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Surgeon event highlights v2

Url: /Media/Southampton-Clinical-Research/Video/Surgeon-event-highlights-v2.mp4

Surgeon event highlights

Url: /Media/Southampton-Clinical-Research/Video/Surgeon-event-highlights.mp4

Papers Trust Board - 11 November 2025

Description: Date Time Location Chair Agenda Trust Board – Open Session 11/11/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-11-November-2025.pdf

Papers Trust Board - 29 November 2022

Description: Date Time Location Chair Agenda Trust Board – Open Session 29/11/2022 9:00 - 13:20 Conference Room, Heartbeat/Microsoft Teams
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Papers-Trust-Board-29-November-2022.pdf

Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 11 November 2025 9:15 Approve the minutes of the previous meeting held on 11 November 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:40 including Maternity and Neonatal Safety 2025-26 Quarter 2 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:50 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:20 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.6 11:00 5.7 11:15 5.8 11:25 5.9 11:30 5.10 11:45 5.11 11:55 5.12 12:05 5.13 12:15 6 6.1 12:25 7 12:35 8 Break Finance Report for Month 8 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICB System Report for Month 8 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 8 Review and discuss the report Sponsor: Steve Harris, Chief People Officer Learning from Deaths 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience Infection Prevention and Control 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control Medicines Management Annual Report 2024-25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist Annual Ward Staffing Nursing Establishment Review 2025 Discuss and approve the review Sponsor: Natasha Watts, Acting Chief Nursing Officer CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager Any other business Raise any relevant or urgent matters that are not on the agenda Note the date of the next meeting: 10 March 2026 Page 2 9 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 10 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 January 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB System Report for Month 8 5.9 People Report for Month 8 5.10 Learning from Deaths 2025-26 Quarter 2 Report 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report 5.12 Medicines Management Annual Report 2024-25 5.13 Annual Ward Staffing Nursing Establishment Review 2025 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b 1c 1b 1b, 3a 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 11/11/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Martin de Sousa, Director of Strategy and Partnerships (MdS) (item 6.1) Lucinda Hood, Head of Medical Directorate (LH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.12) Vickie Purdie, Head of Patient Safety (VP) (item 7.3) Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness (KP) (item 5.13) Scott Spencer, Health and Safety Advisor (SS) (item 7.3) 4 governors (observing) 2 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that no apologies had been received. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Item deferred to the next meeting. 3. Minutes of the Previous Meeting held on 9 September 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 9 September 2025, subject to a minor correction at 5.10. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Actions 1281, 1283 and 1284 were closed. • Action 1282 was to be addressed through item 5.6 below. • In respect of action 1285, the Quality Committee would monitor progress on complaints response times. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • In terms of the internal audit reports, which had been received by the committee, whilst there were a number of points for the Trust to address, no areas of significant concern had been identified. • There was a focus on ‘imposter fraud’ whereby individuals who had turned up to carry out a shift were not who they claimed to be. Whilst there had been no reported incidents at the Trust, the Trust had implemented controls at the ward level, which would be subject to testing during 2025/26. 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • In September 2025, the Trust had reported that it was in line with its Financial Recovery Plan. Of the £110m Cost Improvement Programme (CIP) target, 76% had been fully developed. • The committee had reviewed the Finance Report for Month 6 (item 5.8), noting that the Trust had reported an in-month deficit of £5.4m, which was in line with the Financial Recovery Plan. • The committee had expressed concern that 17% of the CIP target was not fully developed and that the Trust was £2.5m off-track in terms of delivery of the target at Month 6. • Whilst progress had been made in terms of addressing patients with no criteria to reside and mental health patients, this remained an area of concern. • The committee considered the NHS England Medium Term Planning Framework, noting that the first submission by the Trust was due prior to Christmas 2025. 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • There continued to be little improvement in terms of the number of patients with no criteria to reside or mental health patients, which impacted staffing numbers. • The Trust was adopting a harder line in respect of its approach to violence and aggression, which included a greater willingness to exclude individuals. • The current participation rate in the Staff Survey was lower than the national average, which was likely indicative of staff morale and engagement. Page 2 • The Trust’s workforce numbers remained above plan, with limited options available to address this issue, especially in the absence of funding for restructuring costs. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • The committee received an update in respect of mental health patients, noting that although there were significant issues in the Emergency Department, the whole pathway for these patients remained a problem. • The committee carried out a six-monthly review of the Trust’s progress against its Quality Priorities, noting that good progress had been made on four of the six priorities and two were slightly behind. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published the Medium Term Planning Framework, which was intended to encourage organisations to think beyond a 12-month time horizon and to progress the NHS 10-Year Plan. The Trust was expected to provide its first submission prior to Christmas 2025, but the detailed planning assumptions had yet to be received from NHS England. It was noted that a more detailed report on the Medium Term Planning Framework was to be received as part of the closed session of the meeting. • The Strategic Commissioning Framework had been published by NHS England, which provided welcome clarifications about the future role of integrated care boards. • The Trust had been placed into Tier 1 for both Urgent and Emergency Care and for Elective performance. There was a national expectation that trusts would have no patients waiting over 65 weeks for elective care by 21 December 2025. Where organisations had more than 100 such patients at the end of October 2025, they had been placed into Tier 1. The Trust was taking steps, including mutual aid, to attempt to address the number of long waiters, but there was insufficient capacity in the system. • Resident doctors were due to strike for a further five-day period commencing on 14 November 2025, having rejected the Government’s latest offer to resolve the ongoing dispute with the British Medical Association. • The Hampshire and Isle of Wight Integrated Care Board and NHS England South East Region had carried out a visit to the Trust’s paediatric hearing services in May 2025. The report, received in October 2025, had been positive about the service. • The Trust and the University of Southampton had been awarded £16.3m by the National Institute for Health and Care Research. The Trust was one of only four organisations out of 15 applications to receive an award. • The NHS Business Services Authority had announced the award of a £1.2bn contract to Infosys to deliver a new and enhanced workforce management system for the NHS to replace the existing Electronic Staff Record system. The 2030 target date for implementation was considered ambitious. Further details would be considered by the People and Organisational Development Committee when available. Page 3 5.6 Performance KPI Report for Month 6 Andy Hyett was invited to present the ‘spotlight’ report in respect of Diagnostics, the content of which was noted. It was further noted that: • Diagnostics performance was a key element of the pathway, as delays in diagnosis had a consequential impact on the overall length of pathways such as those for cancer and patients on a Referral To Treatment pathway. • Although there were some concerns with Diagnostics in the Trust, the Trust, generally, performed better than other organisations. The Board discussed the matters raised in the Diagnostics ‘spotlight’. This discussion is summarised below: • There had been a long-standing issue with waiting times for cystoscopy due to insufficient capacity. However, a plan was being developed to improve the situation, although it was considered appropriate that the plan should also address broader issues with urology as a whole. • There was concern regarding the availability of magnetic resonance imaging (MRI) scanners, particularly as two scanners were out-of-action. It was noted that the current set-up in terms of MRI scanners was not fit for the longer term and a strategy for the future needed to be developed. • There was a disparity between capacity and demand in respect of the neurophysiology service, as this service had previously relied on outsourcing. • Generally, activity was increasing, but overall performance appeared to be declining. There was also the additional financial challenge that Diagnostics was funded under a ‘block’ contract arrangement which did not fully take into account the demand for these services. • There were concerns about the electrical supply capacity at the Southampton General Hospital site and the ability of the Trust to expand its Diagnostic capacity with this limitation. It was considered that a better longer-term model would be for scanners at local community diagnostics centres. Actions Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Andy Hyett agreed to develop a long-term solution to the neurophysiology service. Andy Hyett was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s Emergency Department had recorded performance of 67.6% against the four-hour standard during September 2025. The department remained busy with c.450 patients and 120 ambulance attendances per day. • There had been some initial performance impacts with the roll out of the MIYA system in the Emergency Department, but this appeared to have now been addressed with performance up to previous levels. • A number of initiatives were being introduced into the Emergency Department in order to improve performance. These included the layout of the service, pathway re-designs, having General Practitioners in the department, and arranging with non-urgent patients to attend at a scheduled time rather than waiting in the department. Page 4 • In October 2025, the Trust had recorded 363 patients waiting over 65 weeks on a Referral To Treatment pathway against a national target of no such patients by the end of December 2025. • The Trust was making use of the independent sector, weekend working, and was requesting capacity from other providers to address the number of patients waiting over 65 weeks. • The planned industrial action by resident doctors posed a challenge, noting that the national expectation was that trusts maintain 95% of their capacity during this period. It was noted that, in contrast to previous instances of industrial action, resident doctors were apparently less forthcoming in terms of whether they intended to participate in the industrial action. • The Trust continued to report one of the lowest Hospital Standardised Mortality Rates in England. • The Trust’s cancer performance, based on a BBC article, was 21 out of 121 trusts. It was noted that whilst the number of patients being referred on a cancer pathway had increased significantly, the number of patients diagnosed with cancer had not materially changed. • There appeared to have been an increase in the number of pressure ulcers and ‘red flag’ incidents. Work was ongoing to address the findings of the pressure ulcer audit which had been presented to the Quality Committee on 2 June 2025. • The number of patients having no criteria to reside and mental health patients remained high. Actions Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. 5.7 Break 5.8 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had submitted its Financial Recovery Plan to NHS England in August 2025, which committed to an additional £23m improvement in the Trust’s financial position to deliver a full-year position of a £54.9m deficit. In the absence of these additional improvements, the Trust had been forecasting a year-end position of a £78m deficit. The revised target was subject to a number of assumptions, including the need for demand management and improvements in non-criteria to reside and mental health patient numbers. • There were a number of risks to the achievement of the Financial Recovery Plan, including whether there would be improvements in mental health and non-criteria to reside and/or steps taken to manage demand, high levels of activity, and whether it would be possible to reduce the workforce and close theatres. The need for the Trust to focus on achieving the 65-week wait target in particular could impact the Trust’s ability to close capacity. • The Trust had reported an in-month deficit of £5.4m (£30.8m year-to-date), which was in line with the trajectory set out in the Financial Recovery Plan. The Trust’s underlying deficit had seen some marginal improvement during the period. • The Trust’s cash position remains an area of significant concern. Cash requests had been made to NHS England, but the latest request for November 2025 had been rejected. It was therefore likely that the Trust would need to manage its supplier payments in accordance with its available cash. Page 5 5.9 ICS System Report for Month 6 Ian Howard was invited to present the ICS System Report for Month 6, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £48m. • A significant improvement in the run-rate would be required for the system to be able to deliver its 2025/26 plan. • The system was one of the worst in England in terms of the number of beds occupied by patients having no criteria to reside with approximately 23% of beds being occupied by such patients compared with a national average of 12%. • The system was also below plan in terms of its targets for access to General Practitioners and targets relating to mental health patients. It was noted that the performance in these areas had a consequential impact on the Trust’s performance in areas such as urgent and emergency care performance. 5.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The overall workforce fell by 73 whole-time-equivalents (WTE) during September 2025 and was reported as being 54 WTE above the Trust’s 2025/26 plan. The reduction in workforce had been driven through a combination of the impact of the recruitment controls, mutually agreed resignation scheme (MARS) leavers, and a significant drop in use of temporary staff during the month. • On 15 October 2025, the Trust had heard the collective grievance brought by the Royal College of Nursing in respect of the removal of enhanced NHS Professionals rates. It was decided not to reverse the decision in order to maintain equity with the rest of the workforce and consistency across other local providers. A number of actions had been agreed following the hearing. • Sickness rates had increased to 3.8%, although the Trust still benchmarked well against peers. • There were concerns about the potential impact of influenza during the winter period and therefore the Trust was taking a number of actions to promote vaccination of staff. The Trust was currently third in terms of uptake in the Region. • The level of participation in the national Staff Survey remained a challenge with only 32% of staff having completed the survey compared with a national average of 38%. It was considered likely that the recent difficult decisions taken and the impact on staff was impacting staff experience and engagement. • The People and Organisational Development Committee would be examining statutory and mandatory training levels together with the latest proposed national changes. Page 6 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including UHS Self-Assessment Return Natasha Watts was invited to present the NHS England audit and review of ‘Developing Workforce Safeguards’ (2018), including the Trust’s Self-Assessment Return, the content of which was noted. It was further noted that: • ‘Developing Workforce Safeguards’ was published in October 2018 and included a range of standards to assure safe staffing across the workforce. NHS England had initiated an audit, review and improvement plan amidst concern about a national reduction in compliance. • The Trust had submitted a self-assessment as part of this NHS England review. This assessment showed that the Trust continued to comply with the majority of the standards. • The audit exercise has been used as an opportunity to identify opportunities for improvement. Twelve recommendations have been developed, of which nine were assessed as ‘green’ and three as ‘amber’. 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report and Update on the 10-Point Plan, the content of which was noted. It was further noted that: • Resident doctors were due to strike for five days from 14 November 2025. This would be the thirteenth strike in recent years. It was noted that, in addition to pay, the dispute also concerned working conditions and the shortage of posts and consequent risk to resident doctors of unemployment. • The Trust had performed a self-assessment against the 10-Point Plan and it was noted that the majority of the plan’s contents had been considered by the Trust for some time. There were also a number of dependencies on the part of NHS England in areas such as lead employer models. • A national review of statutory and mandatory training was expected to enable portability of training records to facilitate staff moving between NHS organisations. • There had been significant improvements in respect of gaps in rotas. 5.13 Annual Clinical Outcomes Summary Luci Hood and Kate Pryde were invited to present the Annual Clinical Outcomes Summary Report, the content of which was noted. It was further noted that: • The paper provided an overview of the clinical outcomes reviewed by the Clinical Assurance Meeting for Effectiveness and Outcomes (CAMEO) over the 12-month period to September 2025. • The majority of specialities provide reports to CAMEO, although outcome data can be more difficult in some areas to capture than in others. • The outcomes reviewed by the CAMEO and outputs from this body were also influencing the development of the Trust’s clinical strategy. • The strains on the capacity of services posed a risk to clinical outcomes. Page 7 • There was potential that a ‘quality’ override could form part of the NHS Oversight Framework in the future, operating in a similar manner to the ‘financial’ override by limiting the segmentations available to an organisation. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review Martin De Sousa was invited to present the review of Corporate Objectives 2025/26 for the second quarter, the content of which was noted. It was further noted that: • Of the 12 objectives agreed for 2025/26, six were rated ‘green’, four were ‘amber’ and two were ‘red’. • The ‘red’ rated risks were that relating to the Trust’s financial performance and that relating to the Trust’s achievement of its workforce plan for 2025/26. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • BDO had completed its audit of the Trust’s risk maturity and had presented its report to the Audit and Risk Committee on 13 October 2025. The audit had highlighted a number of strengths including the Board Assurance Framework, risk definition, and use of risk in decision-making. In terms of opportunities for improvement, the audit report suggested some improvements in articulation of operational risks and use of ‘SMART’ methodology for actions. • The Board Assurance Framework had been reviewed by relevant executive directors and committees since it was last presented to the Board. There had been no changes to the ratings or target dates. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 28 October 2025 The Chair presented a summary of the Council of Governors’ meeting held on 28 October 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Governor attendance at Council of Governors’ meetings • Review of the Council of Governors’ Expenses Reimbursement Protocol • Appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025 • Membership engagement • Feedback from the Governors’ Nomination Committee It was noted that the Trust’s work on violence and aggression received particular attention from the Governors. 7.2 Register of Seals and Chair’s Action Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 It was further noted that one further item had been sealed on 7 November: Deed of Guarantee between University Hospital Southampton NHS Foundation Trust (Guarantor) and CHG-Meridian UK Limited (Beneficiary) regarding the payment and due performance obligations of UHS Estates Limited (UEL) under the Guaranteed Contract and specifically the Stryker Power Tools delivered to UEL under the pre-contract open build period with CHG. Seal number 307 on 7 November 2025. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and to the additional document referred to above. 7.3 Health and Safety Services Annual Report 2024-25 Spencer Scott was invited to present the Health and Safety Services Annual Report 2024/25, the content of which was noted. It was further noted that: • The number of incidents reportable pursuant to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) had increased substantially to 68 such incidents compared to 39 in 2023/24. The majority of these incidents related to moving and handling or exposure to infectious diseases. • There was a concern that there had been a reduction in the number of health and safety related reports and escalations whilst at the same time the number of RIDDORs had increased. • Four areas of concern were highlighted: Entonox surveillance of maternity staff, display screen equipment compliance, the Southampton General Hospital loading bay, and workplace temperatures during the summer. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 January 2026 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 03/02/2026 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: Scheduled for TBSS on 03/02/26. Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. 1294. Cystopscopy/urology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1295. Neurophysiology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a long-term solution to the neurophysiology service. 1296. Watch & Reserve antibiotics usage Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. Page 2 of 2 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 24 November 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee received an update in respect of the Trust’s commercial activities, noting that the Trust had robust systems in place to maximise cost recovery for private patient and overseas visitor income. The Trust’s private patient unit project continued to progress. The Trust was also seeking a partner to manage its parking provision. • The committee received the Finance Report for Month 7. The Trust had reported a £5.1m in-month deficit (£35.9m year-to-date), which was in line with the trajectory contained in the Financial Recovery Plan. The underlying deficit remained flat at £6.4m. Whilst there had been a slight reduction in the number of mental health patients, there were c.240 patients having no criteria to reside at any point during the period. There was an increased level of scrutiny in respect of non-pay expenditure. • The committee reviewed an update on the Trust’s measures for financial improvement, noting that the Trust was forecasting achievement of £85-95m against its target of £110m Cost Improvement Programme delivery for 2025/26. • The committee noted the Trust’s approach and the timelines associated with the Medium Term Planning submission. It was noted that the framework set ambitious financial and performance targets. • The committee received an update in respect of the Trust’s Theatre Experience Programme, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee reviewed the Trust’s productivity, noting that the Trust’s productivity had fallen by 3.3% compared to the prior year due to high-cost growth. • The committee received an update in respect of the Trust’s cash position and forecast and supported a proposal to request further cash support for January 2026. • The committee received an update on Capital Planning for 2026/272029/30. It was noted that it was expected that the Trust would be allocated c.£40m per annum, although there were concerns about the impact of the Trust’s cash position and the ability of the Trust to meet this level of expenditure. N/A N/A Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 15 December 2025 Key Messages: • • • • • • The committee received the Finance Report for Month 8 (see below). The committee discussed the Trust’s future transformation programmes, noting that the areas of focus would be: urgent and emergency care, elective care, and automation of administrative processes. The committee was assured that the programmes were felt to be suitably ‘bold and ambitious’ and were grounded in realistic opportunities, rather than ‘blue sky’ ideas. The committee reviewed the draft capital plan for 2026/27 – 2029/30, noting that the Trust had been allocated c.£40m of capital departmental expenditure limit (CDEL) per year. It was noted that the Trust’s cash position could place constraints on the Trust’s capital programme. The opportunity to secure funding from national programmes outside of CDEL should be pursued vigorously. The plan was to be discussed in a Trust Board Study Session prior to submission in February 2026. The committee reviewed, challenged and discussed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. The committee provided feedback in respect of the proposed submission noting that some of the assumptions within the 2025/26 plan had not materialised with regard to matters such as reductions in non-criteria to reside numbers and the committee sought assurance that learnings had been applied to the development of the medium-term plan submission. The committee was assured that such assumed reductions within the 2026/27 plan were based purely on actions which were deemed to be within the Trust’s control. The committee suggested some changes with regard to the plan, particularly around growth assumptions in the cost base, and agreed to recommend the revised plan to the Board for approval. It was noted that more detail and reviews would be required prior to the final submission date in February 2026. The committee received an update in respect of the Trust’s cash position and supported a proposal to make a further request for cash support from NHS England for January 2026. The Trust reviewed and supported a proposal for transforming the Southern Counties Pathology network. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust had reported an in-month deficit of £4.9m (£40m year-todate), which was consistent with the Trust’s Financial Recovery Plan. • November 2025 had been a challenging month due to costs associated with industrial action, patients with no criteria to reside and mental health patients. • The Trust had received c.£3m of income out of £6.1m for elective over-performance. • There had been a slight improvement in the Trust’s underlying deficit. Page 1 of 2 Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 21 November 2025 Key Messages: • • • • The committee reviewed the People Report for Month 7 including progress against the workforce plan. During October 2025, the overall workforce grew by 14 whole-time-equivalents (WTE). Although the substantive workforce had reduced by 15 WTE, there had been lowerthan-expected turnover and increased temporary staffing usage due in part to high sickness levels. The Trust remained on track, however, with respect to its Financial Recovery Plan trajectory. There were concerns about the response rate to the Staff Survey, which was below the national average. The Trust’s vaccination campaign for staff had started well with the uptake rate for the flu vaccine amongst staff at 43%. The committee considered the outputs of the review by NHS England of statutory and mandatory training and the implications for UHS. It was noted that a revised framework would facilitate passporting of training between NHS organisations. The Trust was aligned to the Core Skills Training Framework across six out of eleven areas and ten out of eleven areas for the Utilising E-Learning for Health material. The committee received an update in respect of the Trust’s Inclusion and Belonging strategy. It was noted that resource constraints and the impact of the current financial and operational environment on staff morale had impacted progress towards achievement of the objectives set out in the strategy. The committee reviewed the People risks contained within the Trust’s Board Assurance Framework. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 15 December 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the People Report for Month 8 (see below) including progress against the workforce plan and Financial Recovery Plan. • The committee considered the workforce implications of the Trust’s medium term plan submission, noting that there were a number of national expectations and targets, such as those relating to sickness rates and elimination of agency spend. In addition, the committee noted the risks associated with the plan, including those where the Trust was reliant on progress with respect to non-criteria to reside and mental health numbers. • The committee received an update regarding the Trust’s Violence and Aggression workstream, noting that the Trust had adopted a revised approach to violence, aggression and abuse directed at staff with a greater willingness to take action against violent/abusive patients and members of the public. A violence and aggression board had been established to provide executive oversight and leadership, and the Trust’s policy was being revised. This work would be accompanied by a comprehensive communication plan for both staff and members of the public. • The committee reviewed the Trust’s progress against its objectives for Year 4 of its People Strategy. 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The overall workforce fell during November 2025, with substantive numbers falling by 52 whole-time-equivalents (WTE). However, temporary staffing use had increased during the month due to increased sickness and operational pressures, which offset much of the reduction in substantive numbers. • The Trust was over its original plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to hit the Trust’s Financial Recovery Plan target, the overall workforce would need to fall by a further 137 WTE (including a 72 WTE reduction in temporary staffing) by the end of March 2026. • A forecast based on the previous year’s temporary staffing usage for the remaining months of the year indicated that the Trust would end the year approximately 500 WTE above the Trust’s 2025/26 plan. • The Trust had submitted a baseline assessment against the 10 Point Plan to improve Resident Doctors’ working lives in August 2025, which indicated that the Trust compared favourably against other organisations in the South East. The main issues concerned space available for doctors to work in and timeliness of reimbursement of course-related expenses. • The Trust was expected to meet a target of 95% of job plans having been signed off prior to 31 March 2026. At the start of December 2025, 55% of job plans had been signed off. Page 1 of 2 Any Other Matters: • Sickness absence had increased in November 2025 to 4.2% in month due to seasonal illnesses. • The staff survey closed on 28 November 2025. The completion rate for the staff survey had been lower t
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Papers-Trust-Board-13-January-2026.pdf

Quality account 24-25 final

Description: QUALITY ACCOUNT 2024/25 QUALITY ACCOUNT Contents Part 1: Statement on quality from the chief executive 1.1 Chief executive’s statement and welcome 3 Part 2: Priorities for improvement and statements of assurance from the Board 2. Introduction 5 2.1 Priorities for improvement 6 2.1.1 Progress against 2024/25 priorities 6 2.1.2 Quality Improvement Priorities - 2024/25: Final Reports 8 2.2 Priorities for improvement for 2025/26 28 2.3 Statements of assurance from the Board 47 2.3.1 Review of services 47 2.3.2 Participation in national clinical audits and confidential enquiries 47 2.3.3 Recruiting to research 52 2.3.4 Commissioning for Quality and Innovation (CQUIN) payment framework 52 2.3.5 Statements from the Care Quality Commission (CQC) 52 2.3.6 Payment by results 53 2.3.7 Data quality 54 2.3.8 Data Security and Protection Toolkit (DSPT) 54 2.4 Overview of Quality Performance 55 2.4.1 Single Oversight Framework 55 2.4.2 Reporting against core indicators for 2024/25 55 2.4.3 Learning from deaths 67 2.4.4 Seven-day hospital services 70 2.4.5 Freedom to Speak Up 72 2.4.6 Rota gaps 74 2.4.7 Duty of Candour 76 Part 3: Other information 3.1 Our commitment to safety 77 3.2 Our commitment to improving the experience of the people who use our services 81 3.3 Our commitment to improve the quality of our patients’ environment 83 3.4 Our commitment to sustainability and the environment 85 3.5 Our commitment to staff 89 3.6 Our commitment to education and training 91 3.7 Our commitment to clinical research 98 3.8 Our commitment to technology 102 3.9 Conclusion 103 Part 4: Appendices 104 2 QUALITY ACCOUNT Part 1: Statement on quality from the Chief Executive 1.1 Chief Executive’s statement and welcome I am pleased to present this year’s quality account, which reflects our ongoing commitment to delivering safe, effective and compassionate care for our patients. 2024/25 has been a challenging year for UHS and the wider NHS and social care system. We have navigated operational pressures, with increasing numbers of patients who are medically fit but do not have an onward care package in place to be discharged, alongside a rise in winter infections and a record number of attendances to our emergency department. In the face of these challenges, our teams have worked tirelessly to enhance patient outcomes, improve service accessibility and ensure that the care patients receive meets the highest standards. I want to recognise the hard work of our staff in ensuring safety, driving innovation, and adapting to changes. This report highlights successful initiatives that have improved patient care over the past year. It also provides an overview of our quality priorities for 2024/25 and sets out our quality improvement priorities for 2025/26. We are proud to have maintained our focus on quality and achieved most of our objectives, enhancing the experience for those who use our services. Patient experience is an important priority for UHS. In 2024/25 we have successfully recruited approximately 2,000 ‘involved patients’, which will ensure that we co-design our services with those who use them, keeping our focus on our Trust values of patients first, working together and always improving. 2025/26 promises to be an exciting year for patient experience, with the development of the Patient and Family Support Hub, which will integrate voluntary services and ensure equitable access to support services for all. Our long-standing commitment to delivering safe, high-quality care is underpinned by the Fundamentals of Care programme - eight care commitments that patients, families and carers can expect from their care at UHS and these statements have been written in conjunction with patients, relatives and staff. In 2024/25 the programme has made significant progress in embedding Fundamentals of Care into our organisational culture. This has been achieved through developing understanding with newly registered professionals in our preceptorship programme, support worker development opportunities and the ongoing empowerment of staff through leadership development. In 2024/25, we have continued to strengthen our internal quality assurance programmes by aligning the clinical accreditation scheme with the CQC single assessment methodology. We are collaborating with other internal programmes - such as infection control, Patient-Led Assessments of the Care 3 QUALITY ACCOUNT Environment (PLACE) and friends and family feedback - to triangulate data and enhance oversight of key quality metrics, including patient safety, effectiveness, patient experience, and outcomes. This approach provides us with valuable intelligence to help us uphold our Trust values. 2024/25 marked one year of Patient Safety Incident Response Framework (PSIRF) implementation at UHS which has helped develop ‘just and learning’ culture across the organisation. Safety awareness has increased through our education programmes that have achieved good attendance and feedback. This coming year we will continue to build on the work that has been undertaken as part of implementation of the national safety standards for invasive procedures (NATSSIPS) 2. We continue to collaborate with our partners and develop our work as an integral organisation in the integrated health and social care system, building on trusted relationships across organisational boundaries are essential in improving health outcomes for our whole population. I want to recognise the amazing dedication of our staff in maintaining the safety of both colleagues and patients, fostering innovation, and adapting to evolving circumstances. Throughout this year, our teams across all services have strengthened their collaboration with our partners. As we continue to advance towards an integrated health and social care system, these trusted relationships are proving essential in our ability to respond effectively. To the best of my knowledge, the information contained in this document accurately reflects our performance, provides a true account of the quality of the health care services we provide, and where we have succeeded and exceed in delivery on our plans. David French Chief Executive Officer 26 June 2025 4 QUALITY ACCOUNT Part 2: Priorities for improvement and statements of assurance from the Board 2. Introduction Despite it being an extremely challenging year and unprecedented demand in the emergency department during 2024/25, the Trust maintained a strong focus on quality assurance. This was undertaken through established programmes and clinical leadership oversight of key safety and patient experience indicators, including falls, pressure ulcers, and venous thromboembolisms. The Fundamentals of Care initiative continued to be embedded, supported by high-quality peer reviews and weekly matron-led quality walkabouts aligned with CQC domains. The clinical accreditation scheme (CAS) was enhanced with updated documentation reflecting learning from themed walkabouts and aligned with national frameworks. A new governance framework for mortality and morbidity meetings was introduced to improve learning dissemination and escalation. The Trust also opened a Patient and Family Support Hub (P&FSH), advanced volunteer recruitment through a system-wide passporting approach, and began implementing NatSSIPs 2. In response to rising violence against staff, de-escalation training was rolled out, leading to a reduction in physical restraint and violence incidents. The Trust’s commitment to continuous improvement was demonstrated through training over 1,000 staff, outperforming NHS averages in improvement metrics, and achieving measurable service enhancements, including a 5.25% reduction in average length of stay, increased theatre throughput, and expanded use of patient initiated follow up pathways. Every year all NHS hospitals in England must prepare and publish an annual report for the public about the quality of their services. This is called the quality account and makes us at UHS more accountable to our patients and the public which helps drive improvement in the quality of our services. Quality in healthcare is made up of three core dimensions: Patient experience - how patients experience the care they receive Patient safety - keeping patients safe from harm Clinical effectiveness - how successful is the care we provide? 5 QUALITY ACCOUNT The quality account incorporates all the requirements of The National Health Service (Quality Accounts) Regulations 2010 (as amended) as well as additional reporting requirements. This includes: • How well we did against the quality priorities and goals we set ourselves for 2024/25 (last year). • It sets out the priorities we have agreed for 2025/26 (next year), and how we plan to achieve them. • The information we are required by law to provide so that people can see how the quality of our services compares to those provided by other NHS trusts. Additional information about our progress and achievements in key areas of quality delivery. Stakeholder and external assurance statements, including statements from our Council of Governors, Hampshire and Isle of Wight Integrated Care Board and Southampton County Council’s Health Overview and Scrutiny Committee. 2.1 Priorities for improvement This section reflects on the 2024/25 quality improvement priorities at UHS and outlines our quality improvement priorities for 2025/26. 2.1.1 Progress against 2024/25 priorities Last year, we upheld our commitment to delivering the highest standard of care, influenced by various national, regional, local, and trust-wide factors. Throughout the year, we encountered unprecedented demand on our services, contending with challenges related to operational, capacity, patient flow, infection prevention, and safety. Despite these difficulties, we were confident in our ability to maintain our focus on quality priorities. Our teams worked diligently to achieve their goals under these challenging circumstances. We are proud to present our accomplishments and how our successes have continued to enhance the quality of services we provide to those who rely on us. 6 QUALITY ACCOUNT Overview of success Core dimension Patient experience Patient safety Clinical effectiveness Quality priority Progress Exploring the provision of a support centre for people using our services. Creating a behaviour framework behind our values, bringing them to life to improve our patient and staff experience. Volunteering - a new focus. Achieved On hold Achieved Acuity and deteriorating patients: continuing to improve how we keep patients safe from harm. We will ensure that Fundamentals of Care (FoC) are provided to all our patients in collaboration with our patients, their family, and their carers. Improving our morbidity and mortality (M&M) meetings. Achieved Achieved Achieved Develop the Trust’s approach to reducing the impact of health inequalities (HIs). Help develop a UHS quality management system approach. Achieved Achieved 7 QUALITY ACCOUNT 2.1.2 Quality Improvement Priorities - 2024/25: Final Reports Quality Improvement Priority One: Exploring the provision of a support centre for people using our services (year one) Why was this a priority? UHS is a regional centre for many disease types, but we recognise there is inequality in provision of support facilities in the Trust for all our patients and their friends and families regardless of their clinical conditions. While cancer patients have access to designated centres such as The Maggie’s Centre and Macmillan facilities, other disease types have no comparable options despite often having enhanced needs. Patients who are nearing the end of their life are frequently spending their final days in bays with other patients as side rooms are prioritised for isolation purposes, and there are few areas available that can accommodate a hospital bed for patients to have time with their family away from their clinical setting. Apart from the UHS Patient Support Hub, there are no designated spaces that are accessible for patients, families, or carers, often resulting in staff offices and education rooms being inappropriately repurposed to meet their needs. Growing feedback from complaints and Friends and Family Test (FFT) responses emphasis our inability to provide patients, carers and their families access to spaces for respite and support. In addition, a recent UHS carers survey indicated that while we recognise that being a carer can sometimes be demanding both physically and emotionally, there are no designated areas for them to have their own personal needs met. Creating a bespoke support facility at UHS would help to address these needs and would be the first facility of its kind in an acute trust in England. What have we achieved? Estate has been identified. Work has started to repurpose the underutilised Macmillan Centre into a generic non-disease specific Patient and Family Support Hub. This agreement made through the Trust Investment Group was to end the current agreement with the Macmillan charity and to approach Southampton Hospitals Charity to support a refurbishment and further investment into the hub (for example funding a carers shower provision). Key areas identified for further development • Major grant request submitted to Southampton Hospitals Charity due to go to Charity Trustee Board in March 2025. • Recruitment of a band 7 mnager role (appointed in January 2025 and starting 31 March 2025); • Rebranding and merging (of current Patient Support Hub) started in February 2025. 8 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? Once the Patient and Family Support Hub is launched there will be a constant drive for patient and service user involvement, co-designing the space, there will be surveys on before and after, end of life quality of care will improve Progress metrics • Reduction in adverse event reporting that a patient died in an open bay. • Carers survey improvement. • P&FSH FFT results. Quality Improvement Two: Creating a behavior framework behind our values, bringing them to life to improve our staff and patient experience Creating a behaviour framework behind our Trust Values to bring them to life in our everyday work and interactions is still very much a priority. However, the work has been paused to ensure it aligns to the development of the new Trust strategy, both these pieces of work need to be produced side by side. It is anticipated the work on the behaviour framework will commence alongside the development of the overall Trust strategy and timelines for launch and embedding will move to 2025/26. 9 QUALITY ACCOUNT Quality Improvement Priority Three: Volunteering Why was this a priority? To value the contribution our volunteers make to our organisation, we wanted to improve the onboarding process to provide more guidance and support for our volunteer colleagues, and to work with them more closely to build in flexibility and be more creative in the kind of roles and support they could offer. What have we achieved? • We worked with our systems partners to complete a successful bid through Volunteering for Health (VfH) and have plans to develop a unified and standardised approach of volunteer recruitment using a passporting system. • Our key relationship is with the Hampshire and Isle of Wight Voluntary Community and Social Enterprise (VCSE) sector Health and Care Alliance (HIVCA) and it has allowed us to further explore a more system-wide approach, with a view to sharing resources, ideas, and opportunities both internally and outside the organisation on a regular basis. • We have worked with HIVCA and fostered a collaborative learning environment, aiming to streamline and standardise the volunteer onboarding processes over the coming year. • We have built upon current onboarding and training processes and are particularly developing the enhanced care training for our volunteers to support their awareness of working alongside patients who have mental health issues, dementia, delirium, learning disabilities and autism. • We are working with information governance leads to consider how the Trust’s internal policies can create equitable opportunities for a range of volunteers, to support them in accessing limited patient records, to allow them to document the interactions that they have with patients in support of the provision of collaborative holistic care. • We have begun to develop a new “ABC” approach to offering our volunteering roles, codesigning new roles for volunteers, and providing a flexible ‘responsive volunteering’ process that can support the organisational pressures as they arise and dovetailing the offer from our experience of care teams. • We have started to build relationships with the NHS care responder volunteer’s service looking at how they can enhance our existing offering provided by our responder volunteers. Key areas identified for further development • We have more scope to develop a more robust support process for volunteers during their placements through building better relationships between the volunteers and their clinical teams. • We will grow our volunteering hub space in spring 2025, to offer a more effective space for volunteers to access practical and welfare support from voluntary services, giving them a clear base and point of contact. • Working with HIVCA in the system-wide partnership, we will continue to explore the VfH funding and how it can develop the ‘passporting’ system for the volunteers across the network. • As our new Patient and Family Support Hub becomes established, we will work with the NHS responders and our existing responder volunteers to ensure a more extensive five to seven day/ week service (including evenings). 10 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? The key metrics for measuring these outcomes will come from: • Our responder volunteer statistics through the Patient and Family Support Hub. • Our outcomes associated with the HIVCA partnership and the VfH bid i.e. progress with a passporting system including potential recruitment of a post to develop and establish this new system. Progress metrics • Year one funding from the VfH bid was received by the partnership to develop the partnership with the HIVCA support meetings every six to eight weeks. • The system-wide volunteer onboarding and passporting system has not yet been established but will continue to progress with the partnership. • We will have developed a responsive volunteer network, available five days a week with an established support system in place. • We are an open and inclusive recruiter of volunteers and monitor the equality, diversity and inclusivity of the volunteers we recruit, seeing a more diverse range of volunteers that begins to more accurately represent our local community. What our patients/relatives/carers tell us 11 QUALITY ACCOUNT 12 QUALITY ACCOUNT Quality Improvement Priority Four: Acuity and deteriorating patients: continuing to improve how we keep patients safe from harm ADULTS AND PAEDIATRICS Why was this a priority? The recognition, assessment, and escalation of a deteriorating patient either adult or child are a key element of our trust-wide patient safety and quality strategy with the aim of improving clinical outcomes for acutely ill patients. How rapidly we respond to patient deterioration both in and out of hours is a key determinant of patient and quality outcomes. What have we achieved? Five new starters have successfully completed their supernumerary period. The critical care outreach team (CCOT) resumed its 24/7 service on 16 December 2024. Recruitment for the final vacancies was completed in December 2024, with both new recruits scheduled to commence their roles by 31 March 2025. An education task and finish group has been established, which has conducted a gap analysis with all education leads and reviewed both internal and external training resources. Standards are currently under revision. The medical education and simulation team is testing the Acute Life-threatening Events-Recognition and Treatment (ALERT) course, which includes resident doctors and junior nurses. Initial feedback was presented to the deteriorating patient group on 25 September 2024. The Trust’s acute deterioration education day continues to review feedback and evaluations for study days. The acuity surveillance pilot was successful, and the CCOT is now formally implementing this initiative. Monthly acuity reports are generated at the Trust, division, care group, and ward levels, or through bespoke reporting. These reports incorporate various metrics, including National Early Warning Score 2 (NEWS2) and National Paediatric Early Warning Score (NPEWS) activations, Call 4 Concern activations, a 24-hour overview of NEWS2 activations, cardiac arrest calls, CCOT activations and reasons for referral, and unplanned admissions to the intensive care unit (ICU). Quarterly data on cardiac arrests, Treatment Escalation Plans (TEP), and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) are presented to the resuscitation committee and the deteriorating patient group (DPG). Challenges persist in collecting robust sepsis data. UHS is participating in the national Martha’s Rule pilot programme, with Call 4 Concern implemented in March 2024 and all activations reported on Ulysses. A task and finish group has been established to explore patient wellness questions, which is a fixed agenda item at the DPG. The bi-monthly DPG has been established, with increasing medical engagement, and regular reports are submitted to the patient safety and quality committee (PSSG). Key areas identified for further development • Further roll out of Martha’s rule UHS-wide including Call 4 Concern. • Gain feedback from divisional governance teams regarding incidents to ensure learning is identified and appropriate action plans are devised and implemented. Collaboration with maternity and neonatal services. • Development of acuity dashboard. • Medium- and long-term service development commenced including workforce planning. 13 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? • Bimonthly deteriorating patient group meetings to review current trends and themes, implementation of appropriate actions and evaluation of actions. • Biannual review of deteriorating patient group terms of reference. • Quarterly report to patient safety steering group. • Yearly assurance report – Trust quality committee. Progress metrics • Patient observation compliance data. • NEWS2 and NPEWS activations and data analysis. • Analysis of all unplanned admwissions to ICU from ward areas – adult and paediatric for themes to inform education and practice. • Adult and paediatric ICU stepdown data. • Adult critical care outreach team activity and outcome data. • Adult and paediatric cardiac arrest and outcomes data. • Adult TEP & DNACPR data. • Complaints and adverse event reports related to failure to rescue and failure to escalate. • Percentage of patients diagnosed with sepsis within the emergency department receiving appropriate antibiotics within one hour of sepsis diagnosis. • Analysis of adult and paediatric Call 4 Concern data, action plan developed, implemented, and adjusted in response to themes. • Analysis of patient/service user feedback on Call 4 Concern service. • Analysis of staff feedback on Call 4 Concern service. Volunteers and quality patient safety partners helped to promote the Call 4 Concern work 14 QUALITY ACCOUNT Quality Improvement Priority Five: Fundamentals of Care Why was this a priority? Patient Experience - Fundamentals of Care (FoC) was established as a priority in 2024/25 due to evidence that post COVID we had not yet returned to a less task-focussed and more patientfocussed level of care. The priority was developed to create a foundation and structure to tackle these care standards of care and to challenge practices, in response to patient and relative feedback. What have we achieved? Since commencing in late 2023 the following has been achieved: • We have established the FoC project board and this group continues to meet every three months to provide an overall project view, share successes and opportunities for learning, discuss the workstreams continuing under the eight standards and to escalate challenges through a formal governance structure (through quality committee and QGSG). • We have had one quality patient safety partner (QPSP) on the project board since conception. Subsequent events have involved two other QPSPs and have broadened the ‘patient voice’. • Each of the standards has a lead who oversees a multi-professional working group with clinical team representation. Some groups have chosen to pair due to links in their primary and secondary project drivers and actions. Matron involvement is driving the patient facing team involvement. • The project board is minuted, with an action tracker. The board is attended by the corporate nursing team and is supported by our deputy chief nurse, chaired by our head of patient experience. It is also supported by our chief nursing informatics officer, members of the transformation team and communications. • There is a FoC project manager in place who has worked with the transformation team to create a project plan in collaboration with workstream leads, a communications plan and drive forward key initiatives including business intelligence and the development of a clinical quality dashboard so we can measure the impact of the FoC. • Enhancing leadership and role modelling of the FoC has been a key focus through leadership in practice study days. These sessions, held three times annually, target leaders across the organisation to address and challenge behaviours related to the FoC. Incorporating the patient voice, these study days are grounded in real patient stories and involve the practical application of skills using simulated patients. 15 QUALITY ACCOUNT • As part of the patient hygiene working group, we have undertaken surveys using volunteer support, of patients and staff in the clinical decision unit (CDU), acute medical unit (AMU3), trauma assessment unit (TAU) and Macmillan acute oncology service (MAOS) in relation to their experiences of patient hygiene care and the impact of the trial patient hygiene packs. • Existing surveys, PALS interactions, complaints, adverse event reports (AER), Friends and Family Test (FFT) are followed up and reviewed by senior managers accordingly. These inform the FoC workstream through the head of patient experience. • Since conception, sharing the patient perspective and reflecting what patients would like to hear from us has been key. The posters around the organisation on our care commitments and resources on staffnet and the virtual learning environment (VLE) for staff, support this. These resources include: o Resources developed by each group to share during the monthly focussed trolley dashes. o Videos developed by staff for staff, to improve awareness of some key facts about each of the eight standards. Staff on Bassett ward engaging patients with dementia in crafting activities • Strong presence of the FoC throughout education as it has been mapped to the health care support worker (HCSW) induction, is included on preceptorship for all staff groups, has been presented to some university students at the University of Portsmouth and is embedded in lots of local training and development initiatives. The head of patient experience delivers many sessions across the organisation and beyond. Head of patient experience engaging with clinical staff in cardiovascular and thoracics on how to assess the FoC in their area 16 QUALITY ACCOUNT • The What Matters To Me (WMTM) project was trialled in some clinical areas from October 2024 (F7 and G7). Due to challenges in engaging the volunteer support to maintain this project it has temporarily been halted. The boards have an agreed template, agreed by a QPSP, and based upon feedback from staff and patients. The values of this project are echoed in local projects we have seen. • The FoC is being reviewed in conjunction with matron walkabout and the clinical accreditation scheme (CAS). Starting in February 2025, a new monthly focus is being established, with five core questions associated with a FoC standard and five specialist questions associated with that topic. This is forming past of ward benchmarking with a new self-assessment tool being implemented. Key areas identified for further development • Clinical representation in these working groups is to be re-established/built upon to support further engagement in the clinical areas/teams. • Continuing to establish links and support in child health, maternity and outpatients to ensure a bespoke but collaborative roll out of FoC. • To continue strong patient engagement and involvement, linking with involved patients where required with the support of our existing FFT results, the national inpatient and urgent and emergency (U&E) care surveys. • Resources to continue to grow to create a repository of information for staff and develop their knowledge around the FoC and to support each other in challenging behaviours and practices. • Employ interim project manager to maintain the project and support new ones whilst the current project manager is on maternity leave, focusing on establishing the dataset to evidence the FoC. • Strengthen the recruitment of volunteers for WMTM through the successful bid to Volunteering for Health (VfH) through the recruitment and investment in a volunteer coordinator, as part of a partnership with other organisations in Hampshire and Isle Of Wight (HIOW), including the charity sectors. • Successful implementation and evaluation of WMTM boards across key areas in organisation, with full volunteer support for the obtaining of photographs of the patients from themselves/ families to maintain that person-centred focus. How will ongoing improvements be measured and monitored? Improvements will be measured and monitored through FFT feedback, feedback from selfassessment tools and ongoing surveillance of the clinical quality dashboard. Progress metrics Reduction in clinical Iincidents: We’ve seen a decrease in the number and severity of incidents related to the FoC across inpatient settings. A key theme in early 2024 involved patients reporting being asked to urinate in incontinence pads. Six adverse event reports (AERs) were recorded in Q1, with none reported in Q3, indicating improvement. Reduction in complaints: While we don’t yet tag complaints specifically to FoC, we’ve observed a decline in ‘patient care’ complaints - from 14.67% in Q1 to 13.91% in Q3. We’re also exploring refinements in complaint categorisation to better align with FoC themes. 17 QUALITY ACCOUNT Increase in compliments: Patient and family feedback is gathered through various channels. For example, our urgent and emergency care survey showed an overall satisfaction score of 7.68/10. Improved oerformance against metrics: Throughout 2024, we’ve redesigned our improvement metrics in collaboration with clinical teams. These are now reflected in the clinical quality dashboard, supported by a comprehensive data dictionary developed by our project manager. 18 QUALITY ACCOUNT Quality Improvement Priority Six: Improving our morbidity and mortality (M&M) meetings Why was this a priority? The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents. It supports our processes for learning and improving patient safety and clinical effectiveness and replaces the old serious incident framework. An important element of the PSIRF is the focus on strengthening the processes for local learning through M&M meetings. M&M meetings (or clinical review meetings) have a central function in supporting our services to achieve and maintain high standards of care. They allow us to review the quality of the care that is being provided to our patients and learn lessons from outcomes. They are multi-disciplinary meetings which provide a safe place for learning, for supporting comprehensive conversations and ensuring governance standards are met. They allow us to identify any opportunities for improvement and are an important opportunity for education. They also provide opportunities for senior staff to model appropriate professional behaviour and engage the significant expertise of clinicians at the point of care. There is also a growing trend in M&M meetings to identify how resilience within complex systems enables good outcomes in the face of the kind of challenges and uncertainties which we are experiencing, and which are inherent within healthcare delivery. What have we achieved? The medical advisor for patient safety is leading efforts on morbidity and mortality (M&M) meetings. A comprehensive framework for M&M meetings at UHS has been developed, establishing expectations for a safe learning environment that is multiprofessional and multi-disciplinary, with a systematic meeting structure and agenda focused on learning, governance integration, and patient-centred care. This framework is supported by a handbook, resources, and education for M&M leads. A dedicated Teams channel has been created to provide resources for M&M leads. An M&M workshop was held as part of the WHO Patient Safety Day on 12 September 2024, focusing on creating strong learning environments, maintaining patient centrality, and learning from palliative care. The workshop was attended by 20 M&M leads and governance representatives. Additionally, 20 M&M leads attended a study day on 23 January 2025, covering topics such as human factors and systems thinking, PSIRF, keeping the patient central, appreciative inquiry in M&M, creating strong learning environments, managing difficult behaviour, and expanding the scope of M&M beyond mortality. The study day was well received, and another is planned for early April. Regular meetings are held with M&M leads and the medical patient safety advisor to provide support and identify areas needing assistance. An electronic M&M recording system was developed and trialed to capture and evidence outcomes, but it is no longer supported by the Trust, prompting the investigation of alternatives. A clear escalation process from M&M meetings to the existing governance structure has been established, with actions recorded. M&M meeting outcomes are now a standing agenda item in governance meetings. 19 QUALITY ACCOUNT UHS - 6 key principles of M&M Safety A safe space for learning. A meeting atmosphere that is conductive to open discussion with a focus on ‘Just and Learning Culture’ and an emphasis on understanding the systems factors, not focusing on individuals. Multiprofessional and Multi-disciplinary Ensuring active participation across staff groups and different disciplines. Meeting Framework Systematic agenda selection process, structured meeting format and objective analysis of data, including consideration of systems factors, and human factors and ergonomics. Learning Focus Comprehesive discussions to generate actionable learning and system improvement. Using an appreciative inquiry approach to emphasise and learn from the every day, as well as where things can go wrong. Governance Hospital-wide system to record outcomes, lessons learned, and dissemination of recommendations to ensure action and learning. Supporting our integrated approach to quality across the organisation. Folow up to ensure actions are completed. Clear pathways for central reporting and escalation of concerns. Patient Centred Keeping the patient and the family central to the learning. Ensuring that the patient voice is heard when learning from events. Completing feedback and duty of candour to help build trust. Training as part of the WHO World Patient Safety Day: Discussing how to create psychological safety in meetings 20 QUALITY ACCOUNT Key areas identified for further development • Development of electronic recording process that can be used for all M&M meetings. • Need to develop stronger links and greater support from local governance. How will ongoing improvements be measured and monitored? Regular review of M&M meetings with the M&M leads to ensure that: • M&M meetings are represented by the multi-disciplinary. • Terms of reference are in place. • Incorporating mortality data. • Using a recording app (when available). • Outcomes are linked to actions and governance processes. Progress metrics The electronic recording system is not currently supported so we cannot measure this (and it makes it hard to audit actions and escalations as these would be audited via this). Survey of clinical staff (163 replies) and their view on M&M. Key findings: • 73% staff feel UHS views the meetings as important. • 75% that their department views these as important. • 60% that they are fit for purpose. • 75% that they make a difference to patient safety. • 80% agree that systems factors are considered. • 35% felt they were well supported by local governance. 21 QUALITY ACCOUNT Quality Improvement Priority Seven: Develop the Trust’s approach to reducing the impact of health inequalities (HIs) (year one) Why was this a priority? The causes of health inequalities are complex, but research has shown that the main drivers of health inequalities are social determinants; the environments people live in, access to employment and the kind of start they had in life. Inequalities are also driven by the ways in which health services are designed and delivered, and by the quality of clinical care received. The NHS plays an important role in both mitigating against the wider determinants and in reducing healthcare-based inequalities. As well as a moral and social responsibility, NHS trusts have a legal duty to consider health inequalities. A new requirement from NHS England asks that trusts describe the extent to which they have exercised its functions consistently with NHS England’s views set out in the statement on information on inequalities. Addressing health and care inequalities is a core focus of the CQC’s 2021 strategy. To reinforce this commitment, the CQC has outlined five equality objectives aimed at tackling disparities in health outcomes. They have made it clear that action will be taken where care falls short for particular groups. Providers are expected to proactively identify, engage with, and respond to individuals who face barriers to accessing care or experience poorer outcomes. These efforts will be reflected in the CQC’s assessment frameworks. Failure to address health inequalities also carries a significant financial burden for NHS trusts. Estimates suggest these disparities cost the NHS around £5.5 billion each year. Eliminating health inequalities could potentially reduce the volume of treatments provided by the NHS by up to 15%, easing pressure on services and resources. What have we achieved? Governance A health inequalities board has been convened, chaired by the chief medical officer and attended by representation across UHS, patient partners, public health teams from the local councils and the population health team within the integrated care board. The board has set some initial objectives. These will be delivered through five areas of focus, each with a dedicated sponsoring director and a detailed delivery plan. These areas of focus are: • Clinical priorities. • Data and measurement. • Enabling the organisation. • Communications and engagement. • Strategy and approach. Clinical priorities Three clinical priorities have been set, based on national guidance on services where there is greatest health inequalities impact. The public health leadership from the local councils and integrated care board were involved in this prioritisation to ensure that we chose areas with high prevalence locally, and where it was felt an acute trust can have greatest impact. Priorities set are tobacco dependency, hypertension and obesity. 22 QUALITY ACCOUNT Tobacco dependency In Southampton, smoking rates are higher than the national average. It is estimated that one in six Southampton deaths are attributable to smoking (JSNA, 2021). 70% of our lung cancer patients and 86% of our COPD patient deaths are directly attributable to smoking. People who smoke are 36% more likely to be admitted to hospital than non-smokers and have poorer treatment outcomes including reduced response to treatments, prolonged recovery and increased risk of complications, across many areas including surgery, cancer and cardiovascular disease (Royal College of Physicians, 2020). This leads to increased length of stay, higher rates of emergency department attendance and greater pressure upon outpatient clinics due to smoking-related comorbidities. We have been focusing on improving identification of those who have been admitted who smoke, increasing the delivery of very brief advice to all patients who smoke and increasing referral to tobacco dependency services on the ward for those who do not opt out. We’ve been reviewing our data to understand how we are supporting those most at risk of being impacted by health inequalities. Obesity In 2022 to 2023, 29.5% of adults in Southampton were estimated to be living with obesity, above the national average. Southampton has one of the highest childhood obesity rates in the county. There are a large number of conditions linked with obesity, including cardiovascular disease, hypertension and liver disease. There is a multi-disciplinary service provided at UHS for children which provides excellent outcomes, reversing clinical impacts such as hypertension and type two diabetes. This programme seeks to identify opportunities to collaborate with our system to prevent the increasing levels of childhood obesity, reflecting the national focus on left shift and prevention. Adult obesity services are in review across our system. Hypertension Hypertension is amongst the leading causes of death in Southampton and Hampshire. High blood pressure causes threat to life expectancy linked with stroke, vision loss, heart failure, heart attack, kidney disease/failure. Hypertension identification and control have both been a challenge across Hampshire and Isle of Wight. Although hypertension treatment is delivered in primary care, there are actions we are taking as a trust to support this important priority. This includes: • As the largest employer in the city we have the opportunity to improve health by supporting our staff. We are developing materials to support our staff to understand the importance of blood pressure monitoring and approach to accessing help with high blood pressure. We hope this knowledge will extend to families, communities and how we support our patients. • Support people to ‘wait well’ whilst on our waiting list, with improved guidance on controlling and monitoring blood pressure while waiting for surgery, reducing the number of cancelled procedures due to high blood pressure. • Consider how improved data sharing on blood pressure readings between UHS and GPs can support onward support for hypertension. 23 QUALITY ACCOUNT w Data and measurement Several positive steps have been taken in measuring and understanding health inequalities within our services. These have been: • Building new dashboard that enables us to assess whether access to our services in equitable related to IMD decile, age, gender and ethnicity. • Assessment of equitable delivery of smoking cessation services. • Assessing the acute impact of hypertension control. • Collaborating with the Integrated care board on producing the data required for national reporting guidelines. Enabling the organisation We wish to support staff across our organisation to understand health inequalities, to recognise them within services, to access to tools to enable service change and to have routes to escalate issues. We have appointed a health inequalities officer who will be a key link to support services to achieve this. We have begun developing training that will be available across the organisation. We have also established escalation routes for raising concerns related to health inequalities. Communications and engagement There have been a number of excellent case studies communicated during this year through existing communications channels such as the Connect magazine. HELIXR, a pioneering programme that supports vulnerable patients with chronic liver disease through the introduction of peer support workers, attracted news coverage and was featured on the BBC and ITV Meridian in March. We have been attending events across Southampton including Pride and the Black Business and Arts Festival to show our support and to connect with our communities. We’ve been reaching out to grow the number and diversity of our involved patients, aiming to reflect the diversity of our population in our feedback and helping us to better serve the needs of our community. Strategy and approach We have worked on establishing this approach to delivering health inequalities over the year, which is now seeing results in progress in all prioritised areas for improvement. We have taken discussions to our Trust Board to establish how we will move this important work forward in years to come. We have also reflected on how population health, prevention and health inequalities will feature in our developing updates to our trust and clinical strategies. Key areas identified for further development There are detailed delivery plans for all of our priority areas over the next year, which will enable us to keep driving towards our aims. Highlights from these plans include: • Designing and publishing health inequalities training for all staff. • Creating an internal staff campaign, recognising the impact of health inequalities within our people and providing advice. • Establishing a health inequalities operational group who receive escalations of health inequalities issues and assess trust-wide implications and support improvements. • Delivery of planned improvements within our three prioritised clinical specialties. • Connecting with our communities and engagement leads across our city, improving our insights into the local drivers of health inequalities and identifying improvement opportunities. • Reviewing our use of QEIAs for change and decision making. 24 QUALITY ACCOUNT • Development of Trust and clinical strategies with making impact on health inequalities included. • Making use of the data sets we have built to drive change within our services and measure our impact. How will ongoing improvements be measured and monitored? We have clear objectives against all priorities with delivery timelines. We will continue to assess our progress in delivering against these. The dashboards that have been built will enable us to measure change over time, demonstrating where we have been able to impact on the equality of access to services. We will continue to work with our patients to gain feedback on how well we have met their needs while under our care. Progress metrics During 2024/25, we significantly advanced data capabilities to measure health inequalities across UHS services. We now track outpatient and inpatient waiting lists, discharges, and emergency department performance by age, gender, ethnicity, and Index of Multiple Deprivation - enabling long-term impact assessment. Staff access to this data will also be monitored. While some planned measures were successfully implemented, others remain in progress and will continue into year two (2025/26) of this quality priority. As part of our hypertension programme, we aimed to reduce theatre cancellations and non-elective admissions. Pathway improvements are underway and will be implemented in 2025/26, supported by expanded data sources. Combined with the Hampshire and Isle of Wight Intergrated Care Board’s (HIOW ICB) cardiovascular disease (CVD)-focused ‘signature move’ in primary care, these efforts are expected to reduce non-elective admissions. HIOW ICB data for 2024/25 shows: • ~95 CVD-related ED attendances/month • ~420 non-elective admitted episodes of care/month • ~2,340 bed days/month Our tobacoo quit rates continue to be better than expected nationally. Throughout the year, the health inequalities board reviewed case studies from eight services, showcasing impactful improvement work. These have been documented to support organisational learning. 25 QUALITY ACCOUNT Quality Improvement Priority Eight: Develop a UHS quality management system approach (year one) Why was this a priority? In April 2023, NHS Improving Patient Care Together (IMPACT) was launched to support all NHS organisations, systems, and providers at every level (including NHS England) to have the skills and techniques to deliver continuous improvement. NHS IMPACT’s five components form the basis of all evidence-based improvement methods and underpin a systematic approach to continuous improvement: • Building a shared purpose and vision. • Investing in people and culture. • Developing leadership behaviours. • Building improvement capability and capacity. • Embedding improvement into management systems and processes. Taking a more integrated quality approach is also a key component of our ‘always improving’, clinical effectiveness and Trust strategies in support of our ‘outstanding patient outcomes, safety and experience’ strategic pillar. To establish our current position, the Trust undertook a self-assessment to gauge its organisational maturity against the IMPACT framework and identified ‘embedding improvement into management systems and processes’ as an area of opportunity to improve and employ best practice. It was also a recommendation from the Thirlwall Inquiry that organisations focus on their ability to triangulate different quality indicators to build
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/quality-account-24-25-final1.pdf

Aria ePrescribing v13.6 MR1.2 user training guide

Description: Aria E-Prescribing v13.6 MR1.2 User Training Guide Every effort has been made to ensure that the material in this manual was correct at the time of publication but cannot be held responsible for any errors or inaccuracies. We reserve the right to change or replace information contained in the manual without notice. For the most up to date version please refer to the UHS website. All references made to patient records are fictitious for the purpose of training only. Page 1 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager CONTENTS This training guide has been produced as a generic document for the 6 Trust of the former Central south coast cancer NETWORK (CSCCN); it can be used as an aid to producing cascade training guides either by role or profession at each individual trust if required.1 ................................................................General Course Information 2 2 Information Governance....................................................... 5 3 Logging on to Aria ................................................................ 7 4 Creating and Modifying a New Patient ................................. 9 5 Adding Patient History........................................................ 16 6 Patient EXAM..................................................................... 29 7 patient Vital Signs .............................................................. 53 8 PRESCRIBING .................................................................. 60 nb Once prescription Approved by prescriber and pharmacy either prescriber/nurse/pharmacy can move the date without the need to re-issue the prescription. By moving the date this will not produce a different pharmacy order number (yellow file) because no clinical amendments have been made. ................................................... 95 9 Pharmacy........................................................................... 96 10 nurse drug administration ................................................. 115 11 scheduling........................................................................ 127 12 Patient journal .................................................................. 149 13 Logging Off ...................................................................... 151 14 re-setting your Password.................................................. 152 15 Icon Glossary ................................................................... 153 16 Fault Reporting................................................................ 157 17 Help with using Aria ......................................................... 158 18 Version Control LoG ............................................................ 160 Varian have produced two reports for the SACT data; 182 SACT – Public Health Data – Patient Drug Administration Details – 2015 182 SACT – Public Health Date – Patient Drug Dispensed Details - 2015 182 THIS TRAINING GUIDE HAS BEEN PRODUCED AS A GENERIC DOCUMENT FOR THE 6 TRUST OF THE FORMER CENTRAL SOUTH COAST CANCER NETWORK (CSCCN); IT CAN BE USED AS AN AID TO PRODUCING CASCADE TRAINING GUIDES EITHER BY ROLE OR PROFESSION AT Page 2 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager EACH INDIVIDUAL TRUST IF REQUIRED. Page 3 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 1 GENERAL COURSE INFORMATION COURSE TITLE METHOD OF TRAINING DURATION PRE-REQUISITES E-PRESCRIBING ABOUT THE COURSE The Aria E-Prescribing software is a computer system that is used across the 6 Trusts of the former Central South Central Cancer Network (CSCCN). This course is intended for users who will be prescribing chemotherapy to patients, approving and dispensing chemotherapy in pharmacy and recording the administration of chemotherapy by nursing staff within the Aria application. SUITABLE FOR This manual is suitable for any user requiring access to the Aria system. This includes Clerical and Administration staff, Nursing Staff, Pharmacy staff and Clinicians. OBJECTIVES This course will enable the student to perform the following: 1. To be able to log on and off of the system 2. To record relevant patient history, diagnosis and vital signs 3. To prescribe specific chemotherapy regimens 4. To approve and dispense drugs in pharmacy 5. To be able to record the administration of chemotherapy to patients 6. To be able to enter patients into the scheduling system Page 4 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 2 INFORMATION GOVERNANCE Information Governance (IG) sits alongside the other governance initiatives of clinical, research and corporate governance. Information Governance is to do with the way the NHS handles information about patients/clients and employees, in particular, personal and sensitive information. It provides a framework to bring together all of the requirements, standards and best practice that apply to the handling of personal information. Information Governance includes the following standards and requirements: Information Quality Assurance The NHS Confidentiality Code of Practice Information Security The Data Protection Act 1998 Records Management The Freedom of Information Act 2000 Caldicott Report December 1997 What can you do to make Information Governance a success? Keep personal information secure Ensure confidential information is not unlawfully or inappropriately accessed. Comply with the Trust ICT security policy and Staff Code of Confidentiality. Do not share your password with others. Ensure you "log out" once you have finished using the computer. Do not leave manual records unattended. Lock rooms and cupboards where personal information is stored. Keep personal information confidential Only disclose personal information to those who legitimately need to know to carry out their role. Do not discuss personal information about your patients/clients/staff in corridors, lifts or the canteen Ensure that the information you use is obtained fairly Inform patients/clients of the reason their information is being collected. Organisational compliance with the Data Protection Act depends on employees acting in accordance with the law. The Act states information is obtained lawfully and fairly if individuals are informed of the reason their information is required, what will generally be done with that information and who the information is likely to be shared with. Make sure the information you use is accurate Check personal information with the patient. Information quality is an important part of IG. There is little point putting procedures in place to protect personal information if the information is inaccurate. Page 5 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Only use information for the purpose for which it was given Use the information in an ethical way. Personal information which was given for one purpose e.g. hospital treatment, should not be used for a totally separate purpose e.g. research, unless the patient consents to the new purpose. Share personal information appropriately and lawfully Obtain patient consent before sharing their information with others e.g. referral to another agency such as, social services. Comply with the law The Trust has policies and procedures in place which comply with the law and do not breach patient/client rights. If you comply with these policies and procedures you are unlikely to break the law. Page 6 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 3 LOGGING ON TO ARIA Access to Aria is via a Citrix connection. However local Trust policy will govern how much you see of this login process. Most trusts will have an Icon on the desktop which will take them to the login boxes below. Type in your user ID in the User ID field Type password in to the Password field Select the appropriate institutions in the ‘From’ and ‘Login To’ drop down boxes. The ‘From’ field will always need to be CSCCN The ‘Login To’ field will define what work location you are logging into. For example, what Ward or Clinic do you wish to work in? Click OK On subsequent logins the above ‘From’ and ‘Login to’ fields will be pre-filled as the system remembers what you last logged into. This can be changed at any point. On your first login you will be required to change your password from the one issued to you with your username. The following box will display: Page 7 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager There are certain parameters that need to be observed when creating a new password. These are: The password must be between 6 and 10 characters long have a letter as the first character be mixed case contain at least 2 numeric's be unique from the previous 5 passwords Examples of how acceptable passwords may look are below: Sunsh1ne1 Sunshine01 sunSh11ne On your first login you will also be required to confirm your details are correct within the Aria System. DO NOT CHANGE any details in this box. If there are any changes that need to be made contact your local IT Support who will look into it. Click ok. Page 8 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 4 CREATING AND MODIFYING A NEW PATIENT When logging into Aria Manager, the first window you see is the ‘Open Patient’ window. It is also possible to add patient status icons to appear attached to the patient record on the open patient window and other screens. Select Patient Workup – Patient Status icon from drop down menu Two icon that may be useful would be C/R (Concurrent Chemo-Rad) and Ambulance that could be used to indicate transport. Page 9 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Eg Chemo-Rad and Transport have been added to this patient and the icons appear on the top right of the screen The ‘open patient window’ shows all the patients who have been entered into Scheduling or who have had a ‘chart’ opened today. By highlighting a patient and then clicking on blue tick the following Patient Tracking window opens (actual Institution list may vary). Page 10 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By highlighting a patient and then right clicking on it a brief Patient Information window appears By clicking on the clipboard icon (to right next to bar code) a list will appear of the last 15 patient charts opened by the user. Page 11 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager In this window you can add New patients or Modify an existing patient – click on the relevant button on right of screen. Either New, Modify or View. In most cases within the network the requirement to add new patients to the Aria system will not be needed as there will be a data feed from the local Patient Administration System that will populate it. However, to create a new patient click ‘New’ on the right hand side of the screen. This will open the Modify Patient Window. DO NOT create a patient on Aria if there is a PAS data feed within your Trust as this may create duplicates on the Aria database. In the event of duplicate patient entry found please contact system administrator (d.kimber@nhs.net or Debbie.wright@uhs.nhs.uk) who will investigate and contact Varian if required. Page 12 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Patient Modify window The Tabs are: General – Where name, DOB etc… is stored Patient IDs – contains NHS, Hospital etc… Temporary Address Contacts – Next of Kin details etc… Demographics – Patient personal details for example Ethnicity and Religion. This screen is useful to record Advance Directives such as ‘Organ Donor’ and Feeding Restriction alerts. Providers - Details of patient’s Consultant – needed for SACT report Referrals – Details of referring clinician unlikely to be used Photograph – Unlikely to be used within the NHS General Tab To enter a New Patient the same will appear but it will be a blank template You can enter details in any of the tabs, much of this information will be imported by the PAS interface, but anything can be updated or amended. Page 13 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Patient IDs Tab In this window the NHS number will always appear along with any internal hospital ID. If appropriate you can also add a CDF PT ID, a Private PT ID or a Study #. Temporary Address and Contacts can be amended as necessary. Demographics Tab Demographics – any of these can be amended, the down arrow on right of a field means a drop-down list will appear. Advance Directives, if yes then you can tick any of these and they will appear later on. Page 14 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Provider Tab Providers must be completed, top box is the consultant and the bottom box is the GP – this may, or may not, come over from PAS. When the Provider is added in this window it will automatically populate the Visit Provider in Scheduling. This field is required in many reports. NB Relationship must be entered as Consultant for GMC number to populate in SACT and other reports Page 15 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 5 ADDING PATIENT HISTORY Once you have your patient in the system then you need to add some History. Highlight the patient, you can change the first window you view by amending the ‘Proceed to’ button on the top right of screen (next to bar code) e.g. Patient History. Click Open…button on top right The patient has opened in the Patient History window because that is what was selected under Proceed To. The second tool bar has now become available to use (starts Chart, History etc). If history wasn’t the default page then it can be selected by clicking on History (3rd button from left on top tool bar). The main sections to be completed are: Medical Procedure / surgical Family Social Allergies – this is essential Medications – this is essential Page 16 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager As information is entered the tab will change to blue in colour. Medical – this shows and then can be amended as necessary. Procedure/Surgical can also be entered here. Page 17 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Family – this window opens and then can be updated. Page 18 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Social – following window opens to be updated Allergies and Medications can be entered and this will then work in conjunction with the First Data Bank to look at drug interactions. Allergies – following window opens to be updated Page 19 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click on New, select the Type eg Drug Page 20 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager For Drug allergy, start typing the drug name in the Allergy box eg asp and then click on the torch button (right of screen) Page 21 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A list will of drugs will appear, select drug required eg penicillin V (tablet oral), OK Page 22 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Page 23 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Tick the Response or Other which will give a text box for comments. Click OK or Save – New to add another drug if necessary. The allergies will now appear on the Allergies window Page 24 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If no allergies tick “No Known Allergies” – these icons will be seen in numerous screen indicating whether an allergy has been recorded, no known allergy or no allergy information has been recorded. Medications – following window opens to be updated Page 25 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click New (bottom left) to add new medication, the following window will open Type in the start of the drug and then click the torch to search the First Data Bank and enter all relevant details, those will down arrows contain drop down selections. It is sufficient to only add the drug name because this is used to Page 26 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager check for drug interactions, contra indications etc, dose and frequency is not necessary. Click OK and drug now appears, this screen will also show any chemotherapy agents the patient is/has received. Page 27 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Page 28 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 6 PATIENT EXAM Once the patient has History updated the following stop is to enter Exam. Open the patient, from Open Patient window, you can change the Proceed To to Exam and then Exam window will open or if you Proceed To another window e.g. Patient History, the second Tool Bar will be highlighted and then select Exam (6th button from right), the following window will open. NB if you add Diagnosis/Problems via the History window you will not see the prompt for Performance Status, therefore it is recommended that you always use the Exam window when entering a diagnosis. Click New.., the following window opens Page 29 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager In the Code section, click the magnifying glass on the right and the following window opens Page 30 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This code type is ICD-10. In the search criteria select either Code or Key words, by selecting Keywords and typing lung the following appears Select the correct Clinical Description eg C34.2 Malignant neoplasm of bronchus or lung, unspecified and the following appears Page 31 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager The Definition page has now opened, and any of the white boxes can now be updated. There are also four other “tabs” now available Pathology – includes Cell Histology which is required to populate morphology in the SACT report Lesions Staging – required for SACT report Tumour Markers Pathology – following window opens Page 32 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Pathology Item Select Cell History (morphology for SACT) – following window opens to be updated Page 33 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Cell Category – drop down menu Cell Type drop down will populate once cell category has been selected Page 34 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Cell Grade drop down Page 35 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Lesions – open the following window Click New in either Local Lesions or Metastatic Lesions and the following window opens Local – Page 36 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Metastatic – Page 37 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Staging – opens the following window Click New (left of screen), some disease site staging will also have G (grade), all Criteria must to be completed to give Stage of the disease Page 38 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select Tumour eg T1 and add a date into the Date Staged box To get a complete staging also enter assessments for both nodes and metastasis; ensure a date is entered into the Date Staged box. Page 39 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Nodes Metastasis Page 40 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Approve and the information now appears as follows Click Save (left of screen). If you click Close you will be asked it you want to save changes as well. Page 41 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Close (right of screen) and the information appears on the Diagnosis / Problems window Page 42 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager RoS/PE – Review of Symptoms/Physical Exam – review of symptoms window opens Page 43 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Assess and the following window opens Select system(s) and disease site(s), click OK. It is advisable to tick all as normal and then only tick Abnormal to those that apply, as below Page 44 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Approve and the following appears on the ROS/PE window. You will see that the abnormal symptom appears with a red A. Page 45 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Physical Exam – following window opens Click Assess and the following window opens Page 46 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select system(s) and disease site(s), click OK. It is advisable to tick all as normal and then only tick Abnormal to those that apply, as below Page 47 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Approve and the following appear in the Physical Exam window, again showing any abnormal PE with a red circle. Page 48 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager NB: Both RoS/Physical Exam list can be customised by each Provider to show a shorter list if required. This is carried out in Manager (System AdminProvider/RoS Exam Defaults – select the Provider then Sites) Performance Status – the following window will appear Select Scale from drop down Page 49 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select Performance Status from drop down Page 50 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager The following appears Click Approve and the information now appears on the Performance Status window Page 51 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Page 52 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 7 PATIENT VITAL SIGNS Once Exam has been completed the next step is Vital Signs. In ‘Open Patient Window’ click to Open a highlighted patient, the second Tool Bar will then be available and click on Vital Signs, the following window will open. Enter the information; ALWAYS enter height and weight to calculate the BSA required to calculate drug doses. If a result is entered that is outside of the range set (see values in brackets) then alerts will be show; H = high value L = low value LL = very low value Alarm bell icon – can view extra information by clicking on it Page 53 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager See window below By clicking on the “pen” icon to the right of each line you can view Result History (selected from the drop down menu) Results can also be viewed in the Flow Sheet (click icon in second row) Page 54 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If you right click on any of the results you can also View Details eg BMI shows Page 55 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You can also see the doses of each drug administered and the toxicities recorded. NB Each drug has to be administered in the Drug Admin window to appear in the Flow Sheet Dose Recordings, therefore it is important that nurses do complete the drug administration. With a pathology interface you will also be able to view results in this window. Page 56 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If a result has been entered incorrectly and then “errored” you can view the results by selecting Assessments from the top row, then Tests from the drop down menu and select the required date eg Dec 23, 2015 Select View from the Results section at the bottom of the screen Page 57 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click ERR Result Set (top right of screen) to view the errored result Click on the E to view Reason For Error By clicking on the “pen” icon in the Results View window and selecting Result History from the drop down menu you can also view history eg Result History: Height Page 58 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Once all the details for the patient have been entered then treatment can be allocated. You must check you have completed the following data before you can enter any treatment for the patient; Modifying patient details/ entered new patient details History – including allergies Exam – including diagnosis / morphology / staging / performance status Vital Signs Once all the above have been entered then open the patient , change ‘Proceed To’ to Medication and open the patient, the following window will appear you can then select the treatment required, from the diagnosis already entered the list will then filter by disease site e.g. lung, breast etc and show the regimens entered in those disease areas. Page 59 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 8 PRESCRIBING The system will default to regimens assigned to patient diagnosis No BSA (right of screen) indicated that no Vital Signs have been entered Eg for a lung diagnosis the following will appear in top box with sub folders, if applicable eg SCLC, NSCLC and mesothelioma Page 60 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click the folder to show the regimens for lung NSCLC Select the regimen required, the following will appear Page 61 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You can see that this is the first cycle, see Cycle on right of screen. NB: Information page (right of screen below Cycle box) – this is the protocol summary, however from October 2010 protocol summary will no longer be shown here. You can view protocols by clicking Applications – Protocols (top row of the screen) this will then open the UHS website page which contains protocols. Alternatively you need to view the protocol please refer to UHS website (http://www.uhs.nhs.uk/HealthProfessionals/Extranet/Services/Cancercare/Chemotherapy-protocols/Chemotherapy-protocols.aspx ) Select Blue square in select box on right of screen to select all the Order button will be available and a tick will appear in the Day 1 and Day 8 box (or manually tick Day 1 and/or Day 8). Day 1 + 8 can be ordered at the same time as two separate files will be produced for pharmacy orders. Page 62 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Order…, if no value is present for creatinine the following message will appear NB although creatinine result might be available via pathology interface it needs to appear after height and weight have been entered to be able to calculate the dose, therefore at cycle 1 it may be necessary to enter the result manually. Click CrCl button on right of screen and enter the Creatinine result in this window, then Approve Page 63 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Now select Order on top right of screen you will see the Dose Calculation Management pop up box to enable the height, weight and BSA to be reviewed Page 64 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Enter consultant in Ordered by, and complete Line of Tx, Tx Intent and Tx Use (these are required for SACT report) Page 65 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By highlighting one of the drugs more buttons will become available on the right of the screen, as below To change the date for the whole regimen – click on the calendar page next to Start on below the Ordered by box. To change the date for an individual agent – click Adjust Start on right of the screen, and then select the required date. Page 66 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By highlighting an agent and then clicking on the up and down arrows on the bottom right of the screen you can change the order of an agent. OR By clicking the “pen” icon (next to the Approve box) you can change the order of an agent eg move pre-medication to the top of the list, change the Rx Seq # to the correct order. You can now add any support eg extra antiemetic support (that are not already included as part of the regimen) or favorites eg antibiotics, as required. Click Favorites and the following window appears Page 67 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A list of files will appear eg antiemetics, antibiotics, skin care etc, click the file to open and the list of drugs in that file will appear. Page 68 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select the drug required and click Add to add it to the regimen. Support – click the support tab on top right, and the following window appears The support regimens have been set up in files. Click the yellow file and a drop down will appear (the same way treatment is allocated) Click on TTO Levomepromazine and the support regimens will appear. Page 69 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Tick the regimen (the same way treatment is allocated) and click Add to add to the regimen. NB – some support regimens selected here need to be added to each cycle individually they have not all been set up for cycles of treatment only courses eg 21 days. (see Appendix 2 and 3). You can Adjust Dose, Adjust Start etc. It is advisable NOT to adjust any drug dose using the Modify button only use the Adjust Dose button. Any dose banding will be removed if the dose is amended in the Modify window. Dose banding is only applied when using Adjust Dose button. Click Adjust Dose and the following window appears Page 70 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You can select Dose Modification from the top line eg 75%, 50% etc however this will reduce all agents including any antiemetics that have been prescribed unless you select Change Chemo. Therefore it is advised to dose reduce per agent and remember to include a reason in the Modification Reason, either by clicking on the drop down arrow or entering text in the bottom right text box. In the Calculation / Rounding column the red dots denote dose rounding and the red circle dose banding has been applied to that particular agent. You will see that gemcitabine has been reduced to 75% of the original dose and the reason given was infection. Page 71 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This message will appear when agent appears in more than one day of the cycle. The Order / Rx page now shows the dose reduction to 75% in red and at the end of the drug line the Dose Mod. Reason has a page with lines on it. Page 72 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If the drug has been set up with dose banding (eg gemcitabine) when you Adjust Dose a red circle appears next to the Calculation/rounding dose Page 73 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By clicking on the red circle you can view the dose banding table set up for the drug dose eg gemcitabine The red dot with a number indicated the agent is rounded to the nearest eg carboplatin in this regimen is rounded to the nearest 50mg If no “rounding” match is found for an agent then the default rounding is used; Up to the nearest 1 for calculated doses > =10 Up to the nearest 1/100th (0.01 decimal place) for calculated doses <10 Page 74 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager When ordering subsequent cycles you can view the previous doses from the last cycle Click on the note pad to the left of Last Ordered This shows the dose of current order at the top and the dose of the last order at the bottom. Once all drug doses are correct then the prescription has to be approved. Page 75 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click the Approve button on the bottom of the screen and the following User Authentication will appear – this is the prescriber electronic signature Click Ok the First Databank Interaction Screening window appears Click Accept the printing window will appear select Internal to print agents for administration in hospital, select Pickup-Internal for TTOs or both as appropriate. Page 76 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If you click Cancel at this point the prescription is put as “pending” in the Orders/Rx window, and a prescription will not be printed despite the printing box just having appeared on the screen. However when the treatment is “approved” the prescription will print (along with any that you “cancelled” at this point previously eg if you clicked Cancel twice 3 prescriptions will print one for each of the cancelled actions and the actual approved one – they will however all be the correct version) Although you can only see the oral dexamethasone all the drugs have been approved. In this window you are approving the prescription to be printed either to pharmacy, in clinic etc. Click Approve and the following window appears (Treatment) Page 77 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By clicking on the pen in the Treatment box (next to 4 x 21 days) you can Modify / Delay / Discontinue / View Regimen decisions Modify – This currently shows the Active treatment days. Page 78 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Day 8 treatment can be omitted by clicking Inactive on the required drug Page 79 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Alternatively by clicking Custom you can state which cycle to Inactivate You need to click the speech bubble (next to Ordered By) before this action can be approved (NB the speech bubble only appears for a non-prescriber). Page 80 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager NB: Any notes that are entered when using the “speech bubble” do not show again anywhere on the screen in Aria but are kept in the database, they can only be viewed by a Varian database analyst if requested to do so for a full patient history audit. Therefore Varian suggests using the patient Journal (see section 12) which is aimed at being a running commentary of patient events. Click Ok and then Approve button will appear so that any modification can be approved. Page 81 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This message will appear if no reason for making change is entered When back in the Treatment window the Inactive days will be shown in red. Page 82 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Delay – If a prescription has been Approved and Dispensed then use Delay here to move treatment date. You cannot Re-issue the prescription once dispensed. Also add a comment to the patient journal to record this action (see section 12). Page 83 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Ordered by must be selected and again the speech bubble (top right) must be completed before this action can be approved eg delay for 1 week Click OK then approve, the delayed regimen will show “delayed” in red against it Page 84 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If any agent has been missed off or there is a need to add another agent after the treatment has been approved, click New (top right of screen) and then add the Favorite/Support as required. Page 85 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This will now show as “Other Drugs Ordered”. Page 86 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager If you need to add any additional information to an agent eg actual start date for GCSF – highlight agent Click Modify The Admin Instructions box on the bottom left of the screen contains the information that will print of any prescription. Therefore enter the start date in the Admin Instructions box. Page 87 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click OK Discontinue – the following message will appear By clicking yes the following box will appear, as above click the speech bubble before approving. Page 88 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager NB – If you are discontinuing a regimen but there are still agents to be administered ensure you select the correct dose recordings you wish to discontinue. It may be that you need to select “Starting from effective date ... “ to enable to the remaining agents from the cycle to be administered. Once approved the following will appear Page 89 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By clicking on the medication history you will see all previous treatment. Page 90 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A patient must have treatment discontinued before any new treatment can be allocated. NB – any extra antiemetic support medication associated with the treatment must also be discontinued BEFORE the treatment, it will not automatically be discontinued with the treatment, you need to select each regimen and discontinue as above. To delete an agent in a regimen: By highlighting an agent the Delete button becomes available (NB it is preferable to delete rather than discontinue to enable ability to “undelete” the agent in future cycles if necessary). This confirmation message will appear. Page 91 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager The deleted agent appears on the Orders/Rx window scored out and also when Approved in the Treatment window Page 92 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Another useful way of finding information about the current treatment is in the Treatment window; by clicking on the pen icon at the end of each line you can view information about each drug for each specific day of each cycle, the same information can also be found in Flow Sheet (see section 7). For example, gemcitabine - shows dose given, the red cross indicates not Dispensed For example gemcitabine - indicates a drug modification any Dose Mod Reason can be viewed by clicking on page to show any reason entered. Page 93 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager NB a red star appears next to Ordered if the dose administered in Drug Admin differs from that Approved by the prescriber, the reason for this may be that pharmacy made an amendment when dispensing the drug, which would follow through to the Drug Admin window but would not change the original prescribed dose. For this amended dose to appear in future cycle the prescriber would need to adjust the dose in the Treatment window. If a prescriber has Approved treatment and then wishes to amend any part of the prescription, in the Orders Rx window the order can be re-issued (5th button down on right of screen) causing the treatment to be put back into a Pending state for the prescriber to amend and then Approved in the usual. Page 94 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager However a prescription cannot be re-issued if pharmacy has already dispensed it, it would need to be discontinued or ‘un-dispensed’ by pharmacy. If only the dates need changing this could be carried out in the Drug Admin window (see section 10). NB Once prescription Approved by prescriber and pharmacy either prescriber/nurse/pharmacy can move the date without the need to re-issue the prescription. By moving the date this will not produce a different pharmacy order number (yellow file) because no clinical amendments have been made. Page 95 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 9 PHARMACY Suggested order for pharmacy screening; Check patient journal to look at any relevant information entered by doctor, nurse, pharmacy etc Check bloods in flow sheet Check doctor approval time Pharmacy approve – check doses, can “review” prescription and screen Pharmacy dispense Once all the treatment has been approved pharmacy then need to review and approve the prescription. Click the Orders / Rx tab to open the following window (NB at this point the prescription can be re-issued back to the prescriber should any amendments be necessary – click Reissue button) You will now see that this treatment has been approved, if you click on the A after Approved you will see who prescribed (created), approved, signed (electronic authorisation box) and last modified the treatment (Prescription Order Audit Report). Page 96 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click on the yellow folder in the Order # column to open the treatment Click Review tab on the right to review the prescription details in pharmacy Page 97 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager View on the top tool bar will show all users who have accessed the patient record (select View - Access Log from drop down menu) – it shows user with date and time. Page 98 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager By clicking on the Rx button (right of screen) you can show the BSA (Dose Calculation Management) If “Cap” appears because Aria has capped the dose at 2.4m² you can click “Actual” OR “Cap” to switch between them should you have a large patient that you do not want to cap at 2.4m². You cannot reduce the capped dose to 2m² at this point the prescriber would need to “modify” the dose in the treatment window. By clicking the Screen… button on the right of the screen the following window appears, this links to the First Data Bank drug system showing interactions, contraindications, warnings etc. Page 99 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Once pharmacy has reviewed the prescription it then needs to be approved and dispensed by pharmacy. Page 100 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click on Pharmacy Approve button on the right of screen, following window appears Click on the yellow file to open the treatment, as below Tick the box next to the prescription and then click the Checked Approve button. Page 101 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A button = Ordered by Audit eg prescriber By clicking on the Rx √ button you can see who approved the treatment in pharmacy This is for all agents you cannot select individual agents therefore when you see the Rx √ it means that the whole prescription will be approved and therefore OK to dispense. To dispense the prescription in pharmacy click the Pharmacy Dispense button, the following window appears Page 102 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click on each yellow folder to open each drug, the Admin Date will appear Click the Dispense button on bottom left of the screen, the following window appears Page 103 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager At this point, if necessary, a pharmacy batch number can be added in the Drug Lot # field eg 124578 This can then be viewed by nurses in the drug admin window Any additional dispensing comments can be added in the note pad at the end of each agent, this can also be view by nurses in the drug admin window by clicking on the page icon next to Dispensing Page 104 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager At this point, if necessary, a drug dose could be modified by pharmacy, click Modify Dose button for the specific drug to be modified and the following window will appear. However this function should only be used as a last resort ie for compounding error so that the nurse drug administration screen is correct for the agent/vehicle supplied by pharmacy eg prescribed volume was 250ml but 500ml has been made or needs to be substituted to reduce wastage. It would be better to re-issue the prescription back to the prescriber to make any amendments. Page 105 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager When this Aria message box appears select No – this is because may agents have been set up as non standard Form/Route when dose banding was applied and if you click Yes you will be selecting a non dose banded agent. The reason for the dose modification can be entered and then will appear with a red star against each modified line. Page 106 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager The modification information can be viewed by clicking on the page button next to the red star and the following will appear as Dispensing Comments. Click Approve button on button right of screen this will return to the Prescription Dispensing window and the Dispensing details modified star now appears and the treatment is now showing as Dispensed Page 107 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager A button = the audit button in this window shows who has “dispensed” each agent Page 108 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You can print the prescription from this screen by clicking on the printer button at the botton, the following window appears, select Prescription Type You can check the printer by clicking on the yellow folder/printer icon on top right Page 109 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Pharmacy can view all treatment for a day or date range by clicking on Pharmacy button on the top Tool Bar, select Pharmacy Dispensing on the drop down that appears and the following window appears This is colour code to show when orders have been approved. Page 110 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Select Show Prescription Details at the bottom to show order and administration date and pharmacy status Click the “magnifying glass” icon to show the treatment Page 111 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Highlight the line below the patient name if the Rx box is showing then the following window will appear showing the Pharmacy Approval Details. If a patient is highlighted by clicking on the yellow file with red arrow on the far right of the screen that patient’s treatment window will open and the following will appear which takes you straight to the Orders / Rx details. Page 112 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Where patient scheduling is being used for patients prescribed treatment in Aria then Pharmacy can also view a list of treatment by selecting Pharmacy on the top Tool Bar, and then Schedule Drug Orders from the drop down list, the following window appears Page 113 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager There are several different filters on the top of the screen that can be applied e.g. date, Sort By and Drug To View either by Ordered, Pending or Planned e.g. select Ordered and click Show Orders the following list appears This can be printed off in pharmacy if necessary. Page 114 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager 10 NURSE DRUG ADMINISTRATION Once the pharmacy have dispensed the medication then the nurse needs to do the drug administration, to open click the Drug Admin button on the second Tool Bar, the following window appears The patient Date of Birth can be seen after the name and gender on the top right of screen above Dose Recordings tab By clicking View on the top bar you can check patient demographics. By highlighting an agent and then clicking on the up and down arrows on the bottom right of the screen you can change the order of an agent. The days of administration can be amended by clicking Adjust or Adjust All buttons on the bottom on the screen, the following window appears. However this should not be used routinely but only as a last resort if not previously adjusted by the prescriber. Page 115 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager This can be adjusted by Days or Date, if Date is selected the current date and a calendar will appear next to the Days to Adjust box. Page 116 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Click Adjust (top right of screen) and the Admin date will change Click OK and the screen will return to the Drug Administration window Page 117 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager Highlight the drug to be administered and click Record button on bottom left of screen, the following appears Page 118 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager You will see any Drug Lot # if entered by pharmacy when dispensing. If you click on page icon next to dispensing you can also view any pharmacy comments. Enter the time of administration and click OK, the screen will return to the Drug Administration window and a C will appear to the left of the date, showing the treatment has been started but not completed. Page 119 of 182 Version 1 December 2015 D Kimber Network e-Prescribing System Manager To enter the end of administration, highlight drug, click Record and enter the end time and click Approve the Drug Administration window is now only showing agents still to be administered. Page 120 of 182 Version 1 December 2015 D Kimber Network
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Papers Trust Board - 9 September 2025

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

Description: Date Time Location Chair Observing Agenda Trust Board – Open Session 07/01/2025 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Fatemeh Jenabi, Specialty Registrar (shadowing Joe Teape) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 5 November 2024 9:15 Approve the minutes of the previous meeting held on 5 November 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance and Investment Committee 9:20 Dave Bennett, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:25 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:30 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 2 Report 5.4 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.6 Break 10:35 5.7 Finance Report for Month 8 10:45 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 ICB Finance Report for Month 8 10:55 Receive and discuss the report Sponsor: David French, Chief Executive Officer 5.9 People Report for Month 8 11:05 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Freedom to Speak Up Report 11:15 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.11 Guardian of Safe Working Hours Quarterly Report 11:25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 5.12 Learning from Deaths 2024-25 Quarter 2 Report 11:35 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendees: Natasha Watts, Deputy Chief Nursing Officer/Jenny Milner, Associate Director of Patient Experience 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report 11:45 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Lead Infection Control Director/Julie Brooks, Deputy Director of Infection Prevention & Control 5.14 Annual Medicines Management 2023-24 Report 11:55 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist 5.15 Annual Ward Staffing Nursing Establishment Review 2024 12:05 Discuss and approve the review Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Rosemary Chable, Head of Nursing for Education, Practice and Staffing Page 2 6 STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update 12:15 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Annual Assurance for the NHS England Core Standards for Emergency 12:25 Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendees: John Mcgonigle, Emergency Planning & Resilience Manager/ Danielle Sinclair, Deputy Emergency Planner 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 11 March 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 7 January 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB Finance Report for Month 8 5.9 People Report for Month 8 5.10 Freedom to Speak Up Report 5.11 Guardian of Safe Working Hours Quarterly Report 5.12 Learning from Deaths 2024-25 Quarter 2 Report 5.13 Infection Prevention Control 2024-25 Quarter 2 Report 5.14 Annual Medicines Management 2023-24 Report 5.15 Annual Ward Staffing Nursing Establishment Review 2024 7.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPPR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3a, 3b 1b 1c All 1b, 3a 1a, 3a, 5b, 5c Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 3x3 9 4x4 16 Open (Technology & Innovation) 3x3 9 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4 x3 12 4x3 12 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 3x5 15 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Mar 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 25 3 x 2 Apr 6 25 3 x 3 Apr 9 25 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x3 6 4 x 2 Apr 8 27 3 x 2 Apr 6 27 2 x 2 Dec 4 24 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x x x Minutes Trust Board – Open Session Date 05/11/2024 Time 9:00 – 11:30 Location The Ark Conference Centre, HHFT/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) (item 5.1) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Ali Keen, Head of Cancer Nursing (AK) (item 4.11) Kelly Kent, Head of Strategy and Partnerships (KK) (item 5.1) 4 governors (observing) 2 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of her activities since September 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Minutes of the Previous Meeting held on 10 September 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 10 September 2024. 3. Matters Arising and Summary of Agreed Actions In respect of action 1175, it was noted that there had been an increase in the number of incidents of delays in giving of medication or pain relief, missed symptoms, and insufficient staffing numbers. However, in part the increase in numbers of incidents was considered to be due to efforts to encourage reporting of such incidents, and the situation had improved more recently. It was agreed to close this action. Page 1 It was noted that there were no other matters arising or overdue actions. 4. QUALITY, PERFORMANCE and FINANCE 4.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 14 October 2024, the content of which was noted. It was further noted that: • The committee reviewed the lessons learned from the 2023/24 annual accounts, and noted that the issues encountered should be resolved in time for the 2024/25 accounts due, largely, to the implementation of a new finance system. • The committee also received a report in respect of the risk of impersonation fraud for bank/agency staff and the procedures that had been put in place to mitigate this risk. 4.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 21 October 2024, the content of which was noted. It was further noted that: • The committee had reviewed the Finance Report for Month 6 (item 4.7) and discussed the Trust’s re-commitment to its 2024/25 plan in support of its request for deficit support funding from NHS England. • The position in respect of cash was challenging and the committee discussed what the Trust should do in the final quarter of 2024/25. It was noted that the rules on when and how much cash support could be requested were somewhat unclear. • The committee discussed a potential expansion of the activities of UHS Pharmacy Limited, although it was subsequently noted that the specific potential opportunity had since failed to materialise. • The committee also discussed the Trust’s financial recovery programme. 4.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 21 October 2024, the content of which was noted. It was further noted that: • The Trust had been below its plan in terms of whole-time-equivalent (WTE) numbers, although this position would change from October 2024 onward due to the onboarding of newly qualified nurses and the failure of the Integrated Care System transformation plans to deliver in terms of reduction in patients having no criteria to reside and mental health support. • The committee noted the cumulative impact on staff of having to balance staff numbers, performance, and patient experience. • Whilst noting that the annual appraisal rate remained low, it was suspected that more appraisals than recorded had taken place, but that these had not been recorded on the Electronic Staff Record. 4.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 14 October 2024, the content of which was noted. It was further noted that: Page 2 • Patients’ access to a rehabilitation and recovery service during and after intensive care unit (ICU) admission was limited due to a lack of service provision. The Trust was non-compliant with national guidance in this area. • Due to resource constraints the Trust was unable to systematically roll out the National Safety Standards for Invasive Procedures (NatSSIPS) 2. However, it was noted that a solution to this issue was being considered. • There had been no significant improvement in terms of the Trust’s system partners in respect of supporting the Trust with mental health admissions. • The committee also reviewed the Maternity and Neonatal Safety Report, based on data available at September 2024, and including the NHS Resolution Maternity Incentive Scheme Year 6 progress update, the local response to the Care Quality Commission’s National Report Review of Maternity Services in England 2022-2024, and the Antenatal and Newborn Screening Annual Report 2023/24. 4.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • Whilst the commitment in the Autumn Statement to additional funding for the NHS was welcomed, it was unclear at this stage what this additional funding will mean in practice and how it would be allocated. • There had been recent media coverage of the Trust’s ongoing dispute with its porters following a press release by the UNITE union. • Arbitration proceedings were expected to commence in respect of a long- running dispute with BAM Construction relating to the construction of the east wing annex building. • Significant changes in employment legislation were anticipated between now and 2026, although, due to the nature of employment conditions in the NHS, it was not anticipated that these changes would have a significant impact on the Trust. • The new combined community provider, Hampshire and Isle of Wight Healthcare NHS Foundation Trust was launched on 1 October 2024. • A meeting had been held with the now independent hospital charity to discuss priorities over the medium term. • The national NHS staff survey had launched on 20 September 2024 and would run until 28 November 2024. It was noted that the participation rate thus far had been below that seen in previous years. • The Trust’s quality and patient safety partners programme had won the ‘Patient Involvement in Safety’ award at the Health Service Journal’s Patient Safety Awards on 16 September 2024. • There was a concern that the Government’s intended 10-Year Plan for the NHS, which was expected to redirect focus on prevention and community healthcare, could result in an immediate loss of funding for acute providers, i.e. before the longer-term preventative measures had had an opportunity to take effect. 4.6 Performance KPI Report for Month 6 Joe Teape was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s overall performance was good compared to other teaching hospitals. In August 2024, the Trust was first for its 65-week wait performance, and second for the 60-day cancer metric. Page 3 • The month of October was proving to be challenging with increased bed occupancy and surge capacity having to be opened. Type 1 Emergency Department attendance was over 400 per day. • Whilst there had been improvements in the length of stay, the impact of this had largely been negated by the high demand being experienced. • The ‘W-45’ initiative was to be implemented at the end of November 2024, whereby ambulances would automatically hand over patients to emergency departments after 45 minutes. It was noted that this policy would potentially put strain the relationship between the Emergency Department and the South Central Ambulance Service (SCAS). • It was noted that there were potential issues with the data presented in terms of the number of virtual appointments and use of MyMedicalRecord. The Board discussed the high levels of attendance in the Emergency Department. It was noted that: • The Trust’s winter plans did not assume 400 attendances per day. • Attendances were typically of higher acuity, and did not appear to be as a result of patients being unable to access GP services. • The Trust had a number of projects underway in order to direct patients to alternative routes into the hospital, such as through the Same-Day Emergency Care service. • The importance of ensuring the wellbeing of staff during such a period of sustained demand was also noted. • In addition, the Trust had requested funding for GPs in the Emergency Department as had occurred in previous years as a means of reducing demand on the Emergency Department. Action: Joe Teape agreed to investigate the data in respect of virtual appointment and MyMedicalRecord numbers presented for Month 6. 4.7 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had received additional funding in respect of 2023/24 Elective Recovery Fund (ERF) performance, funding for industrial action costs, and deficit support funding from NHS England. As a result, the Trust had recorded a year-to-date deficit of £8m, a variance of -£4.7m against plan. • The Trust’s underlying deficit continued to be £5-6m per month. • The Trust had 200-220 patients with no criteria to reside at any one time, and expected reductions in mental health demand had not been realised due to non-delivery of system programmes. • The Trust had also undertaken £17m of unpaid activity in the first half of 2024/25. • The Trust had recorded 130% ERF performance in month and 128% year-to- date. It also continued to maintain low bank and agency use, and had delivered £32m of Cost Improvement Programme benefits. • There was significant financial pressure throughout the NHS in England. 4.8 ICB Finance Report for Month 6 Ian Howard was invited to present the ICB Finance Report for Month 6, the content of which was noted. It was further noted that: • The report tabled to the meeting had been prepared by the Hampshire and Isle of Wight Integrated Care Board (ICB) for all providers in the system. Page 4 • The system’s 2024/25 plan targeted a deficit of £70m. • During the first half of 2024/25, the system had received £55m in deficit support funding from NHS England and a surplus of £20m would be required during the second half of the year in order to be able to meet its 2024/25 target. • Meeting the 2024/25 target would likely be challenging. • The system had yet to see any significant benefit from the six transformation programmes. • It was noted that the ICB report would benefit from additional information in respect of workforce and equality, diversity and inclusion. 4.9 Recovery Support Programme (RSP) Undertakings – Self Assessment Ian Howard was invited to present the paper ‘Recovery Support Programme (RSP) Undertakings – Self-Assessment’, the content of which was noted. It was further noted that: • In June 2024, the Trust, along with all other organisations in the Hampshire and Isle of Wight Integrated Care System (ICS) under the Recovery Support Programme had submitted a self-assessment in respect of the undertakings entered into in 2023. NHS England had provided feedback in respect of these self-assessments in August 2024. • All providers had been asked to provide a further self-assessment, which would then be incorporated into a system-wide response in January 2025. • The evidence supplied by the Trust in support of its self-assessment indicated significant engagement by the Trust’s Board with the organisation’s undertakings under the RSP as well as progress against these undertakings since the previous submission. • Factors such as the number of patients having no criteria to reside and other matters beyond the Trust’s control remained a concern in terms of the Trust’s ability to fully meet the undertakings. • The action plans for the ICS transformation programmes should be included as part of the Trust’s response to the request for a self-assessment. Decision Having discussed the proposed response by the Trust, the Board agreed the proposed self-assessment, and authorised David French and Ian Howard to submit it to the Hampshire and Isle of Wight Integrated Care Board, subject to there being no material changes prior to submission. 4.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The Trust was currently under its 2024/25 plan by 249 whole-time-equivalents (WTE). However, this situation was expected to change in October 2024 due to the impact of onboarding of newly qualified nurses and midwives, and also due to non-delivery of ICS transformation programmes in non-criteria to reside and mental health, which assumed a reduction of 167 WTE. • The Trust benchmarked well in terms of its sickness absence rate and turnover. • The Trust had plans to transfer recording of appraisals from the Electronic Staff Record to the Visual Learning Environment platform, which was considered to be more ‘user friendly’ and was therefore expected to improve recorded appraisal numbers. Page 5 • The Trust was in active negotiations with Unison in respect of the Band 2/3 pay dispute. • The People and Organisational Development Committee was to examine the overall workforce picture in more detail. 4.11 Cancer Patient Experience Survey Results 2023 Ali Keen was invited to present the Cancer Patient Experience Survey Results 2023, the content of which was noted. It was further noted that: • The survey involved 132 trusts, and had a 58% response rate at UHS (1,064 patients). • At the Trust 15 out of 59 questions scored above the expected range, which indicated that the Trust was a positive outlier when compared to trusts of a similar size and demographic. • Patients with longer-term health conditions and women tended to have worse experiences than other groups. • The care by and quality of staff at the Trust were rated highly. • There were opportunities for improvement in some areas such as administration and communication around appointments. 5. STRATEGY and BUSINESS PLANNING 5.1 Corporate Objectives 2024-25 Quarter 2 Review Martin De Sousa and Kelly Kent were invited to present the Corporate Objectives 2024/25 Quarter 2 review, the content of which was noted. It was further noted that: • The report now incorporated a forecast for the end of year. • The overall picture was positive with 12 objectives shown as ‘green’, two as ‘amber’, and two as ‘red’. • The main areas of risk in terms of the objectives concerned the deliverability of a stretching financial plan. • The completion of year two of the Public Sector Decarbonisation Scheme was also at risk due to the state of steam duct tunnels, which required substantial remediation ahead of work commencing on the low temperature hot water system. 5.2 Board Assurance Framework (BAF) Update Craig Machell was invited to present the Board Assurance Framework Update, the content of which was noted. It was further noted that: • In September and October 2024, the Board’s committees had reviewed the BAF risks assigned to them, and the Audit and Risk Committee had reviewed the entire BAF. • As a result of these reviews, it had been agreed to increase the risk rating for Risk 1c (Infection Prevention Control) and to extend the target date. In addition, the target dates for all risks were to be reviewed to ensure that they were realistic. • The Board agenda now included an annex, which indicated where papers were linked to a BAF risk and the impact of any decision by the Board on the Trust’s achievement of its target risk rating. Furthermore, Board papers now Page 6 had a clear link to any relevant BAF risk included as part of the new cover sheet. 6. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Feedback from the Council of Governors’ (CoG) Meeting 23 October 2024 The Chair provided an overview of the meeting of the Council of Governors held on 23 October 2024. It was noted that the meeting had addressed the following matters: • Attendance at Council of Governors meetings • Appointment of a member of the Governors’ Nomination Committee • Planning for the Governors’ strategy session in December 2024 • Membership engagement • Feedback from the Working Groups • The external auditor’s report on the Annual Accounts In addition, on 31 October 2024, the Council of Governors had met with the Hampshire and Isle of Wight ICB to discuss future plans for the system and opportunities for collaboration between providers. 6.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7. Any other business There was no other business. 8. Note the date of the next meeting: 7 January 2025 9. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 27/02/2025 Pending Update: Item tentatively scheduled for TBSS on 27/02/2025 Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 27/02/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 27/02/25 Study Session. Trust Board – Open Session 05/11/2024 4.6 Performance KPI Report for Month 6 1181. MyMedicalRecord (MMR) Teape, Joe 07/01/2025 Completed Explanation action item Joe Teape agreed to investigate the data in respect of virtual appointment and MyMedicalRecord numbers presented for Month 6. Update: The issue was related to the MMR – drop-in logins in month and the increase in the previous month which was noted in the Month 6 report, as oncology had been added to the system and all patients notified in that month driving a surge in logins. Page 1 of 1 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Finance & Investment Committee Meeting Date: 25 November 2024 Key Messages: • • • • • • • • For month 7, the Trust had reported an in-month deficit of £4.5m and a £12.5m year-to-date deficit. The Trust was £9.2m behind plan. The non-delivery of system-wide transformation programmes represented approximately half of the overall deficit. The recent pay awards resulted in an additional £2m cost pressure. Elective Recovery performance was 125%, which was lower than previously due to operational challenges in October 2024, high levels of annual leave, and the performance achieved in October 2019 on which in-month performance was based. The Trust’s workforce numbers were beginning to increase as anticipated as newly qualified staff members were onboarded. The ongoing discussions with Unison in respect of the Band 2/3 pay dispute would likely lead to additional one-off costs as well as recurring costs if any pay increase were agreed. It was expected that the Trust would be below the NHS England minimum cash holding during Quarter 4. It was forecast that the Trust would deliver £67.7m of CIP for 2024/25 against £84.9m of identified schemes. The Trust’s Always Improving programme had succeeded in delivering a 3.6% reduction in length of stay. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Not applicable. Any Other Matters: • The committee received a quarterly update from Estates, Facilities and Capital Development. • The committee supported the Trust’s bid for external funding in support of the Southampton Elective Hub. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Finance & Investment Committee Meeting Date: 16 December 2024 Key Messages: • • • • The Trust’s financial position remains difficult despite significant levels of savings being delivered in areas such as patient flow, theatres, and outpatients. The main contributor to the Trust’s deficit continues to be non-delivery of system-wide transformation programmes, especially those concerning patients having no criteria to reside. The Trust was forecasting to achieve c.£67m of its cost improvement programme target for 2024/25, a shortfall of £17m against the identified opportunities. However, much of the unachieved amount assumed delivery of system transformation programmes. The Trust’s cash balance was initially expected to fall below the NHS England minimum holding level during Quarter 4. However, the Trust has received £12m of additional cash, which now means that the Trust’s cash balance should not fall below minimum required levels until Quarter 1 of 2025/26. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust’s in-month deficit was £5.7m and a year-to-date deficit of £18.2m, £14.8m behind plan year-to-date. • The Trust has carried out £21m of unfunded activity during the year. • The Trust continues to benchmark well in terms of value for money, and continues to apply measures to ensure financial grip and governance with strong controls in place. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). • The risk rating for Risk 5a has been increased from 15 to 20 due to the deteriorating cash balance and the ongoing financial pressures. Any Other Matters: • The committee reviewed the outputs of the review of non-pay expenditure carried out by Deloitte. • The committee supported the outline strategy for a possible private patient unit. • The committee gave its support in principle for the Trust to bid for £1.75m of funding in support of the Trust’s Same-Day Emergency Care service. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.2 Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: People & Organisational Development Committee Meeting Date: 13 December 2024 Key Messages: • • • • • The Trust’s substantive workforce grew by 7 whole-time-equivalents (WTE) during November 2024 in line with forecast. However, an adjustment has also been made to the substantive numbers being reported due to the status of a hosted network (the CRN), which expanded following a TUPE transfer of staff. The rate of bank staff usage had increased in November 2024 due to the need to open surge capacity. This was expected to continue during the remainder of the year. Reduction in bank benefit has been assumed though, commencing in January linked to NQNs exiting supernumerary periods. The non-delivery of system-wide transformation programmes continues to pose a significant risk to the Trust’s delivery of its 2024/25 workforce plan. A Mutually Agreed Resignation Scheme (MARS) has been approved by NHS England, which was expected to deliver a reduction in workforce of c.20 WTE by March 2025. The Trust was forecasting a total workforce of 13,464 WTE at the end of the year – broadly flat compared with the end of 2023/24. Increases in substantive workforce has been forecasted during December and January. Due to the volatility of predicting start dates during the Christmas period, a reforecast may take place in January. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust is above its 2024/25 workforce plan by 77 WTE due to a combination of the planned increases in substantive staff as newly qualified employees are onboarded, and the assumed reduction in workforce requirements due to delivery of system-wide transformation programmes. • The system-wide transformation programmes assumed a reduction in workforce of 218 WTE. Non-delivery of these programmes therefore poses a significant risk to the Trust’s achievement of its overall 2024/25 workforce plan. • The Trust’s sickness absence rate was 3.3% against the target of 3.9%, and turnover was lower than expected. • The response rate to the Staff Survey was low compared to the national average. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 3a, 3b and 3c have been updated, following discussions with the respective Executive Director(s). • The financial situation and uncertainty in respect of the NHS long-term workforce plan poses a significant underlying risk, and it was suggested that increasing the rating of risk 3c should be considered to reflect this. Any Other Matters: • A detailed update was provided in respect of the ongoing industrial dispute with the porters and in respect of the Band 2/3 pay dispute. Page 1 of 2 • The need to manage ongoing industrial disputes was impacting the Trust’s People team’s capacity to make progress on other areas, such as those relating to transformation. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.3 Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Quality Committee Meeting Date: 25 November 2024 Key Messages: • • • • • • • There had been seven never events reported during 2024/25. There had been a decrease in the number of category 2 pressure ulcers, which was possibly due to increased training rates. Three prostate patients had been lost to follow up, and there were concerns in respect of capacity within the prostate service. Overall, the Quality Indicators show a system under pressure. There were also concerns in respect of cardiac surgery services due to staffing levels and culture within the team, which had led to cancellations and increased waiting lists. The PALS/complaints service had had 2,135 interactions during Quarter 2. The top themes related to clinical treatment, patient care, and communication. The number of Inquests was increasing, which was putting pressure on services. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.12 Learning from Deaths 2024-25 Quarter 2 Report Assurance Rating: Risk Rating: Substantial Medium • Whilst the overall death rate had increased, this was in line with national trends. The Trust was performing well, and was one of 13 trusts scoring below the expected figure. • A mobile application to share the outputs of mortality and morbidity meetings was being reviewed. • The lack of available side rooms was leading to an increasing number of patients dying on wards rather than in a private environment. 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report Assurance Rating: Risk Rating: Substantial High • The Trust was expected to miss most bacteraemia targets for 2024/25. • The Trust was mid-table compared with other teaching hospitals. • The rate of MRSA had increased to 4-5 cases per annum from 2020 onwards, compared with 0-2 per annum between 2015 and 2020. • An audit of hand washing had raised concerns about the compliance rate. • The loss of experienced staff since the COVID-19 pandemic was considered to be a significant contributor to the decline in performance. Any Other Matters: The committee reviewed the Maternity and Neonatal Safety 2024-25 Quarter 2 Report and noted the following: • Caesarean section rates remained high. • The Trust’s post-partum haemorrhage rate remained above the national expectations, but no key themes had been identified following review of this matter. • In a review of third- and fourth-degree tears, no key themes had been identified. • One maternal death was under investigation. Page 1 of 43 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 43 Agenda Item 4.6 Report to the Quality Committee, 25 November 2024 Title: Sponsor: Author: Purpose Maternity and Neonatal Safety 2024-25 Quarter 2 Report Gail Byrne, Chief Nursing Officer Alison Millman, Quality Assurance and Safety Midwifery Matron Jessica Bown, Quality Assurance and Safety Midwifery Matron Hannah Mallon, Quality Assurance and Safety Neonatal Matron Marie Cann, Maternity and Neonatal Safety Lead Emma Northover, Director of Midwifery (Re)Assurance Approval Ratification Information x x x Strategic Theme Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks Foundations for the and collaboration future x Executive Summary: NHS Resolution (NHSR) requires that the Maternity & Neonatal (MatNeo) service reports to our Trust Quality Committee each time it meets. This Quarter 2 (Q2) 24-25 MatNeo services safety report will continue to be adapted and responsive to safety concerns or issues within our service providing assurance around safety improvements impacting our families, services, and staff. The information provided is for assurance and reassurance, whilst meeting the requirements of NHSR Maternity Incentive Scheme (MIS)Year 6 and highlights the safety improvement work and learning from all aspects of the services. We ask members to continue to support the MatNeo Services and provide monitoring and scrutiny as required. Contents: This report provides an update in relation to the following areas for Quarter 2 2024/25: 1. Perinatal Quality Surveillance – Maternity & Neonatal Dashboard (Appendix 1) 1.1. Scheduled Caesarean Section Capacity 1.2. Post Partum Haemorrhage (PPHs) 1.3. Episiotomy 1.4. 3rd and 4th degree tears 1.5. ITU transfers 1.6. Apgars 500ms (43.58%) NMPA target is 1500mls (5.8%) NMPA target is 35% Global majority booked CoC Model – Q2 compliance 19.5%, National target is > 35% The most vulnerable families are still supported by our Needing Extra Support Teams (NEST) and as we progress workstreams around future workforce plans, the service aspires to develop new and more sustainable CoC models of care. To give assurance we monitor and audit outcomes to ensure that groups most likely to be offered a CoC model are not showing as exceptions in our data or when clinically reviewing adverse outcomes. 1.9 FFT recommenders as % of responders Current compliance: 83.9% of responders would recommend our service. This has fallen slightly from Q1 (87.4%). As mentioned in the previous Committee report, the % of responders who would recommend our postnatal ward dropped to 67% in September 2024. This was escalated to the inpatient matrons and an improvement plan focusing on two areas has been developed (Appendix 2). These areas are: • Partner or someone else involved in service users care being allowed to stay with them as much as the service user wanted during their stay in hospital. • After the birth, ensure that women and birthing people are given the opportunity to ask any questions they may have about their labour and birth. 1.10 Maternity Opel 4 Diverts There has been an increase in the number of occasions when the Maternity Service has moved through escalation and ultimately declared OPEL 4. There are escalation processes and policies in place that aim to ensure appropriate decision making and the safety of our families and workforce. This issue has been widely monitored through Birthrate Plus reporting and reviewed within safety incident investigations and is on our Risk Register (Risk 259 High Red). As per the Trust’s PSIRF plan, harm tools are completed for each Opel 4 exceeding 24 hours to review the wider impact and harm associated with the service being on
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Papers Trust Board 6 June 2024

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 06/06/2024 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Diana Eccles, Tim Peachey (from 12:00) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient or staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 28 March 2024 9:15 Approve the minutes of the previous meeting held on 28 March 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee (Oral) 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee (Oral) Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee (Oral) 9:35 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 1 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Finance Report for Month 1 10:30 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 Break 10:45 5.9 People Report for Month 1 10:55 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Infection Prevention and Control 2023-24 Annual Report 11:10 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Interim Lead Infection Control Director/Sue Dailly, Infection Prevention Matron 5.11 Learning from Deaths 2023-24 Quarter 4 Report 11:20 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Freedom to Speak Up Report 11:30 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.13 Fuller Inquiry Report 11:45 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gavin Hawkins, Divisional Director of Operations, Division B 6 STRATEGY and BUSINESS PLANNING 6.1 CRN Wessex 2023-24 Annual Performance Report 11:55 Receive and note the annual report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Clare Rook, Chief Operating Officer, CRN: Wessex 6.2 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 1 May 2024 12:25 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 25 July 2024 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date Time 28/03/2024 9:00 – 13:00 Location Chair Microsoft Teams Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Ceri Connor, Director of OD and Inclusion (CC) (item 4.12) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 4.14) Sophie Limb, HR Project Manager (SL) (item 4.12) 1 member of the public (item 5) 6 governors (observing) 5 members of staff (observing) 1 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of her activities since February 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Minutes of the Previous Meeting held on 30 January 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 30 January 2024, subject to amending a reference to ‘radiology’ on page four to ‘radiotherapy’. 3. Matters Arising and Summary of Agreed Actions It was noted that all actions had been completed or were not yet due. Page 1 In terms of action 1102, the service was provided by NHS Blood and Transfusion, and funding had been removed. 4. QUALITY, PERFORMANCE and FINANCE 4.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to provide an overview of the meeting held on 18 March 2024. It was noted that: • The committee had reviewed the losses and special payments report and noted that although the individual size of each occurrence was not material, these instances nonetheless did have a significant impact on individual patients. • The committee reviewed the Board Assurance Framework (item 6.1). • The committee reviewed an internal audit report on data quality and noted that there were only some minor matters to address. In addition, there were no outstanding actions from previous reports. • The committee reviewed the internal audit plan for 2024/25, which would include examination of long waiters, the discharge process and rostering. • The external audit plan for the 2023/24 financial year was agreed. 4.2 Briefing from the Chair of the Charitable Funds Committee Steve Harris was invited to provide an overview of the meeting held on 27 March 2024. It was noted that: • The charity was in a position to transfer to the new charitable company. • Gail Byrne would be appointed as a director of the new charitable company on a temporary basis to represent the Trust. • The annual report and accounts for 2023/24 would be the final item of business requiring Board approval. 4.3 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 25 March 2024. It was noted that: • The committee reviewed the Finance Report for Month 11 (item 4.10) and the planning for 2024/25, noting that the underlying position presented a challenge for 2024/25. • The committee reviewed the Trust’s productivity assessed against that in 2018/19. The NHS England formula showed a 18% decline in the Trust’s performance. However, the basis of the formula was open to debate and the perception in the organisation was different given the demands on the Trust’s capacity. The Trust’s modified formula showed a lower decline in productivity and work was ongoing with the central team. • The committee reviewed the maintenance requirements in the Trust’s estate, which were significant owing to its age. • The committee reviewed the proposed capital prioritisation for 2024/25 and 2025/26. 4.4 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 20 March 2024. It was noted that: • The committee reviewed the People Report for Month 11 (item 4.11) and noted that the additional recruitment controls were having an impact. Page 2 • The committee reviewed the Staff Survey results (item 4.12), noting that key themes were staff burnout and morale. 4.5 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 18 March 2024. It was noted that: • The committee reviewed the patient safety and experience reports for the third quarter and noted some concerns regarding infection prevention control and pressure ulcers. In addition, there was some concern about overcrowding in the resuscitation area. • The committee had carried out a thematic review of never events, especially in Dermatology. • The committee reviewed the Trust’s performance in terms of its quality priorities for 2023/24. The Trust had achieved all its objectives, except one, which had been partially achieved. It was intended that there would be eight quality priorities in 2024/25. • It had been confirmed that the Integrated Care Board would fund the tobacco dependency programme in 2024/25. • Work was also taking place to provide additional capacity in the Paediatric Intensive Care Unit. 4.6 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care Board (HIOW ICB) had launched a consultation on how it will re-shape itself for the future. The ICB had been required to reduce its running costs by 20% during 2024/25 and by a further 10% during 2025/26. • Junior doctors had voted to continue industrial action for a further six months. • In the Spring Budget, the Chancellor announced additional funding for the NHS, although, once inflation had been taken into account, the NHS budget would remain broadly flat. • The NHS England Workforce Race Equality Standard data report showed some improvements, but further work was required. • Steve Brine, the Member of Parliament for Winchester and Chandler’s Ford had been hosted by the Trust on a visit the week before. This afforded an opportunity to discuss the Hampshire County Council consultation, social care and non-criteria to reside. • The latest NHS patient survey showed a reduction in satisfaction, but this was largely due to waiting to get into the system. • There was significant pressure from NHS England for trusts to achieve the targets set. The Trust has demonstrated strong performance during 2023/24 across the six targets. • A nurse from the Trust has received a national recognition award based on their work on the ‘Diabasics’ initiative and the first episode of ‘Surgeons at the Edge of Life’, filmed at Southampton General Hospital, had been broadcast on BBC2. • Thanks were expressed to all staff for their performance during the year. 4.7 Performance KPI Report for Month 11 Joe Teape was invited to present the Performance KPI Report for Month 11, the content of which was noted. It was further noted that: • In terms of the Trust’s performance compared with comparators, the Trust was top quartile for the majority of indicators and top half for others. Page 3 • There were 19 patients who would breach the 78-week wait target at year end, 18 of which were corneal patients where materials were unavailable. It was noted that there was a national shortage of materials. • There were expected to be about 50 breaches of the 65-week wait target, of which around 30 were corneal patients. • The Trust had achieved diagnostic performance of 92% achieving the sixweek target. • There had been high volumes of patients in the Emergency Department during February and March 2024. However, the Trust had achieved 70.6% for type 1 performance and expected to achieve the 76% target by the end of March 2024. • The Trust’s Referral To Treatment metric was beginning to improve and there were some examples of very good waiting list management in Trauma and Orthopaedics and in Women and New Born. • The key point to emphasise was that, although it might not seem so at times, the Trust was out-performing most other comparable organisations. It was considered appropriate that staff communications should be worked on to reinforce this message. In terms of the Trust’s Key Performance Indicators: • The Quality Committee had seen significant improvements in diagnostic performance. • The two-week wait cancer target performance had also improved since April 2023. • Unfortunately, due to significant challenges with flow, overnight ward move performance had dropped significantly during the month, leading to poor patient experience. • In addition, the rate of pressure ulcers appeared to be increasing. 4.8 Non-Criteria to Reside Spotlight Report Joe Teape was invited to present the Non-Criteria to Reside Spotlight Report, the content of which was noted. It was further noted that: • Management of non-criteria to reside patients was one of the Trust’s biggest risks in terms of its operational and financial performance and achievement of its targets. • The Trust has seen 20%+ of beds occupied by patients without criteria to reside, which significantly impacted patient flow in the Emergency Department and has led to ambulance handover delays. • In addition, stays in hospital of longer duration were known to lead to worse patient outcomes. • The Trust was unable to have a significant impact on this issue, as the main driver was insufficient funding availability in local authorities. • In terms of what the Trust could do, work was ongoing to improve the discharge process by having conversations about care needs early on as part of the Trust’s flow transformation programme. 4.9 Break 4.10 Finance Report for Month 11 Ian Howard was invited to present the Finance Report for Month 11, the content of which was noted. It was further noted that: Page 4 • The Trust had received £24.6m of cash support from NHS England and £5m in funding in relation to the impact of industrial action between December 2023 and February 2024. • A year-end deficit of £1.4m was forecast. • The Trust’s underlying monthly deficit was currently £4m, and the Trust’s underlying deficit had been £4-5m a month during 2023/24. • Cost Improvement Programme delivery was expected to be £62m at year end, an increase of £17m compared to the previous year. 4.11 People Report for Month 11 Steve Harris was invited to present the People Report for Month 11, the content of which was noted. It was further noted that: • Total workforce had reduced by 20 whole-time equivalents (WTE) during the month, although the Trust remained 266 WTE above plan. • Use of bank staff had reduced, although it was expected that more bank staff would be used in March 2024 as substantive staff used leftover annual leave before year end. • Average turnover was 11%, below the target of 13.6%. The Board discussed the report and noted that it was necessary to review training expectations in order to make best use of staff time. In addition, it was noted that funding for internationally recruited nurses was likely to reduce and that apprentice and student nurse numbers had reduced. 4.12 UHS Staff Survey Results 2023 Report Ceri Connor, Sophie Limb and Steve Harris were invited to present the UHS Staff Survey Results 2023 Report, the content of which was noted. It was further noted that: • The Trust scored above average in all of the People Promise areas and there had been an improvement in the areas regarding managers and appraisals. • However, the overall NHS average had increased, thus narrowing the gap. • The participation rate was lower than in the previous year and the overall scores hid pockets of concern. The Board discussed the results of the Staff Survey. It was noted in particular that the Trust had invested significant sums into wellbeing, but that morale was low. It was considered that this demonstrated the importance of local management to staff morale. In addition, the Board discussed the impact of the change in approach from granting significant autonomy during the pandemic to increasing levels of control, which had been received negatively by staff. However, it was noted that, whilst in some areas, such as with regard to patients, there was a general culture of accountability, there appeared to be less of a general culture of accountability with respect to finances and budgets. The possibility of ‘earned’ autonomy was considered as a means of mitigating against those who had acted properly being penalised by the actions of others. Page 5 4.13 Maternity and Neonatal Perinatal Quality Surveillance Dashboard Report The Maternity and Neonatal Perinatal Quality Surveillance Dashboard Report was noted. It was further noted that the additional information in respect of post-partum haemorrhage data (action 1101) was contained within the report and had been discussed at a maternity safety champions’ meeting. 4.14 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There had been seven exception reports constituting a breach and resulting in a financial penalty, which were due to exceeding the maximum 13-hour shift duration. All reports were from General Surgery. • There were also concerns in Gynaecology due to the complicated rotas, inadequate rest provision and facilities. • The position of a junior doctor was a difficult one due to a lack of patient contact during the pandemic, industrial action and changes in the assignment of foundation posts. Action: Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. 5. Patient Story David Livermore was invited to relate his experience of attending an appointment at the Eye Unit in October 2023 and, in particular, the difficulties he encountered as a wheelchair user. It was noted that his treatment had been carried out in a room inappropriate for his needs and that he had been asked personal questions in the waiting room. Following discussion with the Board of his experiences, David Livermore offered his services to the Trust to advise on disability access as an ‘expert patient’. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) update, the content of which was noted. It was further noted that: • The Trust’s Risk Management Policy and Strategy had been updated, with the main changes being in relation to the Trust’s risk appetite following the Trust Board Study Session held in December 2023. • Work was being carried out to improve the Board’s visibility of operational risks and to improve links between operational risks and the BAF. Page 6 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Remuneration and Appointment Committee Terms of Reference It was noted that the Remuneration and Appointment Committee had reviewed its terms of reference at its meeting held on 28 March 2024. It was further noted that some minor changes were proposed, largely to update references to documentation and NHS organisations, and, in terms of the executive pay guidance, to better reflect current practice and the available frameworks. Decision: Having reviewed the Remuneration and Appointment Committee terms of reference tabled to the meeting, it was agreed to approve these terms of reference. 8. Any other business There was no other business. 9. Note the date of the next meeting: 6 June 2024 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/03/2024 4.14 Guardian of Safe Working Hours Quarterly Report 1127. Junior Doctors Grundy, Paul Hulbert, Diana 27/06/2024 Pending Explanation action item Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. Page 1 of 1 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 5.5 David French, Chief Executive Officer 6 June 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • Infected Blood Inquiry • General Election • Industrial Action • HEFMA Award • Capital Funding • 2024/25 Planning The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 9 Infected Blood Inquiry On 20 May 2024, the Infected Blood Inquiry published its report into more than 30,000 people becoming infected with HIV and hepatitis C after being given contaminated blood products in the 1970s and 1980s. The report said that: • Too little was done to stop importing blood products from abroad, which used blood from high- risk donors such as prisoners and drug addicts; • In the UK, blood donations were accepted from high-risk groups until 1986; • Blood products were not heat treated to eliminate HIV until the end of 1985, although the risks were known in 1982; and • There was too little testing to reduce the risk of hepatitis from the 1970s onwards. The UK Government has established a compensation scheme for those impacted. The report can be read at: http://www.infectedbloodinquiry.org.uk/reports NHS England’s formal response to the report is attached as Appendix 1. During the Inquiry, the Trust was made aware of patient cases which would be cited in the report and was offered an opportunity to comment. We chose not to comment in detail on individual cases, primarily due to the time elapsed since they happened. NHS England has commissioned an ongoing patient support service for those affected and it is likely that UHS will be one of two providers in the region offering this service. Funding for a fiveyear period has been confirmed. General Election The Prime Minister has announced that a general election will be held on 4 July 2024. There are a number of practical implications for the Trust as a public body to maintain political impartiality and to ensure that public resources are not used for the purposes of political parties or campaign groups during the pre-election period which commenced on 25 May 2024 and will continue until the day after the election. During this period, the following key principles should apply: • No activity should be undertaken which could be considered politically controversial or influential. • NHS trusts have discretion in their approach, but must be able to demonstrate the same approach for every political party, official candidate and designated campaign group. • The NHS may be under media spotlight, locally and nationally, so it is advisable to have a plan in place for how the organisation will manage the pre-election period and the potential for the organisation to be singled out in the media. Normal business and regulation needs to continue during the pre-election period. However, where a board meeting needs to take place, the agenda should be confined to those matters requiring a board decision or oversight. Matters of future strategy or future deployment of resources may be construed as favouring one party over another and should be avoided. Use of the confidential part of the agenda to discuss matters which may be politically controversial is not recommended. Care should be taken not to comment on the policies of political parties or campaign groups. Page 2 of 9 Organisations should not start long-term initiatives or undertake major publicity campaigns unless time critical (such as a public health emergency). Public consultations should not be launched during the pre-election period, and it is advisable to extend the period for those already running to take into account the pre-election period. The timing of the election means that formal Secretary of State approval for the Solent / Southern transaction is unlikely to happen before the election and therefore the formation of the new Trust, previously scheduled for 1 June, is likely to be delayed. Industrial Action On 29 May 2024, it was announced that junior doctors would stage a five-day strike, commencing on 27 June 2024 and ending on 2 July 2024. This will be the eleventh walkout by junior doctors since March 2023. As during previous periods of industrial action, the Trust will seek to minimise any impact on patient care by organising consultant cover wherever possible. HEFMA Award Paula Melhuish, Deputy Director of Estates and Capital Development, received the Outstanding Service Award from the Health Estates and Facilities Management Association on 13 May 2024. Paula has been a long-serving and esteemed colleague at UHS and has recently announced her retirement. Capital Funding Due to its Emergency Department performance at the end of 2023/24, the Trust was awarded an additional £2m in capital departmental expenditure limit (CDEL) as part of a scheme to reward high-performing trusts. There were several categories where the top-10 performing trusts received additional CDEL, including absolute ED 4-hour % performance and most improved ED 4-hour performance. NHS England agreed that the type 3 Urgent Treatment Centre attendances at RSH and Lymington should be included in the overall UHS performance and that, combined with significantly improved 4-hour performance at SGH, this meant that UHS was in the national top-10 for absolute ED 4-hour performance. terms of using the CDEL allowance, plans are being developed to increase the department’s same day emergency care (SDEC) capacity. The additional CDEL is not cash-backed so we are in discussions with NHSE regarding the cash funding. 2024/25 Planning The CFO and I will update the Board on the status of the 2024/25 planning round which is not yet finalised. At a meeting in London with NHS England executives, the ICS was asked to improve its position further in return for some financial incentives. This challenge was accepted, although the allocation of this further stretch to individual providers has not yet been agreed. The structure and leadership of the ICS-wide transformation programmes has been reviewed and changed. The structure of the programmes was considered by CEO, Chairs and ICB colleagues and it was agreed there should be six programmes for 2024/25, as set out below. The Board should note that I requested to retain the leadership role on the Planned Care programme, mostly because we have an agreed way forward, have good traction and can now see improvement happening. In addition, I was asked to take on leadership of the Workforce programme which, following discussion with the Chair, I have agreed to do. Page 3 of 9 Programme Mental Health Discharge Urgent and Emergency Care Local Care Planned Care Workforce CEO lead Ron Shields, SHFT Penny Emerit, PHU David Eltringham, SCAS Alex Whitfield, HHFT David French, UHS David French, UHS Each programme has been asked to set out its objectives and deliverables for the year ahead by 18 June 2024. I will share the results of this exercise with the Board in due course. Page 4 of 9 Appendix 1 Classification: Official To: • All integrated care boards and NHS trusts: - chairs - chief executives - medical directors - chief nurses - chief operating officers - chief people officers - heads of primary care - directors of medical education • Primary care networks: - clinical directors cc. • NHS England regions: - directors - chief nurses - medical directors - directors of primary care and community services - directors of commissioning - workforce leads - regional heads of nursing - regional heads of communications NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 20 May 2024 Dear colleagues, Publication of the Infected Blood Inquiry final report Earlier today, the Infected Blood Inquiry published its final report at: www.infectedbloodinquiry.org.uk/reports. The Prime Minister has subsequently issued an apology on behalf of successive Governments and the entire British state. On behalf of the NHS in England, now and over previous decades, Amanda Pritchard issued a public apology, saying: Publication reference: PRN01368 Page 5 of 9 “Today’s report brings to an end a long fight for answers and understanding that those people who were infected and their families, should never have had to face. “We owe it to all those affected by this scandal, and to the thorough work of the Inquiry team and those who have contributed, to take the necessary time now to fully understand the report’s conclusions and recommendations. “However, what is already very clear is that tens of thousands of people put their trust in the care they got from the NHS over many years, and they were badly let down. “I therefore offer my deepest and heartfelt apologies for the role the NHS played in the suffering and the loss of all those infected and affected. “In particular, I want to say sorry not just for the actions which led to life-altering and lifelimiting illness, but also for the failures to clearly communicate, investigate and mitigate risks to patients from transfusions and treatments; for a collective lack of openness and willingness to listen, that denied patients and families the answers and support they needed; and for the stigma that many experienced in the health service when they most needed support. “I also want to recognise the pain that some of our staff will have experienced when it became clear that the blood products many of them used in good faith may have harmed people they cared for. “I know that the apologies I can offer now do not begin to do justice to the scale of personal tragedy set out in this report, but we are committed to demonstrating this in our actions as we respond to its recommendations.” The report is sobering reading, documenting failings over multiple decades, and making recommendations across a wide range of areas, including recognition, support and compensation; education and training; monitoring of and testing for Hepatitis C; the safety of blood transfusions; preventing future harm, via duty of candour and regulation; as well as giving patients a voice. We write now to set out the initial steps we are taking in response. Support for those affected The Department of Health and Social Care is providing £19 million over five years to provide a bespoke Infected Blood Psychological Support Service which is expected to be rolled out later this summer. We have listened to the experiences of those involved, including patients, their families and staff, and are working with them to design and develop this service, which will provide dedicated support for those affected, located around the country. Copyright © NHS England 2024 2 Page 6 of 9 This service will include talking therapies, peer support, and psychosocial support, as well as access to other treatments or support for physical or mental health needs where appropriate. In the interim, the existing England Infected Blood Support Service remains available here: www.nhsbsa.nhs.uk/england-infected-blood-support-scheme. Further information about existing testing and support services, including those commissioned by the Government, can be found at: www.nhs.uk/infected-blood-support. Supporting affected staff It is important to also recognise that some of our colleagues may be affected by the publication of today’s report in some way, whether through personal or professional connection to the issue. Employers may therefore wish to increase promotion of their local health and wellbeing support for staff. Details of nationally-commissioned routes of support, including the 24/7 text helpline Shout and NHS Practitioner Health, can be found at NHS England - Support available for our NHS People. Continuing to find and treat people with blood-borne viruses Although it is likely that the majority of those who were directly affected have now been identified and started appropriate treatment given the time that has elapsed since the last use of infected blood products, there may be people who have not yet been identified, particularly where they are living with asymptomatic Hepatitis C. We ask that systems continue to work with partners, including community groups and charities, as well as Hepatitis C Operational Delivery Networks, to promote local testing options for anyone at risk, or anyone who is concerned. This should include promotion of the new national service for at-home Hepatitis C self-testing kits, available via hepctest.nhs.uk. For those who are concerned about the risk of HIV infection, further information can be found here: information on HIV diagnosis and the HIV testing services search tool. Hepatitis B, another infection that can be linked to infected blood, usually clears up on its own without treatment; however, people concerned about Hepatitis B infection should be directed towards relevant hepatitis B information or their local sexual health clinic or GP practice. Today's report highlights that in some cases those affected by infected blood products were told of their diagnosis in ways which were insensitive and inappropriate. We would therefore ask you to ensure that patients and their families are supported through the process of receiving test results – of whatever kind - in a compassionate and considerate way. Copyright © NHS England 2024 3 Page 7 of 9 Ensuring patients can access the right information. We recognise following the publication of this report, some patients may raise questions directly with their primary and/or secondary care teams, or through other points of contact with the NHS. We will be sharing materials with relevant service providers to ensure frontline clinicians and other colleagues in patient-facing roles are able to provide appropriate information or signposting. We expect that this will be particularly relevant to: • Providers of NHS 111 services • GP practices and community pharmacies • Trusts providing services where blood products are used • Mental health providers Maintaining confidence in current blood and blood products and related treatment The infected blood and blood products that have been the subject of this Inquiry were withdrawn in 1991. In the intervening decades, comprehensive systems have been put in place to ensure the safety of both donors and recipients of blood and blood-derived products. Today, blood and blood products are distributed to NHS hospitals by NHS Blood and Transplant (NHSBT), which was established in 2005 to provide a national blood and transplantation service to the NHS. NHSBT’s services follow strict guidelines and testing to protect both donors and patients. NHS Blood and Transplant has published clear information about these processes here: Infected Blood Inquiry - NHS Blood and Transplant (nhsbt.nhs.uk). Nationally, NHS England will work with NHS Blood and Transplant and others to communicate the safety of current blood products. Assessing further recommendations and next steps As set out above, the final Inquiry report includes a number of important recommendations for the NHS. NHS England will be considering these in detail alongside the Department for Health and Social Care and other relevant bodies. In addition, an Extraordinary Clinical Reference Group is being convened to inform any immediate actions which should be taken. The next steps from this work will be shared as soon as possible, including through relevant clinical networks. Copyright © NHS England 2024 4 Page 8 of 9 Yours sincerely, Amanda Pritchard NHS Chief Executive NHS England Professor Sir Stephen Powis National Medical Director NHS England Dame Ruth May Chief Nursing Officer England Dr Emily Lawson DBE Chief Operating Officer NHS England Copyright © NHS England 2024 5 Page 9 of 9 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Issue to be addressed: Performance KPI Report 2024-25 Month 1 5.6 David French, Chief Executive Sam Dale, Associate Director of Data and Analytics 6 June 2024 Assurance or reassurance Y Approval Ratification Information The report aims to provide assurance: • Regarding the successful implementation of our strategy. • That the care we provide is safe, caring, effective, responsive, and well led. Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: (Clinical, Organisational, Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: Summary: Conclusion and/or recommendation This report covers a broad range of trust performance metrics. It is intended to assist the Board in assuring that the Trust meets regulatory requirements and corporate objectives. This report is provided for the purpose of assurance. This report is provided for the purpose of assurance. Page 1 of 24 Report to Trust Board in June 2024 Performance KPI Board Report Covering up to April 2024 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 24 Report to Trust Board in June 2024 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts is used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 24 Report to Trust Board in June 2024 Introduction The Performance KPI Report is presented to the Trust Board each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘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, performance concerns, and requests from the Board. • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. Due to the timing of the April 2024 Board meeting, the following referral to treatment data points were not included in the March KPI report. They have now been updated for March 2024 and April 2024: - • 31 - Patients on an open 18 week pathway (within 18 weeks) • 33 - Patients on an open 18 week pathway (within 52 weeks) • 34 - Patients on an open 18 week pathway (within 65 weeks) • 35 - Patients on an open 18 week pathway (within 78 weeks) • 35a - Patients on an open 18 week pathway (within 104 weeks) • 32 - Total number of patients on a waiting list (18 week referral to treatment pathway) Changes of note within the report itself: • 53 – The digital metric monitoring page loading time for the CHARTS system has been tightened from under five seconds to under three seconds • 55 – The metric monitoring the rollout of inpatient noting for nurses has been removed as this is now considered complete. This will be revisited when the noting solution is rolled out for doctors • 39 - The 2024/25 national cancer target changes will be reflected next month when April 2024 data is made available • 40 - The 2024/25 national cancer target changes will be reflected next month when April 2024 data is made available • 37 - The metric now reflects the published 2024/25 national year-end target of 5% of patients waiting over 6 weeks for diagnostics Page 4 of 24 Report to Trust Board in June 2024 Summary This month’s spotlight report covers diagnostic performance. It highlights that UHS consistently increased the volume of elective diagnostic tests delivered throughout the 2023/24 financial year and into the start of the 2024/25 financial year. The diagnostic waiting list reduced by 12% in 2023/24 and in April 2024, 89.6% of patients received their diagnostics within six weeks. The national performance target has been set at 95% by March 2025 and the organisation is working with all services to ensure we maintain waiting times for services that are compliant and address any demand and capacity barriers preventing achievement. The paper describes the activity and performance trends for the hospital and explores modality sites in more detail. Areas of note in the appendix of performance metrics include: 1. The Emergency Department (ED) four hour performance position reduced to 66.0% (April 2024) from 71.7% (March 2024) for type 1 attendances, however UHS remain in the top quartile when compared to peer teaching hospitals across the country. 2. In April, the overall RTT waiting list increased by 2.4% to 59,485. 3. The trust continues to report zero patients waiting over 104 weeks and reported 15 patients waiting over 78 weeks for April 2024. All 15 patients are within ophthalmology and impacted by the ongoing national shortage of corneal graft tissue which is being overseen by NHS Blood and Transplant service. The longest waiting patients will be booked for surgery as soon tissue has been confirmed. 4. The trust reported 66 patients waiting over 65 weeks which predominantly reflects corneal transplant patients again and low volumes within gynaecology and several surgical specialties. The trust is committed to achieving the national target of zero patients waiting over 65 weeks by September 2024 and the ambition to achieve zero patients waiting over 52 weeks by March 2025. 5. The volume of patients not meeting the Criteria to Reside in hospital decreased in April averaging 216 which is a 10% reduction compared to March 2024, yet this remains a significant impact on patient flow through the organisation. 6. There were zero never events reported for April 2024. 7. The volume of medication errors reduced to two in April 2024 which is now below the monthly target following the increase seen in March 2023. 8. The number of Gram-negative bloodstream infections continues to be marginally above the monthly target of 19. The increased incidence in cases continues to be reported both nationally and locally across the Hampshire and Isle of Wight integrated care system. 9. The digital metric to monitor page loading times on CHARTS system has successfully remained at 99% despite increasing the time target by 40%. Ambulance response time performance The latest unvalidated weekly data is provided by the South Coast Ambulance Service (SCAS). In the week commencing 13th May 2024, our average handover time was 16 minutes 56 seconds across 725 emergency handovers and 22 minutes across 52 urgent handovers. There were 44handovers over 30 minutes, and six handovers taking over 60 minutes within the unvalidated data. The volume of weekly handovers over 60 minutes increased by 73% from March 2024 (averaging 7.5 per week) to April 2024 (averaging 13 per week). Page 5 of 24 Report to Trust Board in June 2024 Spotlight Report Spotlight: Diagnostic Performance The following report is based on the validated April 2024 submission. Introduction Diagnostics are a critical component of a patient’s pathway, facilitating an accurate and complete diagnosis, personalised treatment plans and the appropriate monitoring of a patient’s condition. Timely access to diagnostic tests is essential for ensuring that patients re ceive an early diagnosis whilst improving patient experience and delivering an efficient use of NHS resources. The 2024/24 NHS priorities and operational planning guidance confirmed that “systems are asked to continue to work towards the elective care recovery plan target of 95% of patients receiving their tests within 6 weeks”. The national ambitions acknowledged that the NHS delivered record diagnostic activity in 2023, but also highlighted that additional capacity in community diagnostic centres had been partly offset by an unprecedented increase in unscheduled diagnostic activity in acute trusts. This national diagnostic target applies to 15 different diagnostic tests, although performance is measured at a Trust level. These tests are broadly divided into three categories: • endoscopy (e.g. gastroscopy, cystoscopy); • imaging (e.g. CT, MRI, barium enema); • physiological measurement (e.g. echocardiogram, sleep studies). Our teams prioritise diagnostic procedures based on clinical urgency (for example patients with cancer) but aligned to this is a continual review of the longest waiting diagnostic patients. This spotlight paper highlights the current diagnostic performance position for UHS against the national targets and other hospitals. It also describes the current volumes of activity being delivered and the impact on the waiting list. We explore any performance concerns across the different modalities, outlining the challenges that services are facing and the steps being taken to achieve the 2024/25 target. In summary, there was an overall reduction in the diagnostic waiting list across the 2023/24 financial year as UHS successfully increased the delivery of diagnostic activity to manage current levels of demand. The diagnostic waiting list currently stands at 8,849 patients (April 2024) which is a reduction of 12% since April 2023 (10,033 patients) and 24% since the peak levels seen in June 2022 (11,671 patients). The April 2024 performance position is 89.6% for the percentage of patients receiving diagnostic tests within six weeks. The latest comparison data available (March 2024) placed the hospital 5th when ranked against peer teaching hospitals across the country. All organisations are facing challenges due to high demand, workforce shortages and equipment limitations and funding, but the organisation is striving to achieve the 95% target set for 2024/25. Page 6 of 24 Report to Trust Board in June 2024 Spotlight Report Activity and Waiting List Elective diagnostic activity being delivered at UHS consistently increased throughout 2023/24 and into 2024/25 helping to manage the waiting list despite high referral volumes and the complications caused by industrial action throughout the previous year. Graph 1 illustrates that diagnostic activity levels delivered in 2023/24 were 6% higher than 2022/23 and 17% higher than pre-pandemic levels. Overall there was a 12% reduction in the diagnostic waiting list across the 2023/24 financial year (graph 2) despite some levelling off in winter months and a small recent increase which is being closely monitored. The waiting list stands at 8849 patients for April 2024 which breaks down into
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