Minutes of the Board of Directors meeting on 29 January 2026

Minutes for the Public Board of Directors Thursday 29 January 2026 at 9:30am

Held in the Cheer Room, The Studio, Riverside West, Whitehall Road, Leeds, LS1 4AW

Attendance

Board members

Name	Role	Apologies
Mrs M McRae	Chair of the Trust	Sent apologies
Mrs Z Burns Shore	Non-Executive Director	Attended
Mrs J Forster Adams	Chief Operating Officer	Attended
Mrs D Hanwell	Chief Financial Officer and Deputy Chief Executive	Sent apologies
Mr C Henry	Non-Executive Director (Senior Independent Director)	Attended
Dr F Healey	Non-Executive Director	Attended
Dr C Hosker	Medical Director	Attended
Ms K Khan MBE	Non-Executive Director	Attended
Dr S Munro	Chief Executive	Attended
Mr D Skinner	Director of People and Organisational Development	Attended
Miss N Sanderson	Director of Nursing and Professions	Attended
Miss K Wilburn	Non-Executive Director	Attended
Mr M Wright	Non-Executive Director (Deputy Chair of the Trust)	Attended

All members of the Board have full voting rights.

Also in attendance

Mrs C Edwards – Associate Director of Corporate Governance / Trust Board Secretary
Mr K Betts – Corporate Governance Officer
Dr Hayley Lyon – Consultant Clinical Psychologist, Leeds Low Secure Service (for minute 26/002)
Mr Ferenc Ebozue – Service User (for minute 26/002)
Four governor / member of the public attended the meeting.

Minutes

Mr Wright opened the public meeting at 09:30 and welcomed everyone.

26/001 – Apologies for absence (agenda item 1)

Apologies were received from Mrs Merran McRae, Chair, and Mrs Dawn Hanwell, Chief Financial Officer.
Mr Wright, Deputy Chair, chaired the meeting in the absence of Mrs McRae. The meeting was quorate.

Mr Wright welcomed Dr Hayley Lyon, Consultant Clinical Psychologist, Leeds Low Secure Service, Ms Aishia Williams Matron, Leeds Forensic Inpatient Service, and Mr Ferenc Ebozue, Service User, acknowledging the importance of starting with a service user story. Mr Ebozue shared his experiences with the Board, noting that he had spent 3 years and 5 months in hospital, therefore it was difficult to pick individual stories to share so he was sharing his wider thoughts with opportunity for discussions. He commented that mental health was a great leveller in life and as a patient in Forensic Services there was a difference with acute care as admission into the Forensic Service was not necessarily because you were more unwell, but due to unlawful acts whilst mentally unwell, which was an added layer of oversight that was not easy to break free from.

He noted that an absolute discharge from Forensic Services was challenging, with lifelong monitoring usually in place, and the core mission of the service should be to give service users the best possible life given the restrictions. Staff and facilities were key to this, and he noted a few key points:
• Staffing crisis was a patient crisis: one reduced staff member on shift impacts on the ability of service users to move around
• Staff wellbeing was important with the need for more realistic guidelines of staff working conditions, as treating staff with empathy allowed them to support service users
• Need for a reduction in waste
• Need for increased investment in psychology: they are often the only person who sees service users as human rather than a risk, and provide an essential safeguard
• Prioritise ongoing psychological intervention to also address institutional trauma caused by long term hospitalisation which was important for quality of life
• Rational requests from patients should be listened to: they have no power to challenge so important to respond as they feel silenced if not
• Celebrating staff is important as service users never forget staff who put in time and effort with them
• Logic of facilities was often flawed, for example medium secure facility had desk and shelving but this was not available in low secure which may lead to a lack of motivation for service users
• Small indignities add up to leave people not feeling like a valued member of society

He felt that his experiences were representative of broader observations and reflected everyday reality for people in the broader forensic estate. He commented that it was a flawed system which, whilst not a criticism, was an opportunity for change, many of which were practical elements that would make a difference to those who would not be able to leave the system.

He explained that psychology was a lifeline in locked wards and finding common ground could be difficult, so it helped social interaction. Admission to forensics was a traumatic experience and there was a lack of understanding for what it was like for service users as an indefinite admission was challenging to manage and deal with for future life.

Mr Wright thanked Mr Ebozue for his story and the points made and asked if the document he referred to could be shared across the Board which was agreed.

Mrs Burns Shore noted the importance of the ongoing trauma element, so that was important to consider along with the small indignities which were easier to fix. Prof Healey noted it was a powerful story, and it would be helpful for Mr Ebozue to share his experiences more widely to help the wider system. Mr Ebozue responded that he had limited interaction with services currently which was positive but discussing it brought an emotional component to deal with at times.

Dr Hosker commented that Forensic Services had been challenged at times but had moved forward, and the solvable issues were important to consider as there was an opportunity to help others. Ms Khan thanked Mr Ebozue for sharing his experiences and the depth and breadth covered in aspects of care. Mr Wright reiterated his thanks to all for attending.

The Board of Directors thanked everyone for attending the meeting and sharing the engagement work within the Forensics Service.

26/003 – Declaration of interests for directors and any declared conflicts of interest in respect of the agenda items (agenda item 3)

The Board of Directors noted that there were no changes to the declarations of interests, and no conflicts in respect of any of the agenda items.

26/004 – Minutes of the previous meeting held on 27 November 2025 (agenda item 4)

The minutes of the meeting held on 27 November 2025 were received and agreed as an accurate record.

26/005 – Matters arising (agenda item 5)

The Board of Directors noted that there were no matters arising.

26/006 – Actions outstanding from the public meeting of the Board of Directors (agenda item 6)

Mr Wright presented the action log which showed those actions previously agreed by the Board in relation to the public meetings, those that were completed and those that were still outstanding.

In relation to the ethnicity data action, Mrs Forster Adams confirmed that this had been completed and shared with the Finance and Performance Committee. It was agreed that the action log update for the Committee would be shared with the Board for completeness.

The night rostering action was reviewed at the Finance and Performance Committee and was part of the wider rostering work. It would continue to be reviewed through the Committee, and escalations and updates would be provided to Board as required. The action was closed.

The action in relation to the operational priorities’ trajectories was to be reviewed by a small working group to agree appropriate trajectories. It was agreed that this would remain ongoing at the current time.

Mr Skinner confirmed that the action related to long term sickness within corporate services remained ongoing as further detail was awaited.

The Board received the cumulative action log, agreed to close the actions that had been completed and noted the updates provided for ongoing actions.

26/007 – Report from the Chief Executive (agenda item 7)

Dr Munro presented the Chief Executive’s report, taking the content as read.
She noted key points including that Industrial Action had concluded and been well managed, and the current ballot would conclude at end of January 2026. The second round of executive led engagement events had concluded and feedback was being evaluated currently.

She noted that the medium term plan would be covered at the private Board meeting, and that there had been a request for submission of Board minutes noting the discussions which had been fulfilled. She informed the Board of the joint meeting with NHS England regional team and ICB Chair with Leeds Community Healthcare NHS Trust (LCH) and LYPFT to discuss the high level strategic points. Feedback from the regional team was to focus on trajectories for Out of Area Placements and Length of Stay performance, and that they were satisfied with the responses provided including interaction with Getting it Right First Time (GIRFT) and external validation.

In relation to the alignment with LCH, a Board to Board meeting had been held in January 2026, and comments were due from both Boards in relation to the Strategic Outline Case which will be tabled for approval at the Extraordinary Board meeting in February 2026.

She noted that the ICB voluntary redundancy scheme would conclude in February 2026 therefore the final position was unknown at the current time, however there was a risk across all organisations and West Yorkshire as the impact was unclear, especially in relation to loss of expertise. She noted that the ICB core Executive Team was expected to be appointed in May 2026, with final date for implementation following a Management of Change process being October 2026. The CEO was stepping down, and the Chair replacement was not known, therefore the immediate impact was a risk with unknown implications.

She referenced the Reasons to be Proud and team achievements which were important to acknowledge, and noted that Amy Pratt had been appointed as Lead Governor.

She informed the Board that the Trust had received notification that the CQC would undertake a Well Led inspection on 14 to 16 April 2026 in line with the new approach, and before then would carry out unannounced inspections of core services. The Trust would commence planning for this and the Board Strategic Development Session on 10 March 2026 would review the position.

Mr Wright thanked Dr Munro for the report.

The Board received the report from the Chief Executive and noted the content.

26/008 – Report from the Chair of the Finance and Performance Committee for the meeting held on 27 January 2026 (agenda item 8)

Mr Henry presented the Chair’s report from the Finance and Performance Committee meeting taking it as read. He noted the detailed discussions that had taken place including the financial performance at month 9, the deterioration in the run rate, the reduced position with the Cost Improvement Programme and the capital programme position.
He highlighted the discussion regarding the expenditure across bank and agency staff, including the positive trajectory throughout the year with some increases due to staff absences. The Committee reviewed and discussed the organisational priorities and focused on delays in completion of some areas and the assurance provided to address this. The Committee also reviewed the Board Assurance Framework and were satisfied with the controls in place. He noted the positive update from the procurement team and the Green Plan review which was noted to be progressing well.

Mr Wright thanked Committee members and Mr Henry for the report.

The Board of Directors received the Chair’s report from the Finance and Performance Committee and noted the matters reported on.

26/009 – Report from the Chief Financial Officer (agenda item 9)

In absence of Mrs Hanwell, Dr Munro presented the report taking it as read by the Board. The month 9 position remained positive, and she highlighted the detail on the trajectory for the rest of the financial year and future years, acknowledging the challenges with the Cost Improvement Programme and run rate, however she noted positive work to date and confidence in the forecast.

Mrs Burns Shore acknowledged the importance of non-recurrent support that was offered for the financial position and queried whether this would cease in due course. Mr Henry commented that the Finance and Performance Committee had reviewed the plan for future years, the expectation and prediction on modelling for the interest rates, and the impact of this. He added that the finance team had been realistic but cautious on the elements that could be risks around this, acknowledging that there were several unknowns at the current time. Mr Wright commented that the challenge was to achieve balance at the end of the financial year, and there would be discussion in the private Board meeting regarding projections.

Dr Munro commented that the medium term plan would be covered in the private Board meeting as there were significant shifts to manage and the Trust did not want to be reliant on non-recurrent support however the Trust was not in the territory that others were for support. The aspiration of the 10 year plan was for all Trusts to use Foundation Trust status to generate surplus and reduce the need for support.

Miss Wilburn raised that the Trust was achieving the financial plan but not by means that were optimal and using non-recurrent funds, therefore there were risks that remained for addressing in future. Mr Henry acknowledged that this would be the hardest year, but the Finance and Performance Committee were assured by the quality of financial management and projections presented.

Mrs Forster Adams noted that the run rate deterioration was linked to the Out of Area Placement position which had been noted at the Committee. This was impacted by delayed discharge in complex rehabilitation, but this was expected to recover by year end.

Mr Wright thanked Dr Munro and Mr Henry for the updates provided.

The Board received the Chief Financial Officer’s report and noted the content.

26/010 – Organisational Priorities Q3 Update Report (agenda item 10)

Dr Munro presented the update report, taking it as read, noting the collective responsibility across all Executive Directors for the schemes. She added that detailed assurance for the priorities sat within other reports to Committees or Board.

In relation to the People Plan metrics and the alert regarding disciplinary process, she noted that this was due to the metric process as disciplinaries had halved in number, which was a significant improvement, but due to the overall shrinking number it looked like deterioration. She noted that the final building arrangements were being expedited for the Perinatal Service, but all enabling work had taken place, and the area was freed up to make the changes once the legal position was agreed.

Prof Healey queried if there was any more that could be done to address any digital interoperability issues in relation to the Respect form, and Dr Hosker responded that it was in hand and whilst the paper process led to potential duplication, by the summer there should be the ability to edit the document on the care record therefore progress was being made.

Mr Wright noted that, as discussed at Finance and Performance Committee, the report was put together in individual sections by managers keen to demonstrate progress therefore there may be a need for oversight of updates before the report is published. Dr Munro responded that this linked back to the working group action from the action log, and they would be able to consider how to demonstrate progress with the work done and align this to the outcome needed. Mr Wright thanked Dr Munro for the report.

The Board received the Organisational Priorities Q3 Update Report and noted the content.

26/011 – Report of the Chief Operating Officer (agenda item 11)

Mrs Forster Adams presented her report, noting the depth of the discussion at Finance and Performance Committee. She highlighted key points including that the work on site at Red Kite View had started with an 11 week programme of work which would ensure progress was made. She noted that the team had managed the service extremely well during this time.

She informed the Board that the seasonal variation with flow had not been seen as expected, and work was underway to understand any immediate actions needed as this provided an extra layer of oversight for learning and escalation. She added that consultant medics had been involved which provided insight into short and long term action needed. This impacted on the financial plan and performance, therefore the Board should expect to receive a business case for use of PICU to support this.

A case for change had been received from acute services with further work to be done on it with support from Royal College of Psychiatrists and GIRFT colleagues.

She confirmed that Physical Health assessments had seen a general improvement, and performance deterioration within older adults had been addressed quickly and would be resolved.

In relation to waiting times in Emergency Departments, she informed the Board that through a programme of work the acute liaison service had introduced a triage process that was being trialled and was producing an immediate positive impact. She noted that it was not yet possible to confirm the National Oversight Framework indicators yet, however length of stay for adults and older adults would remain areas of focus.

She alerted the Board to a delay in progress with the refresh of the Care Services Strategic Plan and an update would be provided at the next Board meeting and Council of Governors.

Ms Khan commented it was positive to see that Out of Area Placements were closer to home than in the previous position, which would have a positive impact on service users and families. Mrs Forster Adams acknowledged this and noted that further work was needed to understand what was reasonable in terms of closer to home.

Mr Wright referenced the increasing number of service users in the community setting, and the impact on service delivery due to this which was important to acknowledge. Prof Healey thanked Mrs Forster Adams for the helpful report and commented that it may be helpful to have a wider strategic discussion to understand wider issues within inpatient care that could be done outside of a hospital ward setting, linked to the Mental Health Act and future changes. Mrs Forster Adams responded that this linked to work with acute colleagues about the consideration of the future model of care and how this would be delivered. Dr Hosker added that the transformation group was working on this to consider these wider issues and he offered reassurance that discussions were taking place. Mrs Forster Adams confirmed that the work was being reported through the Care Cervices priority groups, through to the Quality Committee and Board. It was agreed that the implications of the amendments to the Mental Health Act would be discussed at a future Board Strategic Discussion session.

Mrs Forster Adams noted that discussions regarding Neighbourhood Health had commenced and would be referenced in more detail in her next report to the Board. Mr Wright thanked Mrs Forster Adams for her report.

The Board received the Chief Operating Officer report and discussed the content.

26/012 – Report from the Chair of the Quality Committee for the meetings held on 11 December 2025 and 15 January 2026 (agenda item 12)

Dr Healey presented the Chair’s Report from the Quality Committee meetings held on 11 December 2025 and 15 January 2026, taking them as read. She confirmed that whilst there were differences in how Chair reports were approached, all assurance was provided to the Committee as needed through relevant reports. She highlighted that the Committee had received the annual report on resuscitation, which had evolved over the past year and was presented to the Committee to provide assurance on the position. It was a collaborative report across functions and was a good example of many services and leads contributing to deliver the report.

She provided reassurance to the Board that the service reports were reviewed and questioned by the Committee to determine that the self-assessment process was accurate, and it demonstrated that the Executive Directors knew the strengths of services and where additional support was needed. Dr Munro commented that the process would be helpful for the CQC inspection that would take place, and routine annual reporting was useful to be able to demonstrate assurance.

Mr Wright thanked Dr Healey for the reports.

The Board of Directors received the Chair’s reports from the Quality Committee and noted the matters reported on.

26/013 – Quality Committee Terms of Reference (agenda item 12.1)

Dr Healey noted that the changes were mostly technical, however there was one amendment to note regarding the entirety of sexual safety reporting through to Quality Committee instead of Workforce Committee.

The Board of Directors noted and approved the Quality Committee Terms of Reference.

26/014 – Report from the Director of Nursing and Professions (agenda item 13)

Miss Sanderson presented the report taking it at read by the Board. She highlighted the enhanced therapeutic observation work, which continued to progress positively. She noted that it was now possible to enter in Care Director the detail of the observation plan for service users which was beneficial. The vaccination campaign had achieved the national target, but uptake had been below the aim for the flu vaccine.

Following on from the student nurse job discussion at the Board meeting in November 2025, she updated that the previous offer was a job for all student nurses trained at the Trust, however adjustments had been made to the process and student nurses ready for qualification were now asked to apply for up to 3 vacancies. This gave the opportunity for job interview experience and allowed Care Services to consider areas of expertise and interest; therefore, she was confident it would allow for a better appointment process for student nurses and services.

In relation to clinical supervision training, she updated that more facilitators had been recruited based on the findings of evaluation, and content was being refreshed for the training. She informed the Board that the Trust had maintained accreditation for the Triangle of Care, and it was important to note that a Trust could not be considered for a three star triangle of care accreditation unless it was a combined community Trust, therefore this was an area to aspire to over the next 18 months.

She noted the recent internal audit regarding claims and complaints which received low assurance and confirmed that work had already been undertaken to make improvements which had already had a positive impact. Work had been done to engage service users, families and carers to understand how to improve the process, whilst also aligning policies to those of NHS England expectations.

Mrs Burns Shore noted the positive messages within the report and queried whether bank staff were disproportionately undertaking the enhanced observations as previously reported. Miss Sanderson responded that work undertaken identified that was not the case and reminded the Board that substantive staff regularly picked up bank shifts so may be those undertaking the observations.

In relation to the complaints audit findings, Mrs Burns Shore asked if performance data was being triangulated with other relevant data. Miss Sanderson responded that the complaints data gave false assurance as it included a smaller number of metrics, therefore the data reviewed would be widened to include more than just national targets and would include the overall position. Prof Healey added that the 60-day completion rate would be an important metric, but with the acknowledgement that reasonable timescales would be agreed with complainants where necessary. Dr Munro noted that there had already been a significant improvement in recent weeks with response rates, and it had been maintained that a conversation was had following receipt of the complaint with the lead investigator, with an opportunity to meet ahead of getting the written response as these were important elements of the process. Complex complaints involving staff who had left the Trust remained a challenge but was being worked through.

Dr Munro noted that the team involved in the culture of care work had presented at the Committees in Common and the feedback was excellent regarding the focus on lived experience, and it was acknowledged by others as important to support lived experience colleagues therefore this should be shared widely across all wards to support improvements in all areas.

Miss Wilburn noted that, in relation to enhanced therapeutic observations, the discussion at Finance and Performance Committee regarding bank usage indicated that the volume was declining but the cost was increasing as they were used at evenings and weekends. She felt it was important to not duplicate reporting but to ensure that it was understood in expenditure reporting. Miss Sanderson noted that the team were working on how to align systems to be able to collate data in that way and provide more detail regarding observations needed and bank shifts requested. It was agreed that Miss Sanderson would provide assurance and more detail on bank staff usage for shifts and the percentage used for enhanced observations in her next Safer Staffing report. Mr Wright thanked Miss Sanderson for the report.

The Board of Directors received the Report from the Director of Nursing and Professions and noted the content.

26/015 – Safer Staffing Report (agenda item 13.1)

Miss Sanderson presented the report taking it as read by the Board. She noted that the numbers of registered nurses above establishment were starting to reduce and the implementation of the staffing establishment tool supported this. In relation to breaches of shifts with no registered nurse, she confirmed that this was reported, however explained that such was the speciality of the registered nurses that it wasn’t possible to move them around services to address this therefore short term sickness led to risks which was mitigated through associate nursing roles.

She confirmed that vacancies remained as per previous months in specific areas, and this was starting to reduce due to newly qualified preceptees commencing in roles across wards and services. There was a continued focus on embedding a multi-disciplinary team focus on working within services and away from specific roles for specific professions.

Mr Wright thanked Miss Sanderson for the report.

The Board of Directors received the Safer Staffing Report and noted the content.

26/016 – Report from the Chair of the Workforce Committee for the meeting held on 4 December 2025 (agenda item 14)

Mrs Burns Shore presented the report, taking it as read by the Board, noting previous discussions regarding an increase in Freedom to Speak Up contacts, therefore Mrs Shereen Robinson, Freedom to Speak Up Guardian, had been invited to attend the Committee at any point ahead of Board for escalations and support.

She noted that the process for reasonable adjustments was to be reviewed at the next Committee meeting to ensure progress was being made to reduce time delays. Mr Skinner noted it was a complex issue including procurement and Access to Work and the timelines did not always match up and recommendations were not always possible, therefore there was a need to review the process, and he was confident that the right colleagues were looking at solutions.

Mrs Burns Shore noted that compulsory training for the coming year and the work entailed would also be reviewed by the Committee. In relation to the Council of Governors query regarding support for care leavers being included as a protected characteristic, she was confident that work was taking place already as if it was a protected characteristic.

Mr Henry noted several Freedom to Speak Up ambassadors had stepped down so there would be a need to review this over the coming months. Dr Munro acknowledged this and noted that there had been an increase in the working hours of Mrs Robinson to support this which would be reviewed on an ongoing basis to support the service through the merger process for staff engagement.

Mr Wright thanked Mrs Burns Shore for the report

The Board of Directors received the Report from the Chair of the Workforce Committee and noted the content.

26/017 – Report from the Chair of the Audit Committee for the meeting held on 20 January 2026 (agenda item 15)

Mr Wright presented the Chair’s report, taking it as read, and noted that there were no specific areas for escalation. He highlighted that the complaints and claims internal audit had been reviewed and whilst it was a low assurance report the management response was detailed and clearly addressed the issues. The delivering financial efficiencies (CIP) internal audit had received a split opinion, with processes for delivering the CIP being good, however the issue was that they had not all been achieved. He added that the deferred internal audit regarding the quality dashboard would be added to the programme in the next year.

The Board received and noted the content of the Report from the Chair of the Audit Committee.

26/018 – Audit Committee Terms of Reference (agenda item 15.1)

The Board of Directors noted and approved the Audit Committee Terms of Reference.

26/019 – Mental Health Legislation Committee Terms of Reference (agenda item 16)

The Board of Directors noted and approved the Mental Health Legislation Committee Terms of Reference.

26/020 – Board Assurance Framework (agenda item 17)

Dr Munro presented the Board Assurance Framework noting that it had been updated and there were no significant areas to note. She highlighted the discussion at the Executive Risk Management Group in January 2026 regarding the target risk scores and whether they were achievable and confirmed that this would be reviewed in Q1 of 2026/27, including a full review at the Board Strategic Development Session in April 2026 to consider the strategic risks for the coming year. Mrs Edwards agreed to add this to the agenda for the session.

Mr Wright noted that at a recent meeting of Chairs of Audit Committees there had been a discussion on the distinction between issues and risks, with the Board Assurance Framework meant to identify risks but often issues were included instead, therefore this was worthy of consideration when reviewed. Prof Healey added that the reality of complex NHS organisations was that there were known problems and a need to acknowledge that the risk framework did not always support that to be realised. Mr Henry noted that in relation to Strategic Risk 6 and the Digital Plan, the outline business case for EPR replacement, and the Digital Plan refresh would need to acknowledge the significant impact of the merger from a digital perspective. Dr Munro confirmed that this had already flagged in the Due Diligence process.

Ms Khan noted the fire safety risk that had been added to Strategic Risk 5 and Prof Healey noted that it had been discussed at the Audit Committee and assurance provided that it was high risk with mitigation in place to reduce implications. Dr Munnro added that it had been reviewed at the Executive Risk Management Group and subsequent communication had provided assurance that the right steps were being taken.

The Board received the Board Assurance Framework and noted the content.

26/021 – Approval of the appointment of the Senior Independent Director (agenda item 18)

Mr Wright presented the paper regarding the updated role description and proposal for Mrs Burns Shore to take on the role after the departure of Mr Henry. Mr Wright noted that the role description did not reference the Freedom to Speak Up role, however it was acknowledged that they did not have to be the same role. Prof Healey noted that there was an opportunity to review roles through the merge process and reduce any duplication across roles.

Mrs Burns Shore confirmed she was happy to take on the Freedom to Speak Up role at the same time. Handover would take place over the coming weeks, and she would formally commence in the roles on 1 April 2026.

The Board approved the Senior Independent Director proposal.

26/022 – Use of Trust Seal (agenda item 19)

The Board noted that the Trust Seal had not been used since the previous meeting.

26/023 – Any other business (agenda item 20)

There were no additional items of business raised.

26/024 – Resolution to move to a private meeting of the Board of Directors

At the conclusion of business, the Chair closed the public meeting of the Board of Directors at 12:00 and thanked members of the Board and members of the public for attending.

The Chair then resolved that members of the public would be excluded from the meeting having regard to the confidential nature of the business transacted, publicity on which would be prejudicial to the public interest.