The Board of Directors consists of a balance of executive directors with defined portfolios and non-executive directors drawn from a range of backgrounds who bring rigorous and constructive challenge to the Trust.
The Board of Directors is a unitary board that makes corporate decisions. The executive posts are occupied by appropriately qualified professionals able to discharge the functions expected from those professions and as defined in the Trust’s constitution.
The Trust does not have any non-voting directors. All the members of the Board of Directors have equal voting rights on all Board matters. Only those directors listed in the terms of reference for a committee can vote on matters dealt with by that committee. The only exception to this is when a vote is being cast by a substitute director agreed prior to the meeting.
Full-time executive directors are not permitted to take on more than one non-executive directorship of an NHS foundation trust or another organisation of comparable size and complexity. During 2021/22 none of the executive directors held any such additional appointment.
The Trust has in place director and officers’ liability insurance as part of the NHS Resolution membership scheme.
The Chair uses performance assessments and evaluations as a basis for determining individual and collective professional development programmes for non-executive directors relevant to their duties as Board members.
The effectiveness of the Board of Directors and individuals is assessed annually using an appraisal tool (Evalu8). The tool was chosen to enable the views of all governors and directors to be collected and included into the process. The information gathered from Evalu8 is then used to report back to the Board of Directors, and in the case of individuals, informs their one-to-one appraisal with their line manager. The use of the two methodologies enhances the validity of the appraisal.
The Board committees provide an annual report on their performance to the Board of Directors.
The Chair is appraised annually, jointly by the Senior Independent Non-Executive Director and the Lead Governor. The appraisal is reported to the governor’s nominations and remuneration committee before being reported to the full Council of Governors.
The Chair appraises the Chief Executive’s performance each year. The Chair conducts the appraisal taking into account the observed performance of the Chief Executive and the performance results achieved by the Trust.
It is within the powers of the Council of Governors to remove or suspend any non-executive directors. The process is set out within the Trust constitution. These powers have not been required in 2021/22.
Challenge and assurance
The Board, and in particular non-executive directors, are able to challenge assurances received from the executive management. Information is presented in such a manner to ensure that there is sufficient understanding and information to enable challenge and to take decisions on an informed basis.
Members of the Board of Directors can access independent professional advice at the Trust’s expense, where they judge it necessary to discharge their responsibilities as directors.
The Board has a duty to notify the regulator, and the Trust’s Council of Governors. The Board must also consider whether it is in the public’s interest to disclose any major, or potential new developments in the Trust’s sphere of activity (which are not currently public knowledge), which it is able to disclose and which may lead by virtue of their effect on its:
- assets and liabilities
- financial position or
- on the general course of its business,
to a substantial change to the organisation’s:
- financial wellbeing
- healthcare delivery performance or
- reputation and standing.
In light of the COVID-19 pandemic there have been, and are continuing to be, a number of emergency changes being implemented at pace. Additional disclosures are listed in the section below.
Additional disclosures: emergency and temporary service changes
The Trust had in place an emergency temporary closure of its inpatient Child and Adolescent Mental Health Services (CAMHS) Unit. The service is now being provided by an intensive home treatment team. This model had been in place for two years and has successfully managed children and young people in the community.
The Trust is part of the East-Midlands Alliance for CAMHS, only a very small number of patients require inpatient care in units in neighbouring counties. This service was reviewed and following public engagement via the Lincolnshire County Council’s Health Scrutiny Committee has become a permanent change in service.
The Trust had in place a temporary closure of Rochford Ward, one of its functional mental health older adult inpatient units. This allowed for the development of Brant Ward into a new single room facility in 2019/20. During the closure a very successful home treatment team was instigated. There has been no increase in patients having to go out of area to receive care as a result of this change.
This service was reviewed and following public engagement via the Lincolnshire County Council’s Health Scrutiny Committee the closure of Rochford Ward has become a permanent change in service.
To assist United Lincolnshire Hospitals NHS Trust to manage Grantham Hospital as a “Green” (COVID-19 free) site, the Dementia ward in the hospital (Manthorpe Centre) was temporarily closed. A Dementia Home Treatment Service was established to offer specialist support for the patients previously admitted to Manthorpe Ward.
Then a full review of the model of care for the dementia home treatment and the services at Manthorpe Ward is planned for 2022/23.
Infection prevention and control restrictions associated with the management of the COVID-19 pandemic, coupled with the rates of infection and isolation amongst the workforce have led to a number of emergency changes to services across the Trust. These have included:
- the reduction of the number of beds on three adult acute care wards with dormitory areas to support social distancing
- a short term closure of the Psychiatric Intensive Care Unit (PICU) for two months to support a staffing crisis
- from February 2021 the Temporary Closure of Ashley House (an open rehabilitation Unit) to support staffing shortages.
The Trust has worked alongside
- NHS statutory bodies and partners
- local authority and third sector partners
- the Local Resilience Forum to manage the impact of these changes.
The full implications of the changes made and the lessons to be learnt in the configuration of future services will be managed by the Trust in partnership with the wider Community and will undoubtedly lead to a number of future consultations and long-term service changes which will accelerate the delivery of the NHS Long Term Plan (LTP).
The Trust also implemented emergency procedures to:
- enable its services and governance arrangements to be amended and to continue during the COVID-19 social distancing restrictions
- ensure adequate capacity for urgent and exceptional actions and activity.
The Trust put in place a major incident response in accordance with its major incident and business continuity plans. This included moving all Council, Board and Committee meetings to an online (Microsoft Teams) platform. All Council, Board and Board Committee forward agendas have been reviewed and either maintained or formally adjusted to ensure continued effective governance arrangements. Board meetings have been held in public using Microsoft Teams live meetings.
Attendance at Board and Board committee meetings
To support the Board in carrying out its duties effectively, a number of committees have been formally established. Each committee receives a set of regular reports as outlined in their respective terms of reference and each provide highlights and exception reports to the Board after each meeting.
The following table outlines Board members’ attendance at Board and committee meetings during 2021/22 against the total possible number of meetings for which an individual was a member. Committee attendance is shown in relation to those committees of which a director was formally a member.
The non-executive directors, will if required, hold meetings without the executive directors being present. These provide an opportunity for non-executive directors to consider the performance of the executive team in the delivery of Trust priorities. If directors were to have concerns that could not be resolved about the running of the Trust or a proposed action, these concerns would be documented and recorded in the minutes of the Board meeting.
Joint Board meetings
The Council of Governors and the Board of Directors continue to work together to develop an effective working relationship. The Board of Directors meets with the Council of Governors three times a year to discuss the strategies and plans. These Joint Council and Board meetings provide a valuable tool in helping the governors to discharge their responsibilities for providing a view on the Trust’s Annual Plan and assessing the performance of the Board of Directors. In turn, this enhances their overall governance responsibility and accountability to the people of Lincolnshire.
At every meeting of the Council of Governors, the Chief Executive delivers a report in relation to the Trust’s strategic position and plans. In addition, a performance assurance report is presented by the non-executive directors. During the course of the year the governors have not had cause to take a vote on the directors’ performance. The Trust has a policy (as articulated in the Constitution and the Responsibilities and Codes of Conduct) to underpin the power and influence of governors to ensure the directors participate in meaningful engagement. These were comprehensively reviewed and updated in 2021/22.
No individual is permitted to hold, at the same time, positions of director and governor. All the directors on the Board of Directors and the governors on the Council are assessed to ensure they meet the ‘fit and proper persons test’ as described in the provider licence. This assessment for directors is undertaken on appointment and includes references, enhanced Disclosure and Barring Service checks, Companies House Register and documentation checks. Directors, at appointment and reappointment, are subject to Disclosure and Barring Service and document checks.
Annual public meeting and members’ meeting
Every September, the Trust holds an annual public meeting (APM) at which members of the Board of Directors set out the organisation’s financial, quality and operating priorities for the forthcoming year. Sufficient information is disclosed, both qualitative and quantitative, of the organisation’s achievements and operation, to allow governors, staff and members of the public to evaluate its performance.
At the Annual Members Meeting, the Lead Governor gives an account of governor activities and the Director of Corporate Governance provides an update on membership demographics.
The 2022 meeting will be held online on 28 September 2022. A copy of the meeting programme will be published on our website nearer the date of the event.
To register your attendance, please contact us:
Trust Board committees
In 2021/22 the Board of Directors has had in place a robust structure of Committees that had been reviewed and restructured in 2020/21. This was to address the changing demands of the health economy driven by the needs to service the developing Integrated Care System, NHS Long Term Plan, The NHS People Plan and ongoing changes in the regulatory framework.
The committees listed below have had their terms of reference reviewed in September 2021 and have been meeting effectively throughout 2021/22:
- Appointment and Terms of Service.
The work of the committees is evaluated on an annual basis against agreed forward agendas, with highlights and exceptions reports and minutes provided to the Board of Directors. Each committee has a specified membership from within the Board of Directors. On occasion other directors will attend in relation to an agenda item and their attendance is duly recorded.
Each committee of the Board is provided with suitable and sufficient support, technical advice and resources to effectively deliver its terms of reference.
During the COVID-19 pandemic a degree of proportionate governance was applied to release time to focus on the management of the pandemic and the provision of direct care. The dates and agendas of some committee meetings were adjusted to respond to this. However, all of the forward agenda items were tracked and all of the business was conducted either at a later date or on a priority basis.
The Audit Committee is an independent non-executive committee of the Trust Board, and has no executive members. It is responsible for monitoring the externally reported performance of the Trust and providing independent and objective assurance on:
- the effectiveness of the organisation’s governance, risk management and internal control
- the integrity of the Trust’s financial statements, in particular the Trust’s annual report and accounts
- the work of internal and external audit and local counter fraud providers and any actions arising from that work.
To enable independent access to the non-executive directors, the internal auditors, the external auditors, the counter fraud specialist and the freedom to speak up guardian are formally in attendance at the Audit Committee.
The committee met in ordinary session four times during the course of the year, and in one extra-ordinary session to receive and scrutinise the 2020/21 annual reports and accounts on behalf of the Board of Directors. The names of the Chair and members of the Audit Committee and their regularity of attendance at meetings are disclosed in the table above.
The Chair of this committee is responsible for its effectiveness. All other members collectively have the necessary business, reporting, auditing and governance skills to fulfil their responsibilities which ensure the committee’s effectiveness. The Trust is satisfied that the committee is sufficiently independent.
The Trust has ensured one or more members of the committee have had recent and relevant financial experience. This is important as these individuals are best equipped to make rigorous challenge on any financial reports presented to the committee which contain financial key performance indicators and strategic financial risks.
The Audit Committee’s overriding objective is to independently contribute to the governance framework and ensure an effective internal control system is maintained. The committee reports to the Board of Directors and it is authorised to:
- Oversee the establishment and maintenance of an effective system of internal control, and management reporting.
- Ensure that there are robust processes in place for the effective management of clinical and corporate risk to underpin the delivery of the Trust’s principal objectives.
- Oversee the effective operation and use of internal audit.
- Encourage and enhance the effectiveness of the relationship with external audit.
- Oversee the corporate governance aspects that cover the public service values of accountability, probity and openness.
- Ensure that there is an effective counter fraud function that meets the standards for providers for bribery and corruption.
A copy of the full terms of reference for this committee, which have been approved by the Board of Directors and agreed with the Council of Governors, is available on request from the Director of Corporate Governance.
Audit services are retendered for up to five years on a three, plus one, plus one basis. The duration of the tender allows the auditor to develop a strong understanding of the Trust’s finances, operations and forward plans. The Council of Governors, following a tendering process, reappointed Deloitte as the Trust’s external auditor from 1 April 2017 for up to five years. The Council of Governors approved a policy for additional services (renewed every two years), for the procurement of such services from the Trust’s external auditors. This contract will be concluded after the completion of the 2021/22 annual accounts and report.
The Director of Finance and Information agrees a plan of additional services to be commissioned for consideration by the Audit Committee. The Audit Committee considers the plan, considers any potential threats to the objectivity and independence of the auditors, and determines whether it is satisfied that the auditors’ independence is not jeopardised. It also takes into account the scope of the audit work to be carried out.
The Trust has an internal audit function which complies with NHS audit code. Its three year plan is developed through working with the Board of Directors to assess risk to controls and is then refreshed by the Audit Committee to gain assurance of the controls in place at the Trust.
The Trust’s internal Auditors for 2021/22 were Grant Thornton, who commenced a new three-year contract to provide the service on 1 April 2019. A one year contract extension option has been taken up for services in 2022/23 after which the contract will be retendered.
The Director of Finance and Information has the responsibility for preparing the Accounts. The Accounts are presented to the Board of Directors for approval following an external audit review. The Accounts and Annual Report are presented to the Council of Governors.
During 2021/22 the Audit Committee has scrutinised the key financial, operational and strategic risks and has provided scripting on behalf of the Board of Directors of the Board Assurance Framework (BAF). It reviewed progress reports and evaluated the findings of significant internal and external audit work. The Audit Committee has received regular reports on counter fraud activity at the Trust, ensuring appropriate action in matters of potentially fraudulent activity and financial irregularity. It has fulfilled its oversight responsibilities with regard to monitoring the integrity of financial statements and the Annual Accounts, including the Annual Governance Statement (AGS) before its submission to the Board.
The Audit Committee regularly reviews its arrangements that allow staff or other parties to raise, in confidence, concerns about possible improprieties in matters of financial report and control, clinical quality, patient safety, and other matters. This includes having the Freedom to Speak Up Guardian in attendance at Audit Committee meetings.
The Quality Committee exists to provide assurance to the Board that appropriate and effective governance mechanisms are in place for all aspects of quality including service user experience, health outcomes and compliance with national, regional and local requirements.
The Quality Committee membership consists of three non-executive directors and four executive directors. The names of the Chair and members of the Quality Committee and their regularity of attendance at meetings are disclosed in the table above.
During 2021/22 the Quality Committee’s terms of reference and forward agenda were kept under review, reviewed in line with the other committees of the Board.
The committee is authorised by the Board of Directors to:
- Provide assurance to the Board that the Trust has in place:
- structures, processes and controls to ensure that the legislative requirements set out within the terms of reference (these ensure the safety, rights and quality of service delivery) is maintained to all of our service users, carers, staff and the public.
- Shape quality improvement, culture and organisational development within the Trust.
- Provide assurance to the Board that appropriate and effective governance mechanisms are in place for all aspects of quality including:
- patient experience
- health outcomes
- compliance with national, regional and local requirements.
The committee and its sub-committees provide a focused set of assurance reports. The committee’s agenda includes deep dives into a particular area of concern or challenge have been identified.
The Sustainability Committee has the oversight and ownership of the Finance, Procurement, Estate and Digital Strategies and the performance framework for the Trust.
The names of the Chair and members of the Sustainability Committee and their regularity of attendance at meetings are disclosed in the tables in the section above titled "Attendance at Board and Board committee meetings".
The committee is authorised by the Board of Directors to:
- Oversee and give detailed consideration to all aspects of the financial arrangements of the Trust, providing the Board with assurance that the financial issues of the organisation including capital expenditure are being appropriately addressed.
- Oversee and give detailed consideration to all aspects of the Trust’s Estate, providing the Board with assurance that the Estate is fit for purpose and planned to meet future need and that business cases are progressed effectively to achieve this need.
- Have oversight of the Trust’s performance management framework, including the incorporation of quality and workforce metrics, undertaking detailed consideration of specific issues where performance is showing deterioration or there are issues of concern.
- Scrutinise the Information Management and Technology strategy, policy, plans and performance, undertaking detailed consideration of specific issues where performance is showing deterioration or there are issues of concern.
- To discharge its duties in line with the Investment Appraisal Framework.
The committee undertook its duties and ensured that the Trust’s finance and performance enabled the Trust to remain a going concern.
The Board of Directors, in 2020/21, recognised the increasing need for a committee focused on People in order to deliver the NHS People Plan. This committee operated throughout 2021/22.
The names of the Chair and members of the People Committee and their regularity of attendance at meetings are disclosed in the table in the section headed " Attendance at Board and Board committee meetings" above.
The committee is authorised by the Board of Directors to:
- Provide assurance to the Board through a clear performance dashboard that the key operational risks are being addressed and that we have in place structures, processes and controls to ensure that the legislative requirements in regard to people’s safety, rights and expectations are maintained (in this context “people” means: our service users, carers, staff, volunteers, students and the public).
- Provide assurance to the Board that appropriate and effective governance mechanisms are in place for all aspects of people legislation, regulation and best practice in order to comply with national, regional and local requirements.
- Shape the culture, organisational development, learning and leadership of people within the Trust.
- Shape the leadership within the Trust through a programme of direct presentation to the Committee.
- Shape the workforce transformation to align with the skills and competencies that staff will need to deliver transforming services to ensure that our service users and carers receive high quality care.
Appointment and Terms of Service (ATS) Committee
The Appointment and Terms of Service Committee is responsible for the appointment and nomination of executive directors. It reviews the size, structure and composition of the Board to ensure that there is an appropriate balance of skills, experience, knowledge and independence.
Chaired by the Trust Chair, the names of the other members of the Appointment and Terms of Service Committee and their regularity of attendance at meetings are shown in the section " Attendance at Board and Board committee meetings" above.
There is a formal, rigorous and transparent procedure for the appointment of directors which is subject to scrutiny by the Appointment and Terms of Service Committee. In considering appointments to the Board of Directors, the committee:
- Takes into account the Trust’s recruitment and selection policy.
- Considers the balance of skills, knowledge and experience already in place.
- Includes governors as patient representatives and colleagues in the recruitment process.
There are no performance related elements of the remuneration of executive directors.
The Nominations and Remuneration (NOMS) Committee
Non-executive directors are separately recruited and recommended to the Council of Governors for appointment by the Nominations and Remuneration Committee of the Council of Governors.
The members of the Nomination and Remuneration Committee are:
- Paul Devlin until April 2021
- Kevin Lockyer from May 2021
- Debbie Abrams
- Linda Lowndes until September 2021
- Michael Regan from October 2021
- Ron Oxby until May 2021
- Andy Rix from June 2021
- Jacky Tyson
- Daniel Fleshbourne until March 2022
Foundation Trust membership
As a Foundation Trust, members are able to elect representatives to the Council of Governors, stand for election to the Council of Governors and apply for positions as non-executive directors of the Trust.
Through governors, members receive information about the Trust, and are consulted on plans regarding the future development of the Trust and its services.
Membership is open to anyone aged over 12 years, living in Lincolnshire and the other localities where the Trust provides services. Staff who are permanently employed by the Trust or hold a fixed term contract of at least 12 months, or who have been continuously employed by the Trust for at least 12 months are automatically registered as members unless they choose to opt out. During 2021/22 no members of staff opted out of Trust membership. Eligibility to become a member of the Trust is based on criteria as described below:
- Public member: based on local authority area in the immediate vicinity.
- Service user or carer member: open to anyone who has been an inpatient or outpatient within the previous five years, or a carer of such a former service user.
- Staff member: currently employed by the Trust on a contract.
- Stakeholder member: represents the interests of a key partner.
The Trust strives to ensure that its membership reflects the full diversity of the local population in terms of age, gender, sexual orientation, disability, ethnic background, religion and belief. As on 31 March 2022, there were 9,157 members of the Trust.
The Trust will continue with its approach to ensure it is truly representative of the community it serves. The membership catchment area is made up of constituencies representing the local population, service users, carers and staff. For details, refer to following table. Members in each constituency vote for governors to represent them.
The following table highlights the Trust’s membership figures for 31 March 2022:
Membership development and engagement strategy
In 2021/22 a full review, including a public and membership consultation, was conducted on the Governor and Membership Strategy. The results of the consultation on the strategy were reviewed and monitored by the Representation Committee and the approved by the Council of Governors and the Board of Directors. The final approved version is available on the Trust Website:
The strategy describes the Trust’s objectives for the membership and the approach to be used to ensure the organisation develops and engages with a representative membership. It outlines plans for raising awareness about membership and for the recruitment, retention and involvement of members. A detailed action plan to deliver the strategy has been developed and is monitored by the Council of Governors’ Representation Committee.
The Trust is committed to recruiting members from the diverse population served by the Trust. Membership is open to all those eligible to be a member, regardless of any protected characteristic specified by the Equality Act 2010 or any marginalised or disadvantaged groups.
The membership database is regularly reviewed to ensure that the membership is representative of those eligible to be members. Specific groups that appear to be underrepresented are targeted in recruitment campaigns in order to seek to increase membership representation in these areas. The restrictions imposed to manage the pandemic in 2020/21 and 2021/22 have severely restricted this activity. It is intended to resume a fuller programme in 2022/23.
A dedicated membership officer supports the wider membership and the Governors to carry out their duties. Pre-induction, induction training and development sessions are offered to governors to enhance their effectiveness in working with members and the general public.
The Representation Committee logs, addresses and responds to ideas, innovations and issues raised by members. It's work is publicly reported at the Council of Governors meetings and is published on the Trust website. The Council of Governors and Board of Directors have a public question time scheduled as part of their respective meetings where members of the public can openly voice questions. Minutes and recordings from both meetings are published on the Trust’s website. Through its governance structures the Trust will continue to be responsive to the needs of the membership and wider community.
Public events, which are attended in person or online by governors, provide information about local mental health and learning disability services. They also create a forum for both members and the general public to speak with governors about any service and related issues. Over the past 12 months, governors’ activities in these areas have been restricted to largely online activity.
To ensure regular communication with members, the Trust implements a number of feedback mechanisms, these include the Trust magazine Better Together, website, membership events, the annual public meeting and the use of social media. Staff members are kept up to date with the activities of the staff governors through updates on the Trust’s intranet.
Service user and carer involvement
Service user and carer involvement in the Trust has taken many forms, however all are geared for one purpose: to help shape and improve local services and the care environment.
Service users and carers attend and contribute to a wide range of activities including staff selection, meetings, committees and working groups, bringing their particular expertise to both team level decision making and also to an organisational wide level; some of these involvement activities are detailed as follows:
- Staff employment - service users and carers are regularly involved in the recruitment and selection processes for staff,from shortlisting applicants, interviewing potential candidates to assisting with the subsequent appointment of a new staff member.
- Interest groups - individuals (not necessarily Trust members), are canvassed for their opinions through focus groups, research studies, working parties and surveys.
- Governor election information sessions - information sessions held for prospective new governors.
- Member recruitment events - range of events held throughout the county to actively promote the Trust and mental health services with a view to recruiting new members.
- New governor induction sessions - designed to support newly appointed governors immediately following their election, to help familiarise them with the workings of the Trust.
- Annual public meeting and annual members meeting - a large scale, one day public event held every September that shares information about the Trust’s performance from the previous 12 months and its proposed activities for the immediate future. The Board of Directors and Council of Governors talk openly about the opportunities and challenges that will influence the organisation over the coming year, (as detailed in this annual report). This event also facilitates the formal presentation of the Annual Report and Accounts. In 2020/21 and 2021/22 this has been held online.
- PLACE inspections - Patient Led Assessments of the Care Environment (PLACE) are annual inspections of inpatient premises in terms of cleanliness, food, privacy, dignity, wellbeing and the environment (suspended during 2020/21 and restarted in the later part of 2021/22).
Benefits of being a member of the Trust
The benefits to being a member of the Trust include:
- Receiving regular updates on enhancements to local mental health and learning disability services, particularly relating to conditions of personal interest.
- Receiving copies of the printed magazine, Better Together, which contains news from Lincolnshire and further afield and a one-page e-bulletin update containing important Trust news.
- Being invited to attend member interest events, open days, governor drop-in sessions and lectures on mental health topics.
- Being able to comment, through questionnaires and meetings, on plans for local mental health services.
- Voting for someone to sit on the Council of Governors, or standing for election as a Trust governor.
- Having direct contact with governors, to ensure views are taken into account when decisions are made on the future direction of services.
Membership information can be downloaded from the Trust’s website or by contacting:
Additionally, members can contact their respective governor directly via the Trust’s website.
Compliance with the Code of Governance
The Board considers itself compliant with all provisions of the NHS Foundation Trust Code of Governance and has made the required disclosures in this annual report.