Board of directors minutes May 2024

Contents

Minutes of the board of directors meeting on Thursday 30 May 2024, 10am at:

Unity Centre
Rotherham
S65 1PD

Present

• Kathryn Lavery, Chair.
• Richard Chillery, Chief Operating Officer.
• Ian Currell, Director of Finance and Estates.
• Steve Forsyth, Chief Nurse.
• Sarah Fulton Tindall, Non-Executive Director.
• Kathy Gillatt, Non-Executive Director.
• Carlene Holden, Director for People and Organisational Development.
• Dawn Leese, Non-Executive Director.
• Toby Lewis, Chief Executive.
• Dr Graeme Tosh, Medical Director.
• Dave Vallance, Non-Executive Director.
• Pauline Vickers, Non-Executive Director (from 10:57am).
• Dr Janusz Jankowski, Non-Executive Director, joined virtually.

In-attendance

• Richard Banks, Director of Health Informatics.
• Dr Richard Falk, Associate Non-Executive Director (from 10:57am).
• Philip Gowland, Director of Corporate Assurance and Board Secretary.
• Jo McDonough, Director of Strategic Development
• Jyoti Mehan, NeXT Director
• Lea Fountain, NeXT Director

3 members of staff, 1 member of the public and 6 governors joined the meeting.

Welcome and apologies

Reference

Bpu 24/05/01 and Bpu 24/05/02

Mrs Lavery welcomed all attendees to the meeting, particularly Steve Forsyth, Carlene Holden and Dr Richard Falk as it was their first Board meeting.

Apologies for absence were noted from Dr Jude Graham, Director of Psychological Professionals and Therapies and Rachael Blake, Non-Executive Director.

Mrs Lavery highlighted that it would be the last board meeting attended by Mr Currell who would be leaving the trust over coming weeks and thanked him for his contribution and hard work as director of finance.

Quoracy

Reference

Bpu 24/05/03

Mrs Lavery declared the meeting was quorate.

Declarations of interest

Reference

Bpu 24/05/04

Mrs Lavery presented the declarations of interest report which outlined the changes to the register since the last meeting relating to Steve Forsyth, Carlene Holden, Rachael Blake and Dr Richard Falk. Entries for Sheila Lloyd, Nicola McIntosh and Justin Shannahan had been removed.

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

Patient story

Reference

Bpu 24/05/05

Mrs Lavery welcomed Sarah to the meeting who was invited to share her daughter’s story and experience with Rotherham Children and Young People Mental Health Service (CAMHS). Sarah is the mother to 3 children with special educational needs (SEN), her daughter was diagnosed with attention deficit hyperactivity disorder (ADHD) through Rotherham CAMHS. Sarah expressed that it had taken 4 years to reach a diagnosis from initial referral, Sarah’s daughter was now in secondary education and it had taken her entire junior school education to reach a diagnosis, following assessments for both ADHD and ASD. Sarah’s daughter also had social and emotional mental health difficulties and Sarah spoke about the challenges this created in school. Sarah’s oldest son had a diagnosis of ADHD and autism spectrum disorder (ASD) and her youngest son had a diagnosis of ASD.

Sarah conveyed her belief that the waiting list for an assessment was too long and questioned if RDaSH was working to improve these timescales. She explained that her daughter would be waiting 9 to 12 months for medication and was waiting to be assigned to the appropriate sensory pathway. In addition, she questioned the mental health support that could be offered for her daughter during this period. Sarah referred to her work in the community with S62 (a collection of peer support groups in the community of Rotherham) and the number of neuro-diverse individuals that were being supported, that had not been supported early enough. She questioned the mental health support offered to children following diagnosis, in order to prevent mental health difficulties later on in life.

Dr Tosh expressed his apologies on behalf of the trust for Sarah and her daughters experience, and he noted the 2024 investment made into ADHD and ASD services for adults and children to improve waiting times. He then mentioned the work undertaken to separate neuro-diverse diagnosis from a mental health diagnosis. Dr Tosh advised that ADHD was a treatable condition and was uncertain why Sarah’s daughter would be waiting for medication following diagnosis, he noted that the trust was ensuring the necessary clinicians were working on the front line to enable treatment to be prescribed immediately after diagnosis. Sarah felt that medication shouldn’t be the only route to treating ADHD, and that other routes of intervention or coping mechanisms should be explored first.

Supporting Mr Vallance’s comment about support arrangements, Ms Fountain asked if there was any guidance or support offered during the period that Sarah’s daughter was waiting for an assessment. Sarah advised that the main source of support was through the voluntary community sector, which didn’t help in dealing with the psychological impact.

Mr Lewis noted that the trust was investing approximately £1.5m to improve the waiting list position. With reference to promise 14, excluding neurodiversity, the aim for no young people to be waiting longer than 4 weeks for meaningful intervention through CAMHS services from July 2024. He noted that good progress was being made with this aim, and there was confidence it would be met during quarter 2.

In terms of next steps, Mr Lewis was interested in the pattern of meaningful support being offered whilst people were on the waiting list, highlighting the use of third sector resource to support this. He expressed disappointment that Sarah’s daughter had been waiting 9 to 12 months for mediation and agreed to follow this up outside of the meeting.

Mr Banks questioned the difference in experiences between face to face and digital assessments. Sarah felt that face to face was the better method as it provided more effective interaction and a better understanding of the patient and their complexities.

Mrs Lavery and the board thanked Sarah for taking the time to speak about her families experience regarding Rotherham CAMHS and noted the intended reflection time later on the agenda.

Action

TL

Standing items

Reference

Bpu 24/05/06

Minutes of the previous board of directors meeting held on 28 March 2024.

The board approved the minutes of the meeting held on 28 March 2024 as an accurate record, subject to a minor wording amendment requested by Ms Fulton Tindall under 24/03/11 (report from the Mental Health Act Committee).

Matters arising and follow up action log

Reference

Bpu 24/05/07

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.

4/03/17, CEO Report (WRES data)

Mr Lewis challenged the closure of the paper on WRES and asked that it remained on the log until the board was satisfied with the meaningful response. This was agreed through the chair.

Report from the Quality Committee

Reference

Bpu 24/05/08

Mrs Leese presented the paper, particularly highlighting the detailed discussion held around safe staffing, and encouraged the board to read the supplementary paper issued by Mr Lewis which focused on the recent safe staffing “stock take”.

She referred to the discussion held at the last board following receipt of the safe staffing declaration and the areas of further work required. She provided an update that positive progress was being made to better understand the aggregate data at ward level and what planned safe staffing levels should look like in both ward and community settings.

There was continued monitoring at the Quality Committee in respect of venous thromboembolism (VTE) assessments, malnutrition universal screening tool (MUST) assessments, out of area placements, resuscitation compliance and the closure of internal audit actions. The patient safety and complaints reports were deferred to July 2024 as there was a need to ensure the data was fully understood and triangulated across the organisation. In response to Mr Lewis, Dr Tosh confirmed that he was confident in the accuracy of the data contained within the learning from deaths annual report.

Ms Gillatt requested to see the key findings and recommendations from the findings of the independent review of Greater Manchester Mental Health NHS Foundation Trust (GMMH). It was agreed that this would be circulated to Board members outside of the meeting. Mr Forsyth provided assurance that contact had been made with the lead investigator from GMMH to ensure the trust gained a full insight into the report.

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

Action

SF

Report from the Commissioning Committee

Reference

Bpu 24/05/09

Mrs Leese presented the paper, which was of the final meeting of the committee. There were ongoing quality and safety issues in respect of the one of the services provided within South Yorkshire and the committee had continued to have robust oversight of the position. There were now a number of extreme risks on the risk register relating to this area of work.

Mrs McDonough provided an updated position, noting that the trust had worked with NHS England as part of the rapid review of quality at Ellern Mede. NHS England had agreed to escalate this to the next level of oversight through a quality improvement process.

The associated governance and monitoring arrangements would continue via the Public Health, Patient Involvement and Partnerships Committee and where necessary in the finance and quality committees.

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

Report from the Public Health, Patient Involvement and Partnerships
Committee

Reference

Bpu 24/05/10

Mr Vallance presented the paper and highlighted that progress was being made in respect of the draft equity and inclusion and research and innovation plans. He reiterated the importance of “data insight” especially in terms of equity and inclusion.

Mr Lewis referred to the work ongoing to finalise the core data sets on routine patient relevant data by protected characteristics – he emphasised the importance of the board’s role in the review of inequalities data as part of routine reporting and the progress required at pace.

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

Action

RB and JM

Report from the People and Organisational Development Committee

Reference

Bpu 24/05/11

Mr Vallance presented the paper and highlighted that the committee had a positive discussion around the transition into the new ways of working and the broader measures in respect of the people and teams plan.

For accuracy, Mr Lewis requested for the sentence regarding Rotherham exceptional reports in relation to section 136 to be removed.

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

Report from the Mental Health Act Committee

Reference

Bpu 24/05/12

Ms Fulton Tindall presented the paper, highlighting the detailed discussion held in respect of the legislation compliance performance report. The presentation of the data going forward would include real numbers as opposed to percentages and it would be disaggregated by protected characteristics.

The committee would become more focused on the trust’s compliance with the legal obligations for each patient in a given period, this shift in emphasis had been welcomed by the board as a whole.

Compliance with section 132 rights was ranging between 80% to 85% and there would be focus at the next meeting around the nature or rationale for non-compliance and the associated documentation.

Ms Fulton Tindall was pleased to note that a new system had been implemented in April 2024 to provide a more efficient way of recording section 17 Leave.

The board received and noted the report from the Mental Health Act Committee.

Report from the Audit Committee

Reference

Bpu 24/05/13

Mrs Gillatt presented the paper highlighting that the preparatory work for the annual report and accounts 2023/2024 was progressing to plan. The key risks for 2023/2024, as per the external auditors, were property valuation, management override of controls and overstatement of trade creditors and accruals. Trust materiality was reported at £4.25m.

The interim head of internal audit opinion had been received with a reduction to limited assurance and conversations were ongoing with 360 Assurance to ensure there was a collective understanding of the assessment methodology and associated conclusions.

Mr Lewis commented on the interim opinion received and that the opinion proceeded from internal audit’s view that the board’s decision around the management of its board assurance framework (BAF) was mistaken. In addition, it proceeded from the belief that medium and high risk internal audit actions were delivered too late, data validation was ongoing in respect of this. The annual governance statement would fairly represent the disagreement between internal audit’s opinion and Mr Lewis’s more positive opinion. It was agreed with internal audit that the final opinion would distinguish and more accurately reflect the period of transition through 2023/2024 to the new operating model.

With reference to the clinical audit plan 2024/2025, work was ongoing to ensure there wasn’t any duplication with the internal audit plan 2024/2025 or more importantly gaps between them.

There was an improvement noted in the response to internal audit recommendations, and this would continue to be a key focus area in terms of management oversight.

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

Report from the Finance, Digital and Estates Committee

Reference

Bpu 24/05/14

Mrs Vickers presented the paper, highlighting the focus on performance against the finance plan at year end.

The trust reported a £3.55m deficit forecast at year end (the original planned deficit was £6.15m). The care groups were on track to underspend on their budgets and the savings plan was on track.

The most significant area of challenge was agency spend, new processes, additional controls and oversight would be implemented as part of the agency reduction plan and this would continue to be a key focus area for the committee.

The draft finance, capital and savings plans for 2024/2025 had been reviewed and scrutinised by the committee and would be discussed later on the board agenda.

Work continued to rebase trust-wide vacancy factors as part of 2024 to 2025 planning to ensure a consistent approach was taken across all areas. Mr Lewis commented that the trust’s vacancy factor historically ranged from 0% to 6% and that 2.5% was the intended vacancy factor over the coming year, in line with organisational workforce plans.

The draft digital plan was reviewed and additional success measures included with a clinical and cyber security focus.

An update was received regarding statutory and mandatory compliance for estates services as part of the estate plan, this was aligned with the draft capital plan in terms of emerging risks. The 2023/2024 procurement improvement plan would be a focus at the August meeting.

The board received and noted the report from the Finance, Digital and Estates Committee.

Chief executive’s report

Reference

Bpu 24/05/15

Mr Lewis drew attention to the key items within his report.

During 2023/2024 the coroner issued a regulation 28 report specifically to RDaSH in respect of mental health disengagement. Whilst no responsibility for the death of the young person was found, a significant piece of work had been undertaken around the trust’s disengagement policy, it is important that the clinical audit programme 2024/2025 comprehensively included engagement and disengagement behaviours. Mr Lewis stressed the importance of this work given the number of individuals that had disengaged from mental health services, and reflected on the likely outcome of the Nottingham enquiry which may become a systemic issue nationally.

The second regulation 28 letter, issued to NHS England, was in relation to eating disorder liaison services and a paper would be issued from the South Yorkshire Mental Health and Autism Collaborative Board on local compliance with the medical emergencies in eating disorders (MEED) guidance. Mr Lewis expressed that it was extremely difficult to assess compliance with the guidance unless as a health system, there were designated beds for people with an eating disorder that were not entirely focused in a physical hospital, this was an apparent gap in South Yorkshire’s provision.

Mrs Leese assured the board that all regulation 28 reports were received at the Quality Committee and confirmed that there would be a review at July’s meeting to consider if the work in response was on track.

With reference to the investment on reducing waits in ADHD, Mr Lewis congratulated Dr Tosh and Sadie Watkinson-North on the agreement of shared care arrangements in Rotherham. This was real progress and offered the prospect of a maximum 1 year wait for adults over coming months. There was less clarity on the children’s waiting time trajectory and this was being discussed further through delivery reviews.

Mr Lewis referred to the trust’s staff networks, particularly the success of the Disability and Wellbeing Network (DAWN) and the significant overspend of the new central ‘reasonable adjustments’ budget. During June, Mr Lewis and Mrs Lavery would be reviewing all of the staff networks and the outcome would be brought back to the board in due course. This work was linked to the creation of the new trust People Council which would bring together key staff and representatives to hear the staff voice at a senior level.

Mr Lewis noted the concerns regarding the use of Oxevision and that whilst there was now a hugely improved position in terms of consenting practice and recording, this needed to be sustained. There would be a similar focus in respect of the resuscitation concerns highlighted at the last meeting. Mr Chillery provided an update in terms of Oxevision compliance, noting that mental health wards in Doncaster and Rotherham were at 100%, and North Lincolnshire were at 81%. Mr Lewis noted that the quality and safety plan would include the key areas of trust wide focus and he reconfirmed that he was very reluctant to turn off Oxevision as it was part of the trust’s wider improvement in terms of consent issues.

Mr Lewis suggested further reflection on the learning from prior attempts that hadn’t succeeded to drive forward the consented use of Oxevision. There was a strong reflection from the care group delivery reviews and crucial role of team leaders and ward managers in driving this forward.

Mrs Lavery expressed congratulations regarding the new trust People Council and staff network arrangements. Ms Fountain shared her congratulations around the overspend on reasonable adjustments and the representation of the trust’s communities and health inequalities.

As Executive Sponsor for the DAWN Network, Mrs McDonough highlighted the previous challenges with accessing the right reasonable adjustments and positive progress made in supporting staff. Some issues remained in terms of delays in access which would be rectified as the work progressed.

Mr Vallance referenced that around 600 people joined the trust on a yearly basis with a potential lack of induction and feeling unsupported, he expressed the importance of ensuring there was a shared culture and ensuring staff were “job ready”. Mr Lewis commented that a range of feedback suggested there was inconsistency in the induction process and noted the further work required to improve the “job ready” position. The trust would move back to a face to face induction in the coming months which would include an induction into the communities.

Mrs Holden noted that the people promise exemplar site had recently commenced which focused on trust staff retention. During 2023/2024, a quarter of staff leaving the trust did so with less than 1 years’ service.

She reiterated that the trust’s induction programme would be upscaled and improved.

Ms Mehan commented that the induction programme was internally focused and encouraged the value of inducting staff into the communities. Mr Lewis agreed. He highlighted the great success in the recruitment of consultant psychiatrists since Christmas and noted Ms Mehan’s point in suggesting that the consultant psychiatrists could work with local general practitioners (GPs) to understand the referral process and ways of working as part of their induction.

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

Action

TL and KL

Change in responsible officer

Reference

Bpu 24/05/16

Dr Tosh presented the paper which included a request for the board’s approval in the transition the role of responsible officer from Dr Graeme Tosh, Executive Medical Director, to Dr Sunil Mehta, Deputy Medical Director, from the 1 July 2024.

The board approved the transition of the responsible officer to Dr Mehta from 1 July 2024.

CQC preparedness, Well Led Domain

Reference

Bpu 24/05/17

Mr Gowland presented the CQC preparedness briefing which focused on the Well Led Domain.

The paper set out the ongoing work which supports the ambition of achieving a good rating for well led. The framework proposed in the paper was welcomed by board members. A further update would be provided to the board in September to outline the complete self-assessment against the CQC framework, including other aspects of work such as the code of governance and next steps in relation to the Good Governance Improvement (GGI) report.

Mr Lewis drew attention to the GGI report, reminding the board that GGI were commissioned to review the new operating model and that they would be returning in December 2024 to provide further feedback on its implementation. The intention of the report was to provide a framework for the re-assessment later in the year although it offered recommendations in the intervening period. The report made seven recommendations, a number of which were linked to the business of the board, such as the refresh of the board assurance framework and the voice of patients, linked to promise 5, the remaining recommendations required further reflection in terms of informing a response. Mr Lewis was particularly interested in the outcome of the re-assessment later in the year, at which point the operating model would be fully embedded. Mrs Lavery agreed with Mr Lewis’ perspective and reflected on the board accepting the collective and individual responsibility and moving forward with the new ways of working.

Mr Vallance felt that the report was vaguer than expected and referred to the areas of work to take forward as a board before the next re-assessment by GGI. Mrs McDonough referred to the follow up report and evaluation, questioning if the leadership within the care groups would be engaged as part of the work. Mr Lewis suggested that it would, at a point in time through a separate process.

Mr Chillery commented on the need to clarify the purpose and the conduct of meetings, and the support required to ensure people are confident in chairing meetings and holding people to account. Mr Lewis agreed with the point raised, recognising the developmental work required to provide the necessary support. He highlighted the intended “shift” from an assurance culture to a delivery culture.

In response to Mr Vallance, Mr Lewis clarified that the evidence in respect of the Well Led framework would be collected, a self-assessment would be undertaken in June with an update to the board in September.

The board received the CQC preparedness briefing, Well Led Domain and agreed the recommendations included in the report.

Action

TL

Constitutional amendment, composition of the membership and council of governors

Reference

Bpu 24/05/18

Mr Gowland presented the paper which included the proposal to amend the composition of the membership of the council of governors (CoG) within the constitution.

Through a series of discussions with the CoG and reviews of the constitution, there are a number of items identified as impacting on governor recruitment. The primary objectives was to ensure the composition of the CoG was achievable and workable in terms of recruitment and flexibility, and representative of the communities the trust served.

Lead Governor Jo Cox thanked the governors involved in the discussions, with particular thanks to Susan Black, Corporate Assurance Officer for her continued support to the governors. The discussion and consideration around the composition of governors arose from the 2023/2024 election process, where the current constitution meant that there more candidates than vacancies in some areas, with no candidates for particular areas. Jo then summarised the proposed amendments that were fully supported by the CoG and included in the paper. The board was invited to discuss any amendments to that work.

From a practical perspective, Mr Gowland suggested that having a staff governor for each care group, and one for corporate or backbone services was preferable to that CoG suggestion of “clinical” and “non-clinical” staff.

This was actively agreed after discussion, recognising that we needed our arrangements to now reflect our structure.

Mr Lewis questioned if there was a limit of 9 partner governors and if there wasn’t then he suggested the current seat for the voluntary, community and social enterprise (VCSE) representation should be maintained. Following discussion, it was agreed that VCSE would retain the partner seat. Mr Lewis was keen to ensure there was sufficient representation to achieve geographical parity where appropriate and asked for this to be considered as part of partner governor recruitment.

Mr Chillery and Ms Fountain acknowledged the introduction of youth representation and considered the environment and support required to ensure they could effectively fulfil the role and have a voice. Jo Cox expressed that the governors felt strongly around the introduction of youth representation and felt this was currently a gap, and two youth positions were proposed to enable peer support. Mr Gowland clarified that a suggestion was made from the children’s care group that their youth “patient voice body” could be the source of those seats.

The board agreed the amendments to the composition of the membership or council of governors within the constitution, including the supplementary proposals made regarding the alignment of staff governors to the organisational structure and VCSE.

Leadership development

Reference

Bpu 24/05/19

Mrs Holden drew attention to the key points, recognising the importance of the trust’s new leadership development offer (LDO). She highlighted the number of individuals across the trust that came forward to help in shaping the offer, a commercial tender process commenced in February which initially attracted 5 suppliers. A robust presentation day and a competitive dialog process has been undertaken to determine the chosen supplier and this process would be concluded and final supplier(s) chosen in the coming weeks.

It was anticipated that the LDO would be launched at the Leaders’ Conference in September. Approximately 150 senior leaders would commence the 3 year programme during 2024/2025, with a further roll out over the next two financial years. Mrs Holden highlighted the need to ensure there was a consistent approach and application across the trust footprint, recognising the organisational strategy and promises. Supplementary to the core programme, a number of additional elements would be considered separately, including Restorative, Just and Learning Culture, team effectiveness and development tool (TED) and a focus on protected characteristics or inclusion of the communities to enable shared learning.

Ms Fulton Tindall asked how staff would receive and be engaged with the offer and Mrs Holden advised that a number of working groups had taken place with a range of professions where some colleagues were favourable of leadership development and others not so. Discussions had also taken place via the education and learning CLE group and delivery reviews.

Mr Vallance emphasised that the success of executive leaders would make the biggest difference through active participation by setting clear expectations, including coaching and mentoring. He encouraged the introduction of quarterly reviews by the executive leaders to ensure active management.

Mr Banks referred the wider leadership skills required, and questioned how this would be linked to trust wide recruitment in terms of expected skill sets for new members of staff. Recognising that the trust was lacking in terms of line managers induction, Mrs Holden advised that new staff with line management responsibilities would go through a comprehensive programme, and noted the use of job descriptions, portability of MAST training and succession planning.

Recognising the significant leadership changes as part of the new operating model, Mr Chillery considered the development of modern matrons and service managers and the need to ensure there was a consistent offer across the organisation in terms of the wider leadership support aside from the programme: although both of the named roles are part of the Top Leaders’ Cadre.

Mr Lewis noted the importance of viewing the programme as skills development and agreed with Mr Vallance around the trust’s active role in progressing this work forward. He clarified that there would be one leadership development offer for the trust.

Discussion ensued regarding the baseline measures in respect of practical skills and the subsequent transparency around this.

Mrs Gillatt recognised the significant investment in people for the 18 month programme and queried the plans in the event of staff dropping out or leavers. Mrs Holden noted that this would be considered and there would be a level of flexibility dependent on individual circumstances. Mr Lewis stated that 40% of leaders worked in corporate services and the work required to ensure staff were prepared for the programme.

Mr Vallance offered his support on behalf of non-executive directors to accelerate or amplify the programme and noted he would be joining the programme board. The board recognised the need to review the wider leadership support to line managers within this financial year, and agreed to revisit the effectiveness of what is being done during Q4 2024/2025.

The board supported proceeding with the leadership development offer in 2024/2025 as outlined, subject to receipt of a satisfactory and affordable bid.

Action

CH

Clinical and Operational Strategy, strategic objective two

Reference

Bpu 24/05/20

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

Mrs McDonough presented the update, noting that the paper set out the complexities and difficulties associated with the implementation of strategic objective two and its key promises, and the shift required in order to address health inequalities.

She highlighted the significant challenge of being able to maintain consistency around clinical standards across the organisation, at the same time as delivering care to meet the needs of local communities, with an impact on health inequalities and narrowing the gap. She then considered the board’s role in driving this ambition forward.

In terms of improving community engagement, Mrs Lavery questioned how this would work in terms of digital exclusion. Mrs McDonough noted that work was required to identify ways of engaging with all communities, regardless of digital access.

Mrs Leese suggested there was a theme emerging throughout the meeting in respect of patient experience and the difference between the trust’s view and people’s journey and experience of the care delivered. She referenced the capacity and capability required to understand and gain insight on whole patient journey, such as poverty proofing, digital access and wait times.

Mr Forsyth referred back to the patient story and the need to consider the family or social aspect, as opposed to providing care in isolation.

Following on from Dr Falk’s comment around engagement with primary care, Mr Lewis referenced promises 7 and 8 and the challenges they posed in terms of the trust’s relationship with local GPs which required a further learning discussion.

Mr Lewis then noted the challenges in respect of recognising and responding to specific needs of rural communities (promise 12) and the focus required as a board to learn and determine the way forward to address this.

Mrs McDonough summarised the intention to work with communities to minimise the impact on inequality and the collective focus required from a trust wide perspective. The equity and inclusion plan would be presented to the board in due course, where decisions would be made in terms of commitment to resource the plan.

The board received and noted the report on clinical and operational strategy focused on strategic objective two.

Action

JMc

Finance plan

Reference

Bpu 24/05/21

Mr Currell presented the paper and drew attention to the key points.

The paper provided an update on the revised financial plan 2024/2025 that was submitted to NHSE at the beginning of May, with an intended deficit of £3.8m. General growth funding of £0.7m had been included in the trust’s South Yorkshire (SY) ICB contract allocation and £0.7m of funding had been allocated to cover additional depreciation charges in line with the national funding model. The trust so far had not received any service development funding (SDF).

Mr Currell referred to the areas of material risk, noting the achievability of the CIP target (£6.7m), the trust was currently £1.4m short against identified schemes, and the assumed slippage on in year costs of £2.4m.

The other key risk was in relation to Adult Eating Disorder Provider Collaborative (AED PC). The trust’s 2024/2025 plan assumed a balanced position on the AED activities, with discussion ongoing between the trust and NHSE on additional funding in 2024/2025. This risk has been included in the trust’s plan submission to the ICB and NHSE.

Mr Currell referenced the cost pressure reserve (appendix 3) of £3.4m, highlighting the positive plans in place to make a difference to improve patient care, and the funding received for ADHD waiting lists.

In response to Ms Gillatt, Mr Currell advised that whilst the trust had a deficit plan, there were cash reserves in place.

Mr Lewis referred to the five areas of material risk and the dependence on the closure of beds which was embedded in the plan. This remained subject to discussions and by the end of July, the trust would need to conclude which option was to be progressed from October 2024.

He then referred to the agency reduction plan, which assumed a £1m benefit from this workstream. He noted the introduction of revised approval mechanisms agreed through the clinical leadership executive. Routinely agency would require agreement from the care group director, relevant clinical executive, and for the next two quarters at least from himself. He acknowledged that it was foreseeable that on occasion clinical advice may be perceived to be being overruled but highlighted his confidence that the “three ticks” system would bring greater rigour to approvals and to the pace of exiting agency commitments. The expectation is was that quarter 3 agency will be materially lower than quarter 1.

Mrs Leese sought further clarity around the potential to overrule clinical advice on decisions regarding agency use. Mr Lewis noted that agency would not be utilised without all three “ticks” being satisfied that every alternative had been exhausted. This was expected initially to be difficult to achieve as existing analysis suggested historic practices had not been as purposive as they now would be. There would however be an assessment and record of the impact of every decision made. Mrs Leese emphasised the importance of ensuring that quality and safety would be fully considered. Mr Lewis drew attention to the mechanisms to do that, and highlighted the harms arising from agency use.

Mr Vallance noted the absence of waiting list data at board level and, referring to the funding received to reduce the ADHD waiting list, sought clarification on the plans in place to address other service waits. Mr Lewis referred to the robust bid process that had taken place, with scrutiny received at the clinical leadership executive (CLE). A number of the bids approved were related to waiting times, however several were not supported due to the absence of numeric and quantified data. Mr Chillery was leading on the process regarding waiting lists. The comparative data on ADHD waiting times would be brought to the board in quarter 2.

In response to Mrs Vickers and the oversight of the vacancy factor, Mr Lewis noted that the 2.5% vacancy factor applied to directorate level, and the rosters would run in line with the budgeted WTE. This was perhaps the first time that vacancy factors had been coherently used as a tool within the trust, and we would to evaluate their impact.

In response to Mrs Lavery around the national requirement to lower staffing numbers, Mr Lewis referenced the perception that since 2019, the NHS had employed a large number of staff and had not seen the productivity gains. This was not the case for the SY ICB and with the significant reduction in agency use, the trust would be operating within the spirit of the intention, with the trust seeking to become fully staffed against its establishment. Mr Lewis wasn’t aware of any instruction to the trust to enforce a “vacancy freeze” and he advised the board that such blunt instruments were highly questionable, preferring instead the scrutiny model applied now by care groups and executive directors.

The board reconfirmed its support for the 2024/2025 financial plan noting that the deficit would be exceeded if the AED contract with NHSE was not “back to back” with the ICB submitted plan.

Action

RC

Capital plan 2024/2025

Reference

Bpu 24/05/22

Mr Currell presented the paper which set out the proposed revisions to the phase 1 capital plan agreed at board on the 28 March 2024 and the proposed phase 2 capital plan. The two phases reflected concern to ensure clinical risk was widely considered before making relative choices.

The proposed plan for phase 2 totalled £5.6m, and therefore the total capital plan was £6.7m against an allocation of £6.6m. Mr Currell advised that the level of over commitment was manageable in year either through in year bids for additional funding or through the management of slippage and phasing of schemes.

The paper also set out the schemes that were not supported at this point in time, drawing attention to the likelihood some will not proceed at all.

Mr Currell highlighted the significant schemes as Great Oaks refurbishment (phases 3 and 4) and the mental health inpatient doors, and the requested that the board delegated approval of the two related business cases to the finance, digital and estates (FDE) meeting in June.

The paper set out the detail of the review of ligature risk and door safety, being undertaken by the chief nurse across all inpatient areas. The full cost of this programme could range from £0.5m up to a potential £3.3m. The budget was currently set at £1.9m. The paper outlined a “door panel” to oversee this work, chaired by the chief executive. This would hold and manage the risks being debated and report back to the board in due course.

Mr Forsyth summarised the concerns in relation to the current inpatient doors, noting that the trust was awaiting a response from the current provider in terms of the identified queries.

Mrs Leese was pleased to see a well thought out capital plan and valued Mr Forsyth’s expertise and input into the ligature review work. She referenced the ongoing action on the QC action log around the completion and assurance in respect of ligature risk assessment. She then referred to the areas that were not currently prioritised as part of the plan, such as Hazel and Hawthorn wards.

Mr Lewis noted that the section of the plan referred to was about not prioritised in 2023/2024 but agreed for 2024/2025. Mr Lewis confirmed that there would be a full review of ligature risk by ward, by quarter 4. Interim assurance would be provided through the QC.

The board:

• approved the revisions to the phase 1 capital plan set out in appendix 1
• approved the phase 2 capital plan set out in appendix 2
• approved the prioritised schemes which would be progressed when funding becomes available set out in appendix 3
• approved delegation of approval of the Great Oaks Phase 3 and 4 business case to Finance, Digital and Estates Committee
• approved the recommendations set out in appendix 5 paragraph 17 regarding the ligature risk and door safety review

Action

SF

Our 28 promises, success?

Reference

Bpu 24/05/23

Mr Lewis presented the paper which provided a summary of the work undertaken over the last six months to create a working “finish line” measure for the promises and noted the split over four categories of progress.

Mrs Lavery welcomed the paper and noted that 10 promises are now in delivery, which is welcome and perhaps not widely understood.

Ms Gillatt questioned if there would be a phase focused on the embeddedness of the promises. Mr Lewis noted the development of the quantifiable success measures that would offer this, alongside an evaluation of how it feels following delivery.

Mr Chillery suggested allocating time for the board to further discuss the promises in depth, it was agreed that this would be allocated to a future board timeout. He was especially concerned to explore the “handover” from design to delivery.

Mr Vallance queried if the paper was measuring the completion of the task or the intent. Mr Chillery commented that the focus was not solely on the outcome measures, but also how they fit with the other promises. Mr Lewis welcomed the depth of discussion, which he hoped would be ongoing.

The board received and noted the 28 promises update.

Productivity

Reference

Bpu 24/05/24

Mr Lewis presented the paper in respect of productivity, recognising the strong support from the South Yorkshire ICB for the trust to lead work in this area. The paper focused on best use of time in all disciplines and professions. Izaaz Mohammed (incoming director of finance) would be leading this work from October. Mr Lewis suggested that the board returned to this topic within the August timeout.

Ms Fulton Tindall commented that the paper was innovative and it provided a positive stance in terms of being efficient and effective.

Mr Vallance sought further understanding on the nature of the challenges being faced across the communities and the associated data. Mr Lewis noted that the ICB had agreed to fund some of the work in this space and emphasised his particular focus on the interface with general practice. There was ample space for the trust to help release time for others as well as focusing on its own agenda.

The board received and noted the paper on productivity and agreed to discuss further at the August board timeout (DN it has subsequently been proposed to use the October timeout for this work).

Board assurance framework

Reference

Bpu 24/05/25

Mr Gowland presented the paper which brought together in one place all of the relevant information on the risks to the achievement of the board’s strategic objectives.

Following previous discussions in March, the board spent time in its April timeout to consider the risks further and this paper set out the key strategic deliver risks that would be the board’s focus during 2024/2025, each risk had an assigned risk lead and board assurance Committee in terms of monitoring, oversight and reporting. The paper included the first draft of key controls and the sources from which the board would seek assurance on the effectiveness of those controls in mitigating the risk.

Mr Gowland referenced the key topics discussed throughout the meeting that featured within the strategic delivery risks, such as challenges in working with diverse populations, addressing health inequalities, primary care and productivity.

Mrs McDonough referred to the risk relating to primary care and commented on the trust’s role in working to build an effective relationship with local GPs. Mr Lewis confirmed that this was covered within the risk and requested for the word “sides” to be amended to “parties” within the risk description.

Mr Vallance referred to the risk assigned to SO4 and questioned the focused view being the NHS Terms and Conditions as the blocker, rather than the trust’s own ability to lead change. Mr Chillery referred to the strong cultural normality around 5-day working and how this would need to be addressed.

Ms Gillatt asked if financial stability and culture had been considered as potential risks. Mr Gowland noted the change focus of the strategy and that whilst referred to in the paper, the board, in its timeout, had agreed that financial stability would not impede on the ability to deliver the strategy. In response to Mrs Vickers, it was greed to circulate the risks that were not included in the final set of strategic risks, with an explanation to where else they are being taken forward.

From an operational risk perspective, Mr Gowland clarified that the boards focus would be on the extreme risks only. In terms of strategic risk, the board would be sighted on the keys as part of its work plan, and Mr Gowland with the Audit Committee chair would meet with the strategic risk leads 3 times a year to review progress on the actions to mitigate the risks.

The board received the strategic delivery risks (board assurance framework) Update and supported the proposed risks and their identified lead executive and board committee.

Action

PG

Integrated Quality Performance Report (IQPR) including Finance Report M12

Reference

Bpu 24/05/26

Mr Chillery introduced the Integrated Quality Performance Report (IQPR) for April 2024, including the finance report for month 12.

The “Big Six” Long term plan targets had been agreed for 2024/2025. The IQPR contained the fields previously seen by the board, except some data currently held nationally in the Mental Health Services Data Set (MHSDS) report (this would return to “normal” in mid-June). Talking Therapies remained below the volume target of 1,915 with actual performance of 1,359, this was a key focus at the recent delivery reviews.

There was a sustained improvement in a number of key quality metrics, with a slight downward trajectory in respect of VTE and MUST. This continued to be a key focus at the Quality Committee.

There was a positive improvement around personal development reviews (PDRs), the 90% standard had been met (at 91.09%), and a small drop in sickness absence rates from 4.91% to 4.53%.

The IQPR was currently under review in order to strengthen it further, and associated feedback was awaited from the care groups.

M12 finance report

Mr Lewis commented on the Better Payment Practice Code, 85.9% of invoices had been paid within the timescale against a target of 95% at the end of March, he requested future reporting separately identified recent month not cumulative performance.

The board received and noted the Integrated Quality Performance Report (IQPR) April 2024 and the M12 Finance Report.

Action

IC

Operational Risk Report, extreme risks

Reference

Bpu 24/05/27

Mr Gowland presented the paper and noted the increase in the number of extreme risks.

There were currently 5 extreme risks which were all subject to regular review by the respective risk owner and to monthly scrutiny via the risk management group.

Mr Lewis requested for future iterations to include the risk target mitigation date and key planned actions.

The board received and noted the operational risk report, extreme risks update.

Action

PG

Board Annual Work plan 2024/2025

Reference

Bpu 24/05/28

Mr Gowland presented the proposed board annual work plan for 2024/2025.

The work plan would, when and where necessary, be added to as matters emerge or escalate during the year that require the board’s attention or decision. In addition, there was an intent to also consider a thematic focus for future board’s meetings, starting in July with an “education” focus. Over the coming weeks, proposed topics would be identified.

Mr Banks suggested an additional item to be added on an annual basis around cyber security in line with the FDE Committee terms of reference and work plan. Mr Lewis confirmed that the enabling plans would be included in the final iteration of the work plan.

The board agreed the Work plan for 2024/2025.

Supporting papers

Reference

Bpu 24/05/29

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:

• Learning from Deaths Annual Report 2023/2024
• Guardian of Safe Working Hours (to 31 March 2024)
• Freedom to Speak Up, quarter 4 (to 31 March 2024)

The board received and noted the additional reports for information.

Any other urgent business

Reference

Bpu 24/05/30

There was no further business raised.

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

Reference

Bpu 24/05/31

Mrs Lavery gave a brief overview of discussions from the meeting in particular the CQC preparedness, Well Led update, leadership development, constitution amendment, the focus on strategic objective two and the new strategic delivery risks.

Questions

Reference

Bpu
24/05/32

There were no questions raised by members of the public.

Final note

Reference

Bpu 24/05/33

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: August 27, 2024
Next review due: August 27, 2025

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