Contents
- Introduction
- Patient story
- Standing items
- Board assurance committees
- Key matters for decision or assurance
- Routine reports
- Supporting papers (previously presented at committees)
Minutes of the board of directors meeting on Thursday 26 September 2024, 10am at:
The Pavilion
Askern Road
Bentley
Doncaster
DN5 0HU
Present
- Dave Vallence, Non-Executive Director and Chair.
- Rachael Blake, Non-Executive Director.
- Richard Chillery, Chief Operating Officer.
- Sarah Fulton-Tindall, Non-Executive Director.
- Steve Forsyth, Chief Nurse.
- Kathryn Gillatt, Non-Executive Director
- Carlene Holden, Director of People and Organisational Development.
- Dr Janusz Jankowski (virtually attended), Non-Executive Director.
- Kathryn Lavery (virtually attended), Chair
- Dawn Leese, Non-Executive Director.
- Toby Lewis, Chief Executive.
- Izaaz Mohammed, Director of Finance and Estates.
- Dr Diarmid Sinclair, Interim Medical Director.
- Pauline Vickers (virtually attended), Non-Executive Director.
In-attendance
- Joy Bullivant (virtually attended), Governor.
- Glyn Butcher, People Focussed Group.
- Sarah Dean, Corporate Assurance Officer (minutes).
- Lea Fountain, NeXT Director.
- Philip Gowland, Director of Corporate Assurance and Board Secretary.
- Dr Jude Graham, Director for Psychological Professions and Therapies.
- Ann Llewellyn, Governor.
- Kate McCandlish, Deputy Director of Nursing.
- Jyoti Mehan, NeXT Director.
- Jo McDonough, Director of Strategic Development.
- Paula Rylatt, Deputy Patient Experience and Involvement Director.
- Ian Spowart (virtually attended), Governor.
- Cora Turner (virtually attended), Care Group Director, Physical Health and Neurodiversity.
- David Vickers (virtually attended), Governor.
- Kate, Patient Story
- Wayne, Patient Story
Introduction
Welcome and apologies
Reference
Mr Vallance welcomed all attendees to the meeting and advised he would be chairing today’s meeting on behalf of Mrs Lavery, who was absent unwell.
A warm welcome was given to Dr Sinclair in his role as interim medical director. Apologies for absence were noted from Richard Banks, Director of Health Informatics and Dr Richard Falk, Associate Non-Executive Director.
Quoracy
Reference
Mr Vallance declared the meeting was quorate.
Declarations of interest
Reference
Mr Vallance presented the declarations of interest report which outlined the changes to the register since the last meeting which relates to the removal of Dr Graeme Tosh and the inclusion of Dr Diarmid Sinclair as the interim medical director.
Mr Lewis declared a related interest, given his forthcoming involvement relating to disciplinary staff cases of racism, with respect to the anti-racism paper later on the agenda. Mr Gowland, on behalf of Mrs Vickers, declared her new interest, director of Marsh and Vickers Coaching Limited.
The board received and noted the changes to the Declarations of Interest report.
Patient story
Reference
Experiences of care within a ward
Mr Vallance welcomed Kate and Wayne to the meeting who were invited to share their stories and experiences of care within a ward. Thanks were also given to Mr Butcher for providing peer support today for Kate and Wayne alongside Mrs Rylatt.
Wayne and Kate both offered detailed reflections on their admissions and care. They highlighted both positive kindness and difficulties with their care. Wayne explained the impact that detention had on him and highlighted how ward areas changed in his view over weekends and evenings. Wayne suggested introducing quiet times on an evening, reducing lighting and turn off bedroom lighting, update notice boards with information for patients, and to have more staff generally on weekend and bank holidays.
Kate highlighted that communication and environmental factors were part of the negative experiences of care on the ward such as being stripped of her mobile phone, laces and cords. Kate did not believe anyone observed her on her first day of admission whilst she suffered hallucinations, and felt she would have felt safer by someone staying with her. Overall Kate believed RDaSH had saved her life and there were lots of positive experiences, however communication and environmental factors could be improved.
Board members reflected that the environmental factor of lighting in patients’ bedrooms related to the use of Oxevision, and acknowledged the ethical issues this presented in relation to sleep deprivation.
Mr Lewis referred to the development of the workforce and the role of peer support workers which was underway. Each clinical service would have a peer support worker aligned to it and working with patients in their care. Kate and Wayne agreed this was positive to hear and it would have been helpful for them to have someone on the ward with lived experience.
Ms Fountain noted Kate did not feel able to come forward for help when her mental health deteriorated and questioned whether there was anything different which could have been done to have made her feel safer. Kate stated it was mostly down to the stigma that surrounded mental health at that time, and mental health awareness was more prominent and available.
In response to Mr Chillery, Wayne suggested communication within the ward environment could be improved with up-to-date patient notice boards including the activities planned for the week ahead. The board noted work would be incorporated within the patient communication workstream, a part of the wider inpatient improvement work to be discussed later on the agenda.
Mr Vallance and the board thanked Kate and Wayne for taking the time to speak about their experiences and noted the intended reflection time later on the agenda.
Standing items
Minutes of the previous board of directors meeting held on 25 July 2024
Reference
The board approved the minutes of the meeting held on 25 July 2024 as an accurate record.
Matters arising and follow-up action log
Reference
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.
The board supported Mr Lewis’ request to change ownership of the open action regarding Response to Regulation 28’s (open action board public 24/05/15a), to himself.
Board assurance committee report to the board of directors
Report from the Trust People Council
Reference
Mr Vallance presented the report of the inaugural Trust People Council (TPC) meeting held on 24 July 2024. The TPC explored promise 26 and the working approach to anti-racism, and he noted the paper on the topic later on today’s agenda. The TPC understood it had been established to provide direct advice and that advice would be considered in public, alongside the People and Organisational Development Committee. The TPC Terms of Reference would be drafted and will be considered at its next meeting before being presented for approval to the board of directors in November.
The board received and noted the report from the Trust People Council.
Action
Report from the Quality Committee (QC)
Reference
Mrs Leese presented the paper and highlighted significant progress had been made in relation to safe staffing. A comprehensive 6-month assessment of the ward-based nurse staffing programme showed arrangements were robust and compliant with required standards. Evidence was provided of the operational management of day to day safe staffing and forward look to effectively manage nurse staffing resources. There were no immediate risks identified, and further work was ongoing to continue progressing the 6 monthly workforce assessment (annual due March 2025).
Compliance with resuscitation equipment checks remained a key area of focus, and with a significant improvement made recently, the topic would revert to routine reporting (next to QC in January 2025). Significant progress had also been made with respect to medical devices compliance and staff competency.
Work continues to address the outstanding actions in relation to the implementation of the Patient Safety Incident Response Framework (PSIRF) and Complaints Management process. The final report is expected at QC in November 2024.
Work was underway in relation to quality safety impact assessment (QSIA) to assess and provide assurance of the cumulative impact and any mitigating risks as a result of service change.
Mr Lewis noted the report stated there were 3 overdue internal audit actions relating to complaints and safe staffing, and would need to understand any residual 2023 to 2024 audit recommendations and actions as he believed they were 100%.
Mr Vallance gave thanks to Mrs Leese for her work and contributions as Chair of QC, noting this was her final QC report to the board of directors prior to her departure.
The board received and noted the report from the Quality Committee.
Report from the Audit Committee
Reference
Mrs Gillatt presented the paper which confirmed the conclusion of the 2023 to 2024 external and internal audit work and the start of the 2024 to 2025 internal audit plan.
The change in internal audit’s approach for 2024 to 2025 was acknowledged with the intention to support improvement and to enable additional insight into the elements of the head of internal audit opinion throughout the year.
Improvements had been made in relation to the risk management framework. The revised oversight arrangements were in place in regard to the strategic delivery risks.
The board received and noted the report from the Audit Committee.
Report from the Mental Health Act (MHA) Committee
Reference
Ms Fulton Tindall presented the paper, highlighting there were 439 detentions in quarter 1 under the Mental Health Act. The committee continued to identify issues with incorrect receipt, scrutiny and recording, an issue the board was already sighted on, as well as appropriate induction and preparedness of temporary medical staff.
In response to this, a new weekly urgent metrics review report had been introduced at ward level (senior level) for continued oversight and almost real time checks. This should start to show improvements within key areas of Mental Health Act compliance.
In response to Mrs Leese, Dr Graham advised a pilot questionnaire had been developed and trialled to understand and learn from peoples experience of care who had been detained under the MHA.
The board received and noted the report from the Mental Health Act Committee.
Report from the People and Organisational Development (POD) Committee
Reference
Ms Blake presented the paper and highlighted sickness absence rates had increased slightly due to short term sickness absence (seasonal variation). Flu vaccination roll out had commenced with increased ambition from last year’s programme.
The vacancy rate had reduced with the delivery of the target to be ‘97.5% staffed’ by January 2025 being on track, with recruitment campaigns underway across directorates.
In regard to guardian of safe working hours, a monitoring exercise review had led to a change in shift patterns. There was further work underway within Doncaster on exception reporting and breaches.
Reporting of Injuries, Diseases, and Dangerous Occurrence Regulations (RIDDOR) showed an increase in incidents. The People and Organisational Development (POD) Committee discussed support for staff and the approach taken to deal with such incidents, including the acceptable behaviour policy and anti-racism work.
Mr Lewis and Dr Sinclair referred to medical revalidation and the medical appraisal policy ratification, noting the need to ensure there was no confusion between the trust’s proposed new approach and that required of medical staff to maintain registration.
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
Mr Vallance presented the paper, highlighting the progress made against the promises under the PHPIP remit.
The board’s community involvement framework was in development (promise 5), recognising there may be challenge with shifting mindsets from attendance at NHS and other meetings to community engagement. The trust’s approach to community power would need to be considered further to understand how changes would be made. Mrs McDonough explained community power and engagement was explored with partners and peers at the Leaders’ Conference held 27 September 2024.
Health inequalities data remained in development, and he noted this was part of the strategic objective 2. Although some baseline data was available, there remained gaps in generating data and (or) evidence to support interventions that address health inequalities. Mrs McDonough advised health inequalities data was already being reflected within care group delivery reviews to help better understand and help improve service delivery rather than monitor and target data.
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
On behalf of Mrs Vickers, Ms Fulton-Tindall presented the paper highlighting the work to rebase trustwide vacancy factors as part of 2024 to 2025 planning was complete. Monthly monitoring continued to ensure a consistent approach was taken across all areas.
The NHSE Investigation and Intervention Report found the trust had strong controls with respect to agency spend. The trust was working across South Yorkshire providers to share best practice and review rostering controls.
Mr Lewis clarified that the delivery of the Cost Improvement Programmes (CIPs) was on track. Mr Mohammed noted he was confident schemes had now been identified to deliver the Savings Plan in full.
The board received and noted the report from the Finance, Digital and Estates Committee.
Chief Executive’s report
Reference
Mr Lewis drew attention to the key items within his report.
The trust had previously been involved with two Regulation 28 letters, of which the board had previously been sighted on, with a further letter recently issued in relation to the death through suicide of a patient in Rotherham older peoples services. Mr Lewis and Dr Sinclair would be responding to the Coroner’s Regulation 28 letter by 30 October.
A specific review of ward bedroom doors, bathroom doors and ongoing ligature risk concluded that previously identified risks could be mitigated or tolerated, and that the trust would therefore continue to use the existing bedroom door supplier. Work was progressing to complete the replacement programme as part of the previously approved capital programme 2024 to 2025, with the exception of section 136 doors and other environments were to be considered alongside wider anti-ligature work.
There had been continued progress made in relation to basic inpatient ward practice. In particular Grab Bag audits, recording of MHA Section 132 rights and Oxevision consent, with oversight at the delivery reviews.
A number of questions were raised and explored, and in response to Mr Vallance, Mr Lewis confirmed the board would be able considering all plans associated with the strategy in the October timeout, deferred from the cancellation of the August session owing to leave.
The board received and noted the chief executive’s report and the forward actions it contained.
Mr Lewis then noted the two annexes to his report considered under succeeding items.
Action
Independent investigation of the NHS in England by Lord Darzi
Reference
Mrs McDonough presented the paper which outlined the key issues faced by patients, carers and communities, and by public sector staff, through the present circumstances of NHS delivery. The report recognised the root causes of those key issues faced, such as funding models and NHS reorganisation.
The findings recognised health inequalities across the nation; increasing long term conditions and worsening mental health, and the damaging impact these have. The recommendations require consideration and shift in how wider social systems would be supported to be able to address this over the next 10 years.
The board recognised the optimistic opportunities made within Lord Darzi’s recommendations alongside the NHS 10-year plan, and the alignment with the trust’s clinical and organisational strategy and promises including addressing health inequalities, social care, expanding homecare and virtual ward, unlock community power, and delivery of shorter waiting times.
Mrs McDonough acknowledged the risk of “novelty” and explained that place and system “groups” were already mushrooming with this in mind. The executive was carefully considering how best to contribute to that work, with a particular emphasis on ensuring patient voice.
The board received and noted the Independent investigation of the NHS in England by Lord Darzi.
Emergency preparedness resilience and response (EPRR) provisional standards submission
Reference
Mr Chillery noted the latest report before the board, prior to submission regionally. The report provided the projected EPRR Core Standards statement for 2024 to 2025. Currently there was a strong indication this would be 60.35% compliance by November 2024.
In support of this estimated compliance and to meet the national minimum standards for EPRR, Mr Chillery suggested the EPRR standards compliance report should be presented to the board twice yearly (November and July) as a minimum.
He also noted that a new business continuity management policy was included within the papers today and that it required approval by the board. There were no concerns of suggested amendments and the board of directors approved the business continuity management policy.
Mr Vallance queried standard 5 “governance” and how the board would be satisfied there was sufficient EPRR resource. Mr Chillery explained the investments made including additional resource within the EPRR portfolio, as well as each Care Group have a senior identified EPRR lead. Overall the organisation benchmarked well compared to other trusts in terms of resource.
Mr Lewis noted the EPRR compliance trajectory and that by July 2025 the planned evacuation tests should have taken place. Further participative exercises would be planned.
The board received and noted the EPRR provisional standards submission.
Key matters for decision or assurance
Anti-racism (including reference to WRES)
Reference
Ms Holden presented the report and explained the paper built on the 2023 Staff Survey results, the discussions held at TSC and POD Committee, and recent experiences of colleagues as a result of the riots and supportive interventions that were implemented.
The report outlined the clear message on values and that racist behaviour would not be accepted or tolerated. To support this, the acceptable behaviour policy had been developed and would be implemented from 1 October 2024.
Reflecting on the 2023 staff survey results and following the recent riots, it highlighted that not all incidents were being reported or escalated, and this area would require further exploration. New phraseology would be implemented for all colleagues ‘if you walk by it, you stand by it’ to call out unacceptable behaviour.
Supportive interventions in place for colleagues include training models, the half learning days, the new 5-day induction programme and active bystander training that forms part of the leadership development offer.
Other areas of related focus were the organisation wide appraisal approach, which is to be reframed; a review of recruitment processes; and talent management. Ms Holden advised accreditation was being explored as a result of the work with the REACH network.
The workforce, race, equality standard (WRES) data submission focussed on 9 areas and reflected the outcomes of the 2023 staff survey. Ms Holden proposed that information was reviewed via the people and teams group, and POD Committee during October, prior to publication before 31 October 2024.
Dr Graham reflected the importance of the work underway in support of promise 26 and the many strands that seek to address unacceptable behaviour, including discrimination and anti-racism, to support colleagues and people in care.
Mr Mohammed reflected on the half learning days, top leader and senior leadership offers, and emphasised the importance of embedding supportive training and awareness on anti-racism for colleagues within the organisation and being able to explore what that means within teams.
Mrs McDonough recognised the support provided by the REACH network in response to the riots and contribution to the anti-racism conversations within teams and supportive interventions put in place.
In response to Ms Fountain, Ms Holden confirmed the actions identified within the report had been co-produced with the REACH network and the Anti-Racist Alliance.
Ms Blake stated it was good to see the co-production with the REACH network and drive to take forward those conversations and actions identified. Ms Blake recognised the need for continued support for all staff and to understand why some racist incidents were not reported, noting reverse mentor programmes and other programmes would be part of the approach (associated with promise 26).
Mrs Gillatt provided positive feedback from a recent peer review and was pleased with the positive reinforcement and supporting interventions in response to the riots.
Mr Lewis highlighted the importance of changing HR practices, and welcomed the review of the recruitment processes and external investigators to support any investigations relating to racism.
Ms Holden agreed to provide a progress report against promise 26, including all forms of discrimination, and the trust’s commitment to address and fight such, to the board in March 2025.
The board received and noted the progress with the development of promise 26, to become an anti-racist organisation by 2025, and that a progress report against the actions underway would be presented to the board in March 2025.
The board delegated power to Ms Holden on behalf of the board to review the WRES data via the people and teams sub-group of CLE and POD Committee during October, prior to publication before 31 October 2024.
Action
Clinical and operational strategy: Strategic objective 4
Reference
Mr Lewis presented the report and highlighted the paper was the fifth and last paper presented to the board providing context to each strategic objective and the challenges in their delivery. He felt the series had been helpful to the work of the board, and other colleagues supported that advice.
Mr Lewis highlighted the current staffing and service provision were antithetical to a notion of 7 day working model of care. An example of where this doesn’t current occur is the lack of patient discharge over weekends. The change required (to address this) may be countercultural for some colleagues, but he also recognised that safety and resource availability would also be key challenges.
Mr Lewis emphasised labels like ‘high quality therapeutic care’ mean very different things to different people. An important element was to support ward environments, acknowledging the human environments and challenges to achieve interdisciplinary and multi professional (MDT) ways of working (promise 18). Mr Lewis summarised success to this would not be quick and would require organisational development work such as peer support and lived experience to work with clinical professionals and teams, and expert providers such as Virginia Mason Institute.
Dr Graham suggested those changes would need to be clinically led and considerations would include therapeutic issues and interventions such as medication, talking treatments and environments (for example light and sound sensitivity).
Mrs Leese stated that she found the paper useful to understand the complex work ahead and the path to deliver the promises within strategic objective 4, as well as the link to enabling plans to support this.
Mr Lewis acknowledged there had been significant change across the organisation over the last 18 months with more change ahead. It was important the board recognised the challenges ahead in delivering the strategic objectives as previously presented, and the board would continue to revisit the strategic objectives regularly.
The board received and noted the Clinical and Operational Strategy focused on strategic objective 4.
Trust bed base including closure of Emerald
Reference
Mr Chillery presented the paper and highlighted the current, and historic, use of adult and older adult bed based environments resources and arrangements. The work in progress does not currently consider physical health or frailty bed bases.
The work and emerging clinical model had been clinically led by the CLE and considered where the bed base sits within an enhanced therapeutic offer in the community. The future workforce model was in development and would consider multi-disciplinary teams. Further, safe admission and discharge processes were under review including complex discharge and packages of care. Mr Chillery had established a Complex Panel with each of the 3 local authorities.
In 2023, the Goldcrest ward in Rotherham closed with a corresponding reinvestment and enhancement to the Assertive Outreach team. This had been evaluated successfully, with improved outcomes for patients who had been seen and no reports of serious incidents. This would now be repeated in Doncaster, and in October 2024, Emerald Rehab unit would close with again an increased investment in assertive outreach care.
Mr Chillery drew attention to 3 scenarios of bed models detailed within the report which highlighted the length of stays and improvement work identified. During quarter 3, wider engagement would take place over the principles of changes with relevant stakeholders, partners and people with lived experience. The future medium-term bed base arrangements would be formalised and presented to the board in March 2025.
Mrs Leese stated the report provided transparency around benefits realisation and clear ambition, noting this would require support and contribution with partners and across the systems. Mr Lewis confirmed there had been initial conversations within ICB about the implications of this programme of work and were at a point where it would be positively received. In addition, local authorities would help shape the complex care programme of work.
Dr Graham emphasised any bed base changes and implementation would require co-production from people with lived experiences, and there would be instances where an inpatient may not be able to be discharged safely within the community due to severity of illness.
The board received and noted the trust bed base report, and work was being done on developing the future bed-based care arrangements and closure of the Emerald Rehab unit in Doncaster in October 2024. The future medium-term bed base arrangements would be formalised during 2024 to 2025 (Q4) and presented to the board in March 2025.
Action
Biannual report of the board’s security champion
Reference
Mr Vallance expressed his concerns regarding the paper and introduced Steve Forsyth to introduce it. It concerned the scope of the role of the non-executive patient and staff security champion. This role would support executive led work on three key objectives, which the paper detailed. Ms Fulton Tindall had agreed with the chair to take on this role.
A 6-month programme of work would involve spending time with colleagues and patients to understand security and personal safety concerns. The 3 key areas of safety and security identified were lone working arrangements, the appropriate behaviour policy and the work to reduce violence and aggression towards colleagues within our wards. The time spent and intelligence gathered would test whether the support in place was effective as could be and that it represented best practice.
As discussed earlier in the meeting, it was recognised there had been an increase in RIDDOR incidents (minute item board public 24/09/12). The role would provide an additional lens on safety and security concerns, and ensure there was continued learning from such.
In regard to the demands and time required to undertake the role, Mr Lewis added the role was very specific to be able to hear the staff and patient voices, as well as reviewing data to be able to challenge relevant executives. There was no expectation Ms Fulton-Tindall would collate all data but that those assurances would be supported and provided via the chief nurse alongside listening to those experiences from staff and patients. Ms Fulton-Tindall noted there would be differentiating contributions between the role of executive director and the role of non-executive patient and staff security champion, and it was agreed that work would be undertaken outside the meeting to define the role.
However, mindful of comments made, and conscious of the chair’s absence, the final agreement of the role was deferred until later in 2024 to 2025. The paper was not approved.
Action
Induction of new RDaSHians into our communities and trust
Reference
Ms Holden presented the report and highlighted the imminent changes to induction programme to commence in October 2024.
During the pandemic, the 1-day face to face induction changed to a virtual event. It was recognised that induction was an important part of a person’s experience within the recruitment process. The new induction process would take place over 5 days, be community based and rotate across 3 localities. Mr Lewis stated it would be purposefully rotated across community locations and not trust locations and property.
The induction would introduce new starters to the 28 promises, our values and our communities. The induction programme itself was flexible, and would be interactive with question and answer sessions not presentations. The expected positive benefits from the new induction programme included staff engagement, increased retention and lower absenteeism. But any assessment would at 100 to 365 days.
Mr Gowland noted the significant investment for new recruits which complemented the learning half days, leadership offer and other development initiatives.
In response to Ms Fountain, Ms Holden confirmed the induction programme would be flexible with reasonable adjustments made for those who require such as people who had a disability or who worked part time.
The board received and noted the induction of new RDaSHians into our communities and trust report, recognising the changes in trust induction arrangements from October 2024 with requirement to evaluate the trust induction programme over the next 12 to 18 months.
Action
Out of area (OOA) placement risk share
Reference
Mr Mohammed presented the paper and highlighted the developments made since the last meeting.
South Yorkshire (SY) ICB had made an offer of settlement on general OOA placement of an £8.7m FYE budget transfer, with a contract period 1st October 2024 to 31st March 2027. The offer was within the limit delegated to the chief executive and director of finance previously.
There was further due diligence to undertake on the residual £16m the ICB intends to hold, which was expected to be completed within 2 weeks.
Mr Mohammed proposed commencement of negotiations with Humber and North Yorkshire (HNY) and North Lincolnshire Place for a similar transfer of budget risk.
The board received and noted the out of area placement risk share report, and approved the proposed settlement with South Yorkshire Integrated Care Board (SYICB) of an £8.7m FYE budget transfer, with a contract period 1st October 2024 to 31st March 2027.
The board delegated power to Mr Mohammed and Mr Lewis on behalf of the board to conclude the remaining due diligence on the residual £16m of budget the ICB intends to hold.
The board delegated power to Mr Mohammed and Mr Lewis on behalf of the board to continue negotiations with HNY ICB and North Lincolnshire Place to achieve an equitable OOA placement risk share, in line with the parameters agreed for South Yorkshire.
Action
Adult eating disorder contract
Reference
Mr Mohammed presented the paper and highlighted negotiations with NHSE on a settlement for the AED contract gap had concluded.
The residual risk on the contract was within the previously agreed figure of £350k. The settlement was a 3-year contract that would transfer to SY ICB on the 1 April 2025.
Mr Mohammed recommended that the board re-approve contracting with NHSE on the basis of this settlement. Mrs McDonough stated her support and she noted it was positive to see the commitment from NHSE regarding complex packages of care.
The board received and noted the adult eating disorder contract, noting the conclusion of negotiations with NHSE on the AED risk. The contract value gap had been negotiated down to within the tolerance previously approved by the board (£350k). The settlement was for 3 years and novates to SY ICB on 1st April 2025. The board reapproved the proposal and contracting with NHSE on the above basis.
Routine reports
Promises and priorities scorecard
Reference
Mr Lewis presented the paper and highlighted the purpose of the paper was to provide an assessment of promises and priorities, utilising a four-colour traffic lights to enable a clear understanding of progress.
The intent of the pecking order referenced in the paper should provide clarity that safety critical work and promises take priority, and other national and regional initiatives, have a place but are suggestions (with the exception of formal enforcement).
The promises scoring approach reflected “deliverology” ideas most associated with Professor Michael Barber, and provided an overview visual of the work undertaken to date as well as expectations during Q3 and Q4. Mr Lewis advised the board forward plan would include specific updates relating to promises to demonstrate progress.
In response to Mr Vallance, Mr Lewis confirmed the promises and priorities scorecard would be shared to provide visibility with relevant board Committees. Mr Lewis cautioned this remained in a “testing” phase and to be kept collectively inside and across CLE sub groups and patient partners.
Mr Lewis acknowledged that some promises may be undeliverable within the timeframe originally committed and would require slightly different timeframes for delivery, such as promise 19 “eliminating OOA by 2024” would be undeliverable. Another recognised challenge would be to deliver the NHS green plan (promise 27) which might require an estimated £18m investment.
The board received and noted the promises and priorities scorecard update on the work to date and expectations for coming months.
Action
Strategy delivery risks 2024 to 2025
Reference
Mr Gowland presented the report noting that the board had previously received and considered the strategic delivery risks (SDR) in July and since then lead executives had progressed on their respective risks. In some cases, this included the additional scrutiny meetings with the chair of the Audit Committee and himself.
The report focused on 3 SDRs and provided further detail about the controls being established and assurance that those controls were working with regard to SDR1, SDR3 and SDR4.
Key actions had been identified, and a “map” would be developed of expected progress of action, reporting and reassessment in the management of those SDRs.
Mr Gowland reflected on the earlier discussion and papers received today, recognising the leadership development offer, induction and cultural change would be pivotal to mitigate elements of all three SDRs.
Mr Gowland agreed with Ms Fountain’s suggestion to enhance the mitigations (controls) being put in place and the assurances, by which the board know those controls were working.
The board received and noted the strategy delivery risks 2024 to 2025 report, noting the planned next steps to enhance reporting.
Integrated quality performance report (IQPR)
Reference
Mr Chillery presented the paper and highlighted there were a number of metrics within the top 10 which showed improvement.
A reduction in breaches of section 136 length of stays was achieved and maintained. Whilst achieving the rolling target and standard in perinatal mental health delivery, there had been a decline. Mr Chillery advised the team were investing in an expert analyst to deliver capacity and demand work, to help understand where the challenges are within services and would expect to see the benefits from this in Q4.
There remained challenges and variable performance in respect of talking therapies (OP03a) and reliable recovery (OP03c).
The new RTT pathways for mental health (OP08d) continued to improve, but remained below the 92% target. An update would be provided at the next meeting as to when this target would be met. The waiting list validation programme of work was supporting patients waiting up to 18 weeks and demonstrated continued improvement.
There had been an increase in racist incidents (QS29), and he noted the acceptable behaviour policy would be implemented in October 2024. The vacancy rate was 7.48% (against the target of 2.5%) with 278 vacancies. Mr Lewis noted there were 216 people who had accepted an offer of employment and start date confirmed.
The board received and noted the integrated quality performance report.
Action
Operational risk report, Extreme risks
Reference
Mr Gowland presented the report and highlighted since the last board meeting, four extreme risks had been de-escalated, while 1 new extreme risk had emerged. The resultant five extreme risks were all subject to regular review by the respective risk owner and monthly scrutiny via the risk management group (RMG) and clinical leadership executive (CLE).
Mr Gowland advised the next report of operational risks, in November 2024, would be extended to include the low likelihood and high impact operational risks, as agreed in the revised Risk Management Framework at the board in March.
Mr Lewis requested the extreme risk in relation to speech and language therapy service (DCG 11 to 17) was scrutinised via the risk management group to confirm proposed actions and expected reduction in risk score.
The board received and noted the operational risk report, extreme risks update.
Action
Supporting papers (previously presented at committees)
Supporting papers
Reference
Mr Vallance 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:
- health, safety and security annual report 2023 to 2024 (including fire information not available at the Quality Committee)
- bi-annual safe staffing review
- medical revalidation annual report 2023 to 2024
- guardian of safe working hours
With respect to the health, safety and security annual report 2023 to 2024, a further report would be presented to the board (via QC) in March 2025 confirming that mitigation had been actioned to address the risks highlighted within the report. Mr Lewis welcomed this, as the report had raised some very fundamental questions of grip and competence across a number of corporate functions.
The board received and noted the additional reports for information.
Action
Any other urgent business
Reference
There was no further business raised.
Any risks that the board wishes the risk management group to consider
Reference
The board recommended and agreed that oversight of risks highlighted within the health and safety action plan to be reviewed via the risk management group.
Action
Public questions
Reference
There were no questions raised by members of the public.
Final note
Reference
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: March 31, 2025
Next review due: March 31, 2026
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