Public Board Agenda – 13 November 2025
Unconfirmed Minutes of the Board of Directors meeting (Public session) held on Thursday 11th September 2025 10:00hr
Clinical Education Centre, Russells Hall Hospital
Present:
Rachel Barlow, Group Chief Development Officer (RB)
Laura Broster, Group Director of Communications (LB)
Gary Crowe, Deputy Chair (CG)
Peter Featherstone, Non-executive Director (PF)
James Fleet, Chief People Officer (JF)
Joanne Hanley, Non-executive Director (JHa)
Anthony Hilton, Associate Non-executive Director (AH)
Liz Hughes, Non-executive Director (LH)
Karen Kelly, Chief Operating Officer/Deputy Chief Executive (KK)
Mick Laverty, Associate Non-executive Director (ML)
Mohit Mandiratta, Non-executive Director (MMa)
Martina Morris, Chief Nurse (MM)
Sir David Nicholson (SDN) Chair
Vij Randeniya, Non-executive Director
Kat Rose, Chief Integration Officer (KR)
Adam Thomas, Group Chief Strategy & Digital Officer (AT)
Chris Walker, Interim Director of Finance (CW)
Lowell Williams, Non-executive Director (LW)
Diane Wake, Chief Executive (DW)
In Attendance:
Helen Attwood, Directorate Manager (Minutes) (HA)
Helen Board, Board Secretary (HB)
April Burrows, Freedom to Speak Up Guardian [for item 9.4]
Fouad Chaudhry, Consultant (FC) [for Guardian of Safe Working Report]
Helen Codd (HC) [for item 7.1]
Sally Cornfield, Partnership Programme Director (SO) [for item 7.1]
Ninette Harris, Sustainability Lead – DGFT
Paul Hudson, Deputy Medical Director (PH) for [Jonathan Odum]
Claire Macdiarmid, Director of Midwifery [for item 8.3]
Mr Max Osborne, ENT Consultant (MO) [for the Patient Story]
Dr Ayeshea Shenton, ENT Consultant Surgeon (DrS) [for the Patient Story]
Mr Woo-Young Yang, ENT Consultant (WYY) [for the Patient Story]
Apologies
Anne-Maria Newham, Non-executive Director
Catherine Holland, Non-executive Director
Jonathan Odum, Interim Medical Director
Governors and Members of the Public and External attendees
Julius Adams, Trust Governor for Halesowen
Arthur Brown, FT Member and former Governor
Alex Giles, Trust Governor for Stourbridge and Lead Governor
Siddique Hussein, FT Member
Angelika Pachowicz, Trust Governor for Brierley Hill [part of the meeting]
Corbett Meadow Action Group members: Helen Cook, Paul Watson. Anne Millward-Baker
25/60 Apologies and Welcome
The Chair welcomed members of the Corbett Meadow Action Group to the meeting who presented the Board with a petition and confirmed that an electronic version would be shared with the Trust for circulation to the Board. The Chairman confirmed that the petition would be circulated to all Board members and the Trust would formally respond to the petition in writing.
The Chair welcomed Board colleagues, Governors, members of the public, foundation trust members and external attendees. Apologies were noted as listed above. The Board noted that this was Anthony Hilton’s last meeting and the Chair thanked him for his commitment to the Trust during his time at Dudley.
25/61 Staff and Patient Story – ENT Head and Neck Faster Diagnosis Standard (FDS) Pathway Update
The meeting was joined by Mr Woo-Young Yang, Mr Max Osborne, Consultant ENT Surgeons and Dr Ayeshea Shenton, consultant radiologist specialising in head and neck, who presented on the new pathway and shared the Patient Story.
The presentation provided information on the redesigned suspected head and neck cancer pathway and its impact on patients. The story was told by a patient who had noticed a neck lump in February 2025. She underwent an ultrasound scan of the neck lump, which showed findings suggestive of metastatic cancer in one lymph node from the throat. The ultrasound scan, neck lump biopsy, CT scan, MRI scan and throat biopsies were performed in a very quick succession, only days after one another. The patient complimented the head and neck cancer team at the Trust for their service and compassion and felt that she could not have received better care in the private sector. The Board noted the need for additional head and neck Radiology capacity.
PF commented on the inspirational leadership from the team. He asked about using the same approach for other clinics. DrS confirmed that the close working between Ultrasound and the ENT service offered a perfect model for diagnosis compared to other cancers. WYY confirmed that the ICB would like to share the model with other specialties.
The Chairman thanked Mr Yang, Mr Osborne and Dr Shenton for their presentation. He commented on the remarkable performance and league table position. He wished the team good luck at the upcoming HSJ awards.
It was RESOLVED to
25/62 Declarations of Interest
The Chair declared that he was the shared Chair of Sandwell and West Birmingham NHS Hospitals Trust, Royal Wolverhampton NHS Trust and Walsall Healthcare Trust. The Declarations of Interest Register for all board members was available on the Trust website.
25/63 Minutes of the previous meeting held on 10th July 2025
The minutes of the previous meeting were approved as a correct record.
It was RESOLVED to
- approve the minutes of the last meeting
Action Sheet of 10th July 2025
25/52.1 Corporate transformation update – deferred to November.
25/48 Lung cancer screening programme – in progress. Update to the next meeting.
25/64 Chief Executive’s Overview and Operational Update
DW summarised her Chief Executive’s report given as enclosure two and highlighted the following key areas:
DW confirmed that an Improvement approach was at the heart of the organisation and described some of the improvement work that had taken place during the year. The Board heard feedback from the Community Frailty improvement event and the recommendations and actions where the Trust was focussed.
Operational Performance remained incredibly strong, the Trust is achieving national ED standards and cancer targets. The work on ambulance handover delays was ongoing and the Trust was working to maintain a consistent approach.
The Trust had been assigned as segment three of NHS Oversight Framework and position 33 out of 134 in the league tables. The Trust was working to maintain and build on this excellent position.
The Trust was currently undertaking a Provider Capability assessment that would be considered at the next Board workshop on 9th October.
The Board noted the much improved response rate to the Pulse Survey and was currently preparing for the next staff survey.
The Board noted the position in relation to Block Contract payments.
DW also updated the Board on the impact of the recent resident doctors industrial action noting limited effect on operational and safety performance.
DW recognised the Leng Review and noted the important work that Physicians Associates undertook in the organisation.
The Board was asked to approve the name change to the Dudley Group University NHS Foundation Trust and Russells Hall University Hospital.
MMa raised the Leng Review and asked for assurance that staff were appropriately supported. PH confirmed that the review had impacted staff and assurance that the Trust was providing comprehensive support.
In response to a question from MMa about the cost of the name change in respect of signage and other branded items, LB confirmed that the cost of amended signage would initially be £7.5k and thereafter would be phased in as an when documents and other materials required update.
ML asked about the preparation for the annual staff survey and how response rates compared to other organisations. DW confirmed that the Trust benchmarked well as part of the league table where response rates varied between 45 and 50% and noted that the matter of the Trust’s approach to improving them was also picked up via the Trust Management Team. The Trust works very hard to drive an increased response rate and had previously been nominated for a HSJ award for this work.
AH commented on the Leng Review and that Aston University were also supporting its students. He congratulated the Trust for achieving University status and that it was being nationally recognised.
VR commented on the recently published league tables and asked how best practice was shared. DW confirmed that there were some benefits to league tables and that organisations look at how they can work well together to share good practice and improve services. AT added that this was the cornerstone of the NHS Impact work; taking and sharing learning across other organisations.
PF commented on the good news in the report and asked about the Urology GIRFT review and having recently seen the DaVinci robot, asked what the robotic fellowship meant for the Trust. DW confirmed that a Robotic Strategy for the Black Country was being developed and confirmed that each of the four providers each had surgical robots in place. The Trust was to advertise shortly for a second Renal Consultant to improve outcomes for our patients.
It was RESOLVED
- To receive as assurance that The Dudley Group NHS Foundation Trust is represented and have a voice within the Black Country Integrated Care System and at regional and national levels.
- To approve the name change for the Trust and Russells Hall Hospital as described in the preamble to this minute.
25/65 Chair’s Update
Public Questions
The Chair presented the Public Questions, given as enclosure three.
Nandi Shalembe, Foundation Trust Member, asked:
- At the last meeting held, we spoke about lung cancer, and how to publicise it so people can start to get themselves checked. Yes we spoke of “hubs”. Just to ask if we you have considered billboards especially in places where we know is rush hour time, where people are on their way home from work stuck in traffic and bored so they start gazing, e.g. places like Merry Hill etc, bus stops or stations.
LB confirmed that placing high-impact adverts in locations such as Merry Hill, bus stops and commuter routes can certainly boost awareness and benefit from strong recall, especially in high-footfall areas. For example, highway billboards often achieve recall rates of up to 60%. When it comes to actual engagement or conversion of awareness into action, the numbers tell a different story. Across the industry, the typical engagement rate for outdoor advertising sits between 3% and 6%. So, in summary these channels are important but might not reach a specific audience and can have a high cost per interaction as a result.
- At the last Board meeting the Chief Nurse had mentioned that having an input from members of the public due to their experiences in maternity would be beneficial. I’d like to make her aware of a lady named Joanne Bussey. She is Parent and Family engagement lead for West Midlands perinatal network (neonatal critical care clinical network) who is very happy to assist in any manner. If you think this is a good idea I’ll pass over her details, as I have had a word with her and she’s more than happy to interact.
MM thanked NS for her suggestion to put us in touch with Joanne Bussey. Providing Joanne is a Parent and Family Engagement Lead for the West Midlands Perinatal Network, it is likely she is already engaging with our teams. Claire MacDiarmid (Director of Midwifery) or Katie Philpott (Head of Midwifery) will be happy to be contacted to discuss the offer further and engage with Joanne.
- Hawnes Lane Surgery doesn’t seem to be operating at the moment, and everyone is using Feldon Lane Practice. Appointment booking to see a GP is between the hours of 8am-11am via phone books, as a Halesowen resident the phone is busy at 8am by the time you get through, may that be 9.15 there no slots left and you told to ring again the following morning. Yes you can book online, but there is a 4 weeks waiting period as there is a back log. What can you do to improve this? Also repeat prescription method has changed now you can’t call over the phone, bearing in mind there’s vulnerable people, the old and those that might be on opioids. How do we tackle this seeing Hawnes Lane doesn’t seem to be active.
Dr Mandiratta, GP Partner at Feldon Lane Practice, that also operates Hawnes Lane confirmed that Hawnes Lane is fully operational and with Nandi’s agreement has asked the Practice Manager to liaise with her directly to resolve the queries raised.
The Chair spoke briefly about the journey to a single Board and thanked everyone for their cooperation in the process. GC confirmed that considerations for the selection of group non-executive directors would conclude by the end of October. Approval would be sought by the Chair and Chief Executive, the Council of Governors and NHS England. The Deputy Chairs would meet individually with all non-executive directors to share the outcome of the process and discuss next steps.
It was RESOLVED
- To note the public question and answer provided.
25/66 Integrated Committee Upward Assurance Report
GC introduced the report given as enclosure four, including upward assurance from each of the Committees, Finance & Productivity, Quality, People, and Integration. Non-Executive Committee Chairs were invited to raise any particular items for escalation to the Board.
GC summarised the following key areas to assure, advise and alert for Board members to note:
Assure
Finance & Productivity Committee
Continued strong operational performance, particularly in elective pathways and cancer targets. Good progress on the Emergency Department redesign project. Improved Emergency Preparedness, Resilience, and Response (EPRR) compliance, moving from partial to full assurance. Procurement performance exceeded savings targets and benchmarked in the top national quartile.
Quality Committee
Reduction in complaints backlog following implementation of the responsiveness improvement plan. Decrease in Trust-acquired pressure ulcers, indicating improved preventative care. Significant improvements in diabetes care and insulin safety, with reduced incident rates.
Safeguarding Level 3 mandatory training compliance increased to 84% (from 70%). Developing Workforce Safeguards compliance 9 of 12 safe care standards fully met, 3 partially met. Positive findings from the Clinical Nurse Specialist review, confirming appropriate capacity and skill mix.
Reduction in hospital-onset CDI and BSI cases in Q1 2025/26, below national thresholds.
Weekly assurance reports confirmed consistent performance in care of acutely unwell children in ED.
Quality Impact Assessments (QIAs) were being effectively applied within the Cost Improvement Programme.
UNICEF Baby Friendly Initiative reassessment yielded very positive feedback, Trust accreditation maintained.
Assurance received from the latest safe staffing nursing staffing review, with approved uplifts for wards C3 and C1a/b, subject to funding. In addition, review of the Clinical Nurse Specialist workforce was undertaken with the paper and recommendations which are being progressed.
People Committee
Workforce KPIs show positive trends, vacancy rate reduced from 10% to 9%, improved retention, and high compliance with mandatory training (93.6%) and appraisals (92%). Deep dive into the Surgery, Women’s & Children’s division highlighted progress on staff survey actions, sickness absence, and training. Band 2/3 back pay is on track for payment in September 2025. ESR alignment between Dudley and Sandwell progressing well, supporting best practice standardisation.
Integration Committee
Strong engagement and early positive impact from Community Frailty Intervention teams and Care Home pilots. Community Services update aligned with the 10-year plan; CNC improvements include extended phoneline hours (6am–10pm), electronic referrals, and dedicated WMAS line. Six-month Health Inequalities update showed progress through equity-focused service planning, strengthened governance, and enhanced education and training.
Advise
Finance & Productivity Committee
Continued scrutiny of the Black Country Pathology Service, with noted minor improvement. Winter Plan and Length of Stay actions to remain standing items, focusing on bed base reduction and improved patient flow. A deep dive report on screening programmes had been requested.
Quality Committee
Fourteen WTE vacancies filled by newly qualified midwives starting in Sept/Oct 2025; bank staff used to mitigate. 9WTE Midwifery Support Worker vacancies also recruited. Monthly meetings and deep dives underway to review cleaning provision across the Trust. Discharge Lounge reinstated.
REACCT and Care Transfer Hub models launched. CCTD and HITWAFE workstreams improved compliance with Estimated Discharge Dates to 85%. Digital Bed Management system now live and fully integrated, enhancing real-time bed visibility and operational flow. Chest Pain Pathway deferred, paper now received via RAG Highlight Report with assurance and next steps outlined.
Digital Collaboration work ongoing across the ICB and providers to explore joint contracts for Patient Administration System and Electronic Staff Record.
People Committee
Sickness Absence increased to 5.68% in July, driven by long-term sickness. Mitigation includes occupational health access, return-to-work interviews, and targeted departmental support. Winter pressures may impact sustainability. Medical Bank pay rates proposed changes may prompt collective action. All Trusts advised to conduct risk assessments and align system-wide approach.
Integration Committee
End-of-year report on High Oak and Chapel Street to be received. Future communications to include areas for improvement and feedback. Escalation to the ICB regarding decision not to offer Dudley Quality Outcomes Framework in 2026/27 and delay in risk stratification tool development.
Joint Infrastructure Committee
Infrastructure Project Authority (IPA) Gateway 5 Review graded ‘green’ with a commendation from the Review Team. Joint Workshop held on 18th July, early progress on 2025/26 priorities, long-term ambitions, and shared best practice. 3-year Digital Plan well progressed and will be merged with the Estates Plan into a unified Infrastructure Plan.
Alert
Operational performance concerns on ED triage and ambulance handovers contributing to delays in flow, use of Temporary Escalation Areas and poor patient experience. Financial pressures on delivering the workforce plan, cost improvement plan and financial risk in the Winter Plan. Quality concerns focus on compliance to Quality and Safety standards and practice.
Finance & Productivity Committee
The Winter Plan presented a financial risk to achieving this year’s budget. The lack of a fracture liaison service in the Dudley Borough. The Trust faced a shortfall of £17.3m of Cost Improvement Programmes, noting the ongoing work to mitigate this.
Quality Committee
Fragility of the Mental Health Act Administration Service contracted from Walsall Healthcare NHST. Current inability to fully meet the MIS Year 7, Maternity and Neonatal Voices Partnership (MNVP) safety action due to a lack of national funding. Mitigations in place will support compliance but requires a longer-term solution. Increase in incidents to open Temporary Escalation Areas (TES) areas due to continued flow and challenge for ambulance offload requirements. Work ongoing to improve current low compliance with second assessment for VTE to link with discharge planning, the downward trend for sepsis compliance in ED and Vital Signs Q1 compliance at 60%, although noting this is improving.
Stillbirth rate increased to 3.48 per 1,000 births in July. A Deep Dive was underway, with oversight in place to monitor impact and outcomes. Increase in complaints, with no new themes or trends. Divisional review ongoing to explore how early intervention can prevent complaints and early resolution.
People Committee
Workforce Plan has a negative variance of 60 WTE, with bank usage over plan by 84 WTE, industrial action has contributed to a medical bank increase.
Non-executive committee chairs were invited to contribute to any matter that may require more discussion.
It was RESOLVED to
- Approve and note the report of assurances provided by the Committees upward reports, the matters for escalation and the decisions made.
25/24.1.1 Finance Report Month 4 (July 2025) including Cost Improvement Update
CW presented the Month 4 (July 2025) Finance Report given as enclosure five. The Board noted the following key highlights:
Assure
After technical changes the July cumulative position was a £5.622m deficit. This position was £0.160m better than the financial plan submitted to NHS England in March.
The Trust was forecasting achievement of the 2025/26 financial year planned break even position after technical adjustments noting an associated risk to deliver that the Trust was actively mitigating.
The Trust was forecasting a healthy cash balance for the 2025/26 financial year.
The Board was asked to note the Black Country Integrated Care System July 2025 financial position and year end plan of breakeven. The July position was £0.045m better than the financial plan submitted to NHS England in March. The System had received the first two quarters deficit funding from NHS England.
Advise
The Trust’s financial forecast for the 2025/26 financial year remained in line with the plan at a breakeven position. The Trust continued to review the financial risk to achieve the plan which stood at £30.476m. The Trust needed to have a fully mitigated plan for the risk by the end of September.
Pay expenditure to the end of July was overspent against plan for the first time this financial year with an overspend of £0.028m. Additional costs were incurred in July relating to medical cover for the resident doctors’ industrial action. The Trust needed to ensure it reduced both bank and agency expenditure for the remainder of the financial year.
Alert
Agency expenditure usage continued to see an increase against plan and was above the target by 13 whole time equivalents resulting in a cumulative overspend of £0.434m at the end of July. 99% of agency expenditure relates to consultants and career grade doctors.
Non-pay expenditure was above plan at the end of July by £2.209m. This was related to cost improvement savings shortfall and increased drug and devices expenditure.
Currently there was £14.316m of the cost improvement programme still classed as opportunities with no plans in place to deliver this amount with all mitigation plans in place by the end of September to deliver the full cost improvement plan.
GC asked in relation to bank and overstaffing against plan, how the Trust was assured about the best use of bank and that there sufficiently robust controls in place. CW confirmed that there was much work undertakes in terms of divisional challenge. As Finance Director he remained to be assured around grip and control on bank usage. JF added that there were issues in Nursing, Medical and Admin and Clerical. The Trust undertook prospective rostering but noted that Bank spend had increased and greater control was required adding that some immediate actions were being taken and these would be discussed in detail at the Private Board.
LH commented on medical cover for leave and what controls were in place. JF agreed that greater grip was required in respect of leave management and was one of the measures being taken.
PF raised deficit funding and how risk was being managed at system level with associated risk and mitigations. CW confirmed that funding was released on a quarterly basis. Finance Directors and Chief Executives met on a quarterly basis to consider the overall risk. There was one Black Country risk ahead of plan but all organisations were in the same position in terms of CIP delivery. There would be greater oversight by NHSE for trust’s that were not on plan.
ML asked about tracking the use of higher value bank staff. CW confirmed that the high cost spend was tracked through the divisional challenge meetings. Tracking WTEs is not exact and vacancy freezes are a blunt tool to achieve this. JF outlined the work underway to manage sickness levels and steps to improve nurse leadership to improve controls.
The Chair asked if actions that were underway would deliver the needed change and improved position. The Board needed to be clear about the actions to be further assured.
It was RESOLVED to
- Note the financial performance for Month 4 (July 25) and the reported Trust and System 2024/25 financial year end position.
25/25 Our Place – Build Innovative Partnerships to Improve the Health of our Communities
25/25.1 Dudley’s Approach to Neighbourhood Health
KR presented Dudley’s approach to Neighbourhood Health given as enclosure six. The Board noted the following key highlights:
Assure
In July Dudley partners undertook a National requirement to complete and submit a “Neighbourhood Health Maturity Self-Assessment” which evaluated system-wide progress across the six core components of Neighbourhood Health. The assessment clearly defined the standards, expectations, and developmental priorities required to advance integrated neighbourhood working in Dudley.
In July the Dudley Health and Care Partnership hosted a workshop to have a conversation about what Neighbourhood Health and hubs look like or mean to the people of Dudley and to provide an overview of what is already happening locally (in Dudley we have strong foundations with existing Family Hubs and integrated Community Partnership Teams well established). Also in July, Dudley completed an application to the National Neighbourhood Health Implementation Programme (NNHIP). All partners, including Primary Care Network Clinical Directors were instrumental in completing the application, and have committed to do more to hear the voice of our Primary Care clinicians. A further workshop on Neighbourhood Health for Primary Care would be led by the Place Development Team in September/October. In addition to plans for Neighbourhood Health, to include the development of Children’s Integrated Neighbourhood Teams (CPTs in Dudley), there would be further discussion amongst GPs regarding the announcements of new Neighbourhood contract’s which was a subject of discussion and debate.
Advise
Unfortunately the Trust was unsuccessful in achieving a place on the NNHIP programme but would continue to develop Neighbourhood Health Plans as stipulated in the Planning Framework for the NHS in England. Further guidance was awaited on what was required within the plans; noting that a lot of the work undertaken to date and outlined in the report provided to Board in July would form the foundation of the Plan.
Alert
There were ongoing conversations with Primary Care regarding the announcement of a new contract which was a subject of discussion and debate.
Neighbourhood Health Services will be discussed at the September Health and Wellbeing Board. Ongoing changes in both the ICB and the Local Authority may impact the pace of change in Dudley.
SC and HC invited Board members to engage via Slido and share what they consider were the opportunities for Dudley Group in developing Neighbourhood Health. Key messages included prevention, Social Care, meaningful engagement and Community first. Board members shared their thoughts and reasons for identifying specific messages.
The Chair outlined the importance of the work in moving to a Community Service and how it aligned with the 10 Year Plan. The Trust had huge resources to help engage our communities.
He thanked KR, HC and SC for their work.
It was RESOLVED to
- Consider what are the key opportunities for Dudley in developing Neighbourhood Health, commit to providing strategic leadership to the development of Neighbourhood Health Services and contribute to the development of Dudley’s Neighbourhood Health Plan and ensure the Trusts Five-year Integrated Delivery Plan supports the delivery of Dudley’s Neighbourhood Plan.
[There was a short comfort break]
25/26 Deliver Right Care Every Time
25/26.1 Chief Nurse and Medical Director Report
MM and PH presented the combined Chief Nurse and Medical Director Report given as enclosure seven that focussed on the quality metrics.
Assure
Whilst nationally there was apparent bureaucratic overlap and fragmentation as detailed in the report, as a provider Trust, it was important that we influence change whilst working through mitigations that promote a culture of quality and safety for our patients and staff. Mitigations were in place to manage the associated risks, and these would continue to be proactively reviewed as the NHS landscape and associated governance changes progress.
Advise
As well as the recommendations made with regards to regulation and associated governance, Dr Penny Dash made important recommendations with regards to patient voice, complaints management, critical importance of moving care into community, ongoing focus on growing the digital agenda and a significant opportunity to positively influence the health inequalities agenda across the NHS and wider. In addition, it made an important point of absent national quality strategy for social care.
Alert
None to note.
GC commented on some of gaps identified in the report and the call for action to do more. AT agreed that the need to focus on our in-year objectives.
LW added he was encouraged around the conversations on AI and the opportunities it offered and encouraged the Board to champion its use in the organisation.
VR wanted to understand the opportunities relating to AI and how we used it as a strategic driver. LH added that we need a plan for implementation. ML commented that there is a risk of using AI and then retrofitting to solve a problem. PF suggested collaboration with Local Authorities.
AT confirmed that data sharing agreements were not an issue and confirmed that the Data Strategy would be presented to the Board in November.
The Chair thanked PH and MM for their comprehensive report.
It was RESOLVED to
- Draw assurance from the work undertaken by the Chief Nurse and Medical Director’s office, to drive continuous improvements in the provision of high quality of care and patient experience and contribute to the successful achievement of the Trust Strategy’s objectives.
25/26.2. Integrated Quality and Operational Performance Report
PH, KK and MM presented the Integrated Quality and Operational Performance Report given as enclosure eight. The Board was assured that the performance reports had been considered in detail at the respective Committees prior to submission to the Board of Directors.
The report summarised the Trust’s Quality and Performance data for the month of July 2025 (May/June for Cancer and VTE). The Board noted that the associated data pack was included the reading room.
Board received detailed papers to provide assurance that:
- The nursing safe staffing reviews continue to be undertaken in line with national process – the latest inpatient safe staffing report was shared where an uplift was recommended and approved for wards C3 and C1a and C1b, subject to identified funding as per the current financial envelope.
- A review of the Clinical Nurse Specialist workforce has been undertaken, with opportunities identified, related to professional and process aspects which are being taken forward.
- An assessment has been undertaken against the refreshed Infection Prevention and Control Assurance Framework, which identified overall compliance apart from ongoing challenges with hospital cleanliness consistencies and food rating. A deep dive is in progress, which will provide an opportunity to identify what further interventions are required.
Assure
Quality:
ED Acutely Unwell Child: Performance in the care of acutely unwell children had improved through a dedicated meeting chaired by the Head of Children’s Services, with input from senior MDT members. Progress was monitored via weekly assurance reports and SPC charts. Key improvements include Paediatric ED triage compliance increased from 65% to 89%, with no missed triages since mid-June. Specialty review compliance improved from 22% to 56–76% following targeted education. Sepsis response and e-observations compliance have improved across all paediatric areas. A robust paediatric clinical review of incident and deterioration (PaediCRID) monitoring and learning process is in place. The group would continue until improvements were embedded and sustained.
In line with the Patient Safety Incident Response Framework (PSIRF), the IPC team conducted post infection reviews for all Hospital Onset Healthcare Associated (HOHA) cases to identify recurring themes and support shared learning. Due to the Trust exceeding BSI thresholds in 2024/25, and with further threshold reductions for 2025/26, the IPC team was developing a targeted improvement plan to run alongside the existing CDI improvement plan. Encouragingly, there has been a reduction in HOHA cases for both CDI and BSI in Q1 2025/26, with 22 cases reported compared to 44 in Q1 2024/25. A refresh of the IPC BAF had been completed and was located in the reading room associated with the meeting.
Gold Standards Framework (GSF): GSF accreditation had been successfully achieved for AMU 1 and 2, C1b, and B2 Hip, with re-accreditation for C7.
Performance:
Discharge Ready Date (DRD): In July, performance against the Discharge Ready Date (DRD) metric improved significantly, with the average days from DRD to discharge reducing to 3.63 from the 5–6-day trend seen earlier in the year and demonstrated the impact of strengthened discharge planning and closer coordination with community partners.
Emergency Performance: In July ED 4-hour performance was at 78.40% vs the national target of 78%.
Cancer Performance: 28 Day Faster Diagnosis Standard (FDS): Achieved 78% against national target of 77% (March 2026 national target is 80%). Increased focus on individual tumour site pathways to achieve monthly plans submitted to NHSE and for performance to be sustained.
DM01 Performance: DM01 for July continued to improve with performance of 88.4% compared to 87.1% in June. Backlog and number of 13+ week waits has reduced from 263 last month to 192.
Elective Restoration & Recovery: Performance against the 18-week RTT standard had shown continued improvement, with 62.9% of patients treated within 18 weeks; a position that is 1.4% ahead of trajectory.
Advise
Quality:
Safer staffing: Staffing compliance and Care Hours Per Patient Day (CHPPD) were slightly lower in July compared to June. There was a minor increase in care support worker bank usage, while registered nurse bank usage remained consistent.
Bank usage continues to be utilised in areas with high vacancy rates, particularly in the Emergency Department (ED) and medical emergency wards, including coverage for the Temporary Escalation Space (TES) areas and additional beds in the Acute Medical Unit (AMU). The Corporate Nursing Team had continued to provide support in line with the established rota.
As of July, 130 student nurses on placement within the Trust are due to qualify between February and September 2025. Of these, 22 have been offered positions within the Trust, while 108 students were still seeking employment. The NHS England Chief Nursing Officer (NHSE CNO) has announced a Graduation Guarantee for all newly qualified nurses and midwives. The Trust awaited further guidance from the Integrated Care Board (ICB) regarding a system wide implementation approach.
Pressure Ulcers (PUs): In July, there was an increase in Trust acquired pressure ulcers, with 157 incidents reported compared to 135 in June. Of these, 83 occurred in inpatient ward areas and 74 in community settings. Of the 157 incidents, 32 triggered a Serious Incident Triage (SIT) investigation. Outcomes of the investigations found 22 cases resulted in no harm and 10 in low harm. No cases were classified as moderate harm. Key themes identified include inaccurate risk assessments and delays in equipment provision.
These concerns have been escalated to the supplier. A new equipment tender process is currently live, with evaluations of the top three suppliers scheduled for 19th and 20th August. The Trust continued to work collaboratively with system partners to identify and implement strategies to reduce pressure ulcer incidence.
Falls: The total number of in-patient falls decreased slightly to 88 in July compared to June. Two After Action Reviews (AAR) were conducted, with one incident resulting in moderate harm and the other in low harm. The rate of recurrent falls has remained stable.
A trolley risk assessment has been developed for implementation across Emergency Department (ED), theatres, maternity, and day case areas and is in final consultation stage.
Performance:
ED Triage: July’s Overall Triage position is 81.8% vs 95% national target. Arrivals via ambulances and front door triages were high, limiting the front door triage performance, along with high acuity of patients.
Cancer (Data to June) 28-day FDS: Performance to be sustained. Forecast shows achievement of monthly plan from July 2025.
31 day combined & 62 day combined: Gynae and skin capacity most challenged. Extra slots have been provided for both tumour sites and shows an improved position from July onwards.
DM01: Sleep Studies equipment and additional workforce providing extra capacity. Staffing challenges in June and July have impacted recovery plan and revised trajectory will clear 6+ week backlog by October 2025.
Elective Restoration & Recovery: For 52-week waits, a revised trajectory was agreed through the annual planning process, extending delivery to the end of Q2. Corrective actions are in place to recover this position and achieve zero 52-week breaches by the end of September. There were no 65-week breaches reported in July.
Alert
Quality:
ED Sepsis: The Trust has noted a downward trend in sepsis compliance within the Emergency Department (ED). The department have identified several contributing factors impacting on their ability to deliver consistent, high quality sepsis care. There has been a noticeable rise in the number of patients triggering for sepsis, alongside a general increase in patient acuity, placing further pressure on available staff.
Despite the current challenges, the department remain fully committed to improving sepsis compliance to ensure the best outcomes for patients and maintain high clinical standards within the department. The department aim to meet to formulate a targeted action plan, drawing from the weekly Paediatrics Assurance Report submitted to the Divisional TRI.
This will provide regular oversight and accountability. Utilisation of the AQUA data, provided by the Deteriorating Patient Lead, to inform actions based on specific areas of low compliance, this will enable data driven, focused improvements. The ED Sepsis Lead will attend the DPG meeting monthly, accompanied by a member of the nursing team. This will enhance shared learning, increase understanding of sepsis related harm, and build team wide ownership of compliance targets.
MM shared with the Board that meetings had taken place to better understand the underlying challenges and ensure that remedial actions are robust. At the Risk and Assurance meeting chaired by MM this week, the Divisions were requested to share their sepsis improvement plans for oversight. The latest sepsis assessment and antibiotic delivery compliance (August) had improved, which was encouraging. However, a real focus was required on sustainability to ensure these cycles of underperformance do not continue. As part of this and a recent thematic review of incidents, MM and colleagues have engaged with the Improvement team and a programme has been developed, focusing on developing a learning organisation. This would initially be piloted in the Division of Surgery, Women and Children.
Temporary Escalation Space (TES) Incidents: The number of incidents related to Temporary Escalation Space (TES) areas being opened increased in July to 26, up from 21 in June. This continues the upward trend in TES use reporting observed since January 2025. In July, 53.8% of incidents were associated with site wide TES spaces and 46.2% occurred in the Emergency Department (ED). The increased usage of TES and ED corridor spaces is primarily due to reduced patient discharges at the divisional level, leading to limited patient flow from ED and challenges in meeting West Midlands Ambulance Service (WMAS) offload targets. The discharge lounge was closed as an inpatient area on 8th August and now resumes as originally intended. Further extensive work remains on eliminating the use of TES areas. Notably, there has been improved compliance in the completion and updating of TES risk assessments on Datix. Additionally, AMaT audits for TES areas designed to monitor quality and safety went live on 1st July.
VTE: Initial VTE screening compliance remains compliant; however, there remained low compliance with second assessments. A meeting is to be scheduled to review recent VTE incidents and to ensure that meaningful and impactful actions are implemented to improve second assessment adherence.
Performance:
Discharge Ready Date: An organisational decision is required regarding the longer-term future of the Pathway 1 bridging model. While the initiative has delivered clear benefits in supporting timely discharge and maintaining flow, the associated costs present a material financial risk if continued without wider system support.
LH confirmed that the Committee were concerned around sustaining Sepsis and VTE at an acceptable level.
LW was pleased to see progress on the discharge ready date. LW commented on the performance update and noted that the Finance & Productivity Committee recognised the progress and were now looking for assurance on its sustainability. DW confirmed that the only risk was to ERF income.
It was RESOLVED to
- Receive the report and draw assurance from progress made and efforts to deliver against national standards and local recovery plans.
25/26.3 Perinatal Quality Surveillance Dashboard
CM presented the Perinatal Quality Surveillance Dashboard given as enclosure nine. The Board noted the following key highlights:
Assure
On July 17th the UNICEF Baby Friendly (BFI) initiative team visited the Maternity Unit to reassess the service under the BFI Standards. The Trust received very positive feedback from the assessment team on the day and passed just over 50% of the elements; this meant that the Trust accreditation for BFI status remained. There would be a period of time where the BFI team would work with the Trust to ensure the other 50% of elements were in an improving state and would be achieved. There was very positive feedback about the positive culture and kindness of staff.
The report contained current compliance with MIS year 7. There were no safety actions (SAs) in a red position. Green actions highlight those that are complete but have not been heard or discussed at all required meetings or committees. All 10 Safety actions were on a trajectory to be fully compliant by the end of the reporting period (30th November 2025).
Appendix 2 outlined the current position across Maternity and Neonatal services at The Dudley Group NHSFT in relation to the letter received from NHSE in June 2025, outlining the intention for a national rapid independent review into Maternity and Neonatal services. A further update would be provided once instruction/information has been received from the national teams with next steps.
Advise
Maternity Regional heatmap; The Trust was scoring 26 and has returned to a GREEN rating for August 2025. An outline of the red scores was highlighted within the report. Scores would begin to further decrease when new recruits commenced in Midwifery Support Worker and Registered Midwifery posts. Results were expected to be published from the latest CQC Maternity survey during November 2025 which indicated a further improvement.
There was one new case referred to and accepted by the Maternity and Newborn Investigations (MNSI) during June and July 2025. There had been no new internal incident responses commenced during June and July 2025. There had been two Patient Safety Incident Investigations concluded during June and July 2025. An initial touchpoint meeting for Saving Babies Lives V 3.2 scored the Trust as 96% compliant. Actions were ongoing to gain full compliance in the final required elements.
Alert
Stillbirth rates at the Trust increased to 3.48 per 1,000 births in July and followed an upward trend observed over the past quarter, with rates of 3.0 in June, 2.99 in May, and 2.73 in April. The national rate stood at 3.22 (MBRRACE, 2025 State of Nation report, 2023 data). The recent rise related to four stillbirths occurring in June and July, with no reduction in numbers over the previous rolling 12 months. An outline of the cases was discussed at the Quality Committee and Mortality Surveillance Group. All cases were being reviewed through governance processes and PMRT, and families’ views sought as part of the process.
The requirements of MIS Year 7, SA7 outlined that Terms of Reference of attendance at a number of specific meetings, must show that the Maternity and Neonatal Voices Partnership (MNVP) lead
was a quorate member. The Trust has identified that whilst the MNVP have been invited to these meetings and feature in the terms of reference, they do not currently have capacity to attend all meetings. The technical detail of the SA does specify that as long as this escalation occurs to the Trust Board, and the Integrated Care Board, they remain compliant with the scheme. The escalation has been discussed at length at the Quality Committee and Local Maternity and Neonatal System (LMNS). The appendices to accompany the full report were located in the reading room.
The Chair thanked MMcD for the comprehensive report and noted that she was also assisting Sandwell with their Maternity Services.
It was RESOLVED to
- Note the report and the assurances and matters of concern provided against the requirements of SBL V 3.2 and MIS year 7.
25/26.4 Learning from Deaths
PH presented the Learning from Deaths report given as enclosure 10. The Board noted the following key highlights:
Assure
- Sustained improvement of perinatal/paediatric mortality
- Summarised Hospital Level Mortality Indicator and Hospital Standardised Mortality Ratio (SHMI/HSMR) remain stable and within expected range
- Structured Judgement Reviews providing assurance of good care for the Trust
Advise
- CUSUM (Cumulative Sum control chart) alerts are early warning triggers, 4 alerts – 1 SHMI and 3 HSMR
- The Trust may observe some instability in the SHMI when Emergency Care Data Set (ECDS) coding is implemented.
Alert
- Fast track discharge on Risk Register
It was RESOLVED to
- Note the report and the assurances that mortality continues to improve within the expected levels.
25/26.5 Winter Plan 2025/26 Board Assurance Statements
KK presented the Winter Plan 2025/26 Board Assurance Statement given as enclosure 11. The Board noted the following key highlights:
Assure
In line with the NHS England Urgent and Emergency Care Plan 2025-6 the Trust has prepared the Winter Plan according to the key deliverables highlighted. The full winter plan was included within the reading room and the board were asked to review the document that had been completed confirming Board assurance for return to NHS England.
The Plan has followed the internal Trust governance processes and has been previously presented at Public Board in July 2025 and to Finance and Productivity Committee in both June and July 2025.
The document demonstrated that all of the assurance requirements had been met within the plan and noted that the Black Country system stress took place on the 10th September and the NHSE regionally led stress testing to take place on September 17th. For this reason there may be alterations to the plan based on the findings of these events that occurs post presentation to the Board.
Advise
The Winter Plan is to remain a ‘live’ document with modifications made in response to any unexpected variation to the activity that has been planned for.
Alert
There are likely to be outputs from both the stress testing that is due to take place later in September and also from the findings of the work with the delivery partner, Newton. Any developments will be added to the plan and updates provided to both Quality Committee and Finance and Productivity Committee.
JR joined the meeting. The Plan was tested at the Winter Plan exercise the previous day with strong feedback received on Dudley’s Plan.
The Chair commended the huge amount of work undertaken and the layers of assurance provided.
VR welcomed the positive plan and asked about the flu vaccine rollout and how the Trust would encourage up take.
It was RESOLVED to
- Approve the assurance statement for submission to NHSE and note the work undertaken on the winter plan for this year.
25/27 Our People – To be a Brilliant Place to Work and Thrive
25/27.1 Workforce KPIs
JF summarised the Workforce KPIs report given as enclosure 12 noting that the full KPI report was located in the reading room.
Assure
Turnover and Retention: Trust-wide turnover has decreased to 6.66% (target ≤8%) and normalised turnover to 2.82% (target ≤5%). Retention remains strong at 92.9% (target≥80%).
Mandatory Training and Appraisals: Compliance remains above target with mandatory training at 93.56% and appraisals at 92%.
Bank Fill Rates: Improved to 83% in July, with no non-medical agency shifts filled via the centralised team.
Recruitment and Workforce Planning: Contracted WTE increased slightly, and the Trust is actively managing recruitment and retention through targeted initiatives.
Advise
Sickness Absence: In-month sickness absence rose to 5.68% (target ≤5%), with rolling 12-month absence at 5.36%. Mitigations are in place, including targeted interventions and enhanced support.
Vacancy Rate: Decreased to 9% from 10% in July but remains above the ≤7% target. Continued monitoring and recruitment efforts are underway.
Employee Relations: Grievance KPI compliance improved to 67%, but MHPS and bullying/harassment cases still exceed the 12-week resolution target. Policy updates and training are ongoing.
Alert
Long-Term Absence: 138 long-term absence cases remain open, with 18% of episodes accounting for 55% of FTE days lost (18 cases over 6 months in length)
Medical & Dental Turnover: High turnover at 20.85%, with normalised turnover at 3.79%. Deanery rotations contribute significantly.
Rostering Unavailability: Unavailability at 29% exceeds the 22% budgeted level, posing risks to staffing and budget control – this is actively being managed via Roster Confirmand Challenge meetings.
Apprenticeship Activity: Recruitment freeze has impacted apprenticeship sign-ups and levy utilisation. Risk of under-delivery in funded programmes.
It was RESOLVED to
25/27.2 Performance Against Workforce Forecast
JF presented the Performance against Workforce Forecast report given as enclosure 13 noting that the full data report was located in the reading room.
Assure
Substantive Workforce: Positive variance of +37 WTE against plan, reflecting effective vacancy control and recruitment freeze impact.
Corporate Services & CCCS Divisions: Both divisions show positive performance against plan, with CCCS maintaining low agency usage and Corporate Services benefiting from substantive staffing reductions.
Right Shift, Right Band Initiative: Flagged pay grade mismatches reduced by 37% since July, with weekly reporting and system alerts now embedded.
Sickness Absence Management: ESR training, new EAP service, and targeted Occupational Health interventions have led to improved return-to-work compliance and reduced length of long-term sickness cases.
Advise
Bank Workforce Usage: Increased to 585 WTE, 84 WTE above plan, driven by industrial action and capacity demands. Controls and reporting improvements are in place, but further reductions are needed.
Agency Workforce Usage: Increased to 19 WTE (13 WTE above plan), with spend concentrated in high-cost specialties. Steering groups and exit strategies are being developed.
Divisional Performance: Medicine and SWC divisions continue to report over-plan performance, requiring sustained reductions to meet year-end targets.
Alert
Surgery, Womens and Childrens (SWC) Division: Consistent underperformance across Months 1–4 posed a significant risk to achieving year-end workforce targets.
Primary Care Complexity: Hosting arrangements for funded posts in Dudley Place continue to impact performance and delivery.
Financial Risk: Agency overspend of £275k to June and continued above-plan bank usage threaten financial sustainability and delivery against the workforce plan.
It was RESOLVED to
- Receive the report for assurance.
25/27.3 Workforce Race Equality Standard and Workforce Disability Equality Standard
JF presented the WRES and WDES report given as enclosure 14. The Board noted the following key highlights:
Assure
The Workforce Race Equality Standard (WRES) and the Workforce Disability Equality Standard (WDES) provide key indicators and benchmarks for evaluating the impact and effectiveness of interventions for improving the experiences of staff across the organisation.
The Dudley Group NHS Foundation Trust has implemented a range of actions and interventions to embed an inclusive and compassionate culture which promotes equality and challenges all forms of discrimination.
Advise
This report presents The Dudley Group NHS Foundation Trust’s performance against the Workforce Race Equality Standard (WRES) and the Workforce Disability Equality Standard (WDES) metrics for 2025. The report highlights key trends, as well as areas of progress and ongoing challenges. The report also sets outs the Trust’s strategic actions to advance equity across the organisation.
Alert
Whilst improvements have been made for both WRES and WDES metrics there still remain some disparities and challenges for ethnically diverse staff and disabled staff. The Board are invited to consider the updated WRES and WDES metrics, as well as the plans for driving further improvements and to take assurance that this work has the support of the Trust’s wider leadership
LW asked about discrimination from the public. JF confirmed that the Trust has a zero tolerance approach. LB confirmed that a communications campaign was underway, using staff members’ children.
GC commented on Board member diversity and the lack of progress and asked what planning was in place for future leaders and requested that the emerging plan be presented to the People Committee. JF confirmed that there were plans in place that included to re-establish reverse mentoring and shadow Board’s and acknowledged there was more to do in this area.
In response to a point raised by PF about cultural competency, JF confirmed that work was underway as part of the Trust’s alignment with Sandwell.
The Chair concurred with the need for increased diverse representation at senior levels across the organisation and requested that the plan be presented at a Board meeting.
Action Plan to increase diversity and support development of future leaders to be presented at a Board meeting JF.
It was RESOLVED to
- Approve the latest Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) results, particularly the areas of improvement and those areas requiring further focus intervention, ahead of public publication.
25/27.6 Freedom to Speak Up Guardian Report
AB the Freedom to Speak Up Guardian presented her report given as enclosure 15. The Board noted the following key highlights:
Assure
The FTSU delivery plan for 2025 – 2028 would be launched at the end of September in line with FTSU Week 13th – 17th of October. The second Black Country Collaborative conference would be held on the 15th of October.
Advise
The FTSU team had received a total of 55 concerns raised during the reporting period of April 2025 – June 2025 quarter 1 of the 2025/2026 financial year. The total number of concerns raised in 2024/2025 had increased overall by 50% compared to 2023/2024.
Alert
The National Guardian’s Office would close as part of the government’s 10 Year Health Plan. The role of Freedom to Speak Up Guardian would remain across the health service.
It was recognised to be positive that people are speaking up. LB added that we need to demonstrate that we are listening. JH suggested moving to assure rather than under advise as a matter of assurance.
The Chair thanked AB for her work.
It was RESOLVED to
- Note the report and assurances provided.
25/27.7 Guardian of Safe Working Report
FC presented the Guardian of Safe Working Report given as enclosure 16. The Board noted the following key highlights:
This is the 8th report from the Guardian of safe working (GOSW) and covered the period between 16 February 2025 and 31 August 2025.
Assure
The purpose of the report was to give assurance to the Trust Board that Junior Doctors in Training (JDT) were safely rostered, and their working hours were compliant with the Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016 (TCS).
No fines had been issued in the reporting period. The outcome of the Exception Reports in the period was a combination of TOIL and payment.
Advise
There had been 22 exception reports raised in the period. 2 carried forward from the previous report. Eight had been fully closed with 12 ERs are pending. There were currently 10 vacancies in the junior workforce.
Alert
Reforms to the Guardian of Safe Working process would commence 12th September 2025 including a new reporting pathway to HR and the Guardian of Safe Working Hours (GOSWH) instead of clinical supervisors, increased timeframe for submitting reports, revised fining guidance and a mandate for employers to provide a choice of payment or time off in lieu (TOIL) for worked additional hours.
GC asked if there were any disadvantages of the new system. FC confirmed that it took away the opportunity to liaise with the supervisor in the first instance.
DW asked about the vacancy number included in the report and asked for assurance around medical staffing and rostering and agreed to pick this up outside of the meeting.
It was RESOLVED to
- Note the report and assurances provided.
25/28 Governance
25/28.1 The Green Plan
RB presented the Green Plan given as enclosure 17. The Board noted the following key highlights:
Assure
The Trust’s Green Plan set out how the organisation would reduce its environmental impact and contribute to improved health and life chances for the local population. The Board was asked to discuss the Green Plan and act as advocates for this agenda.
The Trust’s purpose was to improve the life chances and health outcomes of the local population. A key part of this was working collaboratively with partners to build healthier, fairer and more sustainable communities.
The Green Plan was central to that ambition and provided a framework for how the Trust would reduce its environmental footprint while supporting sustainable models of care.
The Green Plan outlined actions across the following domains for discussion:
- Travel and logistics
- Asset management
- Climate adaptation
- Capital projects
- Sustainable models of care
- Procurement
- Use of natural resources
The Joint Infrastructure Committee, with a remit covering digital, data, estates, facilities and sustainability, was aligned with the Government’s 10-year plan. The Committee would ensure that infrastructure development supported clinical excellence, improved outcomes, and a sustainable future for the communities served by the Trust.
The Infrastructure Committee would oversee the final submission of the Green Plan to NHS England by the end of October 2026.
The Green plan document was located in the reading room associated with this meeting.
ML commented that the plan should articulate how the plan aligned with the national shift. VR asked about the driver for the plan, cost or sustainability. RB commented that there were opportunities to invest and save money and phasing was important. A dashboard would be presented to the Infrastructure Committee.
The Chair asked if the PFI contract provided difficulties. LH confirmed that it could be challenging but there were still opportunities available. Relationships with the PFI providers were improving and they were more open to engage and noted an issue with Summit investment. RB would be raising this with the PFI provider at the next Board to Board with them.
It was RESOLVED to
- Endorse the importance of sustainability as a driver of improved health and life chances and act as advocates for the Green Plan within the Trust and with external partners.
25/28.2 Board of Directors and Committee Effectiveness Report
HB presented the Board of Directors and Committee Effectiveness Report given as enclosure 18. The Board noted the following key highlights:
Assure
Reflective of best practice, the Trust had undertaken an effectiveness review of the operation of its board and those of sub committees using an established process for the period 2024/25.
The effectiveness review of the Audit Committee followed the guidance set out in the NHS Audit Committee Handbook and completed an online survey and completed a detailed process checklist.
Following publication of The Insightful Provider Board guidance by NHS England in November 2024, the Trust commissioned the Good Governance Institute to facilitate a self-assessment evaluation followed by a workshop with the Board, based on NHS England’s guide. A summary of the output was appended to the report.
Alongside the review activity, the People Committee piloted an NHS Providers committee meeting effectiveness matrix tool that was undertaken by the deputy director of governance that enabled a ratings approach to the key elements that contribute to effective meetings; meeting management, Papers, Challenge, Outcomes, Relationships and behaviours. Each committee received it feedback report during Q1 2025/26.
Advise
The were no areas flagged as being of significant concern or representing any associated risk. The Board was asked to note that the report is for the period 2024/25 and that the Terms of Reference and workplans for all committees were being kept under review as part of the journey towards group working with Sandwell and the establishment of the Joint Committees.
It was RESOLVED to
- Note that the Trust had followed best practice to undertake an annual review of the operation of the Board and its sub-committees and that there were no areas flagged as being of significant concern or representing any associated risk.
25/28.3 Quarterly Trust Strategy and Annual Plan Progress Report April – June 2025
AT presented the quarterly Trust Strategy and Annual Plan progress Report given as enclosure 19. The Board noted the following key highlights:
The full report was located in the reading room showed progress against each of the six in-year objectives identified in the Annual Plan 2025/26 using a revised and simplified format.
Progress against each of the ten assurance metrics that are being used to track progress against the new strategy which was formally approved at Board of Directors in July 2025 was also shown.
Assure
Recruitment to positions to enable the Care Navigation Centre to start operation, along with the development of pathways to support alternatives to hospital attendance and admission, meant that the new service was set to go live from 1st September.
Anti-bullying and anti-discrimination policy and toolkit had been launched and promoted across the organisation, including via the Make It Happen tours in May and June.
Plans to reduce back-office costs have been submitted to NHSE with plans for a £800k reduction included within the cost improvement programme this year.
Advise
Care Transfer Hub launched by bringing together different agencies into same physical space and electronic bed management system had been developed and due to be deployed in the second quarter providing better information about the bed state and improving flow through the hospital.
A business case for an elective hub in the south of the Black Country had been developed with the aim of using space at Sandwell Health Campus.
Acute therapy appointments were now being offered in community locations with plans for use of four additional outpatient rooms at Merry Hill Centre being developed with some outpatient services set to re-locate next quarter.
Alert
Cost savings associated with the transformation of non-elective pathways had not yet materialised and support had been sought from an external consultancy.
Changes to the NHS Payment system this year threaten the financial viability of the elective hub business case so that the emphasis was now on the relocation of services rather than provision of additional capacity.
It was RESOLVED to
- Note the progress report for Quarter 1.
25/28.4 Board Assurance Framework
HB presented the Board Assurance Framework (BAF) given as enclosure 20.
The Board of Directors was asked to receive a summary of each of the six BAF risks and the Trust’s Board Assurance Framework current position as presented in appendix 1.
HB highlighted the following:
Of the six risks listed, committee assurance ratings had been assigned as follows:
- three are assigned a ‘positive’ rating – BAF 1,3 & 5
- three are assigned an ‘inconclusive’ – BAF 2,4 & 6
- none were assigned a ‘negative’ rating
The Board was advised that BAF 6 overseen by the Joint Infrastructure Committee would be subject to further work. In response to the Chair’s query about the risk appetite rating table demonstrated in the report HB to check the colour coding.
[post meeting note: Current risk score for BAF 5 incorrectly stated as 20 on summary table when correct score is 16 and has been amended]
It was RESOLVED to
- Approve the BAF summary report noting the ongoing development related to BAF 6 overseen by the Infrastructure Committee.
25/29 Any other Business
There was none raised.
25/30 Date of next Board of Directors Meeting
The next meeting would be held on Thursday 13th November 2025.
25/31 Meeting Close
The Chair declared the meeting closed at 13:45 hr.
………………………………………………
Sir David Nicholson
Chair Date:
