Minutes from the Public Council of Governors Meeting – 22 July 2025

Minutes for the Public Council of Governors’ Meeting
22 July 2025 at 1pm

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

Attendance

Governors

Name	Role	Apologies
Les France	Public Governor	Attended
Matthew Knight	Public Governor	Sent apologies
Nicola Lister	Public Governor	Attended
Dr Ivan Nip	Public Governor	Sent apologies
Oliver Beckett	Public Governor	Sent apologies
Miranda Arieh	Public Governor	Sent apologies
Carole Myers	Service User Governor	Attended
Becky Oxley	Service User Governor	Sent apologies
Peter Ongley	Carer Governor	Attended
Jon Salway	Carer Governor	Attended
Ian Andrews	Staff Governor	Attended
Nicola Binns	Staff Governor	Attended
Dr Gail Harrison	Staff Governor	Attended
Amy Pratt	Staff Governor	Sent apologies
Adam Redhead	Staff Governor	Sent apologies
Anne Toone	Staff Governor	Sent apologies
Cllr Ian Cuthbertson	Appointed Governor	Attended
Tessa Denham	Appointed Governor	Attended
Gabriella Obeng Nyarko	Appointed Governor	Attended
Cllr Fiona Venner	Appointed Governor	Attended

Board members

Name	Role	Apologies
Merran McRae	Chair of the Trust	Attended
Zoe Burns Shore	Non-Executive Director	Attended
Joanna Forster Adams	Chief Operating Officer	Attended
Dawn Hanwell	Chief Financial Officer and Deputy Chief Executive	Attended
Cleveland Henry	Non-Executive Director (Senior Independent Director)	Attended
Dr Frances Healey	Non-Executive Director	Attended
Dr Chris Hosker	Medical Director	Attended
Kaneez Khan	Non-Executive Director	Attended
Dr Sara Munro	Chief Executive	Attended
Darren Skinner	Director of People and Organisational Development	Attended
Nichola Sanderson	Director of Nursing and Professions	Sent apologies
Katy Wilburn	Non-Executive Director	Sent apologies
Martin Wright	Non-Executive Director (Deputy Chair of the Trust)	Attended

Also in attendance

- Kieran Betts – Corporate Governance Officer
- Rose Cooper, Deputy Head of Corporate Governance
- Clare Edwards, Associate Director for Corporate Governance
- Dr Michael Farrall, Acute Liaison Psychiatry Service
- Donna Hanson, Clinical Team Manager, Acute Liaison Psychiatry Service
- Dr Jamie Pick, Clinical Director for Community Mental Health Teams and Inpatient Acute Services
- Michelle Place, Community Mental Health Development Manager
- Salma Younis, Audit Director of KPMG

Minutes

25/044 – Welcome and introductions

Mrs McRae opened the public meeting at 1pm and welcomed everyone.

25/045 – Apologies for absence (agenda item 2)

Apologies were noted from the following governors: Miranda Arieh (Public Governor); Oliver Beckett (Public Governor); Matthew Knight (Public Governor); Dr Ivan Nip (Public Governor); Becky Oxley (Service User Governor); Amy Pratt (Clinical Staff Governor); Adam Redhead (Clinical Staff Governor); and Anne Toone (Non-Clinical Staff Governor).

Apologies had also been received from Nichola Sanderson, Director of Nursing and Professions and Katy Wilburn, Non-executive Director.

The meeting was quorate.

25/046 – Changes to any declarations of interest and declaration of any conflicts of interest in respect of agenda items (agenda item 3)

No governor advised of any change to their declaration of interests or declared any conflict of interest in respect of agenda items.

25/047 – Non-executive Directors’ Fit and Proper Person declarations (agenda item 3.1)

The Council noted that all non-executive directors had been judged and declared themselves to be fit and proper.

The Council received a presentation on the Acute Liaison Psychiatry Service (ALPS) from Donna Hanson and Dr Michael Farrall. This included an overview of the function of ALPS, key service objectives and response rates, as well as referral information and a summary of the assessment process.

Firstly, the Council discussed the support in place for frequent attenders at A&E and heard that there was a Frequent Attenders Service which managed individual cases relating to both mental and physical health. The Council heard that ALPS would hold multidisciplinary team discussions about any complex cases and refer as needed to the Frequent Attenders Service. Cllr Venner also noted the importance of community provision such as the Crisis Café for providing people with social support outside of A&E. The Council also heard that work was taking place to review whether people in crisis were being brought to A&E appropriately for the care they required.

The Council then discussed the over-representation of black, and minority ethnic men sectioned under the Mental Health Act. The Council noted that the ALPS team did not deal with mental health detentions directly but heard about what equality and diversity training was available to staff and the specific training for mental health assessors. The Council also heard about the work to reduce health inequalities and noted that information and assurance on this was being reported to the Mental Health Legislation Committee. The Council also discussed the research the Synergi Collaborative had done on early mental health interventions in schools. It was agreed that an item would be scheduled for a future Council of Governors’ meeting on the Health Equity Strategic Plan alongside an update from Synergi-Leeds to provide further information and assurance on this matter (action for Joanna Forster Adams).

The Council then heard about what training was available to staff around complex trauma and Post-Traumatic Stress Disorder which included an e-learning package on trauma developed by NHS England as well as in-house training on trauma informed care. Carole Myers emphasised that staff should be encouraged to undertake this training. She also noted the importance of staff using careful language when people present in crisis and heard that ALPS act as advocates for patients in acute settings.

Members of the Council then raised some issues about accessing mental health support via A&E including experiencing long waits at A&E for a referral to ALPS. The Council heard about some of the reasons why a mental health assessment might need to be delayed and discussed if there were ways to speed up the triage process, especially for those who had been seen by ALPS previously. The Council also queried whether demand was higher at nights and weekends and heard that the data had been reviewed to see if there was a trend of when demand for ALPS was highest, but they had concluded there was no clear pattern in terms of when people were more likely to present in crisis. Merran thanked the governors for the issues they had raised and suggested that Dr Chris Hosker answer any follow-up questions outside of the meeting.

Joanna Forster Adams then thanked Donna Hanson and Dr Michael Farrall for their presentation and highlighted the vital support that ALPS provided to those in need. She noted that some of the issues raised by the governors sat outside the remit of ALPS but reassured the Council that there was a commitment across the partnership and wider NHS to solve the A&E challenges including ambulance transfer issues and long waiting times for mental health support. She added that the Trust’s Head of Operations for Liaison Services was leading on a piece of work to improve the experience of people accessing mental health support via A&E. The Council noted that there would be an opportunity for governors to be involved in this programme of work.

The Council thanked Donna Hanson and Dr Michael Farrall for the presentation.

The Council received the presentation on the Acute Liaison Psychiatry Service and thanked Donna Hanson and Dr Michael Farrall for the information provided.

Donna Hanson and Dr Farrall left the meeting.

25/049 – Minutes of the public Council of Governors’ meeting held on 6 May 2025 (agenda item 5.1)

The minutes of the public Council of Governors’ meeting held on the 6 May 2025 were approved as a true record.

25/050 – Matters arising (agenda item 6)

Cllr Venner referred to an issue raised at the May Council meeting regarding the Mental Health Crisis Helpline. She explained that the helpline would only speak to a family member of a person in crisis if they were the nearest relative, which meant that other family members or friends were unable to access the service. In addition to this, she noted that the helpline now only took referrals from professionals which further restricted access to the service.

Cllr Venner noted that Joanna Forster Adams had agreed to raise this directly with the helpline as the approach contradicted how it was supposed to operate, and she asked for an update on this. Joanna acknowledged that the issue needed to be resolved, and the process made more accessible. She informed the Council that Alison Kenyon who was the Crisis Transformation Lead for Leeds was progressing this with the relevant people. Joanna agreed to feedback to Cllr Venner on the issue directly and then report an update to the February Council of Governors’ meeting (action for Joanna Forster Adams).

The Council noted the matter arising.

25/051 – Questions from members of the public for the Council of Governors (agenda item 6.1)

The Council did not receive any questions from members of the public.

25/052 – Cumulative Action Log – actions outstanding from previous public meetings (agenda item 7)

The Council received the cumulative action log, noted the updates provided, and agreed the actions reported as complete.

25/053 – Report from the Chair of the Trust (agenda item 8)

Merran McRae presented her report and summarised the key points. Merran then acknowledged that it was Les France’s final Council of Governors’ meeting, having completed three full terms as a public governor and served as Lead Governor during this time. On behalf of the governors and the Board of Directors, Merran thanked Les for his significant contribution to the work of the Council. Merran also acknowledged that it was Oliver Beckett’s last meeting as a public governor after serving one term of office. She thanked Oliver for his contribution to the work of the Council.

The Council received the report and noted the information provided.

25/054 – Report from the Lead Governor (agenda item 9)

Ian Andrews presented his report which summarised the activities he had undertaken as Lead Governor since the last meeting and planned activities for the coming months. He noted that he would be continuing to hold one-to-one meetings after each Council of Governors’ meeting and encouraged governors to book onto these. He also shared some feedback on the NHS Providers Governor Focus Conference 2025 which he had recently attended.

The Council received the report from the Lead Governor and noted the updates provided.

25/055 – Report from the Chief Executive (agenda item 12)

Sara Munro introduced her Chief Executive’s Report which included updates from across the Trust and local partnership. She also summarised the update on the Trust’s priorities for 2025/26 and the overview of the 10 Year Health Plan for England, both of which accompanied her main report.

In reference to log number 25/035 on the Council of Governors’ cumulative action log, she informed the Council that the changes to Integrated Care Boards had not progressed further as they were awaiting approval from NHS England to move forward and consult on the changes. She added that the blueprint for the regional footprint of NHS England would provide clarity as to how the regional teams would interact with local providers, but this had not yet been released.

She went on to discuss the changes to the NHS foundation trust status as referenced in the 10 Year Health Plan and explained that the implications of this were still unclear; however, any amendments would require changes in legislation which would take time to enact. She informed the Council that implementation guidance was expected over the coming months, which NHS Chief Executives had been invited to contribute to, and she would continue to share information with governors but in the meantime the work of the Trust would continue as normal. She also referenced the outcome of the Dash Review of patient safety and the implications for the Healthwatch network across England which would also take time to enact.

The Council then received further clarity on the new segmentation system for the performance of individual trusts as per the NHS Oversight Framework. The Council also received assurance from Merran on Sara’s interim Chief Executive role at Leeds Community Healthcare NHS Trust. The Council thanked Sara for her report.

The Council received the report from the Chief Executive and noted the updates provided.

25/056 – Report from the Chair of the Mental Health Legislation Committee – 15 May 2025 (agenda item 14.1)

Kaneez Khan introduced the report from the recent Mental Health Legislation Committee meeting and summarised the key points. The Council noted that the Committee had received an update on the progress of the “Terminally Ill Adults (End of Life) Bill”, also known as the “Assisted Dying Bill”. The Council noted that the Royal College of Psychiatrists had announced that it would not support the Bill in its current form and Dr Hosker provided further details on the reasons for this. The Council also noted there had been an increase in the number of Community Treatment Orders (CTOs) and discussed what might be contributing to this.

The Council received the report from the Chair of the Mental Health Legislation Committee.

Salma Younis joined the meeting.

25/057 – Auditors’ Report on the Annual Accounts (agenda item 10)

The Council received the Auditor’s Annual Report which provided a summary of the findings and key issues arising from their 2024/25 audit of the Trust. To support this, Salma Younis delivered a presentation which outlined the scope of work that had been undertaken. Firstly, she discussed the financial statements audit which looked at key risks relating to the valuation of land and buildings, fraud risk to expenditure, and management override of controls. She confirmed that the Trust had received an unqualified (satisfactory) opinion in relation to this audit. Salma then discussed the assessment of the Trust’s value for money arrangements which looked at financial sustainability, governance, and improving economy, efficiency and effectiveness. She confirmed that the work had not identified any significant weaknesses in the Trust’s arrangements.

The Council then heard about the internal audit process at the Trust, undertaken by Audit Yorkshire, and how the Head of Internal Audit Opinion, amongst other governance elements, informed the external audit opinion. The Council noted that more details on this were provided in the Auditor’s Annual Report 2024-25.

Jon Salway noted the information provided on the valuation of land and buildings and asked if this was affected by the numerous construction projects that were currently happening in Leeds. Salma explained how the Trust’s building assets were valued, which was based on their cost to rebuild at that time, and was therefore not significantly impacted by external factors; however, if the buildings were to be sold then this would be subject to market value.

The Council also received further clarity on what was meant by “material” and “significant” with regard to the audit. Salma explained how the materiality threshold for each organisation was calculated and what factors were considered when deciding the amount that would be deemed “material”. She went on to explain that any findings which were over the reporting threshold would be deemed “significant” and would therefore have to be reported to the Trust’s Audit Committee.

The Council received the Auditor’s Report and noted the information and assurance provided.

Salma Younis left the meeting. Michelle Place and Dr Jamie Pick joined the meeting.

25/058 – Update on the Community Mental Health Transformation Programme (agenda item 11)

Michelle Place and Dr Jamie Pick delivered a presentation on progress with the Community Mental Health Transformation Programme. The Council heard that although this work was specific to working age adults some of the community-based roles had been designed to support people of all ages and that the community offer for older people was in development.

Gail Harrison was pleased to note that analysis of the EMERGE Leeds: Complex Emotional Needs Service had indicated that receiving treatment by the service led to a reduction in the use of other services, such as A&E and Crisis, up to 12 months after discharge. The Council noted that preventative work such as this could help to reduce the costs associated with inpatient admission and Gail highlighted the importance of doing this kind of economic analysis across the whole care pathway. Cllr Venner then noted that EMERGE provided support for young people aged 18 to 25 and asked what provision was in place for older people who would have previously been supported by this service. Dr Pick explained that it had been a conscious decision for the investment to focus on the 18-25 age group to meet the demand but acknowledged that this had left a gap in provision for those aged over 25 which was being looked at.

Joanna Forster Adams highlighted the importance of working in partnership to progress community transformation and thanked Michelle Place for her contribution to this. She then referenced the ongoing work to reduce health inequalities and was pleased to hear that the transformation work was linked into the Health Equity Strategic Plan.

Peter Ongley asked how individuals known to mental health services could be supported to easily access services at the point of need to help prevent a crisis occurring. Michelle acknowledged that this was a challenge and explained that they were looking at how to support people back into the system quickly. The Council also heard that they were looking at how to develop closer working between mental health professionals and primary care in order that patients get a more consistent response when mental health support is required.

Jon Salway noted that there were a number of different computer systems being used across health and care sectors in Leeds and asked what the impact of this was. Michelle acknowledged the challenges associated with transferring data between systems which led to an increased risk of information being missed or incorrect and explained how this was being managed. Cleveland then outlined the work taking place to improve the interoperability of systems across the country but noted that this would take several years to complete.

Carole Myers then highlighted the importance of building trauma informed care into the Community Mental Health Transformation Programme and ensuring that services were accessible for people with complex trauma. Michelle agreed that this was an important area of consideration for the programme.

The Council then discussed the grant holders involved in the programme. Tessa Denham noted the reduction from 25 voluntary sector partners the previous year to nine this year and queried if these partners could be part of real change if their funding only lasted one year. The Council heard that an alliance contract had been developed to provide more flexibility and stability for third sector partners, and this should help to support a more collaborative approach across sectors. The Council also noted that the Trust had sub-contracting arrangements in place with some partners to deliver services on a longer-term rolling basis and that these arrangements were separate to grant funding.

The Council received the update on the Community Mental Health Transformation Programme and thanked Michelle Place and Dr Jamie Pick for the information provided.

Michelle Place and Dr Jamie Pick left the meeting.

25/059 – Report from the Chief Financial Officer (agenda item 13)

The Council received the report from the Chief Financial Officer which provided an overview of the Trust’s financial position at month 1. Dawn Hanwell explained the scale of the financial challenge for the year ahead and emphasised that the Trust had a statutory duty to live within its revenue resources and to breakeven as a minimum.

The Council then heard how the Trust’s approach to recruitment was being impacted by its financial position. Dawn informed the Council that the recent temporary vacancy freeze had been lifted; however, to support the Trust’s efficiency programme, there was a robust process in place to review which vacant posts would be recruited to and this would be informed by various factors including workforce redesign.

Nicola Lister asked how decisions were made around prioritising or reducing service provision and how much involvement the Trust had in this. Dawn explained how services were commissioned using block funding contracts which made it challenging to prioritise and adapt services according to need. However, she informed the Council that outcome measures would become an important factor in the commissioning of services going forward and therefore it was key for trusts to be able to robustly evidence the quality of care provided. The Council noted that the implementation of outcome measures across all care services had been included as one of the Trust’s 14 organisational priorities for 2025/26.

Gabriella Obeng Nyarko then asked how an organisation’s financial status could affect its level of autonomy. Dawn explained how the new performance assessment framework would work, with higher performing trusts in level 1 and 2 experiencing greater autonomy than those in levels 4 or 5. She added that the detail around this had yet to be released but she would be able to provide more information in due course.

The Council received the update on the Trust’s financial position for information.

25/060 – Report from the Chair of the Workforce Committee: 30 April 2025 (agenda item 14.2)

Zoe Burns-Shore introduced the report from the recent Workforce Committee meeting and summarised the key points. She then referred to the Trust’s financial position as per the report from the Chief Financial Officer and explained how the refreshed People Plan was designed to support the Trust to focus on key workforce areas in a resource constrained environment.

Ian Andrews asked if the workforce performance data indicated whether the vacancy freeze that happened earlier in the year had impacted on quality at the Trust. Zoe responded that she was a member of both the Quality Committee and Workforce Committee, and neither committee had cause for concern about resource levels as a result of pausing recruitment, but this would continue to be monitored closely.

The Council then discussed the metrics that were used to measure quality and asked whether these were sufficient to develop a clear understanding of quality across the organisation. The Council heard how the Quality Committee received an annual presentation from each service line using STEEEP (Safe, Timely, Effective, Efficient, Equitable and Patient-centred care) which was an established framework for measuring quality. Dr Frances Healey then outlined other means of gathering assurance on quality specific to mental health trusts, for example, the link between stable leadership and lower levels of restrictive practice. The Council was assured by the responses provided but noted that improvements needed to be made to the recording of clinical information to support the measurement of quality and this was work in progress.

The Council received the report from the Chair of the Workforce Committee.

25/061 – Report from the Chair of the Audit Committee: 8 April 2025 (agenda item 14.3)

Martin Wright introduced the report from the recent Audit Committee meeting and summarised the key points.

The Council received the report from the Chair of the Audit Committee.

25/062 – Reports from the Chair of the Quality Committee: 10 April and 8 May 2025 (agenda item 14.4)

Dr Frances Healey introduced the reports from recent Quality Committee meetings and summarised the key points. She also provided some clarity on the mortality rate figures in the Quality Performance Report.

The Council received the reports from the Chair of the Quality Committee.

25/063 – Reports from the Chair of the Finance and Performance Committee: 22 April and 27 May 2025 (agenda item 14.5)

Cleveland Henry introduced the reports from recent Finance and Performance Committee meetings and summarised the key points. Tessa Denham then asked what was being done to address the increase in the Gender Identity Service waiting list. Sara Munro informed the Council that there had been a national review of access and waits for gender services led by NHS England and the intention was to create a centralised waiting list with a national team distributing referrals to individual organisations. Dr Hosker added that there was an embedded improvement lead within the Trust’s Gender Identity Service and senior members of the team had contributed to the review and attended regular meetings with the national team.

The Council received the reports from the Chair of the Finance and Performance Committee.

25/064 – Approval of changes made to the Procedure for the Repayment of Governors’ Expenses (agenda item 15)

The Council approved the changes that had been made to the Procedure for the Repayment of Governors’ Expenses, prior to being ratified by the Policy and Procedures Group.

25/065 – Review of the Council of Governors’ Terms of Reference (agenda item 16.1)

The Council was assured that the Terms of Reference had been reviewed to ensure they continue to be fit for purpose and reflected the changes to the meeting arrangements for 2026 and approved the update as per the cover sheet.

25/066 – Annual Cycle of Business for 2026 (agenda item 16.2)

The Council received its Annual Cycle of Business for 2026 which had been updated to reflect the new meeting arrangements; was assured that it included all the statutory duties which the Council must carry out and was assured that the areas which governors had asked to be kept informed on had been captured. The Council approved the Annual Cycle of Business for 2026.

25/067 – 2026 meeting dates (agenda item 16.3)

The Council noted the meeting dates for 2026 which had been updated to reflect the new meeting arrangements and noted the request that governors advise the Corporate Governance Team if they are unable to attend any of the meetings.

The Chair of the meeting closed the public meeting of the Council of Governors of Leeds and York Partnership NHS Foundation Trust at 4:15pm. She thanked governors and members of the public for their attendance.