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Recipe book - For babies who need to make the most of every mouthful

Description: RECIPE BOOK For babies who need to get the most out of every mouthful Contents 04 06 11 14 15 16
Url: /Media/UHS-website-2019/Docs/Services/Child-health/DietaryAdvice/Recipe-book-For-babies-who-need-to-make-the-most-of-every-mouthful.pdf

Papers Trust Board - 11 March 2025

Description: Date Time Location Chair Agenda Trust Board – Open Session 11/03/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 7 January 2025 9:15 Approve the minutes of the previous meeting held on 7 January 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 10 10:10 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:45 5.8 Finance Report for Month 10 11:00 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Finance Report for Month 10 11:15 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 10 11:20 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Mortuary Standards Compliance Update (Oral) 11:35 Sponsor: Gail Byrne, Chief Nursing Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 3 Review 11:40 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 11:50 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) meeting 29 January 2025 12:00 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:05 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 7.3 Audit and Risk Committee Terms of Reference 12:10 Review and approve the Terms of Reference Sponsor: Ian Howard, Chief Financial Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.4 Finance and Investment Committee Terms of Reference 12:15 Review and approve the Terms of Reference Sponsor: Dave Bennett, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.5 Quality Committee Terms of Reference 12:20 Review and approve the Terms of Reference Sponsors: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.6 Remuneration and Appointment Committee Terms of Reference 12:25 Review and approve the Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.7 Trust Executive Committee Terms of Reference 12:30 Approve the proposed amendments to the Terms of Reference Sponsor: David French, Chief Executive Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 13 May 2025 10 Items circulated to the Board for reading 29 January 2025 Message from Ian Howard re Update on legal dispute with BAM 10.1 South Central Regional Research Delivery Network (SC RRDN) 2024-25 Q3 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer Page 3 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 4 Agenda links to the Board Assurance Framework (BAF) 11 March 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 10 5.8 Finance Report for Month 10 5.9 ICS Finance Report for Month 10 5.10 People Report for Month 10 5.11 Mortuary Standards Compliance Update 5.11 Corporate Objectives 2024-5 Quarter 3 Review 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b All Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 3x3 9 4x4 16 Open (Technology & Innovation) 3x3 9 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 4x5 20 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Dec 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x3 6 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x Minutes Trust Board – Open Session Date Time 07/01/2025 9:00 – 13:00 Location Chair Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) James Allen, Chief Pharmacist (JA) (item 5.14) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Julie Brooks, Deputy Director of Infection Prevention & Control (JB) (item 5.13) Rosemary Chable, Head of Nursing for Education, Practice and Staffing (RC) (item 5.15) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.11) Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian (CMb) (item 5.10) John Mcgonigle, Emergency Planning & Resilience Manager (JMc) (item 7.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.12) Danielle Sinclair, Deputy Emergency Planner (DS) (item 7.1) Julian Sutton, Lead Infection Control Director (JS) (item 5.13) Fatemeh Jenabi, Specialty Registrar (FJ) (shadowing JT) 1 member of the public (item 2) 6 governors (observing) 4 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. The Board welcomed David Liverseidge, who had been appointed as an independent non-executive director with effect from 1 January 2025. Page 1 It was noted that Joe Teape had accepted an appointment as chief executive officer of Torbay and South Devon NHS Foundation Trust, and, accordingly Joe Teape would be leaving the Trust in February 2025. It was further noted that Jenni Douglas-Todd had been appointed as chair of the partnership between Portsmouth Hospitals University NHS Trust and Isle of Wight NHS Trust, commencing on 1 April 2025. 2. Patient Story Gillian Muir, one of the Trust’s ‘involved patients’, was invited to relate their experience of treatment for tongue and thyroid cancer in 2022. It was noted that: • Both the treatment received and staff were rated positively. However, the referral process was open to criticism. • In addition, it was considered that it would be beneficial to have a single point for information for patients as well as more information about self-help and on the patient journey. • The importance of the emotional aspect of treatment was noted as was the benefit of using patients to help other patients. Action Gail Byrne agreed to consider how the recommendations made in patient stories could be captured and action taken as a result. 3. Minutes of the Previous Meeting held on 5 November 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 5 November 2024. 4. Matters Arising and Summary of Agreed Actions It was noted that all actions were either closed or not yet due for completion. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 25 November and 16 December 2024, the content of which was noted. It was further noted that: • The Trust’s financial position remained challenging with additional cost pressures due to the pay awards and non-delivery of system-wide transformation programmes resulting in a year-to-date deficit of £18.2m. • There was a shortfall of £17m in respect of delivery of the Trust’s Cost Improvement Programme (CIP), largely due to non-delivery of system transformation programmes. • The Trust benchmarked well against comparator organisations in terms of its value-for-money and elective recovery delivery. • As at the end of November 2024, the Trust had carried out £21m in unfunded activity. • The Trust’s cash balance remained a concern, as it was being eroded by the Trust’s underlying monthly deficit and was expected to fall below the minimum required level in the first quarter of 2025/26. Page 2 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 13 December 2024, the content of which was noted. It was further noted that: • As anticipated, the Trust’s workforce had grown slightly in November 2024. However, the main challenge to meeting the Trust’s 2024/25 plan remained the non-delivery of system-wide transformation programmes in mental health and non-criteria to reside, which the Trust had assumed would enable a reduction in its workforce by 218 whole-time-equivalents (WTE). • The committee received an update in respect of the ongoing industrial dispute with portering staff and in respect of the Band 2/3 pay dispute. • The committee reviewed the Board Assurance Framework and suggested that the rating of risk 3c should be increased to reflect the financial situation and uncertainty around the NHS long-term workforce plan (item 6.1). • Issues such as ongoing industrial disputes were impacting the Trust’s capacity to make progress on other areas such as organisational and cultural development and transformation. 5.3 Briefing from the Chair of the Quality Committee including Maternity and Neonatal Safety 2024-25 Quarter 2 Report The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 25 November 2024, the content of which was noted. It was further noted that: • There had been seven ‘never events’ during 2024/25. • The committee had reviewed the Learning from Deaths 2024-25 Quarter 2 report (item 5.12), and it was noted that the risk rating attributable to this area in the Chair’s Report was aggregated. • The committee had reviewed the Infection Prevention and Control 2024-25 Quarter 2 report (item 5.13). • The committee had scrutinised the Maternity and Neonatal Safety 2024-25 Quarter 2 report in detail. 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • There had been a water supply failure on 18 December 2024 due to a technical problem at a nearby water treatment works, which resulted in a loss of water for three days. Southern Water supplied the Trust with water via tankers during this period to ensure that soft (non-potable) water was available throughout the interruption. The Trust’s Estates team managed this incident well. • It had been a difficult start to 2025 with high Emergency Department attendance levels and ambulance volumes, exacerbated by the national prevalence of seasonal illnesses such as influenza, which impacted both patient and staff numbers. • In order to manage Emergency Department attendances as high as 450 patients per day, the Trust had been required to situate patients in other areas of the hospital, which placed additional logistical burdens on staff. • The high rates of attendance meant that the Trust was close to declaring a critical incident, noting that other local providers had already done so. • There were 263 patients having no criteria to reside awaiting discharge. Page 3 • The Government had made a number of announcements prior to Christmas in respect of possible reforms, including introduction of a league table for NHS providers. • In addition, the Government had announced its targets for the NHS, including a commitment that 92% of patients were seen within 18 weeks, which would likely pose a significant challenge, as currently only around 60% of patients were seen within this timeframe. There was also a possibility that a cap would be introduced on Elective Recovery Funding. • Based on discussions with NHS England, it was understood that the £22bn of additional funding announced in the Autumn Statement had already been allocated to address pay awards and other cost pressures, and accordingly 2025/26 would likely feel like a 1-2% decrease in terms of funding. The messaging from NHS England appeared to have also altered to one of providers doing what they could within the available funding envelope, rather than attempting to deliver against all targets whilst at the same time delivering a break-even financial position. • It was proposed to regulate NHS managers, and a consultation, closing on 18 February 2025, had been launched on 26 November 2024. It was agreed that any such regulation needed to be fair and equitable. • The Trust had opened a new state-of-the-art special care baby unit, designed to increase capacity and offer enhanced specialist care. 5.5 Performance KPI Report for Month 8 Joe Teape was invited to present the Performance KPI Report for Month 8, the content of which was noted. It was further noted that: • The Trust continued to perform well when compared to other equivalent organisations. • During November 2024, there had been an average of 450 patients per day attending the Emergency Department, and four-hour performance at Southampton General Hospital was 56.1%. • There had been improvements in cancer waiting times against the 28-day faster diagnosis and 31-day targets. • The Trust’s Referral To Treatment waiting list had reduced slightly, and the Trust’s performance against the 18-week target was top-quartile. • Between August and October 2024, the Trust’s performance against the six- week diagnostic standard was 87%, which although below the national target, was top-quartile. 5.6 Break 5.7 Finance Report for Month 8 Ian Howard was invited to present the Finance Report for Month 8, the content of which was noted. It was further noted that: • The Trust had reported a £5.7m in-month deficit (£18.2m year-to-date) and was £14.8m behind its 2024/25 plan. • The Trust had submitted its financial recovery plan to the Hampshire and Isle of Wight Integrated Care Board and was on track with this plan, with the exception of the pressures due to the pay award. • Based on the national month 7 productivity data, average national increased productivity was 1.7% whereas the Trust had recorded 4% during the same period. • The Trust’s cash position continued to deteriorate and there was a significant risk that additional cash support would be required in the fourth quarter. Page 4 • There was a risk that a cap would be applied to Elective Recovery funding in 2024/25 based on month 8 performance. 5.8 ICB Finance Report for Month 8 Ian Howard was invited to present the ICB Finance Report for Month 8, the content of which was noted. It was further noted that: • The Integrated Care System had reported a year-to-date deficit of £39.71m, compared to a planned year-to-date deficit of £10.23m. • £70m of cash support had been received and the ICS was forecasting achieving break-even at the end of the year. The Board discussed the ICB Finance Report for Month 8 and challenged the requests contained in the report in respect of the assurance to be given by Executive Directors regarding the system-wide transformation programmes. It was noted that whilst Executive Directors would be able to provide assurance regarding the Trust’s contribution, it would not be reasonable to expect them to provide assurance regarding matters outside their control. The Board additionally challenged the assertion that the Hampshire and Isle of Wight Integrated Care System would achieve break-even at the end of 2024/25, noting that there was no expectation that the system transformation programmes would deliver significant benefits in the final quarter. Actions Ian Howard agreed to coordinate a report to the Board in respect of the Trust’s contribution to the Hampshire and Isle of Wight Integrated Care System transformation programmes. The Chair and David French agreed to discuss the requests of the Board in the ICB Finance Reports with the Integrated Care Board’s chair. 5.9 People Report for Month 8 Steve Harris was invited to present the People Report for Month 8, the content of which was noted. It was further noted that: • The Trust was 77 whole-time-equivalents (WTE) above its 2024/25 plan and was projecting to be 186 WTE above plan at year end. The plan assumed a reduction of 218 WTE linked to improvements in mental health and patients having no criteria to reside through successful delivery of system-wide transformation programmes. These transformation programmes had yet to deliver any significant benefit. • An update was provided in respect of the industrial dispute with portering staff. It was noted that an ACAS-facilitated deal had been brokered and agreed with staff, although the mandate for strike action remained in force until May 2025. • An update was provided regarding the ongoing pay dispute relating to Band 2 and 3 staff. 5.10 Freedom to Speak Up Report The Freedom to Speak Up Report was tabled to the meeting, the content of which was noted. It was further noted that: • There had been 97 cases reported during 2024, most of which related to allegations of bullying or issues with team dynamics. Only one report related to a patient safety issue. Page 5 • It would be necessary to review responses to the staff survey regarding attitudes toward speaking up. • A ‘heatmap’ to triangulate safety, quality and wellbeing concerns was under consideration. The Board discussed the report and queried why staff felt unable to utilise line or senior management to resolve many of the issues reported via the Trust’s Freedom to Speak Up process. The importance of visibility on the part of the leadership team was noted. Actions Gail Byrne agreed to consider how Freedom to Speak Up can be used for its original purpose of raising concerns of safety. 5.11 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • The vacancy rate for resident doctors was 9.16%, which was in line with previous years and low compared with peers. • There had been an average of 48 exception reports per month over the past 12 months. The most common reason had been due to working hours breaches and the majority had been in relation to F1 grades. • A lack of office space and lockers remained an issue. • The generation of a sense of belonging amongst resident doctors posed a challenge. • The session on resident doctors at the Trust Board Study Session in November 2024 was a welcome opportunity to speak to the Board about the lives of resident doctors. 5.12 Learning from Deaths 2024-25 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths 2024-25 Quarter 2 Report, the content of which was noted. It was further noted that: • The Trust’s relative mortality rate was lower than expected compared with national figures. The Trust was one of 12 other trusts (out of 119) in this position. • The Independent Medical Examiners Group had commenced work during the second quarter and was responsible for reviewing all deaths. • An electronic application was being developed to assist in disseminating the outputs from Mortality and Morbidity meetings. • There had been an increased number of reports of patients dying in bays rather than side-rooms, which correlated with complaints received. 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control 2024-25 Quarter 2 Report, the content of which was noted. It was further noted that: • In line with a more general national trend, the Trust was not expecting to meet its targets in respect of infection prevention and control. Page 6 • However, the Trust compared favourably with peers. • A hand-washing campaign had been carried out in October and November 2024. • Rates of clostridioides difficile were increasing both nationally and internationally. • The situation with regard to the candida auris outbreak appeared to be improving following the interventions made by the Trust. The screening arrangements would likely be required indefinitely and the maintaining of the fundamentals of care programme expectations was crucial to preventing future outbreaks. Action Gail Byrne agreed to include an item on infection prevention control at a future Trust Board Study Session to include details of an Australian study, point of care testing, and progress on the roll out of the Fundamentals of Care programme. 5.14 Annual Medicines Management 2023-24 Report James Allen was invited to present the Annual Medicines Management 2023-24 Report, the content of which was noted. It was further noted that: • During 2023/24, the Trust spent £219m on medicines, a four per cent increase compared to 2022/23. • Training continued successfully, although operational pressures had led to some challenges in this area. • The pharmacy team’s support to clinical trials had improved. • Improvements were required to the Trust’s estate to make it more suitable for the safe storage of medicines, especially given the increased volume and acuity of mental health in-patients and the resulting challenges in terms of security of patients’ medication. • The aseptic site at Adanac Park was expected to be ready in the coming months • Consideration was being given as to whether to stop prescribing over-thecounter medicines on discharge in order to accelerate the discharge process. 5.15 Annual Ward Staffing Nursing Establishment Review 2024 Gail Byrne was invited to present the Annual Ward Staffing Nursing Establishment Review 2024, the content of which was noted. It was further noted that: • It was a requirement from the National Quality Board that the Establishment Review be discussed by the Board in open session. • Out of the 37 recommendations which were made following the Francis inquiry in 2013, the Trust was compliant with 35. The areas of non-compliance related to the allocation of time for supervision time for statutory and mandatory training and in relation to equality, diversity and inclusion. Progress was being made in these areas, but further action was required to achieve full compliance. • The Trust was compliant with 37 out of 38 of the recommendations included in the NICE guideline on safe staffing for in-patient wards. An action plan was in place to address the single area of non-compliance. Page 7 • The Trust had conducted a robust six-monthly ward staffing review. Areas of challenge related to night shifts and the increasing number of patients with enhanced care needs. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework Update, the content of which was noted. It was further noted that: • Five of the Trust’s risks were rated ‘critical’ and five were outside of appetite. • The rating of risk 5a had been increased from 15 to 20 due to the continuing financial pressures and the erosion of the Trust’s cash balance. • A new scoring matrix was being rolled out for the operational risk register and BAF risks. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) John Mcgonigle was invited to present the Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response, the content of which was noted. It was further noted that: • The Trust had reported full compliance in 60 out of 62 core standards as part of the self-assessment, with an overall assurance rating of ‘substantially compliant’. • The two key areas for improvement were in respect of lockdown procedures and the Trust’s approach to business continuity. • The Trust had also carried out a deep-dive into its cyber security arrangements. 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 8. Any other business The Board expressed its thanks to Joe Teape for his time as Chief Operating Officer, noting that this would be his last Board meeting at the Trust. 9. Note the date of the next meeting: 11 March 2025 Page 8 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 01/04/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 01/04/2025 Study Session. Trust Board – Open Session 07/01/2025 2 Patient Story 1200. Recommendations Byrne, Gail 11/03/2025 Pending Explanation action item Gail Byrne agreed to consider how the recommendations made in patient stories could be captured and action taken as a result. Trust Board – Open Session 07/01/2025 5.8 ICB Finance Report for Month 8 1201. Transformation programmes Howard, Ian 11/03/2025 Pending Explanation action item Ian Howard agreed to coordinate a report to the Board in respect of the Trust’s contribution to the Hampshire and Isle of Wight Integrated Care System transformation programmes. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 07/01/2025 5.8 ICB Finance Report for Month 8 1202. ICB Finance Reports Douglas-Todd, Jenni French, David 11/03/2025 Pending Explanation action item The Chair and David French agreed to discuss the requests of the Board in the ICB Finance Reports with the Integrated Care Board’s chair. Trust Board – Open Session 07/01/2025 5.10 Freedom to Speak Up Report 1203. Raising concerns of safety Byrne, Gail 11/03/2025 Pending Explanation action item Gail Byrne agreed to consider how Freedom to Speak Up can be used for its original purpose of raising concerns of safety. Trust Board – Open Session 07/01/2025 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report 1204. Trust Board Study Session Byrne, Gail 03/06/2025 Pending Explanation action item Gail Byrne agreed to include an item on infection prevention control at a future Trust Board Study Session to include details of an Australian study, point of care testing, and progress on the roll out of the Fundamentals of Care programme. Update: Item tentatively scheduled for TBSS on 3 June 2025. Page 2 of 2 Agenda item 5.1 Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: Audit & Risk Committee Meeting Date: 20 January 2025 Key Messages: • • • • • The committee considered the accounting policies and management judgements in respect of the 2024/25 annual accounts, noting that most of these were consistent with previous years. It was further noted that a full re-valuation was due to take place this year in respect of the Trust’s property, plant and equipment, a process which occurs every five years. The impact of IFRS16 was also noted. The committee reviewed the Trust’s compliance with the Code of Governance for NHS Provider Trusts, noting that the Trust was compliant in all areas or had appropriate explanations for areas of non-compliance, of which there were only a few. These had also been areas of non-compliance during 2023/24. The committee received a report on cyber risk, including recent trends and the steps that both the NHS and the Trust were taking to counter the threat posed. The committee received updates in respect of the internal audit programme, including the reports in respect of an audit of the Fit and Proper Persons framework and of Data Quality. An update was provided in respect of the work of the counter-fraud team, including an update on the work being undertaken to manage the risk impersonation fraud by those pretending to be agency/temporary staff. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • All risks had been reviewed with the relevant executive director(s). • It was suggested that the BAF needed to more adequately reflect the Trust’s estate risk and the target date should be reconsidered. 7.3 Audit and Risk Committee Assurance Rating: Risk Rating: Terms of Reference Substantial N/A • The committee reviewed its Terms of Reference, proposing to only make minor changes. • The committee recommended that the Board approve the revised Terms of Reference. Any Other Matters: • The committee received an update in respect of the tenders for internal and external auditors. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: Finance and Investment Committee Meeting Date: 27 January 2025 Key Messages: • • • • • • • • • • The committee reviewed the Finance Report for Month 9. The Trust’s financial position remained challenging with a £4.5m in-month and £22.7m year-to-date deficit recorded against a plan of £3.3m. Furthermore, the Trust’s cash position remained challenging. The underlying position had deteriorated during December 2024 due to lower than expected Elective Recovery income. In addition, there had been up to 500 Emergency Department attendances per day and circa 250 patients having no criteria to reside. The Trust was anticipating a year-end deficit of circa £35m once additional pay pressures had been taken into account. There were concerns that a cap would be applied to Elective Recovery funding based on month 8 figures. A significant proportion of the Trust’s undelivered Cost Improvement Programme related to non-delivery of system-wide transformation programmes. The Trust’s capital programme was £11.6m behind plan with £50.4m due to be spent during the remainder of the financial year. The committee received a report on the management of leases from an accounting perspective, noting that further work on reviewing leases was required. An update was received in respect of the annual planning and budgetsetting process, noting that no national planning guidance had yet been received. It was expected that 2025/26 would be challenging due to an anticipated real terms reduction in funding and possible cap on Elective Recovery funding. The committee received an update in respect of the Trust’s project to optimise operating services as part of the Always Improving programme, noting good progress being made in this area. The committee received an update in respect of Digital, noting the progress being made in respect of system developments and laptop upgrades as well as the latest position regarding the proposed system-wide Electronic Patient Record system and the planned go-live for the new Emergency Department system in April 2025. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 7.4 Finance and Investment Assurance Rating: Risk Rating: Committee Terms of Reference Substantial Low • The committee reviewed its Terms of Reference, proposing to only make minor changes. • The committee recommended that the Board approve the revised Terms of Reference. Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: Finance and Investment Committee Meeting Date: 24 February 2025 Key Messages: • • • • • • • The committee considered a draft of the Trust’s annual plan submission to the Hampshire and Isle of Wight Integrated Care Board. The draft plan identified significant financial challenges continuing from the underlying financial pressures reported during 2024/25. The committee received an update in respect of the Trust’s inpatient flow programme, noting that whilst a 5% improvement in length of stay had been achieved, much of this had been offset by increased demand. The committee reviewed the Finance Report for Month 10 (see below). The committee received an update in respect of the Trust’s cash position, noting that it appeared likely that additional revenue support would be required in the first quarter of 2025/26. The committee received an update regarding the Trust’s 2024/25 Cost Improvement Programme. The Trust had identified £89.3m of schemes and forecast delivery of £76.3m of improvements. The committee received an update on the Trust’s decarbonisation programme, including on proposals for installing heat pumps, solar panels and renewing/replacing infrastructure. The committee noted an update in respect of UHS Estates Limited, including the risk associated with the management of endoscopy scopes and their replacement. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 10 Assurance Rating: Risk Rating: Substantial High • The Trust’s underlying monthly deficit was c.£6.5m. There was a year-to-date deficit of £15.2m, £11.8m behind plan. • The Trust had reported a £7.5m surplus during the month due to oneoff items. • The Trust was forecasting an year-end deficit of £17.65m following work to agree a Hampshire and Isle of Wight Integrated Care System ‘landing plan’ for 2024/25. • The Trust’s capital programme was £12m behind plan, with £39.3m due to be spent during the remainder of 2024/25. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). • It was proposed to extend the target date for risk 5a, but to include an interim target as at April 2026 between the current position and the ultimate objective of reducing this risk to 9. Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.3 i) Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: People & Organisational Development Committee Meeting Date: 24 January 2025 Key Messages: • • • • • • • As forecast, the Trust’s workforce was seven whole-time-equivalents (WTE) above its plan at the end of December 2024. However, the total workforce had decreased by 90 WTE, owing to the impact of Christmas resulting in deferral of start dates until January 2025. It was forecast that the Trust would be 146 WTE above plan at the end of 2024/25, noting that the Trust had assumed a reduction of 220 WTE due to the impact of system-wide transformation programmes including Non-Criteria to Reside and mental health. The Trust was experiencing particularly high sickness levels due to the impact of seasonal illnesses. The committee received a presentation on the Trust’s internal leadership development programmes, including those relating to senior, operational, and emerging leaders as well as programmes targeted at under-represented groups. The committee received an update on staff health and wellbeing, noting that uptake for influenza and Covid-19 vaccinations was low at 50% and 30% respectively. The committee was updated on the status of the disputes with UNITE for Portering and with UNISON regarding Band 2 and Band 3 pay. The committee noted that the formal consultation in respect of transfer of staff to UHS Estates Limited had commenced. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Not applicable. Any Other Matters: The committee noted that an action plan had been agreed with the porters and that the team had moved from Estates, Facilities and Capital Development to the Site team. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.3 ii) Committee Chair’s Report to the Trust Board of Directors 11 March 2025 Committee: People & Organisational Development Committee Meeting Date: 24 February 2025 Key Messages: • • • • The committee reviewed the People Report for Month 10 (see below). It was noted that January 2025 had been challenging, especially in terms of managing high levels of staff sickness due to seasonal illnesses as well as the impact of increased demand on the Trust’s services. Furthermore, the increasing number of patients requiring enhanced care placed further pressure on the Trust’s workforce numbers. It was expected that difficult decisions would be required to meet the financial and workforce expectations for 2025/26. As part of this, it would be necessary to ensure that quality indicators were monitored. In addition, the Trust will need to be focused on ensuring that staff still feel valued and supported to deliver the first class care they aspire to. This would
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Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 11 November 2025 9:15 Approve the minutes of the previous meeting held on 11 November 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:40 including Maternity and Neonatal Safety 2025-26 Quarter 2 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:50 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:20 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.6 11:00 5.7 11:15 5.8 11:25 5.9 11:30 5.10 11:45 5.11 11:55 5.12 12:05 5.13 12:15 6 6.1 12:25 7 12:35 8 Break Finance Report for Month 8 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICB System Report for Month 8 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 8 Review and discuss the report Sponsor: Steve Harris, Chief People Officer Learning from Deaths 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience Infection Prevention and Control 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control Medicines Management Annual Report 2024-25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist Annual Ward Staffing Nursing Establishment Review 2025 Discuss and approve the review Sponsor: Natasha Watts, Acting Chief Nursing Officer CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager Any other business Raise any relevant or urgent matters that are not on the agenda Note the date of the next meeting: 10 March 2026 Page 2 9 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 10 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 January 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB System Report for Month 8 5.9 People Report for Month 8 5.10 Learning from Deaths 2025-26 Quarter 2 Report 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report 5.12 Medicines Management Annual Report 2024-25 5.13 Annual Ward Staffing Nursing Establishment Review 2025 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b 1c 1b 1b, 3a 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 11/11/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Martin de Sousa, Director of Strategy and Partnerships (MdS) (item 6.1) Lucinda Hood, Head of Medical Directorate (LH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.12) Vickie Purdie, Head of Patient Safety (VP) (item 7.3) Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness (KP) (item 5.13) Scott Spencer, Health and Safety Advisor (SS) (item 7.3) 4 governors (observing) 2 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that no apologies had been received. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Item deferred to the next meeting. 3. Minutes of the Previous Meeting held on 9 September 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 9 September 2025, subject to a minor correction at 5.10. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Actions 1281, 1283 and 1284 were closed. • Action 1282 was to be addressed through item 5.6 below. • In respect of action 1285, the Quality Committee would monitor progress on complaints response times. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • In terms of the internal audit reports, which had been received by the committee, whilst there were a number of points for the Trust to address, no areas of significant concern had been identified. • There was a focus on ‘imposter fraud’ whereby individuals who had turned up to carry out a shift were not who they claimed to be. Whilst there had been no reported incidents at the Trust, the Trust had implemented controls at the ward level, which would be subject to testing during 2025/26. 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • In September 2025, the Trust had reported that it was in line with its Financial Recovery Plan. Of the £110m Cost Improvement Programme (CIP) target, 76% had been fully developed. • The committee had reviewed the Finance Report for Month 6 (item 5.8), noting that the Trust had reported an in-month deficit of £5.4m, which was in line with the Financial Recovery Plan. • The committee had expressed concern that 17% of the CIP target was not fully developed and that the Trust was £2.5m off-track in terms of delivery of the target at Month 6. • Whilst progress had been made in terms of addressing patients with no criteria to reside and mental health patients, this remained an area of concern. • The committee considered the NHS England Medium Term Planning Framework, noting that the first submission by the Trust was due prior to Christmas 2025. 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • There continued to be little improvement in terms of the number of patients with no criteria to reside or mental health patients, which impacted staffing numbers. • The Trust was adopting a harder line in respect of its approach to violence and aggression, which included a greater willingness to exclude individuals. • The current participation rate in the Staff Survey was lower than the national average, which was likely indicative of staff morale and engagement. Page 2 • The Trust’s workforce numbers remained above plan, with limited options available to address this issue, especially in the absence of funding for restructuring costs. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • The committee received an update in respect of mental health patients, noting that although there were significant issues in the Emergency Department, the whole pathway for these patients remained a problem. • The committee carried out a six-monthly review of the Trust’s progress against its Quality Priorities, noting that good progress had been made on four of the six priorities and two were slightly behind. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published the Medium Term Planning Framework, which was intended to encourage organisations to think beyond a 12-month time horizon and to progress the NHS 10-Year Plan. The Trust was expected to provide its first submission prior to Christmas 2025, but the detailed planning assumptions had yet to be received from NHS England. It was noted that a more detailed report on the Medium Term Planning Framework was to be received as part of the closed session of the meeting. • The Strategic Commissioning Framework had been published by NHS England, which provided welcome clarifications about the future role of integrated care boards. • The Trust had been placed into Tier 1 for both Urgent and Emergency Care and for Elective performance. There was a national expectation that trusts would have no patients waiting over 65 weeks for elective care by 21 December 2025. Where organisations had more than 100 such patients at the end of October 2025, they had been placed into Tier 1. The Trust was taking steps, including mutual aid, to attempt to address the number of long waiters, but there was insufficient capacity in the system. • Resident doctors were due to strike for a further five-day period commencing on 14 November 2025, having rejected the Government’s latest offer to resolve the ongoing dispute with the British Medical Association. • The Hampshire and Isle of Wight Integrated Care Board and NHS England South East Region had carried out a visit to the Trust’s paediatric hearing services in May 2025. The report, received in October 2025, had been positive about the service. • The Trust and the University of Southampton had been awarded £16.3m by the National Institute for Health and Care Research. The Trust was one of only four organisations out of 15 applications to receive an award. • The NHS Business Services Authority had announced the award of a £1.2bn contract to Infosys to deliver a new and enhanced workforce management system for the NHS to replace the existing Electronic Staff Record system. The 2030 target date for implementation was considered ambitious. Further details would be considered by the People and Organisational Development Committee when available. Page 3 5.6 Performance KPI Report for Month 6 Andy Hyett was invited to present the ‘spotlight’ report in respect of Diagnostics, the content of which was noted. It was further noted that: • Diagnostics performance was a key element of the pathway, as delays in diagnosis had a consequential impact on the overall length of pathways such as those for cancer and patients on a Referral To Treatment pathway. • Although there were some concerns with Diagnostics in the Trust, the Trust, generally, performed better than other organisations. The Board discussed the matters raised in the Diagnostics ‘spotlight’. This discussion is summarised below: • There had been a long-standing issue with waiting times for cystoscopy due to insufficient capacity. However, a plan was being developed to improve the situation, although it was considered appropriate that the plan should also address broader issues with urology as a whole. • There was concern regarding the availability of magnetic resonance imaging (MRI) scanners, particularly as two scanners were out-of-action. It was noted that the current set-up in terms of MRI scanners was not fit for the longer term and a strategy for the future needed to be developed. • There was a disparity between capacity and demand in respect of the neurophysiology service, as this service had previously relied on outsourcing. • Generally, activity was increasing, but overall performance appeared to be declining. There was also the additional financial challenge that Diagnostics was funded under a ‘block’ contract arrangement which did not fully take into account the demand for these services. • There were concerns about the electrical supply capacity at the Southampton General Hospital site and the ability of the Trust to expand its Diagnostic capacity with this limitation. It was considered that a better longer-term model would be for scanners at local community diagnostics centres. Actions Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Andy Hyett agreed to develop a long-term solution to the neurophysiology service. Andy Hyett was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s Emergency Department had recorded performance of 67.6% against the four-hour standard during September 2025. The department remained busy with c.450 patients and 120 ambulance attendances per day. • There had been some initial performance impacts with the roll out of the MIYA system in the Emergency Department, but this appeared to have now been addressed with performance up to previous levels. • A number of initiatives were being introduced into the Emergency Department in order to improve performance. These included the layout of the service, pathway re-designs, having General Practitioners in the department, and arranging with non-urgent patients to attend at a scheduled time rather than waiting in the department. Page 4 • In October 2025, the Trust had recorded 363 patients waiting over 65 weeks on a Referral To Treatment pathway against a national target of no such patients by the end of December 2025. • The Trust was making use of the independent sector, weekend working, and was requesting capacity from other providers to address the number of patients waiting over 65 weeks. • The planned industrial action by resident doctors posed a challenge, noting that the national expectation was that trusts maintain 95% of their capacity during this period. It was noted that, in contrast to previous instances of industrial action, resident doctors were apparently less forthcoming in terms of whether they intended to participate in the industrial action. • The Trust continued to report one of the lowest Hospital Standardised Mortality Rates in England. • The Trust’s cancer performance, based on a BBC article, was 21 out of 121 trusts. It was noted that whilst the number of patients being referred on a cancer pathway had increased significantly, the number of patients diagnosed with cancer had not materially changed. • There appeared to have been an increase in the number of pressure ulcers and ‘red flag’ incidents. Work was ongoing to address the findings of the pressure ulcer audit which had been presented to the Quality Committee on 2 June 2025. • The number of patients having no criteria to reside and mental health patients remained high. Actions Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. 5.7 Break 5.8 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had submitted its Financial Recovery Plan to NHS England in August 2025, which committed to an additional £23m improvement in the Trust’s financial position to deliver a full-year position of a £54.9m deficit. In the absence of these additional improvements, the Trust had been forecasting a year-end position of a £78m deficit. The revised target was subject to a number of assumptions, including the need for demand management and improvements in non-criteria to reside and mental health patient numbers. • There were a number of risks to the achievement of the Financial Recovery Plan, including whether there would be improvements in mental health and non-criteria to reside and/or steps taken to manage demand, high levels of activity, and whether it would be possible to reduce the workforce and close theatres. The need for the Trust to focus on achieving the 65-week wait target in particular could impact the Trust’s ability to close capacity. • The Trust had reported an in-month deficit of £5.4m (£30.8m year-to-date), which was in line with the trajectory set out in the Financial Recovery Plan. The Trust’s underlying deficit had seen some marginal improvement during the period. • The Trust’s cash position remains an area of significant concern. Cash requests had been made to NHS England, but the latest request for November 2025 had been rejected. It was therefore likely that the Trust would need to manage its supplier payments in accordance with its available cash. Page 5 5.9 ICS System Report for Month 6 Ian Howard was invited to present the ICS System Report for Month 6, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £48m. • A significant improvement in the run-rate would be required for the system to be able to deliver its 2025/26 plan. • The system was one of the worst in England in terms of the number of beds occupied by patients having no criteria to reside with approximately 23% of beds being occupied by such patients compared with a national average of 12%. • The system was also below plan in terms of its targets for access to General Practitioners and targets relating to mental health patients. It was noted that the performance in these areas had a consequential impact on the Trust’s performance in areas such as urgent and emergency care performance. 5.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The overall workforce fell by 73 whole-time-equivalents (WTE) during September 2025 and was reported as being 54 WTE above the Trust’s 2025/26 plan. The reduction in workforce had been driven through a combination of the impact of the recruitment controls, mutually agreed resignation scheme (MARS) leavers, and a significant drop in use of temporary staff during the month. • On 15 October 2025, the Trust had heard the collective grievance brought by the Royal College of Nursing in respect of the removal of enhanced NHS Professionals rates. It was decided not to reverse the decision in order to maintain equity with the rest of the workforce and consistency across other local providers. A number of actions had been agreed following the hearing. • Sickness rates had increased to 3.8%, although the Trust still benchmarked well against peers. • There were concerns about the potential impact of influenza during the winter period and therefore the Trust was taking a number of actions to promote vaccination of staff. The Trust was currently third in terms of uptake in the Region. • The level of participation in the national Staff Survey remained a challenge with only 32% of staff having completed the survey compared with a national average of 38%. It was considered likely that the recent difficult decisions taken and the impact on staff was impacting staff experience and engagement. • The People and Organisational Development Committee would be examining statutory and mandatory training levels together with the latest proposed national changes. Page 6 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including UHS Self-Assessment Return Natasha Watts was invited to present the NHS England audit and review of ‘Developing Workforce Safeguards’ (2018), including the Trust’s Self-Assessment Return, the content of which was noted. It was further noted that: • ‘Developing Workforce Safeguards’ was published in October 2018 and included a range of standards to assure safe staffing across the workforce. NHS England had initiated an audit, review and improvement plan amidst concern about a national reduction in compliance. • The Trust had submitted a self-assessment as part of this NHS England review. This assessment showed that the Trust continued to comply with the majority of the standards. • The audit exercise has been used as an opportunity to identify opportunities for improvement. Twelve recommendations have been developed, of which nine were assessed as ‘green’ and three as ‘amber’. 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report and Update on the 10-Point Plan, the content of which was noted. It was further noted that: • Resident doctors were due to strike for five days from 14 November 2025. This would be the thirteenth strike in recent years. It was noted that, in addition to pay, the dispute also concerned working conditions and the shortage of posts and consequent risk to resident doctors of unemployment. • The Trust had performed a self-assessment against the 10-Point Plan and it was noted that the majority of the plan’s contents had been considered by the Trust for some time. There were also a number of dependencies on the part of NHS England in areas such as lead employer models. • A national review of statutory and mandatory training was expected to enable portability of training records to facilitate staff moving between NHS organisations. • There had been significant improvements in respect of gaps in rotas. 5.13 Annual Clinical Outcomes Summary Luci Hood and Kate Pryde were invited to present the Annual Clinical Outcomes Summary Report, the content of which was noted. It was further noted that: • The paper provided an overview of the clinical outcomes reviewed by the Clinical Assurance Meeting for Effectiveness and Outcomes (CAMEO) over the 12-month period to September 2025. • The majority of specialities provide reports to CAMEO, although outcome data can be more difficult in some areas to capture than in others. • The outcomes reviewed by the CAMEO and outputs from this body were also influencing the development of the Trust’s clinical strategy. • The strains on the capacity of services posed a risk to clinical outcomes. Page 7 • There was potential that a ‘quality’ override could form part of the NHS Oversight Framework in the future, operating in a similar manner to the ‘financial’ override by limiting the segmentations available to an organisation. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review Martin De Sousa was invited to present the review of Corporate Objectives 2025/26 for the second quarter, the content of which was noted. It was further noted that: • Of the 12 objectives agreed for 2025/26, six were rated ‘green’, four were ‘amber’ and two were ‘red’. • The ‘red’ rated risks were that relating to the Trust’s financial performance and that relating to the Trust’s achievement of its workforce plan for 2025/26. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • BDO had completed its audit of the Trust’s risk maturity and had presented its report to the Audit and Risk Committee on 13 October 2025. The audit had highlighted a number of strengths including the Board Assurance Framework, risk definition, and use of risk in decision-making. In terms of opportunities for improvement, the audit report suggested some improvements in articulation of operational risks and use of ‘SMART’ methodology for actions. • The Board Assurance Framework had been reviewed by relevant executive directors and committees since it was last presented to the Board. There had been no changes to the ratings or target dates. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 28 October 2025 The Chair presented a summary of the Council of Governors’ meeting held on 28 October 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Governor attendance at Council of Governors’ meetings • Review of the Council of Governors’ Expenses Reimbursement Protocol • Appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025 • Membership engagement • Feedback from the Governors’ Nomination Committee It was noted that the Trust’s work on violence and aggression received particular attention from the Governors. 7.2 Register of Seals and Chair’s Action Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 It was further noted that one further item had been sealed on 7 November: Deed of Guarantee between University Hospital Southampton NHS Foundation Trust (Guarantor) and CHG-Meridian UK Limited (Beneficiary) regarding the payment and due performance obligations of UHS Estates Limited (UEL) under the Guaranteed Contract and specifically the Stryker Power Tools delivered to UEL under the pre-contract open build period with CHG. Seal number 307 on 7 November 2025. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and to the additional document referred to above. 7.3 Health and Safety Services Annual Report 2024-25 Spencer Scott was invited to present the Health and Safety Services Annual Report 2024/25, the content of which was noted. It was further noted that: • The number of incidents reportable pursuant to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) had increased substantially to 68 such incidents compared to 39 in 2023/24. The majority of these incidents related to moving and handling or exposure to infectious diseases. • There was a concern that there had been a reduction in the number of health and safety related reports and escalations whilst at the same time the number of RIDDORs had increased. • Four areas of concern were highlighted: Entonox surveillance of maternity staff, display screen equipment compliance, the Southampton General Hospital loading bay, and workplace temperatures during the summer. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 January 2026 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 03/02/2026 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: Scheduled for TBSS on 03/02/26. Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. 1294. Cystopscopy/urology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1295. Neurophysiology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a long-term solution to the neurophysiology service. 1296. Watch & Reserve antibiotics usage Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. Page 2 of 2 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 24 November 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee received an update in respect of the Trust’s commercial activities, noting that the Trust had robust systems in place to maximise cost recovery for private patient and overseas visitor income. The Trust’s private patient unit project continued to progress. The Trust was also seeking a partner to manage its parking provision. • The committee received the Finance Report for Month 7. The Trust had reported a £5.1m in-month deficit (£35.9m year-to-date), which was in line with the trajectory contained in the Financial Recovery Plan. The underlying deficit remained flat at £6.4m. Whilst there had been a slight reduction in the number of mental health patients, there were c.240 patients having no criteria to reside at any point during the period. There was an increased level of scrutiny in respect of non-pay expenditure. • The committee reviewed an update on the Trust’s measures for financial improvement, noting that the Trust was forecasting achievement of £85-95m against its target of £110m Cost Improvement Programme delivery for 2025/26. • The committee noted the Trust’s approach and the timelines associated with the Medium Term Planning submission. It was noted that the framework set ambitious financial and performance targets. • The committee received an update in respect of the Trust’s Theatre Experience Programme, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee reviewed the Trust’s productivity, noting that the Trust’s productivity had fallen by 3.3% compared to the prior year due to high-cost growth. • The committee received an update in respect of the Trust’s cash position and forecast and supported a proposal to request further cash support for January 2026. • The committee received an update on Capital Planning for 2026/272029/30. It was noted that it was expected that the Trust would be allocated c.£40m per annum, although there were concerns about the impact of the Trust’s cash position and the ability of the Trust to meet this level of expenditure. N/A N/A Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 15 December 2025 Key Messages: • • • • • • The committee received the Finance Report for Month 8 (see below). The committee discussed the Trust’s future transformation programmes, noting that the areas of focus would be: urgent and emergency care, elective care, and automation of administrative processes. The committee was assured that the programmes were felt to be suitably ‘bold and ambitious’ and were grounded in realistic opportunities, rather than ‘blue sky’ ideas. The committee reviewed the draft capital plan for 2026/27 – 2029/30, noting that the Trust had been allocated c.£40m of capital departmental expenditure limit (CDEL) per year. It was noted that the Trust’s cash position could place constraints on the Trust’s capital programme. The opportunity to secure funding from national programmes outside of CDEL should be pursued vigorously. The plan was to be discussed in a Trust Board Study Session prior to submission in February 2026. The committee reviewed, challenged and discussed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. The committee provided feedback in respect of the proposed submission noting that some of the assumptions within the 2025/26 plan had not materialised with regard to matters such as reductions in non-criteria to reside numbers and the committee sought assurance that learnings had been applied to the development of the medium-term plan submission. The committee was assured that such assumed reductions within the 2026/27 plan were based purely on actions which were deemed to be within the Trust’s control. The committee suggested some changes with regard to the plan, particularly around growth assumptions in the cost base, and agreed to recommend the revised plan to the Board for approval. It was noted that more detail and reviews would be required prior to the final submission date in February 2026. The committee received an update in respect of the Trust’s cash position and supported a proposal to make a further request for cash support from NHS England for January 2026. The Trust reviewed and supported a proposal for transforming the Southern Counties Pathology network. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust had reported an in-month deficit of £4.9m (£40m year-todate), which was consistent with the Trust’s Financial Recovery Plan. • November 2025 had been a challenging month due to costs associated with industrial action, patients with no criteria to reside and mental health patients. • The Trust had received c.£3m of income out of £6.1m for elective over-performance. • There had been a slight improvement in the Trust’s underlying deficit. Page 1 of 2 Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 21 November 2025 Key Messages: • • • • The committee reviewed the People Report for Month 7 including progress against the workforce plan. During October 2025, the overall workforce grew by 14 whole-time-equivalents (WTE). Although the substantive workforce had reduced by 15 WTE, there had been lowerthan-expected turnover and increased temporary staffing usage due in part to high sickness levels. The Trust remained on track, however, with respect to its Financial Recovery Plan trajectory. There were concerns about the response rate to the Staff Survey, which was below the national average. The Trust’s vaccination campaign for staff had started well with the uptake rate for the flu vaccine amongst staff at 43%. The committee considered the outputs of the review by NHS England of statutory and mandatory training and the implications for UHS. It was noted that a revised framework would facilitate passporting of training between NHS organisations. The Trust was aligned to the Core Skills Training Framework across six out of eleven areas and ten out of eleven areas for the Utilising E-Learning for Health material. The committee received an update in respect of the Trust’s Inclusion and Belonging strategy. It was noted that resource constraints and the impact of the current financial and operational environment on staff morale had impacted progress towards achievement of the objectives set out in the strategy. The committee reviewed the People risks contained within the Trust’s Board Assurance Framework. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 15 December 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the People Report for Month 8 (see below) including progress against the workforce plan and Financial Recovery Plan. • The committee considered the workforce implications of the Trust’s medium term plan submission, noting that there were a number of national expectations and targets, such as those relating to sickness rates and elimination of agency spend. In addition, the committee noted the risks associated with the plan, including those where the Trust was reliant on progress with respect to non-criteria to reside and mental health numbers. • The committee received an update regarding the Trust’s Violence and Aggression workstream, noting that the Trust had adopted a revised approach to violence, aggression and abuse directed at staff with a greater willingness to take action against violent/abusive patients and members of the public. A violence and aggression board had been established to provide executive oversight and leadership, and the Trust’s policy was being revised. This work would be accompanied by a comprehensive communication plan for both staff and members of the public. • The committee reviewed the Trust’s progress against its objectives for Year 4 of its People Strategy. 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The overall workforce fell during November 2025, with substantive numbers falling by 52 whole-time-equivalents (WTE). However, temporary staffing use had increased during the month due to increased sickness and operational pressures, which offset much of the reduction in substantive numbers. • The Trust was over its original plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to hit the Trust’s Financial Recovery Plan target, the overall workforce would need to fall by a further 137 WTE (including a 72 WTE reduction in temporary staffing) by the end of March 2026. • A forecast based on the previous year’s temporary staffing usage for the remaining months of the year indicated that the Trust would end the year approximately 500 WTE above the Trust’s 2025/26 plan. • The Trust had submitted a baseline assessment against the 10 Point Plan to improve Resident Doctors’ working lives in August 2025, which indicated that the Trust compared favourably against other organisations in the South East. The main issues concerned space available for doctors to work in and timeliness of reimbursement of course-related expenses. • The Trust was expected to meet a target of 95% of job plans having been signed off prior to 31 March 2026. At the start of December 2025, 55% of job plans had been signed off. Page 1 of 2 Any Other Matters: • Sickness absence had increased in November 2025 to 4.2% in month due to seasonal illnesses. • The staff survey closed on 28 November 2025. The completion rate for the staff survey had been lower t
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Papers Trust Board - 9 September 2025

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 09/09/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd David French, Tim Peachey 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 15 July 2025 9:15 Approve the minutes of the previous meeting held on 15 July 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance and Investment Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:25 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:30 including Maternity and Neonatal Safety 2025-26 Quarter 1 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:35 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 4 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.6 UHS Operating Plan 2025-26 and Board Assurance Statement 10:30 Receive and approve the Plan Sponsor: Andy Hyett, Chief Operating Officer Attendee: Duncan Linning-Karp, Deputy Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 4 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Operational Delivery Report for Month 4 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 11:10 People Report for Month 4 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Learning from Deaths 2025-26 Quarter 1 Report 11:20 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Annual Complaints Report 2024-25 11:30 Receive and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.13 11:40 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Receive and note the Annual Report. Approve the Statement of Compliance. Sponsor: Paul Grundy, Chief Medical Officer 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 11:50 Receive and discuss the report and strategy Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Corinne Miller, Named Nurse for Safeguarding Adults/ Dannielle Honey, Named Nurse for Safeguarding Children 6 STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update 12:05 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 16 July 2025 12:20 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 People and Organisational Development Committee Terms of Reference 12:30 Review and approve Sponsor: Steve Harris, Chief People Officer 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 11 November 2025 10 Items circulated to the Board for reading 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Quarter 1 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 9 September 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 4 5.6 Operating Plan October 2025 – September 2026 5.8 Finance Report for Month 4 5.9 ICS Operational Delivery Report for Month 4 5.10 People Report for Month 4 5.11 Learning from Deaths 2025-26 Quarter 1 Report 5.12 Annual Complaints Report 2024-25 5.13 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 1a, 1b, 1c 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b, 3b 1b, 3b 3b, 3c 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date Time 15/07/2025 9:00 – 13:00 Location Chair Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd (JD-T) Present Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (shadowing CM) Julie Brooks, Deputy Director of Infection Prevention and Control) (JB) (item 5.12) Phil Bunting, Director of Operational Finance (PB) (item 7.2) Martin De Sousa, Director of Strategy and Partnerships (MDeS) (item 6.1) Christopher Kipps, Clinical Director of R&D (CK) (item 6.2) Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian (CMb) (item 5.11) Laura Purandare, Deputy Director of R&D (LP) (item 6.2) Julian Sutton, Clinical Lead, Department of Infection (JS) (item 5.12) Karen Underwood, Director of R&D (KU) (item 6.2) 1 members of the public (item 2) 4 governors (observing) 3 members of staff (observing) 1 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. 2. Patient Story Verity Elbro-White was invited to present her experience of the birth of her second child at Princess Anne Hospital. The mother was diabetic, and the pregnancy was complex. It was noted that: Page 1 • Both the community midwife and diabetic team had been excellent. The midwife had advised that the patient go to hospital because she was feeling unwell, following which she underwent a caesarean section. • The patient felt valued and listened to, with the care patient-centred. • The surgical and neonatal intensive care teams were also excellent and compassionate. • Attention was also paid to family members. 3. Minutes of the Previous Meeting held on 13 May 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 13 May 2025. 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. It was noted that action 1247 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 9 June 2025, the content of which was noted. It was further noted that: • There had been a delay in the production of the Trust’s Annual Report and Accounts due to issues with reconciling information from the Trust’s ledgers into the accounts. NHS England had been notified, and it had been agreed that the Trust would submit its accounts by 21 July 2025. • The committee had reviewed the internal auditor’s report for 2024/25 and noted that out of the six reviews undertaken during the year, the results were good overall. • The committee received an update from the Trust’s external auditor and noted that it was necessary for the Trust to simplify its processes in order to prevent a repeat of the delay in producing end-of-year accounts. 5.2 Briefing from the Chair of the Finance and Investment Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 2 June 2025 and 23 June 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Reports for Month 1 and Month 2 (item 5.8), noting that the Trust’s reported deficit remained in line with its plan. • The Trust’s underlying deficit remained at c.£7m per month. • The committee reviewed the Trust’s Cost Improvement Programme, noting that the Trust was targeting £110m of savings for 2025/26. It was further noted that even with full delivery of the Trust’s workforce plans, there would still be a shortfall. • The committee received an update on the contracting process for 2025/26, noting that there was a risk that there would be £20-30m of unfunded activity during the year based on the current position. • The committee also continued to monitor the Trust’s cash position. Page 2 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Report in respect of the meeting held on 25 June 2025, the content of which was noted. It was further noted that: • The committee reviewed the People Report for Month 2 (item 5.10), noting that the Trust was on track in terms of its plan to reduce its workforce by c.700 and had received more than 220 applications under the Mutually Agreed Resignation Scheme. • The committee received an update on organisational change and the support being given to staff on managing change. • An update was provided in respect of the Trust’s education programmes, noting that there was a risk due to a lack of resource. • The committee would be reviewing the recently published 10-Year Plan in detail, particularly in terms of the organisational development elements and the plan’s implications for the Trust. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 2 June 2025 and to provide an update following the meeting held on 14 July 2025, the content of which was noted. It was further noted that: • There had been a further never event, although no harm had resulted. • The committee received a report on pressure ulcers and noted some concerns with respect to the regular turning of patients. • An update on the Fundamentals of Care programme was received and it was noted that improvement in general standards was limited in the absence of sufficient staff. • The committee noted an update in respect of job planning and that this provided good assurance of the process. • The committee reviewed the Maternity and Neonatal Safety Report for Quarter 4 and confirmed that there was nothing requiring escalation to the Board. Tim Peachey was invited to present the Maternity and Neonatal Workforce Report, the content of which was noted. It was further noted that: • The Trust expected to be compliant with the requirements of the NHS Resolution Maternity Incentive Scheme for 2025/26. • Although the Birthrate Plus assessment indicated a reduction in the birth rate, the acuity was, however, higher. • According to assessment, the Trust was approximately nine midwives below the required level. However, there was a plan in place to address this shortfall using the existing workforce. • There was a national shortage of neonatal nurses, although the Trust was attempting to address this issue through its in-house training programme. • In terms of the obstetrics workforce, there remained an issue with the number of trainees. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Trust had opened a new Neonatal ICU facility on 11 July 2025 as part of its work to improve the quality of the environment in the department. • The Government had published its 10-Year Health Plan for the NHS in England, which was based on reforming the NHS through three shifts: hospitals to community; analogue to digital; and sickness to prevention. Page 3 • NHS England had published the NHS Oversight Framework for 2025/26 under which organisations would be segmented based on their performance against a range of metrics. Whilst the Trust was one of the best performing trusts, the impact of a financial override and being in the Recovery Support Programme meant that the Trust would be placed in segment 5, the lowest category of performance. • Whilst the NHS waiting list nationally had fallen, the Trust’s waiting list has continued to grow. This was partially due to the impact of the cap on elective funding which had caused the Trust to cease outsourcing some procedures on the basis that it was not financially viable. • Notification had been received from the British Medical Association that resident doctors would embark on a five-day strike commencing on 25 July 2025. There was a risk of industrial action by other staffing groups, as both the Royal College of Nursing and Unite were conducting consultative ballots in respect of the 2025/26 pay award and other matters. 5.6 Performance KPI Report for Month 2 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 2, the content of which was noted. It was further noted that: • In the spotlight on Referral To Treatment, despite the Trust treating more patients, its waiting list had grown by 1%. Certain services accounted for much of this growth, with other services seeing flat or reducing waiting lists. The increase had also been driven by the decision to cease outsourcing some specialities due to the impact of the elective recovery funding cap. • There were three ways to address the increasing size of the waiting list: refusing referrals, validation, and treating more. The ‘patient choice’ agenda made refusing out-of-area referrals difficult. • The Trust’s performance across the constitutional standards indicated that the Trust was operating in a challenging environment and was delivering at activity levels far in excess of pre-COVID-19 levels. • Attendances at the Emergency Department remained high, averaging 433 attendances per day across March, April and May 2025. The Trust’s performance against the four-hour standard was 56.2%, a reduction of 4.5% compared to April 2025. • There had also been a reported increase in the number of Category 2 Pressure Ulcers (per 1,000 bed days) to 0.37 in May 2025, above the target of 0.3. • The Trust continued to benchmark in the top quartile when compared to peer teaching organisations against the national cancer performance targets. • Pressure on flow had caused an increase in overnight ward moves. 5.7 Break 5.8 Finance Report for Month 2 Ian Howard was invited to present the Finance Report for Month 2, the content of which was noted. It was further noted that: • The Trust had reported an in-month deficit of £3.8m, which was consistent with the Trust’s annual plan. The underlying monthly deficit remained at £7.2m. • There had been a number of ‘one-offs’ during the month which had reduced the underlying deficit to meet the planned level of deficit. The Trust continued to target recurrent savings. • Whilst the Trust remained on an improving trajectory, there was some concern regarding the pace of improvement. Page 4 • The Trust was involved in a number of contractual disputes in respect of currently unfunded or insufficiently funded services. • The Trust’s cash position remained an area of concern and continued to be closely monitored. The Trust had five operating days of expenditure, although this was supported in month by holding c.£13m of payments. There remained a significant risk that the Trust’s cash balance would reduce to close to zero in the first half of 2025/26. 5.9 ICS Operational Delivery Report for Month 2 Ian Howard was invited the present the ICS Operational Delivery Report for Month 2, the content of which was noted. It was further noted that: • The previous ICB Finance Report had been expanded to now include operational and performance information across the system. • The Hampshire and Isle of Wight Integrated Care System had reported that it was on plan for Month 2 with a reported deficit year-to-date of £18.25m against a planned deficit of £18.3m. • All organisations in the system would receive deficit support funding for Quarter 1 and Quarter 2. Whilst there was no clear national picture, it was believed that other organisations were in a similar position. • The South East region’s plan for 2025/26 was for a deficit of £95m at Month 2. 5.10 People Report for Month 2 Steve Harris was invited to present the People Report for Month 2, the content of which was noted. It was further noted that: • In May 2025, the workforce grew by 19 whole-time-equivalents (WTE), although was still below plan by 107 WTE. In addition, in June 2025, there had been a reduction in the overall workforce size of 99 WTE driven by the closure of surge capacity and higher turnover during the month. • There had been a freeze on hiring for administrative and clerical roles since March 2025 and only 70% of clinical leavers were being replaced. However, patient demand was not reducing. • The Trust had carried out a divisional restructure, reducing its clinical divisions from four to three. • Even full delivery of the Trust’s Cost Improvement Programme workforce reduction schemes would still produce a shortfall in terms of the Trust’s achievement of its 2025/26 plan. Whilst the Trust was currently on plan in terms of its workforce numbers, it was expected that it would deviate from this later in the year. • The Trust had accepted 42 applications under the Mutually Agreed Resignation Scheme and a number of others were under consideration. The majority of accepted applicants were from clinical administration teams, • The Trust was carrying out work to benchmark its temporary pay rates against others. • Transparency about the changes was key to mitigate against the anxiety in the workforce. A number of engagement activities were taking place, including regular ‘Talk To David’ sessions. • An Equality and Quality Impact Assessment process was in place and was undertaken in respect of decisions. The impact of decisions would be monitored through the Quality Governance Steering Group. It was also Page 5 necessary to ensure that there was a strategic view of decisions rather than just individual cases. The Board discussed the controls on recruitment. The content of the discussion is summarised below: • It was questioned whether a complete freeze on non-clinical recruitment could be sustained for the full year, and that shortages in administrative staff were already having an impact. It was noted that there had already been restrictions on recruitment for these staff groups during the previous year. • It was noted that decisions made by providers in isolation could impact other providers. However, chief medical officers across the system had agreed to discuss plans collectively. 5.11 Freedom to Speak Up Report Christine Mbabazi was invited to present the Freedom to Speak Up Report, the content of which was noted. It was further noted that: • The Trust had received 37 Freedom to Speak Up cases between December 2024 and June 2025, compared to 64 cases during the same period in 2023/24. There had also been a lower number of patient safety and health and safety reports. • Although there had been fewer reports via Freedom To Speak Up, there were other routes for raising concerns and Freedom To Speak Up was meant to provide a route where other options were unavailable or not possible. • It had been reported that the National Guardian Office function was to be abolished. The Board discussed the report, the key points from which are summarised below: • The Freedom to Speak Up framework was designed to facilitate reporting of patient safety related concerns. However, there had been few such reports through this route, with the mechanism being used more as a conventional ‘speak up’ method to report matters such as bullying and harassment. • Moreover, it was not clear whether the lack of such reports via Freedom to Speak Up was an indicator whether the more conventional reporting mechanisms were working effectively and hence there was no requirement to use Freedom to Speak Up. • It was agreed that it would be helpful to have data from the other means of reporting patient safety concerns included in the report in order to provide greater assurance. Action Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. 5.12 Infection Prevention and Control 2024-25 Annual Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control 2024/25 Annual Report, the content of which was noted. It was further noted that: Page 6 • The Trust had exceeded the threshold for Clostridioides Difficile and Methicillin-resistant Staphylococcus aureus (MRSA) cases during the year. However, the Trust had been successful in improving antimicrobial stewardship by 1%. • There had been a surge in respiratory infections in early 2025, which the Trust had managed well due to the use of its rapid testing diagnostic tool. The Trust had also successfully mitigated outbreaks of norovirus. • The measures taken to prevent the spread of Candida auris had been successful with only four acquisitions since September 2024. • Only 59% of areas had achieved the accreditation scheme standard, but there were actions in place to address this and improve standards as well as support through the Fundamentals of Care programme. 5.13 Guardian of Safe Working Hours Quarterly Report Paul Grundy was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There was a resident doctor vacancy rate of 8%, which was good compared with others. • Exception reports had decreased since the winter months. 711 exception reports had been received over the past 12 months, an average of 59 per month. • The People and Organisational Development Committee would continue to receive updates in respect of work being carried out to improve the lives of resident doctors. • The main challenge in terms of steps required to improve working conditions remained the Trust’s estate and the limited options for providing office space. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 1 Review Martin de Sousa and Kelly Kent were invited to present the Corporate Objectives 2025/26 Quarter 1 Review, the content of which was noted. It was further noted that: • Twelve objectives had been agreed for 2025/26. • The Trust was on track with 75% of objectives recorded as ‘green’ and the balance being ‘amber’. • The main risks to achieving the Trust’s objectives related to availability of people and financial constraints. 6.2 Research and Development Plan 2025-26 Karen Underwood and Chris Kipps were invited to present the Research and Development Plan 2025/26, the content of which was noted. It was further noted that: • 2024/25 had been a challenging year, but despite this there had been a number of significant successes. These included an award to host a new Commercial Research Delivery Centre, launch of the South Central Regional Page 7 Research Delivery Network, and securing funding for a secure data environment. • There remained challenges in terms of available capacity to set up and deliver studies. • Key Performance Indicators were to be focused on national priorities. • The plan for 2025/26 would focus on efficiency and working regionally. • The Trust had increased the size of its commercial portfolio. However, there needed to be a balance with non-commercial studies to support the Trust’s wider strategy. Decision Having considered the proposed Research and Development Plan for 2025/26, the Board approved the plan. 6.3 Board Assurance Framework (BAF) Update and Risk Appetite Statement Lauren Anderson was invited to present the Board Assurance Framework (BAF) Update, the content of which was noted. It was further noted that: • All risks had been reviewed by the relevant executive(s) and by the Board’s committees since the Board Assurance Framework was last presented to the Board. • The risk ratings had been increased for three risks. This was broadly due to the tension between the Trust’s finances and increasing demand. As a result, 60% of BAF risks were now at the ‘critical’ level. • The risk descriptions indicated crossover in terms of mitigations, demonstrating a holistic approach to risk management. Lauren Anderson was invited to present the Trust’s Risk Appetite Statement, the content of which was noted. It was further noted that: • The Trust’s Risk Appetite Statement had been updated following the Trust Board Study Session held on 3 June 2025. • Due to the current environment, the Trust was required to tolerate a higher level of risk. • The main changes in terms of risk appetite were to reflect the need to make decisions that might adversely impact patient experience and a lower appetite for financial risk. Decision: The Board agreed the Risk Appetite Statement tabled to the meeting. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Review of Standing Financial Instructions 2025 Ian Howard was invited to present the review of the Standing Financial Instructions, the content of which was noted. It was further noted that: • There were two main changes proposed: an additional section on employee expenses and reducing non-pay approval limits for certain bands. • The Standing Financial Instructions had been benchmarked against others to address differences of approach. • The proposed changes had been reviewed and supported by the Audit and Risk Committee at its meeting held on 9 June 2025. Decision: The Board approved the proposed changes to the Standing Financial Instructions tabled to the meeting. 8. Any other business There was no other business. 9. Note the date of the next meeting: 9 September 2025 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 13/05/2025 - 5.6 Performance KPI Report for Month 12 1246. Virtual outpatients appointments Linning-Karp, Duncan 09/09/2025 Pending Explanation action item Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 13/01/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Page 1 of 1 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: Finance and Investment Committee Meeting Date: 21 July 2025 Key Messages: • • • • • • • • • The committee reviewed the Finance Report for Month 3, noting that the Trust had reported a £4.5m in-month deficit. This was £1.1m above the plan submitted to NHS England. The Trust’s underlying deficit was £6.5m in month and income had been lower than expected. Whilst the Trust’s financial trajectory was improving, it was not improving at the rate required to deliver the plan. The committee received an update in respect of the Trust’s cash position, noting that the Trust had received additional cash from the ICB during the month. However, the Trust expected to record a negative cash balance in December 2025. Accordingly, the Trust was investigating further measures to manage its cash position. There was also a risk due to any unfunded elements of the pay award and additional costs due to industrial action. The committee reviewed the Trust’s CIP performance, noting that whilst the Trust was close to full achievement, there had been fewer recurrent schemes delivered than anticipated with a greater proportion of savings being delivered through non-recurrent savings. The committee received an update in respect of the Trust’s productivity, noting that this would be one of the metrics to be included in the new NHS Oversight Framework. The committee received an update regarding the Outpatient Transformation Programme. The committee reviewed Wessex NHS Procurement Limited’s performance, including its delivery of CIP. The committee received the quarterly UHS Digital report. The committee received an update on the proposed Hampshire and Isle of Wight elective hub and on a possible Urgent Treatment Centre at Southampton General Hospital. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: Finance and Investment Committee Meeting Date: 2 September 2025 Key Messages: • • • • • • The committee reviewed the Finance Report for Month 4 (see below). The committee reviewed and discussed a draft of the Trust’s Financial Recovery Plan, which was to be reviewed by the Board on 9 September 2025. The committee requested some clarifications and proposed some additions to ensure that long-term implications were understood. These changes would be incorporated into the paper to go to the Board. Suggestions for further action were also raised, but some of these had been discounted due to the impact on operations and detriment to the short-term position. The committee received an update in respect of the Trust’s cash position, noting that the Trust had received cash advances in June and July and that the ICB had agreed to provide additional cash in August and September. In addition, the process for requesting cash support from NHS England had now been published, although this would likely require some adjustments to the Trust’s governance to establish a ‘cash committee’ – it was considered appropriate to review the terms of reference for the Finance and Investment Committee and possibly to separate out the cash monitoring activities. It was further noted that NHS England had published guidance which suggested that trusts should have a minimum of four days’ operating expenditure in cash. The committee supported the submission of a request for cash support from NHS England, noting that the consequences of not receiving such support would be extremely serious (see also BAF review below). The committee received an update in respect of ongoing and recent contracting disputes, noting that a number of significant disputes had been closed and two remain in dispute and have been escalated. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 4 Assurance Rating: Risk Rating: Substantial High • The Trust had recorded a year-to-date deficit of £19.5m, which was £5.8m above its 2025/26 plan. • There had not been the one-off benefits seen in previous months during Month 4, which meant that the Trust’s position had worsened. However, its underlying month-on-month deficit was improving with £6.5m being recorded in month (previous months had been c.£7m). • The Trust had also received less income than anticipated from areas such as the Channel Islands, genomics, pathology, and CAR(T). There was also a risk that the Trust would not be fully paid for its over performance in terms of elective work, but this was being pursued with the relevant commissioners. • The Trust was also above its workforce plan by 55 whole-timeequivalents and the unfunded element of the pay award amounted to £2.4m per annum, of which £1.4m related to the training and Page 1 of 2 Any Other Matters: education contract and the balance being as a result of the settlement not accurately reflecting the Trust’s staffing mix. • However, the Trust was on track in terms of its CIP delivery, albeit there had been higher non-recurrent delivery than expected. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). • It had been agreed to increase the rating of risk 5a from 20 to 25 on the basis that the Trust did not, currently, have an agreement for the provision of cash support, and that the Trust was reliant on third parties to resolve many of the underlying issues. It was also noted that the need to reduce activity and spending now would likely require increased expenditure in future years in order to recover the Trust’s position. • It was agreed that the target risk ratings should be amended to show a rating of 20 at April 2026 and 15 at April 2027. The committee noted new guidance in respect of strengthening financial management and supporting delivery in 2025/26. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: People and Organisational Development Committee Meeting Date: 21 July 2025 Key Messages: • • • • • • • The committee reviewed the People Report for Month 3 and noted that the size of the workforce had reduced during June 2025. There had been 110 whole-time-equivalent (WTE) staff who left during the month and the Trust was phasing new starters. In addition, the Trust had been able to close surge capacity and was closing wards, which had led to a reduction in bank staff use. Based on the forecast, the Trust expected to be c.350 WTE short of its 2025/26 plan based on the delivery of the ‘green’ and ‘amber’ rated CIP programmes. The Trust continued to experience increased demand and there had been an increase in the number of patients having no criteria to reside. In addition, new resident doctors and newly qualified nurses would impact the Trust’s workforce numbers and the forecast made no assumptions regarding industrial action. The committee noted that administrative and clerical staff had been hardest hit by the recruitment restrictions over the past two years, which was causing difficulties in some areas. The committee discussed the potential intake of newly qualified nurses, noting the difficulty of balancing the Trust’s short-term concerns of needing to reduce its workforce with the longer term need for qualified staff. The committee received an update on the organisational change activities underway, including the proposed divisional restructure and MARS programme. The committee received an update in respect of the planned industrial action by resident doctors. The committee reviewed the National Education and Training Survey for 2024, which covered all staff in training posts in the NHS. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee reviewed five draft Equality and Quality Impact Assessments relating to the measures required to deliver the Trust’s 2025/26 plan. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: People and Organisational Development Committee Meeting Date: 1 September 2025 Key Messages: • • • • • • The committee reviewed the People Report for Month 4 (see below). The committee noted the recent announcement by the Government of a ‘graduate guarantee’ for nurses. It was noted that, prior to this announcement, the Trust had decided to increase the level of offers to newly qualified nurses, but to phase start dates in line with predicted turnover and anticipated vacancies in nursing posts. The committee noted that there were significant challenges across the organisation with staff impacted by multiple factors, including: increased car parking rates, building work requiring temporary relocation of 300-400 car park users to Adanac (Park and Ride), a reduction in enhanced bank rates back to standard Agenda for Change levels, and a decision to no longer offer free tea and coffee in theatres for staff (in line with other areas of the Trust). This coupled with the ongoing financial environment and workforce controls would impact staff engagement and satisfaction with the Staff Survey due to launch at the end of September 2025. The committee also expressed its concern for staff – particularly those from overseas – in view of the recent political climate regarding immigration. The committee reviewed the workforce related elements of the Trust’s proposed recovery plan, noting that the Trust was dependent on a number of material assumptions in order to be able to meet its 2025/26 plan. These included: availability of funding for further restructuring, reductions in mental health and no criteria to reside numbers, and reduction in overall activity levels. The committee received an update in respect of the industrial action undertaken by resident doctors in July 2025 and noted that about one third of staff eligible took part in the strike and that most clinical activity continued. It was also noted that F1 doctors were to be balloted separately by the BMA with the focus more on pay and availability of training places. The Trust has been required to produce a selfassessment of ten actions relating to doctors’ working conditions and to determine how to achieve these actions which will be presented to committee and to Board through the update by the Guardian of Safe Working at UHS. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.10 People Report for Month 4 Assurance Rating: Risk Rating: Substantial High • The overall workforce had increased by 10 whole-time-equivalents (WTE) in July 2025. Whilst the substantive workforce had decreased by 18 WTE, increased numbers of mental health cases, coupled with industrial action, had led to an increase in use of temporary staff. • Accordingly, the Trust was above the NHSE 2025/26 workforce plan by 55 WTE. • 65 applications under the Mutual Agreed Resignation Scheme (MARS) had been approved with all successful applicants due to leave Page 1 of 2 Any Other Matters: by the end of November 2025. This would deliver a recurrent saving of £2.2m based on the whole-year saving, albeit at a one-off cost of £1.1m, which meant that it was broadly cost neutral for 2025/26. • The Trust completed its divisional restructure on 1 July 2025, which was expected to deliver a saving of £700k and 12 WTE 7.2 People and Organisational Assurance Rating: Risk Rating: Development Committee Terms N/A N/A of Reference • The committee reviewed its terms of reference and recommended that the Board approve the updated terms of reference. • Only one minor change was proposed – to remove reference to the Charitable Funds Committee on the basis that this committee no longer existed. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that
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Papers Trust Board - 15 July 2025

Description: Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd Apologies Alison Tattersall In attendance Lauren Anderson, Corporate Governance and Risk Manager (from 9:30) (shadowing Craig Machell) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 13 May 2025 9:15 Approve the minutes of the previous meeting held on 13 May 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 4 Report and Maternity and Neonatal Workforce Report 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 2 10:10 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:40 5.8 Finance Report for Month 2 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Operational Delivery Report for Month 2 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 2 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 Infection Prevention and Control 2024-25 Annual Report 11:30 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control 5.13 Guardian of Safe Working Hours Quarterly Report 11:40 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 1 Review 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin De Sousa, Director of Strategy and Partnerships 6.2 Research and Development Plan 2025-26 12:00 Discuss and approve the plan Sponsor: Paul Grundy, Chief Medical Officer Attendees: Christopher Kipps, Clinical Director of R&D/Karen Underwood, Director of R&D/Laura Purandare, Deputy Director of R&D Page 2 6.3 Board Assurance Framework (BAF) Update and Risk Appetite Statement 12:10 Review and discuss the update. Review and ratify the risk appetite statement. Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Review of Standing Financial Instructions 2025 12:35 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 9 September 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 15 July 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 2 5.8 Finance Report for Month 2 5.9 ICS Finance Report for Month 2 5.10 People Report for Month 2 5.11 Freedom to Speak Up Report 5.12 Infection Prevention and Control 2024-25 Annual Report 5.13 Guardian of Safe Working Hours Quarterly Report 6.1 Corporate Objectives 2025-26 Quarter 1 Review 6.2 Research and Development Plan 2025-26 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 1c 3b All 2a Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 4x5 20 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 13/05/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Ceri Connor, Director of OD and Inclusion (CC) (item 5.11) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Diana Hulbert, Guardian of Safe working Hours and Emergency Department Consultant (DH) (item 5.12) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.13) Natasha Watts, Deputy Chief Nursing Officer (NW) (item 5.13) Helena Blake, Head of Clinical Quality Assurance (shadowing G Byrne) Raquel Domene Luque, Interim Lead Matron, Ophthalmology (shadowing G Byrne) 1 governor (observing) 6 members of staff (observing) 3 members of the public (observing) Apologies Keith Evans, Deputy Chair and NED (KE) Alison Tattersall, NED (AT) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Keith Evans and Alison Tattersall. 2. Patient Story Item postponed to the next meeting. 3. Minutes of the Previous Meeting held on 11 March 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 March 2025. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. It was noted that action 1218 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Ian Howard was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee considered the going concern assessment in respect of the 2024/25 annual accounts and agreed that it was appropriate that the accounts be prepared on a going concern basis. • The committee additionally noted that there had been no significant issues raised by the Trust’s external auditors. • The committee received a report on losses and special payments during 2024/25, noting that these payments generally related to lost patient property. • An update was received in respect of Information Governance. The Trust – in common with most others – was not expected to meet the standards set out in the Data Security and Protection Toolkit due to the introduction of the Cyber Assurance Framework as part of the Toolkit requirements. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 28 April 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Report for Month 12 (item 5.8), noting that the Trust had achieved its forecast deficit of £7m for 2024/25 following the receipt of revenue support. Furthermore, the Trust had achieved £85.3m of Cost Improvement Programme delivery and Elective Recovery performance of 127%. Nonetheless, the Trust’s underlying deficit was circa £75m. • The Trust’s cash position remained challenging with the Trust likely to require revenue support during either the first or second quarters of 2025/26. • The committee reviewed the Trust’s proposed 2025/26 plan during March 2025 and noted that there were no material changes between the draft reviewed and that submitted on 23 April 2025. • The committee supported a proposal for the Trust to participate in the elective hub at Winchester. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 25 April 2025, the content of which was noted. It was further noted that: • The committee received a briefing in respect of the Staff Survey 2024 (item 5.11). • The committee reviewed the People Report for Month 12 (item 5.10), noting that the Trust had ended the year 373 whole-time-equivalents (WTE) above plan. This was largely due to the reductions in patients having no criteria to reside and mental health patients not materialising. In addition, there had been higher than normal use of bank staff in March 2025 and lower than anticipated staff turnover. Page 2 • An update in respect of the planned organisational restructuring, including regarding the Equality and Quality Impact Assessment process being developed. • It was considered likely that the delivery of the Trust’s 2025/26 workforce plan would necessitate additional workforce controls. It would be important to ensure that appropriate support was provided to staff in managing at a time of increased demand, financial pressures, and a reducing workforce. 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee reviewed the Trust’s quality indicators, which continued to indicate that the organisation was under pressure. • Following an incident at Derriford Hospital in Plymouth on 4 March 2022 whereby a member of the public had suffered fatal injuries due to the downwash from a landing helicopter, the Trust had commissioned a review of its own safety arrangements. It was noted that some additional safety measures would be required. • A visit by NHS South East Region to the Princess Anne Hospital in February 2025 had provided some positive feedback about the service. The Maternity and Neonatal Safety 2024/25 Quarter 3 Report was noted. It was further noted that: • The report had been reviewed by the Quality Committee at its meeting held on 17 March 2025. • The proportion of births via caesarean section remained high at over 40%, with late requests in particular placing additional pressure on theatre capacity. • Following successful recruitment of additional staff in late 2024, operational pressures had reduced substantially compared with the previous situation. • A never event relating to a missing swab was under investigation. • The Trust was currently over establishment in terms of its number of midwives and expected to be staffed above the requirement indicated by the anticipated birthrate for the area by the end of 2025/26. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • Significant reorganisations of NHS England and integrated care boards (ICBs) had been announced. NHS England was to be abolished, and certain functions merged into the Department of Health and Social Care. Integrated care boards were expected to have to reduce their costs by 50%. • A ‘model’ integrated care board blueprint had been published, which appeared to imply that a significant proportion of ICB functions could be redistributed to providers. • It was expected that the number of ICBs would reduce to 25-30, with each serving populations of c.2m. In Hampshire, ICB and local authority boundaries were expected to align, which was considered to be beneficial. • The British Social Attitudes Survey 2024 showed the lowest satisfaction rating for the NHS since the survey began. • The Spring Statement and subsequent messaging indicated that there would not be additional funding during 2025/26. • The Trust continued to face significant pressure due to patients having no criteria to reside. Historically, there were typically around 100 such patients at Page 3 any one time, whereas 281 had been reported on 13 May 2025. This was the equivalent of six wards. • The Trust faced significant financial pressure during 2025/26 with a lower financial settlement than expected. In order to meet its plans, the Trust would be required to deliver c.£110m of Cost Improvement Programmes, reductions of 5% in divisions and 10% in Trust Headquarters, coupled with clinical and non-clinical recruitment controls. The Trust continued to experience high demand for services, especially in the Emergency Department. • It was important to protect the frontline and assist the organisation with managing at such a time. 5.6 Performance KPI Report for Month 12 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 12, the content of which was noted. It was further noted that: • The Trust continued to face significant challenges in terms of its Emergency Department performance, with only 57.2% of patients spending less than four hours in the main Emergency Department. An external review was to take place. • There had been a four-month trajectory of increasing numbers of falls. Whether there was any correlation between the increasing number of falls and number of patients having no criteria to reside was being investigated. • The Trust continued to report strong Elective Recovery performance, although the size of the Trust’s waiting list continued to increase. There was some concern as to whether the financial pressures were impacting elective performance and waiting times. • There had been a decrease in the number of virtual outpatient appointments. • Ten never events had been reported as of the end of March 2025. The Trust expected regulatory scrutiny as a result. • The metrics reported in respect of research and development were being reevaluated. Duncan Linning-Karp was invited to present the spotlight on the Mental Health Patient Cohort, the content of which was noted. It was further noted that: • Regular reports on mental health patients were provided to the Quality Committee. • During 2024, there were 347 patients with a decision to admit to a mental health bed whilst at UHS (2023: 303), of these only 13.2% were transferred within the expected 12 hours (2023: 18.5%). During the first quarter of 2025, there had been 92 such patients. If the numbers remained consistent for the rest of 2025, a growth rate of 6% was expected. • In terms of patients brought to the Emergency Department as a hospital-based place of safety detained under section 136 of the Mental Health Act 1983, only 22% of patients brought to the Trust had a physical need, whereas the remaining patients were brought to the Emergency Department due to the lack of an available facility. • There were insufficient beds available at mental health providers, who were also impacted by delayed discharges. • The enhanced care required by mental health patients placed significant demand on the Trust’s resources. The situation appeared to be worsening with around 100 patients at any one time, of which around 10 were acute. • The Trust has met with the Integrated Care Board and mental health provider to push for a working group to address the issue that care for mental health patients at the Trust cost significantly more than the cost for looking after Page 4 patients at a dedicated facility due to the need to engage specialist agency staff. Actions Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. 5.7 Break 5.8 Finance Report for Month 12 Ian Howard was invited to present the Finance Report for Month 12, the content of which was noted. It was further noted that: • The Trust had delivered its forecast £7m deficit at year end. This had been achieved through a combination of additional Cost Improvement Programme (CIP) delivery and additional revenue support • Whilst the Trust had delivered £85.3m of CIP, a significant proportion of this was non-recurrent. The Trust continued to record an underlying deficit of £6- 7m per month. • The Trust had £17m in cash, below its usual minimum holding of £30m. The Trust continued to closely monitor and manage its cash position, but it was likely that support would be required in the first quarter. • During 2024/25, the Trust had carried out £34m of unpaid for activity, particularly in terms of Emergency Department, non-elective and outpatient follow ups. There were, however, limited opportunities to reduce this activity due to quality impacts . 5.9 ICB Finance Report for Month 12 Ian Howard was invited the present the ICB Finance Report for Month 12, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had achieved a breakeven position for 2024/25. It was noted that this represented a significant achievement given that the system was reporting a cumulative deficit of £80m at Month 5. • The system-wide transformation programmes had had a lower-than-expected impact on the Trust. 5.10 People Report for Month 12 Steve Harris was invited to present the People Report for Month 12, the content of which was noted. It was further noted that: • At year end the Trust was 373 WTE above its 2024/25 plan. There had been a significant increase in use of bank staff in March 2025 due to annual leave and the number of mental health patients. The size of the substantive workforce had, however, reduced, albeit at a lower level than expected. • The formal consultation in respect of the organisational changes had been commenced with the unions. The Trust would be moving from four to three divisions and reducing its workforce. • The Trust had announced its intention to reduce the size of its workforce by 780 WTE (c.6%). This was to be achieved via a combination of natural Page 5 attrition and vacancy control and through a Mutually Agreed Resignation Scheme. • There were a number of risks to achievement of the Trust’s 2025/26 workforce plan, including: quality and safety risks (mitigated through Equality and Quality Impact Assessment); a lower-than-expected turnover rate due to a lack of opportunities elsewhere; the Trust’s cash position; and delivery of non-criteria to reside and mental health patient reductions. • The Trust had released a statement to staff and was awaiting guidance in respect of the recent Supreme Court ruling regarding the definition of a woman under the Equality Act 2010. 5.11 UHS Staff Survey Results 2024 Report Steve Harris was invited to present the UHS Staff Survey Results 2024 Report, the content of which was noted. It was further noted that: • The results of the Staff Survey had been discussed in detail by the People and Organisational Development Committee on 24 March 2025 and at a Trust Board Study Session held on 1 April 2025. • The Trust benchmarked well in certain areas, such as recommendation as a place to work and in terms of views of line management. However, the response rate was lower than in previous years and violence and aggression and civility and dignity scores remained areas of concern. The Board discussed the results of the Staff Survey and agreed that the Trust should focus its efforts on violence and aggression and on helping staff to manage change. It was noted that there was a strong correlation between line manager engagement and the survey response rate. 5.12 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There was to be a change in the exception reporting process from September 2025. The Trust was considering how best to manage these changes. • The financial constraints during 2025/26 would potentially impact the locum fill rate. • The Trust’s estate remained an issue, but work was ongoing, including consideration of re-purposing existing spaces. • Concerns had been expressed from some seeking consultant posts about the impact of the organisational changes on these opportunities. • The duration of handovers continued to result in breaches of working hour limits. 5.13 Learning from Deaths 2024-25 Quarter 3 and 4 Reports Jenny Milner was invited to present the Learning from Deaths Report, the content of which was noted. It was further noted that: • The Trust’s expected death rate remained lower than the national average, with the Trust ranked 12 out of 119. Page 6 • Further improvements in terms of the sharing of learning from Mortality and Morbidity meetings were required. Consideration was been given to using the Ulysses tool. • The Trust’s medical examiner service had reviewed more than 1,000 deaths since inception. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 4 Review Martin de Sousa and Kelly Kent were invited to present the Corporate Objectives 2024/25 Quarter 4 Review, the content of which was noted. It was further noted that: • The Trust had delivered 50% of its annual objectives for 2024/25 and 37.5% of objectives had been partially achieved or had incurred minor delays. Two objectives remained ‘red’. • Particular areas to highlight included progress on long-waiters, patient experience, turnover/sickness of staff, and capital scheme delivery. The Trust had also been successful in slowing the rate by which the waiting list grew and in delivering Cost Improvement Programmes. • Areas of concern included the financial position, patients with no criteria to reside, and staff experience. • The Trust was in control of the delivery of some of the objectives, but full delivery of others was outside of the Trust’s control. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) Update, the content of which was noted. It was further noted that: • The BAF had been previously reviewed by the Board in March 2025, following which it had been reviewed by the relevant executive directors and committees. • None of the ratings of the risks had been amended. However, the target dates for three risks had been extended to reflect the challenges in achieving the target rating. • The Trust was holding a higher overall level of risk than had previously been the case. It was considered important to ensure that risks were managed across domains and not in silos. • The Trust was using its risk appetite to support decision-making such as in capital prioritisation and in terms of the decisions required to deliver its 2025/26 plans. • A risk appetite review had been scheduled at a future Trust Board Study Session on the basis that the current situation potentially necessitated changes in terms of the Trust’s stated risk appetite. Action The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Page 7 6.3 South Central Regional Research Delivery Network (SC RRDN) 2024-25 Annual Performance Review and 2025-26 Annual Plan Paul Grundy and Clare Rook were invited to present the South Central Regional and Research Delivery Network (SC RRDN) 2024/25 Annual Performance Review and the SC RRDN 2025/26 Annual Plan, the content of which was noted. It was further noted that: • During the year the organisation transitioned from the Clinical Research Network Wessex to the South Central Regional Research Delivery Network, whereby the Wessex and Thames Valley and Midlands Clinical Research Networks were integrated into a single entity. • In the Wessex region, 33,000 participants were recruited to over 500 studies during the first half of the year. A further 35,000 participants were recruited to over 800 studies during the second half of the year in the South Central region. • Commercial research remained a priority, with the South Central region benchmarking well in terms of recruitment. • In terms of the 2025/26 plan, the NHS 10-year plan was awaited, as this would likely impact the plan. It was currently intended that the network would focus on the National Institute for Health Research’s seven priorities. A stakeholder group was being convened to inform the SC RRDN’s direction of travel. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governos’ (CoG) meeting 29 April 2025 The Chair presented a summary of the Council of Governors’ meeting held on 29 April 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Annual Report and Quality Account Timetable 2024/25 • Draft Quality Account • Corporate Objectives • Non-NHS Activity • Governor Attendance at Council of Governor meetings • Council of Governors’ Elections 2025 • Appointment to the Governors’ Nomination Committee • Membership Engagement and Governor activity • Chair’s and Non-Executive Directors’ appraisal outcomes 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. It was further noted that, due to an issue with the electronic signature platform, a number of items were included in the report, which should have been included in previous reports. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. Page 8 8. Any other business Gail Byrne informed the Board that a joint targeted area inspection of the Trust’s Emergency Department and Maternity service by the Care Quality Commission (CQC), social services and the police was scheduled to take place on 20 May 2025, which would focus in particular on safeguarding of children. In addition, a routine Ionising Radiation (Medical Exposure) Regulations inspection was due to take place in June 2025. It was noted that the CQC had recently carried out unannounced inspections at Portsmouth Hospitals University NHS Trust and at South Central Ambulance Service NHS Foundation Trust. Accordingly, it appeared likely that the Trust should also expect an unannounced CQC visit, followed by a Well-Led review. It was noted that this was Dave Bennett’s last formal scheduled Board meeting, as his second three-year term was due to expire on 14 July 2025. The Board expressed its thanks to Dave Bennett. 9. Note the date of the next meeting: 15 July 2025 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Trust Board – Open Session 13/05/2025 - 5.6 Performance KPI Report for Month 12 1246. Virtual outpatients appointments Linning-Karp, Duncan 15/07/2025 Explanation action item Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. 1247. Friends and family test Byrne, Gail 15/07/2025 Explanation action item Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. Trust Board – Open Session 13/05/2025 - 6.2 Board Assurance Framework (BAF) Update 1248. Risk appetite Byrne, Gail 03/06/2025 Explanation action item The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Status Pending Pending Completed Page 1 of 1 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Audit & Risk Committee Meeting Date: 9 June 2025 Key Messages: • • • • • The committee considered the results of a review of historical private activity (pre-2022/23) which had not been invoiced by the Trust. It was noted that, of the £2.5m total, £1.6m had since been paid, but that £0.9m should be written off. It was further noted that this issue should not arise in future due to changes in contracting arrangements and improvements in processes. The committee noted an update in respect of the Trust’s submission as part of the annual National Cost Collection exercise. The committee received a report on waivers of competitive tendering between October 2024 and March 2025, noting that these represented c.£11m of activity over the period. The committee reviewed a draft of the Annual Report and Accounts for 2024/25. The committee noted that the external audit had not progressed as planned. The committee received the Quarter 4 Fraud, Bribery and Corruption Work Plan Update Report, noting that under the Counter-Fraud Functional Return that the Trust was green-rated. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.3 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • There had been an increase in the number of critical risks recorded from 30-35 to c.50. Many of these risks related to staffing or capacity. • It was noted that some of this increase was driven by new risks being identified (or existing risks worsening), but that existing critical risks were not being closed due to insufficient resources. • In addition, following the Six Facet survey, there had been an improvement in the articulation of Estates-related risks, which was now reflected in the total number of operational risks. • The committee reviewed the Board Assurance Framework, noting that all risks had been reviewed by the relevant executive(s). 7.2 Review of Standing Assurance Rating: Risk Rating: Financial Instructions 2025-26 Substantial N/A • The committee reviewed the Trust’s Standing Financial Instructions, noting that changes were proposed to two areas: employee expenses and non-pay requisition limits. Any Other Matters: • The committee reviewed the Trust’s internal audit plan and agreed that a cyber security audit should be included as part of the plan. Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the Finance Report for Month 1. The Trust had reported a deficit of £4.4m in line with its plan whereby the Trust would move from a deficit to breakeven to surplus over the course of the year thereby achieving an overall breakeven position at year end. • The Trust’s underlying deficit was £7.2m in month. This was driven by patients having no criteria to reside, activity above block contract levels, and mental health patients. Use of bank staff had normalised when compared to Month 12, but there had been high drugs spend and lower than expected income which was under investigation. • The Trust was on track in terms of its Cost Improvement Programme (CIP). • The committee received an update in respect of the Trust’s cash position, noting that the Integrated Care Board had agreed to move scheduled payments to aid the Trust’s position. The Trust was forecasting a £7m negative balance in March 2026. • The committee reviewed the ‘Acute Drivers of Deficit’ report prepared by Deloitte, noting that many of the identified areas were long-term and/or structural issues. • The committee received an update on the Trust’s financial improvement programmes, noting that although c.£80m of the £110m CIP was currently viewed as ‘high risk’, this was expected to improve as schemes became more mature. • The committee noted the Trust’s response to a request to consider proposed workforce targets based on removing 50% of reported increases in corporate services expenditure since 2018/19. It was noted that the Trust expected to deliver this target through its existing plans. • The committee received an update in respect of the national and local contracting process, noting that most areas had now been agreed. The potential changes in Elective Recovery Funding posed a risk to the Trust. In addition, it was likely that £20-30m of activity would remain unfunded. N/A Any Other Matters: The committee received the Always Improving – Transformation End of Year Report, noting progress made. Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 23 June 2025 Key Messages: • • • • • The committee reviewed the Finance Report for Month 2 (see below). The committee received an update in respect of the Trust’s cash position, noting that the position continued to deteriorate. It was further noted that discussions were underway with local providers, as some providers have cash whilst at the same time others risked running out. The committee received an update on the Urgent and Emergency Care Transformation Programme, noting that the Trust was targeting a reduction in length of stay by a further 5%. The committee noted an update from UHS Estates Limited and progress on a number of programmes. The committee considered a summary of the Spending Review presented by the Chancellor of the Exchequer on 11 June 2025. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 2 Assurance Rating: Risk Rating: Substantial High • The Trust had recorded an in-month deficit of £3.8m, which was in line with its plan to reach a breakeven position by year end. • The Trust had achieved its planned Cost Improvement Programme delivery level, although much of this was due to non-recurrent savings, which creates a challenge later in the year. • The Trust’s underlying deficit remained at £7.2m, consistent with Month 1. • Income had been lower than expected with reductions in income from pathology and the Channel Islands. Non-pay costs for drugs and clinical supplies also remained a challenge. • The committee reviewed the Trust’s workforce trajectory for 2025/26, noting that even if all ‘red’ CIP schemes were to deliver, this would still result in a shortfall. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.3 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: People and Organisational Development Committee Meeting Date: 25 June 2025 Key Messages: • The committee reviewed the People Report for Month 2 including progress on the Workforce Plan for 2025/26 (see below). • The committee noted that the plans for the Divisional restructure are now underway with the intention of implementing these on 01 July 2025. It is understood that whilst not all people plans have been finalised at a granular level, it is anticipated that most issues will be resolved through natural attrition and through the Mutually Agreed Resignation Scheme (MARS). • The MARS application window has now closed and there has been significant interest with 220+ applications submitted. These are currently being assessed for suitability and it is planned that the outcomes will be shared with applicants by 04 July 2025. Not all applications will be accepted as some posts cannot be surrendered, and the organisation cannot afford to accept them all. Whilst each resignation will represent a long-term saving there is a very real risk to in year cost pressures as all successful MARS applications will need to be funded locally, as there is no national funding to support this. • Additional recruitment controls also remain in place including a freeze on non-clinical recruitment, and a hold on 30% of clinical recruitment. • The committee noted that the scale of organisational change is significant and this is likely to be unsettling for staff. A number of support mechanisms have been implemented focussed on wellbeing, and this includes specific organisational change workshops targeted at leaders across the Trust to support them in supporting the wider workforce. The committee reflected that this is a positive step and that once the organisational restructure has completed, this should be used as a foundation for implementing change and leadership training as business as usual. • The committee received an update on the organisation’s education position and the current challenges and opportunities related to this. The committee acknowledged the significant risk to future workforce as a result of the current challenges across the NHS, in combination with the restricted and reduced funding streams which facilitate staff access to education and development. The committee noted the need to review education capacity again at UHS once the long-term workforce plan is published later in the year. Page 1 of 2 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.10 People Report for Month 12 Assurance Rating: Risk Rating: Substantial High • The Trust’s overall workforce grew by 19 WTE in May 2025 however it is still below the NHSE plan by 107 WTE. It was noted that turnover remains lower than average and it is suspected that this will be due to system wide recruitment controls limiting roles UHS staff may move into, in addition to a wider lack of opportunity in the jobs market as general employer confidence reduces. • Additionally, whilst both remain below plan, there has been an increase in temporary staffing bank and agency usage noting that April was a very low month. • The committee noted that the workforce plan is ambitious and sets out a reduction in headcount of c.750. All schemes to deliver this have been assessed for maturity and continue to be worked up, although even if it were to be assumed that all are followed through to completion, there is still a shortfall which needs to be addressed. Significant work has been undertaken to forward plan the trajectory. • It was noted that consideration had been given to the recruitment controls and whether these needed to be taken further, however as it will take several months to fully implement and see the benefit of those in place currently, this was decided against. The improvements in forecasting, and monthly review, will support this decision so that it can be reviewed again later in the year, probably September. • The committee discussed the need to track indicators related to people, money, performance and quality and consideration will be given to a balanced scorecard. • The committee received a further update in respect of the Band 2/3 pay dispute and in respect of the portering department. • The committee also received a series of updates on recent national letters to Trusts including a required review of job evaluation processes and analysis work on non-frontline nursing roles. Page 2 of 2 Agenda Item 5.4 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Quality Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • It was n
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-15-July-2025.pdf

Papers Trust Board - 13 May 2025

Description: Agenda Trust Board – Open Session Date Time Location Chair Apologies In attendance 13/05/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Keith Evans, Alison Tattersall Helena Blake, Head of Clinical Quality Assurance (shadowing Gail Byrne) Raquel Domene Luque, Interim Lead Matron, Ophthalmology (shadowing Gail Byrne) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story (This item has been postponed until the next meeting) The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 11 March 2025 Approve the minutes of the previous meeting held on 11 March 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:10 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:15 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:20 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:25 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 3 Report 5.5 9:30 5.6 10:00 5.7 10:40 5.8 10:55 5.9 11:05 5.10 11:10 5.11 11:20 5.12 11:30 5.13 11:40 6 6.1 11:50 Chief Executive Officer's Report Receive and note the report Sponsor: David French, Chief Executive Officer Performance KPI Report for Month 12 Review and discuss the report Sponsor: David French, Chief Executive Officer Break Finance Report for Month 12 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICS Finance Report for Month 12 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 12 Review and discuss the report Sponsor: Steve Harris, Chief People Officer UHS Annual Staff Survey Results 2024 Report Discuss and note the report Sponsor: Steve Harris, Chief People Officer Attendees: Ceri Connor, Director of OD and Inclusion/Sophie Limb, HR Project Manager Guardian of Safe Working Hours Quarterly Report Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant Learning from Deaths 2024-25 Quarter 3 and 4 Reports Review and discuss the reports Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience STRATEGY and BUSINESS PLANNING Corporate Objectives 2024-25 Quarter 4 Review Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships Page 2 6.2 Board Assurance Framework (BAF) Update 12:00 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 6.3 South Central Regional Research Delivery Network (SC RRDN) 2024-25 12:10 Annual Performance Review and 2025-26 Annual Plan Receive and note the annual report and plan Sponsor: Paul Grundy, Chief Medical Officer Attendee: Clare Rook, Chief Operating Officer, CRN: Wessex 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) meeting 29 April 2025 12:25 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 15 July 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:40 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 May 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 12 5.8 Finance Report for Month 12 5.9 ICS Finance Report for Month 12 5.10 People Report for Month 12 5.11 UHS Staff Survey Results 2024 Report 5.12 Guardian of Safe Working Hours Quarter 3 Report 6.1 Corporate Objectives 2024-5 Quarter 3 Review 6.3 South Central Regional Research Delivery Network Annual Performance Review and 2025-26 Annual Plan 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3b, 3c All 1b, 2a Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 3x3 9 4x4 16 Open (Technology & Innovation) 3x3 9 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 4x5 20 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Dec 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x3 6 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither X X X X X X X X Minutes Trust Board – Open Session Date Time 11/03/2025 9:00 – 13:00 Location Chair Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) 2 members of the public (item 2) 5 governors (observing) 7 members of staff (observing) 1 members of the public (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. 2. Patient Story Gregg and Serra [SURNAME] were invited to present their experience as the parents of a child who underwent successful open-heart surgery at Southampton General Hospital in September 2024, having been diagnosed with an atrioventricular septal defect in 2023. It was noted that: • The care provided by the Trust’s staff had been exceptional, including for being able to put matters into layman’s terms to assist understanding. • The interaction between staff and the child patient was also praised, with the parents reporting that their child had been viewed first of all as a person, rather than as simply another patient. 3. Minutes of the Previous Meeting held on 7 January 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 7 January 2025. Page 1 4. Matters Arising and Summary of Agreed Actions An update was provided in respect of the following actions: • 1200: it was noted that discussions had been had with Natasha Watts and Jenny Milner and the action was ongoing. • 1201: it was noted that an update would be presented in the closed session of the meeting. • 1202: the Trust had written to the Integrated Care Board. • 1203: it was noted that a meeting had been arranged to discuss Freedom to Speak Up on 21 March 2025. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 20 January 2025, the content of which was noted. It was further noted that: • The committee considered the accounting policies and management judgements for the 2024/25 annual accounts. • The committee reviewed the Trust’s compliance with the Code of Governance for NHS Provider Trusts, noting that the Trust was compliant in all areas or had appropriate explanations for the few areas of non-compliance. • The committee had received a report on cyber risk, noting that the main risk was from suppliers not having adequate protection and the Trust’s operations being impacted as a result of the loss of service. • The committee considered a report in respect of the risk of individuals impersonating agency staff and noted the Trust’s controls to mitigate against this risk. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 27 January and 24 February 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Report for Month 10 (item 5.8), noting that the Trust was forecasting a year-end deficit of £17.65m and delivery of £76m in efficiencies under the Cost Improvement Programme. • It was further noted that the Trust was anticipating that it would have carried out c.£40m of unpaid activity by the end of the year. • The committee considered a draft of the Trust’s annual plan submission, noting that 2025/26 would present a significant challenge. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 January and 24 February 2025, the content of which was noted. It was further noted that: • The committee reviewed the People Report for Month 10 (item 5.10), noting that whilst the Trust was forecasting to be 125 whole-time-equivalents (WTE) above its 2024/25 plan, the total substantive workforce would be 50 WTE lower than in March 2024. • There had been high levels of sickness absence over the period, which had resulted in increased use of bank staff. Concern was expressed in respect of the low uptake rate for vaccinations by staff compared to previous years. Page 2 • Appraisal rates were lower than anticipated, but it was possible that this was due to issues with the transfer of recording of appraisals to the Virtual Learning Environment system. 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 27 January 2025, the content of which was noted. It was further noted that: • The committee had received an update in respect of the ‘Fundamentals of Care’ programme and noted that the programme was progressing well. • The committee reviewed the progress of the Always Improving outpatients and discharge programmes. • The committee reviewed the interim Maternity and Neonatal Safety Report, noting that there was nothing to escalate to the Board. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • There had been significant changes in the leadership of NHS England with effectively all executive directors having resigned. Furthermore, there were expected to be significant reductions in the NHS England workforce and changes in the relationship between NHS England and the Department for Health and Social Care. • The Trust had received a request to provide feedback on a proposed management and leadership standard for the NHS. The Trust intended to respond to the consultation. • Concerns had been raised in respect of the Trust’s adult cardiac waiting list due to a mismatch in referrals against operations performed, which had resulted in an improvement plan being submitted to NHS South East Region and a quality visit on 4 February 2025. The Trust’s congenital cardiac team was also under pressure due to insufficient capacity. • Positive feedback had been received following a visit to the Trust’s maternity services by NHS South East Region and the Local Maternity and Neonatal System team. • On 28 February 2025, the Trust had announced the opening of the refurbished Muslim prayer room facilities. • The Trust’s mechanical thrombectomy service was now a 24/7 service and that it was expected that the service would treat up to 1,200 patients a year over the next five years. • Dr Stephen Harden, a consultant in cardiothoracic radiology at the Trust, had been elected as the incoming president of the Royal College of Radiologists for a three-year term commencing on 1 September 2025. 5.6 Performance KPI Report for Month 10 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 10, the content of which was noted. It was further noted that: • The Emergency Department remained under significant pressure due to the level of attendances (11,728 during January 2025), with performance against the four-hour wait target being 61% in January 2025 and 55% in February 2025. • The average number of patients having no criteria to reside was 232 during January 2025. • The Trust’s performance in respect of the 62- and 28-day cancer targets remained high at 79.1% and 83.6% respectively for December 2024. The Page 3 Trust’s performance in these areas was higher than the national targets for March 2026. • Compared to equivalent teaching hospitals, the Trust was second in the country for 65-week waits and joint first in the country for 78-week waits. It was expected that the outstanding 65-week wait patients at March 2025 would be limited to those awaiting material for corneal transplants, of which there was a national shortage, and a small number of complex patients. • The Trust’s mortality rate had fallen as expected and the Trust was ranked as having one of the lowest mortality rates in England. • There had been an increase in the number of incidents of pressure ulcers during January and February 2025. It was noted that often there was an increased number of patients with co-morbidities during the winter months, who were at greater risk of developing pressure ulcers. • Whilst staffing levels had been problematic during September and October 2024 in the Maternity service, the situation had since improved as newlyqualified nurses became substantive. • Further work was ongoing to promote wider use of virtual clinics as an alternative to face-to-face appointments. • The Trust was intending to spend £1.5m on hardware by the end of the year to address the issues caused by the average age of the Trust’s IT estate. Action Craig Machell agreed to add A/I to a future Trust Board Study Session agenda. Gail Byrne agreed to present a deep-dive on pressure ulcers to the Quality Committee. 5.7 Break 5.8 Finance Report for Month 10 Ian Howard was invited to present the Finance Report for Month 10, the content of which was noted. It was further noted that: • The Trust had been working with system partners to agree a ‘landing plan’ for the system for 2024/25 to deliver a break-even position. The Trust’s forecast was for a year-end deficit of £17.65m. • The Trust had recorded a £7.5m in-month surplus and a year-to-date deficit of £15.2m, £11.8m behind its plan. However, there remained an underlying deficit of c.£6.5m, which would pose a significant challenge for 2025/26. • The Trust was forecasting to have insufficient cash in May 2025 and therefore would require additional cash support. It was noted that cash support would require certain commitments from applicants and that requests were not always fulfilled. • The messaging from NHS England appeared to be that difficult decisions would be required to deliver a financially sustainable NHS and that there would be no additional funding. It was noted that a number of these decisions would be better made at a national level to ensure consistency across the country. 5.9 ICB Finance Report for Month 10 The ICB Finance Report for Month 10 was noted. 5.10 People Report for Month 10 Steve Harris was invited to present the People Report for Month 10, the content of which was noted. It was further noted that: Page 4 • Unison had put an offer to its members to resolve the dispute over Band 2/3 pay. It was expected that the vote would conclude at the end of March 2025. • The consultation in respect of the transfer of staff to UHS Estates Limited had progressed well, with the transfer expected to take place on 1 April 2025. • Progress continued to be made in respect of the action plan agreed with portering staff. • The Trust had exceeded its workforce plan by 153 whole-time-equivalents (WTE) at the end of January 2025. There had been a significant increase in use of bank staff due to continued high levels of sickness absence and the need to open surge capacity. • It was forecast that the Trust would be 125 WTE above its plan for 2024/25. It was noted that the Trust had anticipated a reduction in staffing numbers of c.220 WTE due to reductions in patients having no criteria to reside and delivery of system transformation programmes. However, these assumptions had not materialised. 5.11 Mortuary Standards Compliance Update Gail Byrne was invited to provide an update in respect of the actions required following the Fuller Inquiry, the content of which was noted. It was further noted that: • The action plan and outputs from the Fuller Inquiry had been presented to the Board at its meeting held on 6 June 2024. • It was noted that all the actions identified had been completed. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 3 Review Martin De Sousa and Kelly Kent were invited to present the ‘Corporate Objectives 2024-25 Quarter 3 Review’, the content of which was noted. It was further noted that fifty per cent of objectives were on track to be delivered in full (a reduction compared to the second quarter), 37.5% were amber and 12.5% were red. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework Update, the content of which was noted. It was further noted that: • There were six risks rated as ‘critical’ (i.e. 15 or above), with one risk (risk 3c) having been upgraded from 12 due to increased likelihood given reductions in the available funding and workforce. • The target dates for six risks had also been extended, including two out to April 2030 due in part to uncertainty in respect of funding availability. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (CoG) meeting 29 January 2025 The Chair presented a summary of the Council of Governors’ meeting held on 29 January 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report Page 5 • Chair and Non-Executive Director Appraisal Process • Audit and Risk Committee Terms of Reference • Governors’ Nomination Committee Terms of Reference • Annual Business Plan • Noting the appointment of David Liverseidge following the original approval given in 2024. • Governor Attendance • Membership Engagement 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. It was further noted that the following items had been sealed on 7 March 2025: • TP1 Land Registry between University Hospital Southampton NHS Foundation Trust and Prime Infrastructure Management Services 4 Limited (the Transferor) and University Hospital Southampton NHS Foundation Trust (Transferee) relating to Land forming part of an accessway adjoining Plot 2, Bargain Farm, Frogmore Lane, Nursling, Southampton, Hampshire SO16 0XS. Seal number 291 on 7 March 2025 • TP1 Land Registry between University Hospital Southampton NHS Foundation Trust and Prime Infrastructure Management Services 4 Limited (Transferor) and University Hospital Southampton NHS Foundation Trust (the Transferee) relating to Land forming part of an accessway adjoining Plot 2, Bargain Farm, Frogmore Lane, Nursling, Southampton, Hampshire SO16 0XS. Seal number 292 on 7 March 2025. • Underlease between Just Retirement Limited (the Landlord) and University Hospital Southampton NHS Foundation Trust (the Tenant) relating to Aseptic Pharmacy and Offices on the Ground, 1st and 2nd Floors at Plot 2 Adanac Health and Innovation Campus, Nursling, Southampton, Hampshire SO16 0XS. Seal number 293 on 7 March 2025. • Reversionary Underlease between Just Retirement Limited (the Landlord) and University Hospital NHS Foundation Trust (the Tenant) relating to Ground and first Floor Sterile Services Unit and Offices at Plot 2 Adanac Health and Innovation Campus, Nursling, Southampton, Hampshire SO16 0XS. Seal number 294 on 7 March 2025. • Underlease between Just Retirement Limited (the Landlord), IHSS Limited (the Tenant) and University Hospital Southampton NHS Foundation Trust (the Trust) relating to Ground and first Floor Sterile Services Unit and Offices at Plot 2 Adanac Health and Innovation Campus, Nursling, Southampton, Hampshire SO16 0XS. Seal number 295 on 7 March 2025. • Sub-Underlease between University Hospital NHS Foundation Trust (Landlord) and UHS Estates Limited (Tenant) of Aseptic Pharmacy and Offices on the Ground, 1st and 2nd Floors at Plot 2 Adanac Health and Innovation Campus, Nursling, Southampton, Hampshire SO16 0XS. Seal number 296 on 7 March 2025. Page 6 Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and in respect of the items listed above. 7.3 Audit and Risk Committee Terms of Reference Craig Machell was invited to present the proposed changes to the Audit and Risk Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The Audit and Risk Committee had reviewed its terms of reference at its meeting on 20 January 2025, following which input had been sought from the Council of Governors at its meeting held on 29 January 2025. • It was proposed to amend a reference in paragraph 10.2 and to update Appendix A. Decision Having considered the proposed amendments to the Audit and Risk Committee’s Terms of Reference, the Board approved the changes. 7.4 Finance and Investment Committee Terms of Reference Craig Machell was invited to present the proposed changes to the Finance and Investment Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The Finance and Investment Committee had reviewed its terms of reference at its meeting on 27 January 2025. • It was proposed to update Appendix A. Decision Having considered the proposed amendments to the Finance and Investment Committee’s Terms of Reference, the Board approved the changes. 7.5 Quality Committee Terms of Reference Craig Machell was invited to present the proposed changes to the Quality Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The Quality Committee had reviewed its terms of reference at its meeting on 27 January 2025. • It was proposed to amend a reference in paragraph 10.2 and to update Appendix A. Decision Having considered the proposed amendments to the Quality Committee’s Terms of Reference, the Board approved the changes. 7.6 Remuneration and Appointment Committee Terms of Reference Craig Machell was invited to present the Remuneration and Appointment Committee’s Terms of Reference, the content of which was noted. It was further noted that: Page 7 • The Remuneration and Appointment Committee had reviewed its terms of reference at its meeting on 11 March 2025. • No changes were proposed. Decision Having considered the Remuneration and Appointment Committee’s Terms of Reference, the Board approved the terms of reference. 7.7 Trust Executive Committee Terms of Reference Craig Machell was invited to present the proposed changes to the Trust Executive Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The Trust Executive Committee (TEC) had reviewed its terms of reference at its meeting on 12 February 2025. • It was noted that the most significant amendments were in respect of the following: o Introduction of the pre-TEC process for business cases requiring additional expenditure; o The role of the TEC as a forum for discussion of significant strategic matters; o The TEC’s role in identification of opportunities for system collaboration; o Updates to reflect the current role of the Trust Investment Group and the TEC under the Standing Financial Instructions; and o Other amendments to add clarity about the TEC’s operation and reports received. Decision Having considered the proposed amendments to the Trust Executive Committee’s Terms of Reference, the Board approved the changes. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 May 2025 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 8 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 03/06/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item deferred to Study Session on 03/06/2025. Trust Board – Open Session 07/01/2025 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report 1204. Infection prevention Byrne, Gail 03/06/2025 Pending Explanation action item Gail Byrne agreed to include an item on infection prevention control at a future Trust Board Study Session to include details of an Australian study, point of care testing, and progress on the roll out of the Fundamentals of Care programme. Update: Item tentatively scheduled for TBSS on 03/06/2025. Trust Board – Open Session 11/03/2025 5.6 Performance KPI Report for Month 10 1217. Artificial Intelligence (A/I) Machell, Craig Explanation action item Craig Machell agreed to add A/I to a future Trust Board Study Session agenda. 03/06/2025 Pending Update: Tentatively scheduled for TBSS on 03/06/2024. Agenda item Assigned to Trust Board – Open Session 11/03/2025 5.6 Performance KPI Report for Month 10 1218. Pressure ulcers Byrne, Gail Explanation action item Gail Byrne agreed to present a deep-dive on pressure ulcers to the Quality Committee. Deadline Status 13/05/2025 Pending Page 2 of 2 Agenda item 5.1 Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: Audit & Risk Committee Meeting Date: 17 March 2025 Key Messages: • • • • • • The committee considered the going concern assessment for the 2024/25 accounts and agreed that the accounts should be prepared on a ‘going concern’ basis. The external auditor reported that there had been no significant issues resulting from the transfer to a new finance system. The committee received a report on losses and special payments during 2024/25 and noted that the levels were similar to previous years. These payments were generally related to lost patient property. The committee reviewed the Trust’s Treasury Policy, confirmed the current bank mandate and approved certain minor changes to the Treasury Policy. An update was received in respect of Information Governance. It was noted that the Trust – in common with most others – was not expected to meet the standards set out in the Data Security and Protection Toolkit for 2024/25 due to the introduction of the Cyber Assurance Framework. The Trust had reported six breaches to the Information Commissioner since 1 January 2024, but none of the incidents resulted in further action on the part of the regulator. The committee agreed the Fraud team’s work plan for 2025/26. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • All risks had been reviewed with the relevant executive director(s). • It was suggested that Risk 3c should be reconsidered in terms of what the main risk was given the increase in risk rating to 16, particularly whether the main concern was running out of trained staff as opposed to being unable to deliver training and development. Any Other Matters: • The committee reviewed the outputs from the internal audit reports in respect of rostering, the discharge process, and core financial controls noting that there was nothing significant which required escalation to the Board. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: Finance & Investment Committee Meeting Date: 24 March 2025 Key Messages: • • • • • • The committee received an update in respect of the Trust’s 2025/26 annual plan. It was noted that the NHS in England was forecasting a deficit of £6.6bn, which had resulted in significant intervention by Government, including the abolition of NHS England and 50% reductions in integrated care boards’ costs. These reductions would be supplemented by a national mutually agreed resignation scheme. The Trust anticipated running out of cash in May 2025, but it was understood that cash support would no longer be provided. The Hampshire and Isle of Wight Integrated Care System was aiming to reach a breakeven position in 2025/26. This would necessitate additional controls on recruitment and 5-10% reductions in expenditure/headcount as well as achievement of challenging Cost Improvement Programme targets. The committee reviewed the Finance Report for Month 11. It was noted that the Trust had recorded an in-month surplus of £8.2m due to a number of one-off items. There had been an increase in the use of bank staff due to the need to open surge capacity and the demand resulting from patients with mental health issues. The committee received an update in respect of the transformation plans regarding the ‘living within our means’, urgent and emergency care, and elective care recovery workstreams. The committee reviewed the quarterly update from Estates, Facilities and Capital Development. It was noted that there was a plan for removal of all reinforced autoclaved aerated concrete (RAAC) on the Southampton General Hospital site. It was further noted that the steam ducts on the site continued to be an issue and there was a risk that the Trust was at the limit for electricity usage on the site. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) N/A Any Other Matters: The committee considered a business case in respect of a Hampshire and Isle of Wight Elective Hub in Winchester. It was noted that this proposal was reviewed and approved at the Trust Board meeting on 25 March 2025. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Page 1 of 2 Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: Finance and Investment Committee Meeting Date: 28 April 2025 Key Messages: • • • • • • • The committee reviewed the Finance Report for Month 12 (see below). The committee received an update in respect of the Trust’s cash position, noting that the Trust’s cash position had been relatively stable during the fourth quarter due to receipt of additional one-off funding and careful supplier payment management. However, the Trust was highly likely to require cash support in either Q1 or Q2. The committee noted the report from the Trust’s digital services, noting the successful negotiation of a discount for purchasing new laptops due to the number required. In addition, there had been a leak in GICU which had impacted the switch network, but which had since been rectified. It was further noted that, during the first months of the year, the Trust had blocked more attempted cyber attacks than in the whole of 2024. It was noted that trusts had been set challenging targets for reducing the size of their corporate services, and as such were expected to reduce the size of these services by 50% of the growth since 2018/19. The committee received an update on the Trust’s 2025/26 capital plan, noting that the plan was under review owing to the Trust’s cash position. In addition, it had been agreed to prioritise maintaining the Trust’s level of expenditure on strategic maintenance and to defer the refurbishment of the neuro theatres. The committee reviewed the update from the Trust’s commercial team, including in respect of private and overseas patients, the proposed private patient unit, and Adanac Park. The committee supported the Trust’s participation in the proposed Elective Hub at Winchester. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 12 Assurance Rating: Risk Rating: Substantial High • The Trust had successfully ended the year at where it expected to do so with a deficit of £7m at year end. • The Trust’s underlying position remained a concern with a £6.9m deficit recorded during the month. • The committee reviewed the high use of bank staff during months 8 to 12, noting that the Trust had opened surge capacity during this period and was experiencing significant demand. • The Trust had achieved 127% elective recovery performance against the national target of 113%, and had also delivered its 2024/25 Cost Improvement Programme target in full (£85m). • The Trust had also spent £96m of capital during 2024/25. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). Page 1 of 2 Any Other Matters: • The committee discussed whether the 2030 target for risk 5b was realistic and whether the rating to be achieved by 2030 should be increased. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.3 i) Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: People & Organisational Development Committee Meeting Date: 24 March 2025 Key Messages: • • The committee reviewed the People Report for Month 11. It was noted that February 2025 had continued to be challenging due to high sickness rates, with the Trust close to calling a critical incident. This had driven much higher bank rates. There had been a lower than forecast number of leavers during the month (44 whole-timeequivalents (WTE) against a forecast of 100). The Trust was 267 WTE above its plan. The Trust’s draft Workforce Plan for 2025/26 was reviewed. The Trust was required to deliver a breakeven plan. Accordingly, the Trust was anticipating a freeze on all non-clinical vacancies and holding 30% of clinical vacancies. In addition, there would potentially be a target to reduce headcount by 5-10% as well as additional reductions in use of bank and agency staff. It was further proposed to reorganise the four existing Divisions into three in order to deliver efficiencies. It was noted that even if the Trust achieved fully against all performance targets and implemented the restrictions and reductions above, there would still be a deficit. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.11 UHS Staff Survey Results 2024 Report Assurance Rating: Risk Rating: Reasonable Low • The committee reviewed the Staff Survey results for 2024. • The Trust had maintained its above average position across all of the People Promise domains. • The Trust’s results remained broadly similar to those in 2023, although there had been improvements in some areas, such as satisfaction with immediate managers, flexible working, appraisals, and confidence in reporting unsafe practice, violence, bullying and harassment. • The participation rate was low at 39%, which gave rise to some concern about how reflective of the workforce the results were. A significant difference in engagement between non-clinical and clinical staff was noted. 6.2 Board Assurance Framework Assurance Rating: Risk Rating: Update Substantial N/A • Risks 3a, 3b and 3c had been updated, following discussions with the respective Executive Director(s). • Risk 3c had been upgraded from 12 to 16 to reflect the reduction in national funding for education and training and the more restrictive funding framework. In addition, it was noted that the intended reduction in NHS corporate infrastructure would impact training and development staff. • The committee agreed to review the Board Assurance Framework again once the 2025/26 plan had been approved. Any Other Matters: • The committee received an update in respect of the Band 2/3 pay dispute and in respect of the portering department. Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.3 ii) Committee Chair’s Report to the Trust Board of Directors 13 May 2025 Committee: People & Organisational Development Committee Meeting Date: 25 April 2025 Key Messages: • • • • • • • The committee reviewed the People Report for Month 12 (see below). The committee noted the significant challenges for 2025/26 in delivering the Trust’s Annual Plan and the implications for its workforce. In particular, the Trust was anticipating having to reduce its overall workforce by 6% during the year, coupled with a 20% reduction in bank staff and 30% reduction in agency staff. It was noted that the organisational changes would need to happen at pace, but that there was not presently central funding to support this. The Trust had implemented strict recruitment controls, including a freeze on all non-clinical recruitment and would hold 30% of clinical vacancies. Delivery of the Trust’s 2025/26 plan also assumed significant reductions in the numbers of mental health patients and in patients having no criteria to reside. It had been announced that the Trust would be restructuring its divisions, reducing from four to three. It was anticipated that this would be completed by 1 July 2025. Furthermore, the Trust had a medium- to long-term objective of developing and implementing shared services with other organisations in the Hampshire and Isle of Wight Integrated Care System. The organisational and workforce changes envisaged were to be supported by both an equality and a quality impact asse
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Papers Trust Board - 10 March 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 10/03/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Steve Peacock 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 13 January 2026 9:15 Approve the minutes of the previous meeting held on 13 January 2026 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Ian Howard, Chief Financial Officer, for Chair 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee 9:25 David Liverseidge, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 including Interim Maternity and Neonatal Safety Report Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 10 10:10 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 10 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICB System Report for Month 10 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 10 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 11:35 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Review and discuss the report and update Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 3 Update 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin de Sousa, Director of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 12:00 Review and discuss the update Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 29 January 2026 12:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 7.2 Register of Seals and Chair's Actions Report 12:20 Receive and ratify the report In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.3 Audit and Risk Committee Terms of Reference 12:25 Review and approve the Terms of Reference Sponsor: Ian Howard, Chief Financial Officer, for Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.4 Quality Committee Terms of Reference 12:30 Review and approve the Terms of Reference Sponsor: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.5 Remuneration and Appointment Committee Terms of Reference 12:35 Review and approve the Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 14 May 2026 10 Items circulated to the Board for reading 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Q3 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 10 March 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 10 5.8 Finance Report for Month 10 5.9 ICB System Report for Month 10 5.10 People Report for Month 10 5.11 Freedom to Speak Up Report 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 4x4 16 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x Minutes Trust Board – Open Session Date Time Location Chair 13/01/2026 9:00 – 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd (JD-T) Present Jenni Douglas-Todd, Chair (JD-T) Keith Evans, Non-Executive Director (NED) (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director and Deputy Chair (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) James Allen, Chief Pharmacist (JA) (item 5.12) Julie Brooks, Deputy Director of Infection Prevention and Control (JB) (item 5.11) Blue Cunningham, Patient Engagement & Involvement Officer (item 2) John Mcgonigle, Emergency Planning & Resilience Manager (JMc) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.10) Julian Sutton, Clinical Lead, Department of Infection (JS) (item 5.11) 4 governors (observing) 5 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Blue Cunningham was invited to present the Patient Story on behalf of Jade […], whose nine-year-old daughter, Lucy, had had a bowel resection at the Trust. It was noted that: • Lucy was a very structured child, who relied heavily on planning and knowing outcomes as well as having sensitivities to lots of different sensory inputs. Page 1 • In their treatment of Lucy, staff paid particular attention to Lucy’s needs and adapted their behaviour and took the time to make Lucy’s stay in hospital as comfortable as possible. • This Patient Story clearly demonstrated the Trusts’ values and the time taken in the handling of Lucy by staff likely saved time and effort in the long run by not distressing the patient and then having to manage this situation. 3. Minutes of the Previous Meeting held on 11 November 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 November 2025, subject to reassigning action 1296 to James Allen. 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Action 1293: work had commenced on a broader MRI strategy. This work would be presented to the Quality Committee in due course – the action remained open. • Action 1294: this formed part of a larger piece of work, which would be addressed through the planning cycle. The action could be closed. • Action 1295: a solution had been developed, but the Trust was waiting on a third party to be able to implement the solution. The action could be closed. • Action 1296 was addressed as part of item 5.12 below. It was explained that the metric was based on day cases and national statistics and was intended to show usage levels of the most critical antibiotics. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 November and 15 December 2025, the contents of which were noted. It was further noted that: • The Trust had reported an in-month deficit of c.£5m and, at the end of November 2025, had reported a year-to-date deficit of £40m. • The committee had received an update in respect of the Trust’s theatres improvement plans, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee had received a report on the Trust’s productivity based on the national framework and noted that further work was required to understand the metrics behind the national framework. • The committee had reviewed the Trust’s cash position and supported a proposal to request further cash support for January 2026. • The committee noted that whilst the Trust’s transformation plans were ambitious, they were nonetheless grounded in reality. • In its review of the proposed capital plans for 2026/27-2029/30, the committee noted the challenge of having to balance the Trust’s allocation of Capital Departmental Expenditure Limit (CDEL) with the cash available to the Trust. • The committee reviewed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. It was noted that the assumed reductions in patients with no criteria to reside and mental health Page 2 patients were those reasonably considered to be within the Trust’s control rather than reductions which were dependent on third parties. • The committee supported a proposal for transforming the Southern Counties Pathology network. 5.2 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 21 November and 15 December 2025, the contents of which were noted. It was further noted that: • Whilst there had been reductions in the size of the substantive workforce, this had been offset by an increase in temporary staff due to a combination of demand, sickness absence, patients with no criteria to reside, and mental health patients. • The committee noted changes with respect to statutory and mandatory training, which would facilitate ‘passporting’ between NHS organisations. • The committee received an update in respect of the Trust’s Inclusion and Belonging strategy, noting that progress had been slower than anticipated due to available resource. It was further noted that the external political environment had also created additional challenges in this area. • The committee received an update regarding the Trust’s refreshed approach to violence and aggression, noting a greater willingness to take action against violent/abusive patients and members of the public. It was further noted that the communications accompanying the new approach would be key. • The committee reviewed the Trust’s performance against the ten-point plan for resident doctors, noting that the Trust was, subject to a few exceptions, in a good position. • Whilst the results of the Staff Survey were still under an embargo, early indications were that the participation rate was lower than hoped for. • The Trust’s seasonal vaccination campaign had been successful with over 50% of staff having been vaccinated against influenza. 5.3 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 24 November 2025, the content of which was noted. It was further noted that: • The committee noted that the Trust’s Complaints service, particularly Patient Advice and Liaison Service (PALS), was fragile. There was a backlog of c.500 emails due to resource constraints. • The committee noted that despite the financial pressure the Trust was under, it had sought to maintain staff numbers to ensure patient safety. A significant proportion of the reduction in staff during the year had been from administrative staffing groups. Whilst the Trust had successfully reduced the size of the clinical administrative workforce, it had not been possible to transform how this service was delivered through technical or other means. Therefore, there was a risk of bottlenecks due to insufficient administrative staff with the high level of demand falling on a smaller number of staff. • NHS England had launched changes to maternity care reporting with additional reporting requirements with the aim of developing national standards and approaches. • The committee had reviewed the Trust’s Maternity and Neonatal Safety report for the second quarter and noted that the Trust had demonstrated compliance with the requirements for the NHS Resolution Maternity Incentive Scheme. Page 3 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published latest segmentation and league tables under the NHS Oversight Framework for Quarter 2. The Trust had fallen slightly from 48 out of 134 to 51 out of 134. The Trust remained in segment 5 due to being in the Recovery Support Programme. • The number of patients waiting over 65 weeks in October 2025 had resulted in the Trust entering Tier 1 for elective performance. However, since that time, the Trust had successfully reduced the number of patients waiting over 65 weeks to c.80, with a target to reduce this number to nil by the end of March 2026. • The Employment Rights Bill received Royal Assent on 18 December 2025. The Act included a number of changes which would impact the Trust. These changes were to be reviewed in detail by the People and Organisational Development Committee. • During further strike action by resident doctors between 17 December and 22 December 2025, the Trust had met the national target of maintaining 95% of activity. Roughly one-third of resident doctors had taken part in the industrial action, which compared favourably to other trusts – some had reported a participation rate of 80-90%. • University Hospitals Sussex NHS Foundation Trust had been fined in connection with the death of a patient with severe mental health problems who had absconded from a ward at the trust and subsequently committed suicide. This case was pertinent for the Trust given the number of mental health patients currently being cared for at the Trust in the absence of a more appropriate setting. It was noted that the Trust’s policy was clear on the approach to be taken in the event of a similar situation to that faced by University Hospitals Sussex NHS FT. • On 2 January 2026, the Trust had been informed that its endoscopy service had had its accreditation renewed until 1 November 2026 following an annual review by the Royal College of Physicians’ Joint Advisory Group on Gastro- Intestinal Endoscopy. • Alison Tattersall had been appointed as the Trust’s second Nominated Trustee on the board of the Southampton Hospitals Charity. • The Trust’s department of clinical law – a service established to deal with clinical questions relating to regulatory and legal principles within the Trust – had been in existence for 16 years. 5.5 Performance KPI Report for Month 8 Andy Hyett was invited to present the ‘spotlight’ report in respect of Cancer waiting time targets, the content of which was noted. It was further noted that: • There had been an increase in referrals over recent years, but despite this increase, the Trust had maintained performance, particularly in respect of the 28-day faster diagnosis pathway. • Consideration was being given in terms of demographic groups to be targeted in view of the success of the Targeted Lung Health Check programme and its efforts to target particular sections of the population. • The main challenge in terms of improving performance was in terms of diagnostic capacity, including access to magnetic resonance imaging (MRI) and other imaging services. Improving the diagnostics services remained a key priority, including development of a longer-term strategy for imaging. It was noted that MRI and computed tomography (CT) scan capacity in the UK was lower than that in comparable nations such as those in the US and EU. Page 4 • The Trust maintained a good relationship with the Wessex Cancer Alliance, which was an effective route for obtaining additional funding for cancer care. Action Andy Hyett agreed to provide Jane Harwood with further data regarding the stage at which cancer was diagnosed by socio-economic group. Andy Hyett was invited to present the Performance KPI Report for Month 8, the content of which was noted. It was further noted that: • The Trust’s overall Referral To Treatment (RTT) waiting list for November 2025 had decreased by 0.9% and the Trust had made significant progress in reducing the number of patients waiting more than 65 weeks. • The number of patients waiting for diagnostics marginally increased, but the Trust had maintained its previous performance with c.80% of patients waiting under six weeks for the fourth month in a row. • The Trust’s performance against the four-hour emergency department target had improved by 5.8% since October 2025, achieving 60.4% in November 2025, which was above its in-year performance plan submitted at the beginning of 2025/26. The Board discussed the Performance KPI Report for Month 8. This discussion is summarised below: • In terms of the Trust’s RTT waiting list, it was forecast that there would be c.60,000 patients on this list by the end of March 2026 with performance against the 18-week target expected to be c.67%. • The Trust’s performance in respect of the number of mental health patients spending over 12 hours in accident and emergency was considered to be reflective of the need to admit mental health patients where there was no more appropriate venue available. This situation also gave rise to increased use of agency staff. A workshop had been held with Hampshire and Isle of Wight Healthcare NHS Foundation Trust (HIOWH) and an action plan had been agreed. It was noted that HIOWH was also experiencing challenges in terms of its ability to discharge patients. • The reduction in the percentage of virtual appointments as a proportion of all outpatient consultations compared to 2024/25 was being looked at. • As of 13 January 2026, there were 295 patients with no criteria to reside – equivalent to 12 wards – at Southampton General Hospital. Work was ongoing to create wards specifically for this cohort of patients. It was noted that Hampshire and Isle of Wight Integrated Care System was ranked 39 out of 42 in terms of its number of patients with no criteria to reside. 5.6 Break 5.7 Finance Report for Month 8 Ian Howard was invited to present the Finance Report for Month 8, the content of which was noted. It was further noted that: • The Trust had reported a £4.9m deficit for Month 8 (£40.8m deficit, year-to- date), which was in line with its Financial Recovery Plan. This in-month deficit had also been maintained for Month 9, with the year-to-date deficit increasing to £45.6m. • The Trust’s underlying deficit remained at c.£6m per month with continued high numbers of patients with no criteria to reside and mental health patients coupled with operational pressures. Page 5 • The Trust had carried out between £20m and £30m of unfunded work during the year and had incurred £10m-15m of costs associated with patients with no criteria to reside and mental health patients. • The Trust expected to deliver £90m of savings under its Cost Improvement Programme against its target of £110m. • The Trust had requested £8.4m of additional cash support for January 2026 and expected to require a further £3m of support in March 2026. 5.8 ICS System Report for Month 8 Ian Howard was invited to present the ICS System Report for Month 8, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £65m, which represented a variance of £36m from plan. It was noted that the Trust was a significant contributor to this variance, but that other organisations were also now reporting variances to plan. • The Trust had achieved the best ambulance handover time performance in the system, but further work was ongoing across the system with South Central Ambulance Service (SCAS) to improve performance. 5.9 People Report for Month 8 Steve Harris was invited to present the People Report for Month 8, the content of which was noted. It was further noted that: • The overall workforce fell marginally during November 2025, with reduction in substantive staff of 52 whole-time-equivalents (WTE) being partially offset by an increase in temporary staff usage due to operational pressures and sickness absence. • The Trust remained above its 2025/26 plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to meet its Financial Recovery Plan, the Trust’s workforce needed to reduce by a further 137 WTE. • Sickness absence continued to increase with 4.2% being reported during November and 4.8% being reported for December 2025. • The 2025 Staff Survey had closed. It was noted that the results were expected to be challenging. • The Trust had hit its target of 58% of staff having been vaccinated against flu, which placed the Trust in the top 15 nationally and second in the South East. • There was a significant amount of work ongoing to refresh the Trust’s approach and policies in respect of violence and aggression, including policy changes, training and communications. 5.10 Learning from Deaths 2025-26 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths report for the second quarter, the content of which was noted. It was further noted that: • The Trust continued to benchmark well against other organisations. It was one of only 11 trusts nationally with a lower than anticipated mortality rate based on its summary hospital-level mortality indicator (SHMI) score. • The Medical Examiner Service had reviewed a total of 1,078 deaths, of which 36% had occurred at the Trust’s sites. • Patients with learning disabilities remained an area of concern, although progress was being made in this area. The Trust was one of only a few Page 6 organisations to hold separate meetings to discuss deaths of patients with learning disabilities. • The Trust had procured a system to support organisation-wide learning from Morbidity and Mortality outcomes. 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control report for the second quarter, the content of which was noted. It was further noted that: • For the period covered by the report (July-September 2025), the Trust had exceeded all measures in terms of the annual limits for incidences of bacteraemia. The Trust was in a similar position to other organisations nationally. • There had been two cases of Methicillin-resistant Staphylococcus aureus (MRSA) and 34 cases of Clostridioides difficile (C-diff) during the period. • There had been a focus on invasive device care management (such as cannulas and catheters) and on hand hygiene. • The Trust had successfully managed the Candidozyma auris outbreak, with only three new cases identified since the beginning of 2025, the last of which was identified in April 2025. 5.12 Medicines Management Annual Report 2024-25 James Allen was invited to present the Medicines Management Annual Report 2024/25, the content of which was noted. It was further noted that: • The Trust’s expenditure on medicines during 2024/25 was £215m, a 2% reduction compared to 2023/24 and was on track to spend only £207m during 2025/26. These reductions indicated that the strategy of using less expensive generic and biosimilar medicines had been effective in reducing costs. • The number of approvals for clinical trials and research activity had continued to improve. • The Trust had completed work to decommission nitrous oxide manifolds, which was expected to reduce the Trust’s nitrous oxide emissions by 600,000 litres per year, equivalent to 354 tonnes of carbon dioxide emissions. • An area of focus was the deployment of digital systems. Action Ian Howard agreed to look at the level of savings achieved in terms of medicines costs and how costs of medicines were budgeted for. 5.13 Ward Staffing Nursing Establishment Review 2025 Natasha Watts was invited to present the Ward Staffing Nursing Establishment Review 2025, the content of which was noted. It was further noted that: • The report set out the results of the ward staffing review undertaken between July and October 2025. • There was a renewed national focus on safe staffing. • Overall, the Trust’s staffing establishments remain appropriate and within recommended guidelines. Page 7 • Continued high levels of enhanced care demand, a significantly more junior workforce, managing additional surge areas, and the impact of financial controls had been highlighted as ongoing challenges. 6. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Jon Mcgonigle was invited to present the Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response, the content of which was noted. It was further noted that: • NHS England required all trusts to complete an annual self-assessment against a number of core standards. In its assessment against 62 applicable core standards, the Trust was fully compliant with 56 and not yet fully compliant with 6 standards. • Of the areas where the Trust was not yet fully compliant, these related primarily to governance maturity, exercising and testing, workforce training consistency, and assurance evidence, rather than the absence of emergency response arrangements. • Since an initial report had been submitted to the Trust Executive Committee in November 2025, the Trust had completed development and approval of the Business Continuity Management System, completed the consultation and adoption of Protective Security and Emergency Lockdown arrangements, and had commenced consultation and system engagement for Evacuation and Shelter. • Training was scheduled to take place between February and May 2026 for on- call staff in charge. It was intended to hold a tabletop exercise during 2027. • It was noted that it had been some time since the Trust had practised a major incident response with other partners. • The Trust was on schedule to embed the ‘protect’ duty under the Terrorism (Protection of Premises) Act 2025 by March 2027. Action John Mcgonigle agreed to look at scheduling a major incident response exercise with other partners involved. 7. Any other business It was noted that the Trust had declared a critical incident on 10/11 December 2025 due to an IT system failure. It was noted that this was Keith Evans’ final formal meeting, as his second threeyear term as a non-executive director was due to expire on 31 January 2026. The Board expressed its thanks to Keith Evans for his service and support. 8. Note the date of the next meeting: 10 March 2026 Page 8 9. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 10/03/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. TB 13/01/26: work had commenced on a broader MRI strategy. This work would be presented to the Quality Committee in due course – the action remained open. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. 16/04/2026 Pending Update: Item deferred to TBSS on 16/04/26. Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 13/01/2026 - 5.5 Performance KPI Report for Month 8 1311. Cancer diagnosis Hyett, Andy 10/03/2026 Pending Explanation action item Andy Hyett agreed to provide Jane Harwood with further data regarding the stage at which cancer was diagnosed by socio-economic group. Trust Board – Open Session 13/01/2026 - 5.12 Medicines Management Annual Report 2024-25 1312. Medicines costs Howard, Ian 10/03/2026 Pending Explanation action item Ian Howard agreed to look at the level of savings achieved in terms of medicines costs and how costs of medicines were budgeted for. Trust Board – Open Session 13/01/2026 - 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1313. Major incident response exercise Mcgonigle, John Hyett, Andy 10/03/2026 Pending Explanation action item John Mcgonigle agreed to look at scheduling a major incident response exercise with other partners involved. Page 2 of 2 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Audit & Risk Committee Meeting Date: 27 January 2026 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee considered the accounting policies and management judgements in respect of the 2025/26 annual accounts, noting the impact of the review of the Modern Equivalent Asset valuation estimation methodology. This review was to ensure that the valuation reflects specialised assets based on a modern, functionally equivalent facility at an alternative location, rather than simply replicating the current buildings and equipment. • The committee received an update in respect of the work on the Trust’s interim accounts, noting that there had been significant improvements in terms of use and recording of manual adjustments, with an objective of further reducing the use of manual adjustments in future. • The committee noted the work undertaken to address the issues identified in the production of the 2023/24 and 2024/25 accounts. • The committee reviewed the Trust’s compliance with the Code of Governance for NHS Provider Trusts, noting that the Trust was compliant in all areas or had appropriate explanations for areas of non-compliance, of which there were only a few. • The committee received a report on compliance with the Trust’s Standards of Business Conduct Policy, noting that the level of declarations of interest had remained largely static and that further work would be required to review the Trust’s approach in this area. • The committee received updates in respect of the internal audit programme, including the reports in respect of an audit of cyber security and the Trust’s core financial systems. • An update was provided in respect of the work of the counter-fraud team. It was noted that the risk of temporary worker impersonation was a particular area of focus. In addition, the committee noted the work undertaken to review the Trust’s compliance with the Economic Crime and Corporate Transparency Act 2023. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • All risks had been reviewed with the relevant executive director(s). • There had been no significant changes in ratings or target dates since the BAF had been last reviewed in October 2025. However, the committee challenged how realistic some of the target dates were on the basis that many of the actions required were reliant on third parties. • The committee suggested that the rating for risk 5c should be reconsidered in view of the increasing cyber risk. • It was noted that the actions from the internal audit on the Trust’s risk management maturity were on track. Page 1 of 2 Any Other Matters: 7.4 Audit and Risk Committee Assurance Rating: Risk Rating: Terms of Reference Substantial N/A • The committee reviewed its Terms of Reference and no changes were proposed. • The committee recommended that the Board approve the revised Terms of Reference. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 26 January 2026 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee received the Finance Report for Month 9. The Trust had reported an in-month deficit of £4.9m and continued to report in line with the Financial Recovery Plan. The Trust had also delivered £10.3m of savings under the Cost Improvement Programme during the month. The modern equivalent assets review had been completed, which delivered £3m of benefit during the month. • The committee carried out a deep-dive into the Trust’s underlying financial position, noting that there had been £15.8m of one-off adjustments and that the underlying deficit was £61.4m year-to-date. The monthly underlying deficit continued to be c.£6m and therefore the 2025/26 exit position was assessed to be £72m. • The committee received an update on the Trust’s medium term planning submission, noting that it was expected that the Trust would submit a non-compliant plan. There remained a significant gap between the level of performance required under the framework and the available funding and an absence of proposals from Specialised Commissioning. It was noted that the assumptions regarding noncriteria to reside numbers were based on factors within the Trust’s control, rather than those dependent on third parties. • The committee received an update on financial improvement, noting that the Trust was £4m behind its CIP plan for 2025/26, expecting to deliver £88m of savings by year end compared to the £110m target. The Trust was targeting £50m of CIP savings for 2026/27. Based on national data, the Trust had the tenth smallest opportunity for productivity savings. • The committee considered the Trust’s cash position as at 31 December 2025 and the forecast cash position for the remainder of the financial year. The Trust expected to require a further £2.9m of cash support in March 2026, which the committee supported. • The committee received an update in respect of the Trust’s outsourced cleaning and catering services contract. N/A Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Page 1 of 2 Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 23 February 2026 Key Messages: • • • • • • • • • The committee received the Finance Report for Month 10 (see below). The committee received an update in respect of the impact of the fire at Southampton General Hospital on 1 February 2026, including in respect of the actions being taken to restore the lost services and the Trust’s claims under the NHS Resolution Property Expenses Scheme and under its commercial insurance policy. The committee received an update following the submission of the Trust’s medium term plan on 12 February 2026, noting that the Trust’s current proposed deficit made it an outlier. There remained a significant gap between the level of funding available from commissioners and the performance required under the framework. The committee enquired as to the possible route to resolve and supported the view that pricing of activity needed to be set at a level which did not create an increasing deficit as it currently does in critical care areas. Following the external review recommendations, the committee look forward to a deeper dive into the drivers of the increases in the Trust’s cost base over the past 5-6 years as this has increased at a greater rate than activity levels. This is planned for the March 2026 meeting. The committee received an update in respect of the Always Improving programme, noting that the fire had prompted something of a re-think in terms of organisational and system fundamentals. It was noted that there had been changes in the Trust’s risk appetite in terms of management of patients having no criteria to reside and outpatient appointments. Sustaining the improvements in these areas was considered to be a key priority. The committee received a report on the roll out of the MIYA system in the Trust’s emergency department, which went live on 8 October 2025. It was noted that whilst there had been some initial impact on performance during the first weeks, this had been expected, and the issues appeared to have been largely resolved. The system had delivered improvements in clinical management and in terms of data analytics. The committee noted that the Trust had been awarded £39m in capital funding for 2025/26. It was noted that this was a significant amount of funding to be used during the final months of 2025/26 and that work was ongoing to secure this funding through placing of orders and other activity. The committee received an update in respect of the Trust’s proposed tender for car parking services. The committee supported the proposals to obtain mobile endoscopy units to address the loss of the Trust’s endoscopy service in the fire on 1 February 2026. The committee noted proposals in respect of changes to NHS Property Services. Page 1 of 3 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.8 Finance Report for Month 10 Assurance Rating: Risk Rating: Substantial High • The Trust had submitted a revised forecast to NHS England of a deficit of £49.9m following a request for an ‘art of the possible’ reforecast. The Trust had since received additional funding, which reduced the 2025/26 forecast deficit to c.£45m. • The Trust had reported a year-to-date deficit of £44.8m, with the underlying monthly deficit remaining between £5.5-6m. The Trust expected additional one-offs during the final months, but there was significant risk associated with this. • The Trust was forecasting CIP delivery of £94m for 2025/26, with £78m achieved year-to-date. • Whilst there had been some increase in workforce numbers in December 2025 and January 2026, it was considered normal for this to occur during this period, however this was creating a deviation from the planned workforce numbers. This was explained as the result of the decision taken to address 65- and 52-week waits which had therefore impacted staff numbers. The resulting increased income from additional work had yet to register in the Trust's revenue numbers but was expected in February and March.. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: N/A • Risk 5a remained the Trust’s highest-rated risk at 25 and the target date for reduction had been extended by six months due to continued uncertainty around the funding available during 2026/27 and the impact of the fire on 1 February 2026. • Risk 5b had been assessed following the fire, but it was considered that whilst there had been significant disruption, the event and subsequent activities had been well-managed and demonstrated the effectiveness of the Trust’s evacuation and business continuity plans. Accordingly, no changes were proposed to the rating. • There had been an increase in the rating of risk 5c, largely due to risks surrounding the age of the Trust’s digital infrastructure and uncertainty regarding the OneEPR programme. The committee reviewed the Trust’s cash position and forecast, and the committee supported the additional request to be submitted in February 2026 for cash support up to a maximum of £10m to be received in April 2026. The trajectory for cash support in 2026/27 was to be reviewed at the March 2026 meeting. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 2 of 3 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trus
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Papers Trust Board - 11 November 2025

Description: Date Time Location Chair Agenda Trust Board – Open Session 11/11/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story (item deferred) The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 9 September 2025 Approve the minutes of the previous meeting held on 9 September 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:05 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee 9:10 David Liverseidge, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:15 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:20 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:25 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 6 10:00 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 6 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICB System Report for Month 6 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 11:10 People Report for Month 6 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including 11:20 UHS Self-Assessment Return Review and approve the self-assessment return Sponsor: Natasha Watts, Acting Chief Nursing Officer 5.12 11:30 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Review and discuss the report and update Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 5.13 Annual Clinical Outcomes Summary Report 11:45 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendees: Lucinda Hood, Head of Medical Directorate/Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review 11:55 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin de Sousa, Director of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 12:05 Review and discuss the update Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) meeting 28 October 2025 12:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:25 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.3 Health and Safety Services Annual Report 2024-25 12:30 Receive and discuss Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Vickie Purdie, Head of Patient Safety/Scott Spencer, Health and Safety Adviser 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 13 January 2026 10 Items circulated to the Board for reading 12:45 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 11 November 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 6 5.8 Finance Report for Month 6 5.9 ICB System Report for Month 6 5.10 People Report for Month 6 5.11 Workforce Safeguards Self-Assessment 5.12 Guardian of Safe Working Hours Quarterly Report 5.13 Clinical Outcomes Summary Report 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1a, 3a 3a, 3b 1a, 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x Minutes Trust Board – Open Session Date 09/09/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Alison Tattersall, NED (AT) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Danielle Honey, Named Nurse for Safeguarding Children (DH) (item 5.14) Lucinda Hood, Head of Medical Directorate (LH) (item 5.15) Duncan Linning-Karp, Deputy Chief Operating Officer (DL-K) (item 5.6) Corinne Miller, Named Nurse for Safeguarding Adults (CMi) (item 5.14) Jenny Milner, Associate Director of Patient Experience (JM) (items 5.11-5.12) 1 member of the public (item 2) 30 members of staff (observing) 6 members of the public (observing) Apologies Gail Byrne, Chief Nursing Officer (GB) David French, Chief Executive Officer (DAF) Tim Peachey, NED (TP) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Gail Byrne, David French and Tim Peachey. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Aelwen Emmett, a volunteer at the Trust and former patient was invited to present her experience, focusing particularly on her work to improve the standard of food offered to patients. 3. Minutes of the Previous Meeting held on 15 July 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 15 July 2025. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. In respect of action 1246, it was noted that virtual outpatient appointments had now been built into the Trust’s programme. Furthermore, meetings were to be held with commissioners and the cancer network to improve the quality of referrals. It was noted that action 1246 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 21 July and 2 September 2025, the content of which was noted. It was further noted that: • In July 2025, the Trust had reported that it was £1.1m adverse to its plan, but that the underlying trajectory was improving. • The committee received an update from Wessex NHS Procurement Limited, noting that the company was on track in terms of its Cost Improvement Programme target. • The committee had received an update in respect of both the proposed Hampshire and Isle of Wight elective hub and a possible Urgent Treatment Centre at Southampton. • The committee reviewed the Finance Report for Month 4 (item 5.8), noting that the Trust had reported a year-to-date deficit of £19.5m, which was £5.8m adverse to plan. Key drivers for the Trust’s financial position included the lack of improvement in the number of patients having no criteria to reside and mental health patients, the continued difference between funded and actual activity under block contracts, lower than anticipated income, and higher than planned workforce numbers. • The Trust was ahead of its plan on Cost Improvement Programme delivery. • The committee reviewed the Trust’s proposed Financial Recovery Plan and noted the need to ensure that the long-term impact of decisions needed to be taken into account. • The committee reviewed the Trust’s cash position and noted that cash support would be required in the Autumn and that the committee would be amending its terms of reference to expand its role in terms of cash monitoring and oversight. • The committee reviewed the Board Assurance Framework risks within its remit, noting that Risk 5a had increased to 25 due to the risk associated with the Trust’s cash position (item 6.1). 5.2 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 21 July and 1 September 2025, the content of which was noted. It was further noted that: • The committee reviewed the People Report for Month 4 (item 5.10), noting that there continued to be significant demands on the Trust’s workforce, especially due to the number of patients having no criteria to reside and patients with a primary mental health need. Whilst the Trust’s substantive workforce had reduced, there had been an increase in the number of temporary staff resulting in the Trust reporting that it was 55 whole-time- equivalents above its plan. Page 2 • The committee considered the impact of the recruitment controls on the administrative and clerical workforce and the potential for shortages in these areas causing issues elsewhere. • The committee received an update in respect of the Mutually Agreed Resignation Scheme (MARS), noting that 65 applications had been approved. • The committee received an update on the recruitment of newly qualified nurses, noting that the Trust had pre-empted the announcement of a ‘guarantee’ by the Secretary of State. • The committee reviewed the workforce related elements of the Trust’s Financial Recovery Plan, noting the challenges in delivering what was required and the Trust’s reliance on improvements in patients having no criteria to reside and mental health patients. • The committee reviewed its terms of reference, proposing to make only minor changes (item 7.2). 5.3 Briefing from the Chair of the Quality Committee Diana Eccles was invited to present the Committee Chair’s Report in respect of the meeting held on 18 August 2025, the content of which was noted. It was further noted that: • The committee considered the proposal to revise enhanced rates paid to temporary staff in certain areas to remove the enhancement and bring rates into line with Agenda for Change rates. The committee noted the impact on staff and the concerns expressed by staff members. However, it was further noted that the enhancements were not intended to be permanent. • The committee received the Experience of Care report and noted a continuation in the trend observed during Quarter 4 of staff attitudes featuring as a reason for complaint. It was considered likely that this was indicative of the pressures on staff. • The committee reviewed the Maternity and Neonatal Safety 2025-26 Quarter 1 Report, noting that an action plan was in place in respect of the Maternity Triage Line to address some shortcomings identified in the process. • The committee received the Learning from Deaths 2025-26 Quarter 1 Report (item 5.11), noting that the Trust was one of only 11 trusts out of 119 with a lower-than-expected death rate during the period. • The committee reviewed the Safeguarding Annual Report 2024-25 and Strategy 2025-26 (item 5.14), noting that activity levels remained consistent with prior years, but the complexity of cases had increased. 5.4 Chief Executive Officer’s Report Paul Grundy was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The NHS league tables for 2025 had been published on 9 September 2025. The Trust had ranked 48th out of 134 and had been placed in segment 3 of the NHS Oversight Framework due to the effect of the ‘financial override’. The Trust was temporarily in segment 5 due to being in the Recovery Support Programme. • Trusts were required to submit self-assessments for the Provider Capability Assessment during October 2025. This would inform decisions relating to which organisations to place in the Performance Improvement Programme. • Resident doctors undertook strike action between 25 and 30 July 2025. Approximately one-third of those eligible at the Trust took part in the industrial action and the Trust had performed well in terms of mitigating the impact on activity. Page 3 • The Royal College of Nursing had published results of its analysis of violence and aggression against nursing staff in emergency departments, noting that the number of incidents had increased from 2,093 in 2019 to 4,054 in 2024. • NHS England had published a series of urgent and emergency care improvement guides to assist organisations with managing the winter period. • A number of changes to the organisation of local councils in Hampshire and Southampton were proposed as part of national plans to create unitary councils in place of existing county and district/borough councils. 5.5 Performance KPI Report for Month 4 Andy Hyett was invited to present the Performance KPI Report for Month 4, the content of which was noted. It was further noted that: • The Trust had reported an increase in the number of patients waiting over 52, 65 and 78 weeks alongside an increase in the overall waiting list. The Trust had entered Tier 2 escalation for Referral To Treatment performance. • The Trust had been placed in Tier 1 escalation due to the gap between its current Emergency Department performance and its performance plan for 2025/26. However, indicative data for August and September 2025 showed improved performance. • Work was ongoing to improve flow with task and finish groups established to review the discharge process and to implement rapid improvements. • The number of patients having no criteria to reside and those with a primary mental health need remained high. A workshop had been set up with Hampshire and Isle of Wight Healthcare NHS Foundation Trust in respect of mental health patients. • Steps were being undertaken to reduce the number of inappropriate attendances in the Emergency Department with patients potentially redirected to other areas. However, an Urgent Treatment Centre would be key to alleviating pressure on the Emergency Department in the longer term. The Board discussed the Trust’s performance against national standards. This discussion is summarised below: • Performance against the 62-day standard for cancer waiting times was an area of focus to ensure more consistent performance. • Work was ongoing to extend shared decision-making in order to involve patients in decisions about their care and treatment, noting however that this was more of a challenge with inpatients. • There was a challenge in terms of managing the demand for patients requiring diagnostic services. It was noted that there had been issues with availability of equipment over the summer period. It was acknowledged that diagnostics performance also impacted other areas such as cancer and Emergency Department metrics. • The percentage of over 65s attending the Emergency Department was expected to be a key metric to monitor over the winter period. Actions Andy Hyett agreed to look at the roll out of Pharmacy First. Andy Hyett agreed to carry out a deep-dive into Diagnostics to be either provided as a ‘Spotlight’ in the Performance KPI Report or via a Trust Board Study Session. Page 4 5.6 UHS Operating Plan 2025-26 and Board Assurance Statement Andy Hyett was invited to present the Operating Plan 2025-26 and Board Assurance Statement, the content of which was noted. It was further noted that: • The Operating Plan provided a summary of plans from October 2025 to September 2026, sitting alongside other key policies such as those relating to infection prevention control, major incidents, and influenza. • The Operating Plan would also serve as the Trust’s winter plan, which was recognised as a period of increased pressure. The Board discussed the proposed Operating Plan for 2025/26, this discussion is summarised below: • It was considered likely that, even with delivery of the demand management schemes being led by the Integrated Care Board (ICB), there would be a gap between demand and capacity over the winter period in particular. Therefore, further interventions to improve discharge rates and to reduce the number of patients having no criteria to reside would be necessary. In addition, the Trust would be required to make potentially difficult decisions in respect of prioritisation of patients and possible cancellation of elective procedures. • Concerns were expressed in relation to the trend of low uptakes of seasonal vaccinations, such as that against influenza, which had been seen since the COVID-19 pandemic. This situation would likely create further challenges due to patients with seasonal illnesses requiring additional infection prevention control measures. Furthermore, low uptake by staff members would likely result in increased rates of staff sickness and, accordingly, reduced capacity and/or increased expenditure on temporary staffing. • It was understood that there was a NHS campaign to encourage staff in particular to be vaccinated against influenza, and that plans were in place for senior leaders to visibly support this campaign through being vaccinated. • The Board challenged whether the Trust could meet the targets set out in the Operating Plan given the financial and other pressures currently experienced. • It was additionally noted that the Trust was reliant on external support and delivery of external demand management programmes led by the ICB in order to be able to meet the performance targets, especially in terms of management of the number of patients having no criteria to reside and those with a primary mental health need. • Furthermore, the Trust’s financial position was such that it was required to produce a financial recovery plan, which would require additional financial savings to be made. • It was agreed that the Board should fully consider whether to approve the Operating Plan once it had considered the Trust’s financial recovery plan in the Closed Session of the meeting. [Note: the matters below forming part of item 5.6 were discussed following the approval of the Trust’s financial recovery plan in the Closed Session.] Noting that the Board had discussed and supported the Trust’s financial recovery plan, subject to certain caveats, the Board again discussed the proposed Operating Plan for 2025/26. This discussion is summarised below: • The Trust’s financial recovery plan would need to be supported by NHS England and would also need to deliver in order for the Trust to be able to meet the performance targets set out in the Operating Plan. • The Trust continued to have significant dependence on third parties, especially other providers, the Integrated Care Board, and local authorities, to be able to successfully reduce the number of patients having no criteria to Page 5 reside or number of mental health patients. Without these reductions, the Trust would face significant capacity constraints, which would impact its performance, especially during periods of high demand. Decision Noting the discussions in the Closed Session in respect of the financial recovery plan, and having reviewed the proposed Operating Plan 2025-26 and accompanying Board Assurance Statement, the Board approved the Operating Plan 2025-26 and its submission, subject to the following: • delivery of system-wide programmes to manage demand and reduce numbers of non-criteria to reside and mental health patients, • appropriate support being provided by third parties, including local providers, the Integrated Care Board, and local authorities, especially in terms of supporting discharges and managing numbers of non-criteria to reside and mental health patients, and • support from NHS England for and delivery of the Trust’s financial recovery plan. In addition, the Board authorised the Chair and Chief Executive Officer to sign the Board Assurance Statement. 5.7 Break 5.8 Finance Report for Month 4 Ian Howard was invited to present the Finance Report for Month 4, the content of which was noted. It was further noted that: • The Trust had reported an in-month deficit of £6.8m (£4.8m above plan), although the underlying deficit was showing improvement, reducing to £6.6m. However, this trajectory was not sufficient to deliver the plan. • The Trust was carrying out approximately £2.5m of unfunded activity per month. In order to tackle some of this amount, the Trust had conducted negotiations with other providers and systems to address underfunding on contracts. • There were concerns about whether the Trust’s elective over-performance during the first half of the year would be fully funded. Whilst agreement had been reached in respect of funding three months of over-performance, it was not clear whether this would be replicated in the future. • The Trust would be seeking an activity management plan, which would detail which activities to cease to perform on the basis that the Trust continuing to over-perform against agreed funded activity levels was financially unsustainable and that it was not reasonable that the Trust should be criticised for falling performance in areas such as waiting lists as it sought to manage its finances. • The Trust’s cash position remained an area of concern with cash support to be requested from NHS England. • There appeared to be an emerging risk of slippage against the Trust’s capital programme, which was to be discussed at the Finance and Investment Committee. 5.9 ICS Operational Delivery Report for Month 4 Ian Howard was invited to present the ICS Operational Delivery Report for Month 4, the content of which was noted. It was further noted that: • The Trust was the only organisation within the system currently reporting being off plan. However, there were indicators from other providers with Page 6 significant risks being highlighted about organisations’ abilities to meet their 2025/26 plans. • There was an error in the report in respect of the Trust’s workforce numbers. A correction to the report had been requested. • The Hampshire and Isle of Wight ICS plan was for a breakeven position at the end of 2025/26. However, this was reliant on receipt of £60m of deficit support funding from NHS England, which was at risk because the Trust was no longer reporting being on plan. 5.10 People Report for Month 4 It was noted that two questions had been received from members of the public prior to the meeting (see Annex A), both of which related to the decision to remove the enhancement from NHS Professionals rates paid to staff in certain areas of the Trust such as in Theatres and in the Emergency Department. It was further noted that: • A discussion had also been held with staff prior to the Board meeting, at which a number of other questions had been raised. In particular, staff had expressed concerns about their feeling valued by the organisation. • The reasoning behind the decision to remove the enhancement previously paid on temporary staffing rates was explained as being to provide consistency with other staffing groups and with other providers by aligning rates paid with Agenda for Change rates. This change was part of a package of measures to improve the financial position of the Trust. • The decision to remove the enhancement was supported by an Equality and Quality Impact Assessment as part of the Trust’s process for making decisions of this nature. [Post meeting note: Following the meeting, the Royal College of Nursing, on behalf of its members in the affected areas, submitted a collective dispute. The questions raised in advance of the meeting, together with other related points, were to be addressed as part of the collective dispute process.] Steve Harris was invited to present the People Report for Month 4, the content of which was noted. It was further noted that: • The Trust’s plan for 2025/26 was for a reduction in whole-time-equivalents (WTE) by 765. Whilst the Trust had reduced the size of its workforce, it was still 55 WTE off-plan. • The Trust had reduced the number of divisions from four to three and had implemented recruitment controls whereby only 70% of clinical posts would be recruited to and a prohibition on recruitment to non-clinical posts. • The Trust had also carried out a Mutually Agreed Resignation Scheme (MARS) and had made some redundancies in discrete areas. It was noted, however, that there was a lack of funding for severance payments, which limited the Trust’s options with respect to steps it could take to reduce its workforce. • Temporary staffing was a particular area of focus, both in terms of numbers of temporary staff but also in terms of the cost paid for such staff. This aligned with the work of the South East temporary staffing collaborative which aimed to reduce the price of temporary labour in both bank and agency. Page 7 • Despite its challenges during 2025/26, the Trust had proactively offered roles to newly-qualified nurses ahead of the Secretary of State’s announcement of a ‘graduate guarantee’ on the basis that, from a strategic perspective, the Trust needed to take into account its future workforce requirements. Action Steve Harris and Andy Hyett agreed to respond to the questions and points raised at the meeting held with staff in respect of the NHS Professionals rates matter. 5.11 Learning from Deaths 2025-26 Quarter 1 Report Jenny Milner was invited to present the Learning from Deaths 2025/26 Quarter 1 Report, the content of which was noted. It was further noted that: • The Trust’s summary hospital-level mortality indicator (SHMI) score continued its downward trajectory and was the lowest value recorded since 2018. As such, the Trust was one of only 11 trusts nationally to achieve a lower-thanexpected mortality rate. • Work was ongoing to disseminate lessons from end-of-life care and an additional module for the Ulysses system had been purchased to facilitate data capture and standardisation for Morbidity and Mortality meetings. Action Jenny Milner was to provide further information to the Board in respect of why the Trust’s SHMI score remained low. 5.12 Annual Complaints Report 2024-25 Jenny Milner was invited to present the Annual Complaints Report 2024/25, the content of which was noted. It was further noted that: • The report provided details of complaints received between 1 April 2024 and 31 March 2025 and was the first full year of reporting against the new standard introduced by the Parliamentary and Health Service Ombudsman (PHSO). • Complaints activity had increased by 40% and the Trust was not currently meeting response targets. • The Trust benchmarked higher than others in terms of complaints not upheld. The Board discussed the Trust’s approach to complaints handling and, in particular, whether the Trust was an outlier in terms of the number of complaints not upheld. The Board challenged whether complaints deemed as ‘not upheld’ ought, in some instances, to be considered ‘partially upheld’. Consideration should therefore be given to reviewing the Trust’s complaints against PHSO referrals and outcomes. Action Jenny Milner was to provide further information regarding how the Trust was planning to meet complaints response times. Page 8 5.13 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Paul Grundy was invited to present the Medical Appraisal and Revalidation Annual Report, the content of which was noted. It was further noted that: • The framework published by NHS England was designed to allow the Trust to provide assurance that its professional standards processes meet the relevant statutory requirements and support quality improvement. • Feedback in respect of the appraisals process had been largely positive. • Appraisal compliance rates had continued to rise across the year with a current average of 88.8%. • The Board was required to approve a Statement of Compliance confirming that the Trust was compliant with the Medical Profession (Responsible Officers) Regulations 2010 (as amended). Decision Having considered the Medical Appraisal and Revalidation Annual Report tabled to the meeting, the Board authorised the Chair or Chief Executive Officer to sign the Statement of Compliance. 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 Danielle Honey was invited to present the Safeguarding Annual Report 2024/25 and Strategy for 2025/26, the content of which was noted. It was further noted that: • The report summarised the activity of the Trust’s safeguarding service in 2024/25. It was noted that the service had contributed to reviews of 56 patients where a statutory review had been considered. • The number of referrals under section 42 of the Care Act 2014 caused by Southampton City Council had reduced following the implementation of the council’s new processes. This was not reflective of a reduction in the number of UHS referrals or the complexity of the referrals responded to. • There had been an increase in the number of open cases with Southampton City Council and there had been a 13% increase in the number of patients subject to Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005. • There had also been an increase in the number of scoping reviews compared to prior years, although fewer were progressing to formal reviews. • Following a survey of staff, work was underway to improve the visibility of the team and there was a focus on team wellbeing with support from the psychology team. • The situation in respect of expected changes in the role of integrated care boards was being monitored due to the potential for changes in the team’s scope and remit. Page 9 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • All risks had been reviewed by the relevant executive directors since July 2025. • The revised risk appetites agreed by the Board in July 2025 were being embedded. • The rating of Risk 5a had increased from 20 to 25 due to the lack of agreement for cash support. However, once this agreement had been obtained and the Financial Recovery Plan was in place, it was expected that this risk would again reduce to 20. • An audit of the Trust’s risk management maturity by the Trust’s internal auditors was near to completion. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 16 July 2025 The Chair presented a summary of the Council of Governors’ meeting held on 16 July 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • The Trust’s 2025/26 Operating Plan • Council of Governors’ Terms of Reference • Membership Engagement • Feedback from the Governors’ Nomination Committee Furthermore, the Council of Governors approved the extension of the appointment of Tim Peachey as a non-executive director for a period of 12 months. 7.2 People and Organisational Development Committee Terms of Reference Craig Machell was invited to present the proposed changes to the People and Organisational Development Committee’s Terms of Reference, the content of which was noted. It was further noted that: • The People and Organisational Development Committee had reviewed its terms of reference at its meeting on 1 September 2025. • It was proposed to make only minor changes to remove reference to the Charitable Funds Committee, which no longer existed. Decision Having considered the proposed amendments to the People and Organisational Development Committee’s Terms of Reference, the Board approved the changes. Page 10 8. Any other business It was noted that it was organ donation week during 22-28 September 2025. Action Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. 9. Note the date of the next meeting: 11 November 2025 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 11 Annex A Questions: 1. The Board has agreed a cut in bank pay rates for nursing staff, resulting in local staff being unlikely to maintain their bank roles in this organisation, (based on a survey of over 450 nurses within the affected areas). Currently these roles provide staffing in areas such as theatres and other specialised areas, the impact being these departments can use local skills and knowledge to provide seamless operational delivery. How can the board provide assurance that, a) this will not impact on safety for patients, and b) they truly value nurses for the professional skills they provide for this Trust. 2. Our Emergency Department has recently been placed under Tier 1 monitoring by NHS England, reflecting serious national concerns about safety and performance. The department is already regularly understaffed, with patient care frequently delayed as a result. In light of this, how can the Trust justify reducing NHSP pay rates for Emergency Department nurses — a decision that risks deterring skilled staff from covering shifts and further compromising patient safety and the delivery of safe, timely care? What specific steps will the Trust take to mitigate these risks to patients and staff if the changes go ahead? Page 12 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine Watts, Natasha 13/01/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 5.5 Performance KPI Report for Month 4 1281. Pharmacy First Hyett, Andy 11/11/2025 Pending Explanation action item Andy Hyett agreed to look at the roll out of Pharmacy First. 1282. Diagnostics Hyett, Andy 11/11/2025 Pending Explanation action item Andy Hyett agreed to carry out a deep-dive into Diagnostics to be either provided as a ‘Spotlight’ in the Performance KPI Report or via a Trust Board Study Session. Trust Board – Open Session 09/09/2025 - 5.10 People Report for Month 4 1283. NHS Professionals rates Harris, Steve Hyett, Andy 11/11/2025 Pending Explanation action item Steve Harris and Andy Hyett agreed to respond to the questions and points raised at the meeting held with staff in respect of the NHS Professionals rates matter. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 09/09/2025 - 5.11 Learning from Deaths 2025-26 Quarter 1 Report 1284. SHMI score Milner, Jenny Watts, Natasha 11/11/2025 Pending Explanation action item Jenny Milner was to provide further information to the Board in respect of why the Trust’s SHMI score remained low. Trust Board – Open Session 09/09/2025 - 5.12 Annual Complaints Report 2024-25 1285. Response times Milner, Jenny Watts, Natasha 11/11/2025 Pending Explanation action item Jenny Milner was to provide further information regarding how the Trust was planning to meet complaints response times. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 18/12/2025 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: To be scheduled 18/12/25 or 03/02/26. Page 2 of 2 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 11 November 2025 Committee: Audit & Risk Committee Meeting Date: 13 October 2025 Key Messages: • • • • • • • • • The committee reviewed and discussed the outputs of a ‘lessons learned’ activity following the late publication of the Trust’s annual report and accounts. It was noted that a number of actions had been agreed and that a trial run would be conducted at Month 9. The committee noted the proposal to tender for new valuers for 2025/26 and the review of the Modern Equivalent Asset estimation methodology that would be carried out during the year. The committee agreed with a proposal to write off historical debt from private (mostly overseas) patients on the basis that it was irrecoverable. There had been 68 waivers of competitive tendering during the first half of 2025/26, most of which related to continued service provision. It was noted that the submission as part of the National Cost Collection exercise had been completed in July 2025 and that the Trust was 7% more efficient than the average based on the data. An update was received in respect of Information Governance. The Trust’s Data Security and Protection Toolkit was now rated as ‘approaching standards’ and progress had been made in respect of the backlog in subject access requests. The committee received an update in respect of legal expenditure and claims during 2024/25. The committee reviewed the internal audit reports on the Data Security and Protection Toolkit, CQC Readiness, and risk maturity. The committee received an update on the progress of the Trust’s local counter-fraud team against the plan for 2025/26, noting that imposter fraud was an area of focus. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • The committee had last reviewed the BAF in March 2025, and there had been a definite increase in the level of risk with the ratings of four of the risks having increased since then. • Approximately 25% of the risks on the Trust’s operational risk register were rated ‘critical’ (i.e. 15 or above). • The internal audit of risk management had been positive and the Trust’s risk management framework was considered as being mature. Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 11 November 2025 Committee: Finance and Investment Committee Meeting Date: 22 September 2025 Key Messages: • • • • • • • • • The committee reviewed the Finance Report for Month 5. The Trust had reported an in-month deficit of £5.9m and £25.4m deficit year-todate. The in-month deficit was £4.2m above the original plan, but was in line with the trajectory in the Financial Recovery Plan. The Trust’s underlying deficit had continued to improve, reducing to £6.2m, although this improvement was not yet at the pace required. The main drivers of the variance to plan were variances in income compared with what had been expected during 2025/26 and variances in terms of pay costs. The Trust was expecting to be 95 whole-timeequivalents above plan at year end based on current assumptions. It was noted that the Trust had identified 100% of Cost Improvement Programme savings at Month 5 and 76% of schemes were fully developed. Approximately £37m of savings had been delivered between Months 1 and 5, although higher than anticipated levels of non-recurrent savings had been delivered. The committee reviewed the Trust’s capital forecast, noting that there was a risk of a shortfall against the Trust’s internal CDEL. An update was received regarding the Urgent and Emergency Care transformation programme. The committee received the annual assurance report from UHS Pharmacy Limited, noting the company’s performance during the year and the work being done to expand services internally and externally. The committee considered the Trust’s cash forecast for Month 5, noting that the Trust’s underlying deficit was steadily eroding the Trust’s cash balance. The Trust had introduced strict treasury management measures and had previously received advance payments from the ICB as a means to mitigate the cash position. However, it had been necessary to submit a request for revenue support from NHS England in September 2025 and further such applications would be required from November 2025 onwards. In order to increase the focus on and governance of cash-related matters, the committee reviewed its terms of reference to strengthen the cash-related provisions and agreed to recommend to the Board that the committee be re-constituted as the Finance, Investment and Cash Committee with an Operating Cash Group reporting into the committee. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) N/A Any Other Matters: The revised terms of reference for the committee were reviewed and approved at the Board meeting held on 7 October 2025. Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 11 November 2025 Committee: Finance, Investment and Cash Committee Meeting Date: 3 November 2025 Key Messages: • • • • • • • • The committee reviewed the Finance Report for Month 6 (see below). The committee received an update in respect of the Trust’s performance against its Financial Recovery Plan, noting that progress had been made in terms of putting plans in place regarding patients with no criteria to reside and mental health patients. Good progress had also been made in respect of the ‘grip and control’ measures. At Month 6, the Trust remained on track with the Financial Recovery Plan. An overview of the recently published Medium Term Planning framework was provided. It was noted that the first submission of the Trust’s three-year plan was due before
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Papers Trust Board - 5 November 2024

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 05/11/2024 9:00 - 11:30 The Ark Conference Centre, HHFT/Microsoft Teams Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Minutes of Previous Meeting held on 10 September 2024 Approve the minutes of the previous meeting held on 10 September 2024 3 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 4 QUALITY, PERFORMANCE and FINANCE 9:10 Quality includes: clinical effectiveness, patient safety, and patient experience 4.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans, Chair 4.2 Briefing from the Chair of the Finance and Investment Committee Dave Bennett, Chair 4.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood, Chair 4.4 Briefing from the Chair of the Quality Committee Tim Peachey, Chair 4.5 Chief Executive Officer's Report 9:25 Receive and note the report Sponsor: David French, Chief Executive Officer 4.6 Performance KPI Report for Month 6 9:35 Review and discuss the report Sponsor: David French, Chief Executive Officer 4.7 Finance Report for Month 6 9:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 4.8 ICB Finance Report for Month 6 10:10 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 4.9 Recovery Support Programme (RSP) Undertakings - Self Assessment 10:20 Review and discuss the self-assessment Sponsor: David French, Chief Executive Officer 4.10 10:30 People Report for Month 6 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 4.11 Cancer Patient Experience Survey Results 2023 10:45 To receive and discuss the results Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Ali Keen, Head of Cancer Nursing 5 STRATEGY and BUSINESS PLANNING 5.1 Corporate Objectives 2024-25 Quarter 2 Review 11:00 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 5.2 Board Assurance Framework (BAF) Update 11:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 6 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Feedback from the Council of Governors' (CoG) Meeting 23 October 2024 11:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 6.2 Register of Seals and Chair's Actions Report 11:20 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7 Any other business 11:25 Raise any relevant or urgent matters that are not on the agenda Page 2 8 Note the date of the next meeting: 7 January 2025 9 Items circulated to the Board for reading 9.1 CRN: Wessex 2024-25 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. Page 3 Agenda links to the Board Assurance Framework (BAF) 5 November 2024 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Appetite (Category) Minimal (Safety) Cautious (Experience) Minimal (Safety) Open (Technology & Innovation) Open (workforce) Open (workforce) Open (workforce) Cautious (Effectiveness) Cautious (Finance) Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) Current risk rating 4x5 20 3x3 9 4x4 16 3x3 9 4x5 20 4 x3 12 4x3 12 3x3 9 3x5 15 4x5 20 3x4 12 2x3 6 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Mar 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 25 3 x 2 Apr 6 25 3 x 3 Apr 9 25 4 x 2 Apr 8 27 3 x 2 Apr 6 27 2 x 2 Dec 4 24 Agenda links to the BAF No Item 4.6 Performance KPI Report for Month 6 4.7 Finance Report for Month 6 4.8 ICB Finance Report for Month 6 4.9 Recovery Support Programme (RSP) Undertakings – Self Assessment 4.10 People Report for Month 6 4.11 Cancer Patient Experience Survey Results 5.1 Corporate Objectives 2024-25 Quarter 2 Review Linked BAF risk(s) 1a, 1b, 1c 5a 5a 5a 3a, 3b, 3c 1b All Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x Minutes Trust Board – Open Session Date Time 10/09/2024 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) (9:00-10:00 and 12:00-13:00) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Jane Fisher, Head of Health and Safety Services (JF) (item 7.2) Danielle Honey, Named Nurse for Safeguarding Children (DH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DHu) (item 5.10) Duncan Linning-Karp, Deputy Chief Operating Officer (DLK) (item 5.5) Corinne Miller, Named Nurse for Safeguarding Adults (CMi) (item 5.13) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.11) Jessica Bown, Midwifery Quality Assurance and Safety Matron (shadowing Gail Byrne) 1 member of the public (item 2) 5 governors (observing) 1 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) (from 10:00-12:00) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. 2. Patient Story Allan Peters was invited to relate his experience as a cancer patient, who had been diagnosed with stage 4 lymphoma, and, in particular, his experience of CAR-T cell therapy, which had been successful, with no reappearance of the cancer for more than a year. It was noted that the patient had had a positive experience with staff, and, when he collapsed, had been impressed by the reaction of a student nurse. Page 1 3. Minutes of the Previous Meeting held on 25 July 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 25 July 2024. 4. Matters Arising and Summary of Agreed Actions It was noted that action 1165 could be closed, and the relevant paper had been updated with the correct information. There were no other matters arising or actions overdue. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 19 August 2024. It was noted that: • The committee had reviewed the Finance Report for Month 4 (item 5.7), noting that whilst the Trust was slightly off-plan, it was maintaining its trajectory in terms of an improved position. • The Trust was making progress in terms of its Always Improving programme with some reduction in length of stay. • There were a number of risks to the Trust’s achievement of its 2024/25 plan, including costs incurred from industrial action, insufficient funding for the pay award, and non-delivery of system transformation programmes. The Trust was also delivering £10m of unpaid activity. • The committee received a report from Estates, noting that there had been an improvement in the Trust’s ability to recruit staff. 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 21 August 2024. It was noted that: • The committee had reviewed the People Report for Month 4 (item 5.9), noting that the Trust was below its target workforce level, although there had been an increase in use of bank staff due to the holiday period. The Trust was benefitting by £1.5m a month from these savings in staff numbers. • It was expected that the Trust would go above its planned staff numbers in September 2024 due to factors such as higher than assumed numbers of patients having no criteria to reside. • The committee received an update on violence and aggression in the context of the recent riots. 5.3 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 19 August 2024. It was noted that: • The committee reviewed the Trust’s main quality indicators and noted that the indicators in respect of infection prevention were of concern. However, there had been a reduction in Emergency Department waiting times. • The Trust’s progress in implementing the measures under ‘Martha’s Rule’ was noted. • The committee received the annual medical safety report and reviewed consultant job planning. • There had been difficulties with porting over documents to a new IT system in Ophthalmology. Page 2 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The 2024/25 pay award for Agenda for Change staff was due to be paid in October. In addition, the Government had made an offer to junior doctors, which appeared likely to be acceptable. There were concerns about the extent to which these pay awards would be fully funded. • The Trust had been formally notified of a collective pay grievance for healthcare support workers, which potentially impacted over 1,000 staff and was for up to six years of back pay. • The civil unrest in late July 2024 had had a significant impact on staff, especially from those from black and minority ethnic communities. • The New Hospitals programme had been paused, and the situation regarding the proposed new hospital near Basingstoke was unclear. Separately, the ‘Save Winchester Action Group’ had written to board members of the Hampshire and Isle of Wight Integrated Care Board (HIOW ICB) expressing concerns about the proposed downgrade of Winchester hospital. • The Care Quality Commission had published its adult inpatient survey for 2023, which showed a deterioration in people’s experiences since 2020. • The Trust’s aseptic unit had received a positive audit report and had been assessed as being ‘low risk’. • An inspection of the Trust’s mortuary arrangements had been carried out by the Human Tissue Authority in August 2024. The outcome was awaited. • The NHS’s long-term plan process had commenced, with an expected emphasis on digital and moving away from hospitals to focus on the community and prevention. • The report by Lord Darzi on the NHS had been published. This indicated a variation in both quality of and access to NHS services across the country. • A workshop was scheduled in October 2024 regarding violence and aggression, with the focus now being on there needing to be a limit on what the Trust will tolerate and there being consequences, including exclusion of individuals. 5.5 Patient Safety and Quality of Care in Pressured Services Joe Teape was invited to present the paper ‘Patient Safety and Quality of Care in Pressured Services’, the content of which was noted. It was further noted that: • NHS England had sent all integrated care boards, integrated care partnerships, regional directors and NHS trusts and foundation trusts a letter on 26 June 2024 regarding urgent and emergency care, and requiring boards to assure themselves that the Trust is doing all it can to provide alternatives to Emergency Department attendance and admission, and to maximise in- hospital flow. • The Trust chose to queue patients in the Emergency Department, rather than in ambulances in order to be able to release ambulances. It was considered that this approach was safer than having patients remain in ambulances. • The Trust was able to provide good assurance based on its performance against the standards. • The HIOW ICB was proposing to introduce an initiative to reduce ambulance delays whereby patients would be released to the Emergency Department after 45 minutes. Page 3 5.6 Performance KPI Report for Month 4 Joe Teape was invited to present the Performance KPI Report for Month 4, the content of which was noted. It was further noted that: • The Trust was in the top quartile for seven out of nine measures. Of those where the Trust was below top quartile, one was 78-week waits due to the shortage of corneal transplant material, and the other was the 31-day standard, although improvement was expected. • The Trust was aiming to reduce its 65-week waiters to single digits by the end of September 2024. • There had been an increase in the relative mortality rate, the causes of which were being investigated. • The Trust had not had to open surge capacity. • Ward D4 had been closed for deep-cleaning to tackle candida auris. In terms of the spotlight on waiting lists, it was noted that: • The Trust’s waiting list had increased slightly in year by c.1,500, although the growth was in outpatients waits, not patients waiting for a procedure. • There was an opportunity to triage referrals, with use of advice and guidance for General Practitioners in particular. However, it was noted that GPs were not obliged to accept advice and guidance as an alternative to a referral, and the expected industrial action by GPs was seen as a risk. • The Trust had been successful in stabilising its waiting list, it would now be necessary to reduce it from c.60k to c.40k in order to meet the 18-week Referral To Treatment standard. Action: Gail Byrne agreed to look into the increase in ‘red flag’ staffing incidents in July 2024. 5.7 Finance Report for Month 4 Ian Howard was invited to present the Finance Report for Month 4, the content of which was noted. It was further noted that: • The Trust had recorded an in-month deficit of £3.9m and £16.9m year-to-date. The monthly position continued to improve month-on-month, and the Trust’s cost base remained relatively stable. • The Trust’s Elective Recovery performance would be key to achievement of its 2024/25 plan. There remained significant uncertainties in respect of the costs of industrial action, pay award funding, payments for 2023/24 Elective Recovery Funding (ERF), and 2024/25 ERF. • The reasons for the Trust’s variance to plan were largely driven by costs of industrial action, pay awards, unidentified Cost Improvement Programme (CIP), and non-delivery of system mental health and non-criteria to reside programmes. • Identification of CIP and pay controls were working well, and the Trust had delivered 126% ERF performance. • The Trust was anticipating a deficit of £3.8m and 128.5% ERF performance in Month 5. 5.8 Break 5.9 People Report for Month 4 Steve Harris was invited to present the People Report for Month 4, the content of which was noted. It was further noted that: Page 4 • At the end of July 2024, the Trust was 288 Whole Time Equivalents (WTE) below its overall workforce plan. However, over the following months a significant increase in workforce numbers was expected due, largely, to the onboarding of newly-qualified nurses. • The Trust’s plan was predicated on the delivery of system programmes to reduce the number of patients having no criteria to reside and mental health patients. The assumed improvements in mental health patient numbers represented approximately 160 WTE. • There was a dispute with the Trust’s porters, with Unite threatening industrial action. 5.10 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • The previous year had been a difficult one for foundation year doctors due to the industrial action and associated press around this. • Changes in the structure of doctors’ postings and training had resulted in a loss of the previously firm structure and had generated uncertainty for those impacted. It was necessary to ensure that F1 and F2 doctors felt part of the UHS family. • Improvements in the induction process for F1 doctors were required. A twoweek shadowing period had been received positively. 5.11 Learning from Deaths 2024-25 Quarter 1 Report Jenny Milner was invited to present the Learning from Deaths report for Quarter 1 of 2024/25, the content of which was noted. It was further noted that: • Nationally, the Trust continues to benchmark lower than the expected death rates. • The morbidity and mortality reviews process required refining, as sharing of learning could be inconsistent as was the quality of reviews. A mobile application was being developed to help share learnings. • A recurrent theme had emerged via incident reporting in respect of out-ofhours paediatric palliative care advice and support, as no out-of-hours service had been commissioned. • There had been an increase in the number of complaints relating to the location of the death due to a lack of side rooms. Similarly, there was a lack of private spaces to have sensitive conversations. • A palliative care box had been trialled on Ward D3. Use of charity funding was being considered to enable this to be rolled out elsewhere. 5.12 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Paul Grundy was invited to present the Medical Appraisal and Revalidation Annual Report, the content of which was noted. It was further noted that: • The report was intended to enable the Trust to provide assurance that its professional standards processes meet the requirements of the Medical Profession (Responsible Officers) Regulations 2010 and related guidance. Page 5 • This was the second year of using a portal as part of the appraisals process, which had resulted in an improved user experience. • Compliance rates had continued to improve, and there was a good process in place to remind individuals to complete their appraisals. • There had been an increase in the number of appraisers and these were wellrated. Decision: Having reviewed the Annual Report, the Board approved the Statement of Compliance tabled to the meeting, and authorised either the Chair or Chief Executive Officer to sign the Statement on behalf of the Trust. 5.13 Safeguarding Annual Report 2023-24 Corinne Miller and Danielle Honey were invited to present the Safeguarding Annual Report for 2023/24, the content of which was noted. It was further noted that: • There had been a continued increase in activity across most services, and there had been a sustained increase in the number of Deprivation of Liberty Safeguards (DoLS) applications across the Trust along with requests for support with complex Mental Capacity Act case management. • The year had been challenging due to a loss of key staff. • The Trust had undertaken work to update its policies and Level 3 Safeguarding Adult Training had been rolled out via the Virtual Learning Environment (VLE). • A key area of work had been to review the pathway for adults with local authorities. The response from local partners remained challenging due, largely, to budgetary constraints at these other organisations. • The Trust’s children’s safeguarding team had carried out the self-assessment audit required by section 11 of the Children Act 2004, which highlighted no areas of specific concern or gaps. There had been an 28% increase in referrals as well as an increase in the level of complexity. • The adult safeguarding team had won the ‘UHS Champions Team of the Year’ award. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework, the content of which was noted. It was further noted that: • All risks had been reviewed by the relevant Executive Director(s) since the BAF was last presented to the Board, with an extensive review having been carried out in December 2023 and in April 2024. • Following review by the Finance and Investment Committee in August 2024, risk 5c had been modified to better reflect the Trust’s estates-related risks. • The NHS was designing a dynamic risk assessment framework. • Work was ongoing to compare the Care Quality Commission’s Well-Led framework with the Trust’s BAF, and to identify any gaps. Page 6 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Health and Safety Annual Report 2023-24 Jane Fisher was invited to present the Health and Safety Annual Report for 2023/24, the content of which was noted. It was further noted that: • There continued to be a number of incidents of late reporting of work-related absence, although steps were being taken to streamline the process and to make reporting easier. • There had been a number of losses in staff over the year, which had impacted the FFP3 mask-fitting team in particular. • Improved training had been made available through the Virtual Learning Environment, and health and safety training received was now listed as a skill on staff members’ HealthRoster profile. • Thirty-nine incidents had been reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). • The main causes of injuries were as a result of collisions, slips, trips and falls, sharps, and incidents of violence and aggression. With the exception of the latter, these incidents were generally accidents or a result of human error, with nursing and healthcare assistants being the most likely groups to be injured. 7.3 People and Organisational Development Committee Terms of Reference It was noted that the People and Organisational Development Committee had reviewed its terms of reference at its meeting held on 21 August 2024. Decision: Following discussion, it was further noted that whilst the committee had proposed no changes to the terms of reference, it was agreed that the terms of reference should include specific reference to the CQC’s quality statements given the emphasis within the CQC’s latest framework on equality, diversity and inclusion related matters. 8. Any other business There was no other business. 9. Note the date of the next meeting: 5 November 2024 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. Page 7 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 8 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 27/02/2025 Pending Update: Item tentatively scheduled for TBSS on 27/02/2025. Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 27/02/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 27/02/25 Study Session. Trust Board – Open Session 10/09/2024 5.6 Performance KPI Report for Month 4 1175. 'Red flag' staffing incidents Byrne, Gail Explanation action item Gail Byrne agreed to look into the increase in ‘red flag’ staffing incidents in July 2024. 05/11/2024 Pending Page 1 of 1 Agenda item 4.1 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Audit and Risk Committee Meeting Date: 14 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee reviewed the year end process for 2023/24, and associated ‘lessons learned’. Many of the issues encountered ought to be mitigated by the introduction of a new finance system, together with a ‘rehearsal’ of the year end accounts process to be carried out early in 2025. • The Trust’s National Cost Collection submission for 2024 went well with no validation errors requiring re-submission and data quality was good. Whilst the output will be presented to the Finance and Investment Committee, initial indications were that the Trust was more efficient than the average. • The committee received an update on the Procurement Act 2023 and the potential impact on the Trust. It was noted that the additional reporting requirements had been delayed until February 2025 due to issues with the digital reporting platform development. • The committee received updates in respect of Information Governance and Legal. • The committee received an update on Data Quality, including work ongoing to review cancer waiting times data. • A report on a local proactive exercise in respect of Bank/Agency staff identity fraud showed that whilst the Trust was following the majority of the recommendations to reduce the risk of this type of fraud, current practice could be improved. The committee agreed with the report. 6.2 Board Assurance Framework (BAF) Level of Assurance: Substantial • All risks had been reviewed with the relevant executive director(s). • It is intended that agenda items at Board meetings will be more clearly linked to the BAF risks. • In addition, division-level ‘BAFs’ are under consideration to provide a clearer idea of overall risk at the divisional level to bridge the gap between the operational risk register and Board-level BAF. • 90% of operational risks had been reviewed, an indicator of wellembedded risk management within the organisation. The Trust’s Fraud, Bribery & Corruption Annual Report 2023/24 highlighted no particular areas of concern. The committee reviewed the performance of the Trust’s internal and external auditors. In addition, the committee held a discussion with the external auditors without management present. Substantial Assurance Reasonable Assurance There is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 2 of 2 Agenda item 4.2 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Finance and Investment Committee Meeting Date: 21 October 2024 Key Messages: • • • • • • The Trust has received significant additional cash in October 2024 through deficit support funding and additional payments for 2023/24 ERF performance. The Trust’s financial position remains challenging with a year-to-date deficit of £8m. The Always Improving programme continues to make progress, but will need to go further and faster. The Trust’s data centre arrangements remain a risk and design work is ongoing in respect of a solution. The risk associated with cyber incidents also remains high. The committee supported a business case for possible expansion of UHS Pharmacy Limited and recommends it to the Board. The committee reviewed the proposed financial recovery plan and recommends to the Board its submission to the ICB. The main risk to the achievement of the Trust’s 2024/25 plan remains the need for the ICS transformation programmes to deliver. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 6 Level of Assurance: Substantial • The Trust has received £11.2m of deficit support funding as well as £6.5m of additional funding in respect of 2023/24 Elective Recovery performance. • The year-to-date deficit is c.£8m, with an underlying deficit of c.£6m per month. • The Trust’s monthly income remains strong and ERF performance in September 2024 was 130%. However, costs are gradually increasing, and further investigation is required into pay expenditure. • The full amount of 2024/25 CIP has now been identified. • The most significant risk to the Trust’s achievement of its 2024/25 plan remains delivery of the system transformation programmes. 6.2 Board Assurance Framework Level of Assurance: Reasonable • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Directors. • Risk 5a will be reassessed following the Trust’s self-assessment against the Recovery Support Programme undertakings to ensure that the risk rating and target are appropriate. • A new scoring framework is being developed to improve consistency in the rating of risks. Any Other Matters: The additional cash received in October 2024 means that it is now likely that the Trust will not need additional cash until February 2025, whereas this was previously expected to be the case in November 2024. The Trust has in place effective controls to monitor its cash position, and a regular report on cash will be provided to the Finance and Investment Committee. Page 1 of 2 Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 2 of 2 Agenda item 4.3 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: People and Organisational Development Committee Meeting Date: 21 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The Trust remains below its plan in terms of workforce numbers. However, from October 2024 onward, this position is expected to change. • The risk of non-delivery of ICS transformation programmes is significant. The Trust has assumed a significant reduction in workforce based on delivery of these schemes. • The committee examined the progress against actions designed to improve the lives of resident doctors. It was noted in particular that there was an issue with a lack of availability of office/desk space. • The Trust had been notified that Unite was commencing a ballot of its members commencing on 21 October 2024 as part of the ongoing dispute with porters. 5.11 People Report for Month 6 Level of Assurance: Substantial • The Trust was 249 WTE below its plan. However, this position was expected to change significantly with the onboarding of newly qualified nurses etc. in the autumn. • In addition, the Trust’s plan assumed that the ICS transformation programmes would begin to deliver significant reductions from October 2024 onward. • Turnover and sickness remain below target at 11.1% and 3.6% respectively. Bank and agency rates also remain low. • Appraisal rates remain low at 73%. The Trust was considering a move away from the current ESR system in order to make the appraisal process easier. The Trust had held constructive discussions with Unison as part of the Band 2/3 pay dispute. Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 1 of 1 Agenda item 4.4 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Quality Committee Meeting Date: 14 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The Trust was making good progress against its 2024/25 Quality Priorities. • There were concerns regarding the consistency of approach to infection prevention and control in the Trust. Action plans were being produced and the ‘Fundamentals of Care’ programme is also intended to address many of these concerns. • A never event due to wrong site surgery had been recorded. This is the fifth never event reported during 2024. • The closure of Ward D4 had not been effective in eradicating the candida auris infection with four new cases reported. • There was insufficient resource to roll out National Safety Standard for Invasive Procedures (NatSSIPS) 2 in a comprehensive and systematic manner. • In its review of mental health work, the committee noted the following top three risks: lengths of wait for onward care; parity of esteem for patients; and the level of support from local mental health trusts. 6.2 Board Assurance Framework Level of Assurance: Reasonable • Risks 1a, 1b, 1c and 4a have been updated, following discussions with the respective Executive Directors. • It was agreed that the likelihood of achieving the target risk level for risk 1c (infection prevention and control) by April 2025 should be reviewed. • Staffing remains the main concern for the Trust’s Maternity services. • The possibility of support from Salisbury NHS FT to manage the increasing number of caesarean sections was being explored. Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 1 of 1 Agenda item 4.5 Report to the Trust Board of Directors, 5 November 2024 Title: Sponsor: Author: Purpose Chief Executive Officer’s Report David French, Chief Executive Officer Craig Machell, Associate Director of Corporate Affairs (Re)Assurance Approval Ratification Information x Strategic Theme Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future x x x x Executive Summary: The CEO’s Report this month covers the following matters: • Autumn Statement • Portering Dispute • BAM Dispute • Change NHS • Review into the Operational Effectiveness of the Care Quality Commission • Proposed Legislative Changes • New Hospital Programme – Hampshire Together • Hampshire and Isle of Wight Healthcare • Charity Priorities • Staff Survey • National Patient Safety Award Contents: Chief Executive Officer’s Report Risk(s): N/A Equality Impact Consideration: YES / NO / N/A Chief Executive Officer’s Report Autumn Statement On 30 October 2024, the Chancellor of the Exchequer presented her Autumn Statement. The statement was said to be based on the principles of restoring economic stability and increasing investment. A summary can be found from NHS Providers website: autumn-budget-2024-on-the-day-briefing.pdf The statement set out measures to raise an additional £40bn in taxation. This includes an increase in employer’s national insurance contributions by 1.2% to 15% from April 2025, increases in the rates of capital gains tax, changes to inheritance tax, abolition of the nondomicile tax regime, increased stamp duty on second homes, an increase in the rate of the windfall tax on energy companies, and removal of the VAT exemption for private schools. The Chancellor said that she would reduce wasteful spending and has set a 2% productivity savings target for all departments. The Government will publish its ten-year plan for the NHS in Spring 2025 and re-committed to reducing waiting times to 18 weeks by delivering on its manifesto commitment for 40,000 extra hospital appointments each week. The key announcements for health and care include: • Day-to-day spending for the Department of Health and Social Care will increase by £22.6bn from 2023/24 to 2025/26. This is a two-year average real terms NHS growth rate of 4% – the highest since 2010 (excluding the years affected by the COVID-19 pandemic). • Capital spending will increase by £3.1bn in 2025/26 (compared to 2023/24 outturn) – rising to £13.6bn. This is a two-year average real terms growth rate of 10.9%, although it is still lower than the overall value of the maintenance backlog (£13.8bn). This includes £1.5bn for new surgical hubs and diagnostics scanners, and £1bn towards backlog maintenance. There remains some uncertainty regarding the implications of the additional revenue funding and whether any of the funding announced will provide in-year relief in addition to values already confirmed as part of pay award and Elective Recovery Framework funding. Overall, the commitment to additional capital and revenue investment to the NHS is extremely welcome. We will assess the implications for HIOW ICS and to UHS over the coming weeks and months. The national proposed rise in the minimum wage to £12.21 in April 2025 will exceed the current lowest level within the NHS of £12.08. The national staff council will be working with NHS unions to review the implication of this and how it is addressed at a national level. Portering Dispute The Trust has been formally notified by UNITE the union that it has initiated a strike ballot of its members employed within the portering department at University Hospital Southampton. The ballot commenced on 21 October and will run until 11 November 2024. UNITE is balloting members on a range of issues including conduct, culture and working conditions. Prior to the ballot, and having been made aware of staff concerns, the Trust commissioned an independent external review, seeking views of all the portering department. The ballot has attracted media coverage from the BBC and some other local sources, and the Trust provided a response to the issues raised. The Trust is in active discussions with UNITE and local portering representatives to address the issues being raised and will continue to work constructively to resolve the dispute. Page 2 of 6 Meanwhile, the Trust is actively considering plans to ensure patient services and safety are maintained in the event a strike takes place. This will include enacting the Trust’s business continuity processes through the hospital incident management structure. The Board will be kept informed as plans are finalised and on conclusion of the ballot. BAM Dispute While the Trust was proceeding with the development of the east wing annex, concerns were raised by external structural engineers over the capacity of the existing building to cope with the expected additional weight the development would put on the existing structure. In 2022, the Trust raised a formal issue with BAM, the principal contractor of the existing east wing annex building. Over the last two years the Trust, with the support of DAC Beachcroft, has been trying to get BAM’s representatives to the mediation table to resolve the issues raised on the building. In September 2024, the decision was taken to commence arbitration proceedings against BAM Construction over the inability to agree to a mediator or mediation date. The Trust continues to work closely with DAC Beachcroft during this process, aiming for completion in early 2025. Change NHS On 21 October 2024, the Department for Health and Social Care launched an online portal for individuals to share their views, experiences and ideas to assist in the development of the Government’s 10 Year Health Plan. Staff and members of the public have been asked to: • Give their views on the NHS and health and care. • Tell the Government what they feel is working well and what needs improving. • Share their experiences. • Post their ideas for improving health and care in the future. More information can be found at: Change NHS: help build a health service fit for the future GOV.UK Review into the Operational Effectiveness of the Care Quality Commission On 15 October 2024, the Government published an independent report by Dr Penny Dash, who had been commissioned in May 2024 to review the operational effectiveness of the Care Quality Commission (CQC). The review heard from over 300 people from across the health and care sectors and within the CQC, and analysed the CQC’s performance data. The review found significant failings in the internal workings of the CQC, which have led to a substantial loss of credibility, a deterioration in the CQC’s ability to identify poor performance and support a drive to improve quality. The review summarised these failings as follows: • Poor operational performance – there has been a stark reduction in activity compared with 2019. • Significant challenges with the provider portal and regulatory platform. • Delays in producing reports and poor-quality reports. • Loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement. • Concerns around the single assessment framework and its application. • Lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections to calculate a current rating. • There are opportunities to improve the CQC’s assessment of local authority Health and Care Act 2022 duties. • ICS assessments are in early stages of development with a number of concerns shared. • The CQC could do more to support improvements in quality across the health and care sector. • There are opportunities to improve the sponsorship relationship between the CQC and the Department of Health and Social Care. Page 3 of 6 The full report can be read at: Review into the operational effectiveness of the Care Quality Commission: full report - GOV.UK Proposed Legislative Changes The Government has proposed a number of significant reforms to employment legislation through its Employment Rights Bill. These changes include: • From 2026, employees will have immediate entitlement to paternity leave, unpaid parental leave, and bereavement leave from the first day of employment. Protections for pregnant women and mothers will also be strengthened. • ‘Exploitative’ zero-hours contracts will be banned, giving workers the right to move to guaranteed hours contracts after a 12-week reference period.
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