting that the trust was a positive outlier in terms of agency expenditure across the South Yorkshire region, and the integrated care board (ICB) were looking how other trusts could apply a similar approach.
The committee continued to monitor the progress being made in respect of fire safety compliance and the plans to maintain resilience, reduce backlog assessments and address any high-risk areas. The South Yorkshire Fire Service will undertake informal advisory visits to the trust and they would be completing an audit on the trust’s fire safety compliance in 2025.
In response to Mr Lewis, Mr Mohammed clarified that the fire safety assessments would be completed by March 2025 and would be included in the health and safety report due to be received by the board.
The board received and noted the report from the Finance, Digital and Estates Committee.
Report from the Trust People Council (TPC)
Reference
Board public 25/01/13
Mrs Lavery presented the paper and highlighted the discussions about remote working and the real living wage.
The Trust People Council was pleased to see the new staff governors in attendance at the meeting.
The board received and noted the report from the Trust People Council.
Chief executive’s report
Reference
Board public 25/01/14
Mr Lewis drew attention to the key items within his report.
The board was asked to consider and agree the terms of reference for the All Age Eating Disorders Joint Committee, Mr Lewis outlined the intention being (subject to the approval by all four trusts and the integrated care board (ICB)) that all parties involved, would oversee investment and disinvestment decisions, ensuring a targeted and equitable approach to service provision across the region. The expectation was that the Joint Committee, over the next year, would focus on creating an upstream offer for families and individuals with eating disorders and reshaping the specialist supply model to target unmet needs, better manage deterioration and reduce reliance on private sector beds.
Dr Falk was fully supportive of the collaboration, and queried the risks associated should one of the partners withdraw, Mr Lewis advised that there was no financial risk, however there was some reputational risk. The Joint Committee could carry on if one of the partners withdrew, however wouldn’t be able to continue if the ICB withdrew.
Ms Blake was pleased to see the meaningful engagement with people with an eating disorder and sought clarity around non-executive involvement. Mr Lewis stated that the only board and non-executive involvement would be via the report to the board. He noted it would have been preferable for the paper to more clearly state that on a day-to-day basis the joint committee would lead on mental health EDA collaborative board as chairs and chief executives. He confirmed that public patients and carers were involved in the individual services and their involvement in the community of practice had been reasonably extensive.
Ms Blake then referred to the huge demand on eating disorders and questioned if the new model provided an opportunity for early intervention of support and advice. Mr Lewis advised that this was explicitly the intention of the proposition and by disinvesting in complex care, funds could be released for this purpose, there were two associated risks regarding the allocated pots of money and all members of the Joint Committee would need to be viewed as an accountable body for eating disorders, rather than an institution that provided the service.
Mrs Vickers sought clarity around the trust’s visibility around the financial position, Mr Lewis clarified that the trust would remain fully sighted on this.
Ms Gillatt praised Mr Lewis for his hard work in progressing this work.
Mr Lewis expressed gratitude to Dr Jankowski for his consistent support in this work and drawing attention to the organisations outside of South Yorkshire who could make a positive contribution.
The board approved the delegation of the children’s and adult eating disorder funding and material decision-making to the new Joint Committee, recognising the importance of a collaborative approach to enhance service delivery and outcomes for individuals with eating disorders.
Mr Lewis drew attention to the role of the mayoral combined authorities, and noted its likely greater importance and influence in the future. A positive discussion was held with mental health trust chief executives’ and the combined authority, particularly around pathways to employment. The South Yorkshire Mayoral Combined Authority had acknowledged a lack of support for neurodivergent younger adults as a significant barrier to employment, this was a significant area of progression.
Continued progress was being made in child and adolescent mental health services (CAMHS) and they were close to achieving the four-week waiting time target. Mr Lewis emphasised the importance of this achievement for children, families, and teachers.
Mr Lewis discussed the implementation of SPA time for medical staff, acknowledging the challenges and the need for trust and support in the process.
Mr Lewis noted the positive progress with the Elizabeth Quarter development, with the expectation of space available for use by summer. He expressed gratitude to Mr Mohammed, the teams involved and the North Lincolnshire Council for their support.
Ms Holden highlighted the reduction in vacancy levels, noting that the organisation has revised its vacancy factor to 3.3%, down from an excess of 8%. This improvement was attributed to better managerial capacity and understanding of vacancy levels.
Ms Fountain drew attention to the openness and transparency of complex issues within the report, the attitude taken and desire for inclusivity to the public we serve.
The board received and noted the chief executive’s report and the forward actions it contained.
Promise 14 including waiting lists
Reference
Board public 25/01/15
Mr Chillery presented the paper which provided an update on Promise 14 highlighting the significant improvement in waiting list validation since the last report in November 2023 and expressed his thanks to health informatics, performance and the care groups for ensuring all waits were now visible with live data available on a daily basis.
A number of services had achieved the four-week waiting time target, which demonstrated hard work undertaken and the effectiveness of the improvements made in service delivery, child and adolescent mental health services (CAMHS) are the forerunner for this work. Further work was required to ensure all services were achieving a maximum 4-week waiting time from April 2026, this included the completion of demand and capacity analysis to identify services where demand currently exceeds supply and to link investment plans accordingly. An internal audit on waiting list governance within the care groups was currently ongoing.
Mr Chillery also discussed the ongoing work to address urgent referrals within 48 hours, including establishing a baseline and exploring options to improve response times.
Ms Fulton Tindall commented on the significant improvement in the quality and understanding of data.
Dr Falk referred to adult autism assessment services currently having waits more than 24 months and 1,779 patients on the waiting list, Mr Chillery noted that neurodiversity services were the most challenging area in terms of achieving the 4-week wait, adult attention deficit hyperactivity disorder (ADHD) had been prioritised as there was an intervention. Further work was required to consider the required investment into autism assessment services. Dr Graham confirmed that support and information was provided to those waiting.
Dr Sinclair confirmed to Dr Falk that within the memory service, that patients had often received their scan prior to being seen in the service, hence there was no “second” period of waiting.
Mr Banks reflected on the opportunities available for digital solutions to further assist with the work implementing promise 14.
Mr Lewis reflected on the success gained from a small cohort of people stressing the need to get more people involved to ensure that a whole Trust approach was in place. He noted the challenge of sustaining the delivery of the target once it was achieved.
Mr Chillery further reflected on the anticipated increase on demand within some services, for example wheelchair services and also reflected on the recently reported waiting times for services such as ADHD and autism in neighbouring trusts in the ICB patch.
The board received and noted the promise 14, including waiting lists update.
2025 to 2026 capital plan and indicative revenue plan
Reference
Board public 25/01/16
Mr Mohammed referred to the capital plan within the paper highlighting that core to the £5m plan was the phase 3 and 4 work at Great Oaks in North Lincolnshire, enabling work associated with Hazel and Hawthorne wards on the Tickhill Road site in Doncaster and the development of a HDU. No additional capital funding was anticipated from the system.
He reminded the board that funds associated with information technology (IT) schemes had been brought forward into the current 2024 to 2025 capital plan, in response to the delays on other planned work.
Work on sustainability, and reducing emissions, would be part of relevant schemes and there may be opportunities to source funds in support of this type of work.
Mr Mohammed noted the additional flexibility afforded through the updated IFRS16 requirements.
Mr Lewis confirmed the involvement of Executive colleagues and CLE members in the development of the capital plan.
The board approved the 2025 to 2026 Capital Plan; and noted the new clinically informed minor works process to be launched from February.
Mr Mohammed referred to the indicative revenue plan and highlighted the key assumption was £6m savings programme target and a £3m cost pressure reserve; there was an assumption of zero growth from commissioners.
Mr Mohammed mentioned that ADHD funding was included in the draft plan contained in the paper, however this was subject to confirmation from the ICB along with confirmation of the amount of deficit support funding. Allocations were expected in February and the plan presented at the March meeting would include the updated figures.
As part of the efforts to achieve the £6m target, Mr Lewis detailed the budget cuts, including a 0.5% baseline cut to all of the 23 directorates and the removal of £500k from corporate functions. There was a need to find £1.5m from bed closures from within older people’s services. The net position after investment in community-based services was expected to be £1.5 million. An additional £2.5m needed to be found from out-of-area placement budgets, this was part of the effort to balance the budget sustainably while meeting necessary obligations. A further paper would be developed to outline the plan with the assumptions set out in the paper.
The board noted the movement in the forecast underlying deficit position from £6.2m to £8.4m and the indicative revenue planned deficit of £3.5m for 2025 to 2026 and the assumptions included in arriving at this figure.
Workforce staffing overview (including December 2024 versus 2024 to 2025 plan and versus December 2023)
Reference
Board public 25/01/17
Ms Holden presented the paper and provided an update on workforce and vacancy management and associated workstreams to achieve the aim of being fully staffed by March 2025.
Reference was made to the transfer of bank colleagues to NHS Professionals (NHSP). The trust had been able to secure staff to fill many vacancies through this route. The transfer was part of the effort to reduce agency usage and improve workforce stability.
The current position was 190.70 WTE vacancies, Ms Holden discussed the employment journey, including the process of posting vacancies, reviewing applications, and conducting pre-employment checks. It was noted that 53 candidates had start dates agreed, and 85 candidates were undergoing pre-employment checks.
A 3.3% vacancy factor was projected by the end of the financial year, considering the current recruitment efforts and expected leavers. The importance of continuous recruitment initiatives and the role of managers in the process was noted.
Ms Blake recognised the position in terms of offering alternative employment for people and considered how the trust could further support with community recruitment.
In response to Ms Gillatt regarding “time to hire”, Ms Holden advised that the trust was competitive in comparison to other organisations and noted the positives of having a centralised recruitment team.
Mrs Vickers noted the importance of tracking the impact of implementing the real living wage.
Mr Banks referred to the budgeted vs actuals data and queried if there could be a forecast of actual numbers to the end of 2025. Ms Holden advised that this would be undertaken as part of the workforce return the trust was required to submit annually.
Mr Lewis requested further understanding of the 973 posts, being the difference in number to those in 2018 to 2019, to understand if they were new posts or posts that remained vacant.
Ms Holden confirmed that a new national workforce system was being procured and would be implemented during 2027 to 2030.
The board recognised the progress made and note the current vacancy position, the predicted March 2025 outturn position and the potential future national changes linked to administrative and clerical colleagues.
Promise 3 and 4
Reference
Board public 25/01/18
Mr Forsyth presented the paper and highlighted the successful launch and implementation of Care Opinion across the organisation (promise 4) which was a direct placement of Your Opinion Counts (YOC). Approximately 400 stories had been received through Care Opinion to date which had enabled real time feedback and improved contact with patients and carers, as well as key feedback in terms of service improvement and change.
Mr Forsyth reported on the progress of volunteer recruitment (promise 3), noting the target of 250 volunteers by the end of the quarter 4 2024 to 2025 and the current number of 251 validated volunteers. He emphasised the importance of diversity and the positive impact of volunteers on the organisation.
Mr Forsyth was sorry to announce the passing of Mike Valentine, Mike was a retired pharmacist and had volunteered for the chaplaincy department for over 20 years.
Mr Lewis drew attention to the 240 people from a global majority that had applied to be a volunteer since the summer, comparably 40 people considering themselves as white British had applied. He noted the importance of reaching the target of 350 volunteers with diversity, and ensuring each clinical service and geography had an equal share of volunteers in 2025 to 2026.
The board received the report and noted the assessment of work undertaken to date, including the learning and actions.
The board agreed acceleration possibilities to get to 350 volunteers and making feedback translate into meaningful felt change.
High quality therapeutic care taskforce (HQTC) further discussion
Reference
Board public 25/01/18
Mr Lewis presented the paper and drew attention to the key items.
He discussed the adoption of the culture of care standards and emphasised the importance of a shared understanding of the problems and the challenges of implementing the new standards within inpatient areas. The high-quality therapeutic care task force would support the mobilisation plan for implementing the standards. The plan would focus on integrating quality and safety, patient flow, and staff experience initiatives, whilst ensuring there was a collective understanding of the various problems.
Mr Lewis highlighted the challenges of implementing new standards in inpatient areas, including the need to address variations in practice and ensure consistency across ward areas. He referred to the importance of creating a multi-professional leadership team with representatives from nursing, medical, and allied health professions, this approach aimed to improve collaboration and patient outcomes.
Dr Graham recognised the pace of change across the organisation, and highlighted the variation in practice across staffing structures, partnership organisations and resourcing. Various discussions had been held with NHS England around the Culture of Care programme. The benefits this provided for mobilisation, such as integration with patient safety incident response framework (PSIRF) and patient and carer race equality framework (PCREF) were noted.
In response to Ms Fulton-Tindall, Mr Lewis noted that the culture of care baseline assessment would be undertaken by April 2025 which would demonstrate the position in terms of multi-professional working. The intention was to ensure each ward area had multi-professional ward leadership teams.
The board noted the commencement of the work from February 2025, considered any specific opportunities or risks associated with the work of the taskforce and recognised the internal and external concerns that this work is likely to give rise to.
Our 8 plans
Reference
Board public 25/01/20
Mr Lewis presented the paper and acknowledged the delay in their circulation, the paper included four of the eight plans for discussion. The remaining four plans were not ready for approval and would be presented to the board in March 2025. It was recognised that the committees of the board would focus overwhelmingly on the delivery of the plans following final approval, and the respective work plans would need to reset accordingly.
Quality and safety plan
Mr Lewis emphasised the distinction between safety and quality, the safety focus would be on always standards, Care Quality Commission (CQC) domains and understanding, investigating, involving and improving care when things go wrong, linked to the PSIRF model. In regard to quality, the focus would be on promise 16 and promise 4 as highlighted in the paper. This approach would reduce the number of assurance reports received against various standards and instead focus on the quality and safety plan metrics.
Mr Lewis then discussed how the plan would work operationally, stating that the “always measures” and safety metrics would be the primary focus for safety. The board would aim to have more synthesis of its quality and safety position and would take a consistent approach to evaluating safety and quality issues and a more consistent mindset amongst professionals over time.
Dr Graham noted the opportunity to reshape the committee agendas and work plans, and highlighted the interdependencies between plans.
Mr Lewis referred to the nursing and facilities restructure and the opportunity this provided.
Research and innovation plan
There was a need to further develop the research and innovation plan, with a goal to have a conversation about innovation at the leaders’ conference in September 2025. The 6 research priorities were outlined in the paper, Mr Lewis recognised the need to bridge the gap between grounded research priorities and trust priorities.
Dr Graham noted the other component of grounded research being the psychological observatory and the integration of this within the trust’s research team.
Learning and education plan
Mr Lewis reminded the board of the agreement of the plan in July 2024, and highlighted the commitment to grow the training budget.
He then highlighted the need to focus on organisational learning and the great work and implementation undertaken amongst teams, things that focused on individual and team learning. Regarding organisational learning, there was a question whether it was simply the aggregate of individual and team learning or if it was different, a further conversation would need to take place over the next four to six months to agree this.
Equity and inclusion plan
Mr Lewis highlighted the important focus required on the success measures and the associated data sets for delivering the plan, the continued lack of data sets or their incompleteness would hinder the plan’s success. There were investment propositions around business intelligence and data analytics to address this issue.
Mrs McDonough reiterated that 14 of the 20 promises sat within the equity and inclusion plan and noted the time taken to define what was meant by the success measures.
Ms Blake referred to the challenges with ensuring staff had a full understanding of the plan and associated success measures.
Discussion ensued around the importance of visualising how the plans or promises fit together, and that it was essential to help people understand the connections between different plans and identify any gaps or inconsistencies. Ms Gillatt suggested working on a visual representation to show how the plans fit together.
The board discussed the challenges with implementing the plans, including the need for a clear narrative, particularly for quality and safety, to guide the organisation and address concerns from staff and regulators.
The board noted the material presented, the final version of the plans would be presented in March 2025 for approval.
Operating performance, governance and risk management
Operating risk report (extreme risks)
Reference
Board public 25/01/21
Mr Gowland presented the paper which highlighted the current position in relation to the extreme risks. Six extreme risks were included, four of which were previously reported and two were new.
In terms of out of area placements (O 10/19), this risk remained extreme and was part of a significant work programme taking place over the next year.
One of the new extreme risks related to the failure to address the Crisis team improvement plan in North Lincolnshire, this would be discussed at the next risk management group with a view to potentially reduce the likelihood score. The second new extreme risk related to SMI register duplication, work was ongoing to cleanse the multiple registers and consolidate them into a single, accurate position.
Mr Lewis sought further understanding on the scale of difference between the trust’s SMI register vs wider registers.
Mr Lewis noted the importance of establishing a process to review and identify emerging risks, such as the response to regulation 28 notices. He asked if there was a risk regarding mental health disengagement on the risk register, Mr Gowland agreed to clarify.
The board received and noted the Operational Risk Report update.
Action
PG
Strategy delivery risks 2024 to 2025
Reference
Board public 25/01/22
Mr Gowland presented the report which focused on strategy delivery risks 1, 3 and 4, all of which were subject to review at the respective Committee’s in January 2025.
The internal audit review of the trust’s strategic risk management process had been finalised, with a positive conclusion of significant assurance, and an acknowledgement of the strengthened arrangements in the year including the routine and robust scrutiny at the board and committees.
Mr Gowland mentioned the audit recommendations and the need to ensure that controls in place were directly linked to assurance measures, and the need for clearer target risk scores.
Mr Chillery noted some of the challenges with plotting actions at this current time, and referred to the introduction of the high-quality therapeutic care taskforce and the associated programme of work that would be impactful but was yet to be agreed. Mr Lewis emphasised the importance of identifying an end point risk score.
The board received and noted the Strategy Delivery Risks 2024 to 2025 report, noting the planned next steps to enhance reporting.
Promises and priorities scorecard
Reference
Board public 25/01/23
Mr Lewis presented the paper which highlighted the progress made on the specific promises and the need to focus on delivery in the coming year.
He highlighted the progress on promise 6 (poverty proofing) since the last update. There was an agreed schedule for poverty proofing across the organisation and discussions had commenced around embedding welfare rights, benefits advice and debt support into clinical pathways and to potentially include this as part of DIALOG+. For promise 7, annual health checks continued to be a challenging area, and there was a need to address the SMI register issue.
Mr Lewis noted the work ongoing around promise 27 (net zero target), a series of propositions were being developed for the investment needed nationally to allow us to change the heat sourcing of the main building sites. The trust would be hosting a Climate Adaptation “day” on the 12 February 2025.
For promise 23 (Invest in residential care projects and programmes that support long-term care outside our wards), one live proposal had been developed which would be considered next week regarding Rotherham. Work was ongoing to develop a Doncaster and North Lincolnshire proposal.
In response to Ms Gillatt regarding confidence in delivery, Mr Lewis asked the board to assume all promises would be delivered by 2028, except promise 27, that may need additional external support. He emphasised that the organisation needed to move into a delivery-based approach for 2025 to 2026. The board would need to reengage with the promises in January 2026 to assess progress and make necessary adjustments.
Ms Blake referred to a number of promises and the associated work, she drew particular attention to promise 1 (employment of peer support workers) and queried if the approach was right. Mr Lewis noted the number of bids received for peer support workers and the need to assess this further in terms of the journey to delivery, in March 2025.
The board received and noted the promises or priorities scorecard update on the work to date and expectations in 2025 to 2026.
Integrated quality performance report (IQPR)
Reference
Board public 25/01/24
Mr Chillery introduced the Integrated Quality Performance Report (IQPR) for December 2024.
He referred to the reporting arrangements for the IQPR and the need to focus on each quadrant at the respective committees.
With reference to the top 10 areas of delivery, there was a natural variation in recovery rates and work was ongoing to improve the position. A strong position was reported for the children’s access target and there were challenges in the perinatal service due to staff absence, however the trust wide target would likely be achieved.
The number of section 136 breaches had improved following the introduction of the 24-hour metric, discussions were required in terms of estates intervention to improve this further.
Mr Mohammed provided an update on the financial performance at month 9, the position at the end of December is a surplus of £430k, £572k better than the revised plan.
Mr Forsyth clarified that the safe staffing data continued to be reported as per the NHS England and board requirements.
The board received and noted the integrated quality performance report.
Supporting papers (previously presented at committees)
Supporting papers
Reference
Board public 25/01/25
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 report
- guardian of safe working hours
The board received and noted the additional reports for information.
Any other urgent business
Reference
Board public 25/01/26
There was no further business raised.
Any risks that the board wishes the risk management group to consider
Reference
Board public 25/01/27
Mr Lewis referred to the discussion under board public 25/01/21 (operational risk report) and his request to clarify if there was a risk relating to mental health disengagement on the risk register.
Public questions
Reference
Board public 25/01/28
There were no questions raised by members of the public.
Closing statement
Reference
Board public 25/01/29
The chair resolved “that because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, the public and press would be excluded from the remainder of the meeting, which would conclude in private.”
Page last reviewed: April 08, 2025
Next review due: April 08, 2026
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