Minutes of the Board of Directors meeting 25 September 2025

Minutes for the Public Board of Directors Thursday 25 September 2025 at 9:30am

Held in the in Inspire@ room at Horizon Leeds, 3rd Floor, 2 Brewery Wharf, Kendall Street, Leeds, LS10 1JR.

Attendance

Board members

Name	Role	Apologies
Mrs M McRae	Chair of the Trust	Attended
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	Attended
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	Sent apologies
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
- Miss K McMann – Head of Corporate Governance
- Miss Rose Cooper – Deputy Head of Corporate Governance
- Ms Tracey Ibberson –
- Ms Maddie Ciocoiu –

Dr Wendy Neil – Consultant Psychiatrist / Responsible Officer (for minute 25/084)
Four governor / member of the public attended the meeting.

Minutes

Mrs McRae opened the public meeting at 09:30 and welcomed everyone.

25/077 – Apologies for absence (agenda item 1)

Apologies were received from Mrs Zoe Burns Shore, Non-Executive Director. The meeting was quorate.

Mrs McRae welcomed Mr Ian Dowd, a relative of a Service User of the Older People’s Service at The Mount, Ms Amy Young, Occupational Therapist, and Ms Annie Johnston, Senior Occupational Therapist.

Mr Dowd provided an overview of his family’s experience and his personal story of his mother who was admitted to The Mount in 2024. She was treated for both her mental health and medical issues and initially she was reluctant to engage with the staff. He highlighted the importance of the time provided to his mother by staff who all demonstrated care and compassion, and she was also supported by consistency and familiarity with the care staff. He noted that the multi-disciplinary team (MDT) meetings supported a holistic view of her care which was important in his mother’s treatment. The work between the clinical and pharmacy teams to support her physical health had a positive impact on mental health and she was supported to start small visits out and home. He noted she was now living independently back at home, and this was due to the time taken by all team to develop trust and familiarity with his mother to support her recovery journey.

Ms Young was the allocated occupational therapist for Mr Dowd’s mother and discussed the importance of getting to know service users and building a relationship. She noted how the team worked together to understand who would be best placed to develop a relationship with each service user. They work with the person rather than the diagnosis and understand their challenges and goals to support them to engage with the service and can learn a lot from their knowledge and life experience. They created environments that enabled service users to feel safe and empowered with choice and inclusion in their care planning to give them a sense of control over their recovery journey. She discussed the models of care used to support recovery with graded exposure to their home environment and self-care, highlighting the importance of the support provided at all stages of the recovery journey to ensure successful outcomes. She noted the importance of MDT meetings to bring together different perspectives and insight into each service users’ needs to make recovery more effective.

Ms Johnston highlighted the importance of sharing good practice within the service, including feedback from service users and carers, to ensure the teams provide a good service. The monthly OT development forums allowed good practice to be shared across teams, and they also network across teams to share good practice regarding all elements of the MDT.

Ms Young acknowledged the challenges to implementing good practice, with the main issue being time as there was a need to get to know the individual however the team was stretched, and it could be hard to give everyone the time they needed. She noted that resource demands could be a challenge and could impact on the team’s ability to deliver person centred care which impacted on consistency. Capacity and flow within the acute inpatient service was noted to impact on the ability for collaborative working, linking back to consistency for service users. There was also a risk of re-traumatisation, and the need to build trusting relationships to support recovery was key to managing this. She also noted that staff wellbeing and compassion was prioritised to support staff.

Mrs McRae thanked Mr Dowd for sharing his mother’s story, and thanked Ms Young and Ms Johnstone for showcasing the service provided and the personalised care focus. Mrs Forster Adams thanked them for attending and acknowledged the issues with time and patient flow which had been previously discussed at the Board, and the presentation had helped understand the service delivery element. She urged the team not to lose the authenticity of staff and teams to support development. She noted she would be keen to hear the feedback of the service for any Board support required.

Dr Healey commented the presentation had demonstrated the importance of involving the family in the MDT discussions, and the importance of understanding good practice with a need to hear more of these stories at a national level. Dr Munro acknowledged this and commented how hearing all the elements of the person-centred holistic care was important and inspirational and was a good tool to use for staff motivation and learning through sharing good practice and role modelling.

Ms Khan thanked the team for sharing the story and queried whether it was possible to provide that level of care and quality to all patients. Ms Young responded that every service user was at a different stage, so their needs were different therefore the entire case load was considered to deliver the care individuals required.

Mrs McRae reiterated her thanks to the team, and wished Mr Dowd and his family well, noting it was important to hear the positive story but also acknowledge the challenges faced.

The Board of Directors thanked everyone for attending the meeting and sharing the engagement work within the Older People’s Service.

25/079 – Declaration of interests for directors and any declared conflicts of interest in respect of the agenda items (agenda item 3)

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

Dr Munro noted that there was a need to include her interim role as Chief Executive at Leeds Community Healthcare NHS Trust on the declarations of interest.

The Board of Directors noted that there would be an update to the declarations for Dr Munro. There were no other changes.

25/080 – Minutes of the previous meeting held on 29 May 2025 (agenda item 4)

The minutes of the meeting held on 29 May 2025 were received and agreed as an accurate record.

25/081 – Matters arising (agenda item 5)

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

25/082 – Actions outstanding from the public meeting of the Board of Directors (agenda item 6)

Mrs McRae 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.

She noted that there were two actions ongoing within timeframe and that information had been circulated to address the action related to MSK data. Any queries were to be raised with Mr Skinner or via Workforce Committee.

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

25/083 – Action 29 supporting information – MSK Data (agenda item 6.1)

The Board received the additional information and noted the content.

25/084 – Annual RO and Medical Revalidation Report (agenda item 7)

Mrs McRae thanked Dr Neil, Responsible Officer, for attending. Dr Neil took the report as read by the Board and highlighted several points and priorities. She confirmed that 139 doctors had been recommended for revalidation which was a good position. She noted that work continued to develop the appraiser workforce, and the appraiser development forum provided inhouse bespoke support for the appraiser community across the Trust. She highlighted the work undertaken with the complaints team to move away from dealing with complaints related to medical staff generically to provide more individual responses to complainants and identify support for individual doctors. All medical line managers were approved case investigators which was positive, and the Trust was heavily involved in regional and national networks to share knowledge and good practice.

She noted that the priorities for the coming year focused on resources and the impact on the Trust’s ability to support an increased number of doctors within the Trust. This included those who were not directly connected to the Trust but worked within services as there was a need to include them in oversight processes. She noted that options to consider administrative support within the service had been challenging however there was a need to continue to offer high quality support and appraisals for doctors, and this was challenging with limited resource. She provided assurance to the Board on the delivery of requirements for medical revalidation however it was important to flag the resource issues. Mrs Hanwell noted that discussions would continue regarding the resource issue as there was a need to prioritise where resource was needed and consider urgent areas, acknowledging that the drive to employ more doctors brought a need for a review of resources.

Mrs McRae acknowledged the work that had gone into the process and thanked Dr Neil for the report. As Chair of the Board, she signed the report, and the Board noted the content of the report.

The Board received and noted the content of the Annual RO and Medical Revalidation Report.

25/085 – Report from the Chief Executive (agenda item 8)

Dr Munro presented the Chief Executive’s report, taking the content as read. She highlighted the engagement events that had taken place and had received an overwhelmingly positive response therefore would be followed by another round of events later in the year. She also noted the progress made by the procurement team which was positive and demonstrated that investing in the skills and capabilities of the team had improved the position.

She informed the Board about the visit from Dr Penny Dash, Chair of NHS England, in July 2025, where she met with ward teams and senior leadership teams which was well received.

In relation to the Leeds System Review, she updated the Board that phase 1 had been concluded including the initial stakeholder engagement work with partners, and it was now focusing on the next stage. The report would focus on recommendations including future provider partnerships in Leeds and links to the 10 Year Plan policy framework, with may include specific implications for organisations. She also acknowledged the retirement of Professor Phil Woods, Chief Executive of Leeds Teaching Hospitals NHS Trust.

She noted that, in relation to the 10 Year Plan, working groups had been established with membership including executive level colleagues. The aim was for the working group to develop draft documentation in September 2025, and she would keep the Board updated. She also noted that the future role of governors was unclear at the current time.

She highlighted the importance of the Reasons to be Proud including the work to support interns and apprenticeships within Estates and Facilities, linking to the 10 Year Plan and supporting people into employment.

Mr Wright noted that the 10 Year Plan was aspirational, and it would be important for the Board to have a development session in the future to review the detail and implications, although he acknowledged that there was more detail to be awaited. Dr Munro referred to the planned discussion for the private Board meeting, noting the headline statements regarding workforce changes, and expectations regarding Foundation Trusts and funding regimes including achieving a 3% surplus to fund investments, needed consideration. Mrs Hanwell added that the messaging could be contradictory within the plan therefore there was a need to review how it would be implemented and impact on the organisation. It was agreed that the planned autumn Board Development Session would include the 10 Year Plan to consider its implications.

Mr Henry noted the lack of delivery detail within the Plan, and that there was a need to consider how it is communicated and translated to set accurate expectations.

Mrs Hanwell noted that, in relation to phase two of the Leeds System Review, The Value Circle were linking with Directors of Finance to hold focused discussions regarding the estate elements raised.

Mrs McRae noted that there was organisational responsibility to influence the aspirations of the 10 Year Plan into delivery and that the Mental Health service framework was still being worked through. She thanked Dr Munro for the report.
The Board received the report from the Chief Executive and noted the content.

25/086 – Report from the Chair of the Finance and Performance Committee for the meetings held on 28 July 2025 (agenda item 9)

Mr Henry presented the Chair’s report from the Finance and Performance Committee meeting on 28 July 2025 and acknowledged that the reports from the Chief Operating Officer and Chief Financial Officer would cover some of the updates.

He highlighted the focus on the out of area placements and the financial position for the organisation. He noted the deterioration in physical health checks which was referred to the Quality Committee for further review. The Committee had discussed AI and suggested that there was a need for a further, deeper discussion by the Board to consider opportunities and challenges including any impact on the strategic risks. It had also reviewed the organisational priorities and been provided with assurance regarding the detail within the BAF.

He highlighted that the Data Security and Protection Toolkit had been reviewed, and that there was a need to bring forward a cyber EPRR session for the Trust. The Committee received the Care Service Delivery and Development Group Annual Report noting it was a large report, and discussion had taken place regarding the target audience.

In relation to disciplinary processes for BAME colleagues, this had been referred to the Workforce Committee for further review, and the clinically ready for discharge and flow work had been referred to the Mental Health Legislation Committee to discuss in more detail.

Mr Wright commented that in relation to AI the focus needed to be on ensuring that the appropriate governance was in place to provide assurance that it was being used appropriately. Mr Henry noted that data protection guidance did not change for AI therefore it should be considered alongside the existing framework. Mrs McRae acknowledged that encouraging curiosity was positive, but the use of it needed to be considered more be widely.

Miss Wilburn highlighted the national cost collection discussion that had taken place at the Committee, noting that the return had been completed for this year however it was acknowledged that it was flawed yet used in the Oversight Framework as a metric. It was therefore important to flag this risk to the Board. Mrs Hanwell responded acknowledging the risk however data quality in mental health across the metrics was an issue, and there was a need to improve the data collection across mental health including for the costing process.

Mrs McRae thanked Committee members and Mr Henry.
The Board of Directors received the Chair’s report from the Finance and Performance Committee and noted the matters reported on.

25/087 – Report from the Chief Financial Officer (agenda item 10)

Mrs Hanwell presented her Chief Financial Officer’s report, noting the discussion at Finance and Performance Committee. She highlighted that the Trust was on track with the plan acknowledging the improvement in the medical agency position. She noted that the run rate position was being delivered using nonrecurrent technical flex which was supporting the position for the Trust, therefore a recurrent set of balanced budgets were needed which was in progress. This would include a QIA process which would be undertaken in due course linked to the organisational priorities. She added that the estimate and assessment for the underlying position needed to be entered and medium-term planning commenced which would be shared in more detail as it was progressed through the Finance and Performance Committee.

He informed the Board that the system improvement target now included a mandatory requirement for each Place to take a share of the unidentified £33m. This had been undertaken through a stretch target for Leeds, agreed through the Strategic Finance Executive Group, for each provider to take £0.9m. The Trust would not be amending the current plan and would focus on non-recurrent savings starting in month 6. She noted she was confident that this could be achieved if all other plans were delivered.

She noted that the domains for the financial elements of the Oversight Framework were referenced within the report, and she was confident with the delivery of the finance domain at the current time, however there was no ability to move into a deficit position.

Mr Wright queried if the stretch element of the plan would be reported for Board purposes and Mrs Hanwell confirmed that this would be part of forecast reporting from month 6.

Mr Henry referred to the discussion at Finance and Performance Committee regarding oversight for negative impacts on service delivery because of the efficiencies required. Mrs McRae acknowledged that impacts would be seen but mitigation needed to be understood. Mrs McRae thanked Mrs Hanwell for the report.

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

2025 – 2026 Organisational Priorities Quarter 1 Progress Report (agenda item 11)

Mrs Hanwell presented the report noting the detail provided and that each Executive Director was responsible for a range of priorities. She highlighted the red alert regarding disciplinary numbers for BAME staff which had been referred to the Workforce Committee.

Mr Wright clarified the discussion at Finance and Performance Committee regarding the patient portal and assurance was provided that this would be back on track due to the work underway from a technical perspective.

Dr Munro noted that it was positive for the Workforce Committee to review the disciplinary data however noted that there had been an overall reduction in the number of disciplinaries with less staff in the process therefore the numbers were smaller. She commended the team for the reduction in numbers and providing appropriate support staff. Mr Henry noted that it had been referred as the percentage remained the same despite a reduction in numbers.

Mrs McRae thanked Mrs Hanwell for the report.
The Board of Directors received the 2025 – 2026 Organisational Priorities Quarter 1 Progress Report, and noted the content.

25/089 – Approval of the Data Security & Protection Toolkit (self-certification) (agenda item 12)

Mrs Hanwell presented the report noting the detail and discussion at Finance and Performance Committee. It was the first year this framework had been used which had resulted in added pressure on the outcome measures and level of detail required. The usual audit had been undertaken with one outcome not met, however an action plan had been put in place and the Trust was now approaching the standard required.

She highlighted the domain related to access and administration of system documentation which needed to be addressed. These were mainly finance and HR systems and whilst processes were robust the documentation required was not in place.

She noted that the national standards had not been met by several organisations therefore the focus would be on keeping the same standards next year to support organisations to deliver them before any changes were made.

Dr Healey commended the work and report but queried whether not updating the toolkit would lead to a potential risk that it would fall behind in terms of AI. Mr Henry commented that the standards remained the same whether AI was used or not which would ensure compliance.

Mrs McRae thanked Mrs Hanwell for the report.
The Board of Directors received the Data Security & Protection Toolkit (self-certification) and noted the content.

25/090 – Health and Safety Annual Report (agenda item 13)

Mrs Hanwell presented the report noting the detail provided and that it had been shared and discussed at the Audit Committee as part of the assurance and governance process. She noted that the integrated health and safety position had improved and whilst it was a complex area progress had been made with assurance provided on the work taken to date.

Dr Healey commended the progress made and referred to the detail within the Chair’s Report from the Audit Committee that discussions had taken place regarding the separating of patient and staff data, and work remained underway. She added that there was not yet a definition of what health and safety data included, and it needed to be based on a pragmatic review of Datix categories. She noted that the comments made at Audit Committee were to be included in the final version of the report. Mr Wright added that there were inconsistencies in the data provided to various Committees due to limitations of the system but this needed to be acknowledged within the final report. Mrs Hanwell confirmed that the appropriate amends would be made to the report as required and ongoing work regarding the Datix system was in place to support granularity of detail.

Mrs McRae thanked Mrs Hanwell for the report.
The Board of Directors received the Health and Safety Annual Report, and noted the content and assurance provided.

25/091 – Report of the Chief Operating Officer (agenda item 14)

Report of the Chief Operating Officer (agenda item 14)

Mrs Forster Adams presented her report, noting the depth of the discussion at Finance and Performance Committee. She noted that the report highlighted key areas of concern including patient flow and the out of area placement position, which had improved since the report was written but was still considerably off plan. She provided reassurance that the team were focusing on discharge and barriers to this, with discussions at Finance and Performance Committee noting that there was a need to systematise processes to support this, and appropriate accommodation to discharge people to remained an area of focus.

She highlighted that enteral feeding was noted within the report as it was a national issue. The leadership and commitment of the dietetic team had enabled individual service users to receive appropriate treatment, and alternatives were being provided where needed.

The recent resident doctor industrial action had finished the day before with an immediate offer to reengage in discussions, however there was a risk that action would continue over the coming months and move into other professional groups. She thanked all doctors who had provided cover on rosters during this time, supported by colleagues in the medical directorate. She noted that there were varying numbers involved in the action, alongside annual leave also being taken.

She drew attention to two new sections in the report detailing the significant improvements made within the Older People’s Service and Red Kite View following previous Board discussions.

Mrs Forster Adams noted the discussion regarding physical health checks at Finance and Performance Committee as following sustained improvements a deterioration had been seen, therefore work was underway to review this in detail. This would be shared via Finance and Performance Committee and Quality Committee when concluded.

Mr Wright noted the ongoing discussions with resident doctors and the impact of future strikes, and that the numbers of those taking strike action appeared to be higher compared to other industrial action. Mrs Forster Adams commented that there had been variation in the numbers in all previous action, with some numbers as high as over 70% taking part, therefore it could be variable. She added that variation this time had been between 37-49% which was consistent with previous episodes. She noted the continued discussions with the government and BMA however further episodes were expected.

Mrs McRae thanked Mrs Forster Adams for her report, noting the patient flow challenge however the report showed a continued commitment to improve the position. She noted if further support from the Board was required escalation processes could be used.

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

EPRR (agenda item 15) and EPRR Assurance Standards (agenda item 15.1)

Mrs Forster Adams took the document as read and noted that the EPPR Annual Assurance Statement included a declaration regarding expertise and capacity to meet the duty and maintain compliance. The Trust achieved 74% compliance this year, which was non-compliant overall, however there was a plan in place to improve the position. She informed the Board that due to the small resource and team, including a vacancy since March 2025, she was not able to provide assurance regarding the capacity needed to meet the standard. She noted that work was underway to mitigate this with the support of colleagues outside the EPRR function, however she was unable to provide assurance that the standard would be maintained. It was under constant review by the Executive Team and if the position deteriorated support would be requested.

Mr Wright queried if consideration had been given to combining the function across Trusts to support the team capacity overall. Mrs Forster Adams responded that whilst this would provide resilience across partner organisations, the expertise and capacity may not change as there was a limited EPRR resource across other organisations. Dr Munro added that resilience remained low across all organisations against ever increasing national standards for EPRR.

Mrs McRae noted that as the lead Non-Executive Director for EPRR, she shared the capacity concerns raised and that she understood the caveat regarding assurance and acknowledged the reviews across the system regarding the potential to combine resources. She thanked Mrs Forster Adams for her report.
The Board received and approved the EPRR Assurance Standards.

25/093 – EPRR Annual Report (agenda item 15.2)

Mrs Forster Adams took the document as read and noted it had been reviewed at Finance and Performance Committee previously. It provided a summary of activity within the EPRR team across the last year and there were no areas of escalation.

Mrs McRae thanked Mrs Forster Adams for her report.
The Board received and accepted the EPRR Annual Report.

25/094 – Report from the Chair of the Quality Committee for the meetings held on 12 June and 10 July 2025 (agenda item 16)

Dr Healey presented the Chair’s Reports from the Quality Committee meetings held on 12 June and 10 July, taking them as read. She highlighted the need to advise the Board that the domestic abuse, stalking, harassment and honour-based violence assessment (DASH) audit identified low compliance, therefore further detail and review had been requested by the Committee.

She noted the Quality Dashboard review that had taken place and that more detail would be provided at the Committee meeting in September 2025. She also noted the referrals to other Committees as part of the governance structure and processes.

She highlighted that the report regarding patients being classed as absent without leave (AWOL) was being taken through governance discussions to understand the oversight of continuous improvement as this needed to be agreed.

Mrs McRae 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.

25/095 – Safer Staffing Report (agenda item 17)

Miss Sanderson presented the report taking it as read by the Board. She highlighted the inability to provide registered nurse shift cover on one occasion and that further review of the MHOST data would be undertaken in Q3. She noted that there was a continued high level of vacancies across acute inpatient services but that some vacancies would be filled following recruitment. There was a continued focus on supervision practice and data collected and inputted to improve consistency with compliance figures.

She noted that across the acute female pathway there were higher levels of self-harm and violence and aggression which was linked to the higher levels of bank use, therefore the teams worked consistently above minimum staffing levels.

She highlighted the reduction in vacancies at Red Kite View due to two recruitments and student nurses soon to qualify. She noted that nationally the Trust was engaged in the national programme to improve enhanced care provision through increased observations and the work to develop standards and best practice for implementation and engagement in therapeutic opportunities. She noted that this may lead to increased reporting in restrictive practice due to a change in how it was viewed.

Mr Wright queried the MHOST data collection process and Miss Sanderson responded that it was helpful in some in-patient areas but was linked to the national challenge in that it was the only tool available and not helpful across all areas. She confirmed that there was work ongoing at a national level with mental health services input to review this. She noted it should be considered in line with other tools to provide a more holistic view. Dr Munro acknowledged work undertaken regarding therapeutic observations and the link to costing data as any increase in recording for restrictive practice may change segmentation results, therefore needed to be considered as an unintended consequence.

Miss Wilburn noted that the Specialised Supported Living service was included in several discussions regarding efficiencies and finances, and vacancy levels and patient safety incidents, therefore questioned whether there was a need for further review to understand the detail. Miss Sanderson commented that it was a unique service with limited comparison options, and the tenant group were a unique group of people with varying needs which would impact on some areas, including recruitment. Mrs Forster Adams noted that there had been improvements made with contract arrangements, and the service was subject to frequent review from external agencies. Miss Sanderson added that the peer review process would be included in the next Director of Nursing and Professions report to Board to provide detail and assurance.

Dr Healey noted that six month or annual reporting of data may be more helpful, particularly in some services, and Miss Sanderson acknowledged the point for further consideration of presenting data over a longer period.

Mrs McRae acknowledged the point raised regarding the Specialised Supported Living service and that it would be helpful to see the data in the next Director of Nursing and Professions report. Mr Wright queried whether a recent service visit to the service had taken place. Mrs McRae noted she had visited in the last year however the plan would be reviewed for future service visits and the service would be added if required.

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

25/096 – Report from the Medical Director (agenda item 18)

Dr Hosker presented the report taking it as read by the Board. He summarised key areas including a review by the Andrew Sims Centre regarding the admin function to support the wider directorate and changes in models of training. He noted that more information would be provided as the review progressed.

He informed the Board that medical recruitment continued to improve with a reduction in spend on agency doctors, and the Pharmacy Service recovery continued with a focus on culture and the next stage would include governance structures and processes. There was ongoing development of clinical leadership roles, and the Improvement Team were involved in the fourteen organisational priorities and were also reviewing the wider transformation model across the Trust.

Mr Wright asked for clarification regarding the posts listed for AAC panel and Dr Hosker noted that they would go to advert as part of the quarterly process. He added that work was done with the house trainees through the medical leadership team to consider opportunities for individuals.

Miss Wilburn noted that there had been a request from the Mental Health Legislation Committee for more information on the renewal of retentions, and Dr Hosker noted that work was underway with detail expected in September 2025 which would be shared with the Committee.

Mrs McRae noted that the pharmacy recruitment improvement was positive and queried the one year recovery plan progress. Dr Hosker noted that it had started over one year ago, however a listening exercise had been undertaken that generated additional work therefore extended timelines were in place in some areas. He noted he was satisfied with the rate of improvement.
The Board of Directors received and noted the content of the Report from the Medical Director.

25/097 – Guardian of Safe-working Hours Q4 and Annual Report (agenda item 19)

Guardian of Safe-working Hours Q4 and Annual Report (agenda item 19)

Dr Hosker presented the report taking it as read by the Board. He reiterated the role of the Guardian and the mechanisms in place for escalation of concerns via established routes. He noted that the benchmarking results were favourable for the Trust against comparable organisations. He added that there were gaps in the rota periodically which was inevitable due to short term sickness, however mitigation was built in as required.

The Board of Directors received and noted the content of the Guardian of Safe Working Hours Q4 and Annual Report.

25/098 – Report from the Chair of the Workforce Committee for the meeting held on 5 June 2025 (agenda item 20)

In the absence of Mrs Burns Shore the report was taken as read by the Board. Ms Khan highlighted the issue regarding the training space available across the estate, and the outcome of the review of recruitment processes in relation to BAME staff which identified an equitable process. It was therefore hoped that the review of the disciplinary data and process would demonstrate the same level of equity. Mrs Hanwell noted that the estate space issue needed to be considered in the wider discussions around the use of estate across the system.

Mr Skinner noted the job evaluation process with a drive nationally for Boards to be assured regarding processes in place due to grade drift across organisations. He noted that this would allow parity across roles, and the Trust was working through how to provide assurance to the Committee and Board regarding this programme.
The Board of Directors received the Report from the Chair of the Workforce Committee and noted the content.

25/099 – Report from the Director of People and Organisational Development (agenda item 21)

Mr Skinner presented the report taking it as read and highlighted the disappointing minimal change in sickness absence despite the work programmes underway, therefore the focus remained on sickness management action plans, recording of absence and reasonable adjustments implementation when required. He noted that there had been a national increase in complaints to tribunal around reasonable adjustments not being addressed.

He noted that PDR compliance remained stable and acknowledged the work underway. The challenges around staff not attending face to face training were noted and there was a need to review options to drive compliance. He added that there was a focus on recruitment training with all recruiting managers to undertake the appropriate training.

Mr Henry highlighted the benchmarking detail regarding sickness rates with the Trust being in the top three in the region therefore the deeper issues needed to be understood regarding factors for absence. Mr Skinner responded that there was a downward trend in long term absence and an increase in short term so there was a focus on recording and evidencing action taken to address this through the Return to Work process. He added that the Trust was reviewing a system that would support data recording and oversight. Mrs McRae queried if discussion had taken place with other Trusts regarding their position and actions and Mr Skinner responded that there were differences in approaches to sickness management and the Trust focused on wellbeing.

Ms Khan queried if Non-Executive Directors were non-compliant with appraisals, and Mrs McRae confirmed that they were completed but not recorded on the system and this would be addressed. Ms Khan noted that clinical supervision compliance varied across services and Mrs Forster Adams responded that an improvement plan was in place across areas where there was reduced performance.

Mr Wright noted that there had been an internal audit on time and attendance management which found significant assurance which reflected the work that had taken place, and the improvements made.

Mrs McRae thanked Mr Skinner for the report.
The Board received the report from the Director of People and Organisational Development and noted the content.

25/100 – Report from the Chair of the Audit Committee for the meetings held on 17 June and 15 July 2025 (agenda item 22)

Mr Wright presented the Chair’s reports, taking them as read, noting that the Extraordinary committee had taken place prior to the Extraordinary Board of Directors meeting to approve the accounts and reports.

He noted that the July meeting received a number of internal audit reports with several significant assurance results which linked with the private meeting held with the Trust’s internal auditors who commended the Trust’s ability to provide appropriate responses to audits. He highlighted that the Integrated Governance and Risk Management Audit and the Service User Monies Audit had both received limited assurance however the Committee had reviewed the recommendations and were assured with the proposed responses. He added that the Integrated Governance and Risk Management Audit report noted that where risk appetite was referred to there was a need to review the controls associated with each strategic risk to provide evidence for this position which linked to the later agenda item regarding Risk Appetite.

He noted that the sponsorship register was presented with no sponsorships noted and that as part of the medical revalidation process this should be considered to ensure all sponsorships were appropriately captured and noted to ensure the accuracy of submissions.

Mr Henry noted the length of reports provided to the Committee and that the volume and size of reports was increasing which impacted on the time for authors producing reports, therefore there was a need to limit the size of reports. Mrs McRae responded it would be helpful for Chairs of Committees to note issues at the time of the meeting in order to direct authors to specific reports that could be shorted and understand Committee requirements.

Dr Munro noted that the Integrated Governance and Risk Management audit had demonstrated the limitations of the auditor experience in assessing the governance processes in order to get the brief right, therefore this was being further reviewed.
The Board received and noted the content of the Reports from the Chair of the Audit Committee.

25/101 – Board Assurance Framework (agenda item 23)

Dr Munro presented the updated version of the Board Assurance Framework, which demonstrated the current position.
The Board received the Board Assurance Framework and noted the content.

25/102 – Risk Appetite Statement (agenda item 23.1)

Dr Munro presented the report nothing that a risk appetite position had been developed for each strategic risk using the risk matrix and approach from Good Governance Institute. She noted that the proposal had been reviewed at the Executive Risk Management Group with some amendments made following discussion. She noted it was a step change in the Board approach and the recommendation was for the Board to accept the position at the current time, with Committees to consider their specific allocated risks to include the controls and mitigation in place, in line with the risk appetite to balance the potential for innovation whilst also risk tolerance levels.

Dr Healey noted that it was a helpful and clear report however the position was dependent on multiple factors therefore whilst there was a need for a framework there was the need to acknowledge some risks would need to be taken for wider benefit. Dr Munro acknowledged the challenges with agreeing the appetite and it demonstrated the importance of further discussions to understand acceptable failure levels and tolerance.

Mr Wright highlighted that it was important to note that the BAF framework received significant assurance through internal audit, with several reviews showing that there was a good system of control in place. This evidenced that there was a balanced approach to risk in place with a need to focus and refine the list of controls in line with the risk appetite, and consider the level of risk that the Trust was prepared to accept.

The Board agreed to accept the risk appetite position with further discussion to take place at Committee level over coming meetings. Mrs McRae thanked Dr Munro for the report.
The Board received the Risk Appetite Statement and approved the content.

25/103 – Report from the Committees in Common held on 23 July 2025 (agenda item 24)

Mrs McRae referred to the report, taking it as read by the Board. She highlighted the ongoing discussions regarding arrangements as new landscapes progressed, and the prioritisation for mental health support teams in schools in Bradford and Leeds.

Dr Healey queried the target audience for the report and Mrs McRae confirmed that the reports were for Trusts to note as members of the Committee, and if action was required then this would be allocated as appropriate.
The Board received and noted the Report from the Committees in Common held on 23 July 2025.

25/104 – Use of Trust Seal (agenda item 25)

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

25/105 – Any other business (agenda item 26)

There were no additional items of business raised.

25/106 – 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 12:40 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.