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Annual-report-24-25-final

Description: 2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-24-25-final.pdf

Annual-report-and-quality-account-2019-20

Description: ANNUAL REPORT AND ACCOUNTS 2019/20 Incorporating the quality account 2019/20 Page 2 University Hospital Southampton NHS Foundation Trust Annual
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-and-quality-account-2019-202.pdf

Annual report 2021-2022

Description: 2021/22 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2021/22 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2022 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 36 Directors’ report 37 Remuneration report 59 Staff report 72 Annual governance statement 94 Quality report 105 Statement on quality from the chief executive 106 Priorities for improvement and statements of assurance from the board 109 Other information 182 Annual accounts 210 Statement from the chief financial officer 211 Auditor’s report 212 Auditor’s report including audit certificate 218 Foreword to the accounts 220 Statement of Comprehensive Income 221 Statement of Financial Position 222 Statement of Changes in Taxpayers’ Equity 223 Statement of Cash Flows 224 Notes to the accounts 225 5 Welcome from our chair and chief executive As we emerged from the most severe phase of the COVID-19 pandemic, 2021/22 was another challenging year for everyone at University Hospital Southampton NHS Foundation Trust (UHS). It was also a year on which we can look back with pride at what we achieved together in unprecedented circumstances. Amongst many notable achievements over the past twelve months, we have: • Led on globally ground-breaking research trials to inform the country’s COVID-19 vaccine booster strategy, including the world’s first COVID-19 vaccine booster study of mixed schedules. • Successfully managed infection prevention and control, putting us amongst the best in the country for minimising nosocomial spread. This was against a backdrop of, at times, R-rates in our local community that were amongst the highest in the country. • Published new strategies for digital and sustainability, which respectively set out how we are revolutionising our technical capability to meet changing patient needs and responding to the growing threat posed by climate change as part of the NHS-wide commitment to reaching carbon net zero by 2045. The pandemic also highlighted the vital importance of our staff’s wellbeing so we could continue to meet the needs of the most vulnerable and sick within our community and beyond. In response, we launched and have sustained a comprehensive programme of support to help our staff recognise and address the physical and emotional burden of the last two years. In financial terms, the Trust achieved its forecast breakeven position in 2021/22 on a turnover of £1.15 billion. Our strong, long-term financial performance meant we could continue investing in the capacity and condition of our estate. During the last year we have welcomed patients into our new ophthalmology outpatients area, expanded the majors area of our emergency department, built Hamwic House for treating cancer patients and opened four new operating theatres. Our ambition remains to increase capacity and improve facilities so that we can meet rising demand for our services, treating more people in improved settings than ever before. The momentum we are building is informed and driven by our five-year strategic plan, which describes our collective ambitions on our journey to becoming a world-class organisation. Our successes over the last twelve months were set against a backdrop of exceptional pressure on our services, unlike anything we have seen before. Like most hospital trusts, the lifting of COVID-19 restrictions in the wider community saw significant increases in attendances at our emergency department and increased referrals for treatments including surgery and cancer care. Everyone at UHS is working hard to restore services and bring waiting times down, although there are headwinds impacting our elective recovery. As we write this report, we have more than 200 patients in the hospital who no longer need our care but are waiting for discharge, either to a care home or to their own home with domiciliary care packages. Like many sectors, our local authority partners are struggling to buy or directly provide the capacity that is needed due primarily to workforce shortages. On occasion, the number of patients stranded in our hospitals means we have had to cancel scheduled surgery patients due to a lack of beds. Despite this, we are making good progress on recovering our elective performance, for example the number of elective surgery procedures in May 2022 was over 8% higher than in May 2019, prior to the COVID-19 pandemic. 6 Looking back over the year, our achievements would not have been possible without every single one of our 13,000 staff, who have gone above and beyond to put patients first. As a Trust Board we recognise that our people are our greatest asset. The results of this year’s NHS annual staff survey are encouraging, with the percentage of staff recommending UHS as a place to work being the sixth highest across all NHS trusts in England. However, we know we can do even better and our new people strategy will help us achieve this by introducing programmes which enable our people to thrive, excel and belong in a diverse and inclusive environment. We ended the year by saying farewell to Peter Hollins, who completed his second and final term as chair on 31 March 2022. In the six years of his leadership, the Trust has undergone a huge transformation to the benefit of both patients and staff. Peter has been a trusted and respected colleague whose outstanding leadership has set UHS on course to be a world-class organisation with world-class people delivering worldclass care. We welcome the formation of the Hampshire and Isle of Wight integrated care system on 1 July 2022, which will facilitate increased integration and collaboration across health and social care partners. We look forward to continuing strong relationships with all our partners as we work to develop an NHS of which all the communities we serve can be proud. Jane Bailey Interim Chair June 2022 David French Chief Executive Officer June 2022 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive 2021/22 is the second year that the ways in which the Trust has worked, and the performance it has achieved, have been strongly influenced the COVID-19 pandemic. Our circumstances varied significantly through the year, however, by March 2022: • COVID-19 related restrictions had been removed across the wider community, but remained necessary within healthcare settings; • a combination of partial immunity and improved treatments had reduced the numbers of patients experiencing the most severe symptoms of COVID-19, but the total numbers of people being infected remained very high; and • the numbers of patients attending, or being referred to, healthcare services for other conditions had returned to pre-pandemic levels or higher. Our challenges and priorities have varied through the year in a similar manner, and have included: • providing sufficient urgent care capacity for patients with COVID-19 alongside those with other illnesses or injuries; • running our services with significantly increased levels of COVID-19 related absence amongst our staff, as infection rates have increased in the wider community; and • increasing the numbers of elective treatments provided, back to pre-pandemic levels and higher, to start to reduce patient waiting times and reverse the increases in waiting list sizes caused by COVID-19. Our performance this year has often been impacted by the adversity of the circumstances. We have not always been able to achieve the targets established prior to the pandemic, nor to deliver the standard of service that we would aspire to for our patients. The Trust is proud to have performed well in comparison to other hospital trusts across many performance measures, however, I would like to thank our patients for their understanding and patience, and all our staff for their resilience, commitment and dedication to care for patients and their colleagues. As we begin to emerge from the pandemic, and consider the year ahead, we look forward to working with patients, hospital colleagues, and partners across health and social care to: • continue the recovery from the impacts of the COVID-19 pandemic; • improve our performance against key measures, continuing to perform well in comparison with other hospitals and moving closer to the national targets; and • continue to adapt and improve services such that the outcomes and results achieved for patients will be better than ever before. 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 billion in 2021/22. 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 more than 3.7 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 in the top ten nationally for research study volumes as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver more than 100 outpatient clinics across the south of England, keeping services local for patients 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 offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The NHS patient services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Just under half of the Trust’s NHS patient services are paid for by CCGs and just over half are paid for by NHS England. We provide these 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 Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D 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 11 Trust Headquarters Division Always Improving Central Operations Clinical Outcomes Commercial Development Communications Contracting Corporate Affairs Data and Analytics Education and Workforce Estates, Facilities and Capital Development Finance Health and Safety Human Resources Informatics Medical Examinerss Service Occupational Health Organisational Development Quality Patient Safety Planning and Productivity Procurement and Supply Research and Development Safeguarding Strategy and Partnerships The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. Our values Our values describe how we do things 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. Our 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 our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to continue on its journey to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim 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 tax payer 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 2021/22 these objectives included: • Recovery restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Implementing the ‘Always Improving’ strategy • Delivering the first year of the research and investment plan • Restoring a full research portfolio and preparing for future growth • Delivering joint research and innovation infrastructure with UoS and Wessex partners • Increasing our people capacity (recruitment, retention, education) • Great place to work including focus on wellbeing • Building an inclusive and compassionate culture • Working in partnership with the integrated care system and primary care networks • Integrated networks and collaboration • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS. Performance against these objectives will be monitored and reported to the Trust’s board of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors 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 2021/22 were that: • It would have insufficient capacity to respond to emergency demand, reduce waiting lists for planned activity and provide diagnostics results in avoidable harm to patients • It would not be able to provide service users with a safe, high quality experience of care and positive patient outcomes • It 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 • It would not secure the required ongoing investment to support our pioneering research and innovation, driving clinical services of the future 14 • It would not realise the full benefits of being a University teaching hospital through working with regional partners to accelerate research, innovation and adoption; increasing the number of studies initiated and the patients recruited to participate in these studies and the delivery of new treatments and treatments that would not otherwise be available to patients • It would not be able to increase the UHS workforce to meet current and planned service requirements through recruitment to vacancies and maintaining annual staff turnover below 12% and develop a longerterm workforce plan linked to the delivery of the Trust’s corporate strategy • It would not develop a diverse, compassionate and inclusive workforce, providing a more positive staff experience for all staff • It would not create a sustainable and innovative education and development response to meet the current and future workforce needs • It would not implement effective models to deliver integrated and networked care, resulting in suboptimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • It would be unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (CDEL). • It would not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. • It would fail to introduce and implement new technology and expand the use of existing technology to transform our delivery of care through the funding and delivery of the digital strategy. • It would fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, have added to the risks facing the Trust. This risk has continued into 2021/22 and has been coupled with increases in referrals for cancer and increased attendances to our emergency department and non-elective activity. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52, 78 and 104 weeks has increased significantly. While there was a significant reduction in the number of patients waiting over 104 weeks in 2021/22, with the Trust expecting that no patients will be waiting more than 104 weeks by July 2022, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by future waves of the COVID-19, a continuation of the sustained demand for urgent non-elective activity and an ongoing number of referrals, often requiring more complex treatment due to delays in people visiting their GPs for the first time and presenting with more advanced disease. The Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk and continues to make use of independent capacity for cardiac surgery. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2021/22 (described in the Estates section below), the Trust also committed expenditure in 2021/22 to open further wards and operating theatres during 2022/23 and 2023/24. These initiatives will contribute to further improvements in elective waiting times in coming years. 15 Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2021/22. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of an award-winning COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). While the Trust continued to perform well overall, the Trust exceeded its annual threshold for Clostridium difficile infections and there was one MRSA bacteraemia during March 2022, the only such event in 2021/22. The Trust continued to develop its proactive patient safety culture during 2021/22 with changes to the way in which patient safety incidents are investigated and the launch of its Always Improving strategy and transformation initiatives in theatre efficiency, patient flow and outpatients. Reporting and investigation of incidents continued during 2021/22. The Trust continues to prepare for the implementation of the new patient safety incident response framework in June 2022/23. Partnerships – During 2021/22, the Trust and its partners continued to work together to discharge patients safely, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop the regional COVID-19 saliva testing programme for local schools, hospitals and other employers. The new arrangements for integrated care systems will be implemented in July 2022. This is expected to reinvigorate work with partners at a system, place and provider level in Hampshire and Isle of Wight. The Trust is already part of an acute provider collaborative with other acute trusts in Hampshire and the Isle of Wight and is progressing a number of projects including the development of an elective hub at Winchester Hospital, diagnostics, pathology, endoscopy and imaging networks. The Trust also continued to progress research activity and opportunities with the University of Southampton and Wessex health partners. Workforce – The Trust continued to recruit nurses from overseas and through targeted recruitment campaigns during 2021/22 meaning that the number of nursing vacancies has remained relatively stable. Vacancies in other areas have increased reflecting a more competitive job market, particularly for lower band roles. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. Staff turnover remained above the 12% target during 2021/22 and retention is a key element of the people strategy. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2021/22 we have also focused on supporting our staff to respond to the COVID-19 pandemic and operational pressures by providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2021/22 including opening a new ophthalmology outpatient area, expansion of the majors area of the emergency department and four new operating theatres. These were part of £65 million of capital expenditure in 2021/22 that also included equipment, digital and the backlog maintenance programme. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these in part three of the quality account. The board of directors has also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. 16 The Trust and its partners also been successful in securing external funding including one of only four successful NHSX awards to test the concept of federated trusted research environments with its Wessex health partners and core funding of £10.5 million for the National Institute for Health and Care Research (NIHR) Southampton Clinical Research Facility (CRF) for the period between September 2022 and August 2027. Sustainable financial model –The Trust achieved its forecast breakeven position in 2021/22. Income was more predictable in 2021/22 as block contract arrangements remained in place in response to the COVID-19 pandemic and ensured that costs were covered, however, funding from the elective recovery fund, particularly, in the first half of 2021/22 introduced a degree of income volatility as did changes to the framework for the elective recovery fund half way through the year. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. The financial outlook across the NHS looks extremely challenging going into 2022/23 due to the reductions in non-recurrent funding and efficiency targets. The Trust currently has an underlying deficit, with pressures on energy prices and drugs cost growth within block contract arrangements, which had been supported with non-recurrent funding in previous years. While specific funding has been provided to address inflationary pressures there is a risk that inflation could exceed this funding and raw material and supply shortages could also impact on costs. Performance overview The Trust monitors a very wide range of key performance indicators within its departments, divisions, directorates and executive committee. Assurance for our board of directors and executive committee includes an integrated performance report which is reviewed monthly and contains a variety of indicators intended to provide assurance regarding implementation of our strategy and that the care we provide is safe, caring, effective, responsive and wellled. The integrated performance report also includes a monthly ‘spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, any performance concerns and requests from the board of directors. Assurance for our council of governors includes a quarterly Chief executive’s performance report, which includes a range of non-financial and financial performance information. 17 Performance analysis COVID-19 Impacts In 2021/22, the most prominent impacts of COVID-19 have been in relation to occupancy of inpatient beds by patients with a COVID-19 diagnosis and increased levels of staff sickness absence associated with COVID-19, in addition to normal levels of absence due to other causes. The impact of COVID-19 has varied significantly through the year, linked primarily to the prevalence of the disease within the wider community. In comparison to 2020/21: • bed occupancy (all types) did not reach the same exceptional peaks, however, it exceeded 50 patients between August 2021 and March 2022 and reached an average of 83 in March 2022; • the number of patients requiring treatment in intensive care and high care were much reduced, though still significant; • fewer patients were admitted requiring hospital treatment for COVID-19 alone, and greater numbers were admitted requiring treatment for other medical conditions who were also infected with COVID-19 at the same time; • staff sickness absence levels were typically higher, particularly in the second half of the year when national restrictions had been removed and COVID-19 infections in the community increased – the sickness absence rate (from all causes) peaked at 6% in March 2022 All bed types Intensive care/higher care beds 18 Staff sickness absence Emergency access through our emergency department Following a reduction during the first year of the pandemic, the numbers of patients who presented to receive care at our emergency department increased exponentially in 2021/22. Attendance levels exceeded the higher levels seen prior to the pandemic by approximately 10%. All patients presenting to the emergency department This exceptional increase in the clinical demand upon our department has had a significant adverse impact upon the timeliness of care, particularly for those patients who have a less urgent condition. The department has also continued to deliver services separately for those patients who have respiratory symptoms and those who do not, and to implement additional infection control measures. Emergency access performance is measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department. The national target of 95% was not achieved and the Trust experienced a large deterioration in our own performance to 64% (main ED/Type 1 attendances) by March 2022. Our performance compared favourably with other acute trusts in England despite this, however. 19 Emergency access four hour performance The number and duration of any ambulance handover delays are another important performance indicator. Ensuring that ambulance staff can ‘hand over’ the patients they convey to our emergency department without delay is important because this releases the staff and their vehicle to meet the needs of other medical emergencies in the community. We are very proud to have an exceptionally good record in this regard, working with colleagues in ambulance services to transfer arriving patients into our emergency department and the care of our staff even when the hospital is already fully occupied. 20 Elective Waiting times Demand 2021/22 has seen a continuation of the trend of increasing elective referrals, following a major reduction which occurred at the start of the COVID-19 pandemic. Referral rates to our services are now typically at, or above, the levels seen before the pandemic. Feedback from clinicians is that they are also seeing more patients with advanced disease than they would normally, because of delays in referral to the service/diagnosis. Accepted referrals The number of patients referred to hospital with suspected cancer increased exceptionally during 2021/22; the number of patients seen for a first consultant-led appointment was 27% higher than in 2020/21 and 18% higher than in 2019/20. Performance remained below the national target of 93% throughout the year, with a deterioration to 74% in December 2021 prior to a recovery to 90% in March 2022. Our performance also declined in comparison with other acute trusts in England. Most of the patients who waited longer than two weeks for their first appointment were within our breast service, which sees a very large number of referrals for suspected cancer and experienced a 22% increase in the number of patients seen compared to 2019/20. Additional consultants who specialise in breast cancer have now been recruited and performance in this service returned to target in April 2022. 21 Performance following ‘Two week wait’ urgent referral for suspected cancer 22 Activity The number of UHS hospital appointments, diagnostic tests and elective admissions all increased significantly during 2021/22. The number of appointments undertaken, and diagnostic tests performed, exceeded activity levels in both 2019/20 and 2020/21. The number of elective and day case admissions increased significantly compared to 2020/21 (the first year of the pandemic) yet remained approximately 10% below the levels achieved between April 2019 and February 2020 (prior to COVID-19). There were a wide range of factors influencing these activity levels, and the lower levels of admitted activity specifically, including: • the availability of beds for the admission of elective patients after emergency patients with COVID-19 and other conditions had been accommodated; • the availability of staff to deliver elective care, during periods of increased COVID-19 bed occupancy, and during periods of increased staff absence related to COVID-19; • additional infection prevention measures which were maintained, particularly within inpatient treatment settings where risks of COVID-19 transmission are otherwise increased. Most of the activity has been delivered within NHS hospitals in 2021/22 (local independent sector hospitals were used to replace NHS elective capacity in 2020/21), and we have recruited additional staff and invested in an additional ward, theatres and outpatient rooms in order to be able increase our treatment activity. The graphs below show 2021/22 activity levels as a percentage of those achieved prior to the COVID-19 pandemic. Elective admissions (including day case) 23 Outpatient attendances Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. At the end of March 2022, 20% of patients were waiting more than six weeks to receive their investigation. This is a significant improvement compared to 28% of patients waiting more than six weeks at the end of March 2021, yet still significantly worse than the national target (1%) and UHS performance prior to pandemic. At the end of March 2022, the total waiting list size (including patients waiting less than six weeks) had increased by 14% compared to March 2021 and was 34% larger than before the pandemic. These trends reflect a combination of large reductions in diagnostic activity in the first year of the pandemic, followed by record levels of diagnostic tests being performed during 2021/22 (7% higher than before the pandemic) combined with very high levels of referrals for diagnostic testing over the same period. 24 The tests with largest numbers of longer waiting patients are non-obstetric ultrasound, peripheral neurophysiology, MRI and CT. Initiatives to improve performance include the recruitment of additional staff in the relevant professions and investment in additional equipment, in the context of NHS forecasts that diagnostic demand will continue to increase over the longer term. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 25 Referral to Treatment Our waiting list from referral to treatment increased in size by 27% (9,768 patients) during 2021/22 and is now 36% larger than before the pandemic. Both referrals and hospital activity declined steeply at the start of the pandemic, but referral levels increased more quickly than hospital activity following this. The rate at which the waiting list is increasing has however reduced in the most recent six months. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance has deteriorated from 80% immediately before the pandemic, to 68% at the end of March 2022. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with, and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 26 The fact that some patients wait significantly longer than the 18 week target is a particular concern. In 2020/21 NHS England targeted the stabilisation of the numbers of patients waiting more than 52 weeks and the elimination of waiting times more than 104 weeks (except when patients choose to wait longer). The percentage of patients waiting more than 52 weeks at UHS reduced from 9% to 4%. The number of patients waiting more than 104 weeks reduced, from a maximum of 171, to 59 at the end of March 2022 (of whom only five were wishing to proceed with treatment at that time). The patients who typically wait longest for treatment continue to be those who require admission for surgical procedures in specialities such as ear nose and throat, orthopaedics and oral surgery. The Trust opened four additional operating theatres during 2020/21 and is working in collaboration with partners in the Hampshire and Isle of Wight integrated care system to implement further elective recovery plans. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 27 Cancer Waiting Times The timeliness of urgent services for patients with suspected cancer has unfortunately declined during 2021/22. The Trust continues to perform well in comparison with the teaching hospitals that we benchmark with and deliver a similar range of services, however. We have faced a range of challenges including: • a large increase in the number of new patients referred for investigation; • delays in the onward referral (for specialist investigation or treatment) of patients from other trusts which have also experienced increases in referrals; • the need to provide capacity to investigate and treat the full range of other conditions, alongside those patients with suspected cancer; and • an increase in the complexity of treatment required by new and existing patients, potentially because of delays in referral or treatment during the first year of the pandemic The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. UHS exceeded this level of performance in April 2021 but has not done so since then, performance deteriorated to 66% in January 2022 before recovering somewhat to 72% by March 2022. Treatment for Cancer within 62 days of an urgent GP referral to hospital The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients. Trust performance has been very variable in 2021/22, ranging from 89% to 98% in individual months. Likewise, performance has ranged from below average in some months, to amongst the best in the group of teaching hospitals that we benchmark with. 28 First definitive treatment for cancer within 31 days of a decision to treat A range of initiatives are being pursued to maintain and improve the timeliness of our cancer services including: • changes to some of the processes for the referral and initial assessment of patients with suspected cancer, for example the inclusion of high quality photographs within referrals for suspected skin cancer; • projects to refine processes and procedures for the investigation of suspected gynaecological and urological cancers; • an operating services improvement programme designed to improve the flow of patients, and the numbers of patients treated, through our existing theatre facilities; and • staffing level increases and recruitment to clinical roles in specialities where the increases in demand require this. Quality priorities The Trust set four quality priorities in 2021/22, which were aimed at ensuring we continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. We recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the second year of the COVID-19 pandemic, by limiting the number of priorities to four. We also acknowledged the risk that the delivery of our priorities could be disrupted by the ongoing pandemic and that we needed to be flexible in adapting the priorities to changing circumstances. The Trust set the following four priorities: 1. Introduction of midwifery continuity of carer for women at risk of complications in pregnancy. 2. To support staff wellbeing and recovery. 3. Managing risks to patients delayed for treatment and restoring elective programmes. 4. Reducing healthcare associated infection (HCAI) 29 The Trust achieved three of the quality priorities and partially achieved one priority. In relation to midwifery continuity of carer, the Trust’s performance exceeded the ambition that had been set by NHS England in 2020/21 following its national review of maternity services in 2015 as shown below. NHS England ambition set in 2020/21 35% of women will be booked to receive care in a continuity of carer team 35% of black and minority ethnic women booked to receive care in a continuity of carer team 35% of women living in an IMD-1 area (most deprived areas measured using indices of deprivation) Percentage achieved 41.7% 75% 80% The Trust continued to introduce programmes, interventions and wider support offerings to promote staff wellbeing and recovery in 2021/22. Our 2021/22 annual NHS staff survey results are positive with our scores relating to wellbeing above the benchmark average. Contributing factors to wellbeing such as staff engagement, morale, staff experience in areas such as kindness and respect, feeling valued and trusted to do their job were all above the benchmark average. More information about staff health and wellbeing is included in the staff report below. The Trust only partially achieved the priority relating to managing the risks to patients delayed for treatment and restoring elective programmes. The Trust’s performance against elective waiting time standards are described in more detail above. While the Trust focused on prioritising all patients waiting for surgery to ensure we continued to treat people based on need and urgency, we continue to recognise the impact of delays on people’s quality of life and, at times, outcomes. COVID-19 remained a key area of focus for the Trust in 2021/22 in terms of infection prevention. The Trust implemented a number of awareness campaigns, including its award-winning COVID ZERO campaign, and strategies to reduce in-hospital transmission of COVID-19 and kept these under review throughout the year. The chart below shows the trend of hospital-onset cases of COVID-19, which has broadly followed local and national prevalence of the virus, and the Trust’s performance compared very favourably with its local and national peers. 30 The table below provides an overview of the Trust’s performance against national and other infection prevention standards and limits to minimise infections, the majority of which have been achieved by the Trust. Category National Objectives: MRSA bacteraemia Clostridium difficile infection E coli Bacteraemia End of year RAG Action /Comment R One MRSA bloodstream infection attributable to UHS 2021/22 in March 2022. R 74 cases against a threshold of 64 for the year. G 138 cases in 2021/22 against a threshold of 151. Klebsiella Bacteraemia A 64 cases in 2021/22 against a threshold of 64. Pseudomonas Bacteraemia MSSA G 30 cases in 2021/22 against a threshold of 34. 43 cases in 2021/22 after 48 hours in hospital. Other: Hospital onset, healthcare associated COVID-19 103 hospital-onset probable healthcareassociated cases in 2021/22. 125 hospital onset definite healthcare associated cases in 2021/22. Prudent antibiotic Antimicrobial prescribing Stewardship G The standard contract requirement for reduction in antibiotic usage for 2021/22 was waived, as in 2020/21. Had it been applied as anticipated, the Trust would very likely have met this. Provide Assurance of Infection G The annual infection prevention audit assurance of Prevention Practice programme was reinstated in April 2021 for basic infection Standards the monitoring and assurance of infection prevention prevention and control practices but practice: subsequently suspended in September 2021. You can find more information about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2022/23, in the Trust’s quality account for 2021/22, incorporated in the Trust’s annual report and accounts. 31 Financial performance The Trust delivered a surplus of £0.048 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England and NHS Improvement, su
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Health and safety policy

Description: Health and Safety Policy Date Issued: 21/11/18 Review Date: 21/11/21 Document Type: Policy Version: 10.0 Contents Paragraph 1 2 3 4 5 6 7 8 9 Appendices Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Appendix J Executive Summary / Policy Statement / Flowchart Scope and Purpose Definitions Details of Procedure to be followed Roles and Responsibilities Related Trust Policies Communication Plan Process for Monitoring Compliance/Effectiveness of this Policy Arrangements for Review of this Policy References Trade Unions and Professional Organisations Health and Safety Risk Assessment Form Risk Grading Matrix Fees for Intervention Health and Safety Self Auditing Non Patient Slips Trips and Falls First Aid Provision Display Screen Equipment Noise at Work Page 2 6 7 8 10 21 22 22 22 22 Page 24 25 27 30 34 38 41 43 44 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 48 Executive Summary The Health and Safety at Work etc. Act 1974 (HASAWA) places the duty on an employer to ensure, so far as is reasonably practicable, the health, safety and welfare of all employees and others who may be affected by its acts or omissions. This includes the provision and maintenance of safe plant, machinery, equipment and safe systems of work. Although the ultimate responsibility for compliance with the Act rests with employers, every employee also has a responsibility to ensure that no one is harmed or put at risk as a result of their acts or omissions during the course of their work. It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as reasonably practicable, that persons not his employment who may be affected thereby are not thereby exposed to risks to their health or safety (Section 3 HASAWA) Compliance with the Health and Safety at Work Act is a legal requirement. As such, an offence, committed under the Act would constitute a criminal offence and could lead to prosecution, resulting in a fine and/or a term of imprisonment. If the Trust commits an offence which is a material breach in the opinion of the Health & Safety Executive (HSE) inspector, or if there is or has been a contravention of health and safety law then a notice may be issued to the Trust. If a notice is issued or the inspector sees a material breach of the law, the trust will have to pay a fee. Reference Appendix D In addition to the Health and Safety at Work Act 1974, other Regulations, Approved Codes of Practice, Guidance Notes and Directives will apply. The Trust uses the Health & Safety Executive (HSE) model HSG 65 (see page 3) as a method of ensuring that the work of the Trust is conducted in a safe manner as far as is reasonably practicable. Page 2 of 48 HSG65: Managing for Health and Safety (Third Edition) Page 3 of 48 Health and Safety Policy - Flow Chart Page 4 of 48 UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST Health & Safety Policy Statement of Intent The University Hospital Southampton (UHS) NHS Foundation Trust Board of Directors and I are totally committed to ensuring the health, safety & wellbeing of all staff, patients, contractors and members of the public who are in any way affected by the undertaking of UHS’s activities. We will ensure the provision of appropriate resources, including staff, finance and equipment in a timely manner so as to conduct our activities in accordance with all statutory and regulatory requirements, seeking to exceed such requirements wherever reasonably practicable. We will develop and implement a range of policies and procedures in support of this statement and will ensure their effective communication to all staff and contractors. We will seek to embrace best practice from the wider healthcare community and will proactively seek out innovative and dynamic initiatives that will assist UHS in achieving the highest levels of safety performance and delivering the highest standards of clinical care, reviewing and amending our policies and procedures on a continuous basis. It will not be acceptable for any hazard, risk or safety incident to be ignored by any member of staff, or contractor, and we will ensure that systems and processes exist to identify and mitigate risk as well as for reporting, investigating and learning from incidents when they do occur. In delivering these aims, the Board expects and requires all staff and contractors to conduct themselves in a safe manner at all times and to engage with the Board in any and all safety initiatives that it identifies and implements in order to deliver continual safety improvement Paula Head Chief Executive University Hospital Southampton NHS Foundation Trust Page 5 of 48 1 Scope and Purpose This policy sets out the principles and arrangements by which University Hospital Southampton (UHS) Foundation Trust base both their commitment to Health and Safety and their compliance with legislation. The policy forms part of the UHS’s overall approach to staff and patient safety as set out in the Health and Safety and Patient Safety Strategies. This policy applies to all staff employed by the Trust, either directly or indirectly, and to any other person or organisation which uses Trust services or premises for any purpose. It will also apply to bank, temporary staff, volunteers, young workers, staff working from home and contractors working on Trust business. The principles of this policy shall apply to all Trust work activities, regardless of who has or is supplying or providing them. The aims of this policy are to: o Outline the requirements of Health & Safety Regulations, Health & Safety Guidance and Approved Codes of Practise that apply to the Trust. o To inform managers and staff as to their roles and responsibilities with respect to these. o To demonstrate the Trust’s commitment to reducing accidents and incidents causing ill-health as well as other environmental hazards and risks in the workplace o To set out the organisation’s arrangements for Health and Safety in accordance with HSG 65 o To set out the organisation’s training requirements for Health & Safety The objectives of this policy are to: o To ensure that the Trust has a proactive management system in place to enable it to comply with all relevant statutory health and safety legislation. o To reduce the numbers of accidents and incidents which cause harm o To prevent foreseeable accidents or incidents so far as is reasonably practicable by undertaking suitable and sufficient risk assessments o To demonstrate how UHS complies with its Statutory Health and Safety compliance against Legislation, Regulations, Approved Code of Practice (ACOPs), best practice, etc o To prevent reoccurrence of adverse events as far as is reasonably practicable o To ensure compliance with relevant NHS Litigation Authority standards, Care Quality Commission (CQC) Essential Standards of Quality and Safety and other Department of Health (DoH) requirements such as Health Technical Memorandum (HTM) or Health Building Note (HBN) where practicable. o To ensure that contractors recognise their duty of care to the Trust and their employees and will be bound by their terms of contract to comply with The Health and Safety at Work Act, subordinate regulations and the Trust Consultant’s and Contractor’s Handbook’ Page 6 of 48 2 Definitions o Reasonably Practicable: means that you have to take action to control the health and safety risks in your workplace except where the cost (in terms of time and effort as well as money) of doing so is "grossly disproportionate" to the reduction in the risk. o Competency: knowledge, skills, qualifications, training, experience or ability to undertake a particular job, the term ‘competent person’ also refers to the roles and responsibilities of those managing health & safety matters o Employee: means any member of staff who holds a contract of employment directly with the Trust o Contractors: persons or agencies engaged by the Trust to provide a specific service. This includes bank staff, agency staff, staff employed by other Trusts, organisations and agencies occupying Trust premises o Hazard: a hazard is anything with the potential to cause harm e.g. chemicals, electricity, working at height, noise etc. o Risk: the likelihood that the hazard will actually cause harm, injury or damage; it also considers the consequences, extent and outcome of a hazardous event occurring o Suitable and Sufficient: that all significant hazards have been identified, the risks have been properly evaluated considering likelihood and severity of harm, measures necessary to achieve acceptable levels of risk have been identified, actions have been prioritised to reduce risks, the assessment will be valid for some time, actual conditions and events likely to occur have been considered during the assessment, everyone who may be harmed has been considered o Young person: is anyone under eighteen years of age (young people). The law on working time defines a young worker as being below 18 years of age and above the Minimum School Leaving Age. o Approved Code of Practice (ACOPs): Approved Codes of Practice give practical guidance on compliance. o Volunteer: A person carrying out work activities within the Trust, for the benefit of staff, patients and/or visitors without reward in cash or kind, and on behalf of one of the Trust’s recognised volunteer groups. Reasonable expenses received from the recognised volunteer group will not affect a volunteer’s status. Page 7 of 48 3 Details of Procedure to be followed 3.1 Risk Assessment The law places an ‘absolute duty’ on employers to carry out risk assessments, which should be a record of:  identified hazards arising from or in connection with the work;  who will be affected by the hazards;  the control measures in place or proposed control measures;  evaluation of the risk  review date Health & Safety Risk assessments are required to be undertaken for tasks/ environments/ situations identified as presenting a significant risk of injury either to Trust staff, visitors or patients. Risk assessments should be completed using the Trust’s Generic Health & Safety Risk Assessment Form Appendix B, and scored according to the guidance in Appendix C, and these should be monitored and reviewed in the following circumstances:  whenever there is a significant change e.g. staff, environment or equipment;  after an accident or ‘near miss’;  after non compliance identified through audits and inspection programmes  at least annually Risks that cannot be managed and actioned locally should be escalated to the risk register following guidance contained in the Risk Management Policy and Procedures Health & Safety Risks relating to the following hazards, should be identified and recorded using the specialised risk assessment forms contained in the related Trust policies, listed under section 5 of this policy:  Ionising or Non-Ionising radiation including lasers and other intense light sources  Magnetic Resonance (MR) fields  COSHH,  Visual Display Unit use,  Moving and Handling of patients or equipment  Stress 3.2 Health and Safety Training Details of training course dates and registration information, Statutory and Mandatory Training, Corporate Induction and refresher training are advertised on the Virtual Learning Environment (VLE) and details of training requirements are outlined in the Training Needs Analysis. Specific training including local induction related to the particular work activity must be provided by managers. Where the use of specialist equipment or work practices is required, suitable training will be arranged by the relevant manager. A range of Health and Safety training courses is provided for managers and staff by the Health & Safety Manager/Advisor/Moving & Handling Adviser. These include:  H&S Lead coordinators  H&S Risk Assessments  Control of substance hazardous to health (COSHH)  Moving and Handling clinical handling leads  Moving and Handling load handling leads Page 8 of 48 3.3 Auditing Departments will carry out a health and safety self-audit annually, following the process outlined in Appendix E. Once self audits are submitted to the Health and Safety team, the team will summarise results and report to the Corporate Health and Safety Committee and QGSG. Self audit returns will be followed up in Health and Safety Tours in departments, and in incident investigations and inspections. 3.4 Non Patient Slips Trips and Falls Non Patient Slips Trips and Falls will be controlled as outlined in Appendix F. 3.5 Provision for Emergencies Planning for fire emergencies is the responsibility of the Fire Safety Advisor and controlled as outlined in the Fire Safety Management Policy. Spillages of hazardous substances are managed according to the COSHH policy Planning and provision of first aid is managed as outlined in Appendix G to this policy 3.6 Incident Reporting. All staff are expected to report accidents and incidents using the “Safeguard” incident reporting system, from where appropriate managers will investigate and take appropriate remedial actions. Incidents reportable to the Health and Safety Executive under the RIDDOR Regulations must be brought to the attention of the Health and Safety Team, who will investigate and report appropriately. Guidance on which incidents are reportable under RIDDOR is available on StaffNet at http://staffnet/Workinghere/Staffessentials/Staffhealthandsafety/RIDDOR.aspx Page 9 of 48 4 Roles and Responsibilities 4.1 Chief Executive The Chief Executive (CEO) has overall responsibility to provide a safe environment throughout the Trust, ensuring compliance with the requirements of The Health and Safety at Work etc, Act 1974, all subordinate Health and Safety Regulations, ACOPs & Guidance, the requirements of this policy and any subsequent amendments to these. The CEO has overall accountability for the safety of any member of staff, patient, visitor, contractor, and others, whilst they are on those Trust premises under their control. The CEO is also responsible for the health and safety of other stakeholders and neighbours who may be affected by the work and undertakings of the Trust. The CEO has overall responsibility to make arrangements to ensure:  That the requirements of the Trust’s Health and Safety Policy are organised, planned and implemented  That the Trust Board is informed of relevant health and safety matters affecting the Trust, its employees, contractors, patients, neighbours, other stakeholders and the wider public  That suitable and sufficient resources and support are provided for the training and development of Trust staff in all relevant health and safety matters  That monitoring, measuring, reviewing and auditing of the Trust’s health and safety performance is undertaken  That the Trust's Health and Safety plans and performance are discussed at Board level 4.2 Director of Nursing and Organisational Development The Director of Nursing and Organisational Development, in liaison with the Medical Director, has delegated executive responsibility for health and safety in particular for:  Informing the Board on all relevant health & safety management issues, including alerting the Board to the requirements of this policy and any actual or potential breaches of Health and Safety Legislation  Ensuring, through the Quality Governance Committee structure, that relevant persons are consulted with and informed of any changes that may substantially affect their health and safety e.g. in procedures, equipment or ways of working  Ensuring clear lines of accountability throughout the organisation for the management of health and safety and that all staff groups are represented in the Quality Governance Committee structure  Ensuring that staff are provided with information on the likely risks and dangers arising from Trust work and activity, introduce measures to reduce or get rid of those risks and inform staff as to what they need to do if they have to deal with a risk or danger  Putting arrangements in place to get competent people to help them satisfy health and safety legislative requirements  Ensuring co-ordination and co-operation on health and safety matters between the Trust, its neighbours, contractors and any other relevant stakeholder  Ensuring that suitable plans are in place to manage health and safety Page 10 of 48  Ensuring that adverse health and safety consequences of introducing new technology, equipment or procedures and ways of working are mitigated so far as is reasonably practicable 4.3 Executive and non-Executive Directors All Executive and Non Executive Directors have corporate responsibility to provide a safe working environment and shall ensure adequate arrangements and resources are provided to implement the requirements of this policy, all relevant Safety Regulations and any associated procedures and safe systems of work; and apply this within their respective areas of responsibility. They ensure that health and safety arrangements are adequately resourced and that they obtain competent advice and that they review reports, performance and action plans to ensure compliance. They recognise that it is a criminal offence for a company to fail in any of the duties imposed by the Act, and an accident may give rise to civil liability as well. Directors can be prosecuted for the criminal offence as well as the organisation. 4.4 Director of Quality  Is the operational lead for health and safety, reporting to the Director of Nursing and Organisational Development  Deputise and carry out the duties of the Director of Nursing and Organisational Development in their absence 4.5 Divisional Clinical Directors / Divisional Directors of Operations / Divisional Heads of Nursing / Heads of Departments / Senior Managers/ Managers / Supervisors The following is not an exhaustive list but in general terms, managers at all levels must ensure:  That they have or undertake to obtain such information, instruction and training to enable them to lead on matters of health and safety commensurate with their respective role or position  That all risk assessments are carried out and documented by persons competent to undertake such assessments following Trust policy  That risk assessments are systematically reviewed and where necessary ensure that suitable protocols, plans and procedures are further updated or developed to provide adequate controls and safety precautions  That they support local managers and work with lead risk assessors, staff and staff representatives to provide suitable and sufficient equipment which is serviced and maintained and put systems and procedures in place to control and safely manage any identified risks  That they and local managers discuss and disseminate Trust safety policies and implement the requirements of those respective policies to ensure cooperation and communication by all  That they make adequate funding available to provide any necessary equipment, procedures and ongoing training and supervision to meet the requirements of the Health and Safety Policy and/or where a risk assessment has identified such control measures as being necessary Page 11 of 48  That health and safety performance standards and objectives are set for their managers and those under their supervision  That they manage the timely reporting of accidents and incidents in accordance with the Incident Reporting, Analysis, Investigation and Management Policy  That investigations are undertaken, the Incident Reporting Procedure is followed and that the Significant Incident Requiring Investigation (SIRI) and Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) procedures are followed, where necessary  That they intervene to prevent poor Health and Safety practice or procedures, as needs be  That they ensure any member of staff who ignores or deliberately fails to discharge their responsibilities for health and safety has been reprimanded or disciplined as per the Trust Disciplinary procedure and HR Policies  That they provide safe access and egress to Trust buildings, wards, departments and areas they are responsible for and provide safe means of transport and methods of movement of patients and staff; particularly when evacuation is required.  That they ensure the managers, supervisors and staff under their control or responsibility attend the appropriate training and health surveillance, including induction training, local induction and familiarisation, mandatory and statutory training; health surveillance for dermatitis, latex allergy, upper limb disorder, stress or occupational asthma, and any other training or health surveillance that is deemed necessary  That they maintain a system of regular inspections and audits to determine the degree of compliance with both Trust and local policies & procedures and take appropriate remedial action to address any areas of non-compliance  That they ensure that all staff under their control or supervision are afforded the same level of protection  That health and safety matters are discussed and incorporated as necessary into staff’s job descriptions, appraisals, team meetings and escalated through the local Governance Committee structure. 4.6 Director of Estates & Capital Development The Director of Estates and Capital Development is responsible for ensuring that the H&S Policy is implemented throughout the Estates and Capital Development (E&CD) department, together with its monitoring and updating. The Director of E&CD will be assisted in this by the members of the Estates Management Team, namely: the Deputy Director of E&CD, Head of Estates Maintenance; the Head of Estate Projects; the Head of Compliance; the Infrastructure Services Manager, the Estates Health & Safety Manager, the Head of Clinical Engineering, and Building Maintenance Managers. The Director of E&CD is also responsible for ensuring that the H&S Policy is applied to all work undertaken by design consultants, cost advisers, contractors and subcontractors and suppliers, as is appropriate. 4.7 Health & Safety Manager  Ensures that the Trust has a robust Health & Safety Policy outlining the commitment of the CEO and the Trust Board, to ensuring the Health & Safety of Page 12 of 48 all persons who either work for, or come into contact with, the Trust’s estates and activities.  To liaise effectively with the Health & Safety Executive (HSE), and other safety related external agencies, on behalf of the Trust  To regularly monitor and review all existing Trust wide policies relating to H&S and ensure that all H&S policies are readily available to all staff, that changes are effectively communicated and that they are robustly implemented.  Develop H&S training and ensure implementation strategies facilitate compliance and contribute to the Trust broader Education Strategy.  Analyse H&S related Trust wide adverse H&S events, ensuring appropriate investigation, production of detailed reports, and reporting as appropriate. To analyse health & safety data contained on the system, producing reports as necessary for relevant groups, identifying trends and recommending consequential change/s as required.  Produce an Annual Health & Safety Report for the Board setting out the achievements and shortcomings of the previous 12 months and making recommendations to bring about future improvements  To manage and provide leadership for the Trust Manual Handling Advisor and the Health and Safety Advisor.  Chair the Corporate Health & Safety Committee  Provide Health and Safety Reports to the Trust Board as required  Act as the nominated ‘competent person’ for the Trust as required by law, including providing input to planning of refurbishments, equipment sourcing and implementation, and other work likely to affect the health, safety and welfare of staff, visitors and patients. 4.8 Health & Safety Advisor  Will assist in the development, production and delivery of strategies that procures Trust wide compliance regarding health & safety, with statutory national and local regulations, Department of Health Directives and Trust Policies.  Will prepare and deliver as required senior management reports to various forums where health & safety is discussed.  Take part in investigations of accidents, near misses and other incidents and provide Health and Safety perspective to recommendations for remedial and preventive actions.  Working with the colleagues from the health & safety team to put in place an effective system in order to audit divisional compliance with the Trust Health & Safety strategies, producing reports for that identify both compliant and noncompliant areas.  Will coordinate visits, inspections by the Health & Safety Executive and the provision of such documents that may be requested by an inspector regarding the Trusts statutory duty.  Will provide expert advice and guidance on health and safety policy, guidance and assessment. Page 13 of 48  Work with colleagues in identification of appropriate health & safety training, strategies and contribute to the Trust health & safety education strategy..  Will chair the Health & Safety Leads meetings. 4.9 Trust Moving & Handling Advisor  Acts as the principle advisor for all Trust moving and handling activities by providing moving and handling information, expertise and advice within the Trust on the suitability of moving and handling aids and appropriate training for both staff and patients in order to ensure Trust wide compliance with statutory national and local moving and handling regulations  Undertakes moving and handling audits across the Trust alongside the Trust Health and Safety Team in order to put in place an effective system to audit compliance with the Trust moving and handling strategies. To provide a detailed report of any findings to Senior Managers informing of appropriate actions  Supports Nominated Moving and Handling Leads in providing moving and handling information, expertise and advice to their areas by chairing bi-monthly meetings in order to promote and adapt safer moving and handling practice in areas where moving and handling is challenging. 4.10 Radiation Protection Advisor The Radiation Protection Adviser is a suitably qualified and competent person appointed under the Ionising Radiations Regulations 1999, and is responsible for:  Providing advice and guidance in the safe management and use of radionuclide and radiation generating equipment and the safe storage and disposal of any contaminated waste  Advising the Trust regarding arrangements to undertake and document risk assessments, procedures and systems of work relating to radiation generating equipment and the use of radioactive materials  Providing reports for committees and advising on the updating of relevant Trust Policies  Advising on the investigation of incidents involving ionising radiation and on planning for major incidents involving radioactive material 4.11 Laser Protection Advisor The Laser Protection Adviser must be a suitably qualified, competent person appointed according to the Guidance on the Safe Use of Lasers, Intense Light Source Systems and Light Emitting Diodes (LED’s) in Medical, Surgical, Dental and Aesthetic Practices (MHRA 2015) and is responsible for:  Providing advice and guidance in the safe management and use of lasers and associated equipment  Advising the Trust regarding arrangements to undertake and document risk assessments relating to lasers  Providing reports for committees and updating relevant Trust Policies 4.12 Magnetic Resonance Safety Expert The MHRA Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use 2015 (v4.2) state that the MR Safety Expert is a designated professional with Page 14 of 48 adequate training, knowledge and experience of MRI equipment, its uses and associated requirements. They should:  Develop safe operating procedures and policies and risk management solutions to ensure MR safety for patients, staff and visitors.  Develop an appropriate framework for managing safety in relation to MR, including effective review processes and reporting mechanisms within the Trust.  Prepare and periodically review the MRI local rules for the MRI units across the Trust.  Provide reports regarding MR safety developments to Trust committees and contribute to/update relevant Trust policies (including the Policy for the Safe Use of MRI).  Advise on the implementation of national and international MR guidelines and legislation within the Trust.  Carry out MR safety audits and risk assessments to assess and ensure compliance with national guidelines and good safe practice and to monitor the effectiveness of safety procedures.  Advise on the planning and the configuration of MR facilities in order to promote safety, working with, and recognising the experience of, the system vendor installation team.  Provide patient (and staff/visitor) specific advice with regard to MRI safety, such as that concerning implants (for example).  Assist with the investigation of incidents relating to MR equipment. 4.13 Fire Safety Advisor The Fire Safety Advisor (FSA) is responsible for ensuring the development and implementation of the Fire Safety Management Policy ensuring that safe systems and processes are in place for the continuous effective management of fire safety risks as required by statutory, national, local regulations, department of health directives and related trust policies. The FSA will work with the Fire Manager to put in place an effective system in order to audit divisional compliance with the Trust Fire Management Policy and to analyse fire related Trust wide adverse events producing reports as necessary for relevant groups, identifying trends and implementing change as required. 4.14 Occupational Health The Occupational Health Service are responsible for the assessment and enhancement of fitness for work, for advising about control of health risks in the workplace, and for leading staff health and wellbeing, specifically by providing:  co-ordination and provision of staff health and wellbeing support/services  pre-placement screening  immunisations against infectious diseases  management of sharps and contamination incidents  health surveillance  staff support and counselling  advice about adjustments to work on health grounds Page 15 of 48  rehabilitation back to work after illness  special advice to managers on generic risk assessments  advice to managers on individual risk assessments (taking account of individual susceptibility due to pregnancy or health problems)  health promotion and wellbeing advice  regular feedback to Trust Board on work-related ill health The Occupational Health service is impartial and confidential, aiming to give objective advice to both employees and managers. Employees’ OH records are held securely and are not accessible to anyone outside the OH service. Information about individuals will not be passed to anyone without that individual’s consent. 4.15 HR Department The Director of Human Resources has delegated responsibility for ensuring a robust strategic approach is adopted addressing issues of employee’s health, safety and wellbeing. This includes:  The development and implementation of a series of Human Resource policies which are compliant with health and safety legislation and which reflect the support mechanisms in place to assist and support employees health, safety and well-being.  The commissioning and development of appropriate staff support services. HR Teams are responsible for providing awareness sessions for staff and coaching for managers on the implementation of policies and HR best practice. 4.16 Security Manager The Security Manager for the Trust is the appointed Local Security Management Specialist (LSMS) and will undertake the duties of an LSMS in accordance with Secretary of State Directions to health bodies on measures to tackle violence and general security management measures, and any subsequent advice or guidance issued by the NHS SMS. This includes:  To ensure that all NHS security management work is carried out within a professional and ethical framework developed and provided by the NHS Security Management Specialist (SMS).  To ensure that an inclusive approach to security management work is taken, involving both internal and external NHS stakeholders where appropriate and necessary  To report to the health body’s Chief Operations Officer on security management work locally  To lead on day-to-day work in their health body to tackle violence against staff and professionals in accordance with the NHS SMS national framework and guidance.  Ensure appropriate steps are taken to create a pro-security culture within the health body and amongst contractors so that staff and patients accept responsibility for this issue and ensure that any security incidents or breaches that occur are detected and reported  Attend the health body’s risk management, health and safety and audit committee meetings and ensure appropriate links are made with the health body’s risk assessment process, including the health body’s health and safety Page 16 of 48 representatives, so that security-related issues are an integral part of that process  Participate in the health body’s induction programme for new staff and develop and deliver security awareness sessions for stakeholders  Ensure lessons learnt from security incidents and breaches are fed into risk analysis, both locally and nationally, so that appropriate preventative measures can be developed  Ensure security incidents are reported using the NHS SMS reporting system, ensuring that investigations take place where appropriate, risks are assessed and preventative measures are developed (this will include participation in local and national risk identification projects)  Ensure security incidents and breaches are investigated in a fair, objective and professional manner so that the appropriate sanctions are applied and measures put in place to prevent recurrence  Ensure consideration is given to cases not progressed by the police or CPS and, where appropriate, work is undertaken with the NHS SMS Legal Protection Unit and the health body, and redress is sought where appropriate. 4.17 Infection Prevention Team The Infection Prevention Team are responsible for providing the Trust with advice and guidance on infection prevention and control matters, for supporting staff in the implementation of infection prevention policies, and assisting with risk assessment where complex decisions are required. The Infection Prevention Team are also responsible for escalating concerns to the Quality Governance Steering Group and the Corporate Health & Safety Committee (CHSC). 4.18 Litigation and Insurance Services Department The Litigation and Insurance Services Department is responsible for:  Managing all clinical negligence and personal injury (extending to contract challenges where required) claims ethically and cost effectively on behalf of the Trust. This should be in accordance with Trust policy and procedures, based on NHSLA and NHS Executive (NHSE) guidelines. Ensuring the Trust complies with its statutory legal responsibilities in relation to the management of all claims.  In accordance with the Pre-Action Protocol and Civil Procedure Rules undertake all pre-action investigations; communicate with clinical and non-clinical staff to obtain evidence in the form of statements, internal expert medical and nonmedical opinion and documentation in the context of allegations of negligence or breach of statutory duty, consider the complexities of each case and perform a preliminary analysis of each individual claim to form a reasoned opinion on liability and quantum on the basis of evidence obtained.  In respect of the National Health Service Litigation Authority (NHSLA), Clinical Negligence Scheme for Trusts (CNST), Liabilities to Third Parties Scheme (LTPS) and Properties Expenses Scheme (PES), liaise and negotiate with insurers and external solicitors (both claimant and Trust) on claims covered under the various NHSLA compensation schemes.  Provide regular reports via the Health & Safety Report reporting on a quarterly an annual basis identifying newly reported claims and reporting on lessons learned, themes and actions taken Page 17 of 48  Attend Trust committees as required and to provide ad hoc general healthcare related advice.  Ensure that the Trust’s insurance provision is both adequate and maintained on annual basis. 4.19 National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility (WTCRF) is responsible for:  Ensuring that all research studies, including clinical and non-clinical interventions conducted within its facilities/ in the community by staff/visiting researchers are following Trust policies. The facilities include clinical, non-clinical and research laboratory areas.  Reporting health & safety concerns rising from the management of research that are serious and impact on business to the Research & Development (R&D).  Directly reporting to the Trust’s relevant governance meeting/s as required by those meetings (currently quarterly audits).  Keeping and maintaining the WTCRF risk register and reporting directly to the Trust. Biomedical Research Unit (BRU) is responsible for:  Ensuring that all research studies, including clinical and non-clinical interventions conducted within its facilities/ in the community by staff/visiting researchers are following Trust policies. The facilities include clinical, non-clinical and research laboratory areas.  Reporting health & safety concerns rising from the management of research that are serious and impact on business to the R&D Department.  Directly reporting to the Trust’s relevant governance meeting/s as required by those meetings (currently quarterly audits).  Keeping and maintaining the BRU risk register and reporting directly to the Trust. 4.20 Employees All employees have a responsibility to:  Take reasonable care of their own health and safety and that of others who may be affected by what they do or do not do  Co-operate with the Trust on Health and Safety issues  Not interfere with or misuse anything provided for their or other’s health, safety or welfare  Use any equipment, Personnel Protection Equipment (PPE), and procedures provided by the Trust, take reasonable care of it and to report any accidents, defects, damage, unsafe acts or conditions, near misses, or loss as soon as reasonably possible.  Be aware that willfully or intentionally interfering with or misusing equipment, procedures or safe systems of work will be subject to disciplinary action (See Trust Policy on Disciplinary procedures)  Read and understand the requirements of the Trust’s health and safety policies, other relevant safety procedures, risk assessments, local rules etc, and carry out work in accordance with these requirements Page 18 of 48  Ensure they report immediately any ill health, stress or other medical condition which may be work related or affect their ability to work safely  Ensure they attend any Health and Safety induction or training courses provided for them. 4.21 Trade Union and Staff-side Representatives Trade Union and Staff-side Health and Safety Representatives have the following responsibilities:  To represent Trust employees in consultation and co-operation with managers with a view to developing measures to ensure the health and safety at work of employees  To highlight potential hazards, risks and dangerous occurrences in the workplace (whether or not they are drawn to their attention by employees they represent) and to be proactive by assisting in preventing accidents and adverse incidents in the workplace  To investigate complaints by any employee whom they represent relating to that employee’s health, safety or welfare at work  To make representations to Trust management on any matter affecting the health and safety of employees in the workplace  To assist in Health and Safety audits when requested  To attend and contribute towards Health and Safety Committee meetings Recognised Trade Unions and Staff Organisations for the Trust are listed in Appendix A. It is the responsibility of each of the accredited Trades Unions and the Joint Staff Committee to inform the Corporate Health & Safety Committee, in writing, of their current health and safety representatives and any subsequent changes 4.22 Estates and Capital Developments The Estates Team are responsible for the management of the Estate which covers both new construction works and maintenance of existing assets. Activities related to working at height, roof work, use of cranes, internal flooring, external grounds & gardens and routine inspections, fall within the scope of areas highlighted in this policy. Estates and Capital Developments oversee construction work activity which is defined in detail in Regulation 2(1) of the Construction (Design and Management) Regulations 2015. 4.23 Serco (Cleaning and catering contractors) Serco, our cleaning and catering contractor, has a Health and Safety Policy which their employees must all adhere to. This policy includes the statement below: ‘ “Our work is never so urgent or important that we cannot take time to do it safely and with respect for the environment. Wherever we work, we are committed to the promotion of wellbeing and the prevention of injury, ill health and pollution including seeking to reduce the amount of carbon produced and the sustainable use of global resources, while reducing our waste through good waste management and recycling.” Page 19 of 48 4.24 All Contractors employed by the Trust All contractors and sub-contractors under the control of or employed directly or indirectly by the Trust must undertake their work in a safe manner. This work must be undertaken in accordance with statutory safety requirements and the Trust’s policies and procedures. Contractors and sub-contractors must fully co-operate with the guidance set out in the document Consultant’s and Contractor’s Handbook’ part of the contract documents issued prior to the commencement of any works. They must ensure that:  They and other self-employed persons (engaged on Trust business) assess and document the risks of their work and undertakings and make provision to protect themselves and others in respect of their own work activities.  That they are competent and authorised to carry out the required work and they have the supporting documentation to evidence this through risk assessments, safety plans and/or method statements, permits to work, etc  That all their employees (& sub-contractors) are appropriately informed, instructed and trained in health, safety and welfare related matters pertaining to their own and Trust work activities  That reasonable steps are taken to ensure co-operation and communication between all contractors and Trust staff and other relevant persons  That they report significant accidents and incidents to the Trust when undertaking their work and incidents that fall within Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR)1995 which occur as a result of the contractor’s undertakings  That they provide safe access to and from their workplace for their own staff and all others affected by their undertakings and put in place provisions to deal with a fire and do nothing to compromise the fire systems and procedures already in place within the Trust 4.25 Volunteers and Charitable organisations Even though charity and voluntary workers generously give their time, work and expertise to the Trust, these people are regarded as honorary employees in the eyes of the law and as such are bound and protected by the same health and safety conditions as all other Trust staff. Charity or voluntary workers or any Trust manager or representative responsible for them must ensure that risk assessments of their activities are undertaken and the identified risks are managed 4.26 Health & Safety Management Framework  Quality Governance Steering Group (QGSG) The delegated committee for overseeing the compliance with this Policy and the operation of the Corporate Health and Safety Committee is the Quality Governance Steering Group which is accountable to the Trust Executive Committee and the Trust Board.  Corporate Health and Safety Committee In accordance with the Health and Safety at Work Act 1974, the Safety Representatives and Safety Committees Regulations 1977 and at the request of staff representatives, the Trust has a Corporate Health and Safety Committee which acts in accordance with the Approved Code of Practice as per the requirements of these Regulations. Page 20 of 48  The Corporate Health and Safety Committee sits within the Trust’s Quality Governance & Risk Committee structure and is a key part of the arrangements for managing health and safety issues in the Trust. The details of the functions and Terms of Reference of the Committee and the means of making contact with its members can be found on the Staffnet http://staffnet/WorkingHere/Staffhealthandsafety/Healthandsafetycommittees/Cor porateHealthandSafetyCommittee/CorporateHealthandSafetyCommittee.aspx 5 Related Trust Policies  Patient Safety Strategy  Risk Management Policy and Procedures  Incident Reporting, Analysis, Investigation and Management Policy  Fire Safety Management Policy  Moving and Handling of Loads Policy  Control of Substances Hazardous to Health (COSHH) Policy  Security Policy  Sharps Safety Policy  Lone Worker Policy  Patient Falls Policy – The Management and Prevention of falls  Waste Management Policy  Non-Ionising Radiations, Policy for the Safe Use of  Safe Use of Ionising Radiations Policy  Magnetic Resonance Imaging, Policy for the Safe Use of  All Occupational Health policies relating to Health and Safety  All other Estates policies and procedures relating to Health and Safety  Whistle Blowing Policy Page 21 of 48 6 Communication Plan 6.1 The Trust Health and Safety Policy will be displayed on the Staffnet. 6.2 The Trust Health and Safety Manager/Adviser will provide updated information to nominated care group leads at bi-monthly meetings. . 6.3 The nominated care group leads will disseminate health and safety information through departmental co-ordinators as appropriate and ensure that this information is passed onto all staff. 6.4 Health and Safety is included in the Trust Corporate induction programme held monthly for all new staff. 7 Process for Monitoring Compliance/Effectiveness Key aspects of the procedural document that will be monitored: Element of Policy to be monitored Completion by wards and departments of the H&S self audit tool Monitoring the requirement to undertake appropriate risk assessments Lead Tool/Method Frequency Who will Where results undertake will be reported The completed audit tools and action plans /completed Health & Safety Tour reports Risk assessments Weekly via Health & Safety Tours and on receipt of completed Health & Safety audit tools each March. During inspections, incident investigations and tours All Health and Safety audited areas annually During inspections, incident investigations and tours Corporate Health and Safety Team Health & Safety Team The Corporate Health and Safety Committee The Corporate Health and Safety Committee Where monitoring identifies deficiencies actions plans will be developed to address them. 8 Arrangements for Review of the Policy This policy will be reviewed and validated before the end of September 2019 or sooner if new evidence demonstrates need for a change to current practice. 9 References  The Health and Safety at Work etc Act 1974  Management of Health and Safety at Work Regulations 1999 (2002)  The Health and Safety Executive (HSE) http://www.hse.gov.uk/  Corporate Health and Safety Committee Terms of Reference Page 22 of 48  Safety Representatives and Safety Committees Regulations 1977 (as amended) and Health and Safety (Consultation with Employees) Regulations 1996 (as amended)  HSE-Slips trips and falls in the health service http://www.hse.gov.uk/pubns/hsis2.pdf  HSE-Preventing slips and trips at work http://www.hse.gov.uk/pubns/indg225.pdf  HSE-What causes slips and trips http://www.hse.gov.uk/slips/causes.htm  HSE-‘Falls from Height http://www.hse.gov.uk/falls/  HSE-‘Watch Your Step Campaign http://www.hse.gov.uk/watchyourstep/  HSE- ‘Slips Assessment Tool’ http://www.hse.gov.uk/slips/sat/index.htm Page 23 of 48 Trust Health and Safety Policy Appendix A – Trade Unions and Professional Organisations Appendix A The Trade Unions and Professional Organisations listed below are formally recognised by the Trust as being able to represent their members on individual issues, and for collective bargaining purposes: Association of Clinical Biochemists British Association of Occupational Therapists British Dental Association British Dietetic Association British Medical Association British Orthoptic Society Chartered Society of Physiotherapy Federation of Clinical Scientists General and Municipal Boilermakers Union Royal College of Midwives Royal College of Nursing Society of Chiropodists and Podiatrists Society of Radiographers Union of Construction, Allied Trades and Technicians UNISON UNITE THE UNION ACB BAOT BDA B Diet A BMA BOS CSP FCS GMB RCM RCN SOCP SoR UCATT UNISON UNITE Page 24 of 48 Trust Health and Safety Policy Appendix B – Generic Risk Assessment Form Appendix B - Generic Health & Saf
Url: /Media/UHS-website-2019/Docs/Policies/Health-and-safety-policy.pdf

Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-20-21.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
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

Long-term continuous positive airway pressure (CPAP) treatment - patient information

Description: This leaflet explains what obstructive sleep apnoea (OSA) is, what long-term continuous positive airway pressure (CPAP) treatment for OSA involves and how to use and look after the CPAP treatment equipment safely at home.
Url: /Media/UHS-website-2019/Patientinformation/Respiratory/Long-term-continuous-positive-airway-pressure-CPAP-treatment-3385-PIL.pdf

Annual-report-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2019 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Welcome from our Chair 7 A word from the chief executive 8 Overview of the Trust Statement of purpose and activities 9 History of UHS 9 Our executive team structure 10 Structure of our services 11 Our vision and values 12 Our priorities, key issues and risks 13 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 17 How we monitor performance 18 Detailed analysis and explanation of the development and performance of UHS 18 Regulatory body ratings 23 Environmental matters 24 Social, community, anti-bribery and human rights issues 25 Accountability report Members of the Trust Board 27 Trust Board purpose and structure 31 Board meeting attendance record 2018/19 32 Well-led framework 33 Strategy and finance committee 34 Quality committee 34 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 36 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 37 Disclosures 37 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 40 Annual remuneration statement 49 Remuneration and appointments committee 52 Governors’ nomination committee 54 Staffing report 58 Staff survey results 62 Trade union facility time 66 Statement of chief executive’s responsibilities as the accounting officer 69 Annual governance statement 70 Voluntary disclosures Equality, diversity and inclusion 78 Environmental sustainability and climate change 80 Southampton Hospital Charity 84 Developments in informatics 85 Leading research into better care 85 Investing for the future 86 Quality account and quality report 2018/19 Chief executive’s welcome 88 Our approach to quality assurance 90 Our commitment to safety 90 Duty of candour 91 Our commitment to staff 91 Freedom to speak up 94 Our commitment to education and training 95 Our commitment to staffing rota gaps 96 Our commitment to technology to support quality 97 Our commitment to the Care Quality Commission 98 Our commitment to improving the environment for our patients 100 Review of quality performance 101 Clinical research 101 Review of services 102 CQUIN payment framework 103 Data quality 103 Participation in national clinical audits and confidential enquiries 104 How we are implementing the priority clinical standards for seven day hospital services 105 Learning from deaths 106 Progress against 2018/19 priorities 109 Priorities for improvement 2019/20 128 Conclusion 132 Responses to our quality account 133 Statement of directors’ responsibilities 138 Independent auditor’s report 139 Quality account appendix Appendix 1: Our quality priorities 2019/20 143 Appendix 2: Quality performance data 144 Appendix 3: CQUIN data 151 Appendix 4: Clinical audit and confidential enquiries data 154 Appendix 5: British Society of Urogynaecology 156 Appendix 6: National clinical audit: actions to improve quality 157 Appendix 7: Local clinical audit: actions to improve quality 161 Appendix 8: Shared decision making 173 Appendix 9: Registration with the Care Quality Commission 174 Annual accounts Statement from the chief financial officer 177 Foreword to the accounts 178 Independent auditor’s report 179 Financial accounts and notes 186 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2018/19 was a year of change in the leadership of UHS. Following the departure of Fiona Dalton in March 2018 to run a hospital group in Canada, David French took on the role of interim chief executive officer. On behalf of the Trust Board I would like to thank David for agreeing to do so and also for doing such an outstanding job. During the year we welcomed three new non-executive directors to the Trust; Jane Bailey, Professor Cyrus Cooper and Catherine Mason. Catherine’s talents were also recognised by Solent NHS Trust and she has since left to help lead their organisation as chair. We were delighted to welcome Paula Head as chief executive in September after a rigorous and robust recruitment process. Paula’s experience as chief executive of Royal Surrey County Hospital NHS Trust and, prior to that of Sussex Community NHS Foundation Trust, shone through and we were confident that under her leadership UHS would continue to develop, grow and improve. Demand for our services continues to rise rapidly as the result of a changing demographic and other factors, and at a rate far greater than our income. Despite this our staff continue to deliver exceptional care. I was delighted that this was recognised by the Care Quality Commission in their recent inspection when they again rated us as Good. The revised NHS Long Term Plan will inevitably require us to adapt to the changing pattern of healthcare, but we do so with enthusiasm. This year has shown just how adept we are as an organisation at responding positively to change, not only rising to the challenges it presents, but thriving with it. This is evident in the significant investments we have made in the Trust’s estate this year. Phase one of our new children’s emergency department is complete thanks to the continued support of the Murray Parish Trust. We also approved one of the largest capital investments in our history with the updating and expansion of our general intensive care unit. We recognised that it was as crucial to invest, not just in the physical environment within which we provide healthcare, but within the digital environment too, acknowledging that UHS is an NHS digital exemplar. We have invested significantly in information technology to enhance accessibility and improve both patient and staff experience. We look forward with confidence to helping lead the NHS into a new phase of delivering health and care for the United Kingdom into 2019/20. Peter Hollins Chair 7 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive Since arriving at UHS to take up my position as chief executive officer, I have heard and witnessed some incredible achievements by staff at the Trust. Dr Joanne Horne was named biomedical scientist of the year at the Advancing Healthcare Awards for her work in histopathology; Dr Beth McCausland, quality improvement fellow in dementia care, was named foundation doctor of the year by Royal College of Psychiatrists; Sarah Charters, consultant nurse and mental health lead for the emergency department was awarded an MBE for services to vulnerable adults and her vulnerable adult support team were also winners of a Nursing Times Award in the emergency and critical care category. The medicine for older people therapy team led by Hannah Wood was named most inspiring team at the national #EndPJParalysis awards while Marie Nelson, matron in research and development, and senior research sisters Jane Forbes and Kirsty Gladas won the silver award for clinical research site of the year at the PharmaTimes International Clinical Researcher of the Year Awards. Jean Piernicki, senior nurse manager in occupational health, was awarded the title of Queen’s Nurse in recognition of her high level of commitment to patient care and nursing practice. Fiona Chaâbane, a senior clinical nurse in neurosciences was named winner of the nursing and midwifery award at the BBC’s The One Show Patients Awards. The medicines advice service, led by Dr Simon Wills, picked up the HSJ Value Award for training and development for its medicines learning portal and Matthew Watts, head of news, was named operational services support worker of the year for the south of England at the Our Health Heroes Awards 2018. We were also delighted that the energy and sustainability team collected the clinical NHS Sustainability Award for its green wards project. These are just a few of the individual and team successes achieved this year. Our entire organisation can also be incredibly pleased and encouraged by the outcome of the recent Care Quality Commission (CQC) inspection, which rated UHS ‘good’ overall, with many individual areas being recognised as outstanding by the CQC. You can find full details of the inspection on page 98 of the quality account. Such positive inspection results link to equally positive staff survey results which saw UHS ranked as the second highest acute trust for staff satisfaction and fifth highest for staff recommending the Trust as a place to work and receive treatment. It’s made me incredibly proud to be able to say that I am part of such a driven team and it’s clear that the UHS team share my drive and determination to improve things for patients and staff every day. This is evident in both the successes I have already mentioned, but also in the pioneering work that is taking place across every department. Informatics has been pioneering new digital initiatives which they recently shared with Hadley Beeman, chief technology adviser to the secretary of state and social care. Surgeons Bhaskar Somani and Stephen Griffin have created a ‘twin surgeon’ model that has revolutionised the treatment of kidney stones in children. Dr John Paisey, consultant cardiologist, and his team were among the first in the world to implant and programme a pacemaker using Bluetooth technology. They performed four of the first five procedures in the world. While Professor Mike Grocott and his team created ‘surgery school’ which is transforming the fitness of patients prior to their operations and thereby reducing length of stay. These are by no means the entirety of our achievements this year and I would like to take the opportunity to thank every single member of staff at the Trust who continues to make UHS one of the leading trust’s in the UK. Paula Head Chief executive officer 8 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,900 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2018/19 was more than £878m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 9 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Associate director of corporate affairs (interim) Charlie Helps Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive Paula Head Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services; communications Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer & deputy chief executive David French Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 10 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 11 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 12 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 13 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 14 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2019/20. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 31. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 70. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 16 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2018/19 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 17 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2018/19 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers, including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2016/17 to 2018/19 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases) 2013/14 2016/17 Outpatient appointments 2017/18 2018/19 ED attendances (type one) Referrals (excl March) Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals (excl March) 2016/17 160,000 630,045 99,273 189,194 2017/18 157,993 658,147 104,616 197,522 2018/19 168,791 695,343 110,771 207,209 Increase 2016/17 to 2018/19 5.5% 10.4% 11.6% 9.5% 18 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven, in 2017/18 this increased to twenty, however in 2018/19 there were no black alerts. The chart below shows red alerts logged during 2018/19. Red alerts 2018/19 60 Number of AM and PM alerts 45 30 15 0 4/1/18 6/1/18 8/1/18 10/1/18 12/1/18 2/1/19 Contributing to this change has been an increase in day cases and an increase in length of stay (LoS) for elective patients linked to a more complex case mix. UHS delayed transfers of care 2018/19 The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2018/19. 3,600 Percentage of bed days lost 3,200 2,800 2,400 2,000 April 2018 June 2018 August 2018 October 2018 December 2018 February 2019 19 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS did not meet the target this year. Achievement of this target in 2018/19 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. The Trust has finished the financial year with no patients waiting greater than 52 weeks, and a total referral to treatment waiting list lower than in March 2018. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and all three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard states that 95% of patients should be treated and either admitted or discharged within fours of arrival into ED. However, NHS Improvement set local targets for all NHS organisations with an ambition that the NHS would return to meet the 95% target by March 2019. The local targets set by quarter (to allow for seasonal variations) for UHS were: Quarter 1 - 90% Quarter 2 - 91.4% Quarter 3 - 90% Quarter 4 - 90-95% How did we do? 2018/19 was another challenging year for emergency patients for the whole Hampshire and Isle of Wight area. Whilst we had a positive start to the year achieving quarter 1 and 2 targets, we did not meet quarter 3 or 4 targets. We did, however, meet out local delivery system targets. 20 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year (including all UHS types and Lymington). National 4 hour access target – UHS performance 100% 95% 90% 87.1% 85% 80% 82.1% 82.3% 87.4% 87.4% 93.0% 90.5% 84.7% 82.9% 85.7% 90.7% 88.9% 84.8% 77.9% 81.1% 75% Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 The graph below shows our local delivery system performance against the four hour target over the last year (including all SGH types, Lymington and Southampton Treatment Centre). National 4 hour access target – Local delivery system 100% 95% 91.0% 90% 91.1% 95.1% 92.8% 88.7% 87.1% 89.2% 91.5% 85% 92.9% 88.4% 83.3% 85.9% 80% 75% Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 21 OVERVIEW AND PERFORMANCE REPORT Cancer waiting times There are nine separate cancer waiting times standards (below), each of which can then be split into tumour site specific performance groups. Measures Urgent GP referrals seen in two weeks Breast symptoms referral seen in two weeks Treatment started within 62 days of urgent GP referral Treatment started within 62 days of referral (breast, cervical and bowel screening) 62 day consultant upgrades Treatment started within 31 days of decision to treat Second or subsequent treatment (surgery) started within 31 days of decision to treat Second or subsequent treatment (anti-cancer drugs) started within 31 days of decision to treat Second or subsequent treatment (radiotherapy) started within 31 days of decision to treat Target > 93% > 93% > 85% > 90% > 86% > 96% > 94% > 98% > 98% 18/19 YTD (up to and including Feb 19) 86% 50% 74% 80% Achieved 8 8 8 8 86% 3 93% 8 85% 8 100% 3 100% 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 7.7% in 2018/19. The chart below shows the rise in demand for UHS cancer services over the past three years UHS growth in cancer actvity – 2016/17 to 2018/19 (up to and including month 11) 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 2016/17 up to and incl Feb 62 day target patients 31 day target patients 2017/18 up to and incl Feb 2018/19 up to and incl Feb For staffing performance, please refer to page 58. For financial performance please see page 177. Paula Head, chief executive officer 28 May 2019 22 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2018/19 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2019. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good 23 OVERVIEW AND PERFORMANCE REPORT In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 80 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 24 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 25 FR STAND BODY ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT; Member of Solent Acute Alliance; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel (from May 2018) Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Daughter is a midwife at UHS (from March 2019) Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father and mother are UHSFT simulated patients (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Daughter is employed within the emergency department at UHS (from 1 August 2018) 27 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Simon Porter Senior independent director and deputy chair Dr Mike Non-executive Sadler director Biography Declarations Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2018-19.pdf

Bulevirtide (Hepcludex®) for the treatment of chronic hepatitis D - patient information

Description: This factsheet explains what bulevirtide (Hepcludex®) is, how it is given to treat hepatitis D and the possible side effects.
Url: /Media/UHS-website-2019/Patientinformation/Digestionandurinaryhealth/Hepatology/Bulevirtide-Hepcludex®-for-the-treatment-of-chronic-hepatitis-D-3673-PIL.pdf

Mobocertinib

Description: A chemotherpay document based on Mobocertinib.
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Lung-cancer-non-small-cellNSCLC/Mobocertinib.pdf

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