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Practice reading passages - patient information

Description: This factsheet contains some passages that help you control your breathing pattern when talking.
Url: /Media/UHS-website-2019/Patientinformation/Respiratory/Practice-reading-passages-755-PIL.pdf

If your operation is cancelled or postponed - patient information

Description: This factsheet explains why some elective operations are cancelled or postponed and suggests questions for you to ask before you leave
Url: /Media/UHS-website-2019/Patientinformation/Surgery/If-your-operation-is-cancelled-or-postponed-3618-PIL.pdf

Southampton experts develop computer model of hand to improve finger joint surgery

Description: Southampton experts develop computer model of hand to improve finger joint surgery
Url: /AboutTheTrust/Newsandpublications/Latestnews/2017/May-2017/Southampton-experts-develop-computer-model-of-hand-to-improve-finger-joint-surgery.aspx

Papers Sept 2020 held in closed session due to Covid-19

Description: Date Time Location Chair Agenda - Trust Board Meeting 29/09/2020 9:00 - 16:00 Microsoft Teams Peter Hollins 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 To note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. Minutes of Previous Closed Meeting held on 27 August 2020 (Not for publication) Matters Arising and Summary of Agreed Actions (Not for publication) OPEN ITEMS (For publication) 2 QUALITY, PERFORMANCE and FINANCE 2.1 Patient Story To receive feedback from patients, carers, or other stakeholders about their experience of the Trust's services. 2.2 Briefing from Chair of Charitable Funds Committee for review (Oral) 9:15 Dave Bennett, Chair 2.3 Briefing from Chair of Finance & Investment Committee for review (Oral) 9:20 Jane Bailey, Chair 2.4 Briefing from Chair of People & OD Committee for review (Oral) 9:25 Jenni Douglas-Todd, Chair 2.5 Integrated Performance Report for Month 5 for assurance 9:30 To review the Trust's performance as reported in the Integrated Performance Report Sponsor: Paula Head, Chief Executive 2.5.1 10:15 Access Targets: Cancer Trajectory Update for review Sponsor: Joe Teape, Chief Operating Officer 2.5.2 10:25 ED Performance & Recovery Plan Update for review Sponsor: Joe Teape, Chief Operating Officer 2.6 Violence and Aggression Progression Report for review 10:40 Sponsor: Joe Teape, Chief Operating Officer Attendee: Sandra Hodgkyns, Head of Security/Emergency Planning (LSMS) 2.7 Workforce Race Equality Standard (WRES) and Workforce Disability 10:50 Equality Standard (WDES) Annual Reports 2019/20 for review and Action Plans 2020/21 for review Sponsor: Steve Harris, Chief People Officer Attendee: Gemma Genco, Head of Equality, Diversity and Inclusivity 2.8 Black, Asian and Minority Ethnic (BAME) Experience Improvement Plan 11:05 for approval Sponsor: Steve Harris, Chief People Officer Attendees: Gemma Genco, Head of Equality, Diversity and Inclusivity/ John Norton, Chair, BAME One Voice Network 2.9 Finance Report for Month 5 for review 11:20 Sponsor: David French, Chief Financial Officer 3 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 3.1 Feedback from Council of Governors' meeting 1 September 2020 (Oral) 11:35 Sponsor: Peter Hollins, Trust Chair 3.2 Register of Seals, and Chair's Actions for ratification 11:45 In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Peter Hollins, Trust Chair 4 Follow-up Discussion with Governors 11:50 5 To note the date of the next meeting: 29 October 2020 in the Conference Room, Heartbeat/Microsoft Teams (Closed meeting only) 6 Items Circulated to the Board for reading 6.1 CRN: Wessex 2020/21 Quarter 1 Performance Report Sponsor: Derek Sandeman, Chief Medical Officer Page 2 2.5 Integrated Performance Report for Month 5 for assurance 1 Integrated Performance Report 2020-21 Month 5 Report to the Trust Board of Directors dated Tuesday 29 September 2020 Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Integrated Performance Report 2020/21 Month 5 2.5 Chief Executive 22 September 2020 Assurance Approval or reassurance Y Ratification Information This report is intended to support the Trust Board in assuring that: • the care we provide is safe, caring, effective, responsive and well led in the context of the Covid 19 pandemic • at the same time we continue our journey toward our vision of World Class Care for Everyone. Response to the issue: For the year 2020/21 the Integrated Performance Report has adapted to reflect the current operating environment. In particular we have aligned it with the Care Quality Commission Key Lines of Enquiry and then cut it again to reflect delivery of our Strategic Goals and annual corporate objectives. Implications: This report covers a broad range of trust services and activities. It is (Clinical, Organisational, intended to assist the Board in assuring that the Trust meets regulatory Governance, Legal?) requirements and corporate objectives. Risks: (Top 3) of carrying This report is provided for the purpose of assurance. out the change / or not: Summary: Conclusion This report is provided for the purpose of assurance. and/or recommendation Page 1 of 24 Integrated KPI Board Report covering up to Aug 2020 Sponsor - Andrew Asquith, Director of Financial and Productivity Improvement, andrew.asquith@uhs.nhs.uk Page 2 of 24 Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line Percentiles Control Chart Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). A line percentiles chart is used to represent the distribution of a variable. The 50th percentile shows the median value, we also show the 5th, 25th (lower quartile), 75th (upper quartile) and 95th centiles. A control chart shows movement of a variable in relation to it's control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from it's target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving it's target. 2 Page 3 of 24 Report to Trust Board in September 2020 Introduction The Trust Integrated Performance Report is presented to the Trust Board each month. For the year 2020/21 the Integrated Performance Report has adapted to reflect the current operating environment. In particular we have aligned it with the Care Quality Commission Key Lines of Enquiry and then cut it again to reflect delivery of our Strategic Goals and annual corporate objectives in order to: • Demonstrate that we can assure ourselves that the care we provide is safe, caring, effective, responsive and well led in the context of the Covid 19 pandemic • Ensure that at the same time we continue our journey toward our vision of World Class Care for Everyone. We might adjust/ or add to these indicators – informing the Board and keeping a comparative narrative – if the situation changes as we work through these unusual circumstances. An example of this might be measuring vulnerable groups as the evidence around COVID emerges. The monthly Trust Integrated Performance Report is currently complemented by a ‘Covid-19 Balanced Scorecard’ which is considered by the UHS Integrated Assurance Group, and also available to Board Members, on alternate weeks. August 2020 Summary During August the direct impact of Covid 19 infections upon the Trust continued to reduce. The number of beds occupied by patients with Covid 19 remained in low single figures and at times there were 0 Covid 19 inpatients. Over a 2 week period we tested 0 positive staff or patients. Covid 19 in the local community also remained low, with infection rates estimated at 4-7 per 100,000. Non-elective admission volumes in total remained at approximately 90% of their normal levels. Elective spells increased to approximately 72% of their normal levels. Elective activity continued to be adversely affected by the need to socially distance, particularly in outpatients, infection control guidance (which was relaxed for some cases in the middle of August) and the inability to fill theatre lists when patients cancelled at the last minute because of the need to isolate for 14 days. The trust has sought to prioritise the reduced elective capacity available towards those patients requiring assessment or treatment more urgently, and to provide assessments by telephone or video whenever appropriate. The trust started to develop detailed speciality specific recovery plans in August, in line with the Wave 3 letter, as well as each service 3 Page 4 of 24 Report to Trust Board in September 2020 RESPONSIVE • Emergency Department timeliness deteriorated in August, reaching 85.9% across the month (RE 10). Other Trusts have also seen similar deterioration, though UHS had the fourth best performance out of 8 ‘peer’ Major Trauma Centres (RE9). Attendance numbers increased to approximately 85% of the normal level (RE 8), whilst enhanced infection control precautions remained in place. • The percentage of patients waiting up to 18 weeks from referral to treatment improved marginally to 55% (RE 14). The total number of patients waiting is now above pre-Covid levels, at 34,900 patients (RE 15), and is expected to increase further, due to the recovery in the number of referrals being made to hospital (RE 12). The percentage of patients waiting more than 6 weeks for a diagnostic test (RE 20) improved from 35% to 40%, though the total number of patients waiting continued to increase and is now above pre-Covid levels (RE 19). The average waiting time for new outpatient appointments further reduced in August and is now at 8.8 weeks (RE 18). • Cancer performance measures for July indicate that UHS 62 day performance (RE 21) improved and is now the best amongst our 10 ‘peer’ teaching hospitals, and that 31 day performance (RE 22) further improved to 98.2% and achieved the national standard. The number of patients still waiting with pathways greater than 104 days (RE 23) reduced from 36 to 17. There remain challenges particularly in the head and neck tumour site. 4 Page 5 of 24 Report to Trust Board in September 2020 RESPONSIVE Jun Jul Aug Sep Oct Nov Dec Jan 6,800 6,533 RE1 Non-elective Spells (including CDU) Feb Mar Apr May Jun Jul Aug Monthly Target 6,058 - 4,000 7.5 RE2-L Non Elective LOS Rolling 12 months 6.42 6.0 250 RE3 Number of patients medically optimised for discharge Longer LOS Census average RE4-N (Patients with LOS > =21days) 0 211 227.34 180.19 133.04 - 6.10 123 - 137 - RE5-l Adult midday bed occupancy 95.2% 72.4% 90-95% RE6 Last minute cancelled operations not readmitted within 28 days 3 150 78 RE7 Hospital initiated cancelled ops 91% 80.3% 81% 85.04% 90.7% 71% 766545365325334 Patients spending less than 4hrs in ED RE10-N UHS Total (includes SGH all types and lymington until Jul 19) 91.51% 83.3% 75.05% 82.2% 85.9% 91.27% Q Target - 95% 95% RE11-N Total time spent in ED Total Percentiles UHS Mean, 3:16 50th, 3:06 90th, 4:07 Mean, 2:50 - - 50th, 2:47 RE12 Accepted Referrals 25000 22249 14883 - - RE13 Elective spells 0 2,000 0 1,453 1,191 - - 6 Page 7 of 24 Report to Trust Board in September 2020 RESPONSIVE RE14-N % Patients on an open 18 week pathway (within 18 weeks ) Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 83% 84.0% 78% 72% 54.75% Target > =92% 35000 Total number of patients on a waiting RE15-N list (18 week referral to treatment pathway) RE16 Face to face outpatient attendances 28000 50,000 52,480 33746 34903 24,043 - RE17 Non-face to face outpatient attendances 0 50,000 7,948 0 RE17 - Latest month is awaiting approx ~3k outpatient attendances to be reported 12,900 - RE18 Average weeks waited for first outpatient appointment 9,000 RE19 Patients waiting for diagnostics 4,000 RE20-N % of Patients waiting over 6 weeks for diagnostics 19% 121%% 7.5 7004 2.8% 8.8 - 8794 - 39.61% RE22-N 31 day cancer wait performance (latest data held by UHS) no.patients Target to recover QTD Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul /July 1 94.5% 78.4% N=> N = 12 90% L=> L= 17 of 84% 76.5% 72.6% 95% 111.5 36578645655121 0.5 96.2% 92.4% 88.5% 98.22% N=> 96% N=0 of 805 0.9665821 RE23 Snapshot of waits > 104 days (from referral on a 62 day pathway) 33 38 41 55 52 41 29 35 27 29 11 25 36 17 - - 100% RE24-N 28 Day Faster Diagnosis 70% 10,000 RE25 My Medical Record - UHS patient logins 5,000 0 2500 RE26 Number of Estates Help desk requests and percentage completed on time 900 100% 85% 75% 4,634 1620 81.0% 85% => 75 % - 7,132 - 1516 - 89.6% > 85% 50% 79.80% 89.0% 8 Page 9 of 24 Report to Trust Board in September 2020 RESPONSIVE 50% Monthly Target Target QTD /July - Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Elective inpatient activity - % of same time last year 60.00% 50.19% RE27 UHS Corporate peer average ------------------------------Rank--> 48.32% 000000000047330 0.00% Non-elective inpatient activity - % of same time last year RE28 UHS 110.00% 108.41% 100.61% Corporate peer average ------------------------------Rank--> 000000000046650 0.00% 1st outpatient attendances - % of same time last year 100.00% 96.80% RE29 UHS Corporate peer average ------------------------------Rank--> 70.70% 000000000065570 0.00% 9 Page 10 of 24 Report to Trust Board in September 2020 SAFE • The majority of measures indicate that safety has been maintained during August. • New Covid-19 diagnoses amongst hospital inpatients (SA5, SA6) have reduced significantly, and there were no cases of ‘probable’ transmission or ‘healthcare-acquired’ Covid-19 in UHS inpatient services in August. The Covid 0 campaign continued to be rolled out, focusing on the absolute importance of stopping nosocomial COVID infection. The campaign encourages all people to follow government guidance when walking apart, wear a mask where you can’t, and continue to wash your hands as often as possible. • Statutory and mandatory training compliance further reduced in August. • Both clinical and Serco cleaning scores showed an improvement in August; with both meeting 100. • As expected CHPPD for all areas this month is still elevated at 11.0 (RN 6.7, HCA 4.3) with ward only areas also elevated at 9.4 (RN 5.0, HCA 4.4). This is reflective of new ward configurations, roster changes, additional staff deployments and reduced patient numbers in some areas. • In UHS ward-based areas, the data shows that total nursing staff vacancies have increased to 9.63%. Registered nurse vacancies in ward-based areas have decreased this month to 15.52%. This position is being continuously validated as data, sourced from rosters, has been affected by the significant ward changes in size and specialty focus that have occurred as a result of the COVID-19 restart plan. Annual ward staffing reviews are currently taking place to confirm required levels against the changed configurations. Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target YTD YTD Target SA1-N Cumulative Clostridium difficile 2 SA2 MRSA bacterium 0 100 SA3 Clinical cleaning scores for very high risk areas 99 95 SA4 Serco cleaning scores for very high risk areas 100 99 95 27 5 32 32 0 0 100 98 - 14days after admission 00 0 0 0 0 0 0 0 0 20 30 14 1 0 0 Probable hospital-associated 50 SA6 COVID infection: COVID-positive sample taken > 7 days and 95% - 96.3% YTD Target - - > 95% 12 Page 13 of 24 Report to Trust Board in September 2020 CARING • The majority of measures indicate that UHS has continued to provide caring services during August. • Friends and family negative scores remained below target, at 3.7% (CA1), although maternity saw an increase for the second month, rising to 8.3% (CA2). • Complaints per 1,000 units remained significantly below the target, at 0.27 (CA4). The number of complaints closed on time continues to make a slow recovery following the pausing of complaints investigation at the height of Covid 19. In August the Trust achieved 46%, compared to 41% in July (CA5) • The percentage of women receiving ‘Continuity of Care’ within the Maternity service remained static at 11% and remains well below the target of 35%. A plan has been developed to drive improvements in this aspect of care. • The number of non-clinically justified overnight ward moves rose slightly in August, to 68 (CA9). An action plan is being developed to reduce these. Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target 0.6% CA1-N FFT Negative Score - Inpatients 5% =35% 1.30 CA4-L Complaints per 1000 units 0.00 CA5-L % Complaints closed within 35 days 80% 0% 0.38 81% Page 14 of 24 =70% 13 Report to Trust Board in September 2020 0% Jun Jul Aug Sep 100% % Patients reporting being CA6 involved in decisions about care and treatment 50% 100% % Patients reporting finding CA7 somebody to talk to about worries and fears 50% 100% % Patients with a CA8 disability/additional needs reporting those needs/adjustments were met 50% CA9 Overnight ward moves with a reason marked as non-clinical Jun Jul Aug Sep 135.76 99 76.96 18.16 18.0 Total nursing staff all inpatient CA10 areas - Care hours per patient day13.0 (CHPPD) 8.0 40.0 Same Sex Accommodation CA11 (Non Clinically Justified Breaches) 20.0 2 0.0 9.0 11 4 4 CARING Oct Nov Dec Jan Feb Mar Apr May Jun Oct Nov Dec Jan Feb Mar Apr May Jun 32 12 1 1 0 15 0 0 0 Monthly Target Jul Aug 84% > =90% 91% > =90% 94% > =90% Monthly Jul Aug Target 68 - 11.0 - - 0 0 14 Page 15 of 24 Report to Trust Board in September 2020 EFFECTIVE • The number of patients screened for alcohol and smoking continued to significantly exceed the 80% target, at 97% (EF5) • The number of patients found to have either a moderate or high dependence on alcohol (EF6), or to smoke (EF7) who were given advice or an onward referral continued to exceed the targets, at 80% and 94% respectively. EF1-L Cumulative Specialities with Outcome Measures Developed Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 47 52 52 53 54 223 234 250 255 260 Monthly Target +1 100% EF2 Developed Outcomes RAG ratings 75% 78% 77% 79% 80% 81% 50% 100 EF3-N HSMR - UHS HSMR - SGH 81 75 4.5% EF4 HSMR - Crude Mortality Rate 2.9% 80% 15 Page 16 of 24 Report to Trust Board in September 2020 EFFECTIVE 80% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug % patients screened & found to EF6-N have either moderate or high alcohol dependence given advice 90% 87% 80% or referral 70% % patients screened & found to 100% 83% 94% EF7-N smoke given brief advice or a medication offer 60% Monthly Target > 90% > 90% 16 Page 17 of 24 Report to Trust Board in September 2020 WELL LED • Turnover this month has increased due to the student nurses who joined the trust to support for covid have started to return to their University courses and this has strongly affected the turnover % this month, and is likely to continue next month as these students are leaving UHS. • In clinical ward areas there are 163 registered nurses and 153 healthcare assistants in the covid ‘at risk’ categories who are unable to be deployed to some patient-facing activities. The majority of these staff have now been deployed to low risk areas, as risk levels are continuously reviewed. All nursing staff have been flexibly deployed to manage this deployment safely. A review is ongoing with covid assessments to move our system to be covid age instead of risk level 1 – 3. • This month staffing remains amber overall because some key targets have been missed for staff turnover, sickness and appraisals. The in-month sickness absence rate has seen a decrease and is below its normal position, but the 12 month figure is elevated due to the spoke during the pandemic. • Statutory and mandatory training compliance has seen some slippage (with 6 of 12 measures meeting target) due to COVID-19 and the reductions in training release during that time. • Recognising the pause in appraisals during COVID efforts are now being focused on improving quantity undertaken whilst retaining the important focus on quality of discussion as reflected in our staff survey. • UHS has seen an increase in rates of employment for BAME Band 7+ to 9.37%, but is still on an upwards trend. UHS is now monitoring BAME individual occupying 35 key medical leadership positions. This will be reported on a quarterly basis. WL1-L Substantive Staff - Turnover Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target 13.90% 13.18% 12.46% 12.8% 13.3% 92% 77.24% 17 Page 18 of 24 Report to Trust Board in September 2020 WELL LED Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target WL3-L 100.00% Staff - Medical appraisals completed - Rolling 12-months 50.00% 0.00% 60.00% WL4-L Staff vacancies 10.00% 5.00% 0.00% 4.09% WL5-L Staff - Sickness absence 4.43% 3.7% 2.99% 3.31% 2.91% =76% 30% 20% WL9-L Black & Minority Ethnic Band 7+ Percentage 9% 8.8% 9.4% 15% by 2023 7% WL10 Cumulative Number of staff trained in QI 1001 1064 1171 WL10 - QI training programme, and reporting, is currently temporarily suspended as team members support urgent change programmes as part of our Covid 19 response and recovery WL11 Statutory & Mandatory Training Achieving Target 8 8 8 8 7 7 7 7 7 7 7 6 6 6 6 4 4 4 4 5 5 5 5 5 5 5 6 6 6 6 - 100 WL12 Number of Apprenticeship Starts 53 - 50 29 28 23 0 19 Page 20 of 24 Report to Trust Board in September 2020 WELL LED 0 Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target WL13-L Comparative CRN Recruitment Performance by clinical specialty 44% 44% 52% 56% 52% > =50% 2 WL14-L Comparative CRN Recruitment Performance - weighted 4 5 5 6 Top 5 WL15-L Comparative CRN Recruitment - contract commercial 15 15 13 13 13 Proportion of studies closing in FY on 88% WL16-L time and to recruitment target - 59% 65% 65% 50% non-commercial 452 WL17 NIHR CRF & BRC publications Year on year growth 329 246 137 Top 10 > =80% 20 Page 21 of 24 Report to Trust Board in September 20C20hanges and Corrections Section Responsive Responsive Responsive KPI KPI Name Type Elective inpatient activity - % RE26 of same time last year Addition Non-elective inpatient RE27 activity - % of same time last Addition year 1st outpatient attendances - RE28 % of same time last year Addition Detail Addition of benchmark position - % activity compared to same time last year, with rank and average of corporate peer group CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST OXFORD UNIVERSITY HOSPITALS NHS FOUNDATION TRUST SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST UNIVERSITY HOSPITALS BRISTOL AND WESTON NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST 21 Page 22 of 24 Nursing and midwifery staffing hours - Aug 2020 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. During the last 2 weeks in March and beyond a number of our clinical areas started to change specialty and size to respond to the COVID-19 situation (e.g G5-G9, Critical Care and RHDU). Repurposing of wards to respond to the COVID-19 social distancing recommendations and to enable the separation and restart of services continues with changes sometimes being swift in nature. The data may in some cases not be fully reflective of these changes. WARD C4 (Solent ward) C4 (Solent ward) C6 C6 C6 (Teenage Cancer Trust unit) C6 (Teenage Cancer Trust unit) D2 D2 D3 D3 Critical Care Critical Care E5A E5A E5B E5B F10 E F10 E F11 F11 ASU ASU F6 F6 F5 F5 Acute medical unit Acute medical unit D5 D5 D6 D6 D8 D8 D9 D9 E7 E7 Respiratory high dependency unit Respiratory high dependency unit C5 C5 D10 D10 f7 f7 G5 G5 G6 G6 G7 G7 G8 G8 G9 G9 Registered nurses Total hours planned Registered nurses Total hours worked Unregistered staff Total hours planned Unregistered staff Total hours worked Registered nurses % Filled Day 1383.7 1370.1 1048.9 1253.3 99.0% Night 1069.3 1011.8 713.0 1176.8 94.6% Day 2791.3 2783.6 183.5 414.7 99.7% Night 2049.3 2097.4 102.4% 0.0 320.0 Day 727.5 564.5 331.9 334.8 77.6% Night 674.0 597.0 88.6% 0.0 96.7 Day 1303.0 1671.0 1108.0 909.8 128.2% Night 1057.5 1058.3 713.0 759.0 100.1% Day 1685.5 1641.7 689.2 1157.0 97.4% Night 1046.3 1083.5 686.3 812.5 103.6% Day 21459.4 18076.5 4440.8 2978.6 84.2% Night 20549.2 17565.5 2736.5 2251.8 85.5% Day 1339.7 1171.4 723.4 1019.4 87.4% Night 714.0 679.5 356.5 701.5 95.2% Day 1413.6 1190.3 811.5 1112.0 84.2% Night 713.0 713.0 356.5 597.8 100.0% Day 2313.5 1483.1 623.0 1277.7 64.1% Night 1069.5 1001.5 713.0 793.5 93.6% Day 1953.9 1405.9 774.8 1011.3 72.0% Night 713.0 713.8 713.0 885.5 100.1% Day 1480.3 1056.8 417.5 589.0 71.4% Night 695.0 718.0 356.5 327.5 103.3% Day 2306.0 1384.7 576.8 1345.9 60.0% Night 1069.5 1030.8 701.5 850.0 96.4% Day 1969.1 1534.2 1322.9 1268.3 77.9% Night 1069.5 991.5 712.5 873.5 92.7% Day 3572.8 4020.6 3294.5 3737.1 112.5% Night 3548.8 4008.4 2495.5 3893.3 113.0% Day 1255.0 1313.0 1668.0 1572.3 104.6% Night 1046.5 993.0 934.5 858.0 94.9% Day 1120.5 1061.3 1522.0 1441.5 94.7% Night 713.0 750.5 945.5 820.5 105.3% Day 1134.0 1009.5 1467.5 1700.0 89.0% Night 713.0 794.5 945.5 954.0 111.4% Day 1247.0 1350.7 1711.0 1590.8 108.3% Night 1069.5 978.0 945.5 980.5 91.4% Day 1080.5 1102.5 1232.0 1466.2 102.0% Night 713.0 681.5 713.0 702.5 95.6% Day 1256.3 992.0 521.0 346.5 79.0% Night 1143.0 1037.3 356.5 164.5 90.7% Day 860.0 1037.7 1285.0 602.0 120.7% Night 701.5 678.5 437.0 352.0 96.7% Day 1122.5 995.2 1301.0 1377.0 88.7% Night 702.0 656.5 713.0 552.0 93.5% Day 1083.7 980.4 1749.5 1649.0 90.5% Night 977.5 805.5 713.0 724.5 82.4% Day 1021.0 1277.2 1799.3 1700.8 125.1% Night 1058.8 932.3 701.5 839.5 88.1% Day 1061.9 1049.9 1782.5 1866.0 98.9% Night 1046.5 943.0 713.0 782.0 90.1% Day 742.5 742.5 1354.5 1679.5 100.0% Night 701.5 708.5 1069.5 1092.5 101.0% Day 1079.7 1041.6 1841.2 1829.0 96.5% Night 1069.5 874.0 713.0 805.0 81.7% Day 1080.8 1063.0 1768.8 1910.3 98.4% Night 1070.5 932.5 713.0 736.0 87.1% Unregistered staff % Filled 119.5% 165.0% 226.0% Shift N/A 100.9% Shift N/A 82.1% 106.5% 167.9% 118.4% 67.1% 82.3% 140.9% 196.8% 137.0% 167.7% 205.1% 111.3% 130.5% 124.2% 141.1% 91.9% 233.4% 121.2% 95.9% 122.6% 113.4% 156.0% 94.3% 91.8% 94.7% 86.8% 115.8% 100.9% 93.0% 103.7% 119.0% 98.5% 66.5% 46.1% 46.8% 80.5% 105.8% 77.4% 94.3% 101.6% 94.5% 119.7% 104.7% 109.7% 124.0% 102.2% 99.3% 112.9% 108.0% 103.2% CHPPD Registered midwives/ nurses CHPPD Care Staff 5.0 5.1 8.0 1.2 10.4 3.9 6.2 3.8 5.0 3.6 26.3 3.9 3.7 3.5 3.8 3.4 4.8 4.0 4.1 3.6 8.1 4.2 3.5 3.2 4.1 3.4 7.9 7.5 3.2 3.4 3.4 4.3 2.7 3.9 2.8 3.1 3.1 3.8 16.6 4.2 9.8 5.4 3.3 3.9 3.5 4.6 2.9 3.3 2.9 3.9 3.5 6.6 2.6 3.5 2.9 3.8 CHPPD Overall 10.0 9.2 14.2 10.0 8.6 30.1 7.2 7.2 8.8 7.7 12.3 6.6 7.5 15.5 6.6 7.7 6.6 5.9 7.0 20.8 15.2 7.2 8.1 6.2 6.9 10.1 6.1 6.7 Comments Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained; additional staff used for enhanced care - Support workers. Safe staffing levels maintained. Staff moved to support other wards; Staffing appropriate for number of patients. Staff moved to support other wards; Staffing appropriate for number of patients. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained; additional staff used for enhanced care - Support workers. Safe staffing levels maintained. Beds flexed to match staffing. Beds flexed to match staffing. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers; Additional staff working in this area due to covid restrictions. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Additional staff used for enhanced care - Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained. Safe staffing levels maintained by sharing staff resource; Staffing appropriate for number of patients. Safe staffing levels maintained by sharing staff resource; Staffing appropriate for number of patients. Band 4 staff working to support registered nurse numbers; Beds flexed to match staffing; Safe staffing levels maintained; Covid testing zone requiring additional staffing. Band 4 staff working to support registered nurse numbers; Beds flexed to match staffing; Safe staffing levels maintained; Covid testing zone requiring additional staffing. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Additional staff used for enhanced care Support workers. Additional staff used for enhanced care - RNs; Safe staffing levels maintained. Additional staff used for enhanced care - RNs; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Safe staffing levels maintained. Beds flexed to match staffing; Staff moved to support other wards; Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Beds flexed to match staffing; Staff moved to support other wards; Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Beds flexed to match staffing. Staff moved to support other wards; Safe staffing levels maintained; Beds flexed to match staffing. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care - Support workers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care - Support workers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Page 23 of 24 Nursing and midwifery staffing hours - Aug 2020 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. During the last 2 weeks in March and beyond a number of our clinical areas started to change specialty and size to respond to the COVID-19 situation (e.g G5-G9, Critical Care and RHDU). Repurposing of wards to respond to the COVID-19 social distancing recommendations and to enable the separation and restart of services continues with changes sometimes being swift in nature. The data may in some cases not be fully reflective of these changes. Paediatric high dependency unit Paediatric high dependency unit Paediatric medical unit Paediatric medical unit Paediatric intensive care unit Paediatric intensive care unit Piam Brown ward Piam Brown ward E1 E1 G2 G2 G3 G3 G4 G4 Bramshaw women's unit Bramshaw women's unit Neonatal unit Neonatal unit Maternity service Maternity service Cardiac high dependency unit Cardiac high dependency unit Coronary care unit Coronary care unit D4 D4 E2 E2 E3 Green E3 Green E3 Blue E3 Blue E4 E4 Acute stroke unit Acute stroke unit Regional transfer unit Regional transfer unit E Neuro E Neuro Hyper acute stroke unit Hyper acute stroke unit D neuro D neuro SPI F4 Neuro SPI F4 Neuro Brooke ward Brooke ward Trauma Assessment Unit Trauma Assessment Unit F1 F1 F2 F2 F3 F3 F4 F4 Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night 1627.5 1069.5 1835.4 1707.5 6762.1 5697.8 3695.9 1415.1 2068.0 1380.0 759.3 744.0 2410.6 1705.0 2429.0 1705.0 1120.0 713.0 6894.9 5439.5 8456.9 5383.8 4548.2 3653.1 1412.2 1331.8 1756.2 820.0 1721.2 704.0 1574.8 704.0 1181.7 665.0 1652.1 1100.5 1518.5 1023.0 773.0 682.0 1975.5 1364.0 1564.0 1358.0 1941.0 1364.5 1817.4 1089.0 1171.2 1069.5 535.5 341.0 2428.4 1781.8 1655.7 1023.0 1606.3 1023.3 1470.0 1023.0 1320.0 1162.5 2753.9 2438.4 4695.4 4443.2 2723.0 1178.6 1523.8 1193.8 780.1 793.0 1683.9 1350.8 1994.5 1324.5 1047.3 712.5 4472.4 3814.3 7597.2 4577.8 3991.0 3358.8 1864.8 1613.0 1425.2 780.3 1057.2 706.0 1394.2 682.0 975.7 621.0 1320.7 1069.0 1520.0 880.0 729.5 506.0 1719.0 1265.0 1181.5 924.0 1831.8 1310.0 1254.7 924.0 917.5 736.0 648.7 617.3 1980.8 1736.9 1455.8 803.0 1320.0 869.3 1364.2 860.3 0.0 0.0 352.2 680.5 726.2 587.8 93.0 0.0 620.0 371.3 0.0 0.0 1691.0 1023.0 1188.0 682.0 656.5 345.0 1551.0 1353.0 3137.4 2046.0 2233.7 1366.0 1089.0 968.0 1057.5 1012.0 866.4 341.0 1398.5 788.3 1150.5 682.0 1285.9 396.0 2674.5 1705.0 387.5 330.0 1031.0 1021.5 397.5 319.0 2033.5 1715.0 1143.0 1043.0 600.3 356.5 313.6 341.0 1936.3 1755.3 2000.5 1375.3 1791.2 1364.3 1217.2 693.8 81.1% Shift N/A 92.0 15.6 0.6 Non-ward based staff supporting areas; Safe staffing levels maintained. 16.2 108.7% 0.0 Shift N/A Safe staffing levels maintained. 150.0% 182.0% Additional beds open in the month; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained. 640.9 21.0 5.5 26.5 713.5 142.8% 104.8% Additional beds open in the month; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained. 269.0 472.8 69.4% 78.0% 37.0% 80.4% Beds flexed to match staffing. 39.1 3.2 42.2 Beds flexed to match staffing. 158.5 73.7% 170.4% 12.4 0.5 Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 12.9 83.3% 0.0 Shift N/A Beds flexed to match staffing; Safe staffing levels maintained. 641.0 73.7% 103.4% 7.8 Band 4 staff working to support registered nurse numbers; Non-ward based staff supporting areas; Safe staffing levels maintained. 3.6 11.4 614.8 86.5% 165.6% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 102.7% Shift N/A 0.0 12.0 0.0 Safe staffing levels maintained. 12.0 106.6% 0.0 Shift N/A Safe staffing levels maintained. 791.0 69.9% 46.8% 8.4 Non-ward based staff supporting areas; Safe staffing levels maintained; Beds flexed to match staffing. 3.6 12.0 532.5 79.2% 52.1% Beds flexed to match staffing; Safe staffing levels maintained. 885.5 82.1% 74.5% 8.4 Non-ward based staff supporting areas; Safe staffing levels maintained; Beds flexed to match staffing. 3.7 12.1 583.0 77.7% 85.5% Beds flexed to match staffing; Safe staffing levels maintained. 609.0 93.5% 92.8% Safe staffing levels maintained. 8.1 4.4 12.6 345.0 99.9% 100.0% Safe staffing levels maintained. 1605.5 64.9% 103.5% 10.7 3.3 Staffing flexed to match bed numbers. 14.0 946.0 70.1% 69.9% Staffing flexed to match bed numbers. 2498.7 89.8% 79.6% Safe staffing levels maintained. 5.3 1.9 7.2 1770.8 85.0% 86.5% Safe staffing levels maintained. 1394.4 803.0 87.7% 91.9% 62.4% 58.8% Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit; Band 4 staff working to support 19.0 5.7 24.7 registered nurse numbers. Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit; Band 4 staff working to support registered nurse numbers. 132.0% 81.1% Additional beds open in the month; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the 883.5 9.5 4.6 14.1 Unit. 814.0 121.1% 84.1% Additional beds open in the month; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit. 81.2% 139.7% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Support workers used to maintain staffing 1477.8 4.4 4.9 9.3 numbers. 95.2% 92.9% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Support workers used to maintain staffing 940.0 numbers. 61.4% 163.7% Staffing appropriate for number of patients; Staff moved to support other wards; Band 4 staff working to support registered nurse 1418.5 3.9 4.7 8.6 numbers. 687.4 100.3% 201.6% Staffing appropriate for number of patients; Staff moved to support other wards; Increased night staffing to support raised acuity. 1381.3 88.5% 98.8% 3.8 Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 4.0 7.8 801.3 96.9% 101.6% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 1119.0 781.0 1192.9 748.0 2645.5 1815.0 234.5 396.0 1594.5 1439.5 495.0 427.8 1668.0 1550.5 1435.5 1197.0 585.8 563.5 827.6 660.0 2307.9 1852.0 2242.3 1572.3 2170.0 1486.0 1033.7 915.5 82.6% 93.4% 79.9% 97.1% 100.1% 86.0% 94.4% 74.2% 87.0% 92.7% 75.5% 68.0% 94.4% 96.0% 69.0% 84.8% 78.3% 68.8% 121.1% 181.0% 81.6% 97.5% 87.9% 78.5% 82.2% 84.9% 92.8% 84.1% 97.3% 114.5% 92.8% 188.9% 98.9% 106.5% 60.5% 120.0% 154.7% 140.9% 124.5% 134.1% 82.0% 90.4% 125.6% 114.8% 97.6% 158.1% 263.9% 193.5% 119.2% 105.5% 112.1% 114.3% 121.1% 108.9% 84.9% 132.0% Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month. 4.1 4.8 8.9 Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Staffing appropriate for number of patients; Support workers used to maintain 5.8 4.7 10.6 staffing numbers. Additional staff used for enhanced care - Support workers; Skill mix swaps undertaken to support safe staffing across the Unit; Support workers used to maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to 3.1 5.7 8.7 maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month; Low bed numbers but staff on roster being used in neuro swabbing hub making it look like working on ward in 18.2 9.3 27.4 report. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 5.9 6.0 11.8 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 14.0 6.2 20.2 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to 5.8 5.9 11.8 maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 5.3 6.4 11.6 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Safe staffing levels maintained by sharing staff resource; Staff moved to support other wards; Skill mix swaps undertaken to support safe 5.2 3.6 8.8 staffing across the Unit. Safe staffing levels maintained by sharing staff resource; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit. Safe staffing levels maintained by sharing staff resource; This ward has a high number of admissions and acuity/dependency of patients 8.7 10.3 19.0 which means more Registered nurse and support workers are required. Safe staffing levels maintained by sharing staff resource; This ward has a high number of admissions and acuity/dependency of patients which means more Registered nurse and support workers are required. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 4.5 5.1 9.6 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 3.2 5.3 8.5 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 3.9 6.5 10.3 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 4.5 3.9 8.4 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Page 24 of 24 2.5.1 Access Targets: Cancer Trajectory Update for review 1 Access Targets: Cancer Trajectory Update Report to the Trust Board of Directors dated 29 September 2020 Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Response to the issue: Access Targets: Cancer Trajectory Update 2.5.1 Joe Teape, Chief Operating Officer 16 September 2020 Assurance Approval or reassurance Ratification Information Yes To provide an update to Trust Board on cancer performance following the last report that went to Trust Board in March 2020 and the impact of Covid19 on performance. The report provides an update on UHS cancer performance and covers the following; • Current performance against the key cancer metrics • Challenges faced during Covid-19 and impact on demand • Changes made in managing patients on a cancer pathway Implications: (Clinical, Organisational, Governance, Legal?) Clinical Organisational Governance and risk Risks: (Top 3) of carrying out the change / or not: The top 3 risks are: • Inability to meet required cancer standard targets • Inability to manage cancer patients during a Covid-19 pandemic • Risk of increase in cancer referrals of patients whose cancer may have spread so that the cancer will be harder to treat or no longer be curative Summary: Conclusion and/or recommendation The Trust Board is asked to consider the recent cancer performance and note the impact of COVID 19 has had on activity/demand and performance. The Board is asked to note whilst we have seen improvements in performance since April 2020 there remain significant risks to achievement and further work is being undertaken to develop mitigations & assess the impact of improving referral times from other organizations which impact on UHS. Page 1 of 7 1. Introduction/Background In March 2020 Trust Board was provided with an update on cancer performance and plans on acti
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2020/papers-sept-2020-held-in-closed-session-due-to-covid-19.pdf

Engaging for increased research participation - full report

Description: Engaging for increased research participation Public and healthcare professionals' perceptions For further information contact: Chris Stock Head of R&D communications
Url: /Media/Southampton-Clinical-Research/Marketresearch/Engaging-for-increased-research-participation-full-report-v2.pdf

Annual-report-201617

Description: ANNUAL REPORT AND ACCOUNTS 2016/17 incorporating the quality account 2016/17 Presented to Parliament pursuant to Schedule 7, paragraph 25
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2016171.pdf

Testing for gene variants in inherited breast, ovarian and prostate cancers - patient information

Description: Information about testing for gene variants in inherited breast, ovarian and prostate cancers.
Url: /Media/UHS-website-2019/Patientinformation/Genetics/Testing-for-gene-variants-in-inherited-breast-ovarian-and-prostate-cancers-1980-PIL.pdf

Papers Trust Board 28 March 2019

Description: Agenda Group Name: Date of Meeting: Venue: Time: Apologies to: Trust Board – Open Session 28 March 2019 Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH 9.00am Sue Diduch, Corporate Affairs Administrator 9.00 1. Chair’s Welcome, Apologies and Declarations of Interest 2. Minutes of Previous Meeting held on 28 February 2019 3. Matters Arising/Summary of Agreed Actions 9.15 9.30 9.35 9.40 9.45 10.30 10.40 10.50 4. Quality, Performance and Finance 4.1 Patient Story (Derek Sandeman, Medical Director) 4.2 Briefing from Chair of Audit & Risk Committee for review (Simon Porter, Chair, A&RC) 4.3 Briefing from Chair of Quality Committee for review (Mike Sadler, Chair, QC) 4.4 Briefing from Chair of Strategy & Finance Committee for review (Jane Bailey, Chair, S&FC) 4.5 Integrated Performance Report for Month 11 including Quarterly Patient Experience Report (QIF) for review 4.6 Informatics Update for review (Jane Hayward, Director of Transformation & Improvement/ Adrian Byrne, Director of Informatics) 4.7 2018 NHS National Staff Survey Results for review (Paula Head, Chief Executive/Steve Harris, Director of Human Resources) 4.8 Finance Report for Month 11 for review (David French, Chief Financial Officer) Oral Oral Oral Oral 11.00 5. Chair’s and Chief Executive’s Reports 5.1 Chief Executive’s Report for review and Chair’s Actions for ratification (Paula Head, Chief Executive/Peter Hollins, Trust Chair) 11.05 6. Corporate Governance, Risk and Internal Control 6.1 Feedback from Council of Governors’ Meeting 12 March Oral 2019 to note (Peter Hollins, Trust Chair) 11.15 7. Any other business 8. To note the date of the next meeting: Tuesday, 30 April 2019 in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH In Attendance: Adrian Byrne, Director of Informatics Steve Harris, Director of Human Resources Vicki Havercroft-Dixon, Head of Patient Relations (shadowing Gail Byrne) EXCLUSION OF PRESS, PUBLIC AND OTHERS The public and representatives of the press may attend all meetings of the Trust, but shall be required to withdraw upon the Board of Directors resolving as follows “that representatives of the press, and other members of the public, be excluded from the remainder of this meeting as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted” 11.30-11.45 Follow-up discussion with governors Items Circulated: The following items have been circulated to the Board since the last meeting. Executive directors are happy to take questions from individual members, before the meeting, by e-mail or telephone, or to meet separately to discuss in more detail. 25 February 2019 Press Release: Hospital first to offer all patients chance to manage healthcare online 7 March 2019 Press Release: Eight-week breastfeeding supplement prevents weight loss in premature babies after discharge 12 March 2019 Press Release: Leading doctor warns use of blood test to diagnose heart attacks is “flawed” 15 March 2019 Press Release: Healthcare scientists “hamstrung” by lack of awareness and investment Trust Board Minutes – Open Session Minutes of the Open Trust Board meeting held on Thursday 28 February 2019, in the Conference Room, Heartbeat Education Centre, North Wing, University Hospital Southampton, commencing at 0900 and concluding at 1100. Present: Mr P Hollins, Trust Chair Mrs P Head, Chief Executive Mr D French, Chief Financial Officer & Deputy Chief Executive Mrs G Byrne, Director of Nursing & Organisational Development Ms J Hayward, Director of Transformation & Improvement Dr C Marshall, Chief Operating Officer Dr D Sandeman, Medical Director Mr S Porter, Senior Independent Director/Deputy Chair Ms J Bailey, Non-Executive Director Prof C Cooper, Non-Executive Director Ms J Douglas-Todd, Non-Executive Director Ms C Mason, Non-Executive Director Dr M Sadler, Non-Executive Director PTH PHe DAF GB JH CM DS SP JB CC JD-T CMa MS In Attendance: Mr C Helps, Interim Associate Director Corporate Affairs CH Mr N Pearce, Associate Medical Director for Patient Safety NP Mr M Green, Head of Bereavement Care MG Ms V Boland, Corporate Affairs Manager (minutes) VB Ms S Herbert, DHN/P, Division A (shadowing Mrs G Byrne) SH 1 member of staff 2 governors 19/19 20/19 Apologies Apologies were received from Jenni Douglas-Todd, Non-Executive Director. Chair’s Welcome, Opening Comments and Declarations of Interest The Chair welcomed everyone to the meeting, specifically welcoming back VB. The chair congratulated CMa for her successful appointment as Chair at Solent NHS Trust. Action By There were no declarations of a conflict of interest with any items on the agenda. 21/19 Minutes of Previous Meeting (Agenda item 2) The minutes of the meeting held on 31 January 2019 were AGREED as an accurate record subject to amendments to: 6/19c) the last sentence of the second paragraph was deemed inaccurate and should state that the key performance indicator (KPI) for emergency readmissions be reviewed for next year. 6/19g) date of the major incident that occurred on 30th November 2018 to be provided in full. 22/19 22/19 a) Matters Arising/Summary of Agreed Actions (Agenda item 3) Minute Ref 143/18a) Complexity of Employee Relations Cases and Minute Ref 159/18a) Integrated Performance Report (specifically relating to Diabetes) – It was agreed that the Trust Board Study Session forward plan would be discussed during the closed Board session, to include these items. Page 1 of 6 22/19 b) Minute Ref 6/19j) Staffing – GB confirmed that a more detailed update in relation to the appraisal target would be included in the next Human Resources Report. 22/19 c) The Board noted the latest position on the actions in summary of actions. 23/19 Quality, Performance and Finance Patient Story (agenda item 4.1) DS introduced the patient to the Board. The Board heard a first-hand account of their experience of the Trust’s services. It was noted that the patient felt their experience fell short of their expectations and provided specific examples where the standard of care was disappointing. The patient reported a high standard of care from medical staff. The importance of listening to patients and responding appropriately, and ensuring patients basic needs as well as medical needs were met was emphasised. The Board thanked the patient for attending and providing an overview of their experience noting the value of this. It was confirmed that this information would be used to improve the care provided by UHS. 24/19 Integrated Performance Report for Month 10 including Quarterly Infection Prevention & Control Report (Agenda item 4.2) a) Safe GB advised that there was nothing specific to highlight from the report. There were no further comments or questions. 24/19 b) Caring GB provided an update noting the initiatives being introduced to improve the quality of response to patient complaints and concerns. A patient panel has now been introduced to assist in collecting and understanding patient feedback. It was confirmed that this would be discussed in more detail at the March Quality Committee. The decrease in the percentage of patients with a nutrition care plan was noted. GB will be working with the matrons and ward leaders for areas that are not achieving the expected standard. 24/19 c) Effective DS advised that there was nothing specific to highlight from the report. MS sought additional detail in relation to the four national reports with areas of concern within section E1.2. DS gave a brief overview of these reports noting that diabetes will be scheduled for discussion at a future Trust Board Study Session. 24/19 d) Activity CM highlighted the increase in Emergency Department (ED) attendances compared to the previous January, the significant reduction in non-elective length of stay and the reduction in the percentage of elective operations cancelled as a result of this. The increase in ED attendances was attributed to the opening of the Paediatric ED. An increase had been anticipated however data was being reviewed to confirm the cause as increased paediatric attendances. PHe emphasised the importance of ensuring that the increased attendances do not adversely affect the patient experience. MS congratulated those involved in reducing non-elective length of stay. Page 2 of 6 24/19 e) Emergency Access CM provided an overview noting that ED performance was the average of our local peer group despite the significant increase in attendances. The time to initial assessment metric is currently under development following the introduction of a new triage process within ED. JB drew attention to the continued reduction in eye casualty performance noting the difficulties already within Ophthalmology. CM confirmed that this was being addressed and more detail could be provided if required. PHe introduced the “Best March Ever” concept. CM provided an overview of the steps being taken to achieve this including working with community providers to reduce delayed transfers of care and patients referred to ED, for example, by GPs. PHe added that ED targets were being reviewed and new targets were expected. 24/19 f) Referral to Treatment Time (RTT) CM summarised RTT performance noting improvements in the number of patients waiting over 18 weeks and the number of patients on an incomplete pathway. Patients waiting longer than 52 weeks had been reviewed; patient choice was the reason for delay and there were no clinical concerns due to delayed treatment. 24/19 g) Cancer CM provided an overview of Cancer performance noting a number of measures had not been achieved. CM outlined a recent visit to the Imperial group of hospitals to learn about data analysis that enables better forward prediction and therefore providing more insightful information for the organisation/Board. MS noted the 6-8% increase in cancer activity year on year and suggested that the executive team consider a more a transformational change to address this to ensure this does not have an adverse effect on patients. JH emphasised the increased pressure on services due to identification of cancer at an earlier stage and new initiatives such as lung cancer screening. This would provide better outcomes for patients however would increase the number of patients being treated; this therefore needs to be planned for as part of the Trust’s strategy. PHe summarised the work that is ongoing with commissioners and the Cancer alliance to enable providers to achieve the cancer targets with the increased activity. It was agreed that further information be provided to the Board in relation to this. Action: Update in relation to planning for cancer targets to be provided to the PHe Board. GB noted that a process for reviewing harm as a result of patients waiting longer than 104 days for cancer treatment was being agreed with commissioners. CC queried whether there was any data providing a longer term perspective i.e. over the past five years. JH confirmed this could be made available if requested. 24/19 h) Infection Prevention Report GB provided an update noting that there would be a hand hygiene campaign in March/April 2019 which should have a direct impact on infection control. 24/19 i) Staffing GB summarised the challenges currently being experienced with nurse staffing particularly due to vacancy levels and the steps taken to address this on a daily basis. Page 3 of 6 24/19 j) RESOLVED That the Board NOTE the Month 10 Integrated Performance Report including the Quarterly Infection Prevention & Control Report. 25/19 Learning from Deaths Quarter 3 Report (Agenda item 4.3) a) DS and NP introduced the report. MS thanked NP for a clear report and the reassurance provided by the small number of avoidable cases. MS sought clarification of the personnel involved in reviewing cases and whether any audits were undertaken to ensure the process was working effectively. NP described the process in use. A new medical examiner service would commence in April. PTH queried whether the process identified the consequences for patients who had experienced repeated delays in treatment. NP advised that previous admissions were reviewed however a more formal process would be instigated once the medical examiner service was in place. CC asked whether there was potential for external validation and comparison of availability. NP has been working with other Trusts to ensure their processes mirror UHS’ to allow a comparison between organisations. JH informed the Board that the Hospital Standardised Mortality Ratio (HSMR) is expected to change from April once Countess Mountbatten Hospital becomes independent from the Trust. 25/19 b) RESOLVED That the Board NOTE the Learning from Deaths Quarter 3 Report. 26/19 Freedom to Speak Up Report (Agenda item 4.4) a) GB presented the report summarising the work undertaken and cases received to date. CC confirmed that all cases appeared to have been dealt with appropriately and had not required his involvement. CMa queried whether any trends had been identified so far. GB advised that some cases were protracted Human Resource cases where action had previously been slow. Learning points were being shared when possible, given the need for confidentiality, and this was encouraging others to speak out. 26/19 b) RESOLVED That the Board NOTE the Freedom to Speak Up Report. 27/19 CRN: Wessex 2018/19 Quarter 3 Performance Report (Agenda item 4.5) a) DS provided an overview of the report noting the good performance of the network. MS asked when the last review by the National Institute for Health Research (NIHR) had taken place and the outcome of this. DS confirmed that this took place 6 to 8 weeks ago and positive feedback had been received. MS asked that this information be included in future reports. Action: Future reports to include the outcome of NIHR reviews. DS 27/19 b) RESOLVED That the Board Page 4 of 6 28/19 Briefing from Chair of Strategy & Finance Committee (Agenda item 4.6) a) JB provided an overview of items discussed at the February meeting: • Outcome of 2017/18 reference cost index submission. • Review of latest financial position. • Operational plan 2019/20 update. 28/19 b) RESOLVED That the Board NOTE the update. 29/19 Finance Report for Month 10 (Agenda item 4.7) a) DAF presented the month 10 Finance report, noting for January: • The Trust delivered a control total surplus excluding Provider Sustainability Fund (PSF) of £2.8m. Year to date the Trust is on plan. • In month once non-recurrent items were excluded was break-even, against a Plan target of £2.8m surplus. • Under the single oversight framework the Trust delivered a score for Finance and Use of Resource of a ’1’. • Cost Improvement Plan (CIP) delivery in the month was £2.5m against a target of £2.8m. • Pay has increased by £1m since month 9 due to an increase in substantive, bank and agency costs month-on-month. A proportion related to December pay enhancements for bank holidays. PTH highlighted elective income as £2.9m behind plan year to date. This was attributed to gaps in spinal and cardiac surgery; these tend to be high value cases. PHe noted that whilst the Trust performed well against the NHS Improvement temporary staff pay ceiling, the total head count had increased. DAF confirmed that the data will be reviewed to better present the overall position. CMa asked whether the invest-to-save negative variance related to delays in the replacement of Princess Anne Hospital (PAH) windows. DAF advised that this related to delays in some estates projects such as PAH windows and theatre modernisation due to the requirement to close services to enable work to be undertaken. 29/19 b) RESOLVED That the Board NOTE the month 10 Finance Report. Chair’s and Chief Executive’s Reports 30/19 Chief Executive’s Report (Agenda item 5.1) a) PHe provided an overview of the requirement for the Trust to formally report progress with the flu vaccination programme and approve the achievement of 7 day services standards self-assessment. MS drew the Board’s attention to the percentage of staff concerned about possible side effects from the flu vaccine despite the evidence available to support that they are limited and manageable. PHe highlighted the importance of influencing perceptions of the vaccine and the need for the Trust to target its messages. DS plans to target messages by staff group. 30/19 b) RESOLVED That the Board NOTE the Staff Flu Vaccinations Update and APPROVE the Achievement of 7 day Services Standards Self-Assessment. Page 5 of 6 30/19 c) Items for Ratification Actions taken by the Chair as set out in paragraphs 3.1 – 3.2 were ratified. Strategy and Business Planning 31/19 Revised Equality, Diversity and Inclusion (EDI) Strategy (agenda item 6.1) a) GB presented the updated strategy which has been consulted upon and comments considered and included where appropriate. MS supported the amended strategy. CMa identified that the ‘white other’ group was classified differently within different sections of the strategy. Action: Ethnic group classifications to be consistent within the Strategy. GB The Board discussed the difference between reducing equality and reducing inequity and how this can be addressed alongside the wider health system. 31/19 b) RESOLVED That the Board APPROVE the Equality, Diversity and Inclusion Strategy subject to one minor amendment as outlined above. 32/19 32/19 a) Any Other Business MS provided an update on the recent Diabetes screening event held at the Southampton FC v Cardiff FC football match. 103 people were tested and 2 cases of undiagnosed diabetes identified. The event raised awareness as well as highlighted the value of co-operation between the organisations involved. PHe thanked those involved for their hard work in organising this event. 33/19 Date and Time of Next Meeting Thursday, 28 March 2019 commencing at 0900 in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH. Page 6 of 6 UHSFT – Directors’ Actions Summary for 28 March 2019 Trust Board – Open Session ___________________________________________________________________________________________________________________________________________ Action & Minute Reference By whom Target Date Current Status Trust Board 28 February 2019 Integrated Performance Report for Month 10 (Minute Ref 24/19 g) Cancer - Update in relation to planning for cancer targets to be PHe provided to the Board. CRN: Wessex 2018/19 Quarter 3 Performance Report (Minute Ref 27/19 a) Future reports to include the outcome of NIHR reviews. DS Revised Equality, Diversity and Inclusion (EDI) Strategy (Minute Ref 31/19 a) Ethnic group classifications to be consistent within the Strategy. GB as at 18/3/19 Page 1 of 1 Cover sheet for a report to the Trust Board of Directors dated Thursday, 28 March 2019 Title: Integrated Performance Report Month 11 Category Quality, Performance, and Finance Agenda item 4.5 Sponsor Director of Transformation and Improvement Author Trust Performance Manager Provenance Report to the Board provided by the Trust Executive. Purpose The paper is presented for the Board for Review The Board is requested to consider the performance metrics provided, identify any elements, trends or emerging themes it wishes to pursue further. Relevant to Board  Goal 1 – Trusted on  Goal 2 – Delivering for  Goal 3 – Excellence in goals Quality Taxpayers Healthcare Board Assurance This report relates to all of the aims and objectives contained in the Board Framework links Assurance Framework. Equality Impact Assessment The Trust aims to ensure that any change in performance does not affect one or more cohorts of people with specific protected characteristics. This equality monitoring is conducted operationally. Other standards affected NHS Provider Licence and Constitutional standards. Integrated KPI Board Report covering up to Feb 2019 Executive Sponsor - Jane Hayward, Director of Transformation Jane.Hayward@uhs.nhs.uk March 2019 Overview Safe Amber Caring Green Safe remains amber this month as UHS has failed some KPI's yet we have seen continued good performance in other areas. There were no never events reported in February. There were no avoidable high harm falls or MRSA infections/contaminants in February. C.Diff performance remains better than year to date target. In 18/19 the Trust planned to reduce pressure ulcers by 20% compared to last year, this trajectory has not be met in 18/19, however to date the number of pressure ulcers is very similar year on year. The themes are being collated and the learning is being shared through Pressure Ulcer Panel. VTE risk assessments remain an area of focus for the Trust with the new IT solution being piloted in AMU, Surgery and T&O in January 2019. A decision will be made in March by the Thrombosis committee to roll out trust wide. Complaints were low during November, December and January and increased slightly to levels seen previously in February. The rate of complaints against activity level remains consistent and within target range. Negative ratings through the FFT are under the trust threshold with patients continuing to rate their experience positively. Same Sex Accommodation breaches have fallen to under the trust target. Effective Green There were four national reports published and reviewed in Feburary, of these reports one raised an area of concern (National prostate Cancer Audit Annual Report 2018). There are now 218 outcomes being reported to TEC from 46 specialities. Of these the majority are green (78%) and only 7% graded red. Emergency readmissions was at 10.8% in December which is just below the average of last 2 years (11%). HSMR remained stable in November well below the national benchmark and crude mortality dropped slightly to 3.7% Activity Red Flow Amber New referrals recieved are following expected seasonal variation but continue to be higher than 18/19 in the month, quarter and year to date. New urgent cancer referrals in January did not decrease as seen last year instead are showing a 16% increase in the month. Main ED attendances remain exceptionally high in February compared to previous years. This is contrary to the normal seasonal trend which sees a reduction in the volume but not complexity of attendances, paediatric attendances have increased the most, but other streams also have increased compared to 17/18. There have been a number of changes year on year in services provided and how services are recorded that make year on year comparison difficult, this includes the Lymington surgical services and outpatients (up from August 17, impacts electives and outpatients), the change in TrehceoardveinrgagCeDnUucmhbaeirrso(df oDwelnayfreodmTrSaenpstfeemrsboefrC1a7r,eiminptahcetsTrounstnoinnFeelbercutiavreys)r,etmheairneecdoradti9n4g.oTfhtehenuremsbpeirraotofrpyacteiennttrsew(Ahporihla1v8e, dbaeyecnaisnehs otospoituatlpfaotriegnrtesa)t.er than or equal to 7 days / 21 days also increased yet remained lower than February 2018 by 2% and 4% respectively. Emergency Access Main ED (Type 1) performance reduced in February to 71.4%, compared to UHS February 2018 77.2%, and were 4.8% below the average of our local peer group. This performance was impacted by ED attendances significantly exceeding volumes in previous years and the onset of winter pressures in the inpatient service. Red RTT & Diagnostics Both RTT and diagnostic performance improved again in February. The trend of patients waiting greater than 52 weeks continues downwards and the patients waiting at the end of February have now been treated. Amber Diagnostic performance also improved and achieved the target in February. Pleasing to see Average weeks waited for first outpatient appointment continues to reduce. Cancer Red Cancer performance is currently rated red as we are not achieving a number of measures. Recovery of the Treatment started within 62 days of urgent GP referral wait, is likely to be slow and significant challenges are being experienced linked to significant growth in referrals and the number of additional cancers being treated (192 year to date). Improving trends in waiting times for initial appointment, waiting times for radiology and patients waiting for treatment are encouraging. Research & Dev Research and Development has been rated Amber this month. October recruitment benefitted from activity on a high recruiting meningitis prevention study. Whilst recruitment to this study has ended recruitment Amber projections to year end are satisfactory. Complexity (weighted) performance is also satisfactory with UHS ranked 2nd in the UK for a number of consecutive months. Staffing Amber Staffing remains amber overall because some key targets have been missed including those for turnover, non-medical appraisal completion, total nursing and registered nurse vacancy rates. However, UHS has seen improvements in the following: sickness absence (which has never been lower), turnover (the lowest rate since November 2017), decreases in total nursing and registered nurse vacancy rates and percentage of BME staff at Band 7+ (the highest rate it has been). CHPPD is within normal range this month as expected, after seasonal effects in January and it reflects high patient numbers. Estates Green Estates has been rated green this month as we are meeting all targets in February. The target missed on a 3 month rolling average is for percentage of help desk requests completed on time. Digital Green DigiRounds has demonstrated both time saving in reviewing the patient record during ward rounds, but also the quality of the review that is carried out, as clinicians are able to easily see all the significant elements of the record. It saves junior doctors time in preparing information for consultants (transcribing relevant results etc) prior to the ward round. Records accessed using Digirounds increased to 98,573 in February. Also in February the number of alerts sent using Medxnote increased again to 4079. 1 Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line Percentiles Control Chart Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). A line percentiles chart is used to represent the distribution of a variable. The 50th percentile shows the median value, we also show the 5th, 25th (lower quartile), 75th (upper quartile) and 95th centiles. A control chart shows movement of a variable in relation to it's control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from it's target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving it's target. 2 March 2019 Safe Safe remains amber this month as UHS has failed some KPI's yet we have seen continued good performance in other areas. There were no never events reported in February. There were no avoidable high harm falls or MRSA infections/contaminants in February. C.Diff performance remains better than year to Amber date target. In 18/19 the Trust planned to reduce pressure ulcers by 20% compared to last year, this trajectory has not be met in 18/19, however to date the number of pressure ulcers is very similar year on year. The themes are being collated and the learning is being shared through Pressure Ulcer Panel. VTE risk assessments remain an area of focus for the Trust with the new IT solution being piloted in AMU, Surgery and T&O in January 2019. A decision will be made in March by the Thrombosis committee to roll out trust wide. MMoonntthhllyy Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target YTD YTD Target S1.1 Never Events 1 1 1 - 3 0 1 S1.2 Avoidable High Harm Falls =95% 98% > =95% S1.12 % Thromboprophylaxis . Patients Assessed 95% 93.3% 92.8% > =95% 93% > =95% S1.12 - The IT solution within e prescribing was piloted from 24th January. This has demonstrated improvements in compliance particularly in AMU. This will be seen in April's report containing Feb data. There will be a discussion at thrombosis committee on 21st march about whether we can roll out the IT solution trust wide to increase compliance further. 100% S1.13 Patients appropriately . screened for sepsis 76% 76% 85% 98% 98% 60% 90% S1.14 Sepsis Patients Treated in a . timely manner 82% 77% 86% 82% 85% 60% 90% - - 90% - - 4 March 2019 Caring Green Complaints were low during November, December and January and increased slightly to levels seen previously in February. The rate of complaints against activity level remains consistent and within target range. Negative ratings through the FFT are under the trust threshold with patients continuing to rate their experience positively. Same Sex Accommodation breaches have fallen to under the trust target. C1.1 FFT response rate - Inpatients Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 27% 15% 9% Monthly Target > =20% 0% 0.9% C1.2 FFT Negative Score - Inpatients 5% 0.9% =20% 2.4% =95% 75% C1.6 Although we are maintaining above 90% we are still not reaching 95%. Therefore some focus work to drive this is being done with the ward areas that are consistently achieving below this requirement, as this is reflective of a small pocket of areas. C1.7 Total Complaints Received . 37 48 40 33 44 37 43 44 44 32 50 28 31 32 42 - C1.8 Complaints per 1000 units . 0.50 0.42 0.00 500 C1.9 Bereavement Survey Response Count 0 15% C1.10 Bereavement Survey Negative Score Core Questions - % 0% C1.9/C1.10 - Figures will be updated quarterly (next month) 0.42 =7days Census average 550 Extended LOS Census average 300 256 RF1.8 (Patients with LOS > =21days) 94 =30% 20.9% 66.2% > =80% 95.5% 90-95% 2 8 4 44 46 44 41 42 19 1 12 15 29 32 8 56 40 3 - 150 77 84 - 0 YTD 23.84% 63.17% - RF1.13 - currently undertaking investigation to understand cancelled operations figures 55 RF1.14 Last minute cancelled operations not 5 . readmitted within 28 days 0 2 - - RF1.15 % elective operations cancelled and not 5% 6.5% . readmitted within 28 days 2.4% 314445224641146 70% 100% 92.3% 94.9% RE1.2 Eye Casualty (Type 2) 90.4% - RE1.3 Lymington MIU (Type 3) 85% 100% 99.7% 99.4% 99.6% - 95% RE1.4 UHS Total 85% . . 70% 97% RE1.5 Local Delivery System . . 80% 82.1% 87.5% 90.0% 81.5% 77.9% > =90% 95.0% 83.3% 85.9% > =95% UHS Total (RE1.4) includes SGH all types and lymington. Local Delivery System (RE1.5) is UHS Total and Southampton Treatment Centre (RSH MIU). 14 March 2019 Emergency Access Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target R-3M RE1.6 % patients who left the department 5% 4.7% . before being seen UHS Total 6.8% =92% 80% 4700 4111 3993 RR1.2 Total patients waiting over 18 weeks (in . backlog) - 1700 7 RR1.3 . Patients waiting > 52 weeks for treatment 2 0 RR1.4 Total number of patients on an . incomplete pathway RR1.5 Patients on a surgical waiting List 36000 26000 6900 5900 7,700 RR1.6 Patients waiting for diagnostics RR1.7 . RR1.8 . 5,500 4% % of Patients waiting over 6 weeks for diagnostics 0% Average weeks waited for first outpatient 9.5 appointment 6.5 30978 6541 6651 3.65% 8.44 30037 31297 6701 - 7700 - 0.71% 93% 41 of 1513 90% RC1.2 . Breast symptoms referral seen in 2 weeks 69.1% 25.9% 50.7% => 93% 32 of 75 51% RC1.1 & RC1.2 - Performance has improved significantly in January and February following commencement of a new Consultant Radiologist in post in January. RC1.3 Treatment started within 62 days of . urgent GP referral 89.4% 79.9% 70.5% => 85% 71.4% 18 of 134.5 71% RC1.4 Treatment started within 62 days of . referral (Breast, Cervical & Bowel . Screening) 87.8% 72.0% RC1.4 - All 5 January breaches related to breast surgery RC1.5 62 Day - Consultant Upgrades 86.00% 54.2% => 90% 3 of 24 79% 79.17% 85.71% => 86% 0 of 3.5 86% 17 March 2019 Cancer Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Target no. patients to recover target QTD RC1.6 Treatment started within 31 days of . decision to treat 98.7% 94.9% 91.1% RC1.6 Half of the 41 breaches in January related to either Urology (mainly Prostate) or Breast Surgery => 96% 27 of 341 88% 87.98% Second or subsequent treatment (surgery) RC1.7 started within 31 days of decision to treat 89.5% 76.0% RC1.7 - Approximately 2/3 of the breached pathways in January were for skin surgery, and the remaining pathways were for prostate surgery => 94% 16 of 118 81% 80.51% Second or subsequent treatment (anti 100% RC1.8 cancer drugs) started within 31 days of decision to treat 95% 100% Second or subsequent treatment RC1.9 (radiotherapy) started within 31 days of decision to treat 95% 100.00% 100.00% 100.00% => 98% 0 of 172 100% 99.05% => 98% 0 of 211 99% RC1.10 104 day waits (treated in month) 16 16 16 11 18 20 17 23 26 17 - - - Principal reasons impacting RC1.10 are prostate surgery (same as RC1.3 & RC1.7), also late referrals of patients referred from other trusts and extended waits due to patient choice. 18 March 2019 Research and Development Amber Research and Development has been rated Amber this month. October recruitment benefitted from activity on a high recruiting meningitis prevention study. Whilst recruitment to this study has ended recruitment projections to year end are satisfactory. Complexity (weighted) performance is also satisfactory with UHS ranked 2nd in the UK for a number of consecutive months. CRN Recruitment WR1.1 Participants Recruited WR1.2 Weighted Recruitment WR1.3 Weighted National Ranking - All Studies WR1.4 Specialties Recruiting Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 3000 YTD YTD Target 1602 500 13,729 7,501 1,273 10842 1 1 1 1 2 2 3 4 4 4 5 6 57 1236 12073 14473 60396 60217 - Top 5 53 - tbc The number of research active UHS specialties has been introduced as a new metric this year in response to implementing the new research strategy and the aim for all specialties to be research active. Having identified whether a specialty is research active or not, we are now trying to understand levels of activity in relation to size of department for this to be more meaningful. BRC 200 WR1.5 Papers published in partnership with UOS 0 94 99 153 120 112 Number of BRC papers published are in line with expectations and more detailed analysis is informing the next BRC bid preparations. Activity/Staffing Balance £8,000 6531 WR1.6 Income per WTE £4,000 385 400 4878 - - 19 March 2019 Staffing Amber Staffing remains amber overall because some key targets have been missed including those for turnover, non-medical appraisal completion, total nursing and registered nurse vacancy rates. However, UHS has seen improvements in the following: sickness absence (which has never been lower), turnover (the lowest rate since November 2017), decreases in total nursing and registered nurse vacancy rates and percentage of BME staff at Band 7+ (the highest rate it has been). CHPPD is within normal range this month as expected, after seasonal effects in January and it reflects high patient numbers. WS1.1 HR - Turnover - Rolling 12-months Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Monthly Target 13.67% 13.17% 13.1% 13.0% 92% WS1.4 . Nursing Vacancies (Total Clinical Wards) 11% 13.04% =76% WS1.7 Statutory & Mandatory Training . Achieving Target - 5 5 7 6 7 7 7 7 7 7 8 9 8 8 8 9.5 7 7 5 6 5 5 5 5 5 5 4 3 4 4 4 WS1.8 Total nursing staff all inpatient areas - 8.4 . Care hours per patient day (CHPPD) 8.0 8.3 - WS1.8 The CHPPD for ward based areas in the Trust has decreased from last month to RN 3.7 (previously 3.8) HCA 3.3 (previously 3.3) overall 7.0 (previously 7.2). 6.0 WS1.9 Registered nursing staff all inpatient . areas - CHPPD 5.1 5.0 3.5 3.3 WS1.10 Unregistered nursing staff all inpatient . areas - CHPPD 2.5 5.1 - 3.2 - 9% WS1.11 Black & Minority Ethnic Band 7+ . Percentage 7.5% 7% WS1.11 UHS has a target of 15% Band 7+ BME staff by 2023. WS1.12 Quality of practice experience for doctors . in training (annual report with quarterly . qualitative updates) Minor Risk Minor Risk Minor Risk Minor Risk 8.3% - Minor Risk No risk 21 March 2019 Estates Green Estates has been rated green this month as we are meeting all targets in February. The target missed on a 3 month rolling average is for percentage of help desk requests completed on time. Reactive Maintenance Monthly Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target 2500 R-3M PE1.1 Number of defect work orders and 1300 2197 - - 2078 percentage completed on time 86.2% 86.7% > 85% 89.2% Preventative Maintenance 74.42% 200 PE1.2 Number of statutory maintenance jobs planned and percentage 50 69 - - 131 completed on time 98.6% 94.09% > 95% 98.3% 98.5% 600 308 PE1.3 Number of mandatory maintenance jobs planned and 250 percentage completed on time 98.8% 96.13% 419 - - 99.5% > 95% 99.5% PE1.4 Number of routine maintenance jobs planned and percentage completed on time 125 75 97.7% 92.29% 80 98.8% 88 - 100.0% > 85% 99.7% 2500 PE1.5 Number of Help desk requests and 1000 percentage completed on time 100% 85% Unresolved help desk requests PE1.6 Unresolved help desk requests PE1.7 (over 30 days old) 50% 1500 500 600 1000 200 0 1737 82.3% 1007 498 1640 - 86.6% > 85% 84.3% 569 =95% - - SD1.4 acknowledgment > =95% - - through eQUEST - rolling 3M 85% Release 29 of CHARTS goes live on 23rd January 2019. This includes enhancements to histopathology requesting from the Endoscopy Unit and should result in an increase in both requesting and acknowledgment - this will first appear in the April 2019 data extracts. SD1.5 digiRounds patient records accessed 200000 0 98573 eQuest Results Alerts Sent SD1.6 Decision support notifications (email alerts) 20,000 9345 0 5000 SD1.7 Medxnote 4079 0 SD1.8 InfoQlik (Daily) Activity 50 20.1 35.4 0 100 SD1.9 Sap BI (Daily) Activity 40.0 0 500 351 SD1.10 My Medical Record - UHS patient registrations 0 2,000 SD1.11 My Medical Record - UHS patient logins 968 0 23 March 2019 Changes and Corrections Page Staffing KPI WS1.11 KPI Name Type Black & Minority Ethnic Band 7+ Change - Display Percentage Detail Long term target added 24 • Improvements made to the processes for managing complaints have driven significantly better performance in the timeliness of responses. For January and February, the trust closed 82% of complaints within 35 working days, with an average response time of 30 working days. This is a significant improvement from Q3 where the trust closed just 42% of complaints in the timeframe, with an average response time of 38 working days. • The complaints quality improvement work continues to deliver benefits for patients. The trust has slightly increased the % of complaints being managed informally to 44% of the overall number received (compared to 42% this time last year). There is a plan to return to clearly distinguishing between the PALS function and formal complaints process, and this will likely improve this further and offer patients and families greater access to support in getting early resolution to their concerns. • Good progress is being made in improving how the trust supports patients and carers with disabilities through compliance with the Accessible Information Standard. A flag is now available in ECAMIS, which pulls through into other systems, to alert staff that a patient has information and / or communication support needs. There is also a Staffnet resource to guide staff in how to meet needs. The Experience of Care team are currently working on a number of projects to enable needs to be identified and recorded on the system, while project teams on E2 ward and Princess Anne Outpatients work on embedding and testing the processes and resources. • Patient feedback remains generally high, although with more local variation in FFT feedback scores. Response rates have declined generally, with a significant factor being survey fatigue experienced by both patients and staff. While the FFT remains mandatory, it is often too generic to gain a sense of local ownership. With a new survey contract, the FFT will be augmented with more locally-relevant questions to better empower staff to use feedback to identify improvements, and this sense of ownership will drive better staff engagement and improve responses. Low recommend scores in ED are due to extremely low response rates. • A review of the trust’s provision of interpreting services is underway, with the aim of ensuring that patient needs are being met effectively and that the trust is receiving value for money. Part of this work is looking at the variability of interpreting provision across the trust, identifying areas for piloting efficiency improvement projects. There is a lack of data on how the impact of poor provision of interpreters (as well as other communication support) affects attendance rates, involvement in care, and overall experience- and this review will look at capturing some of this information. • The number of people applying to volunteer increased in Q3 to 98 (from 57 in Q2). Overall for the year to date, the trust has had 242 applications with 115 of these starting and a number of applications still being processed. Retention of volunteers continues to be an issue, with too many new volunteers still leaving within the first 6 months. The team is reviewing its support and supervision processes, but with 824 active volunteers, it remains an ongoing challenge. • The trust successfully bid for funding from the Pears Foundation to develop and grow a youth volunteering programme. The funding will be for two years and will pay for a project worker to lead on collaboration with local schools and colleges to provide short to medium term placements for young volunteers (16-18). • The trust welcomed the first cohort of employee volunteers from the local NHS England team in March. NHSE staff are able to take up to five days each year in order to volunteer within their local community and the trust has agreed a pilot with NHSE to test out new volunteer roles with the group to assess feasibility and value. This includes getting qualitative feedback from patients and carers, a new role in AMU, and supporting the pharmacy team. 25 Complaints PALS Friends & Family Test Volunteers Indicator Complaints received Complex concerns received Complaints closed within 35 days Average working day to close PALS contacts Inpatient positive score Outpatient positive score Maternity positive score ED positive score Applications received New starters Target Q1 Q2 Q3 Q4* n/a 124 120 109 74 n/a 88 91 110 42 = > 66% 64% 59% 42% 82% 95% 97% 97% 96% 97% = > 95% 95% 96% 96% 93% = > 95% 99% 97% 90% NA = > 95% 94% 96% 85% 71% n/a 87 57 98 NA n/a 57 28 30 NA * Data is provisional and for the quarter to date. NA denotes data not yet available. Jan 32 24 81% 31 324 Feb 42 19 78% 30 275 26 Nursing and midwifery staffing hours - February 2019 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. WARD C4 (Solent ward) C4 (Solent ward) C6 C6 C6 (Teenage Cancer Trust unit) C6 (Teenage Cancer Trust unit) D2 D2 D3 D3 Surgical high dependency unit Surgical high dependency unit Registered nurses Total hours planned Registered nurses Total hours worked Unregistered staff Total hours planned Unregistered staff Total hours worked Registered nurses % Filled Day Night Day Night Day Night Day Night Day Night 1303.5 975.5 2572.1 1850.0 645.0 610.8 1196.0 943.0 1507.9 944.8 1230.8 910.8 2267.3 1740.5 661.3 513.0 1184.8 943.8 1325.9 932.4 915.0 644.0 174.5 0.0 332.2 0.0 1055.5 770.5 731.5 641.3 1281.3 829.0 209.5 99.5 166.2 79.0 1136.4 816.5 799.0 798.8 94.4% 93.4% 88.1% 94.1% 102.5% 84.0% 99.1% 100.1% 87.9% 98.7% Day Night 1962.1 1843.2 1865.4 1831.7 312.4 322.0 374.7 321.0 95.1% 99.4% Unregistered staff % Filled t Comments 140.0% Safe staffing levels maintained; Support workers used to maintain staffing numbers. 128.7% Safe staffing levels maintained; Support workers used to maintain staffing numbers. 120.1% Support workers used to maintain staffing numbers. Shift N/A Safe staffing levels maintained. 50.0% Safe staffing levels maintained; Staffing appropriate for number of patients. Shift N/A Staffing appropriate for number of patients; Staff moved to support other wards. 107.7% Safe staffing levels maintained. 106.0% 109.2% Safe staffing levels maintained. Safe staffing levels maintained. 124.6% Safe staffing levels maintained. 119.9% 99.7% Safe staffing levels maintained. Safe staffing levels maintained. Page 1 of 5 Cardiac intensive care unit Cardiac intensive care unit General intensive care unit A General intensive care unit A General intensive care unit B General intensive care unit B Neuro intensive care unit Neuro intensive care unit E5A E5A E5B E5B E8 E8 F11 F11 F6 F6 F5 F5 Acute medical unit Acute medical unit D5 D5 D6 D6 D7 D7 Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night 4911.3 4752.0 4116.4 3848.5 3657.1 3526.0 4334.7 3836.5 1151.2 645.0 1274.0 639.0 1961.3 961.0 1914.6 966.0 2016.5 966.5 1821.0 966.0 3826.1 3202.5 1621.6 972.6 1079.3 667.3 841.7 645.0 4309.8 3986.0 3757.0 3793.5 3438.1 3140.0 4218.1 3649.5 904.2 587.0 1117.0 622.5 1356.9 978.3 1236.9 814.0 1535.9 887.0 1172.9 828.0 3750.9 2871.3 1027.5 794.5 987.0 668.8 816.7 634.0 1123.8 794.3 890.5 644.0 507.8 322.0 694.3 587.0 615.4 322.0 727.5 322.0 1496.0 860.0 726.2 322.0 620.9 644.0 876.4 644.0 3032.7 1808.5 957.0 524.0 1451.7 690.5 949.3 300.0 607.8 472.5 722.9 453.5 373.6 274.5 510.0 545.0 707.0 472.5 724.0 398.2 1592.6 1208.4 629.6 587.5 962.5 736.5 1415.2 1068.0 3772.3 2468.3 1250.1 1077.0 1373.0 777.0 1030.3 323.0 87.8% 83.9% 91.3% 98.6% 94.0% 89.1% 97.3% 95.1% 78.5% 91.0% 87.7% 97.4% 69.2% 101.8% 64.6% 84.3% 76.2% 91.8% 64.4% 85.7% 98.0% 89.7% 63.4% 81.7% 91.5% 100.2% 97.0% 98.3% 54.1% 59.5% 81.2% 70.4% 73.6% 85.2% 73.5% 92.8% 114.9% 146.7% 99.5% 123.7% 106.5% 140.5% 86.7% 182.4% 155.0% 114.4% 161.5% 165.8% 124.4% 136.5% 130.6% 205.5% 94.6% 112.5% 108.5% 107.7% Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained;Additional staff used for enhanced care - Support workers. Support workers used to maintain staffing numbers; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Additional staff used for enhanced care - Support workers. Support workers used to maintain staffing numbers; Band 4 staff working to support registered nurse numbers. Safe s
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2019/Papers-Trust-Board-28-March-2019.pdf

UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2023/24 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2024 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 37 Directors’ report 38 Remuneration report 62 Staff report 75 Annual governance statement 95 Quality account 111 Statement on quality from the chief executive 112 Priorities for improvement and statements of assurance from the board 115 Other information 180 Annual accounts 207 Statement from the chief financial officer 208 Auditor’s report 210 Foreword to the accounts 217 Statement of Comprehensive Income 218 Statement of Financial Position 219 Statement of Changes in Taxpayers’ Equity 220 Statement of Cash Flows 221 Notes to the accounts 222 5 Welcome from the Chair and Chief Executive Officer This has been another busy and undoubtedly challenging year across the NHS and UK health and social care system, and much of what has impacted the national picture has been reflected in the operational focuses and patient and people priorities for University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) over the last year. Meeting and continuing to overcome the challenges we have faced has required an organisation-wide team effort, and looking back at the successes we feel incredibly proud of the achievements of our 13,000 staff. Particular highlights include: • In the top ten in the country (7th) against government targets for elective recovery performance with 118% of activity compared with 2019. • Top-quartile performance against most performance metrics compared to similar sized teaching hospitals, including Emergency Department access, long-waiting patients on Referral to Treatment pathways, Diagnostics and Cancer performance. • Significant investment in new capacity through building new wards and theatres and refurbishing existing areas of the hospital. • Delivery of our highest ever Cost Improvement Programme saving. These achievements place us among the best performing trusts in England in several areas and are even more remarkable against a backdrop of continued periods of industrial action and increasing demand for our services, with many people coming to us with higher levels of acuity than ever before. The Trust’s performance in terms of elective recovery places it as one of the best-performing trusts in England and demonstrates the impact of the Trust’s decision to invest in additional capacity in prior years by building new wards and theatres. The Trust’s Emergency Department performance in respect of its four-hour waiting target at the end of March 2024 has attracted additional capital funding as part of an incentive scheme. Some of this funding will be used to increase the department’s same-day emergency care capacity during 2024/25. From a financial perspective, balancing the complexities of today’s challenges alongside the need to protect and ensure the long-term stability and quality of our service provision, has required the Board to take a number of considered and crucial efficiency improvement actions this year. Whilst challenging, the Trust has seen significant progress in delivering on both its forecasted finance position for 2023/24 and productivity targets. Achieving long-term financial stability is key to us continuing to invest in much needed upgrades and improvements to the parts of our estate that are ageing, and to developing new state-of-the-art facilities and infrastructure that increases our capabilities and capacity into the future. In the last year parts of the hospital have been transformed, with the opening of new wards, theatres and a skybridge to link the estate. Construction of a sterile services and aseptics facility has begun at Adanac Park and the expansion of our neonatal department, where we treat and care for some of our most vulnerable babies and their families, is underway. The development of a new aseptic facility at Adanac Park will have capacity to serve other hospitals within the region and is a significant opportunity for improved system-wide working. 6 We have also worked with our people to design spaces where they can rest, relax and recharge - including a new wellbeing hub and rooftop garden on the Princess Anne Hospital site. In addition, 40 staff rooms across the site have been refurbished thanks to funding from Southampton Hospitals Charity. During the year, the Trust worked to establish the Southampton Hospitals Charity as a separate charitable company to improve its ability to both raise and spend funds. This process completed on 1 April 2024. Work was carried out to refurbish a children’s ward during the year in partnership with the charity. Our people are our greatest asset, and we are pleased to see improvements from the annual staff survey in several areas - such as how people can work more flexibly, access to learning and development and improved satisfaction in support from line managers. We recognise the pressures and demands that come with working in this environment and will continue to ensure everyone working here feels heard, encouraged and supported when raising concerns. At UHS, every opportunity is taken to recognise and celebrate the incredible things our people do here every day, including the return of our in-person annual awards ceremony, monthly staff recognition events and the first ever ‘We Are UHS Week’. These occasions are an important reminder that, even when faced with challenges, there is so much to be proud of and celebrate across the whole Trust. Working together, both within the Trust and across organisational boundaries, remains one of our core values. The partnership between UHS and the University of Southampton is as strong as it has ever been, with more than 250,000 individuals having now taken part in research studies in Southampton. As the lead partner member for Acute Hospital Services on the Hampshire and Isle of Wight Integrated Care Board, we are proactively working with other trusts and healthcare providers in the region to improve the health of the community we serve. In addition, the Trust has continued to work in partnership with other providers across the system to build a shared elective orthopaedic hub in Winchester. It is anticipated that the health and social care system will continue to be a challenging environment in 2024/25. We recognise that many of the big challenges we face can only be solved in partnership with wider local partners, and we are committed to actively playing our part in delivering system-wide solutions. Equally, we will continue to focus on improving whatever is within our internal control, and to work collaboratively with our people to ensure our patients’ experience, safety and outcomes remain central to our decision-making and the actions of everyone at UHS. Jenni Douglas-Todd Chair 19 July 2024 David French Chief Executive Officer 19 July 2024 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer As with 2022/23, this was another challenging year with continued increasing demand for the Trust’s resources and the need to balance this with the need to deliver quality patient care and at the same time maintain a sustainable financial position. Demand for non-elective care continued to increase with an average of 375 attendances per day to our main Emergency Department. In addition, the number of patients on the 18-week Referral to Treatment pathway rose to 58,000. Patients having no clinical criteria to reside in hospital, but unable to be discharged due to the lack of funded care in a more suitable location, posed and continues to pose a significant challenge for the Trust. The number of patients within this category was as high as 270 at times and was consistently higher throughout the year when compared to 2022/23. Despite this the Trust continued to perform well when compared to other comparable organisations, achieving some of the best Emergency Department and elective recovery fund performance in England. The Trust’s financial position continued to be difficult, which required some difficult decisions in respect of spending controls and controls on recruitment. The Trust focused in particular on controlling spending on temporary and agency staff, but in view of the overall workforce numbers compared to the 2023/24 plan, further controls were implemented in respect of substantive recruitment. Due to the additional controls and the Trust’s best delivery to date on its Cost Improvement Programme (£63.4m), the Trust achieved an end of year deficit of £4.5m, compared to the deficit of £26m anticipated in its 2023/24 plan. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1.3 billion in 2023/24. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to nearly four million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 155,000 inpatients and day patients, including about 70,000 emergency admissions sees over 750,000 people at outpatient appointments deals with around 150,000 cases in our emergency department The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 54% is paid for by NHS England and 43% by integrated care boards, predominantly the Hampshire and Isle of Wight Integrated Care Board (ICB). These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board. The ICP is a statutory committee jointly formed between the NHS integrated care board and all upper-tier local authorities that fall within the ICS area. The ICP brings together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Division B Division C Division D Surgery Critical Care Opthalmology Theatres and Anaesthetics Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values The Trust’s values describe how things are done at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. These values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything its staff had experienced during the COVID-19 pandemic and what had been learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. The Trust’s strategy is organised around five themes and for each of these it describes a number of ambitions UHS aims to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care. Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2023/24 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Increasing the number of reported Shared Decision-Making conversations. • Increasing the number of specialities reporting outcomes that matter to patients. • Rolling out the Patient Safety Incident Reporting Framework across the Trust. • Working with patients as partners to improve patient satisfaction. • Treating patients according to need but aiming for no patient to wait, other than through patient choice, more than 65 weeks for treatment. • Delivering national metrics for site set-up time to target for clinical research studies. • Improving the Trust’s position against peers. • Delivering year three of the Trust’s research and innovation investment plan. • Developing the five-year research and development strategy implementation plan and delivery of the first year. • Strengthening and broadening the partnership between the Trust and the University of Southampton. • Supporting delivery of the Trust’s workforce plan for 2023/24. • Reducing turnover and sickness absence rates. • Increasing overall participation in the NHS staff survey and maintaining overall staff engagement score. • Increasing the proportion of appraisals completed. • Delivering the first year objectives of the Inclusion and Belonging strategy. • Working in partnership with acute trusts to agree and implement the acute services strategy. • Producing and embedding an internal framework for network development. • Working with the local delivery system on vertical integration to reduce the number of patients without criteria to reside. • Working with system partners to open a surgical elective hub. • For the Trust to be seen as an ‘anchor institution’ in the local area. • Delivering the Trust’s financial plan for 2023/24. • Engaging the organisation in the challenge to manage demand so that capacity and demand are in equilibrium. • Delivery of the Always Improving strategy priorities. • Delivering the Trust’s capital programme in full. • Entering into a new energy performance contract and delivering the first year of the Public Sector Decarbonisation Scheme. Performance against these objectives was monitored and reported to the Trust’s Board on a quarterly basis. 14 At the end of 2023/24, the Trust had met the objectives set as follows: Corporate Ambition Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future Totals Number of Objectives 5 5 5 5 5 25 Achieved in full 4 3 2 3 2 14 Partially achieved 1 2 2 1 3 9 Not achieved 0 0 1 1 0 2 Particular areas to highlight where the Trust has achieved strong delivery during the year include: • Delivery of quality priorities in Shared Decision-Making and the roll out of the Patient Safety Incident Response Framework. • Achieving the Trust’s 65-week waiter glide path. • Successful delivery of a number of research and development priorities, including work with the University of Southampton. • Maintaining sickness absence and turnover well below the targets set at the beginning of the year, and successfully delivering the first year of the Trust’s Inclusion and Belonging strategy. • Delivery of the Trust’s full available capital budget and completion of the first year of the Trust’s decarbonisation scheme. 15 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2023/24 were that: • There would be a 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. • Due to the current challenges, the Trust fails to provide patients and their families or carers with a highquality experience of care and positive patient outcomes. • The Trust would 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. • The Trust does not take full advantage of its 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 its patients. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails 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. • The Trust does 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. • The Trust is 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 and digital strategies and in transformation initiatives. • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its 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. During 2023/24, the Trust saw continued increased demand for its services, particularly in the Emergency Department In addition, the number of patients having no clinical criteria to reside in hospital, but unable to be discharged due to a lack of appropriate care packages was higher than anticipated and spiked during winter, which significantly impacted patient flow through the hospital and required the Trust to engage additional temporary staff. The number of patients in this category peaked at 270 during the winter. There were particular challenges in respect of those patients with a primary mental health care need who would be better cared for in a more suitable alternative setting. 16 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The Trust continued to experience high demand for its services, especially in the Emergency Department, with average demand during the year being around 375 patients presenting per day in the main adult and children’s emergency department. In addition, the Trust experienced a significant impact on flow within the hospital due to a high number of patients having no clinical criteria to reside in hospital but unable to be discharged. This number was as high as 270 at times during winter: an increase of around 50 patients when compared to the prior year. The Trust also saw an increase in the number of referrals with the number of patients on a waiting list under the 18-week Referral to Treatment pathway rising from approximately 55,000 to 58,000 by the end of the year. In common with other trusts, the ongoing industrial action also impacted the Trust’s ability to provide urgent care and deliver on its elective recovery programme. Quality and compliance Despite the challenges, the Trust’s Emergency Department performance was one of the highest in England in March 2024, which resulted in additional capital funding being awarded. In addition, the Trust’s elective recovery performance was one of the best in England at 118% compared to 2019. The Trust continued to monitor the quality of care delivered throughout 2023/24 through a number of established quality assurance programmes. Clinical leaders monitored key quality, safety and patient experience indicators such as falls, pressure ulcers and venous thromboembolisms. Quality peer reviews were carried out, most significantly through Matron-led Quality Walkabouts every week in and out of hours focusing on the five key CQC questions – safe, effective, responsive, caring, and well-led. The Trust’s Clinical Accreditation Scheme builds on this intelligence, with clinical areas completing self-assessments of performance and review teams completing onsite visits. Patient representatives were included in these review teams. Learning was shared at the Clinical Leaders’ Group and via quarterly reports. The Trust was an active partner in a South-East accreditation network, offering advice and a steer to providers who are just setting up or looking to develop their own scheme, and extended that advice and support to other providers in England. 17 On 15 May 2023, the CQC inspected the maternity and midwifery service at Princess Anne Hospital as part of their national maternity inspection programme. The inspection report was published 11 August 2023, and the Trust retained its overall rating of ‘good’. This year UHS introduced its Fundamentals of Care (FOC) initiative. Whilst this is not a new concept, there were concerns that missed fundamental care had been amplified during the COVID- 19 pandemic. This initiative aims to empower and educate staff at all levels to ensure fundamental care is at the heart of what the Trust does. The Trust completed its transition to the Patient Safety Incident Response Framework (PSIRF) and collaborated with the ICB to develop a PSIRF plan and policy to underpin the change. The Trust implemented the requirements in respect of ‘Martha’s Rule’ where patients, relatives and carers have a legal right to a rapid review by a critical care outreach team during an acute deterioration episode in and out of hours. The Trust continued its focus on infection prevention and control, responding rapidly to rises in infection over the winter, and successfully flexing initiatives and innovations to achieve successful management in a responsive manner. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of further quality improvement projects. This included improvements across theatres, inpatient flow and outpatient programmes. During the year, average length of stay was reduced by 1.64%, day theatre cancellations were reduced by 200, and 42,350 patients were placed onto Patient Initiated Follow Up (PIFU) pathways. Further information can be found in the Quality Account. Partnerships The Trust works within the Hampshire and Isle of Wight Integrated Care System, and is an active member of a number of partner groups including the Acute Provider Collaborative Board and the Health and Wellbeing Board. The Trust develops and agrees its annual financial plans with the Integrated Care Board. The Trust is a member of a number of specific partnership groups for particular services, including the Central and South Genomics Medicine Service, the Children’s Hospital Alliance and the Southern Counties Pathology Network. The Trust works actively as a partner with other provider organisations around clinical networks, particularly with acute Trusts within the Integrated Care System and others closely located geographically. The Trust also links closely with the University of Southampton on a number of topics including research, commercial development and education and has a developed meeting structure to oversee this. 18 Workforce The Trust’s key areas of focus during 2023/24 were in respect of increasing the substantive workforce whilst also reducing reliance on bank and agency usage, and reducing staff turnover and sickness. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 331 whole-time equivalents above its plan for 2023/24. The Trust was successful in reducing staff turnover from 13.5% in 2022/23 to 11.4%, achieving the local target of . Cancer Waiting Times - 2 Week Wait Performance Cancer Waiting Times - 2 Week Wait Performance 100% 90% 80% 70% 60% 50% 40% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance % standard met The national target was for 96% of patients to commence treatment within 31 days of diagnosis. In March 2024, the Trust achieved 92% and performed in the range of 86%-94% throughout the year. The Trust has continued to make progress against the target for treatment of cancer within 62 days of an urgent GP referral, improving performance from 64% in April 2023 to 76% in March 2024 (NHS average: 69%). First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performanceUHS vs. NHSE average Cancer waiting times 31 day RTT performance UHS vs. NHSE average 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% Apr-23 May-23 Jun-2 3 Jul-2 3 Aug-23 Sep-2 3 Oct-23 Nov-2 3 Dec-23 Jan-24 Feb-2 4 Mar-24 Performance NHS Average 27 Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average % standard met 1 00% 80% 60% 40% 20% 0% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance NHS Average 28 Quality priorities Priorities for improvement 2023/24 Last year the Trust continued its ambition to deliver the highest quality care shaped by a range of national, regional, local, and Trust-wide factors. During the year the Trust continued to experience unprecedented demand on its services, with flow, capacity, infection prevention and safety all presenting challenges. However, the Trust was confident in its ability to keep a focus on its quality priorities, and its teams worked hard to achieve their goals even in these difficult circumstances. Priorities are aligned to the three core dimensions of quality: • Patient experience – how patients experience the care they receive. • Patient safety – keeping patients safe from harm. • Clinical effectiveness – how successful is the care provided? Out of the six priories set, the Trust achieved five and partially achieved one. Overview of success Quality Priority One Improving care for people with learning disabilities and autistic (LDA) people across the Trust. Supporting staff delivering this care. Outcome against goals: achieved Key achievements: • LDA working group reestablished. • Development of an improvement plan using the NHS Learning Disability Improvement standards. • The LDA team has moved to the virtual enhanced care group in Division B where operational and governance support, leadership, and peer support/learning opportunities has been strengthened. • Sensory Boxes have been introduced for all clinical areas, funded by the Hampshire and Isle of Wight (HIOW) Integrated care board (ICB). These boxes include noise cancelling headphones, fidget toys, communication books and visual cards to support patients and wards. • Recruited additional Learning Disability Champions. • Established links with the parent carer forum (PCF) for the local area and are now attending regular events. A representative from the PCF sits on the LDA working group. The LDA team are working with the Trust lead for patient experience to develop this aspect of the LDA workplan over the next year. Quality Priority Two Supporting patients, service users and staff to overcome their tobacco dependence via a smoking cessation programme. Outcome against goals: achieved Key achievements: • Package of support available to patients who may be smokers and who need to be supported not to smoke during their treatment. • Fully trained team of tobacco advisors working in the hospital and an advisor working in the outpatient setting supporting the patients once they have returned home. • Devised the IT changes the Trust would like to implement to improve its service and referral process. • Recruited 30 smoke-free champions. • Successfully supported 1,131 patients with a self-confirmed quit rate of 45.6% at 28 days. • Supported 109 outpatients who have successfully achieved a 60% quit rate. • On track to achieve the goal to go smoke-free by April 2024 including the removal of smoking shelters. 29 Quality Priority Three Ensure carers are fully supported, involved, and valued across all our services by developing the carers support service across the Trust in partnership with Southampton Hospitals. Outcome against goals: partially achieved Key achievements: • Carers now have a more comprehensive package of concessions and vouchers to help support their cared-for person (e.g. free parking available onsite for blue badge owners is now available). • Listening events were held to put patients at the centre of transforming the way we deliver care is delivered, enabling their voices to improve the quality of care and outcomes for all. • Developed joint working with local partners (e.g. Children’s Society and No Limits to support young carers). Not yet achieved: • The ‘pathway to support, has not yet been developed. Work is ongoing to develop a new strategy. • A charity-funded carers’ support worker has not yet been appointed. • The carers’ training package has not yet been relaunched. Quality Priority Four Put patients at the centre of transforming the way care is delivered, enabling their voices to improve the quality of care and outcomes for all. Outcome against goals: achieved Key achievements: • Work has continued to work across corporate and divisional services to embed patients and carers into quality and service improvement, creating new patient groups (e.g. Mesh Support Group). • Successfully developed our engagement with various local communities, working to ensure that a range of care experiences are considered ( e.g. there is now a Gypsy, Roma, and Irish Traveller community health liaison officer to ensure that these communities are engaged with and brought into work to improve the inclusivity of our services). • Attending multiple public engagement opportunities (Young Carers’ Festival, Mela, University Freshers’ Fayres, Carers’ Listening Lunch, Hoglands Park Play Day, visits to local temples and ‘Love Where You Live’). • Youth and Young Adult Ambassador involvement has increased, including attendance toat meetings of the Council of Governors, and supporting hospital projects. • A Celebration of Carers Week and Volunteers Week were run. • The Trust has analysed its reported outcome measures to identify health inequalities in its services. This information has been used to set a new quality priority for 2024/25. • An SMS friends and family test text survey has been introduced to improve the response rate on patient feedback from the Emergency Department. In the first three months following the survey launch, responses increased from 24 to 424. 30 Quality Priority Five To develop the Trust’s clinical effectiveness process, connecting to the Trust’s Always Improving approach to measuring, understanding, and using outcomes to improve patient care. Outcome against goals: achieved Key achievements: • The Trust has developed its clinical effectiveness process across the Trust with involvement of informatics, governance and management teams, clinical effectiveness leads as well as reporting committees. • Patient representation onhas been included in the clinical assurance meeting for effectiveness and outcomes (CAMEO) to ensure conversations focus on what matters to patients. • The CAMEO template has been changed to focus discussions on areas the specialty is proud of (strong or improving outcomes), areas for improvement (poorly benchmarked or worsening outcomes) and planned actions. • The Trust encourages the use of run and/or statistical process control charts along with benchmarking where available. • Details of NICE and quality standards and national and regional reviews are included to cover breadth of clinical effectiveness. • How the clinical effectiveness team works has been reorganised, aligning each of them to each division giving a named link which helps to deepen understanding and improve links with governance and improvement activities locally. • Working with informatics to establish a core set of clinical outcome measures which are meaningful to patients, which can be reported centrally (starting with surgical specialities). • Starting to develop an education strategy and platform to support staff with a number of tools used in clinical effectiveness as well as clarity on where and how to record and evidence audit and service improvement. • A revised strategy has been drafted. Quality Priority Six Developing a culture where all clinical staff have a basic knowledge of diabetes. Outcome against goals: achieved Key achievements: • Launch of the ‘Start with the Diabasics’ Initiative, designed to help give diabetes visibility across UHS. • Delivered an extensive education programme to clinical staff across the professions and bands, including the introduction of some e-learning and a Diabasics introductory video has been shown at all trust staff inductions since July 2023. • Supported the development of 45 diabetes link nurses, resulting in all ward areas now having a named diabetes link nurse. • Improved triage for referrals. • Established processes for ‘lessons learned’. • Developed IT solutions to improvingimprove alerts and guidance. • A ‘Ketone Wednesdays’ initiative has been created in response to overuse of blood ketone testing (estimated waste cost of £100,000 per year). • The Trust’s lead diabetes specialist nurse and the Diabasics Initiative were both shortlisted for National Quality in the Care Diabetes Awards (October 2023). • The Diabasics Initiative was mentioned as a case study on the Diabetes UK charity website as an example of good practice that could be reproduced elsewhere. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2024/25, in the Trust’s Quality Account for 2023/24. 31 Financial performance The Trust delivered a deficit of £4.5m from a revenue position of over £1.3bn, following receipt of £24.6m one-off cash support from NHS England. UHS started the year with an underlying deficit as a result of a number of cost pressures, notably demand for services being above block contract levels and the cost of national pay awards being above funded levels. The Trust has also continued to face a number of pressures, including high numbers of patients who no longer meet the criteria to reside in the hospital, and high demand for patients with a primary mental health need. In 2023/24, the Trust delivered a record savings level of £63.4m (5%) across a range of programmes. Trust operating income rose by £107m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Trust operating expenses rose by £89m, incorporating funded inflationary costs as well as costs relating to the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investment of over £75m, including investment in new wards, theatres, decarbonisation, digital infrastructure, neonatal expansion and backlog maintenance. Trust cash and cash equivalents finished the year at £79m, a reduction of £24m from the previous year due to the operating loss and capital investment outlined above. Whilst liquidity remained strong in 2023/24 supported by NHS England cash support, the underlying financial deficit means it is likely to decline further in 2024/25. The Trust is continuing to monitor its cash position closely and is considering whether additional cash support may be required in 2024/25. Sustainability The Trust recognises that everyone has a part to play in responding to the climate crisis. In March 2022, the Trust agreed its own green plan in response to the challenge of the NHS becoming the world’s first health service to reach carbon net zero. Now in its third year, the plan identifies the Trust’s key areas of focus and its ambitions and has seen progress across all areas of the plan. The plan sets out the scale of the challenge, the Trust’s commitment to reducing the impact on the environment and the steps to be taken across the following categories: • Estates and facilities • Clinical and medicines • Digital transformation • Supply chain and procurement • Travel and transport • Waste and resources • Food and nutrition • Adaptation • Biodiversity • Wider sustainability The Trust continues to progress through its green plan and has completed the ‘Greener NHS’ reporting tool for several quarters, which has demonstrated good progress. In addition, the Trust is planning to launch its ‘Our Sustainable UHS’ app for staff, which will give tips on sustainability and create personalised travel plans, including identifying potential contacts for car sharing. In addition, the Trust is considering proposals to implement additional solar power, smart metering and expanding the use of LED lighting. 32 In 2022/23, the Trust was successful in bidding for £29.4m of funding through the Public Sector DeCarbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. During the year the Trust successfully bid for £823k in National Energy Efficiency Funding which has been used to upgrade the lighting at Princess Anne Hospital. Social, community, anti-bribery and human rights issues The Trust recognises its responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK). These rights include: • right to life • right not to be subjected to inhuman or degrading treatment or punishment • right to liberty and freedom • right to respect for privacy and family life. These are reflected in the duty, set out in the NHS Constitution, to each and every individual that the NHS serves, to respect their human rights and the individual’s right to be treated with dignity and respect. The Trust is committed to ensuring it fully takes into account all aspects of human rights in its work. An equality impact assessment is completed for each Trust policy. For patients, the Trust’s safeguarding policies protect and support the right to live in safety, free from abuse and neglect and other policies and standards are designed to optimise privacy and dignity in all aspects of patient care. Feedback from patients and the review of complaints, concerns, claims, incidents and audit help to monitor how the Trust is achieving these objectives. The Trust’s green plan, approved by the board of directors in March 2022, recognises the Trust’s broader role and responsibility to address the issues of climate change, air pollution, waste and environmental decline present to the city of Southampton and the impact that these issues have on the health and wellbeing of the local population served. Although the Modern Slavery Act 2015 does not apply to the Trust, its green plan sets out an ambition to stop modern slavery. The Trust is also committed to maintaining an honest and open culture within the Trust; ensuring all concerns involving potential fraud, bribery and corruption are identified and rigorously investigated. The Trust has a Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Raising Concerns (Whistleblowing) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. Anti-bribery is part of the Trust’s work to counter fraud. This work is overseen by the Audit and Risk Committee, which receives regular reports from the local counter fraud specialist on the effectiveness of these policies through its monitoring and reviews, providing recommendations for improvement, as well as an annual report from the freedom to speak up guardian. You can read more about the work of the Audit and Risk Committee and the Trust’s approach to counter fraud in the Accountability Report. Events since the end of the financial year There have been no important events since the end of the financial year affecting the Trust. Overseas operations The Trust does not have any overseas operations. 33 Equality in service delivery NHS trusts have an essential role in tackling health inequalities, both as part of the services they provide, but also through work with the wider system. By working with those in integrated care systems, local authorities and third sector organisations, the Trust can have a significant impact on the health of the local population. The national focus on health inequalities is growing. This comes with new legal duties around reporting information and expectations to report on improvement programmes. In September 2023, a health inequalities steering group was initiated, under the leadership of the Chief Medical Officer, with representation from clinical, operational, transformation, patient experience, research, organisational development and culture, informatics, public health and the Integrated Care Board. The group focused on scoping future priorities aligned to national guidelines, contractual obligations and priorities, regional priorities, feedback from clinical teams and patients, understanding where action is already being taken, and what the data is showing. Overall, the group
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